Glass. 
 Book 
 
 COPYRIGHT DEPOSIT 
 
SYSTEM OF SURGERY 
 
 
 / 
 WILLIAM TOD HELMUTH, M.D.. 
 
 , SURGERY IN THB KSW TORB HOMOEOPATHIC M 
 
 i .i.n I.) Tin: LAURA PRAMHLIB ri:i : BOSFITA] i )B CH i 
 
 TO THB HOMCBOPATHIC HOSPITAL OB WARD'S I8LAB1 l UK 
 
 1IA1IN \v TORE (.i.I.I I '.I AM) 
 
 B06P] PAL FOB W)M1 \ ; MBMBEB i>k I m 
 EB8T11 HCBOPATBT; 
 
 FELLOW OF THB NEW YORK MBDICO-CHIBUBON W SOCIETY; MXMBBB OB THB BBW FORK 
 STATE HOMCBOPATHIC MEDICAL BOCIBTY, OF Tin. HOHCBOPATHII Ml DH AL MM I 
 STY OF BBW YOB LEY HBMB1 B <>K 1 it K » 
 
 MEDICALS BOMCBOPATHIQUB DB r&AJTl E, OF THI HOMOEOPATHIC 
 
 BOOB 
 EBLA 
 
 FIFTH EDITION, ENLARGED, REARRANGED, REVISED, 
 
 MANY FARTS RE-WRITTEN, AND MUCH 
 
 NEW MATTER ADDED. 
 
 
 
 ILLUSTRATED, WITH 718 CUTS OX WOOD. 
 
 PHILADELPHIA: 
 
 F. E. BOERICKE 
 
 Hahnemann Publishing House. 
 188/. 
 
* 
 
 :, 
 
 4> x 
 
 Copyrighted By F. E. BOEKICKE, 1886. 
 
 SHERMAN & CO., PRINTERS, PHILADELPHIA. 
 
TO 
 
 THE FACULTY 
 
 OF THE 
 
 NEW YORK HOMEOPATHIC MEDICAL COLLEGE 
 
 Shis' Saorfc 
 
 IS RESPECTFULLY INSCRIBED 
 
 THEIR COLLEAGUE, 
 
 THE AUTHOR. 
 
PREFACE TO THE FIFTH EDITION. 
 
 The demand for a fifth edition of this work has given great satisfac- 
 tion to its author. He has endeavored in the following pages by many 
 emendations to render this book more worthy the confidence of the pro- 
 fession than its predecessors, as well as a fair exponent of the <c Surgery 
 of the Present." 
 
 A writer and lecturer in any department of science, after years of 
 constant labor, may become so familiar with his subject that he may 
 assume for his readers certain elementary knowledge, and thus produce 
 a work which, though intelligible to the advanced student, is not 
 entirely comprehended by the beginner. This is the fault of many 
 text books. In the present edition the author has endeavored to 
 remember that he is writing for the first course student as well as the 
 graduate, and has tried wherever possible to insert here and there a 
 little of the literature of surgery (than which no more interesting sub- 
 ject exists), to relieve the monotony of detail, and the bare statement 
 of facts. Whether these efforts have been successful remains to be 
 determined. 
 
 In conclusion, the author returns thanks to Dr. F. S. Fulton for his 
 excellent Chapter on " Trachelbrraphy," to Messrs. William Wood & 
 Co., of New York, for the use of engravings ; and to the cutlers Tie- 
 man & Co., and John Reynders & Co., of New York, and William 
 Snowden, of Philadelphia, for their trouble and generosity in supplying 
 the book with electrotypes of instruments and apparatuses. 
 
 Thanksgiving Day, New York, November 25th, 1886. 
 299 Madison Avenue. 
 
CONTENTS. 
 
 PART I. 
 
 MINOR AND PRELIMINARY SURGERY. 
 
 CHAPTER I. 
 
 Cleanliness — Instruments — Ligatures — Various Articles used in Dressing — Tents — 
 Incisions — Hypodermic Medication — The Aspirator — Paquelin's Thermo-Cau- 
 tery — Galvano-Puncture — Galvano-Cautery — Electrolysis, . . . 33-60 
 
 CHAPTEE II. 
 
 Disinfectants and Antiseptics. 
 
 Antiquity of Disinfection — Cleanliness — Charcoal — Lime — Ashes — Earth — Smoke — 
 Collins's Disinfecting Fluid — Thompson's Deodorizer — Heat — Coffee — Bromine — 
 Ozone — Iodine — Nitrate of Lead — Chlorine — Chloride of Zinc — Chloride of Lime 
 — Labarraque's Solution — Permanganate of Potash — Nitrous Fumigations — Tar 
 Acids, 61-70 
 
 CHAPTEE III. 
 
 Anaesthesia. 
 
 Ether — Discovery of Anaesthesia — Inhalers — Ether by the Rectal Method — Chloro- 
 form — Symptoms of Danger — Death — Nitrous Oxide — Bichloride of Methylene — 
 Bromide of Ethyl — Sickness and Death from Anaesthesia — Local Anaesthesia — 
 Richardson's Apparatus — Anaesthetic Ether — Hydrate of Amyl — Hydramyi — 
 Anaesthetic Mixtures for Small Operations — Hydrochlorate of Cocaine, . 70-86 
 
 PAET II. 
 
 GENERAL SURGERY. 
 
 CHAPTER IV. 
 
 Introduction— Inflammation— Inhibitory Nerves — Connective Tissue — Leucocytes — 
 The Migration Theory — Action of the Capillaries — Hyperaemia — Active Conges- 
 tion — Changes in the Tissues — Changes in the Blood — The Tissue Metamorphosis 
 Theory of Strieker — Symptomatology — Inflammatory Fever — The Terminations 
 — Repair — Immediate Union — First Intention — Granulation — Cicatrization — 
 Fatty Degeneration — Treatment, General and Local, .... 87-109 
 
XVI CONTENTS. 
 
 CHAPTER V. 
 
 Degeneration of Tissue. 
 
 Suppuration — Pus-Corpnscles — Varieties and Analysis of Pus — Fluctuation — General 
 Treatment — Abscess, Acute, Chronic, Diffuse, Eesidual : Time of Operation — 
 Treatment — Hyper-Distension with Carbolic Water — Sinus and Fistula, 109-120 
 
 CHAPTER VI. 
 
 Traumatic Fever — Septicaemia and Pysemia — Hectic — Treatment, . . 120-129 
 
 CHAPTER VII. 
 
 Degeneration (Continued). 
 
 Ulceration ; Sloughing — Ulcers : Simple — Irritable — Indolent — Varicose — Treatment : 
 Local — Straps — Bandages — Skin-Grafting — Sponge Grafting — Medical Treatment 
 —Dry Earth, 129-140 
 
 CHAPTER VIII. 
 
 Degeneration (Continued). 
 
 Gangrene and Mortification — Line of Demarcation ; of Separation — Question of Am- 
 putation in Traumatic Gangrene — Dry Gangrene — Treatment — Hospital Gan- 
 grene — Sloughing Phagedsena, ........ 141-147 
 
 CHAPTER IX. 
 
 Tumors. 
 
 Introductory Remarks — Classification — Diagnosis — Characteristics. Histological For- 
 mation : A. Innocent Tumors — Types of Higher Tissues and Types of Connective 
 Tissues — Types of Epithelial Tissue. B. Sarcomata : Types of Embryonic Tis- 
 sues — Connective Tissue. C. Carcinomata — Different Varieties of Cancer. D. 
 Cystic Tumors and their Varieties — Cysto Sarcoma, .... 147-201 
 
 CHAPTER X. 
 
 Scrofula — Struma — Tuberculosis. 
 
 Definition — Treatment — Scrofulous Ulcer — Division of Tubercle — Gray and Cheesy 
 Granulations, 201-204 
 
 CHAPTER XI. 
 
 Venereal Diseases. 
 
 History of Syphilis — Gonorrhoea — Gleet — Balanitis — Gonorrhoea in Women — Gonor- 
 rhoeal Rheumatism — Gonorrhoeal Ophthalmia — Sycosis, . . . 205-221 
 
 CHAPTER XII. 
 
 Chancroid — Soft Chancre. 
 Definition — Characters of — Seat — Phagedenic — Chancroids in the Urethra, 221-226 
 
CONTEXTS. XV11 
 
 CHAPTEE XIII. 
 
 Syphilis — General Considerations — Chancre — Differential Diagnosis between Chancre 
 and Chancroid — Bubo — Constitutional Syphilis — Affections of the Skin — Tertiary 
 Forms — Syphilitic Iritis — Syphilis of the Larynx — Syphilization — Fumigation — 
 Inunction — Infantile Syphilis, 226-245 
 
 CHAPTEE XIV. 
 
 AVounds : Definition — Classification — Danger of— Dressings for — Sutures — Straps — 
 Antiseptic Treatment — Methods of Healing — Incised — Punctured — Contused — 
 Lacerated — Poisoned Gunshot, 245-291 
 
 CHAPTEE XV. 
 
 The Varied Methods of Dressing Wounds, 291-302 
 
 CHAPTEE XVI. 
 A Concise Eeview of the Antiseptic Surgery of the Present, . . . 302-314 
 
 CHAPTEE XVII. 
 
 HEMORRHAGE. 
 
 The Means and Instruments for Arresting Haemorrhage — Definition — Haemophilia — 
 Haemostatics, Natural and Artificial — Internal Medication — Styptics — Flexion — 
 Compression — Percutaneous Ligation — Acupressure — Various Instruments — Liga- 
 ture — Esmarch's Method— Dittel's Elastic Ligature, .... 315-346 
 
 CHAPTEE XVIII. 
 
 Transfusion. 
 
 History — Uses — Apparatus — Transfusion of Blood ; of Milk ; of Saline and Other 
 Substances, 346-352 
 
 CHAPTEE XIX. 
 
 Amputations. 
 
 Definition — Question of Amputation — Instruments — Methods — Mortality After, 
 
 352-365 
 
 CHAPTEE XX. 
 
 Special, Amputations. 
 Amputation of the Lower Extremities, 365-392 
 
 CHAPTEE XXI. 
 
 Plastic Surgery. 
 
 Antiquity of— General Considerations— Varied Methods of Transplanting Flaps, 
 
 392-395 
 
XV111 CONTENTS. 
 
 PART III. 
 
 SURGERY OF SPECIAL REGIONS AND TISSUES. 
 
 CHAPTEK XXII. 
 
 Diseases and Injuries of the Skin and Cellular Tissue. 
 
 Erysipelas — Poisoning with Rhus — Furuncle, Boil — Anthrax, Carbuncle — Effects of 
 Cold, Pernio — Burns and Scalds — Cicatrices — Paronychia, Whitlow — Lupus — Ele- 
 phantiasis Arabum — Malignant Pustule — Internal Malignant Pustule — Verruca?, 
 Warts — Bed-Sores — Ingrowing Toe Nail — Onychia — Subungual Exostosis — Per- 
 forating Ulcer of the Foot, 396-427 
 
 CHAPTER XXIII. 
 
 Injuries and Diseases of the Muscles, Tendons, and Burs2e. 
 
 Contusions — Thecitis — Dislocations of Muscles and Tendons — Rupture of Muscles and 
 Tendons — Muscular Atrophy — Reflex Muscular Atrophy — Acute and Chronic 
 Bursitis — Ganglion — Sprains — Dupuytren's Contraction, . . . 427-436 
 
 CHAPTER XXIV. 
 
 Injuries and Diseases of the Arteries. 
 
 Arteritis, Adhesive and Diffuse — Atheroma — Embolism— Aneurism : Varieties, Gen- 
 eral Treatment, Medical Treatment — Compression — Manipulation — Rapid Method 
 for External Aneurism, Injection, Ligature — Special Aneurisms, . . 436-463 
 
 CHAPTER XXV. 
 
 Ligation of Arteries. 
 Surgical Anatomy of the Vessels and Methods of Operating, . . . 463-479 
 
 CHAPTER XXVI. 
 
 Injuries and Diseases of the Veins. 
 
 Thrombosis — Thromballosis — Coagulation in Veins — Thrombus — Phlebitis — Varix — 
 Entrance of Air— Wounds— Phlebolith.es, 479-484 
 
 CHAPTER XXVII. 
 
 Diseases of the Capillaries. 
 Erectile Tumors — Nsevi — Telangiectasis, ....... 484-487 
 
 CHAPTER XXVIII. 
 
 The Nervous System after Injuries and Operations. 
 
 Symptoms of Shock — Temperature During — Secondary Shock — Treatment — Tetanus 
 — Wounds of the Nerves — Nerve Stretching — Nerve Suture — Neuralgia, 488-503 
 
CONTENTS. XIX 
 
 CHAPTER XXIX. 
 
 Diseases of the Lymphatics. 
 
 Lymphangitis — Angeioleucitis — Adenitis — Neoplasms — Lympliadenoma — Lymph- 
 oma, * 503-507 
 
 CHAPTEE XXX. 
 
 Injuries and Diseases of the Bones. 
 
 Periostitis — Osteitis, Suppuration and Sclerosis — Osteo-Myelitis — Caries — Scrofula 
 and Syphilis in Bone — Necrosis — Mollities Ossium and Rachitis — Fragilitas 
 Ossium — Atrophy of Bone — Tumors, Innocent and Malignant, . . 507-533 
 
 CHAPTER XXXI. 
 
 Fractures: General Considerations in the Treatment of — Divisions — Causes — Symp- 
 toms — Examination of Patient — Mode of Repair — General Treatment — Flexion 
 or Bending of the Bones — Pseudo-arthrosis — Cracked Bones— Special Fractures 
 in the Various Regions of the Body, 534-608 
 
 CHAPTER XXXII. 
 
 Injuries and Diseases of the Joints. 
 
 Wounds — Synovitis — Arthropyosis — Ulceration of the Articular Cartilages — Genu- 
 throtomy — Anchylosis: False and Spurious — Subcutaneous Osteotomy — Chronic 
 Rheumatic Arthritis — Hip-joint Disease — Loose Cartilages in Joints — Talipes : 
 Varus — Equinus — Valgus — Calcaneus — Tenotomy — Spurious Talipes — Weak 
 Ankles — Genu Valgum — - Knock-knee — Bow-legs — Trigger-finger — Hysterical 
 Joints — Gonalgia — Disease of the Sacro-iliac Synchondrosis, . . 608-648 
 
 CHAPTER XXXIII. . 
 
 Dislocations or Luxations. 
 
 General Considerations — Varieties — Diagnosis — Treatment — Extension and Counter- 
 extension — Manipulation — False Joint — Ancient Dislocations — Special Disloca- 
 tions of Different Joints, . . 648-680 
 
 CHAPTER XXXIV. 
 
 Injuries and Diseases of the Spine. 
 
 Concussion of the Spine, including " Railway Concussion " — Nervous Shock — Spina 
 Bitida — Cleft Spine — Rotary Lateral Curvature — Angular Curvature — Pott's 
 Disease — Caries of the Spine — Lordosis — Psoas or Lumbar Abscess, . 681-693 
 
 CHAPTER XXXV. 
 
 Excisions of Bones and Joints. 
 
 General Remarks — Instruments — Resection of Bones in their Continuity — Excision 
 of the Bones of the Hand— Of the Wrist— Of the Forearm— Of the Elbow— Of 
 the Humerus — Of the Shoulder— Of the Scapula— Of the Clavicle — Of the Ribs — 
 Of the Calcis— Of the Toe— Of the Knee— Of the Leg— Of the Hip, . 693-718 
 
XX CONTENTS. 
 
 CHAPTEK XXXVI. 
 
 Injuries and Diseases of the Head. 
 
 Wounds — Gunshot Wounds of the Scalp — Fractures of the Skull — Concussion and 
 Compression — Application of the Trephine — Cerebral Motor Localizations, 
 
 718-729 
 
 CHAPTEK XXXVII. 
 
 Injuries and DrsEASES of the Nose. 
 
 Malformations — Foreign Bodies — Epistaxis — Lipoma Nasi — Ulceration — Ozrena — 
 Polypus Nasi — Myxoma — Naso-pharyngeal Polypus — Osteo-plastic Resection — 
 Rhinoscopy, 729-739 
 
 CHAPTER XXXVIII. 
 
 Injuries and Diseases of the Mouth and Throat. 
 
 Hare-lip — Double Hare-lip — Restoration of the Upper Lip — Epithelioma — Enlarged 
 Labial Glands — Cysts of the Lip — Vascular Tumors — Restoration of the Lower 
 Lip — Cleft Palate and Staphylorraphy — Gingivitis — Tumors of the Tongue — 
 Glossitis — Abscess of the Tongue — Hypertrophy — Amputation of the Tongue — 
 Malformation of the Frsenum — Ranula — Salivary Calculus and Fistula — Ton- 
 sillitis — Quinsy — Rhinoscopy — Pharyngitis — Gangrenous Pharyngitis — Post- 
 pharyngeal Abscess — Elongation of the Uvula — Spasm and CEdeina of the 
 Glottis, 739-776 
 
 CHAPTER XXXIX. 
 
 Injuries and Diseases of the Jaws. 
 
 Abscess of the- Antrum Highmorianum — Tumors of the Antrum — Osteo-Plastic Opera- 
 tion for Exposing the Cavity of the Antrum — Epulis — Cystic Tumors — Necrosis 
 of the Jaw- Bones — Phosphorus Necrosis — Excision of the Upper Jaw — Excision 
 of the Lower Jaw — Of the Entire Lower Jaw — Anchylosis of the Inferior Maxil- 
 lary, . 777-789 
 
 CHAPTER XL. 
 
 Injuries and Diseases of the Neck. 
 
 Cut Throat — Torticollis, Wry Neck. Diseases of the Glands of the Neck — Parotitis, 
 Mumps — Abscess of the Parotid — Gangrene of the Parotid — Malignant Diseases 
 of the Parotid — Extirpation of the Parotid — Affections of the Duct of Steno — 
 Diseases of the Submaxillary Gland — Cystic Tumors of the Neck — Goitre — Bron- 
 chocele— Derbyshire Neck. Diseases of the CEsophagus — Rupture of the QEso- 
 phagus — Oesophagitis, Inflammatio CEsophagi — Stricture of the CEsophagus — 
 Foreign Bodies in the CEsophagus — Introduction of Tubes — GEsophagotomy. 
 Surgical Affections of the Larynx and Trachea — Syphilitic Laryngitis — Foreign 
 Bodies in the Larynx and Trachea — Bronchotomy — Laryngotomy — Tracheotomy 
 — Tracheotomy with the Thermo-Cautery — Intubation of the Glottis — Laryngo- 
 scopy — Neoplasms — Extirpation of the Larynx, 789-819 
 
CONTENTS. XXI 
 
 CHAPTEE XLI. 
 
 Injuries and Diseases of the Thorax. 
 
 Wounds of the Chest — Hydrothorax — Empyema — Aspiration of the Thorax — Thora- 
 centesis — Puncture of the Pericardium — Pleurotomy — Thoracic Gradual Drain- 
 age — Apncea: from Drowning, from Hanging — Mammary Lymphangitis — 
 Mastitis — Carcinoma of the Mamma — Benign Tumors — Amputation of the 
 Breast 819-832 
 
 CHAPTEE XLIL 
 
 Injuries and Diseases of the Abdomen. 
 
 Wounds of the Abdominal Viscera — Suturing the Intestine — Artificial Anus — Ab- 
 scess of the Abdominal Parietes — Hepatitis — Diseases of the Gall Bladder — Gall 
 Stones — Cholecystotomy — Hepatic Abscess — Paracentesis — Obstruction of the 
 Bowels — Operations for — Colotomy — Perity phlitic Abscess — Gastrotomy and 
 Gastrostomy — Splenectomy— Eesection of the Pylorus — Digital Divulsion of the 
 Pylorus, 832-855 
 
 CHAPTEE XLIII. 
 
 Hernia — Eupture. 
 
 Abdominal Hernia — Frequency and Sites — Varieties and Nomenclature — Medical 
 Management — Diagnosis — Taxis — Puncturing the Intestine — Eeduction by Es- 
 march's Bandage — Trusses — Herniotomy — Kelotomy — Enterectomy for Gan- 
 grenous Hernia — Eadical Cure — By Ligature of Sac — Heatonian Method — 
 Wood's Operation — Inguinal Hernia — Surgical Anatomy — Differential Diag- 
 nosis — Operation — Femoral Hernia — Diagnosis — Operation — Ovarian Hernia — 
 Umbilical Hernia — Obturator Hernia — Ischiatic — Diaphragmatic — Pudendal, 
 
 856-891 
 
 CHAPTEE XLIV. 
 
 Diseases of the Eectum and Anus. 
 
 Examination — Imperforate Anus and Eectum — Foreign Bodies in the Eectum — Pro- 
 lapsus Ani — Haemorrhoids — Fistula in Ano — Tumors in the Eectum — Stricture 
 of the Eectum — Linear Eectotomy — Ulcers and Fissures of the Anus — Excision 
 of the Eectum — Carcinoma of the Eectum, 892-914 
 
 CHAPTEE XLV. 
 
 Injuries and Diseases of the Urinary Organs. 
 
 Malformation — Exstrophy of the Bladder — Epispadias — Hypospadias — Hermaphro- 
 dites — Calculous Nephralgia — Unstable (Floating) Kidneys — Nephrectomy — 
 Nephrotomy — Cystitis — Eetention of Urine — (Ischuria Vesicalis) — Tubercular 
 Cystitis — Catheterism — Abscess and Fistula in the Perinseum — Laceration of the 
 Urethra — Cystotomy — Foreign Bodies — Stricture of the Urethra — Internal and 
 External Urethrotomy — Calculi — Stone in the Bladder — Various Methods of 
 Lithotomy — Operations for Lithotrity — Tumors of Bladder — Prostatitis, 914-987 
 
XX11 CONTEXTS. 
 
 CHAPTER XLVI. 
 
 Diseases of the Male Genital Organs. 
 
 Malformations — Acute and Chronic Orchitis — Fungoid Growths of the Testicles — 
 Cystic Disease — Carcinoma — Castration — Carcinoma of the Scrotum — Hydrocele 
 — Hematocele — Varicocele — Elephantiasis Scroti — Amputation of the Scrotum — 
 Phimosis — Paraphimosis — Epithelioma Penis — Amputation of the Penis — Sperm- 
 atorrhoea, 987-1015 
 
 CHAPTER XLVIL 
 
 Injuries and Diseases of the Female Genital Organs. 
 
 Examination of Uterus — Carcinoma — Scirrhus — Epithelioma, Vegetating and Ulcer- 
 ating — Amputation of the Cervix — Uterine Tumors — Fibro-Myomata — Vaginal 
 Removal, and Laparotomy — Hysterectomy —Vaginal Extirpation of the Uterus 
 — Oophorectomy — Laceration of the Perineum — Vaginismus — Elephantiasis of 
 the Labia 1015-1052 
 
 CHAPTER XL VIII. 
 
 Lacerations of the Cervix Uteri, . 1052-1066 
 
 CHAPTER XLIX. 
 
 Ovarian Tumors. 
 
 Formation — Varieties — Formation of Colloid — Of Dermoid — Fibrous and Fibro-Cystic 
 — Diagnosis — Pseudocyesis — Pregnancy — Parovarian Cysts — Encysted Dropsy of 
 the Peritoneum — Ascites — Microscopical Examination of the Fluid — Albuminoid 
 — Malignant Disease — Treatment — The Performance of Ovariotomy and Sub- 
 sequent Management, 1066-1092 
 
INDEX OF AUTHORS. 
 
 The following List is intended to embrace the chief references that have been made in this 
 Volume to the published labors of others. „ 
 
 Abraham : sponge grafting, 139. 
 
 Adams, J. C: perityphlitic abscess, 851. 
 
 Adams, William: Dupuytren's contraction, 435 ; subcutaneous osteotomy, 620. 
 
 Agnew : popliteal aneurism, 447; gangrene, 141; statistics of amputation, 363-365; 
 
 tracheotomy, 807. 
 Aitken : compound acupressure, 363. 
 Allan: scorpion bites, 260; removal of cancer, 189. 
 Allis : diagnosis of hip-joint disease, 662 ; acupressure forceps, 334. 
 Andouit : elephantiasis arabum, 420. 
 
 Annandale: excision of joint between the os calcis and astragalus, 708. 
 Appia : aphorisms in gunshot wounds, 277 et seq. 
 Archer: nephrectomy, 927. 
 
 Aschenborn : foreign bodies in the oesophagus, 800. 
 Atlee, W. : arsenic in the treatment of cancer, 190 ; encysted dropsy of the peritoneum, 
 
 1077 ; value of Drysdale's corpuscles, 1079. 
 Attomyr : treatment of syphilis, 231 ; treatment of cancer of the lip, 749. 
 
 Bacceli: auscultation and percussion in empyema, 821. 
 
 Backmeister : carbolic acid, 67. 
 
 Baer : impregnation after trachelorraphy, 1066. 
 
 Bagley : treatment of stricture of urethra, 943. 
 
 Baker : necrosis, 521. 
 
 Baldassare : treatment of spina bifida, 684. 
 
 Baldwin: medical treatment of ovarian tumors, 1083. 
 
 Ball : sponge grafting, 139. 
 
 Bailey : treatment of cancer, 185. 
 
 Bantock : antiseptic spray, 307. 
 
 Barton : fracture of the lower end of the radius, 575. 
 
 Barwell: aneurism of the innominate artery, 458; excision of the ankle-joint, 709. 
 
 Bassini: peroxide of hydrogen, 311. 
 
 Bauer : hip-joint disease, 624 ; treatment of genu valgum, 711. 
 
 Bayes : treatment of cancer, 181. 
 
 Beane : anterior and posterior linear -rectotomy, 908. 
 
 Becker : treatment of pseudo-arthrosis, 547. 
 
 Beebe, A. G. : treatment of cancer, 182. 
 
 Bellfield : putrid infection, 305. 
 
 Belmas : suprapubic lithotomy, 962. 
 
 Bellingham : treatment of aneurism, 447. 
 
 Bence: treatment of cancer, 85. 
 
 Berger: extirpation of the larynx, 818. 
 
 Berger : formation of colloid, 1071. 
 
 Bernays : cholecystotomy, 840. 
 
 Beullard: treatment of gangrene, 144. 
 
 Bigelow : ilio-femoral ligament in relation to dislocations of the hip-joint, 657 ; litho- 
 
 lapaxy, 974 ; artery forceps, 37. 
 Billroth: cystic tumors, 192; classification of tumors, 148; and Von Pitha, description 
 
 of arteries of head and neck, 464 ; extirpation of the spleen, 855. 
 Bishoff: intra-venous saline injections, 352. 
 Black : scrofula in bone, 517. 
 Black, F. : treatment of hydrocele, 996. 
 Blakely : treatment of traumatic gangrene, 144. 
 Boeck: syphilization, 241. 
 Boekel : subcutaneous osteotomy, 527. 
 
XXIV . INDEX OF AUTHORS. 
 
 Bokai : post-pharyngeal abscess, 774. 
 
 Bompart : treatment of tetanus, 494. 
 
 Bond: hepatic abscess, 841. 
 
 Bouchut : hare-lip, 740. 
 
 Bowen : treatment of fistula in ano, 902. 
 
 Boyer : amputations, 356 ; caries of bone, 517 ; rachitis, 524 ; exostosis, 529 ; osteo- 
 sarcoma, 530. 
 
 Bradley : subcutaneous osteotomy, 526. 
 
 Bradshaiv: treatment of cancer, 182. 
 
 Brainerd : treatment of false joint, 547. 
 
 Brickie: encysted dropsy of the pelvis, 1089. 
 
 Briddon: excision of the rectum, 913. 
 
 Broadhurst : anchylosis, 616 ; subcutaneous osteotomy, 621 ; anchylosis of the lower 
 jaw, 788. 
 
 Brodie : treatment of gangrene, 144 ; treatment of varix, 482. 
 
 Brown, B.: trachelorraphy, 1059. 
 
 Brown, I. Baker: treatment of uterine tumors, 1025. 
 
 Brown, H. L. : splenectomy, 855. 
 
 Brown, T. R. : internal urethrotomy, 950. 
 
 Brownell : treatment of fistula in ano, 905. 
 
 Brum: operation for the removal of naso- pharyngeal polypi, 734. 
 
 Bryant: traumatic fever, 120; statistics of pyaemia, 125; cyst walls, 192; cancerous 
 tumors, 172 ; treatment of cancer, 180 ; torsion for arresting haemorrhage, 327 ; 
 Pott's fracture, 603 ; method of amputation at hip-joint, 366 ; classification of 
 bone diseases, 509; dislocation of the pubic bones, 653; excision of ankle, 709; 
 gastrotomy, 852; imperforate anus, 896; Listerism, 304. 
 
 Buchanan: restoration of lip, 750. 
 
 Buck: subcutaneous osteotomy, 620; excision of the knee, 711; instrument for hare- 
 lip, 745 ; perityphlic abscess, 850. 
 
 Budd : hepatic abscess, 842. 
 
 Bull: thymol, 70 ; thymol as an antiseptic, 70; etherization by the rectum, 75. 
 
 Bidlen: elephantiasis of the labia, 1050. 
 
 Bumstead : gonorrhoea, 216 ; report on syphilis, 221 ; on the unity or duality of syphilis, 
 227 ; quoting Diday on chancre, 228. 
 
 Burckhardt: extirpation of thyroid gland, 795. 
 
 Burrall : excision of the os calcis. 706. 
 
 Burt : treatment of haemorrhoids, 900. 
 
 Busch : lymphatic fistula, 507. 
 
 Butcher: haemorrhage, 323; excision of knee, 710. 
 
 Butler, John : electrolysis, 58. 
 
 Byford: treatment of uterine fibroids by hypodermic use of secale cornutum, 1027. 
 
 Calhoun, A. W. : cocaine in cataract, 86. 
 
 Cullender: torsion, 327 ; acupressure, 333: rupture of muscles, 429. 
 
 Campbell: use of calendula, 113. 
 
 Cameron: treatment of goitre, 795; shock, 488. 
 
 Canstatt: symptoms of secale cor. in gangrene, 143. 
 
 Capelletti : fractures of the os innominatnm, 567. 
 
 Carey: idiopathic symmetrical myelitis, 514. 
 
 Carnochan : treatment of elephantiasis, 420 ; pulsating bony tumors, 533. 
 
 Catesby : snake-bites, 260. 
 
 Ceccherelli : ovarian hernia, 885. 
 
 Chadwick: anatomy of rectum, 911. 
 
 Champ ionnier e : localization of cerebral injuries, 726. 
 
 Chapard: tetanus, 493. 
 
 Chapelle : reduction of hernia, 865. 
 
 Charcot and Pitres: localization of the cerebrum, 726. 
 
 Chiene : nerve stretching, 497 ; operation for relief of genu valgum, 642 ; antiseptic 
 
 surgery, 303. 
 Ciisholm: removal of the superior maxillary bones, 783. 
 Churchill : hare-lip, 740 ; statistics of amputation, 363. 
 Clapp, H. : pleurotomy, 823. 
 Clark, E. A.: acupressure, 333; interdental splint, 554; fracture of the humerus, 572 ; 
 
 fracture of the olecranon, 581 ; apparatus for treatment of fracture of the femur, 
 
 593. 
 Clark, H. E. : nerve suture, 500. 
 Clark, Le Gros : concussion of the brain, 722. 
 
IXDEX OF AUTHORS. XZV 
 
 Clarke, E. : treatment for vaginismus, 1048. 
 
 Clarke, Lockhart: muscular atrophy, 430. 
 
 Clements, B. A.: dislocation of the clavicle, 651. 
 
 Cloquet: epigastric artery in hernia, 879, 887. 
 
 Coe : formation of fibroids of ovary, 1073. 
 
 Coles: deaths from anaesthesia, 81. 
 
 Colley : treatment of clubfoot, 639. 
 
 Columbat: fibrous tumors of the uterus, 1022. 
 
 Comstock: treatment of hydrophobia, 267; phimosis, 1010; gynepod, 1036. 
 
 Conheim: metastasis of tumors, 152. 
 
 Conklin: impacted fracture of the neck of the femur, 586. 
 
 Conner : dislocation of elbow, 675. 
 
 Cooper, Astley : repair, 100 ; fractures of the pelvic bones, 568 ; dislocation of the 
 
 pubes, 653. 
 Cooper, Bransby: time for operating on hare-lip, 742. 
 
 Cooper, Samuel: gangrene, 144; hypertrophy of the tongue, 761; caries, 515. 
 Cornil and Banvier : ovarian tumors, 1068. 
 Cox, W. C. : nerve stretching, 498. 
 Craigie: hepatic abscess, 842. 
 Creguy : treatment of fissures of the anus, 909. 
 Critchett: manner of strapping ulcers, 136. 
 Crosby : dislocation of hip, 652. 
 Crosley : automatic reduction of hip, 662. 
 Cullen : tetanus, 492. 
 
 Curling : method of tying nsevus, 487 ; castration, 993. 
 Gushing, A. M. : use of calendula, 113. 
 
 Danbridge and Conner : examination of rectum by hand, 894. 
 
 Davis: vaginismus, 1047. 
 
 Dawson: the diagnosis of hip-joint disease, 662. 
 
 Dawson, B. : the proper time for operating for hare-lip, 741. 
 
 Day: elephantiasis arabum, 420. 
 
 Day. John: self-disinfectant, 65. 
 
 Debrand: vaginismus, 1048. 
 
 DeCato : traumatic tetanus, 494. 
 
 Delaney : amputation of the tongue, 762. 
 
 Diday : quoted by Bumstead on chancre, 228. 
 
 Dieulafoy : aspiration of the knee-joint, 610. 
 
 Dittel: elastic ligature, 345. 
 
 Dix : acupressure, 336. 
 
 Dobson: skin-grafting in ulcers, 137. 
 
 Dorsey : insect wounds, 260. 
 
 Dougall: relative power of antiseptics, 306. 
 
 Dougherty : dislocation of the patella, 665. 
 
 Druitt: haemophilia, 317 ; method of tying nsevi, 487 ; hydrocele, 845. 
 
 Dubois: treatment of hare-lip, 742. 
 
 Dudgeon: treatment of boils, 401 ; gonorrhoea! ophthalmia, 219. 
 
 Dulles : suprapubic lithotomy, 968. 
 
 Dunham : treatment uf malignant pustule, 423 ; emplovment of lachesis in phlebitis, 
 
 481; disinfectants, 62. 
 Dunnell: the medical treatment of strangulated hernia, 861. 
 Dunvell: forced flexion, 323. 
 Duplay : diffuse phlegmonous periostitis, 570 ; nerve stretching, 497. 
 
 Earle : cases of fracture of the acetabulum, 569. 
 
 Eckel : treatment of aneurism, 453. 
 
 Emmet: ideas regarding capsulated fibroid tumors of the uterus, 1025; method of per- 
 forming the operation for perineal lacerations, 1035, 1039 ; ovariotomy, 1089. 
 
 Englisch : albuminuria in hernia, 860. 
 
 Erichsen : fatty tumors, 156 ; sebaceous cysts, 200 ; nsevi, 487 ; concussion of the spine, 
 and railway concussion, 682; treatment of hydrocele, 998. 
 
 Esmarch : ideas regarding the application of his bandage in various operations, 342 
 resection of shoulder, 704. 
 
 Eve: remarkable cases in plastic surgery, 394 ; cure of hydrocele by a bayonet stab, 998. 
 
 Fano : concussion of the brain, 722. 
 
XXVI INDEX OF AUTHORS. 
 
 Feryusson: local manifestations in inflammation, 97; opening of abscesses, 117; the 
 question of amputation, 355 ; the operation of staphylorraphy, 758. 
 
 Fischer: naphthalin, 311. 
 
 Fitch : description of his dome trocar and aspirating apparatus, 55. 
 
 Fitz: rupture of the oesophagus, 797. 
 
 Flemminy : changes occurring in the carbolized catgut ligature, 454; hydrophobia, 
 263. 
 
 Fletcher: the analogy between fever and inflammation, 98. 
 
 Forbes, W. F. : nitrite of amyl in hydrophobia, 208. 
 
 Formad: bacilli, 206. 
 
 Foster : comparison of acupressure with torsion, 327. 
 
 Foulis: extirpation of the larynx, 818. 
 
 Fournier : classification of chancroids, 223. 
 
 Fox: classification of elephantiasis of the labia, 1049. 
 
 Franke: sponge grafting, 139. 
 
 Franklin : gunshot wounds, 275 ; amputation in wounds, 289. 
 
 Freyer: transfusion of blood, 350. 
 
 Fry : excision of veins, 482. 
 
 Fulton: trachelorraphy, 1052. 
 
 Gamgee: artificial ischsemia, 341 ; indications for the application of the trephine, 725. 
 
 Ganyhofner and Prebam: the urine in melanotic cancer, 178. 
 
 Garriyues: mediate transfusion, 349. 
 
 Gatchkousky : resorcin in cancer, 186. 
 
 Gasten, 1. McF. : cholecystotomy, 840. 
 
 Gay : statistics of tracheotomy, 807. 
 
 Gibb: amputation at the hip-joint, 345. 
 
 Gibb, G. W. : fractures of the acetabulum, 569. 
 
 Gibney, V. P. : morbus coxarius, 630. 
 
 Gibson, Prof.: snake-bites, 260 ; treatment of hydrophobia, 264; necrosis, 521; frac- 
 ture of patella, 599 ; artificial anus, 836 ; psoas abscess, 692 ; hepatic abscess, 841. 
 
 Gibson, W. A. : treatment of fracture of the patella, 599. 
 
 Gilchrist: calendula as a vulnerary, 113; treatment of fibroid tumors, 96. 
 
 Girard: antiseptic method of dressing wounds, 291. 
 
 Gluck : nerve suture, 500. 
 
 Gluge: steatomata, 156. 
 
 Gocldard : earth treatment, 140. 
 
 Goodell : ovarian tumors, 1074; oophorectomy, 1033. 
 
 Goodheart: aspiration of the thorax, 821. 
 
 Goodwillie: fracture of the lower jaw, 555. 
 
 Gould, A. Pierce: why strictures of the urethra are common at the bulb of the urethra, 
 941 ; haemorrhage in hip-joint amputation, 366. 
 
 Gouley : internal urethrotomy, 947. 
 
 Green: classification of tumors, 149 ; gummatous products in syphilis, 237. 
 
 Gross, S. D.: hydatid tumors, 199; keloid, 420; myeloid tumors, 169 ; differential 
 diagnosis between encephaloid and scirrhus, 176 ; treatment of cancer, 180 ; hem- 
 orrhagic diathesis, 317 ; hare-lip, 742 ; time of operating in cases of hare-lip, 742 ; 
 anchylosis of the inferior maxillary, 787 ; treatment of hydrocele, 997. 
 
 Gross, S. W. : nephrectomy, 925. 
 
 Gruber : treatment of gonorrhoea, 213. 
 
 Gullen: abscess of the antrum highmorianum, 778. 
 
 Gunniny : fractures of the lower jaw, 553. 
 
 Guthrie : gunshot wounds, 276. 
 
 Hayedorn : antiseptic surgery, 296. 
 
 Hale: treatment of ulcers, 204; of gangrene, 144; of goitre, 795. 
 
 Hall, G. A. : tar-plaster, 41 ; strangulated inguinal hernia, 885 ; nephrotomy, 927. 
 
 Hamiltion, O. T. : sponge grafting in ulcers, 138. 
 
 Hamilton, F. H: amputation at hip-joint, 368 ; skin grafting, 395 ; keloid, 420 ; frac- 
 ture of nasal bones, 549 ; enlarged lymphatic glands, 391 ; fracture of the ole- 
 cranon process, 581 ; fractures of the femur, 584, 585, 590 ; fractures of the patella, 
 599. 
 
 Hdmmond: treatment of bed-sores by electricity, 423. 
 
 Hancock: excision of ankle, 709; excision of knee, 717. 
 
 Handcock : fractures of the pubic bones, 567. 
 
 Harris: diaphragmatic hernia, 891. 
 
 Hart and Barbour: ovarian tumors, 1081. 
 
INDEX OF AUTHORS. XXV11 
 
 Hartlaub and Trinks: treatment of hydrophobia, 268. 
 
 Hartmann: ulcers, 204; rachitis, 526; treatment of hydrothorax, 820. 
 
 Harvey: gunshot wounds, 281. 
 
 Hastings: treatment of hydrocele, 996 ; treatment of gonorrhoea, 214. 
 
 Hastings ( U. S. N.) : emphysema, 821. 
 
 Haivard : lyrnphadenoma, 506. 
 
 Hayf elder : Pirogoff's amputation, 379 ; excision of the os calcis, 707. 
 
 Hays: treatment of compound fracture, 609. 
 
 Heath, C : treatment of aneurism, 450 ; method of removing tongue, 764 ; ovariotomy, 
 
 1084. 
 Heath, Q. Y. : forced flexion in hemorrhage, 323. 
 Heath, T. Ashton: abscess, 118. 
 Heaton: radical cure of hernia, 872. 
 Heitzmann: experiments with lactic acid, 432; classification of tumors, 154; ovarian 
 
 tumors, 1068. 
 Hennen: gunshot wounds, 274, 277. 
 Henriques: treatment of burns, 407 ; of fractures, 546. 
 Henry, M. H: coxo-femoral dislocation, Q56 ; varicocele, 1003. 
 Hering: snake poisons, 261. 
 
 Hewitt: concussion of the brain (quoted by Bryant), 722. 
 
 Hewson : uses of earth as a surgical dressing, 140 ; acupressure, 337 ; paper as a surgi- 
 cal dressing, 48. 
 Hey: natural phimosis, 1009. 
 
 Hildebrant : hypodermic use of ergot in the treatment of uterine fibroids, 1026. 
 Hitter: potassa fusa as an antiseptic, 70. 
 Hinton: causes of intestinal obstruction, 846. 
 Hirsch : treatment of whitlow, 413. 
 Hodgen: shock, 491 ; fracture of the vertebrae and sternum, 535 ; operation for lacerated 
 
 perinfeum, 1041. 
 Hodgkin : lympho-sarcoma, 505. 
 Hoffman : treatment of cancer, 184. 
 Holcomb : treatment of gonorrhoea, 212; of caries, 518. 
 Hoi den : perityphlitic abscess, 851. 
 
 Holmes, T.: migration of leucocytes, 92; suppuration, 109; pyaemia, 120, 126 ; classi- 
 fication of tumors, 148 ; neuromatous tumors, 154; hospital erysipelas, 398; lym- 
 phangitis, 504; salivary fistula, 767. 
 Holmes (System of Surgery) : heat in inflammation, 96; vascular tumors, 155; necro- 
 sis, 519 ; laryngeal neoplasms, 815; imperforate anus, 895 ; dislocation of clavicle, 
 652. 
 Home: ulcers, 133; snakebites, 260; stricture of the urethra, 941. 
 Hornbrook : fracture of the patella, 601. 
 Horrocks : uterine tumors, 1023. 
 Hoskin : vaporizer, 70. 
 Howe : transfusion of milk, 350. 
 Hubbard: naevus, 485. 
 Huber : drainage tubes in thoracic cavitv, 824, note ; puncture of the pericardium, 
 
 824. 
 Humphreys: amputation of the tongue, 762. 
 Hunt, W. : treatment of wounds, 304. 
 Hunter, James B.: rectal etherization, 76. 
 Hunter, John: inflammation, 103; gaseous cvsts, 195; gonorrhoea, 209; anchylosis, 
 
 615. 
 Hurd : constitutional symptoms of phimosis, 1010. 
 
 Hutchison, J. C : treatment of hip disease, 629 : intestinal obstruction, 848. 
 Hutchinson: unity or dualism of syphilis, 227: syphilization, 241 ; acupressure, 331; 
 
 operation for phimosis, 102. 
 Hyrtl: sphincter ani tertius, 911. 
 
 Ingals: intubation of the glottis, 811 ; cystotomy, 939. 
 
 Ireland : snake-bites, 267. 
 
 Ituralde : treatment of anthrax, 402. 
 
 Jackson : scorpion-bites, 264 ; burns, 409. 
 
 Jackson, A. Reeves : hysterectomy, 1028. 
 
 Jacoby, G. W. : trigger-finger, 644. 
 
 Jeanes : treatment of bone disease, 508, 522. 
 
 Jernigen : Pott's fracture, 603. 
 
 Johnstone: synovitis, 623. 
 
XXV111 INDEX OF AUTHORS. 
 
 Jones: natural haemostatics, 317. 
 
 Jones and Sieveking : hypertrophy of the tongue, 761 ; hepatic abscess, 843. 
 
 Jordan, Furneaux: rhinoplasty, 737. 
 
 Joslin: stricture of the oesophagus, 798. 
 
 Jourdan : history of syphilis, 206. 
 
 Judson : rotary lateral curvature, 685. 
 
 Kafka : treatment of spermatorrhoea, 1015. 
 Kallenbach: boils, 401. 
 Keegan: litholapaxy in children, 981. 
 
 Keetley : amputation of the hip, 369; radical cure of hernia, 875. 
 Keith: chloroform, 78; value of antiseptics, 307. 
 Kella : treatment of tetanus, 493. 
 Kelsey : examination of rectum, 895. 
 
 Kenyon: treatment of gonorrhoea, 213; of gonorrhoeal rheumatism, 218. 
 Kershaw: muscular atrophy, 431. 
 
 Keyes : excision of the rectum, 913; lithotrity, 971 ; treatment of hydrocele, 999; va- 
 ricocele, 1004. 
 Kidd: treatment of uterine tumors, 1024. 
 King set t : peroxide of hydrogen, 311. 
 Kirkland : hepatic abscess, 841. 
 
 Kocher : healing of wounds, 304 ; subnitrate of bismuth as a dressing, 311. 
 Koehler : excision of the head of the femur, 718. 
 Kohn : use of india-rubber bandage, 45. 
 Kramer : pylorectomy, 854. 
 Kupper : Esmarch's bandage, 341. 
 
 Labbe and Coyne : innocent tumors of the breast, 831. 
 
 La Garde : oesophagotomy, 803. 
 
 La Mott : lacerated wounds, 258. 
 
 Langenbeek: treatment of aneurism, 453; radical cure of hernia, 876. 
 
 Lange: cholecystotomy, 840. 
 
 Lanyin : treatment of hydrocele, 997. 
 
 Lapponi: dislocation of shoulder, 674. 
 
 Laurie: medical treatment of hernia, 862. 
 
 Leal : statistics of tracheotomy, 807. 
 
 Le Cato : treatment of tetanus, 494. 
 
 Lemaine : carbolic acid, 66. 
 
 Lente : dislocation of the pubic bones, 653. 
 
 Leon: cancer of the uterus, 182. 
 
 Levis, B. J. : excision of the rectum, 913 ; bromide of ethyl, 78. 
 
 Liebold : pyaemic fever, 123. 
 
 Lippe : treatment of hypertrophy of the prostate, 987. 
 
 Lister : antiseptic treatment of wounds, 305 ; antiseptic ligature, 338 ; salaembroth, 314. 
 
 Lislon : heat in inflammation, 95 ; gangrene from ergot, 143; anchylosis, 615; fragili- 
 
 tas ossium, 527 ; application of the trephine, 725; operation for phimosis, 1011. 
 Little: talipes, 633. 
 
 Little: plaster-of-Paris splints, 540; artery forceps, 36; fractured patella, 600. 
 Lord : carbolic acid, 67. 
 Ludlam: vaginismus, 1048; causes of death after ovariotomy, 1091. 
 
 Macewen : supra-condyloid osteotomy, 641. 
 
 Macfarlane : nerve stretching, 497. 
 
 Mackenzie: ascites, 845. 
 
 MacLimont : treatment of cancer, 183; enucleation of cancer, 186. 
 
 Magill : burns, 406. 
 
 Malgaigne : classification of uterine tumors, 1022. 
 
 Marcet : hydrophobic symptoms, 262. 
 
 Markne : amputation at knee joint, 372 ; osteitis, 511 ; caries, 515 ; repair in wounds, 
 
 306. 
 Marsdenand MacLimont : treatment of cancer, 186; cancer of lip, 644. 
 Marsh: laparotomy, 848. 
 Marshall: cure of abscesses, 119. 
 Martin: necrosis, 521; hysterectomy, 1032. 
 
 Mason, Frskine: pulsating bony tumor, 533; Esmarch's bandage, 345. 
 Mason, F. W. : treatment of cleft palate, 757. 
 Mason, S. A.: transfusion of blood, 347. 
 
IXDEX OF AUTHOES. XXIX 
 
 Mastin : structure of the urethra, 946. 
 
 Matthews: inhalation of ether, 73. 
 
 McBurney : digital divulsion of the pylorus, 854. 
 
 McClelland: the uses of calendula, 113; nephrectomy, 927. 
 
 McDonnell : intra-venous injection of milk, 351 ; of cocaine, 86. 
 
 McGuire : excision of the os calcis, 707. 
 
 McKensie, Stephen : pressure in ascites, 845. 
 
 McLean, A. : removal of the lower jaw, 785. 
 
 McLean, Le Roy : oesophagotomy, 803; 
 
 McLellan : exostosis, 529 ; osteo-cystoma, 530. 
 
 Metcalf: diagnosis of hernia, 880. 
 
 Metcalf, F. J. : statistics of amputation, 360. 
 
 Meyer, Carl: electric illuminator, 58. 
 
 Michaux : perforating ulcer, 426. 
 
 Michel: ranula, 766; enucleation of cancer, 187. 
 
 Miller: ulcers, 131; enchondroma, 160; question of amputation, 353; treatment of 
 
 hydrocele, 997. 
 Miller ( U. S.) : snake-bites, 265. 
 Mills : spasmodic torticollis, 790. 
 Minor : uterine tumors, 1024. 
 Mitchell : rest after shock, 682. 
 
 Mitchell, Clifford : albuminoids in ovarian fluid, 1081. 
 Moore : treatment of Colles's fracture, 577. 
 Moore: treatment of cancer (quoted by Holmes), 180. 
 Morgan : treatment of hospital gangrene, 145 ; of shock, 490. 
 Morgagni : encysted dropsy of peritoneum, 1077. 
 Morris : burns, 409. 
 Morrison: lupus, 415. 
 Morton, T. G. : transfusion of blood, 350. 
 Mott: aneurism of the innominate, 458; fracture of the radius, 575; hare-lip, 741; 
 
 stricture of the oesophagus, 799. 
 Mouat: treatment of goitre, 795. 
 Mouchet : treatment of spina bifida, 684. 
 Moxon: classification of cancer, 173; periangioma, 436. 
 Muhlenbern : treatment of cancer, 182. 
 Munger : splint for fracture of the femur, 595. 
 Munde: hysterectomy, 1028. 
 
 Murdoch: removal of plaster-of-Paris bandages, 47. 
 Musser and IZeene: cholecystotomy, 839. 
 
 Napheys : formula for the treatment of ulcers, 135 ; of gangrene, 145. 
 
 Neftel: enucleation of cancer, 189. 
 
 Neidhardt : treatment of ovarian tumors, 1083. 
 
 Nelaton: pulsating bony tumors, 533. 
 
 Nev.-man : unstable kidney, 923. 
 
 Newmann, P.: stricture of the urethra, 951. 
 
 Nichols : taxis in hernia, 863. 
 
 Niciare : Esmarch's bandage, 342. 
 
 Nikolaus: traction in taxis, 864; galvano-cautery, 987. 
 
 Noeggerath : diagnosis of ovarian tumors, 1081; formation of ovarian tumors, 1071. 
 
 Norris : statistics of amputation, 362 ; non-union after fracture, 545. 
 
 Obetz, H. L. : whiskey as an anaesthetic, 76. 
 
 OFerrall: elephantiasis of the labia, 1050. 
 
 Ogston : splay foot, 647 ; genu valgum, 641 ; varicocele, 1005. 
 
 O' 'Neil : ingrowing toe-nail, 425. 
 
 Osgood : amputation of the scrotum, 1008. 
 
 Otis, F. N. : stricture of the urethra, 942 ; internal urethrotomy, 949 ; transmission of 
 
 syphilis, 226; cell accumulation in syphilis, 229 ; lithotrity, 971, 972. 
 Otis, G. A : concussion of the spine, 681. 
 Ozanam : treatment of hydrocele, 996. 
 
 Packard : primary anaesthesia, 79 ; dry suture, 250. 
 
 Paget: classification of tumors, 148; sanguineous cysts, 194; proliferous cysts, 196; 
 enchondroma, 159 ; bony tumors, 162 ; myeloid tumors, 149 ; incisions in the 
 treatment of anthrax, 402 ; cancer in bone, 531 ; loose cartilages in joints, 631 ; 
 elephantiasis of the labia, 1049. 
 
XXX INDEX OF AUTHORS. 
 
 Panas : treatment of rarmla, 766. 
 
 Par do : treatment of anthrax, 402. 
 
 Parker, Willard: perityphlitic abscess, 850. 
 
 Parsons : dislocation of the pubis, 653. 
 
 Pattison: enucleation of cancer, 187. 
 
 Pean: excision of the scapula, 705. 
 
 Pease: treatment of cancer, 182. 
 
 Peaslee: diagnosis between ascites and ovarian cysts, etc., 1075 et sequiter ; formation 
 
 of colloid, 1071. 
 Pepper: formation of colloid, 1071. 
 Perry : fissures of the anus, 909. 
 Peters : statistics of tracheotomy, 807. 
 Physick : animal ligatures, 338. 
 Piffard : treatment of lupus, 416. 
 PUcher : mechanism of Colles's fracture, 578. 
 Pirrie: pyaemia, 120; acupressure, 334. 
 Pollock : syphillis in bone, 518. 
 Polk : local anaesthesia, 86 ; nephrectomy, 925. 
 Pooley : gastrostomy, 852. 
 Poore : sacro-iliac disease, 645. 
 Popeau : elephantiasis Arabum,419. 
 Porak : hypodermic use of ergotin in epistaxis, 731. 
 Porter : treatment of enlarged tonsils, 769. 
 Post : Dupuytren's contraction, 435. 
 
 Pott : question of amputation. 354 ; inguinal hernia, 877. 
 Pribam : the urine in melanosis, 178. 
 Prince : plastic surgery, 394. 
 Prudden : action of carbolic acid, 307. 
 Purple : concussion of the spine, 681. 
 
 Pane : treatment of hydrocele, 996. 
 
 Payer : elephantiasis of the labia, 1049. 
 
 Reach : exstrophy of the bladder, 916. 
 
 Reid : treatment of aneurism, 449. 
 
 Peverdin : plastic surgery, 394. 
 
 Richardson : styptic colloid, 321 ; anaesthesia, 80. 
 
 Ricord : gonorrhoea, 209 ; chancroid, 221 ; chancre, 230. 
 
 Riedinger : employment of catgut in haemorrhages, 325. 
 
 Rindfleis.ch : cicatricial tissue, 102; exostosis, 162. 
 
 Roberts : treatment of aneurism, 445. 
 
 Robinson: treatment of epistaxis, 730. 
 
 Robison : treatment of tetanus, 492. 
 
 Roemer : ovarian tumors in the young, 1067. 
 
 Rokitansky : enchondromatous tumors, 160; formation of hare-lip, 741; hypertrophy 
 
 of the tongue, 761 ; hepatic abscess, 842; fibrous tumors of the uterus, 1021. 
 Roussel : apparatus for transfusion, 349. 
 Routh : encysted dropsy of the peritoneum, 1076. 
 Roux : hare-lip, 740; dangers of the operation, 742. 
 Ruggi : fungous synovitis, 613. 
 Ruppaner : treatment of enlarged tonsils, 769. / 
 
 Scdzer : anchylosis, 617. 
 
 Sampson: uterine tumors, 1024. 
 
 Sands: Esmarch's bandage, 342 ; laparotomy in obstruction of the bowels, 848 ; peri- 
 typhlitic abscess, 851 ; use of iodoform, 309 ; lithotrity, 971. 
 
 Savage: classification of tumors, 148. 
 
 Sawyer : treatment of fistula in ano, 905. 
 
 Sayre: treatment of sprains, 434; fracture of the clavicle, 560 ; subcutaneous osteot- 
 omy, 620; hip-joint disease, 623; tenotomy in talipes, 637; spondylitis, 686, 687 ; 
 excision of the hip, 717 ; scoliosis, 685. 
 
 Schneider: pyaemia, 128. 
 
 Schuh: excision of the rectum, 913. 
 
 Scriba : genuthrotomy, 615. 
 
 Scultetus : instruments for haemorrhage, 322. 
 
 Sedillot : treatment of the periosteum in necrosis, 524 ; the use of the trephine, 725. 
 
 Sequard : treatment of tetanus, 493. 
 
 Seyler: chemical constituents of pus, 110. 
 
IXDEX OF ATJTHOBS. XXXI 
 
 : reflex muscular atrophy, 431 : hip-joint disease, 626 : traction in talipes. 634, 
 
 Sharp: hemorrhage. 315. 
 
 Shears: classification of tumors, 150. 
 
 Sherry: keloid, 421. 
 
 Shrady : ligation of the lingual artery prior to amputation of the tongue, 765 ; false 
 
 joint. 548. 
 Simes: listerism, I 
 
 Simon : the inflammatory process, 87, 96. 
 Simpson : acupressure, 329. 
 
 treatment of hare-lip, 745 ; vesieo-vaginal fistula, 1043 : vaginismus, 104S ; 
 
 oophorectomy, lu34. 
 use of styptics. 320. 
 Smith. H. H. : treatment of false joint. 54S ; directions for the application of dressings, 
 
 43. 
 Smith [King's College : treatment of ganglion, 433. 
 Smith. N. : metallic snare, 336. 
 Smith, E. W.z fractures of the femur. r -7. 
 S i i ' . S '." ■ insect woun ds note . 259. 
 Smith, Stephen: dangers of Esmarch's bandage, 341. 
 Snelling : treatment of hydrocele, 845. 
 Snow : anaesthesia. SO. 
 
 Solly: pressure in the treatment of abscess, 119. 
 Southey : thoracic gradual drainage. B22. 
 
 Spence: septicaemia. 120 : injection of pus into the veins. 123 : fusiform aneurism, 463. 
 Spier : artery constrictor, 335 ; treatment of aneurism, 446. 
 Spohn: tourniquet. 327. 
 Stanley: rachitis, 525: removal of lower jaw, 786. 
 
 . treatment of cancer. 182. 
 Starr : suprapubic lithotomy, 965. 
 s . .?: artery clamping. 336. 
 Steel: statistics of pyaemia (Bryant), 125. 
 Stenn : pylorectomy, 854. 
 Stimpson : excision of the rectum, 913. 
 frtokes: treatment of syphilis, 239: Esmarch's bandage. 342. 
 
 :nnective tissue and leucocytes, 90; tissue metamorphosis, 93; swelling in 
 
 inflammation, 96. 
 Strisower: treatment of haemorrhoids, 899. 
 Syrne: excision of scapula, 705; restoration of lower lip, 751. 
 
 Tait : listerism. 305: ovarian tumors, 1066. 1073: cholecystotomy. B4t 
 
 Talbot : ingrowing toe-nail, 424 : tracheotomy. B 
 
 Talko : congenital cysts of the orbit. 194. 
 
 Taylor: hip-joint disease, 62; >25, 27. 
 
 Teale : modified acupressure. 336: rectangular flap amputation. 359. 
 
 Temneson: aspiration, j22. 
 
 Terillan : parovarian cysts, 1076. 
 
 Terry, M. 0.: treatment of carbuncle, 403: of sprains, 435: chronic prostatitis 
 
 ingrowing toe-nail. 425. 
 Tesstip: haemostatics. 321. 
 
 Teste: punctured wounds, 256; poisoned wounds. 264. 
 Theilhaber. exudation in hernial sacs, 863. 
 Thomas. C. M. : calendula, 312. 
 
 3, H. 0. : disease of the hip-joint, 626. 
 Thomas, T. G. : enucleation of fibroid tumors of the uterus, 1025; elephantiasis of the 
 
 labia, 1050; ovarian tumors. 1 
 Thompson : burns. 407 : gunshot wounds. 275. 
 Thompson] Sir Henry : phosphatic deposits, 954 ; lithotrity, 971 ; hypertrophy oi the 
 
 prostate, 9S5 ; tumors of bladder, 982. 
 Thompson, John: phimosis, 1010. 
 Thompson, J. H. : chapter on dressing wounds, 291. 
 Thorer: preparation of calendula, 112. 
 Tiffany: naso-pharyngeal polypus, 736. 
 
 Tillaux : torsion in haemorrhage, 325 ; dislocation, 64S ; dislocation of shoulder. 673. 
 Todd xnd Bowman : hare-lip, 741. 
 Trovers : fractures of the acetabulum, 568. 
 Trelat : lymphadenoma, 506. 
 
XXX11 INDEX OF AUTHOES. 
 
 Trevan: lithotrity, 971. 
 
 Treves: excision of knee, 714. 
 
 Tufnell : diet, with rest, in the treatment of aneurism, 444. 
 
 Ulrich : excision of the humerus, 704. 
 
 Van Bur en : amputation at the hip-joint, 368 ; treatment of aneurism, 448; lithotrity 
 971 ; American method of treating fractures, 495 ; excision of the rectum, 913. 
 
 Vander Poel, S. 0. : gonorrhoea, 21 1 . 
 
 Van de Warker : trachelorraphy, 1065. 
 
 Van Gieson : sectional ligature, 336. 
 
 Veiel : elephantiasis Arabum, 419. 
 
 Velpeau : fracture of the lower jaw, 552 ; Colles's fracture, 575 ; hare-lip, 740, 741 ; 
 suprapubic lithotomy, 962. 
 
 Verebelyi: congenital club-foot, 639. 
 
 Verneuil: gastrotomy, 852. 
 
 Vielinghoff : treatment of cancer, 182. 
 
 Villeneuve : puncture of the pericardium, 824. 
 
 Viluyskin: separation of the sacro-iliac symphysis, 654. 
 
 Virchow : suppuration, 109; thrombosis, 479. 
 
 Vogel: steatomata, 156. 
 
 Vogt : traumatic tetanus, 494. 
 
 Volkmann : excision of the knee, 713 ; antiseptics varied in wounds, 306. 
 
 Von Bruns: extirpation of the larynx, 818. 
 
 Von Nussbaum .* antiseptic method in hospital gangrene, 147 ; treatment of shock, 490 ; 
 fracture of clavicle, 566. 
 
 Wagstaffe : shock after injuries, 489. 
 
 Walker, H. C. : litholapaxy, 978. 
 
 Warren, Joseph H. : radical cure of hernia, 873. 
 
 Warren, J. Mason : myeloid tumors, 169; treatment of hare-lip, 741 ; of hydrocele, 
 
 997 ; ether anaesthesia, 71 et seguitur. 
 Watson, B. A. : skin grafting, 138. 
 Watson, E. : antiseptic ligature, 339. 
 Waxham: intubation of the glottis, 811. 
 Webb : amputation of the scrotum, 1007. 
 Weber: perityphlitic abscess, 850. 
 Weir: antiseptic treatment of wounds, 339; artificial ischaemia, 341; carbolized jute, 
 
 41 : rectal etherization, 76 ; treatment of aneurism, 451 ; nephrectomy, 924. 
 Weiss : bullet forceps, 284. 
 Went: cough impulse, 861. 
 Wheelock: hermaphrodites, 922. 
 
 White : spontaneous cure of vesico-vaginal fistula, 1046. 
 White, J. William : dislocation of tendons, 428. 
 
 Whitehead : amputation of the tongue, 765; stricture of the rectum, 908. 
 Wilks : phosphorus necrosis, 781. 
 
 Willard: calendula as a vulnerary, 113; resection of shoulder, 705; flexion of bones, 544. 
 Williams : synovitis, 610. 
 Wilson: fragilitas ossium, 527. 
 Winslow : pylorectomy, 854. 
 Wolf: stricture of the oesophagus, 798. 
 Wood, H. C : muscular atrophy, 430. 
 Wood, James R. : removal of lower jaw, 785. 
 Wood, John: radical cure of hernia, 875. 
 Woodbury : treatment of urethral excrescences, 1052. 
 Woolston : discovery of anaesthesia, 72. ' 
 Wright: comparative length of the lower limbs, 588. 
 Wulsberg : transfusion of milk, 350. 
 Wurmb : epithelioma, 748. 
 Wyeth : instruments for excision, 696. 
 
 Young : glycerine in internal haemorrhoids, 900. 
 Younghusband : treatment of hospital gangrene, 145. 
 
 Zesas: enterectomy, 834. 
 
 Ziegler : sponge grafting, 138; chemistry of ovarian fluids, 1081. 
 
 Ziemssen: encysted dropsy of the peritoneum, 1076; treatment uterine tumors, 1026. 
 
A SYSTEM OF SURGERY, 
 
 PAET I. 
 
 MINOR AND PRELIMINARY SURGERY. 
 
 CHAPTER I. 
 
 Cleanliness — Instruments— Ligatures — Various Articles used in Dressing — 
 Tents — Incisions — Hypodermic Medication — The Aspirator — Paquelin's 
 Thermo-cautery — Galvano-puncture— Galvano-cautery — Electrolysis. 
 
 There is nothing that more clearly indicates the accomplished surgeon, 
 than the neatness and precision which mark the minor points of his 
 operations. The handling of instruments, the application of bandages and 
 straps, the introduction of sutures, and the quiet self-reliance resulting from 
 a thorough knowledge of what has to be done and " how to do it," imme- 
 diately show to the critical observer the skill and experience of the operator ; 
 while the absence of one or more of these essentials as pointedly indicates 
 the man of limited experience and clumsy fingers. There is as much 
 difference between the surgical performances of different surgeons, as there 
 is between a well-conducted dinner party and a hurried luncheon in a rail- 
 way station ; the one all regularity, precision, and satisfaction ; the other, 
 all hurry, irregularity, and confusion. Attention, therefore, to minor sur- 
 gery should always be encouraged, because a successful treatment of casu- 
 alties, as well as other surgical cases, can be accomplished only by a skilful 
 application of the varied apparatus which have been contrived and intro- 
 duced within the province of surgery. Much practice is required before 
 that degree of neatness, promptness, and carefulness are attained, which 
 are essential components in the character of a good surgeon. 
 
 The first requisite, and one that I cannot too strongly impress upon the 
 student and the operator, is cleanliness. Cleanliness of the person of the 
 surgeon, especially of his hands, cleanliness of the instruments, cleanliness 
 of the table, cleanliness of the patient. I have seen a room in which an 
 operation has been performed, that resembled more the shambles of a 
 butcher than the residence of a human being ; blood was everywhere, — over 
 the operator, over the assistants, and over the patient, and under him too ; 
 soiled towels and dirty sponges were lying around in confusion ; basins 
 full of bloody water were standing here and there ; bloody knives, forceps, 
 and needles had been thrown upon the stained tables and there remained, 
 and, in fact, the whole appearance of the apartment was one of disorder, con- 
 fusion, and blood. This need not be so, and as the surgeon gains experi- 
 ence and self-reliance, he will not permit it to be so. By having an assistant 
 ready to take each instrument from the operator, wipe it, and replace it in 
 the pan containing the disinfecting fluid, and by having competent nurses 
 to remove soiled towels and napkins, and by the surgeon seeing that during 
 the performance of the operation the patient is sponged and kept clean, — a 
 
34 A SYSTEM OF SURGERY. 
 
 severe surgical operation can be carried through its several steps with such 
 neatness and cleanliness, that it will be a pleasure to all beholders. 
 
 The apparatus of dressing consists of two parts, one of instruments for, 
 and the other the pieces of, dressing. 
 
 Instruments. — Of late j^ears the number of instruments has multiplied so 
 largely, and they are so well adapted to the ends for which they are con- 
 structed, that but few of them can be mentioned here. In the ordinary 
 pocket-cases of the day, we have a good variety of instruments, not only 
 for dressing all ordinary wounds, but for performing the minor operations. 
 
 Probes. — Of all the instruments the surgeon uses, in none is the tactus 
 eruditus so much needed as in handling the probe. Delicate and pliable, 
 it should be constructed of silver or gold, a metal that will not corrode, and 
 should have a blunt and somewhat rounded head at one extremity, at the 
 other it should possess an eye for the introduction of threads, wires, or 
 sutures. (Vide Fig. 1.) The probes used in gunshot wounds should be 
 
 Fig. 1. 
 
 larger, heavier, and stronger than those in the ordinary pocket-cases, and 
 may be constructed with porcelain imbedded in one end, as the celebrated 
 probe of Nelaton, which detected the ball in Garibaldi's wound. The greatest 
 gentleness and caution are necessary in the passage of the probe, and time 
 and practice are required before the instrument can be skilfully used. 
 
 Directors. — These, as the name implies, are instruments which direct the 
 course of the knife. They are generally constructed of steel, and are of 
 larger calibre than a probe, having a tolerably broad groove on the one 
 side. (Fig. 2.) In delicate operations the instrument is slid underneath 
 
 Fig. 2. 
 
 £3— 
 
 different structures, and the probe-pointed bistoury being used, the parts 
 are divided without endangering those beneath, or taking the edge from 
 the knife. In hernia?, in operations for the ligation of arteries, especially 
 about the neck ; in delicate dissections of parts lying over important and 
 vital structures, the director is a most indispensable instrument. The 
 handle of the director is flat, and contains a slit, which, with a little manipu- 
 lation, can be used as a wire-adjuster in the closing of wounds; or, as is 
 often found in the French cases, the extremity is flattened out into a spatula 
 containing a groove, wdiich was introduced by Vidal, and which is useful 
 
 in hernias. 
 
 Fig. 3. 
 
 * «?■---' 'G>:w^sNv>v*i-c.g>" 
 
 Scissors. — It is scarcely necessary to describe this instrument, it is so well 
 known. There are several varieties ; curved (Fig. 3), flat, and angular 
 (Fig. 4), which must be used at the discretion of the operator. In opera- 
 tions where there is not much thickness of structure to cut through, where 
 mucous membrane has to be pared, or removed, scissors are preferable to 
 the knife ; but if the parts are of any thickness, they are liable to be bruised 
 
INSTRUMENTS. 
 
 35 
 
 and torn by scissors ; the scalpel or bistoury is, therefore, much to be pre- 
 ferred. 
 
 Fig. 4. 
 
 Forceps. — There are many kinds of forceps used for different purposes. 
 Forceps are constructed to answer the place of the forefinger and thumb of 
 the right hand of the operator. Thus we have the dressing forceps (Fig. 5), 
 which resembles an ordinary scissors, with the exception of the blades, 
 
 Fig. 5. 
 
 which are flat, blunt, and serrated ; it is useful in removing foul or soiled 
 bandages ; in lifting the straps away from ulcers and wounds, and to draw 
 away sloughs, thus preventing fetid and irritating discharges from contact 
 with the surgeon's hands. Forceps should always be used in such cases. 
 
 Dissecting Forceps. — These forceps are entirely different in shape from the 
 former, bearing more resemblance to a pair of tweezers. They are made 
 with a spring, which holds the blades apart, except when compressed by the 
 finger and thumb of the operator. This instrument is used in lifting skin 
 and tissues to be dissected, in picking up minute portions of dressing, etc. 
 
 Needle Forceps (Fig. 6) are of several varieties, and are closed with a slide 
 or a spring. They mostly have a depression in which to fix the head of a 
 
 pin, and when the blades are brought together and fixed, they give a greater 
 leverage, and are very serviceable in passing the pins or needles through 
 
 Fig. 7. 
 
 Russian Needle Forceps. 
 
 the tissues. The forceps for needles which I prefer in all cases is that 
 known as the Russian needle forceps (Fig 7), invented by Dr. Anatol De 
 Gaine, of St. Petersburg. 
 
36 
 
 A SYSTEM OF SURGERY. 
 
 There are besides, artery forceps (Fig. 8), bull-dog forceps, tumor forceps, 
 bullet forceps, and many others, all devised for catching and holding parts 
 which are beyond the reach or manipulations of the fingers. 
 
 Fig. 8. 
 
 The best artery forceps are those known as Wood's (vide Fig. 9) haemo- 
 static forceps, which are used almost exclusively on the continent. Dr. 
 
 Fig. 9. 
 
 Wood's Forceps. 
 
 Little,* of New York, has invented an excellent instrument (Fig. 10), which 
 combines the jaws of the old-fashioned forceps, with the catch-handles of 
 
 Fig. 10. 
 
 Little's Haemostatic Forceps. 
 
 the European forceps. Fig. 11 represents Paen's forceps, which have 
 heavier jaws, and securely hold the tissues grasped. 
 
 Fig. 11. 
 
 Paen's Haemostatic Forceps. 
 
 Dr. Bigelow has also invented a valuable forceps (see Fig. 12). The 
 
 * International Journal of Medicine and Surgery, March 1st, 1881. 
 
INSTRUMENTS. 
 
 37 
 
 operator seizes the artery, closes the forceps, and by slightly moving the 
 button forward, locks the jaws. The ligature is then placed around the 
 
 Fig. 12. 
 
 Fig. 16, 
 
 Bigelow's Forceps. 
 
 blades and partially tied. By pressing forward the button, the 
 small hook will push off the loop from the blades upon the 
 artery and the second knot is tied. 
 
 Fig. 13. 
 
 Knives. — These are of very many varieties and all manner 
 of shapes. The scalpel (Fig. 13) is a short knife having a 
 broad belly, rounded cutting edge, and a straight back. A 
 
 Fig. 14. 
 
 bistoury has a longer and much narrower blade than the 
 scalpel, and is made in various shapes. Fig. 14, c, represents 
 a straight bistoury; Fig. 14, a, a curved sharp-pointed bistoury. 
 
 Fig. 15. - 
 
 Fig. 14, 6, shows a curved probe-pointed bistoury. There are also straight 
 probe-pointed bistouries, all of which are found in the pocket-case. 
 
38 
 
 A SYSTEM OF SURGERY. 
 
 The scalpel and bistoury are, for convenience, often placed in the same 
 handle (Fig. 15). 
 
 The Exploring Trocar (Fig. 16) is one of the most needful instruments 
 that the surgeon holds in his possession. It may also become, in inexperi- 
 enced hands, a very dangerous one. It must be used to assist diagnosis, to 
 explore tumors, especially of the fluctuating kind. It consists of a long 
 needle having a sharp point, which fits into a fine silver canula. Its inser- 
 tion is easily accomplished. 
 
 The Tenaculum (Fig. 17) is a sharp hook which is set in a handle, to catch 
 bleeding vessels and draw them forward, in order that the ligature may be 
 applied. It is especially serviceable in taking up arteries of small calibre. 
 
 Fig. 17. 
 
 6 TIEMANN-CO.NM 
 
 Catheters, both male (Fig. 18) and female, are also to be found in the cases, 
 and for portability, are arranged to unscrew. The male or female end may 
 thus be joined to the straight portion of the catheter. The methods of 
 
 Fig. 18. 
 
 catheterism and the construction of the instrument according to rules, will 
 be mentioned in the chapter on that subject. 
 
 Ligature Thread. — The silk that is now mostly employed by surgeons, is 
 that known as " braided," which comes of varied calibre, and does not kink 
 or twist, and is possessed of great strength. The manner of its carbolization 
 is described in the chapter upon wounds and the method of dressing them. 
 Antiseptic silk for ligatures and sutures can be procured at all the cutlers, 
 as can the different sizes of gut. 
 
 There is also an excellent article known as Surgeon's pure iron dyed silk, 
 manufactured by Snowden, of Philadelphia. This surgical silk is jet black, 
 and has received the especial sanction of Professor Pancoast, and comes in 
 sizes from No. 1 to No. 14 (see Fig. 19). No. 1 is very delicate, and No. 14 
 
 Fig. 19. 
 
 is very strong. The last number Dr. Pancoasc uses for varicocele and in 
 strangulating good-sized bleeding masses. Nos. 2, 3, and 4 he employs for 
 hare-lip, and Nos. 1 and 2 for plastic operations. This latter thread has 
 been allowed to remain in the tissues for weeks. 
 
 For further information on this subject, the student may refer to the 
 chapters above named, and to that on Haemorrhage in another part of this 
 volume. 
 
LIGATURES. 
 
 39 
 
 Another most excellent article is that known as plaited satin sewing silk, 
 which has great advantage over the twisted silk. It always remains beau- 
 tifully smooth (Fig. 20) and never twists (Fig. 21). 
 
 Silk-worm gut is also an excellent form of animal ligature, and is highly 
 spoken of by some authorities. I have not used it often, as the whale 
 tendon and catgut have afforded sufficient satisfaction. 
 
 Whale Tendon Ligature.— I cannot close this portion of the subject without 
 a word on the whale tendon ligature introduced by Ishiguro, chief surgeon 
 of the Imperial Japanese army. The strength of this thread is remarkable. 
 
 Fig. 20. 
 
 Fig. 21. 
 
 The Plaited Satin Sewing Silk 
 
 The Ordinary Twisted Silk. 
 
 A weight of 4 pounds 4 ounces was suspended on a strand 1 meter in length 
 and 0.18 gram in weight (3 grains), but it was not broken. 
 
 The ligature was soaked in a solution of pepsin (2 drachms), dilute hydro- 
 chloric acid (1 drachm), and water (5 ounces), and then kept at the tempera- 
 ture of the body for twenty hours, but showed not the least sign of dis- 
 solution. 
 
 It was tested likewise by soaking in acetic acid and lactic acid (both in a 
 diluted state), and also in liquor potassee, — in all of which cases the strength 
 of the ligature was proved by like* results. The soaking lasted from five to 
 six days, but no dissolution took place. 
 
 The first actual trial was made upon a patient for whom excision of the 
 femur was necessary. In this case one of the ends of the ligature was cut 
 off, close to the knot, while the other was left hanging out of the wound. 
 After the lapse of seven days, an examination was made, and it was found 
 that not the least trace of the ligature was to be detected. Subsequent trials 
 proved that three days after the application were sufficient for the full 
 absorption of this ligature. 
 
 The same experiment was made on the femoral of a dog. On examina- 
 tion five days afterwards, it was found that the ligature had exercised its 
 full power on the vessel, while there was not the least trace of it remaining 
 in the body ; the whole of it having been absorbed by that time. 
 
 Messrs. Stohlmann & Pfarre have these ligatures on hand and it was from 
 them that I procured my supply. 
 
40 
 
 A SYSTEM OF SURGERY. 
 
 Needles. — These are made straight, curved at the points, or curved in the 
 body, with either round or two-edged, or bayonet-shaped points (Fig. 22). 
 
 Fig. 22. 
 
 They vary much in size and shape. The eye is oftentimes placed in the 
 point of the needle, which may be set in a permanent handle (Fig. 23), or 
 used with a needle-holder. 
 
 The needles which I prefer are not those in general use, such as are seen in 
 the figure, but those which are round and firm, with a bevelled and slightly 
 
 Fig. 23. 
 
 curved point, made after the fashion — only much larger in size, than those 
 devised by Dr. Emmet for repairing lacerations of the cervix. Different 
 shaped needles and holders will be found described in the chapter on wounds. 
 
 There are very many other instruments, some of which display great 
 ingenuity, which are mentioned in the chapters treating upon the various 
 surgical operations. To arrange them here would cause unnecessary repe- 
 tition. 
 
 Articles for Dressing. — The articles mostly used for dressing are lint, 
 charpie, marine lint, antiseptic cotton, tow, bran, wood wool, compresses, 
 bandages, adhesive straps, etc., etc. 
 
 Lint. — There are two varieties of this substance : one made by the manu- 
 facturer — patent lint — and coming in packages, procurable from the pharma- 
 ceutist and instrument maker. It is a soft, delicate, pliable mass, consisting 
 of linen, the transverse threads of which have been drawn out by ma- 
 chinery, leaving the longitudinal threads covered by a cottonous substance, 
 which is extremely soft. The second, or scraped lint, is made by scraping 
 a piece of linen cloth, and taking off the soft substance which is thus pro- 
 duced. This is also known as domestic lint, and can be made in a short 
 time. It is, however, at present but little used, being superseded by the 
 manufactured articles for dressing, which, for their cheapness and adapta- 
 bility, are superior to the scraped material. 
 
 Marine Lint is now in great favor among many surgeons. It is prepared 
 of oakum, which is tow saturated with tar, made by picking out the fibres 
 of old tarred ropes. The favor which this dressing has met, has induced 
 the preparation of the substance especially for surgical purposes. It comes 
 in packages, and is called marine lint. It possesses both the antiseptic and 
 astringent properties of the tar acids which it contains, and though of rather 
 
CHARPIE — CARBOLIZED JUTE. 41 
 
 coarse fibre makes a good dressing. I have used it as cushions on which 
 to place stumps after amputation, and have dressed many wounds with it. 
 It is applied to the parts and kept in situ by means of the roller bandage. 
 
 Charpie. — This article is nothing more than the threads of old linen 
 unravelled. A piece of linen should be cut about four or five inches square, 
 and both longitudinal and transverse fibres should be drawn out. It has 
 been asserted that this substance, when made of new linen, acts as a better 
 absorbent than that of the old, but the softness of the latter renders it 
 preferable. 
 
 Charpie is made into many forms by rolling and twisting it in different 
 ways ; thus there is the roll, the tent, the pledget, tampon, pellet, and others. 
 
 A pledget is nothing more than a mass of charpie, which is made smooth 
 on the surface, and by turning underneath or trimming the edges, is given 
 the shape which is most desired. It can, with a little experience, be moulded 
 by the hands into almost any form. 
 
 The roll is composed of a smaller mass of charpie, rolled into the form of 
 a cylinder, the fibres all running in a longitudinal direction, and then being 
 tied in the middle. The roll is useful for absorbing pus in deep wounds 
 and arresting haemorrhages. 
 
 The tent is a conical form of charpie, made by doubling the roll and 
 twisting the free ends to a point ; it is generally used as a dilator. 
 
 Bullets, tampons, pellets, are masses of charpie, generally circular in form, 
 and are chiefly used for the suppression of haemorrhage and the absorption 
 of pus. 
 
 Since the introduction of the varied forms of antiseptic cotton and gauze, 
 the old-fashioned charpie is scarcely ever seen, yet it is a good dressing 
 for all, and can be made readily when other appliances are not at hand. 
 
 Cotton, from its cheapness, its softness, and its pliability, is much used in 
 dressing, especially fractures. It is most excellent in padding splints. It 
 has been used as a direct application to wounds and ulcers, and in some 
 instances with great advantage. 
 
 Absorbent cotton now is in general use by all surgeons, indeed by many, it 
 is used in preference to sponges, especially in those operations in which the 
 blood-flow is moderate. For mopping out wounds, wiping abraded surfaces, 
 the construction of pledgets, tents and rolls, particularly if local medication 
 be desired, absorbent cotton is preferable to any other of the substances 
 used in dressing. 
 
 Antiseptic cotton which is either borated, carbolated, thymolized, listerized, 
 or prepared with corrosive sublimate, makes excellent dressings. 
 
 Carbolized Jute (Corchoris Capsularis). — This substance can be procured 
 already manufactured, but for those who desire to prepare it for themselves 
 the following formula is recommended by Dr. R. F. Weir.* 
 
 For 1 pound = 500 grams of jute. 
 
 50 grams = ^xiij of carbolic acid. 
 200 grams = £i of resin. 
 250 grams = ^lxij of glycerin. 
 550 grams = ^cxxxviij of alcohol. 
 
 Mixed as follows : The finely pulverized resin is dissolved in alcohol by 
 applied heat ; after cooling, the carbolic acid which is dissolved in the re- 
 maining portion of the alcohol is added, and after, the glycerine. The 
 solution is poured then on the jute and worked up with it thoroughly, so 
 as to moisten all its fibres ; it is then carded and put to dry, taking about 
 
 * Am. Journal of the Medical Sciences, April, 1879, No. cliv., New Series. 
 
42 A SYSTEM OF SURGERY. 
 
 four hours and is ready for use in from twelve to eighteen hours after. 
 During its various trials it has fully met all the requirements of an anti- 
 septic dressing, and is now in use in place of the carbolized gauze. 
 Another formula, using benzine instead of alcohol, is as follows : 
 
 For 1 pound (or 7000 grains avoirdupois) of jute — 
 
 Take : Crystallized carbolic acid, 700 grains. 
 
 Paraffin, 700 grains. 
 
 Resin, 2800 grains. 
 
 Benzine, 3 pints. 
 
 Notwithstanding the great economy used in the last, yet the former for- 
 mula (Miinnich) is recommended. 
 
 Tow comes, also, prepared for surgical use, and, when properly cleaned 
 and sorted, makes a fair dressing. 
 
 Bran. — This cleanly article of dressing was introduced by Dr. J. Rhea 
 Barton, of Philadelphia. In many cases of compound fracture, or after 
 operations, where much suppuration is expected, bran applied in the 
 fracture-box, or in junk bags, is all that can be desired. It is cheap and 
 easily obtained, and readily carbolized or rendered antiseptic. 
 
 Sawdust is sometimes used for packing in fracture-boxes. 
 
 Wood Wool. — A very excellent dressing, not only for absorbent but for 
 antiseptic purposes, is known as wood flour or wood wool. It is made of 
 the very finest sawdust from scroll and other kinds of very fine sawing. 
 It is light, cheap, and useful in many ways. That which I have used has 
 been prepared for me by C. Am. Ende, of Hoboken, N. J. 
 
 Compresses are formed of pieces of cotton or linen cloth folded in various 
 ways to best suit the requirements of each particular case. They are used 
 to make and to equalize pressure ; to prevent abrasion ; to separate surfaces, 
 and to fulfil other indications. They have received various names according 
 to the shapes in which the cloth is folded. 
 
 A perforated compress, as its name implies, consists of a pad or many 
 folds of cotton or linen cloth, in which several perforations are made. These 
 compresses are sometimes made of hair, or wool, or moss, and covered with 
 muslin or linen. To relieve parts from pressure, as in the case of bed-sores, 
 and allow a free vent for discharges, this variety of compress is very useful. 
 It is sometimes made of india-rubber, and can readily be inflated with air. 
 
 A graduated compress is one which has a broad base and small apex, and 
 resembles a prism. This variety of compress is useful in dressing fractures 
 of the leg and forearm, to separate the bones before the bandage is applied. 
 
 The pyramidal compress " is one that is accurately formed by placing 
 square pieces of muslin, gradually decreasing in size, on top of each other, 
 and stitching them together to form a pyramid. It may also be made 
 by folding a piece of two and a half inch bandage on itself, to form a 
 pyramid graduated from end to end, and then placing a piece of cotton, or 
 other substance, in the centre of the last turns. Thus formed, it is very 
 useful in making pressure upon certain points, as in cases of haemorrhage 
 from the deep-seated vessels of the leg or forearm." 
 
 Plasters and Straps.— The old-fashioned adhesive plaster is still used, but 
 has very many disadvantages, so many indeed, that it is fast disappearing 
 from the armamentarium of the surgeon. It spoils in warm weather and 
 warm climates ; it cracks and peels off when old ; it requires a certain 
 degree of heat to soften it (sometimes when old no degree of heat will do 
 it) ; it often slips and becomes black with the contact of pus and discharges. 
 
 To obviate these disadvantages many plasters have been introduced to 
 the profession. The two, however, which are especially superior, and which 
 I use exclusively in my own practice, are those made by Seabury and 
 
DRAINAGE TUBES — TAR. 43 
 
 Johnson, New York. The one is known as the salicylated india-rubber plaster, 
 which comes in rolls and spools of different widths, and possesses a great 
 advantage in the fact, that it tears straight, not requiring scissors, and that no 
 artificial heat is necessary to make it adhere to the skin. The other plaster 
 is that known as " Mead's adhesive plaster" which, from its flexibility, its 
 antiseptic, water-proof, and non-irritating qualities, render it a most supe- 
 rior article. In those cases where extension is to be applied (as in the 
 treatment of fractures, the application of splints for hip disease, etc.), it is 
 decidedly the best in use, as it so adapts itself to the contour of the parts, 
 that there is little likelihood of its slipping. 
 
 The preparation of the varied carbolic acid solutions, the protective, the 
 antiseptic gauze, the carbolic spray, the Mackintosh, drainage-tubes, catgut, 
 antiseptic silk, sponges, and carbolized oil, is described minutely in the 
 chapter on the " Varied Methods of Dressing Wounds." The newer articles 
 introduced for dressings will be found in the chapter on " The Present Status 
 of Antiseptic Surgery." 
 
 Drainage Tubes, of which mention is also made in the chapter upon the 
 " Various Methods of Dressing Wounds" are usually made of india-rubber 
 tubing of varied lengths and calibres, in proportion to the size of the cavi- 
 ties into which they are to be placed. Ordinary india-rubber tubing, care- 
 fully rendered antiseptic, and with holes in the circumference about half an 
 inch apart, is always serviceable (Fig. 24). Sometimes a few horsehairs 
 make a good conduit, but for true antiseptic treatment, those drainage-tubes 
 
 Drainage Tube. 
 
 called decalcified bone tubes, rendered thoroughly antiseptic by being kept 
 in carbolized oil, surpass everything of the kind in use. These tubes 
 are prepared by C. Am. Ende, of Hoboken, and are securely packed in 
 bottles of carbolized olive oil. They are prepared chiefly from the leg-bones 
 of fowls. These bones after being thoroughly cleansed are steeped in an 
 acid solution of strength sufficient to. dissolve the calcareous element, thus 
 leaving a tube of pure animal cartilage, which is readily absorbed. 
 
 The satisfaction on removing a dressing (say, an amputation of the thigh) 
 that has remained unsoiled for sixteen days, and finding sutures and 
 drainage-tubes altogether absorbed, and the entire wound healed by first 
 intention, is very great to the surgeon, particularly when he compares the 
 new with the older and more disagreeable methods of dressing wounds. 
 
 Tar. — Dr. George A. Hall, of Chicago, is very partial to a dressing called 
 tar plaster, which is made as follows : 
 
 Pure refined gypsum, pounds 2. 
 
 Oil of tar, ijii. 
 
 Larger quantities in same proportion. 
 
 Triturate well in an iron or porcelain mortar, adding the materials in small 
 quantities, and triturating until mixed so thoroughly that when placed 
 upon a marble slab and smoothed with a spatula, no dark spots or streaks 
 can be seen ; then place in an air-tight dry tin or earthen can, and keep in 
 a dry place. The mixture will, in this form, keep any length of time, and 
 always be ready for use. 
 
44 A SYSTEM OF SURGERY. 
 
 Directions for its Use. — Place a spoonful or more, according to the quantity 
 required for use at one time, upon an earthen plate or marble slab, and with 
 a spatula or knife, mix " olive oil " or " cotton-seed oil " with the powder until 
 it becomes the consistency of cream ; spread upon surgeon's lint and apply 
 to the surface intended. Dr. Hall mentions the following as the cases in 
 which he has found the plaster most serviceable : " All suppurating surfaces, 
 where it is desirable to promote healthy granulation; in indolent ulcers; in 
 burns, after sloughing begins ; in all open wounds after operations where the 
 parts are required to heal by second intention. In our hospital, as well as 
 private practice, I have found it a most valuable dressing. It possesses 
 aseptic and antiseptic properties, and being an inexpensive article, renders 
 it especially applicable for hospital practice. The parts should be well 
 dried before it is applied. To avoid the plaster coming in contact with the 
 integument outside of the wound, surround the raw surface with plaster." 
 
 Rules. — The following rules for dressing are laid down by Dr. Smith, 
 and cannot be too strictly observed by the young practitioner, as they 
 not only promote to a great degree the comfort of the patient, but also 
 facilitate the process of the removal of the old, and the application of new 
 dressings : 
 
 " 1st. Let the surgeon make, or see made, everything that is requisite for 
 the new dressing before removing the old one. 
 
 " 2d. Let him have a sufficient number of capable aids, to whom special 
 duties shall be assigned before commencing the dressing, as this prevents 
 confusion. Thus, in dressing a stump, or wound, there should be one 
 assistant to support the limb ; another to furnish hot water, and change it 
 as required, heat the adhesive strips, etc., etc., by which means the surgeon 
 can give his attention wholly to his own duty. 
 
 " 3d. Let him arrange the bed, as a general rule, after the dressings are 
 changed ; or, if in a case of fracture, before the patient is placed on it. 
 
 " 4th. Let the position of the patient be such as will cause him no un- 
 necessary fatigue. 
 
 " 5th. Let the surgeon, as a general rule, place himself on the outside of 
 the limb, with his face to the patient, as this will give more freedom to his 
 movements, and prevent accidental jars. 
 
 " 6th. Let all the assistants be especially careful to guard against hasty 
 and inconsiderate movements, in order to prevent unnecessary pain to the 
 patient." 
 
 The Bandage. — This is generally the single-headed roller, and should be 
 three inches in width and three or four yards in length. It is a bandage 
 of these dimensions that fulfils most readily the indications, viz., the exer- 
 tion of uniform pressure over the affected part, the prevention of spasmodic 
 action, and at the same time to support other dressings. Great care should 
 be taken to apply the roller regularly over the part, exerting about equal 
 force on every circular and reverse turn. If the fracture be of the compound 
 variety, then the bandage of Scultetus (see page 47) may be employed, as 
 by its use the wounds may be examined and dressed without disturbing the 
 fragments, whenever occasion may require. It may be useful here to speak 
 of the proper method of making the roller. 
 
 Having prepared the strip of cloth, — unbleached muslin which has been 
 washed and ironed being preferable, — fold the end of it eight or ten times 
 firmly upon itself, in order that an axis upon which the roller is to be re- 
 volved be made ; then with the left hand holding this axis, which is placed 
 upon the right thigh, the palm of the right hand, slightly moistened, is 
 applied and the bandage rolled tightly ; by a little practice a good firm 
 roller may thus be made in a very short time. Or, another method is to 
 take up the cylinder, after a few turns have been made upon the thigh, and 
 
THE BANDAGE. 
 
 45 
 
 Fig 
 
 hold it between the thumb and forefinger of the left hand, allow the strap 
 to pass over the right forefinger, and by seizing the roller with that 
 hand, and turning it with the left the 
 manipulation is completed. (See Fig. 25.) 
 In applying the bandage, every suc- 
 ceeding turn should, at least, overlap 
 the one immediately below it, and where 
 there is the slightest inequality of sur- 
 face, the reverse turns must be made. 
 There is quite a knack in doing this 
 nicely, but it may be accomplished as 
 follows : 1. Place the initial end of the 
 bandage on the limb, and hold it there 
 by the thumb of the left hand until, by 
 a turn or two of the roller, there is no 
 possibility of slipping. 2. Gradually 
 ascend upon the limb until there is an 
 enlargement to be covered, which is 
 effected: 3. By placing the thumb or 
 two fingers of the left hand on the point 
 where the reverse turn is to be made, 
 and holding it firmly there. 4. Loosen the long end of the bandage which is 
 held in the right hand, and with a turn of the wrist the reverse is made. 
 (Fig. 26). 
 
 Fig. 26. 
 
 These bandages can be made with quickness by the simple apparatus as 
 seen in Fig. 27, which screws to the table, or Fig. 28, which is made of brass. 
 
 The single-headed roller is nothing more than the bandage rolled upon 
 itself. 
 
 The double-headed roller is a bandage rolled from both extremities until 
 the cylinders meet. 
 
 The spica bandage is made with the single-headed roller, and consists in 
 applying it in such manner that it shall ascend or descend upon the parts 
 to be covered. The directions for its application are the same as making 
 reverses, as shown in Fig. 26. Care must be taken in applying the spica, 
 that equal pressure be made throughout. 
 
 Solid Rubber Bandages. — These bandages are essential to the surgeon in the 
 treatment of any affections requiring gentle and even pressure, accompanied 
 with elasticity. I have employed them in the treatment of sprains and vari- 
 cose veins, in " caking " of the mamma, but more especially in hydrarthrosis 
 of the knee-joint. Dr. Samuel Kohn* reports an excellent result from its 
 
 * Medical Eecord, April 5th, 1879, No. 431. 
 
46 
 
 A SYSTEM OF SURGERY. 
 
 use in a case of syphilitic inguinal bubo, the swelling being dissipated in 
 about ten days. Martin's bandages are made from twelve to eighteen feet 
 
 Fig. 27. 
 
 Fig 28. 
 
 Bandage Rollers. 
 
 in length, from two to three inches wide, and are supplied at their distal 
 ends with tapes. (Vide Fig. 29.) There is an objection to these tapes how- 
 ever ; if they are tied sufficiently tight to keep ihe bandage snug they (the 
 tapes), being inelastic, will, after a short time, materially affect the circula- 
 tion ; therefore it is better to dispense with this method of fastening the 
 bandage, and secure it with a safety-pin. There is a most excellent bandage 
 
 Fig. 29. 
 
 Fig. 30. 
 
 Fig. 31. 
 
 India-rubber Rollers 
 
 made by the Davidson Rubber Company. This bandage is sixty feet long, 
 and is from one and a half to three inches in width. With it are sold the 
 safety-pins wherewith it may be secured (Fig. 30). 
 
 There is another variety of elastic roller which is very serviceable, when 
 some evaporation is desired, especially in sensitive skins, in which eczema- 
 tous eruptions are liable to be either increased or produced by the soiled 
 bandage. This roller is known as the open-mesh elastic bandage (Fig. 31). 
 It was suggested by Dr. Shoemaker. 
 
 Plaster-of-Paris Bandages.— In the chapter upon " Fractures," I shall speak 
 of the plaster-of-Paris splint, and call attention, as I have for many years in 
 my lectures, and in previous editions of this work, to the difference between 
 the plaster splint and plaster bandage or roller. The directions for making 
 the splint I have also noted in the chapter alluded to. To make the bandage, 
 or roller, the best substance is cheese-cloth, cut into strips from two to two 
 and a half inches wide, and from eight to twelve yards long. A newspaper 
 or sheet may be spread upon the floor or on a table, and a few feet of the 
 bandage laid smoothly down upon it; with a spoon the plaster-of-Paris 
 
THE BANDAGE. 
 
 47 
 
 should then be spread on the strip so laid down, and the bandage rolled 
 with moderate tightness, to the point upon which the plaster is sprinkled ; 
 a few feet more is then arranged in a similar manner, and rilled with the 
 plaster and rolled, and so on the process is continued until the entire roller 
 is made. After several rollers are thus made, they should be set on end in 
 a box and covered with plaster-of-Paris, and a tight-fitting lid placed over 
 the box or can. I keep these rollers in a tin box, and in a dry place. 
 
 The preparation of the bandage is much simplified by using a simple 
 box, arranged after the plan as seen in Fig. 32. 
 
 When the bandage is to be applied the rollers should be placed on end 
 in a basin, and sufficient water poured therein to cover them ; they should 
 be allowed to remain thus in soak for a few moments, then the surgeon 
 
 Fig. 32. 
 
 Box for making Plaster-of-Paris Roller Bandages. 
 
 should take one in hand and thoroughly squeeze it, dip it back into the 
 water, give it another squeeze, and begin the application. If it be desired 
 to have a very firm dressing, a basin containing plaster-of-Paris, made the 
 consistency of thick molasses, should be at hand, and after five or six turns 
 of the roller, a handful of the semi-solid material should be laid over that 
 portion of the bandage which has been applied, and smoothly and evenly 
 spread upon it. The further application of this bandage is then continued. 
 To make the plaster set with more rapidity, Dr. Sayre uses the rolling flat- 
 iron (Fig. 33). The removal of a firmly-set plaster-of-Paris bandage is a 
 work that requires both skill and time, and very often the patience, of both 
 
 Sayre's Rolling Iron. 
 
 the patient and the operator. Sayre has invented shears, Henry has done the 
 same, and Esmarch likewise, but there is always a good deal of difficulty. 
 The instrument I use is a circular saw worked by a lever and ratchet, in- 
 vented and manufactured by Colin, of Paris. 
 
 It is said by Dr. F. Murdock,* that by applying nitric acid in the line in 
 which the bandage is to be divided, the plaster is rendered soft, and the 
 division easily effected with an ordinary jack-knife. 
 
 The plaster-of-Paris bandages are prepared ready for use, and neatly and 
 securely packed, by C. Am. Ende, of Hoboken, N. J. 
 
 The many-tailed bandage, or the bandage of Scultetus, is made in the fol- 
 lowing manner. A strip of roller, of sufficient length to extend around the 
 
 * Medical Record, 1882, September 19th. 
 
48 
 
 A SYSTEM OF SURGERY. 
 
 limb to be covered, is laid smoothly upon a table ; a second strip, overlap- 
 ping the first about half an inch, is laid parallel to the first; and so on a 
 third, fourth, and fifth, until as many "tails " are made as will be required. 
 Along the centre of these. a longitudinal strip is laid at right angles, and 
 stitched down. When the bandage is completed, it is applied by laying 
 the longitudinal strip on the posterior surface of the limb, and beginning 
 at the lowest end, bringing the tails one over the other, on the affected part. 
 It will be seen that by such method every tail that is laid over, holds those 
 previously applied, in position. This bandage is especially useful in wounds 
 and in compound fractures, in which it is necessary to examine the parts 
 frequently without materially disturbing the position of the limb. 
 
 Tents are prepared of various substances to dilate passages or to keep 
 wounds and sinuses open. 
 
 The Tupelo tent, which is made of the root of the Tupelo tree, cut into a 
 smooth cylinder, and subjected to powerful pressure, is the best in use. 
 
 Fig. 34. 
 
 Tupelo Tents. 
 
 It retains its roundness, and, above all, its smoothness after expanding, and 
 does not become offensive. These tents are now made with an opening 
 through their centre for drainage. (See Fig. 34.) 
 
 Sponge Tents. — Tents are also made of compressed sponge covered with 
 wax, which being inserted into fistulse, w T ounds, or canals requiring dilata- 
 
 Fig. 35. 
 
 Sponge Tents. 
 
 tion, the heat of the body melts the wax and the sponge expands. These 
 are manufactured by machinery, and made in graded sets (Fig. 35). They 
 can be charged with any medicinal or antiseptic substance required. 
 
 Sea-tangle tents are also used for expansion. 
 
 Paper. — In the surgical wards of the Pennsylvania Hospital, Dr. Addinell 
 Hewson has made use of paper as a surgical dressing with most excellent 
 results. He was led to its use by reading in a daily periodical that paper 
 had been substituted for lint during the Prussian campaign, and after 
 various experiments in regard to strength, power of retaining moisture, 
 elasticity, and pliability, he arrived at the conclusion that common news- 
 paper " answers all the requirements equally well if not better than lint." 
 He says' : " I have tested paper dressings in all varieties of simple incised 
 and lacerated wounds ; in compound fractures, on suppurating surfaces, 
 whether inflamed, indolent or otherwise, and in all the major and minor 
 operations which I performed both as primary and secondary dressings, 
 and with never any results which could lead me to consider paper inferior 
 
THE PUS BASIX — IXCISIOKS. 
 
 49 
 
 to the other means which I had been in the habit of employing for these 
 purposes." 
 
 For stanching haemorrhage, paper, especially the softer blotting-paper, 
 has been found very useful ; in fact the application of ordinary paper as a 
 domestic remedy for trifling haemorrhage has long been known as efficient. 
 
 Dr. Hewson, in his interesting essay, also gives his method of substituting 
 paper for oiled silk as a covering for wet dressings. The cheapness of paper 
 is also made apparent by exact computation. Even when the best quality 
 of blotting-paper, made of purest linen fibre, is used the difference would 
 be as three to thirty-three in favor of paper. 
 
 In the Hahnemann Hospital I have made use of the waxed paper, which 
 is prepared in the house, and for its cheapness and efficacy, in those cases 
 where oiled silk or india-rubber cloth is generally employed, it answers 
 admirably. 
 
 The Pus Basin. — This very necessary modern appliance for dressing is 
 made of metal or hard rubber, and is so curved at its sides that it ac- 
 
 FlG. 37. 
 
 Fig. 38. 
 
 commodates itself to different inequalities of surface. For receiving pus, 
 for catching the water from the syringe, as a receptacle for pins, wires, and 
 straps, it is almost indispensable. For operations about the face, eye, ear, 
 or nose, the removal of scalp tumors, and 
 other operations, the pus cup is quite es- 
 sential. Figs. 36 and 37 represent the 
 different shapes of the basin, made of hard 
 rubber. Fig. 38 shows the soft rubber 
 basin of Warren. 
 
 Incisions. — The method of making inci- 
 sions varies very much in accordance with 
 the operation to be performed and the will 
 of the operator. The positions in which the 
 knife is held, however, may be laid down 
 for the benefit of the student and young 
 practitioner. Before proceeding with any 
 operation, the edges of the instruments should be examined by a competent 
 assistant or by the operator himself, and having satisfied himself of their 
 keenness and cleanliness, the cuts, when made, should be of sufficient 
 length for the purposes required. None but those who have witnessed the 
 embarrassing effects of small incisions can appreciate the value of fair, 
 sweeping, and clean cuts in any operation, whether trivial or important. 
 
 Positions of the Knife. — In some instances the knife may be held as an 
 ordinary carving-knife, the thumb upon the handle, the index finger on the 
 back of the blade near its shoulder, the remaining fingers steadying the 
 instrument, as seen in Fig. 39. Another position of great convenience is 
 when the scalpel is held as the violinist holds the bow ; the blade of the 
 
50 
 
 A SYSTEM OF SURGERY. 
 
 lmife should be turned a little sidewise, and it should be held lightly between 
 the thumb and fingers, as seen in Fig. 40. 
 
 Again, the scalpel is held as a pen, especially in dissections. The extreme 
 mobility given to the instrument with the forefinger and thumb, while the 
 
 Fig. 39. 
 
 First Position. 
 
 hand is steadied by the remaining ring and little fingers, and the rapidity 
 with which the upward and downward motions may be made, render this 
 
 Second Position. 
 
 position a favorite one with many skilful operators. The position is seen 
 in Fig. 41. 
 
 Incisions are called simple ; crucial, X ; or V-shaped ; or resemble 
 
 the letters H, L, T, I ; or they may be in the form of an ellipse, or they 
 may be semicircular. 
 
 Fig. 41. 
 
 Third Position. 
 
 No rules can be given for the shape and direction of incisions, as the 
 surgeon must, in every presenting case, adopt such as will produce the best 
 result with least deformity. 
 
 Hypodermic Medication.— The value of hypodermic medication in many 
 surgical disorders forbids us to leave this portion of the subject without 
 mention of the instruments employed, and the doses of the substances 
 found most efficacious. The hypodermic syringe was invented by Alexander 
 Wood, of Edinburgh ; he conceiving the idea from the instrument used by 
 
HYPODERMIC MEDICATION. 
 
 51 
 
 Mr. Fergusson for injecting nsevi. It consists of a small glass or hard 
 rubber syringe, with one or two movable capillary points ; these are intro- 
 duced beneath the integument, the cylinder having been previously charged 
 with the dose to be administered, and the piston slowly pressed home. The 
 best way to insert the point is to pinch up a portion of the integument 
 between the thumb and forefinger of the left hand, and, taking the syringe 
 in the right, push it into the fold thus held up, as in Fig. 42. 
 
 Many improvements have been devised in the construction of the hypo- 
 dermic syringe, in order to save time and trouble in counting the number 
 of drops to be employed as a dose. Thus, in some, the number of drops 
 
 Fig. 42 
 
 Method of giving Hypodermic Injection. 
 
 or minims is marked upon the piston, and the cylinder made of glass ; by 
 drawing up the piston, the liquid follows, and the exact amount may be 
 measured ; in others the minims are cut into the cyinder (Fig. 43). 
 
 The glass cylinder is in reality a minim measure, which is regularly 
 graded. This, for better preservation, is encased in a metal covering, which 
 
 Fig. 43. 
 
 is fenestrated on one side to show the marks upon the glass. The piston 
 is longer than the cylinder, in order that it can, if necessary, be pushed 
 through to be washed and oiled. 
 
 Sometimes there is considerable trouble experienced in filling the cylinder 
 from the bottle, and some waste of the material. To obviate this, a bottle 
 with a mouth set at right angles with the body, and of sufficient size to 
 admit the nozzle end of the syringe, has been prepared. ( Vide Fig. 44.) 
 
 After using the syringe, it should be carefully rinsed, and the piston 
 worked several times in the cylinder to drive out all the fluids ; the wires 
 should then be immediately inserted into the points. 
 
 In making the hypodermic injection, it must be borne in mind that at 
 most half the stomachic dose should be employed, and in many instances 
 
52 
 
 A SYSTEM OF SURGERY. 
 
 it is better to begin with a dose one-third or one-fourth the quantity admin- 
 istered by the mouth. 
 
 It should also be borne in mind, that the liquids should be fresh and 
 pure; if they are old, they are likely to contain ferments, which, being 
 injected into the tissues, would, in all probability, cause pain and suppura- 
 tion ; indeed, in certain conditions of the system, such results may follow 
 most carefully introduced injections. To obviate such difficulties chemists 
 
 Fig. 44. 
 
 Hypodermic Case. 
 
 have prepared minute tablets, capable of complete solution in small quan- 
 tities of water. These receive the name of soluble compressed tablets. 
 They are very convenient for use. There is no danger of over-dosing the 
 patient, and the solution injected is always pure. 
 The doses may be as follows : 
 
 Muriate of morphine, . 
 Sulphate of morphine, . 
 Atropine sulphate, 
 Strychnine, . 
 Sulph. soda (Hewson), . 
 Sulphate quinine, . 
 Squibb's liquor of opium, 
 Magendie's solution, 
 Tinct. hyoscyamus, 
 Tinct. cannabis, 
 
 £ to f of a grain. 
 | to f of a grain. 
 
 ifo t0 iV of a g rain - 
 Ju to ¥ V of a grain, 
 grs. ij. 
 
 grs. ij to grs. iv. 
 gtt. v to gtt. lx. 
 gtt. iii to gtt. xx. 
 gtt. x to gtt. xx. 
 gtt. x to gtt xx. 
 
 The Aspirator. — The idea of withdrawing abnormal and other fluids from 
 the different cavities of the body has been promulgated among surgeons 
 and physicians from remote ages. Instruments constructed for this purpose 
 were termed pyucla, because they were generally employed for the with- 
 
THE ASPIRATOR. 
 
 53 
 
 drawal of pus, and although variously modified, they were all constructed 
 on the principle of the exhausting syringe. 
 
 Dieulafoy, on the 2d of November, 1859, presented through Professor 
 Gubler, to the Academy of Medicine, an invention of his own, to which he 
 gave the name "Aspirator" and which has become one of the most important 
 instruments in the hands of the profession. It consists of hollow capillary 
 needles, and a suitable air-pump to create a vacuum. 
 
 The varied forms of the aspirator are constructed on these principles, and 
 the numerous operations which can with safety be performed, are daily 
 proving the immense value of the apparatus. 
 
 I have employed this instrument in very many diseases, among which 
 may be noted hydatid cysts of the liver, abscesses of the liver, retention of 
 urine, poisons in the stomach, ovarian cysts, hydrocephalus, spina bifida, 
 
 strangulated hernise, effusions into the pericardium, purulent pleurisy, dis- 
 eases of the joints, diseases of the tunica vaginalis and peritoneum, san- 
 guineous effusions, acute abscesses, suppurating buboes, and other diseases. 
 A glance at the above list of diseased conditions, for which the aspirator 
 can be employed, detects the fact that a majority of them are of the most 
 serious character ; in addition, when we remember the comparative harm- 
 lessness of the punctures and the immediate relief, if not cure, which 
 generally follows aspiration, the wonder is that such an apparatus has not 
 been before constructed. As a means also of diagnosis, the aspirator must 
 hold a high place ; the facility with which the operations may be performed 
 adding much to the general usefulness of the apparatus. 
 
54 
 
 A SYSTEM OF SURGERY. 
 
 The needles of the aspirator are hollow and of various sizes, the smallest 
 being about the calibre of the ordinary hypodermic syringe; to these 
 needles is affixed a stopcock, which shuts off the air; they are also furnished 
 with a screw, by means of which they are attached to one end of an india- 
 rubber tube, the other extremity of which fits into a glass cylinder, in 
 which, by means of a piston (or air-pump) a vacuum is created. ( Vide 
 Fig. 45.) 
 
 The simplicity of the contrivance, and the great suction which can be 
 brought to bear upon even semifluid substances by means of the vacuum, 
 will be apparent. 
 
 When the instrument is to be used, the vacuum is first created, the 
 needle is then inserted into the part desired, the stopcock turned, and the 
 fluid, whatever it may be, is drawn within the glass cylinder. 
 
 Of course, the range of disorders to which the aspirator is adapted, is 
 now pretty well settled. The instrument has had its "run" as every 
 fashionable medicine, every novel instrument, arid every improved method 
 of operation has had before it. Doctors have run mad over Bavarian beer 
 and cod-liver oil; there have been carbolic acid madness, chloral frenzy, 
 and the bacteria craze ; Civiale predicted the exclusive use of the litho- 
 triptor in cases of stone ; Chassaignac would amputate legs with the 
 £craseur ; and even at present, Professor Dittel would accomplish the same 
 result with the " elastic thread." Esmarch's artificial ischsemia has been 
 extended to keeping the blood in the body during serious and prostrating 
 diseases, and the aspirator, modified into a great variety of shapes, has been 
 tried for all classes of disorders, and its use is thoroughly understood. No 
 instrument introduced into the surgeon's armory, has become more valu- 
 able, both as a means of diagnosis and of relief, than that now under con- 
 sideration. 
 
 As is usual, there have been many modifications of the aspirator, and as 
 the simplest is always the best, that represented in Fig. 45, according to my 
 experience, is to be preferred. 
 
 Fig. 46. 
 
 If large quantities of fluid are to be re- 
 moved, the cork may be fitted to a 
 larger bottle. The modification of the 
 trocar needle, by which a rounded in- 
 stead of the usual sharp-pointed ex- 
 tremity is left within important cavi- 
 ties, is one much to be desired. I have 
 also used Reynders' modification of the 
 aspirator, as seen in Fig. 46. 
 
 Its advantage is compactness. Its 
 bottle is small, but nevertheless it is as 
 efficient as an apparatus with bottle of 
 any larger size. This is achieved by 
 the hole in the bottle, F, through which 
 the contents can be emptied, most con- 
 veniently by opening the stopcock C, 
 and removing the fitting Z), connected 
 with the pump, from the bottle B. The 
 stopcock at D controls communication 
 from the bottle with the pump as well 
 as through the needle.* To exhaust the 
 bottle of air, the stopcock C is closed, and the stopcock at D turned as 
 shown in the figure, and the pump worked. By turning the stopcock at C 
 horizontally, as shown by the dotted lines, communication through the 
 needle to the bottle is established. 
 To inject with this aspirator, the bottle is drawn full of liquid with the 
 
 Reynders' Aspirator. 
 
THERMOCAUTERY. 
 
 55 
 
 aspirating end of the pump attached ; the stopcock C being opened and the 
 end G in a basin. The injecting end of the pump is then put on, and the 
 liquid forced out through 'the hole F, stopcock C, and end G; to the latter 
 a needle may be attached, in order to throw the liquid where desired. 
 
 When smaller quantities of fluid are to be withdrawn for chemical or 
 microscopical examination, Dieulafoy's small aspirator (Fig. 47) is an ex- 
 cellent one. 
 
 One of the best of the many modifications of the aspirator is that of Dr. 
 Simon Fitch.* His invention consists in what he terms his u dome trocar," 
 with the addition of "a hose-coupling attachment" for the aspirator. I 
 can testify to the efficacy of the instrument, having used it frequently. 
 
 Fig. 47. 
 
 Dieulafoy's Small Aspirator. 
 
 The description of the apparatus I have given in part from Mr. Tiemann's 
 catalogue, a perusal of which will satisfy the reader of the completeness of 
 the instrument : 
 
 " He has had the distal orifice of the inner canula closed over by a 
 rounded or dome-shaped roof, so that, when it is projected beyond the 
 cutting-point of the outer canula, the two tubes fit closely together and the 
 end of the combined instrument feels perfectly smooth like the end of a 
 sound or catheter, and may be freely moved within the cavity penetrated, 
 as the ovarian cyst, the abdomen, the thorax, the bladder, or even the 
 pericardium, without danger of wounding any viscus or organ, puncturing 
 any vessel, or even scratching or abrading the lining of the cavity, or of 
 any parts contained therein. The base of this dome being of the same 
 external circumference as the inner tube, of which it is the continuation, 
 and fitting the outer tube accurately, when the point of the instrument 
 enters a cavity, there can be no escape of fluid till the dome is advanced, 
 occluding the cutting-point of the outer tube ; then there is disclosed a 
 fenestra or oval aperture on the under side of the inner tube, cut out of the 
 lower wall, and one-third of each side-wall, of the full size of the bore of 
 the tube, and by which the fluid may be freely evacuated." 
 
 Thermo -cautery. — The neatness and efficiency of this instrument have 
 already made it a general favorite with surgeons in those affections which 
 require the actual cautery. Its advantages are, that it may be used steadily 
 for any length of time, the incandescence being kept up at the will of the 
 operator by compressing the air-bulbs. The principle involved is simply 
 the fact that platinum is one of the metals that when slightly heated, gradu- 
 ally becomes incandescent by the contact with certain hydrocarbon vapors. 
 
 * New York Journal of Medicine, April, 1875. 
 
56 
 
 A SYSTEM OF SURGERY. 
 
 A, represents a bottle nearly full of common (not deodorized) benzine. The 
 cork that fits this bottle is perforated by a double tube, to one branch of 
 which an air-blowing apparatus, C, is attached, while to the other is affixed 
 an india-rubber tube, the distal end of which is fitted to a hollow handle, 
 G, into which handle the cauterizing knives or buttons, D, E, are screwed. 
 These latter are made of platina, are hollow, and are rilled inside with 
 platina-sponge. These ends are riveted into cylinders, each containing two 
 tubes, one to conduct the vapor of benzine to the cautery (called also the 
 combustion-chamber) ; the other, to carry off the products of combustion. 
 Sometimes, when a greater length of the instrument is required, an addi- 
 tional tube, F, may be added. B, is an ordinary alcohol lamp. The bottle, 
 A, may be hung by the hook on its side to the vest-pocket of the operator, 
 
 Fig. 48. 
 
 Paquelin's Thermo-cautery. 
 
 who works the air-bulb with the left hand, while he applies the cautery 
 with his right. The end of the cautery, D, is held in the flame of the lamp 
 for one or two minutes to heat the platinum ; the bulb is then gradually 
 inflated, and rapid incandescence is produced, which may be maintained 
 just so long as the air-bulb is worked, which forces the benzine vapor from 
 the vial, through the tube into the handle, and thus to the platina. With 
 this instrument I have performed very satisfactory operations. 
 
 Galvano-puncture. — Galvano-puncture, on account of the pain inflicted, 
 is seldom resorted to, except in the treatment of surgical diseases, where the 
 usual mode of application with moistened electrodes has been resorted to 
 and failed. The procedure is the same as in electrolysis. 
 
 Galvanic Moxa is employed as follows : Denude the part to the extent 
 desired, by means of blisters or other excitants, in two places, one above 
 the other, then apply zinc and silver plates as described for ulcers. Apply 
 the zinc plate to the part from which the discharge is desired, and the silver 
 plate to the other. Sodium is eliminated at the silver, and chlorine at the 
 zinc plate. A poultice applied to the part will give a free discharge of pus. 
 
GALVANO-CAUTERY BATTERY. 
 
 57 
 
 Galvano-Cautery Battery. — The galvanic cautery is rapidly taking the place 
 of the ecraseur of Chassaignac. In the removal of parts where considerable 
 
 Fig. 50. 
 
 haemorrhage is to be ex- 
 pected, it is the instru- 
 ment par excellence. In 
 amputations of the tongue 
 and penis, in certain forms 
 of haemorrhoids, in the 
 removal of carcinomatous 
 growths within cavities, 
 and for the extirpation of 
 certain haematoid neo- 
 plasms, there is nothing 
 that will compare to it. 
 Fig. 49 represents the very 
 favorite battery of PifTard, 
 with cords and agitators. 
 This instrument is very 
 compact, its size being 
 only 6£ x 10 inches, and 
 its weight but 15 pounds. 
 In the cut, the letters a, b, c, d, e,f, and 
 #, represent the varied forms of plati- 
 num knifes, while h shows the handle 
 into which any of the blades may be 
 inserted. 
 
 The Electric Light.— This beautiful 
 method of illumination is now growing 
 in favor, the objections to it, however, 
 
58 
 
 A SYSTEM OF SURGERY. 
 
 being in the care that has to be taken of the battery, and often the un- 
 certainty of obtaining a good light. 
 
 The apparatus which I use, and which has given me excellent results, is 
 that introduced by Dr. St. Clair, and known as the u St. Clair Surgical 
 Electric Battery." It can be used readily for all speculum examinations, for 
 the microscope, and, with a dynamo, can be made to pump an aspirator or 
 
 Fig. 51. 
 
 roll a bandage. Fig. 50 represents the battery, and Fig. 5f the different 
 lamps and cauteries. Carl W. Meyer has also introduced an electric illu- 
 minator for the mouth and throat.* 
 
 Electrolysis.f — When two or more needles connected with the poles of an 
 apparatus, generating a galvanic current of sufficient intensity to overcome 
 the resistance of the circuit, are inserted into living animal tissue, the fol- 
 lowing results take place, viz., the bloodvessels of the part become dilated 
 and engorged, producing intense hyperemia, and the absorbents are stim- 
 ulated to increased activity. In short applications with weak currents, the 
 effect ends here, but should the action of the current be continued, and the 
 tension and quantity slightly increased, the albumen of the part becomes 
 coagulated, and with a still stronger current, the water of the tissues becomes 
 decomposed, the oxygen becoming attracted towards the positive pole, and 
 the hydrogen towards the negative, to find vent at which it bubbles violently 
 through the intervening structures, tearing fibre of muscle, separating cells, 
 nuclei, and filaments, etc., and mechanically destroying anything that may 
 oppose its egress. The salts of the tissues are resolved into their contained 
 acids and alkalies, the acids forming around the positive pole, and the alka- 
 lies around the negative, where both act as powerful escharotics, producing 
 sloughing. Thus the tissue acted upon is made to destroy itself through its 
 
 * Vide Medical Kecord, July 18th, 1885. 
 
 f These remarks on Electrolysis were prepared by the late John Butler, M.D., L K.C.P.E., 
 author of a Text-book on Electro-Therapeutics and Electro-Surgery. 
 
ELECTROLYSIS. 59 
 
 own contained reagents. The operation thus described may practically be 
 divided into four stages : 
 
 1st. The dynamic or absorbent stage, corresponding to what is called by 
 Remak— electro-catalysis. 
 
 2d. The coagulating stage. 
 
 3d. The stage of mechanical disintegration, and 
 
 4th. The escharotic stage, or the stage of complete and ultimate elec- 
 trolysis. We use the first stage only in the treatment of serous effusions, 
 strictures, watery cysts, etc. ; the second stage, in the treatment of aneurism, 
 varicose veins, haemorrhoids, nsevi, and other diseases, where coagulation 
 of the contained blood is desired, and where the production of a slough is 
 not intended ; the third and fourth stages, in growths of a malignant nature, 
 fibrous tumors, polypi, fatty tumors, and in any case where a total or partial 
 destruction of the part may be necessary. In the operation the greatest 
 amount of effect produced is in the immediate vicinity of the needles ; in 
 very mild currents, the cauterizing effect is only produced in the parts 
 directly in contact with the needles ; with strong currents, the size of the 
 slough depends upon the structure of the tissue, the amount of water and 
 salts it contains, the size of the needle, and the duration .of the application. 
 The eschar produced by the positive pole differs essentially from that caused 
 by the negative, inasmuch as the ulcer resulting from the separation of the 
 slough of the first, leaves a cicatrix which heals by contraction like that 
 produced by an acid caustic. No such results take place from the action 
 of the negative pole ; on the contrary the cicatrix is soft and pliable. 
 
 It is, of course, entirely impossible to obtain purely the results of any 
 one of these stages per se ; for instance, in electro-puncture of an ovarian 
 cyst, the result aimed at, is to produce absorption, and so act on the internal 
 part of the cyst as to destroy its secreting powers and prevent refilling. 
 Electrolysis of the watery parts of the contents must and does take place to 
 a greater or less degree, but it forms no part of the desired effect, and so in 
 operating upon aneurism or nsevus, thorough coagulation of the blood is the 
 only thing desired. Electro-puncture, as thus described, is presumed to 
 have been performed with needles made of unoxidizable materials. Should 
 the needle of the positive pole be made of material capable of being acted 
 upon by the acids set free at this point, the results are modified in a great 
 degree. For example, suppose the positive needle should be made of iron, 
 the needle becomes dissolved by the acids set free, and the phosphate, 
 sulphate, and chloride of iron are formed, principally the chloride. From 
 this fact, we would infer that iron needles would be useful when coagulation 
 of blood is the result aimed at, and there is no doubt they assist the accom- 
 plishment of such a result to a considerable extent. Suppose we use zinc 
 needles, we have chloride of zinc- formed, which is a powerful escharotic, 
 and assists materially in hastening the destruction of morbid growths. I 
 have used these needles with a weak galvanic current and long applications, 
 for the destruction of malignant tumors, and believe it to be, in many cases, 
 the most appropriate treatment. The diseased tissue is chemically dissolved 
 under the action of the current, which at the same time influences the 
 morbid nervous impulse which caused the secretion of the diseased cells in 
 the first place; and the electro-chemical action of the already disintegrating 
 structure on the needle forms, molecule by molecule, one of the most 
 powerful escharotics, which destroys, molecule by molecule, any of the 
 diseased mass that may possibly escape the action of the current, and not 
 only that, but it acts as a powerful antiseptic on the slough that otherwise 
 might become offensive before separation had time to take place, and still 
 further it certainly hastens that separation. Another advantage of the 
 operation is that it is comparatively painless, in some cases entirely so. 
 
60 A SYSTEM OF SURGERY. 
 
 Electrolysis of the tissue takes place so slowly that the chloride of zinc is also 
 formed slowly, and immediately uniting with the tissue that is already 
 half numbed by the action of the current, very little pain, if any, is pro- 
 duced. In fact, the strength of the current can be so arranged that no pain 
 is caused. In my opinion, the electro-chemical treatment far surpasses 
 ordinary electrolysis in certain cases, where total destruction of the part in 
 as short a time as possible, and with a minimum amount of pain, is desired ; 
 still a slight eschar around the uninsulated part of the needle is unavoidable. 
 
 In such operations it behooves us to make this latter as slight as possible, 
 which can be done by diminishing the amount of quantity of current used ; 
 that is to say, in any operation requiring a cauterizing effect, a large quantity 
 is required ; in operations where we simply desire to produce the absorbent 
 or electro-catalytic effect, we require tension, but small quantity. 
 
 We will, for the present, dismiss this question of electro-chemical treat- 
 ment, and return once more to the consideration of the effects of the current 
 as applied with unoxidizable material. 
 
 This operation so far, we have only considered as performed by the use 
 of needles introduced into the tissues. The same effects in a lesser degree 
 can be obtained by external application of metallic and other rheophores 
 to the skin, mucous membrane, or denuded tissue. And when we use the 
 current for the sake of its lesser effects, it is frequently applied in this 
 manner. 
 
 One of the greatest difficulties in the technics of electrolysis, so called, 
 to the tyro electro-therapeutist is to avoid doing too much. The operator 
 must have a battery provided with a Brenner's, or other equally accurate 
 rheostat, constant and reliable, capable of giving every variation of quan- 
 tity and intensity of current. He must be quite familiar with its action, 
 and with the effect each variation is capable of producing on living animal 
 tissue. He must also be able to control the electro-motive force to the exact 
 point capable of producing the effect desired, and no more. For instance, 
 what could be more deplorable than that sloughing of the urethra should 
 take place when the effect intended to be produced is merely the absorption 
 of a stricture ? or in operating on a nsevus on the face of a young lady, that 
 an eschar should be caused when we merely aim at coagulation of the 
 morbid growth ? And yet the slightest overstepping of a scarcely defined 
 boundary will cause just such a result. Better far to do too little than too 
 much. It is impossible to state with precision the exact quantity and 
 intensity of current to be used, and that depends upon the size of the 
 growth, the density, and the amount of watery and saline ingredients con- 
 tained. This must be learned entirely by experience. The diseases for 
 which electrolysis are especially applicable, are chiefly strictures of the 
 urethra and oesophagus, nsevi materni, haemorrhoids, hydroceles, certain 
 forms of aneurism, and a variety of tumors, especially cystic and fibrous. 
 
 In the former editions of this work, several cases of successful treatment 
 of each of the above affections were given, but owing to the increased 
 amount of matter necessary to be inserted in this edition, the details have 
 been omitted. 
 
DISINFECTANTS AND ANTISEPTICS. 61 
 
 CHAPTER II. 
 DISINFECTANTS AND ANTISEPTICS. 
 
 Antiquity of Disinfection — Cleanliness — Charcoal — Lime — Ashes — Earth — 
 Smoke— Collins's Disinfecting Fluid — Thompson's Deodorizer — Heat— Coffee 
 — Bromine— Ozone— Iodine— Nitrate of Lead— Chlorine— Chloride of Zinc 
 — Chloride of Lime — Labarraque's Solution — Permanganate of Potash — 
 Nitrous Fumigations — Tar Acids. 
 
 The precise meaning of the word disinfection, is any process by which 
 contagion arising from disease may be destroyed. Common consent, how- 
 ever, has applied the term to the use of agents which will counteract or 
 destroy noxious effluvia or gases arising from decomposing animal or vege- 
 table matter, wherever found ; as well as to the destruction of microzymes 
 arising from diseased processes. 
 
 The use of disinfecting agents in surgical practice, not only in regard to 
 the benefit that may accrue from their use to the patient, but in affording 
 comfort to the surrounding sufferers and attendants, is certainly of much 
 import. In many cases in which large wounds are to be dressed, and 
 where many suppurating sores are grouped together in one apartment, the 
 atmosphere is rendered so noxious that the health of those who, through 
 force of circumstances, are compelled to inhale the vitiated air, is often 
 materially impaired. Untoward accidents may occur from this cause alone. 
 From a knowledge of these facts, and from a proper understanding of the 
 true nature of noxious effluvia, much attention has lately been given to 
 this subject. Within the past ten years very important disinfecting agents 
 have been introduced to the profession. It is not proposed in this chapter 
 to enter upon the theories of ferments, germs, and sporules, but merely to 
 mention some of those materials which are found most reliable in surgical 
 practice in neutralizing the poisonous exhalations from suppurating sores, 
 large wounds, abscesses, or decaying or decomposing substances. The 
 object of the surgeon is to find such agents as may either arrest decompo- 
 sition, or finish the process entirely. 
 
 The efforts to render the atmosphere of large cities and towns as pure as 
 possible by drainage is very ancient. 
 
 Justinian tells us that " the praetor took care that all sewers should be 
 cleaned and repaired, for the health of the citizens, because uncleaned 
 and unrepaired sewers threaten a pestilential atmosphere and are dan- 
 gerous." He also states, that it- was forbidden to throw refuse into the 
 roads. 
 
 In 1732 Petit made some experiments with antiseptics, and in 1750 Sir 
 John Pringle wrote his " Experiments on Septic and Antiseptic Substances, with 
 Remarks relating to their Use in the Theory of Medicine." 
 
 In 1767 the nitrate of potash was highly recommended. 
 
 In 1732 Guyton Morveau instituted fumigation with various acid vapors. 
 
 Dr. Carmichael Smyth employed nitrous fumes, at Winchester, in 1780. 
 
 Chlorine was introduced by Fourcroy, in 1791-2, and was first employed 
 in England by Dr. Cruikshank. 
 
 First in the catalogue of disinfectants are cleanliness and fresh air; 
 nothing can equal them — nothing can be of more benefit to the patient. 
 Free ventilation, so arranged that no absolute draught is produced, and the 
 constant use of the bath, are the great adjuvants to surgical practice, and 
 as these facts are becoming universally acknowledged, our hospitals are 
 
62 A SYSTEM OF SURGERY. 
 
 being so scientifically constructed, that these requisites are attained in the 
 greatest perfection. 
 
 For proper disinfection, however, cause and effect must be considered. 
 If we use substances which will prevent the former, we have what are 
 termed antiseptics; if we employ agents which neutralize the latter, we 
 have only deodorizers. By using substances which render the surrounding 
 atmosphere more pleasant to our olfactories, we have no proof that the 
 unwholesome condition is removed ; and there is no reason why the admix- 
 ture of the two substances may not, perhaps, be even more hurtful than 
 the original disagreeable odor which we have been endeavoring to neutralize. 
 A true antiseptic must possess the power, as before said, not only to prevent 
 the disagreeable odor from being perceptible to the senses, but to destroy, 
 as far as possible, the cause upon which the odor depends. 
 
 Strange as it may appear also, those very agents which generate decom- 
 position and produce the emanations which are hurtful, are the same that 
 when their action is prolonged or intensified, do away with the process 
 entirely* This is well illustrated by the action of heat and moisture, the 
 great producers of decomposition. Increase either, and the process is at 
 once suspended. So also it may be remarked of the so-called chemical 
 disinfectants. They either increase, in a great degree, the oxidation upon 
 which the decomposition depends, or take away the oxygen altogether. 
 
 Disinfectants may be classed into absorbents and antiseptics. The latter, 
 antiseptics, were known to the ancients, and the process of embalming was 
 nothing more or less than a peculiar antiseptic treatment. In fact, the 
 burial of bodies in the earth is another form of the same process. The 
 conservation of meats, fruits, and vegetables of the present day is also a 
 variety of " listerism." 
 
 The division that we have made is all that is necessary for practical 
 purposes ; the former absorbing or neutralizing the volatile or gaseous 
 products of decomposition; the latter preventing the decomposition, or 
 modifying it by chemical union with the substances liable to be decom- 
 posed. 
 
 In searching for materials to purify the atmosphere, it is requisite in 
 many instances, that those be selected which are cheap and can easily be 
 obtained. Among these we find charcoal, lime, copperas, ashes, and earth. 
 In covering over cesspools, in sprinkling damp or moist surfaces, in hospital 
 wards and privies, these substances are used with great benefit. They are 
 classified under the head of absorbents. The charcoal and lime may 
 advantageously be mixed together. In cases of gangrene, of the moist 
 variety, where the stench is great, I have enveloped the parts in pulverized 
 charcoal, with much comfort to the patient and attendants. 
 
 Earth. — Through the experiments of Dr. Addinell Hewson, of the Penn- 
 sylvania Hospital, it has been found that one of the best disinfectants 
 known, is dry earth; it should be free from grit or other foreign material, 
 and should be perfectly dry and finely pulverized. It can be applied to 
 ulcers, suppurating surfaces, recent wounds in which suppuration is to be 
 expected ; in fact, to all wounded or burnt surfaces. 
 
 Smoke. — The smoke from a wood fire is known to have fair disinfecting 
 properties, but oakum soaked in tar, and then lighted and allowed to 
 smoulder, is preferable. 
 
 Various compounds have been used for disinfecting purposes, among 
 which may be noted Collin s's Disinfecting Powder, which consists of two 
 parts of fresco and dry chloride of lime, and one part of burnt alum, well 
 
 * Vide an excellent article on this subject by Carroll Dunham, M.D., in the Transactions 
 of the American Institute of Homoeopathy for 1869, p. 117. 
 
DISINFECTANTS AND ANTISEPTICS. 63 
 
 mixed together ; if the weather be very dry, a little water may be added . 
 The powder may be placed on plates or pieces of glass, and should be 
 renewed every day.* 
 
 The following compound is known as " Thompson's Deodorizer and 
 Disinfectant:" 
 
 Gypsum, 6 parts. 
 
 Fresh-burned ground lime, 2 " 
 
 Prepared charcoal, 2 " 
 
 Wood ashes, 1 part. 
 
 Common salt, 1 " 
 
 This compound slowly develops chlorine gas, and is very cheap as well 
 as efficacious. 
 
 Heat is a powerful disinfectant, combining the properties of both deodori- 
 zation and disinfection. Burn, if possible, old clothes, and the wornout 
 coverings of mattresses or bed tickings, or thoroughly expose them to a 
 dry atmosphere of 280° F. Steam may also be used with most excellent 
 results. 
 
 Fire was used in many ways by the ancients as a purifier, and large fires 
 were often kindled in the streets of their cities, which, with the perfumes 
 of flowers, renewed the air. 
 
 Coffee. — A very good deodorizer is the smoke or vapor which arises from 
 coffee, when it is being roasted over a moderately hot fire. In the dissecting- 
 room I have found it very serviceable, and by keeping a good-sized shallow 
 vessel half full of coffee, and stirring the same occasionally, the atmosphere 
 is entirely deprived (at least so far as olfaction goes) of its unhealthy odor. 
 
 Bromine is an expensive though a good disinfectant. When the stopper 
 is removed from the vial containing it, spontaneous evaporation takes place. 
 It is, however, somewhat difficult to manage, and from its cost, is not very 
 much used. 
 
 Ozone. — Dr. T. Herbert Baker, in his prize essay, gives the preference to 
 this agent for steady and continuous effect. It belongs, according to Dr. 
 Day, to those bodies which disinfect and deodorize by resolving and decom- 
 posing into primitive and innoxious forms the deleterious matters. It 
 does not, however, possess these qualities in so great a degree as chlorine 
 and bromine. 
 
 Ozone can very easily be released, by placing a stick of phosphorus in 
 a cup filled with water, and allowing an end of the phosphorus to remain 
 uncovered. During the night less should remain exposed than during the 
 day, and it should be removed from the apartment altogether for several 
 hours at a time, because ozone in excess is hurtful. 
 
 Iodine is a powerful disinfectant, and can be used with benefit in the 
 following manner : Expose to the air a teaspoonful of the crystals of iodine 
 in a cup or on a piece of porcelain, which may be put beneath the bed, or 
 in a convenient place, and will have a most excellent result. 
 
 During the severe cholera season of 1866, in St. Louis, I employed this 
 substance continually, and also ordered all the vessels used by the patients 
 to be immediately emptied and rinsed with a solution of the tincture of 
 iodine. 
 
 The Nitrate of Lead has been also used with success as a disinfectant. The 
 compound known as Ledoyen's disinfecting fluid, is nothing more than 
 this salt in solution, in the proportion of a drachm to the ounce of water. 
 This is said to be particularly efficacious in the correction of fetid odors 
 depending upon the presence of sulphuretted hydrogen, or hydrosulphate 
 
 * Medical and Surgical Reporter, vol. xix, p. 76. 
 
64 A SYSTEM OF SURGERY. 
 
 of ammonia, which it decomposes. It may also be sprinkled in apart- 
 ments, or mixed with offensive discharges. This substance, however, does 
 not prevent or arrest animal decomposition, nor does it render contagious 
 or marsh miasms innoxious. 
 
 Chlorine. — One of the best antiseptics of the present day is chlorine. Its 
 destructive powers are great, and it was discovered by Scheele in 1774. It 
 is produced in several ways : first, by pouring on peroxide of manganese, 
 muriatic acid ; second, by adding one and a quarter alum-cake, or sulphate 
 of alumina, to one of chloride of lime ; third, by " occasionally dropping a 
 crystal of chlorate of potash into muriatic acid." The action of this gas is 
 twofold : " the chlorine combines with hydrogen and thus forms new com- 
 pounds; with water it renders oxygen nascent, so that it is a powerful 
 oxidizing agent, and so oxygen comes forward." There are many com- 
 pounds of it used for disinfecting purposes. The formula for the United 
 States army hospitals is as follows : eighteen parts of common salt to fifteen 
 parts of binoxide of manganese ; after having mixed them thoroughly, pour 
 upon them a solution composed of forty-five parts of concentrated sulphuric 
 acid and twenty-one parts of water. 
 
 Under the direction of Dr. James R. Wood, the wards of the Bellevue 
 Hospital were thoroughly and effectually fumigated, in the spring of 1875, 
 with chlorine. 25 sacks of salt, and 5000 pounds of manganese were em- 
 ployed. 
 
 The Zinci Chloridi Liquor is much employed for disinfecting purposes, and 
 from considerable experience in its use, I am prepared to speak highly of 
 its properties. The disinfecting fluid of Sir William Burnett is an aqueous 
 solution of the chloride of zinc. It contains 200 grains of zinc to each 
 imperial fluid ounce, and has a specific gravity of .2. It was introduced in 
 1840 ; and besides its deodorizing properties, prevents the decomposition of 
 both animal and vegetable matter. According to Sir William Burnett, it is 
 a sure preventive of dry rot. This substance has no smell of its own, while 
 it totally destroys offensive odors arising from various causes. For pro- 
 ducing a good deodorizing fluid on a large scale, four gallons of water may 
 be mixed with a pint of the original fluid. In the dissecting-room, to 
 preserve bodies for anatomical purposes, one part of the fluid may be added 
 to 15 or 18 parts of water. 
 
 The Calcis Chlorinatae Liquor is another preparation which is highly lauded, 
 and possesses powerful disinfecting properties. The chlorinated lime, like 
 the chloride of zinc, arrests both animal and vegetable decomposition, and 
 has been supposed by some to have the power of destroying pestilential 
 miasms. In exhumations for judicial or other purposes it has been used 
 with success, as it completely destroys the disgusting odor arising from the 
 putrefying mass. The method of applying it, is to envelop the corpse in a 
 sheet saturated with a solution of the substance made by adding a pound 
 of the chloride to a bucketful of water. The chloride of lime, perhaps, is 
 more extensively known and used as a domestic agent for the removal of 
 offensive smells than any other. This material acts by the purifying effects 
 of the chlorine, which is disengaged by the acids, and as carbonic acid is 
 known to be a product of decaying animal and vegetable matter, it may be 
 said that the effluvia furnish the means for their own neutralization. 
 
 Labarraque's Solution of chlorinated soda is another excellent preparation. 
 Its efficacy consists mostly in the powers of chlorine, and is so easily ob- 
 tained, being put up by the chemists in a convenient form for ready use, 
 that it is quite a favorite disinfectant. 
 
 Permanganate of Potash. — This substance is a most excellent disinfectant, 
 but it is not an antiseptic ; it is the base of the well-known Condy's Fluid, 
 and is much used in practice. It is formed, according to the U. S. P., by 
 
DISINFECTANTS AND ANTISEPTICS. 65 
 
 mixing equal parts of very finely powdered deutoxide of manganese and 
 chlorate of potash, with rather more than one part of hydrate of potassa, 
 dissolving in a small quantity of water, and exposing the whole, after 
 evaporation to dryness, to a temperature just that of redness. The mass is 
 treated with hot water, the insoluble oxide separated by decantation, and 
 the deep purple liquid concentrated by heat, until crystals begin to form 
 upon the surface, when it is left to cool and crystallize. The crystals have 
 a dark purple color, and can be dissolved in sixteen parts of water. 
 
 The efficacy of this preparation has rendered its use very extensive, some 
 surgeons preferring it to carbolic acid. A little of the solution poured over 
 the foulest bodies almost instantly disinfects them. 
 
 I have found it very useful in many ways. In fetid perspiration of the 
 feet, a tablespoonful of a solution composed of permanganate of potash 
 grs. viij, to the ounce of water, added to an ordinary foot-bath, is very 
 efficacious. As a gargle, in follicular tonsillitis, it has been used by many, 
 in the proportion of grs. iv to water 3 viij. As an injection, to allay the fetor 
 arising from cancers, a good formula is, permanganate of potash grs. viij to 
 water jj, add to this an equal quantity of water, and use as a lotion or 
 injection. In ozsena it has been used in the proportion of one grain to one 
 ounce of water. 
 
 At certain times, to purify the atmosphere of large hospitals, where pes- 
 tilential or other infectious diseases are being treated, and where numbers 
 are dying of the disorders, it has been found necessary to disinfect the 
 air by fumigations. Of these, the fumigatio Guytoniensis, or oxymuriatic 
 fumigation, is prepared by adding common salt Jiij to black oxide of man- 
 ganese £j, sulphuric acid 3j, and water ^ij ; this may be carried through 
 an apartment or placed in a corner of a room and allowed to remain for 
 several hours. 
 
 Piatt's Chlorides. — A very cheap and excellent disinfectant in every sense 
 of the word, is a saturated solution of the chlorides of metallic salts (Zinc, 
 Lead, Aluminum, Calcium, and Potassium), known as u Piatt's Chlorides. " 
 I have used this solution in large quantities, in both hospital and college 
 work, and also as a dressing, with very good results. Its cheapness, when 
 purchased in bulk, together with its'efficiency, make it a very desirable disin- 
 fectant. 
 
 The Nitrous Fumigation is made by placing nitrate of potash ^iv, and 
 sulphuric acid gij, in a saucer upon hot sand. This should only be used 
 after the patient has left the apartment, as the fumes prove irritating to the 
 respiratory apparatus. This irritation is not so much observed at first, but 
 after a few inhalations the lung substance and mucous membrane of the 
 air-passages become very much irritated, and in time even disintegration 
 may result. 
 
 Vinegar is an agreeable and by no means a mean fumigant. It is well 
 known to possess antiseptic properties. Its preservation of both animal 
 and vegetable substances is well known, the pickling liquids all having 
 this article for a base. It was used in ancient times as a prophylactic, 
 and it is said of Cardinal Wolsey that " he carried in his hand an orange, 
 deprived of its contents and filled with a sponge which had been soaked 
 in vinegar impregnated with various spices, in order to preserve himself 
 from infection when passing through the crowds which his splendor 
 attracted." 
 
 Dr. John Day* recommends the following as a self-generating disinfec- 
 tant : One part rectified oil of turpentine, seven parts benzine ; add a few 
 drops oil of verbena. Each of these agents has the power of absorbing 
 
 * The Medical Record, November 23d, 1878, No. 420. 
 5 
 
66 A SYSTEM OF SURGERY. 
 
 oxygen from the air and converting it into peroxide of hydrogen, a highly 
 active oxidizing agent not unlike ozone. This preparation is cheap, lasting, 
 eas}' of application, and does not injure fabrics of any kind. It may be 
 applied with a brush or sponge, or by sprinkling or pouring over articles. 
 It is very efficient, and the odor not disagreeable. 
 
 Antiseptics. — Tar Acids. — We have already spoken of fumigation with tar, 
 and come now to mention the so-called tar acids, some of which have been 
 very extensively used and with great success. There are several substances 
 given off from tar ; thus from wood tar we have creasote, and from coal tar, 
 carbolic and cresylic acids. 
 
 Creasote is a valuable antiseptic, and we fancy is not so frequently used 
 in this country as it should be. I have applied it with as good success as 
 carbolic acid, in the treatment of wounds, especially after amputations, and 
 have reason to speak well of its disinfecting properties, in the proportion of 
 a drachm of the drug to ten ounces of water, or we may use a fluid drachm to 
 about a pint of water, thus having a preparation of about equal proportions 
 with the aqua creasoti of the U. S. P. Gruelin asserts that water containing 
 one part of creasote to ten thousand, smells of smoke. Before it was dis- 
 covered by Reichenbach, it was used as a secret preparation in Italy, and 
 called aqua binelli. In Silesia, also, there was a preparation much in vogue 
 which received the name of aqua empyreumatica, which contained creasote. 
 
 Carbolic Acid. — This substance, now so much in vogue in surgical prac- 
 tice, was discovered in 1834 by Runge, but was not introduced into general 
 practice until the method of liberating it from the other products of coal- 
 tar was discovered by Laurent in 1841. 
 
 Carbolic acid is introduced in two forms — the crystals, and what is termed 
 the impure carbolic acid. Of these preparations, Dr. Squibb, the best 
 authority on the subject, writes : 
 
 " The crystallized phenol, or miscalled ' carbolic acid crystals, 1 is nearly 
 colorless when first put up, but by keeping or exposure to light and air, 
 it acquires a red or brown tinge. For dispensing, a fluid ounce of water 
 should be added to the contents of each one-pound bottle, and the whole 
 warmed until it is liquid. It will then remain liquid at ordinary tempera- 
 tures, and should be dispensed by minims, not drops. Each minim repre- 
 sents about onegrain of the crystals, and may be so considered in prescrip- 
 tion use. 
 
 " The so-called impure carbolic acid is really coal-tar creasote, or a mixture 
 of the three or more homologous phenols of coal-tar in varying proportions. 
 It contains from 92 to 96 per cent, of these phenols, the remainder being 
 the more volatile tar oils, which are harmless. Cresol, or the so-called 
 cresylic acid, is generally in largest proportion, and phenol, or the crystal- 
 lized carbolic acid, in next largest proportion. This mixture is better than 
 the crystallized carbolic acid for all known uses, whether internal or external, 
 and may, therefore, take the place of the more costly substance with ad- 
 vantage. It is colorless when recently made, but changes, chiefly by the 
 effect of light, through various tints of brownish-red to nearly black, with- 
 out becoming thick or tarry, and without material change in value or effect 
 All the useful portions of it are soluble in about twenty-five times its volume 
 of water by active shaking together. The insoluble residue is impurity 
 (tar oils)." 
 
 In 1863 Dr. Jules Lemaine wrote a treatise on carbolic acid,* in which 
 the virtues of the acid are highly extolled in very many disorders. In 
 1864 F. C. Calvert & Co., of Manchester, England, after numerous experi- 
 
 * Vide an exhaustive review of the work, in the British Journal of Homoeopathy, vol. 
 xxiii, p. 286. 
 
ANTISEPTICS. 67 
 
 ments were finally enabled to render the article pure enough and cheap 
 enough for general use. The drug, however, became in a short period so 
 universally popular, that many worthless articles have been thrown upon 
 the market, and it is therefore well to be prepared with proper tests 
 to ascertain the purity of the article. The following are the suggestions of 
 William Crookes, F.R.S., who has given a great deal of care and attention 
 to the subject. He says : 
 
 " Put a teaspoonful of the carbolic acid in a bottle, pour on it half a pint 
 of warm water, shake the bottle at intervals for half an hour, when the 
 amount of oily residue will show the impurity ; or, dissolve one part of 
 caustic soda in ten parts of warm water, and shake it up with five parts of 
 carbolic acid. As before, the residue will show the amount of impurity." 
 Experiments have shown that very small portions, even %-fajs part, will 
 prevent decomposition. Mr. Crookes found that meat steeped in a one per 
 cent, solution, and then dried, preserved a fresh odor. A solution of albu- 
 men was very slowly and not completely coagulated by a one per cent. 
 solution, and a few drops added to half a pint of fermenting sugar or yeast, 
 stops the action. Cheese-mites, fish, infusoria, caterpillars, beetles, and 
 gnats are immediately destroyed. 
 
 So soon as carbolic acid was introduced, it became a very fashionable 
 and favorite application by both physicians and surgeons, and the medical 
 periodicals were filled with different prescriptions for various diseases. 
 Professor Lister, of the University of Glasgow, offered several preparations, 
 which were received with general favor : 1st, a simple solution, one part of 
 the acid being added to 50 or 100 parts of water ; 2d, carbolated oil, one 
 part of the acid to six parts of boiled linseed oil ; 3d, carbolic putty or 
 paste, being a mixture of carbolic acid and whiting. Vide the antiseptic 
 treatment of wounds in this volume. 
 
 Professor Andrews makes use of simpler preparations than Prof. Lister, 
 as follows : Take one ounce of the crystals, agitate it in a bottle with ten 
 or fifteen ounces of water, settle for a few moments, and the clear five per 
 cent, solution will appear at the top, and the surplus acid settle in the form 
 of a ninety-five per cent, solution. This can be readily mixed with other 
 substances. An ounce of the crystals may be mixed with an ounce of any 
 oil, or an eighth part of collodion mixed with one part of carbolic acid. 
 
 In our own school, besides the valuable paper already alluded to as 
 appearing in the British Journal of Homoeopathy, we have an exhaustive 
 pamphlet by Backmeister, and an article of Dr. Lord in the U. S. Medical 
 and Surgical Journal for January, 1869. 
 
 It has been recommended as very serviceable in cancer by Dr. Beebe, and 
 has been used in a great variety of preparations for very many disorders. 
 A very useful preparation in glycerin, I have used with excellent result in 
 wounds and sloughing ulcers, gangrenous and unhealthy stumps ; it is 
 simply ten drops of carbolic acid to the ounce of glycerin. This is very 
 easily prepared, and is a most excellent application. It is useful also as 
 a solution in which to soak the catgut in preparing the animal antiseptic 
 ligatures. 
 
 Carbolated alcohol is highly spoken of as a dressing for wounds.* 
 
 This drug has been used for diarrhcea,t for pregnancy sickness,! dyspep- 
 sia, vomiting, colic, dysentery,§ constipation, gonorrheal ophthalmia, || bites 
 of venomous snakes, whooping-cough ,^[ sloughing syphilitic ulcers, nsevus,** 
 
 * Medical and Surgical Reporter, August 21st, 1869. 
 
 f Loc. tit, January 23d, 1869, p. 78. 
 
 % British Medical Journal, February 13th, 1869. 
 
 | Hahnemannian Monthly, vol. v, p. 219. || Medical Archives, January, 1870, p. 51. 
 
 If Medical Investigator, July, 1867, p. 117. ** Medical Press and Circular. 
 
68 A SYSTEM OF SURGERY. 
 
 eczema,* pityriasis versicolor,! favus, burns, wounds, ulcers, and ab- 
 scesses, and almost every disorder in the category. It has also been used 
 with many other substances, as iodine, cod-liver oil, lime, calendula, alcohol, 
 potash, and glycerin. 
 
 For a resume of the various carbolic acid preparations, the following, from 
 the Chemist and Druggist, may offer some suggestions. 
 
 As a rule, it is better to dissolve the crystallized carbolic acid (Calvert's) 
 in the proportion of one part by weight of the acid to six of glycerin (car- 
 bolate of glycerin). In this state it can be diluted equally indefinitely. 
 
 In general, a dose (according to the old school) of carbolic acid is 1 grain 
 in an ounce of water. 
 
 As a gargle, 1 or 2 grains to an ounce of water. 
 
 As an injection, 1 grain to 4 ounces of water. 
 
 As a lotion, 15 grains to an ounce of water. 
 
 As an ointment, 30 grains to an ounce of benzoated lard. 
 
 As a liniment, 1 part to 20 of olive oil. 
 
 As a plaster, 1 part of carbolic acid to 3 of shellac. 
 
 The crystallized carbolic acid to be used as a caustic. 
 
 The carbolate of glycerin, as above, should be used in 1 or 2 drop doses. 
 
 Antiseptic oil, for abscesses, 1 part of the acid to 4 of boiled linseed oil. 
 
 Antiseptic putty, 6 spoonfuls of the antiseptic oil, mixed with common 
 whiting. 
 
 Aqueous solution of carbolic acid is one part of acid to forty of water. 
 (One ounce of acid to a quart of hotwater well agitated and filtered.) 
 
 To disinfect sick-rooms : place a portion of the dissolved acid in a porce- 
 lain dish, and float it in a larger vessel of hot water. 
 
 Disinfecting purposes generally : 1 pound of crystals to 6 gallons of water. 
 Fluid, 1 part to 80 of water. Powder, 1 ounce of crystals with 4 pounds of 
 slaked lime. 
 
 For drains : take 1 pound of the fluid carbolic acid to 5 gallons of warm 
 water. 
 
 Toothache is often cured with one drop of carbolate of glycerin, and 
 diarrhoea arrested in half an hour with two drops. 
 
 In all cases of parasitic life it is advisable to commence with very dilute 
 carbolate of glycerin. 
 
 In a somewhat extensive surgical practice I have used carbolic acid many 
 thousands of times, but I have never used any mixture internally, saving the 
 one with glycerin, of which mention has been made, and the aqueous solution, 
 and at times a few drops of the acid with the tincture of calendula. It has 
 proved so very efficacious in these simple mixtures, that I have never had 
 any inclination to use it in other forms, believing that the more simple the 
 solution, the more undivided will be the action of the medicine. In cases 
 of compound fracture, or after resection, I have mixed the dilute acid with 
 the bran dressings, especially when there is great suppuration, and I cannot 
 speak too highly of its efficacy in this particular. The disinfection is com- 
 plete, and the bran which has absorbed the pus forms into cakes, which are 
 readily removed with a spatula or spoon ; fresh carbolated bran is then 
 poured into the box, and the whole thus kept pure and clean. I have used 
 it also to destroy maggots in wounds, with astonishing results. 
 
 To some, the odor of carbolic acid is offensive. It may be removed by 
 combining two parts of gum camphor and one of carbolic acid in crystals, 
 and mixing with whiting ; a liquid is thus formed with powerful disinfecting 
 properties, but entirely free from the odor of carbolic acid. 
 
 * Medical and Surgical Reporter, vol. xxi, No. 1. 
 f lb., vol. xix, p. 426. And many other periodicals. 
 
ANTISEPTICS. 69 
 
 The Glycerob orate of Calcium and the glyceroborate of sodium have both 
 been highly spoken of as antiseptics, and were introduced to the French 
 Academy by M. G. LeBon. Both of these agents are very soluble, are 
 destitute of odor, and are especially free from all toxic action. "When in 
 contact with the atmosphere, they both deliquesce with rapidity, absorbing 
 from the air an equivalent weight of moisture. Alcohol and water dissolve 
 twice their own weight of the salts. 
 
 The calcium salt is the most efficacious, is absolutely innocuous, a strong 
 solution being able to be applied to the eye without any bad results. It can 
 be used also as a preservative of meat and other alimentary products, by 
 coating the same with a varnish made of it * 
 
 Chloralum. — Professor Gamgee, in a London periodical, enumerates the 
 properties of the chloride of aluminum, as employed for medical purposes. 
 This salt in itself is not new, having been long known to chemists, and used 
 by the manufacturers of aluminum. Its true name is the hydrated chloride 
 of aluminum ; this, from its length, is objectionable for ordinary use, there- 
 fore the term chlorralum has been adopted. 
 
 This substance possesses highly antiseptic properties, and has proved 
 useful in my hands, but I judge from the very limited experience I have 
 with it, in preserving specimens and in keeping wet preparations. Accord- 
 ing to the Druggist's Circular, its chief merits consist in being inodorous 
 and as harmless as common salt. Its power of preserving organic substances 
 may arise both from its metallic base and the chlorine it contains. 
 
 A solution of one part of chloralum in twenty of water preserves flesh, 
 which may be suspended in the air to dry, and afterward, if desired, cooked 
 and eaten. A small portion of the solution added to milk, prevents its 
 decomposition, and the beer bottlers now employ its undiluted form in 
 preference to the bisulphite of lime. 
 
 Professor Gamgee asserts, from his experience in its use, that it attracts 
 to itself all moisture ; and the moist particles inclosed or embodying fever 
 germs, are absorbed if a cloth damped with it be suspended in the sick- 
 chamber. In the Middlesex Hospital, in London, it is used by Mr. Camp- 
 bell de Morgan in the antiseptic treatment of wounds. Mr. Edward Lund, 
 of the Manchester Royal Infirmary, employs it to remove the fetor in open 
 cancer. It has also been applied as a collyrium, and as an astringent in 
 diarrhoea. The chloralum powder is also very useful for sprinkling the 
 wards of hospitals, and disinfecting cow-sheds and slaughter-houses. 
 
 Chloralum gained favor in England ; and though comparatively new, the 
 solution is being produced by the thousand gallons daily ; and a thirty per 
 cent, odorless disinfecting powder, at the rate of four tons a day. A com- 
 pany is also established which manufactures chloralum. 
 
 Messrs. Tilden & Co. prepare a solution which they term bromo-chloralum, 
 which is also very highly recommended. Professor Charles A. Lee states 
 that it is a certain, perfect, and prompt deodorizer and disinfectant, and for 
 hospital use is very efficacious. 
 
 Thymol is extracted from the essential oils obtained from the common 
 thyme, thymus vulgaris, the horse mint, monarda punctata, and an Eastern 
 drug called ptychotis djonan. In commerce it consists of irregular broken 
 crystals, nearly transparent and colorless. It has an aromatic taste. Its 
 specific gravity when it is fused is lighter than that of water. It is a powerful 
 antiseptic, and said to be superior to carbolic acid. The advantages claimed 
 for the thymol are : first, its efficiency as an antiseptic ; second, the absence 
 of irritating effect ; third, that it does not injure the instruments used ; and 
 fourth, that a solution of one strength is required for all purposes, the pro- 
 portion being, 1 part of thymol to 1000 parts of water. The formula is : 
 
 * London Lancet, August, 1882. 
 
70 A SYSTEM OF SURGERY. 
 
 Thymol, 1.0 grams or grs. xvss. 
 
 Alcohol, 10.0 " stfrj. 
 
 Glvcerin, 20.0 " %bb. 
 
 Water, 1000.0 " §xxxiv. 
 
 The proportions for making the gauze are : 1000 parts gauze, 500 parts 
 spermaceti, 50 of resin, 16 of thymol* 
 
 From late experience with thymol, this substance has not equalled the 
 expectations of those who have employed it.f 
 
 Dr. Hoskin, in the Boston Medical and Surgical Journal, describes a new 
 and simple apparatus, the object of which is to vaporize certain chemical 
 substances and thus thoroughly to disinfect the air, walls, ceiling, and, in 
 short, the entire contents of any apartment, however large. The instrument 
 by the aid of which this is to be accomplished may be briefly described as 
 consisting of a bottle, a wick, and a bulb of platinum-sponge attached to 
 the free end of the wick. Into the bottle should be poured an alcoholic 
 solution of the substance which it is desired to vaporize (for instance, car- 
 bolic acid) ; the wick is then to be lighted, and the flame extinguished as 
 soon as the ball becomes 'red hot, which requires but two or three minutes. 
 The ball is now fed continuously by the wick, and will continue red hot as 
 long as any fluid remains in the bottle, and in this condition it will readily 
 vaporize the substance in solution, minute particles of which are thus 
 
 scattered throughout the atmosphere It has been estimated that a 
 
 bottle holding two ounces will throw out a constant stream of vapor for 
 about sixteen hours, at an expense not exceeding twenty cents. 
 
 Potassa fusa is recommended by Dr. Hiller, of San Francisco, as a powerful 
 antiseptic, and as possessing great influence over the process of granulation 
 and cicatrization. The doctor employs a weak solution of the caustic ; 
 merely sufficient to make a " soapy " feeling when rubbed between the 
 fingers, and grades this to the susceptibility of the patient. He records 
 cases in which he has injected it into wounds and fistulous openings with 
 marked success. J 
 
 Among the more recently introduced antiseptics, especially employed in 
 the treatment of wounds, are iodoform, the bichloride of mercury, turf, the 
 peroxide of hydrogen, oxidized oil of turpentine, and others — for a de- 
 scription of which, the reader is referred to the ohapter on "The Present 
 Status of Antiseptic Surgei-y" 
 
 CHAPTER III. 
 ANESTHESIA. 
 
 Ether — Discovery of Anesthesia — Inhalers — Ether by the Rectal Method — 
 Chloroform — Symptoms of Danger — Death — Nitrous Oxide— Bichloride of 
 Methylene— Bromide of Ethyl— Sickness and Death from Anesthesia — 
 Local Anesthesia— Richardson's Apparatus — Anesthetic Ether — Hydrate 
 of Amyl — Hydramel — Anesthetic Mixtures for small Operations — Hydro- 
 chlorate of Cocaine. 
 
 In the practice of surgery there are powerful auxiliary means, which, if 
 called to the assistance of the surgeon, will not only render the condition 
 of the patient similar to that which is noticed immediately after the receipt 
 
 * Thymol as an Antiseptic, by William T. Bull, M.D., Medical Recorder, April, 1878. 
 
 t Medical Record, November 23d, 1878. 
 
 X Vide U. S. Medical and Surgical Journal, vol. v, p. 170. 
 
ETHER. 71 
 
 of the injury, but will relax every voluntary muscle in the system as com- 
 pletely as in death, rendering these tissues thoroughly inert, and, at the 
 same time, exempting the patient from pain, which would otherwise be the 
 necessary attendant upon operations. Such a condition is effected by 
 allowing the patient to inhale an anaesthetic agent until its full effect is 
 produced upon the system ; by such means the use of hot baths is dis- 
 pensed with ; antimonials, in repeated doses, that formerly were adminis- 
 tered until the already suffering patient was nauseated to a most distressing 
 degree, are not needed ; tobacco in fume, by chewing, or in the form of 
 enema, is either forgotten or intentionally thrust aside ; and for an expen- 
 diture of the precious fluid ad deliquium animi, is substituted a simple and 
 effectual means, which, if skilfully and judiciously employed, is compara- 
 tively free from danger. 
 
 Anaesthesia may be divided into general, in which the whole system is 
 placed in a condition simulating death, and local, in which only portions of 
 the body are rendered insensible to pain. The fluids in most general use 
 at the present time to produce anaesthesia, are the oxide of ethyl, or ether, 
 commonly and improperly called sulphuric ether ; and chloroform, chloro- 
 formyle, or the perchloride of formyle. 
 
 Ether. — Ether belongs to America, and chloroform to Great Britain. As 
 is well known, the priority of claim to the introduction of ether as an 
 anaesthetic agent, has been hotly contested between Dr. Horace Wells, of 
 Hartford, Conn., and Dr. William T. G. Morton, of Boston, many of the 
 profession taking opposite sides. The American Medical Association, at its 
 meeting, held in Washington, 1870, passed the following resolution, " That 
 Dr. Horace Wells, of Hartford, Conn., was the discoverer of anaesthesia." 
 
 Very distinguished gentlemen, while giving the discovery of the nitrous 
 oxide anaesthesia to Dr. Wells, accord priority of the sulphuric ether anaesthesia 
 to Dr. Morton. In the strenuous effort made by the citizens of Boston to 
 rear a monument to the memory of the latter gentlemen, he is styled ' k the 
 inventor and revealer " of anaesthesia. 
 
 From a careful study of all the facts in the case, there can be no doubt 
 that Dr. Morton introduced the inhalation of sulphuric ether into surgical 
 practice, and we believe that this is all that he claimed. Dr. J. Mason 
 Warren having been personally interested in the introduction of ether, thus 
 writes in the appendix to his Surgical Operations; he says: "The facts, so 
 far as I am acquainted with them, are as follows : In the autumn of 1846, 
 Dr. W. T. G. Morton, a dentist in Boston, a person of great ingenuity, 
 patience, and pertinacity of purpose, called on me several times to show 
 some of his inventions. At that time I introduced him to Dr. John C. 
 Warren. Shortly after this, in October, I learned from Dr. W T arren that Dr. 
 Morton had visited him, and informed him that he was in possession of, or 
 had discovered, a means of preventing pain, which he had proved in dental 
 operations, and wished Dr. Warren to give him an opportunity of trying it 
 in a surgical operation. After some questions on the subject, in regard to 
 its action, and the safety of it, Dr. Warren promised that he would do so. 
 On the Tuesday following, October 13th, after the surgical visit at the hos- 
 pital, a patient was brought into the amphitheatre for operation, this being 
 the first opportunity which had occurred since Dr. Warren's promise to Dr. 
 Morton. Dr. Warren said to us : i I now remember that I have made a 
 promise to Dr. Morton to give him an opportunity to try a new remedy for 
 preventing pain in surgical operations,' and asked the patient if he should 
 like to have the operation done without suffering. He naturally answered 
 in the affirmative. The operation was therefore deferred until Friday, 
 October 16th, when the ether was administered by Dr. Morton with his 
 apparatus, and the operation performed by Dr. Warren. It consisted in the 
 
72 A SYSTEM OF SURGERY. 
 
 removal of a vascular tumor of the neck, which occupied five minutes. 
 During a part of the time the patient showed some marks of sensibility ; 
 but subsequently said that he had no pain, although he was aware that the 
 operation was proceeding. On the following day, a woman, requiring the 
 removal of an adipose tumor from the arm, was rendered insensible by 
 ether, given by Dr. Morton ; and Dr. Warren requested Dr. Hay ward, who 
 was present, to perform the operation. This was successful, the ether being 
 continued through the whole operation, which was a short one, and the 
 patient being entirely insensible. A few days afterwards, Dr. Warren in- 
 formed me that he had learned from Dr. Charles T. Jackson that he had 
 suggested the use of ether to Dr. Morton. 
 
 " The success of this process in the prevention of pain, was now quite 
 established. Its use, however, was suspended for a time, for reasons which 
 Dr. Warren has already given in his first paper on ether; and the experi- 
 ments were not again resumed until November 7th, when Dr. Warren 
 declared his willingness to state the nature of the agent employed. Two 
 important operations were now done successfully at the Massachusetts 
 General Hospital under its agency : one an amputation of the thigh, by Dr. 
 Hay ward ; and the other, a very difficult and bloody operation — removal 
 of a portion of the upper jaw on a woman — by Dr. Warren." 
 
 Shortly after these successful operations, an application for a patent was 
 made, which was obtained in about thirty days, and issued in the names 
 of Dr. C. T. Jackson and Dr. Morton. For some unknown reason, the 
 former gentleman withdrew his name from the patent in favor of the latter. 
 On account, however, of the odium in the minds of the profession connected 
 with patents, either in medicine or surgery, very slight effort was made to 
 enforce it. Ether was in daily use, and but little, if any, notice taken of 
 the infringement. On the 28th of December, 1846, an application was made 
 to the United States Government for an appropriation of $100,000 as a 
 national recompense, which met with decided favor. At that time both 
 Dr. Jackson and Dr. Wells laid claim to the discovery ; this prevented the 
 accomplishment of the design. In 1849, in 1851, and 1853, other efforts 
 were made, but the persistency of the opposition faction rendered them 
 futile. Dr. Morton then, having exhausted his means, and being reduced 
 in circumstances, brought suit against the Government for infringement of 
 his patent, but without success. Contributions were set on foot to relieve 
 him, but from some unknown and unaccountable cause, failed; as did also 
 a second suit against the varied hospitals and infirmaries in which ether 
 had been employed. Dr. Morton finally died, discouraged, disheartened, 
 and penniless. His remains rest in Mount Auburn Cemetery, near Boston, 
 over which, at last, I am glad to say, a handsome obelisk is reared, with a 
 suitable inscription, to the memory of the man who has conferred an 
 inestimable boon upon suffering humanity. 
 
 It seems, however, very probable, from a vast amount of printed and 
 other testimony that I have seen, that the operation above detailed by Dr. 
 Warren, was not the first one in which ether was successfully employed. 
 Dr. E. E. Marcy, formerly of Hartford, now of New York (in December, 
 1844), performed, an operation prior to the operation of Dr. Warren. But 
 there have lately arisen others, whose claims to priority must be remem- 
 bered ; among them, Dr. Crawford W. Long, of Georgia, who, in March, 
 1842, removed a tumor from the neck of Mr. Venables, while the latter was 
 completely anaesthetized with sulphuric ether. 
 
 In the Medical and Surgical Reporter* we find that one Dr. Samuel Wool- 
 sten, an aged physician of New Jersey, knows that ether, with morphine 
 
 * May 27th, 1870. 
 
ETHER. 73 
 
 dissolved in it, was used in surgical operations, to destroy pain, as far back 
 as 1836. He refers to the files of the National Intelligencer of June, 1836, for 
 an advertisement for extracting teeth without pain " by the administration 
 of ether." 
 
 Before closing this brief account of the discovery of the anaesthetic prop- 
 erties of ether, I desire to call attention to a pamphlet bearing the following 
 title : " An Essay on the Exhilarating and Medicinal Effects of Ethereal 
 Inhalation," by Caleb Bently Matthews, M.D., of Alexandria, Virginia, in 
 1824. Dr. Matthews was one of the editors of the Medical Recorder for 1827 
 and 1828, and the essay is dedicated to Thomas C. James, M.D., Professor 
 of Midwifery in the University of Pennsylvania. After some preliminary 
 remarks, Dr. Matthews, in regard to the manner of inhalation, says : " For 
 this purpose it is only necessary to procure an oiled-silk bag, or a bladder 
 of the capacity of one or two gallons, and affix to it a brass air-cock and 
 an ivory or wooden mouthpiece ; such as are usually employed for the 
 purpose of inhaling the nitrous oxide." The doctor then details his symp- 
 toms and the great exhilaration which was produced, and the most marked 
 appearances of face, eyes, and the condition of pulse, with all of which we, 
 in these days, are perfectly familiar. After this, and on the 13th of January, 
 1824, he states that he breathed the ethereal vapor " from a quart bottle 
 containing sixteen ounces of strong sulphuric ether." He inhaled a large 
 quantity, until his friends, alarmed for his safety, persuaded him to relin- 
 quish his experiments, but he sank into a profound slumber. I introduce 
 these remarks to show that an idea of ethereal inhalation was present as far 
 back as 1824; and that, if the experiments had been carried sufficiently 
 far, the great boon to suffering humanity would have been introduced much 
 earlier ; and, more especially, because I desire to record a tribute to the 
 memory of Caleb Bently Matthews, who afterward became one of the most 
 zealous followers of Hahnemann, and was my professor of materia medica 
 in the first years of my student life. 
 
 Ether was used to a considerable extent in this country, but for a period 
 of time gave place to chloroform, on account of the much more rapid 
 anaesthesia produced by the latter, and the much less duration of the stage 
 of excitement, and, perhaps, more especially from an imperfect knowledge 
 of the proper method of administration. In the employment of ether, it 
 must be remembered, that rapid evaporation takes place, and that by the 
 ordinary methods of inhalation, very oftenmore of the fluid escapes into 
 the apartment than is inhaled by the patient, and thus the stage of excita- 
 tion is very much lengthened. 
 
 The ordinary method of administration is as follows : Wrap a towel into 
 the form of a cone, insert a piece of sponge in the apex of this cone, and 
 inclose the napkin in a thick piece of wrapping-paper ; pour a small quan- 
 tity of Squibb 's sether fortior upon the sponge, and hold it firmly over the 
 mouth and nose. 
 
 I have used many inhalers, as they are called, some being much better 
 adapted to the purpose than others, but I have now in my own practice 
 discarded them in toto for many reasons. They soon become soiled and 
 look untidy ; the iron or wire, if such substance be used in their construc- 
 tion, rusts ; but more especially because, when a patient is in a semiuncon- 
 scious state, spitting and vomiting are very common occurrences, and may 
 take place so suddenly that the apparatus cannot be removed in time, and 
 a most discomforting and often disgusting state of affairs presents ; besides, 
 it is not always agreeable to the patient to know that the same inhaler is 
 employed upon all occasions on the faces of all people. 
 
 The following simple and cleanly contrivance I use always, and call it 
 
 the ether cap." Take an ordinary newspaper, and fold it lengthwise, that 
 
74 
 
 A SYSTEM OF SURGERY. 
 
 it may be six or seven inches in width. Then fold an ordinary towel in the 
 same manner lengthwise, but allow it to be both larger and broader than 
 the paper. Insert the paper into the towel, as we would place the leaves 
 
 Fig. 52 
 
 iiiipim 
 
 of a book within the cover, as seen in Fig. 52 (the dotted lines representing 
 the paper). Fold one of the projecting portions of the towel lengthwise 
 over the paper, as seen in Fig. 53, then turn down one of the distal ends of 
 
 Fig. 53. 
 
 the towel over the paper, and neatly pin it there (vide Fig. 54.) Then turn 
 upon itself the towel and paper in folds of seven inches in length, or there- 
 
 FlG. 54. 
 
 
 ■iiiiiiiijij ^ 
 
 abouts, making the last fold to come even with the end of the paper, as 
 seen in Fig. 55. 
 
 Then all that is required, is to fold over the remaining ends of the towel 
 upon the paper and pin them securely. Over this I place a thin piece of 
 
 Fig. 55. 
 
 
 Fig 
 
 . 56. 
 
 
 t 
 1 
 f 
 
 1 
 
 ¥ 
 
 
 K> j| 
 
 P 
 
 
 india-rubber gauze or oiled silk, and we have a very serviceable and cleanly 
 apparatus, as in Fig. 56. 
 
 Into this ether cap first place cotton, and press it firmly to the bottom ; 
 upon this lay a good-sized sponge, and the " cap" is ready for use. 
 
 Having explained to the patient the manner of breathing, viz., to inhale 
 
ETHER. 75 
 
 as rapidly and fully as possible, as long as he retains consciousness, and not 
 to be alarmed at any unpleasant sensations which may be excited at first, the 
 cap is fitted as accurately as possible to the face, the towel accommodating 
 itself to all inequalities of surface, and having been once placed, it is to be 
 kept closely applied, and never once removed, excepting to pour on fresh 
 ether, until anaesthesia is complete. 
 
 It should be borne in mind, however, that there are certain conditions of 
 the body that render the practitioner cautious in the administration of 
 ether. It has been noted by Mr. Lawson Tait, that during the anaesthesia 
 by ether, the kidneys entirely suspend their action, and that in persons 
 suffering from nephritis the effects are often bad. This point I believe was 
 also noted by Dr. Emmet. I can bear testimony to the truth of these re- 
 marks, for in two cases of supra-pubic lithotomy both patients died of 
 uraemia, one on the third, the other on the fifth day, after apparently suc- 
 cessful operative procedure. Bronchitis should also, if present, lead to a 
 careful selection of the anaesthetic. 
 
 Etherization by the Rectal Method. — It appears that the idea of rectal etheriza- 
 tion was originated by Roux in 1847. Experiments were then made by Dr. 
 Vincente Heydo and M. Marc Dupuy, and in the same year Pirogoff pro- 
 duced anaesthesia by the introduction of the vapor of ether into the rectum. 
 From that period until the present, there appears to have been no further 
 effort to introduce the method into general practice, until the article by D. 
 D. Moliere appeared in the Lyons Medicate, March 30th, 1884. 
 
 From the analysis of the thirty cases published by him, it was found 
 that the stage of excitement was reduced, in some cases it was entirely 
 absent; that vomiting was much less frequent, and that a smaller quantity 
 of ether was required than by inhalation. The apparatus for the adminis- 
 tration, at first consisted of a bottle to hold the ether, the cork of which was 
 perforated by two tubes, one in the shape of a funnel, with a stopper, the 
 other serving for the attachment of an india-rubber tube, two feet long, to 
 which was affixed a rectal nozzle. The bottle holding the ether was then 
 placed in a vessel (pitcher) containing water, varying in temperature from 
 110° to 140°. The nozzle being inserted into the rectum, the ether rapidly 
 boiling sent its fumes into the intestines, and, being imbibed, produced 
 the desired unconsciousness. This, however, was found to be an imperfect 
 method, for the reason that there was likely to be a very unequal evapora- 
 tion of the ether. When the water cooled and had to be removed and hot 
 water added, the immediate application of the fresh heated water to the 
 bottle, caused too rapid and sudden evaporation, and therefore an apparatus 
 was constructed to regulate the supply of the anaesthetic. It consisted of a 
 teapot, capable of holding two quarts, into which a siphon was inserted, 
 by which the cold water could *be drawn from the bottom of the vessel, 
 while the hot water could be poured in through the spout of the teapot. 
 
 It was also ascertained that an earthen vessel holding two quarts of water, 
 at a temperature of 130°, will lose 5° of heat in about ten minutes, and that 
 therefore if a steady administration is necessary, the thermometer must be 
 used from time to time and carefully watched. 
 
 Rectal etherization was at once employed by several surgeons in New 
 York. Dr. William T. Bull* reports seventeen cases in which it was used, 
 and from which I make the following analyses : In nine cases there was no 
 stage of excitement; in eight cases there was more or less excitement, 
 though in some instances very slight. In six cases there was no vomiting. 
 In eleven cases emesis occurred, some patients vomiting once, others more 
 frequently. In six cases diarrhoea occurred, in one instance fourteen loose 
 
 * Medical Record, May 3d, 1884. 
 
76 A SYSTEM OF SUKGERY. 
 
 and bloocty discharges taking place ; in several others blood was noticed in 
 the stools. 
 
 Dr. James B. Hunter* reports six cases, without any very unpleasant 
 symptoms being noted. In the first case it took eight minutes to complete 
 the anaesthesia, which was maintained for twenty-five minutes, the quantity 
 of ether used being an ounce and a quarter. In the second case, it required 
 four minutes to produce an effect, when a diarrhoeic passage resulting, the 
 inhaler was emp]oyed. In the third case, the time was six minutes, the 
 quantity required two ounces, and the process maintained twenty-three 
 minutes. In the fourth case (ovariotomy) the quantity of ether required 
 to anaesthetize the patient in six minutes was an ounce and a half. The 
 inhaler was then resorted to. In the fifth case it took seven minutes to 
 produce insensibility, which was maintained twenty-seven minutes by two 
 ounces of ether ; and in the sixth case, unconsciousness was produced by 
 the rectal method, but was kept up by the inhaler. No unpleasant symp- 
 toms followed. 
 
 Dr. Weir also relates two trials of this method, in one of which, he lost 
 his patient, a child of eight months old, upon whom the operation for hare- 
 lip had been performed. It did not recover well from the anaesthesia, had 
 several bloody passages during the night, and died the following morning. 
 Dr. Weir states, that during the latter part of the anaesthesia fresh hot water 
 was used, which caused too free evaporation of the ether, a condition of 
 things which has already been noticed as being likely to occur unless the 
 siphon teapot be employed. 
 
 In the Hahnemann Hospital the method has only been used a few times ; 
 in these, the ether fumes were detected on the breath in about three minutes, 
 and no unpleasant symptoms were noted afterward. 
 
 With the few trials of rectal etherization which have thus far been made, 
 of course a very imperfect estimate of its value can be arrived at. It may, 
 however, when a proper apparatus for the administration of the ether has 
 been constructed, be especially useful in many cases of operation about the 
 mouth and throat. It appears to me, however, that the chief drawback will 
 be in the difficulty in regulating the quantity, after the patient has become 
 unconscious, knowing as we do, how much more susceptible some persons 
 are to the effect of the anaesthetic than others, and how evanescent and 
 subtle is the vapor; — it might be a difficult matter to stop its absorption, 
 even if the rectal tube be withdrawn, if the intestines were thoroughly 
 inflated with it. 
 
 The chief advantages claimed for the method, are the slight stage of 
 excitement, the absence of nausea and vomiting. By the " mixed anaes- 
 thesia," these inconveniences are also vastly modified, and we have not the 
 diarrhoea and tenesmus to apprehend. Time, however, will soon demon- 
 strate the true value of etherization by the rectal method ; until this has 
 been fully established, careful experiments will be necessary, and these, too, 
 often repeated. The decision of the profession is rather against, than in 
 favor of, the method. 
 
 Whiskey has been lately highly spoken of by Dr. H. L. Obetz, who has 
 had considerable experience with it as an anaesthetic. He has operated 
 upon several patients while this agent was employed, and speaks highly 
 of its effects and its freedom from danger.f The author recollects a suc- 
 cessful amputation performed without pain in the Pennsylvania Hospital 
 many years ago by Dr. Norris, the patient being intoxicated. 
 
 Chloroform. — The other anaesthetic agent, chloroform or perchloride of 
 formyle, although known as a chemical product as far back as 1831, and 
 
 * Loc. tit, May 3d, 1884. 
 
 f North American Journal of Horn., March, 1886, p. 305. 
 
CHLOROFORM. 77 
 
 occasionally used in minute doses as an antispasmodic, was unknown as an 
 anaesthetic till the year 1847, when Professor Simpson, of Edinburgh, after 
 experimenting upon himself and some friends, announced its power of 
 producing a state of insensibility to pain. 
 
 Chloroform, when pure, emits a pleasant and fragrant odor, has a sweetish 
 taste, evaporates rapidly, and is dense and colorless. 
 
 The quantity required varies in different individuals ; an average may 
 be set down as from one to three drachms. The purer the article used, the 
 more promptly will it produce the desired effect. When it becomes neces- 
 sary to remove the handkerchief, for the purpose of moistening it again, its 
 reapplication should be quick. Any effort made by the patient to push 
 aside the handkerchief must be resisted; these efforts are made just before 
 the period of insensibility. That the chloroform has acted favorably is 
 known by an increased loudness of respiration. 
 
 Chloroform is the most rapid and effective anaesthetic known ; but it has 
 in the hands of many, and even distinguished surgeons, proved fatal. It 
 is, therefore, in my opinion, not so safe as ether in its administration. 
 
 The following may be laid down as reliable data in the inhalation of 
 chloroform. The patient should fast several hours before the inhalation, 
 and a quarter of an hour before should take either a small dose of brand} 7 
 and water, or a teaspoonful of a solution containing ten or fifteen drops 
 of chloroform to half a tumblerful of water. The patient should always 
 be placed in a recumbent posture, and every article of clothing, either 
 around the neck, chest, or waist, made perfectly loose. The " chloroform 
 cone " should then be placed over the face and nose, and the first few inha- 
 lations taken with full inspirations. Then the pulse and breathing must 
 be carefully noted, and in this connection it may be remarked, that many 
 deaths have resulted after a very few inhalations, and that the watchful 
 practitioner must be ever upon his guard ; he must look especially to the 
 movements of the chest, the color of the face, the contraction of the pupil, 
 and if there is much struggling, more care must be used. If the face grow 
 purple, the signs of impending danger are imminent; if the breathing 
 becomes stertorous, the case becomes alarming ; and if, in connection with 
 these symptoms, gasping and irregular respiration take place, with death- 
 like pallor of the countenance, most active and persevering efforts will be 
 necessary to prevent immediate death. It must not be forgotten that irreg- 
 ular respiratory movements may occur long after death has apparently 
 taken place. I candidly confess that I have never experienced any more 
 unpleasant feelings than when on several occasions I have seen patients on 
 the very verge of death from the inhalation of chloroform. On one occa- 
 sion I was operating for a simple fistula ; in another on an epithelial cancer 
 of the lid ; and in a third, for perineal urethrotomy. Since the last case I 
 have used only the ether prepared by Squibb, and I must say I can operate 
 with much less anxiety, even if a longer period of time be consumed in 
 producing complete anaesthesia. 
 
 In such cases as related, great coolness is required on the part of the 
 operator. The mouth should be opened and the tongue drawn forward; cold 
 water should be dashed in the face, artificial respiration produced, either 
 by the method of Sylvester, or by that more satisfactory of inserting a 
 large flexible catheter into the trachea. During this time, the thorax and 
 abdomen may be struck smartly with the end of a wet towel ; an injection 
 of an ounce and a half of brandy should be given per rectum, and the lungs 
 inflated by means of the catheter, together with alternate pressure down- 
 wards upon the thorax made with the open palms to cause expiration. 
 These manipulations should be long and forcibly persevered in, even if life 
 be apparently extinct. An excellent method of restoring animation is the 
 
78 A SYSTEM OF SURGERY. 
 
 inhalation of pure oxygen gas. In most of our large cities it is made and 
 rendered portable for medical and surgical purposes ; if it can be procured 
 in season, it may be of great service. 
 
 One of the best antidotes for chloroform narcosis is the nitrite of amyl, 
 — a few drops sprinkled on a handkerchief and held before the face. 
 
 Comparison of the Methods.— Of the two agents, there can be no doubt that 
 chloroform is the most satisfactory to administer, but that ether is less dan- 
 gerous, and with the improved apparatus for the administration of the latter, 
 it should, in my opinion, be employed in every case. I have given chloro- 
 form in thousands of cases without a fatal result, although, as I have just 
 stated, on several occasions I came very near losing my patients. The ab- 
 sence of anxiety when ether is employed, and the constant watchfulness 
 which is ever necessary during the administration of chloroform, are suffi- 
 cient reasons for the judicious surgeon to employ the ether. 
 
 With reference to methylene, terchloride of carbon, or other preparations, 
 I can say nothing, because I know nothing, excepting that I have lately 
 read an account of a death at the Charing Cross Hospital, in London, from 
 its use, in the judicious hands of Mr. Edward Canton. 
 
 Mr. Keith* states, that in his earlier cases he had to deplore the effects 
 of chloroform vomiting in ovariotomy, and that he now uses exclusively 
 anhydrous sulphuric ether, made from methylated alcohol, administered 
 through Dr. Richardson's apparatus. The oftener he has used it the more 
 he has been convinced of its superior efficacy. There is infinitely less 
 vomiting with ether than with chloroform, and therefore he holds, and very 
 justly, too, that in cases where the adhesions are not numerous and exten- 
 sive, there is not so much danger to be apprehended by the vomiting ; 
 but where the contrary is the case, the exertion of the emesis has great 
 tendency to open the bloodvessels and immediately produce haemorrhage. 
 
 The Bromide of Ethyl. — This substance was discovered by Serullas in 1827. 
 In 1849 and 1865 it was brought before the profession by Dr. Thomas 
 Nunnelly, who employed it as an anaesthetic in the Leeds Eye Infirmary — 
 but to Dr. Turnbull, and especially to Dr. R. J. Levis, of Philadelphia, 
 belong the credit of introducing it as an anaesthetic agent ; the latter gen- 
 tleman regards it as the best method of abolishing pain during surgical 
 operations. He statesf that " the ethylized patient recovers much more 
 rapidly, than is the case with chloroform or ether. Intellection and mus- 
 cular coordination are regained very soon after the inhalation has ceased. 
 In some instances these functions return as quickly as after the adminis- 
 tration of the nitrous oxide gas, and, on awakening, the patient is able to at 
 once stand erect and to walk." He relates cases of capital operations per- 
 formed under its use ; in one, an amputation of the middle of the thigh, the 
 •patient was under its influence thirty-three minutes, and ten fluid drachms 
 of the ethyl were administered. Consciousness returned in two minutes, 
 but no unpleasant symptoms save slight nausea were noticed. 
 
 Shortly after this case was recorded, the late Dr. J. Marion Sims, of Xew 
 York, lost a patient from its use, and following shortly upon that, Dr. Levis 
 himself was unfortunate in having a death from its administration. In the 
 first instance, an impure article was employed ; in the second, the patient 
 was in the last stage of phthisis. These unfortunate occurrences, however, 
 have deterred surgeons from employing the bromide of ethyl, and, perhaps, 
 from giving it the trial its merits deserve. 
 
 Mixed Anaesthesia. — From considerable experience in the use of anaesthesia, 
 employing it during the winter months daily, I think I may say that the 
 
 * London Lancet, August 23d, 187 >. 
 
 f The Medical Kecord, 1880, vol. xvii, p. 342. 
 
DEATH FROM ANAESTHESIA. 79 
 
 method known as mixed anaesthesia is the best. About thirty minutes 
 before an operation is to be performed, having fasted five hours, the patient 
 receives a hypodermic injection of a solution, ten minims of which repre- 
 sent y^g- gr. of atropine, and 4 grain of morphine. By the time the patient 
 is laid upon the table, there is a slight flush on the face and warmth on 
 the surface, caused by the known action of belladonna on the capillaries ; 
 much less ether is also required to keep the patient perfectly narcotized. 
 After the operation the slumber lasts often for an hour, there is compara- 
 tively slight shock, very little coldness, and but slight vomiting. Especially 
 have I found this method excellent in the performance of prolonged opera- 
 tions, as ovariotomy, resection of bones, etc. 
 
 Primary Anaesthesia. — There is what is called a primary ansesthesia, which 
 is quite profound in some cases, and quite trivial, indeed so much so as to 
 be unnoticeable, in others. In many instances, however, the insensibility 
 is of sufficient length to allow the performance of operations, which do not 
 require much time. Thus, opening abscesses, introducing ligatures into 
 sinuses, incisions for whitlow, brisment force for anchylosis, and similaropera- 
 tions, in point of time, may be performed. Dr. John H. Packard,* who 
 has given a good deal of attention to this subject, says that the exact length 
 of time before this early stage sets in, and the duration of the unconscious- 
 ness, probably vary in each case. The patient may be allowed to administer 
 the ether to himself, or may be told to hold up his hand, and so soon as the 
 hand drops the operations mentioned, or similar ones, may be performed 
 without pain, with immediate and complete recovery of consciousness, and 
 with no unpleasant after-effects. 
 
 The Sickness of Anaesthesia. — After the exhibition of chloroform or ether, 
 there remains in some individuals a deadly sickness and great faintness. 
 In these cases my experience tells me that brandy or stimulants do harm. 
 For the first few moments after their exhibition the patient may appear 
 relieved, but the stimulant effect disappearing, an additional nausea and 
 prostration are added. 
 
 My usual practice is, to mix ten or fifteen drops of chloroform in about 
 six tablespoonfuls of water, and to give a tablespoonful once in thirty 
 minutes. This practice in many instances is productive of good results. 
 As a prophylactic against the vomiting, a few doses may be given before the 
 anaesthetic is administered. 
 
 My colleague, Dr. Burdick, uses with success, vinegar, which he allows 
 the patient to inhale while passing from under anaesthetic influence. He 
 also bathes the head, and allows the patient to hold in his mouth a cloth 
 saturated with it. 
 
 There are some cases, however, that withstand both of these methods ; 
 one of such lately came to my notice. The patient had been two hours 
 inhaling ether, and had undergone a very serious operation, requiring long 
 and careful dissection. The prostration and vomiting from the ether were 
 very intense, but ipecac, relieved her in a short time. Veratrum, camphor, 
 and ammonia, are also very useful in the vomiting that may occur 
 from the use of chloroform. Electricity is also of signal service. One of 
 Garratt's electric disks placed upon the epigastrium soon allays the vomit- 
 ing. The advantage of the latter is found in the fact, that the appropriate 
 medicine may be internally administered. 
 
 Death from Anaesthesia. — There is no doubt in my mind that deaths from 
 anaesthetics are not sufficiently understood even by the profession at large. 
 When such unfortunate accidents have occurred, the heart and brain are 
 the organs which are immediately supposed to be at fault, but I am per- 
 
 * American Journal of the Medical Sciences, July, 1877, p. 130. 
 
80 A SYSTEM OF SURGERY. 
 
 suaded such is not the case, not only from one or two cases that have made 
 a most forcible impression upon my mind, but upon the authority of those 
 gentlemen who have given the matter the most thorough investigation, and 
 whose opportunities for experiment have been exceptionally large and varied. 
 There can be no doubt of two facts which have an important bearing in 
 these cases, the one being, that in very many instances both chloroform and 
 ether are successfully administered to persons who are suffering from organic 
 diseases of the most severe kind ; the second, that deaths occur often in 
 those who have no recognizable disease whatsoever, and in persons who, to 
 all appearances, are in a state of health as near perfect as is generally 
 found. Dr. Benjamin W. Richardson and Dr. Snow, both of whom have 
 made the subject one of exact study and research, testify to this truth. 
 The former gentleman thus writes, in one of his lectures : " When I was 
 engaged in the practice of the administration of chloroform, I was careful 
 to make diagnosis of disease before administration of the narcotic, and on 
 referring to the facts I find that I administered it in the presence of the most 
 severe forms of organic disease. In phthisis pulmonalis, in various stages ; in 
 cancer, in various stages and types of the malady ; in chronic bronchitis, 
 asthma, and hydrothorax ; in mitral disease, hypertrophy, and dilated aorta ; 
 in epilepsy ; in idiocy, with epileptic disease ; in various forms of dropsical 
 effusion ; in paralysis and acute mania, etc., etc. ; and in not one of these 
 administrations was the danger of the administration in any way increased." 
 Dr. Snow, in his book on Chloroform and other Anaesthetics, confirms these 
 facts ; and again on the second point, this same gentleman emphatically 
 says : " Sometimes persons die under chloroform who have no appreciable 
 disease whatever before death, no disease, that is to say, which the most per- 
 fect diagnostician could put his finger on, and say there was a cause of anxiety 
 from the presence of disease." 
 
 From the most recent researches on this subject, and from the experi- 
 ments of Dr. Russell on the " influence of the vagus on the vascular system," 
 it seems now to be a fair conclusion that the asphyxia which we often see 
 in these deaths from anaesthetics is caused by the direct action of the 
 anaesthetic on this nerve. Dr. Richardson further states : " In conclusion, 
 I infer that in every case of death from chloroform, the cause of death is 
 either of the motor or of the controlling nervous mechanism of the heart. 
 I conceive that any primary organic changes of structure leading to death 
 are situated in that mechanism, and must be looked for there, and I think 
 that there is fair ground to assume that in some cases there may be death 
 where there is no actual disease of structure, but simply so extreme a 
 natural delicacy of balance between the nervous functions, that the excita- 
 tion produced by the chloroform is sufficient to arrest motion and destroy 
 life." 
 
 In the case of one of my patients who died on the table after a few inha- 
 lations of ether, the patient was in an excessively nervous condition ; his 
 heart was small and degenerate, but continued its function for some minutes 
 after the arrest of breathing was complete ; showing, to my mind, the fact 
 that the vapor of the ether, in a person of most extreme nervous irritation 
 acted as an excitant or irritant on the nervous periphery of the respiratory 
 surface. There was a spasmodic cessation of the organs of respiration. 
 There was asphyxia, complete and immediate. It took some time, how- 
 ever, for the non-oxygenated blood to stimulate the vagus sufficiently to 
 arrest the heart-beats, which, sooner or later, under such circumstances, 
 must take place. 
 
 In my clinics, and in fact in my entire surgical practice, I have abjured 
 chloroform for years. On two occasions, once in St. Louis, while I was 
 operating for fistula in ano, and once in Buffalo, while removing the lower 
 
LOCAL ANESTHESIA. 81 
 
 eyelid for an epithelioma, I was on the verge of seeing the patients pass 
 from life to death, and from the sensations I then experienced, and the 
 many statistics I have read, I prefer and always administer ether. I 
 grant it is not so pleasant an anaesthetic, its administration takes longer 
 and its effects may be more evanescent ; perhaps, also, there is more emesis 
 during the inhalation ; but I think I express the opinion of most operating 
 surgeons when I say that ether is gradually, even in England, superseding 
 chloroform. According to statistics of Andrews of America, and Richardson 
 of England, as collected by Dr. Coles, I find the following : Deaths from 
 ether, 4 in 92,815 inhalations, or 1 in 23,204 ; deaths from chloroform, 53 in 
 152,260 inhalations, or 1 in 2872, making about eight deaths from the latter 
 to one of the former. In Great Britain for the decade ending 1880, the 
 deaths from chloroform numbered 101, those from ether 11, chloroform and 
 ether 7, methylene 10.* This subject, however, cannot be entered upon in 
 a work like the present. Fatal cases no doubt will continue to occur from 
 time to time, and must always be set down as belonging to those so well 
 classified by Sir James Paget as " surgical calamities." 
 
 Nitrous Oxide. — Much has been said and written concerning the use of 
 the nitrous oxide as an anaesthetic agent. Some surgeons 'have become 
 quite partial to it, and for some operations it will do very well ; but, in my 
 opinion, it will never supersede ether. The many objections, however, to 
 its use, which were mentioned in the former editions of this book, have 
 now been overcome, and since the process of condensation of the gas has 
 been effected, a hundred gallons may be carried in a quart bottle. This 
 method of using the gas also removes one of the greatest obstacles to its use, 
 viz., its impurity. Impure gas will not become liquid. The fact that it is 
 in that state, guarantees the surgeon that it is free from adulteration. In 
 cases, however, in which patients are suffering from undoubted Bright's 
 disease, with albumen and casts in *the urine, ether is not admissible, 
 as has already been explained. In such, it is fortunate that the surgeon 
 possesses an article that will produce insensibility without danger. In cases 
 of lithotomy, where the kidneys are damaged, the nitrous oxide is the 
 preferable agent. 
 
 Bichloride of Methylene. — This preparation, which has been used as an 
 anaesthetic, is made by placing a mixture of alcohol and chloroform in 
 contact with pure zinc. Heat is then applied, and a brisk action is soon 
 established, during which an equivalent of chlorine from the chloroform 
 (CHC1 3 ) passes to the zinc, and after the escape of gases, the bichloride of 
 methylene (CH 2 C1 2 ) distils over. This may be carefully inhaled, and pro- 
 duces rapid anaesthesia. 
 
 Local Anaesthesia. — The boon conferred upon suffering humanity, and 
 upon surgical science by the introduction of chloroform and ether is so 
 great that few actually and fully appreciate its value. But the improve- 
 ments introduced into the field of anaesthesia by the local application 
 of various agents, by which certain painful operations may be performed 
 while the patient still retains his consciousness of everything save suffering, 
 cannot but be hailed with feelings of the highest gratification, both by the 
 profession and the community at large. 
 
 The use of a volatile fluid called rhigolene as a local anaesthetic, was 
 introduced by Henry J. Bigelow, M.D., of Boston. It readily chills the 
 tissues to insensibility, and is far less expensive than either chloroform or 
 ether. Freezing by rhigolene is more speedy and certain than by ether (the 
 use of which was suggested by Mr. Richardson), inasmuch as common 
 ether often fails to produce an adequate degree of cold. Ether boils at 
 
 * Medical Record, vol. xix, 1881, p. 419. 
 6 
 
82 A SYSTEM OF SURGERY. 
 
 about 96°, and rhigolene at 70° ; hence its greater rapidity of evaporation, 
 and consequent absorption of caloric. The rhigolene is more convenient 
 and more easily controlled than the freezing mixtures hitherto employed. 
 Being quick in its action, inexpensive, and comparatively odorless, it would 
 perhaps supersede local anaesthesia by ether or chloroform in small opera- 
 tions (except for its danger of transportation) ; for larger operations, it is 
 obviously less convenient than general ansesthesia. Applied to the skin, 
 the first degree of insensibility is evanescent, but if continued, or used 
 upon a large scale, the danger of mortification or frostbite must be imminent. 
 
 Ether, as a local anaesthetic, was introduced by Dr. B. W. Richardson, 
 who has given great attention to the subject. The doctor states that, at any 
 temperature of the air, the surgeon can produce cold six degrees below zero, 
 and, by directing the spray upon a half-inch test-tube containing water, he 
 can freeze it in two minutes. 
 
 Many nebulizers for atomizing fluids have been introduced besides those 
 of Richardson and Bigelow. The first one of these was exhibited to the 
 Academy of Medicine, at Paris, in 1858, by Sales Girons. This instrument 
 was very expensive, and constructed to force the medicated fluid through 
 a tube with a" fine aperture directly against a metallic plate ; the stream 
 thus ejected with considerable force against the plate, by means of an air- 
 pump, was broken into spray. 
 
 Dr. Bergson's instrument is much more simple, and consists of two tubes 
 bent at right angles with each other, having the glass drawn to a fine 
 extremity at. the angle where the tubes meet. By immersing the perpen- 
 dicular tube in the ether, or other medicated fluid, and by blowing through s 
 the horizontal one, the air in the former is exhausted, the fluid rises from 
 the outside pressure of the atmosphere, and passing through the capillary 
 extremity, is atomized. It is on this simple philosophical principle that 
 the little instrument, long known, and now coming into much more general 
 use, called the Patent Perfume Vaporizer, for the purification of the sick- 
 chamber, is constructed — in fact, a very excellent nebulizer can be made by 
 procuring one of these perfume vaporizers at the druggist's, and having the 
 approximating ends of the tubes ground to a capillary extremity, and then 
 applying thereto an Andrew Clark hand-bag. It is somewhat after this 
 fashion that Dr. James G. Richardson, of Union Springs, New York, has 
 contrived a very neat little apparatus, which may be described as follows : 
 It consists of two tubes, five inches long, and three-sixteenths of an inch in 
 diameter, made of thick glass, and each drawn off at one end to a point, 
 which is to be smoothly ground down till the resulting aperture is about 
 the diameter of a horse hair ; bend one of these tubes, by holding it over 
 the flame of an alcohol lamp, at a right angle, half an inch from its small 
 extremity, and again at its middle in an opposite direction to the same 
 extent ; then attach both tubes to a grooved cork, so that the capillary 
 opening of the bent or lower one, shall be opposite the minute orifice of the 
 straight tube, to the other extremity of which the nozzle of a syringe is 
 affixed, the tubes being held in position by placing them through a large 
 cork. 
 
 Dr. Siegle, of Stuttgart, also invented an instrument by which steam is 
 used instead of air, and is employed to produce the vaporization. 
 
 Dr. Andrew Clark, of London, has introduced a modification of Bergson's 
 tubes. To the horizontal limb he has attached an india-rubber tube, 
 terminating in two hollow balls placed at a short distance from each other, 
 the middle one being the air-reservoir, the other the air-pump. By alter- 
 nately compressing and relaxing the end ball, the air-reservoir is distended, 
 and continuous spray is produced. The instrument which I have employed 
 is Richardson's (Fig. 57), which is used as follows : 
 
LOCAL ANAESTHESIA. 
 
 83 
 
 After filling the bottle two-thirds full with the solution, operate the end 
 ball briskly ; this will extend the netted ball, and force a current of air 
 into the cavity of the silver tube. This column of air, being dispropor- 
 
 FlG. 57. 
 
 tionately large compared with the aperture of the tube, becomes compressed, 
 and exerts firsts an influence upon the surface of the fluid (which is forced 
 by it into the capillary tube) ; second, a pressure upwards, escaping through 
 the orifice at its tip. This continued upward current of air divides into 
 spray the drops collected at the extremity of the capillary cube. The force 
 with which this spray can be thrown is surprising. The jet is steady, there 
 being a nearly uniform pressure kept up by the regulating power of the 
 netted bag, which, by its elasticity, compresses the air in it during the 
 interval of manipulation upon the hand-ball. 
 
 The great desideratum in the use of the instrument, is to employ nearly 
 absolute and negative ether, with which local anaesthesia may be producecl 
 
 Fig. 58. 
 
 Fig. 59. 
 
 Delano's Atomizer. 
 
 Agnew's Metal Atomizer, 
 
 in two minutes. The rhigolene of Dr. Bigelow causes the same effect, and 
 to a greater degree and in less time ; but if the ether be absolute, has a 
 specific gravity 0.720, of negative effect upon the tissues, and a boiling-point 
 of 90° to 92° Fahr., it is very serviceable. Many disappointments may 
 result where the ether is impure and the apparatus imperfect. 
 
 Of late years since local treatment, by spray, of almost all the cavities 
 of the body, has become so fashionable among specialists and patients 
 
84 A SYSTEM OF SURGERY. 
 
 atomizers of all sorts, shapes, and sizes, worked by hand, steam and 
 compressed air, have come into general use. The simplest are always the 
 best, two of them are seen in Fig. 58 and Fig. 59. 
 
 The employment, however, of intense cold for the purpose of producing 
 local insensibility to pain is by no means new in surgical science. It is 
 believed that Dr. James Arnott, of London, thirty years since, was the first 
 to introduce it to the notice of the profession. His mixture was ice finely 
 pulverized and mixed with salt. This is a very effective method to produce 
 temporary local anaesthesia. I have often employed it in the removal of 
 small encysted tumors, for the introduction of the needles of the aspirator, 
 the insertion of a trocar, and superficial incisions. 
 
 Dr. Richardson, at a meeting of the Harveian Society of London, stated 
 that the anaesthesia was produced by the rapid evaporation of the ether, 
 although in the earlier of his experiments he in part attributed the effect 
 produced to the well-known and peculiar powers of ether when inhaled, 
 speaking of it as narcotic spray. There can be no doubt that it is the cold 
 alone that produces the local anaesthesia, and that this freezing is attributable 
 to the rapid evaporation of the liquid used. Now, the force of sensation is 
 supplied by the blood, and where a part is frozen, the blood cannot pro- 
 duce sufficient heat to keep up the sensation of a part. Again, Dr. Richard- 
 son believes that nerve force is brought down with every stroke of the heart, 
 and in verification of this view, he mentioned that local anaesthesia could 
 be much more rapidly induced if, while the cold is being applied, the 
 vessels leading to the part were compressed. There are also some other 
 precautions necessary. When a part is to be frozen, it should be carefully 
 and perfectly dried ; otherwise, a film of ice is produced, and the anaesthesia 
 is obstructed. If the ether is not very pure, this hoar frost is likely to 
 appear, and a good test for the purity of the article in question is to ascer- 
 tain whether it will boil, when poured into the palm of the hand. This 
 can be known b}^ pouring it into the palm of the hand, holding it near the 
 ear, and listening. Another caution given to the members of the Harveian 
 Society was, that the use of chloroform had occasioned a carelessness in 
 operators ; the surgeon would often. laugh and talk while the anaesthesia was 
 being produced. While local anaesthesia is being effected, it is better that 
 perfect silence be maintained. 
 
 Dr. Richardson has invented new compounds of ether. Though the effect 
 of the cold produced by the ether spray is directly haemostatic, as reaction 
 returns there is bleeding, which, if the wound be too soon closed, is a cause 
 of trouble. The observation of the immediate effects of cold led Dr. Rich- 
 ardson to think, " that if they could be supplemented by a styptic which 
 would spray evenly with ether, and which would take up the constringing 
 action when the vessels began to relax, an important desideratum in both 
 medical and surgical practice would be supplied." He had a solution made 
 consisting of absolute ether, having a boiling-point of 92° Fahr., charged 
 to saturation at a low temperature with tannin, and afterwards treated with 
 xyloidin, a little short of saturation. It ran through the spray-tube without 
 blocking, produced good local anaesthesia, and possessed an agreeable 
 odor. 
 
 This xylo-styptic ether spray may be applied to open wounds on the skin, 
 to arrest haemorrhage after teeth extraction, and by means of a uterine tube, 
 uterine haemorrhages from cancerous or other diseases. The styptic ether 
 will keep for any length of time : a small quantity only is required, and it 
 may prove of great use to army and navy surgeons. The other ether 
 compounds are a caustic ether, an iodized ethereal oil, and an ozonized 
 ether. 
 
 Anaesthetic Ether for Local Application. — The above is the name given to 
 
COCAINE. 85 
 
 a thin, bright liquid, which runs like water, and is the hydride of amyl 
 diluted with ether. 
 
 The hydride of amyl is so light that it boils vehemently in the hand, and 
 actively in a glass globe by merely placing the hands upon it. It is pro- 
 curable in any quantity from the careful distillation of American petroleum. 
 After many ingenious experiments, Dr. Richardson ascertained that the 
 best preparation for local anaesthesia is one part of the hydride to four 
 parts of ether, and this he calls the " compound anaesthetic ether for local 
 anaesthesia." It induces perfect insensibility in from ten to twenty seconds. 
 This material is a solvent of many medical substances, which may be 
 applied by means of the atomizer. When prepared with iodine, it is a 
 useful disinfectant. 
 
 Hydramyl can also be used as a general anaesthetic. With these sub- 
 stances, however, I have had no experience whatsoever ; the others, so far, 
 having fully answered all practical purposes. 
 
 Dr. Delcomante, professor at Nancy, claims that the power of sulphuret of 
 carbon in producing local anaesthesia, is much greater than any other sub- 
 stance now in use. He reports that the refrigeration is more complete than 
 with ether, and is obtained in less than one minute. 
 
 Anaesthetic Mixtures for Small Operations. — There are other mixtures w T hich 
 are of great service in reducing the sensibility of the skin, besides ether and 
 its compounds. I always keep in my consulting-room two compounds, one 
 in camphor and ether, as follows : 
 
 R. Camphor, g). 
 
 Ether, gij.— M. 
 
 Or the same quantity of camphor may be dissolved in two drachms of 
 chloroform. The second mixture I employ is : 
 
 R. Chloral hyd . gij. 
 
 Camphor, gij. 
 
 Morphi sulph., ^ss. 
 
 Chloroformi, 3j. — M. 
 
 Either of these solutions, painted several times over the parts and allowed 
 to dry, will produce a degree of insensibility to the use of the knife when 
 superficial incisions are being made. An excellent method of producing 
 local anaesthesia, is to wrap the parts in lint saturated with ether and evap- 
 orate this with a pair of bellows or a syringe. Caustics, especially the 
 Vienna paste, and nitric acid are employed in the production of local insen- 
 sibility to pain. 
 
 Cocaine (C n H 21 N0 4 ) was discovered in 1855 by Niemann, while the plant 
 from which it is made, the Erythroxylon coca, has been known and used for 
 a long period by the natives of Peru and Bolivia. 
 
 Dr. Henry D. Noyes, in September, 1884, sent a notice to Dr. Squibb, of 
 Brooklyn, that a medical student named Koller had discovered the anaes- 
 thetic properties of the hydrochlorate of cocaine in ophthalmic surgery. 
 The idea was at once taken up, and experiments verified the truth of the 
 assertion. The muriate of cocaine, however, is only, as far as *is present 
 known, serviceable as a local anaesthetic applied to mucous surfaces, and 
 to produce local anaesthesia upon the skin, it should be injected subcuta- 
 neously. As before mentioned, it has been employed in gynaecological 
 operations, and also used very extensively in operations about the eye and 
 ear. Any of the medical journals for the last half of 1884 will give the 
 student a full account of the employment of the drug. A 4 per cent, solu- 
 tion is sufficiently strong, and a few drops should be used upon the part 
 
86 A SYSTEM OF SURGERY. 
 
 about ten minutes before the operation is begun. I have employed it only 
 to a limited extent, but with good success in phymosis, hare-lip in a child 
 six days old, the extirpation of a large nasal polypus, in which the effect 
 was surprising, and in the extirpation of a small papule, and as an injection 
 into the bladder previous to operations. 
 
 It must be borne in mind, that the application of cocaine is not always 
 unattended with dangerous symptoms. In the case in which I employed it 
 for hare-lip in a child seven days old, the extreme pallor of face and lips 
 and coldness of the surface, forbade its continued use. About this time 
 Dr. Knapp had called the attention of the profession to its dangers, and 
 shortly after Dr. Peck, Dr. Stevens, Dr. River, and Dr. McDonald * pub- 
 lished cases, showing beyond question, that in some persons the exhibition 
 of the drug was followed by alarming and dangerous symptoms. 
 
 Dr. A. W. Calhounf from a large experience in cataract operations states 
 that he has abandoned the use of Cocaine in all cataract operations by ex- 
 traction, on account of the unfavorable results in those cases in which the 
 drug was used. 
 
 Dr. Polk and others have employed this agent in gynaecological operations 
 and Dr. Carmalt, of New Haven, records the removal of a tumor of the cheek 
 under its influence. 
 
 The use of the agents of which we have spoken for the production of 
 local anaesthesia must be considered as one of the greatest improvements 
 introduced into surgical science. In my own experience, in opening whit- 
 lows and buboes ; in operations for paraphimosis ; lancing of mammary 
 abscesses in females of delicate and nervous temperament, to whom it would 
 have been manifestly unsafe to administer chloroform ; the extirpation of 
 small tumors, and other such operations, its use has been most satisfactory ; 
 and, no doubt, for fistulas, hare-lip, removal of cancer of the lip, and even 
 for tracheotomy, it may be very serviceable ; but when we remember that 
 it is almost impossible to make careful and minute dissections among frozen 
 tissues, perhaps it will not be applicable where the use of the knife is neces- 
 sary. However, we have the authority of Dr. Richardson that it has been 
 satisfactorily used in ovariotomy, amputations of the foot, operations for 
 hernia and Caesarian section. The advantages of the process in the latter 
 were said to be very great. 1st. There was no bleeding ; and 2d, the cold 
 caused the uterus to contract, — two of the greatest desiderata in the opera- 
 tion. We also find records of its successful application for periosteal affec- 
 tions, conjunctivitis, cancerous tumors of the scalp, epithelioma of the lip, 
 fistula in ano, fatty tumor of the side, incisions into carbuncles, applica- 
 tions of nitric acid to chancres, the introduction of the hypodermic syringe, 
 and very many other operations which are recorded throughout the medical 
 periodicals. 
 
 * Medical Record, January 17th. 1885. 
 t Medical Record, May 29th, 1886. 
 
PAET II. 
 
 GENERAL SURGERY. 
 
 CHAPTER IV. 
 
 Introduction — Inflammation — Inhibitory Nerves — Connective Tissue — Leuco- 
 cytes — The Migration Theory — Action of the Capillaries — Hyperemia — 
 Active Congestion — Changks in the Tissues— Changes in the Blood — The 
 Tissue Metamorphosis Theory of Stricker — Symptomatology — Inflammatory 
 Fever — The Terminations — Repair — Immediate Union — First Intention — 
 Granulation — Cicatrization — Fatty Degeneration — Treatment, General 
 and Local. 
 
 From the time of Hippocrates to the present day, the profession has been 
 endeavoring to satisfactorily account for the varied elementary and struc- 
 tural changes which take place during the different stages of inflammation. 
 The physician, the chemist, the microscopist, and pathologist, with perse- 
 vering industry and the most earnest desire to arrive at correct explanations 
 of the many appearances presented during the different stages of the process, 
 have not yet arrived at unanimity of opinion. An approximation to a more 
 correct understanding of many of the changes in the vessels, the blood, and 
 the tissues, has been reached since the introduction of the microscope ; but 
 yet there are very many points altogether shrouded in conjecture. 
 
 Erasistratus taught, and his theory was supposed for years to be the true 
 one, that in inflammation the arteries contained blood, otherwise, that is, in 
 a normal condition, these vessels circulating air. This doctrine was over- 
 thrown by the humoral pathologists, who classified the process in accord- 
 ance with the fluid supposed to be contained in the capillaries, thus : If 
 there was an increased flow of blood, a phlegmonous inflammation was 
 produced ; if the yellow bile predominated, the erythematic or erysipela- 
 tous ; if black bile, the scirrhous ; and if phlegm, the cedematous, thus 
 giving rise to the well-known axiom u ubi irritatio ibi fluxus." Then came 
 the curious doctrine of the Methodists, of insensible corpuscles blocking up 
 insensible pores. 
 
 After years, Stahl calls forth the " anima" the life-giving principle and 
 designates inflammation as a condition of spasm. Hoffmann, Cullen, and 
 others, conceived this to be the true pathology of the condition, and were 
 loud in their praises of the so-called discovery, which was believed for a 
 length of time, but was contradicted by Boerhaave, who brought forward 
 again a doctrine, not far removed from that of Erasistratus ; and so, one 
 theory has followed another with contradiction, argument, and experiment, 
 down to the present day, when, with all our boasted facilities, our knowl- 
 edge is just about as uncertain as it was in the times of old. So uncertain 
 indeed is this point, that in Holmes's System of Surgery* (article Inflamma- 
 tion), Mr. John Simon writes as follows : " The process of inflammation, as 
 regards the intimate nature of those circulatory and textural changes by 
 which it is constituted, is at the time of the issue of this second edition 
 
 * Vol. v., p. 72, " The Process of Inflammation." 
 
88 A SYSTEM OF SURGERY. 
 
 matter of the utmost controversy ; or, perhaps, I should rather say all pre- 
 vious doctrines upon the subject are just now in the very crisis of a recon- 
 sideration of which the morrow cannot be foreseen," and, therefore, the 
 subject is not discussed. At the end of the fifth volume, J. Burdon San- 
 derson has gone very fully into the detail of our knowledge as understood 
 by recent investigators. This gentleman finds that the application of stimuli 
 causes a dilatation of the capillaries with an increase in the blood flow, and 
 so defines the first stage of the inflammatory process. Some again declare 
 that the blood-globules are crowded together in the inflamed parts by the 
 viscidity of the blood itself, thus reverting to the doctrines of old. 
 
 Others again attribute the action of the capillaries, and the stasis of blood, 
 to what are termed "inhibitory nerves," thus bringing the cerebro-spinal 
 system into the field to battle for the spasm of the capillaries, and so indeed 
 we grope on in darkness and ask in vain the questions : Is the increased 
 flow of blood in the capillary vessels, which is said to be noticed in the first 
 stage of inflammation, due to a spasm or to a paralysis of the coats of these 
 vessels ? Are we sure of the method of innervation of the bloodvessels 
 said to produce an acceleration or retardation of the blood ? Can we now, 
 in this our nineteenth century, define with certainty, or draw a line dis- 
 tinctly, between the process of repair which nature evokes to cure the varied 
 lesions to which the body is liable, to which she applies for the safeguard 
 of her temple and the purification of her courts ; — from that process which 
 terminates in disease, overthrow, and death ? How do we positively define 
 the inflammation which cures from the inflammation which kills ? 
 
 Who can positively say whether these changes have their seat in the 
 vessels or in the textural elements of a part? Is there an unusual cell 
 production, and if so, does or does not this increased cell life cause disease 
 or death, or the construction and repair of tissues ? 
 
 So far as my reading goes, even with all the lights that microscopy has 
 endeavored to throw upon this question, there are at present no less than 
 five doctrines, each with its own upholders, which are adduced to explain 
 the pathology of the inflammatory process. 
 
 The oldest, perhaps, of these newer methods, is "the coagulable lymph 
 theory." This coagulable lymph is supposed to contain all the formative 
 elements. In the blastema, floating hither and thither, are found molecules 
 which aggregate and form nucleoli, which arrange themselves into nuclei. 
 A cell-wall then forms, thus constituting rudimentary elements, which 
 ultimately are changed into the varied tissues. 
 
 From the experiments of Goodsir and Redfern, together with the persis- 
 tent and patient labors of Virchow, the school of " cellular pathology " has 
 its origin, and numbers many illustrious names among its adherents. This 
 method is called by Sir James Paget " the local production theory," and 
 embraces the cleavage of the nuclei, or " a process of endogenous germina- 
 tion," thus rendering the inflammatory process one in which the vessels 
 themselves take little part, the pus corpuscles being formed from connective 
 tissue cells, which, with their nuclei, were supposed to undergo continual 
 cleavage, making thereby a continual pus-genesis, hence called, " the sup- 
 purative theory." 
 
 Recklinghausen then places his eye to the microscope, and stands amazed, 
 as in the field he discovers among the stable connective tissue cells a moving 
 corpuscle. Again he examines, and again he sees the peculiar cell, with its 
 peculiar motion, wandering hither and thither with its stretching and re- 
 tracting arms, passing into and without the vessels. 
 
 This discovery, combined with the labors of Williams, Addison, Waller, 
 and Cohnheim, brought forth the celebrated "migration theory," adopted 
 and promulgated by Cohnheim and Billroth, which would teach us that 
 
INFLAMMATION. 89 
 
 the process, instead of being independent of the vessels, has its seat in 
 them ; they not only being the channels from which exudes the cell- 
 stimulating liquor sanguinis, but from which pass and repass, with insinu- 
 ating amceboid movement, the "leucocytes," which constitute in part at least 
 the bond of union in the repair of tissue and assist to mould into shape 
 the new formation. 
 
 Here are three theories, the fourth being that promulgated by the " ger- 
 minal pathologists," among whom Lionel Beale stands prominently fore- 
 most. These declare that invisible particles in the blood escape from the 
 vessels without a rupture of their coats, and that by their proliferation and 
 subdivision the agents for the new formations are developed. 
 
 In conclusion, it is necessary to speak of the more recent theory of 
 Strieker, which, being adopted by the International Cyclopedia of Surgery, is 
 likely to receive a new impetus in this country and in England. This 
 theory takes us first back to the earlier stages of embryonic formation, at 
 which period the fcetus consists of amoeboid cells, — cells which are capable 
 under proper surroundings to go forward toward the formation of more 
 perfect structure, or to retrograde into pus formation. He is of opinion that 
 so soon as inflammation begins, the tissues return to their embryonic state, 
 and that, therefore, the blood or the bloodvessels have very little to do in 
 the formation of pus, but that it is the tissue itself which is converted into 
 pus corpuscles. It is unnecessary in a work of this kind to detail the many 
 experiments, chiefly made upon the cornea, by both Strieker and Norris, by 
 which they appear to prove the correctness of their theories. I am dis- 
 posed, however, to rely, and until further evidence is produced, on the 
 migration theory of Cohnheim, which I shall endeavor to detail as concisely 
 as possible, giving also an outline of the mutation theory also. 
 
 I must say, however, that casting a retrospective glance over the history 
 of medicine, the more I become acquainted with the subject of inflammation, 
 as taught by the old writers, and observe the changes of opinions and the 
 metamorphoses of theories which have taken place, I am not by any means 
 sanguine of the permanency of the present explanations, and have little 
 doubt that hereafter other unknown discoveries in microscopy will shatter 
 the conclusions which are now under special consideration, or at all events 
 materially modify them. 
 
 INFLAMMATION. 
 
 For the better appreciation of what is to follow, the student should be 
 made to understand the meaning of certain terms and certain processes 
 which are familiar to the more recent pathologists, and which are necessarily 
 frequently employed while treating of the inflammatory process. 
 
 Inhibitory Nerves. — The nervous system is now supposed to play a 
 most important part in the establishment of inflammation, and it is neces- 
 sary to consider for a moment the action of those nerves known as the 
 " vasomotor" If an injury is inflicted on any portion of the body, the 
 " centripetal " or " afferent " nerves convey the impression to the cerebro- 
 spinal axis, and by the vasomotor centre (the precise seat of which is at 
 present unknown) is reflected through the " centrifugal " or " efferent " 
 nerves, to the vessels, which causes certain changes to take place in them, 
 which will be hereafter noticed. A fact, however, must be borne in mind, 
 viz., that if there be a division of the spinal attachment of any portion of 
 the ganglionic cord, the effect is similar in regard to the vessels as though 
 the great sympathetic nerve itself were divided, which would seem to prove 
 that the ultimate origin of the nerves is in the cerebro-spinal system. It 
 must also be remembered that these nerves can be affected by a reflex action 
 of the afferent spinal nervous system. 
 
90 A SYSTEM OF SURGERY. 
 
 Connective Tissue is that structure pervading all portions of the body, 
 composed of cell element and intercellular structure. It is in reality, 
 whether in hard or in soft structure, the skeleton of the tissues, and may be 
 divided into the vascular and non-vascular. This tissue, according to 
 Virchow, presents a corpuscle which receives the name of the " connective 
 tissue corpuscle," and is considered by most histologists as " a fixed and 
 stable element." 
 
 " The connective tissues," according to Strieker,* are developed from the 
 middle germinal layer, in which blood and muscle also originate. The 
 typical connective substances are recognized histologically by the circum- 
 stances that they contain extensive and continuous layers of material (in- 
 tercellular substance) which, when compared to the cellular structures 
 distributed through its substance (protoplasma), or the morphological ele- 
 ments in other tissues, always appears as a mere passive substance, and one 
 which participates but slightly in the processes characteristic of life. . . . The 
 connective tissues frequently pass by substitution or genetic succession into 
 one another ; they appear, therefore, to be morphologically equivalent ; so 
 that, in many instances, certain organs or parts of organs, belonging to 
 animals nearly allied to one another, are formed sometimes of one, some- 
 times of another of these tissues." 
 
 Leucocytes, " wandering cells," " exudation corpuscles," " connective 
 tissue derivatives," " migration corpuscles." These terms are synonymous. 
 The first step that was made toward the more intimate acquaintance with 
 the action of these leucocytes, was the discovery made some years back by 
 Dr. C. J. B. Williams, that in inflammation there appeared to be a great 
 disposition of the white blood-corpuscles to arrange themselves, and to 
 adhere to the walls of the irritated capillaries. Addison, in 1843, and 
 Waller, in 1846, not only confirmed the views of Williams, but demon- 
 strated the actual passage of the corpuscles through the coats of the capil- 
 laries. Cohnheim and Recklinghausen then, after much research and 
 experiment, founded the well-known and now generally accepted u migra- 
 tion theory," viz., that the white blood-corpuscles (leucocytes) pass in some 
 mysterious manner through the coats of the vessels, being possessed of that 
 peculiar motion termed " amoeboid," which is seen in the amoeba and other 
 rhizopods. These so-called " wandering cells " stretch out and retract their 
 arms in a most peculiar manner, and so migrate, often to a considerable 
 distance, from the vessel from which they emerge. These corpuscles, by 
 means of their mobility and flexibility, have the power of surrounding 
 minute bodies, and are, as understood by Mr. Sanderson, " masses of con- 
 tractile living protoplasm." It may be noted here that " pus-corpuscles," 
 " lymph-corpuscles," " white blood-corpuscles," and rudimentary cell-forms 
 in general, possess this power of movement, and indeed are identical. 
 
 For more than half a century, pathologists have taught that inflammation 
 consisted, first, in an increased action of the capillary vessels, with increased 
 rapidity of the blood stream, followed by a relaxation of the coats of these 
 vessels, with complete stasis and exudation of liquor sanguinis, and even 
 now, when the action of the vasomotor nerves has been more thoroughly 
 examined, there has not been much advance in the actual certainty of our 
 knowledge regarding the action of the capillaries. On this subject Dr. 
 Sanderson thus pointedly says : " Our knowledge of the innervation of the 
 bloodvessels is, notwithstanding the progress which has been made in the 
 last few years, too imperfect to enable us to harmonize all the facts. But 
 the impossibility of constructing a complete theory on the subject does not 
 
 * A Manual of Histology, by Professor S. Strieker, p. 53. 
 
THE MIGRATION THEORY OF COHNHEIM. 91 
 
 prevent us from drawing some inferences, which will be of use in enabling 
 us to understand what happens in inflammation, at all events better than 
 we should do without it. From what has been stated, it is tolerably clear, 
 that whatsoever difference there may be in other respects, there is one effect 
 in exciting the sensory nerves distributed to any part, which is pretty con- 
 stant, viz., increased activity of the circulation, so that, whether the actual 
 quantity of blood existing in the part at any given moment be greater or 
 less, the quantity of blood which passes through it in a given time is cer- 
 tainly greater." 
 
 After a careful consideration of those conditions which seem to be neces- 
 sary for healthy nutrition, it would seem that inflammation may be defined 
 as " a peculiar perversion of nutrition and secretion," and although this 
 may be taken as in the main correct, yet we must be careful not to confound 
 it with hypertrophy, which may result from extraordinary functional activity, 
 calling for a larger than a normal supply of nutritive elements. 
 
 There are, again, still other conditions in which the bloodvessels may 
 become temporarily turgid with blood, although inflammation (properly 
 so called) may be absent. Thus " active hyperemia" " local congestion" 
 " vital turgescence" are terms used to explain an overloaded condition of 
 the bloodvessels, which may be necessary in some organs at certain times 
 for the proper performance of their functions, and at others when a me- 
 chanical obstruction may interfere with the return of the blood-stream. 
 We find this in the mamma during lactation, in the uterus during preg- 
 nancy ; thus giving an increased blood-supply to meet an increased demand, 
 or when a mental emotion may overload the capillaries in various parts of 
 the body ; or, again, in certain dropsies arising from mechanical gravitation 
 of blood or postural peculiarity. The term hyperemia is applied to local 
 congestions, while by plethora is understood a general fulness of the capil- 
 laries all over the body. 
 
 Hyperemia may also be caused by a division of the sympathetic, thus 
 depriving the capillaries of their nervous force, a fact going to prove the 
 innervation theory. 
 
 The Migration Theory of Cohnheim. — Let us now suppose that an irritation 
 be caused on the surface of the body : we first have the transmission of this 
 irritation through the afferent or centripetal nerves to the vasomotor centre, 
 thence by means of the efferent or centrifugal nerves to the bloodvessels, 
 which first causes a contraction of their coats and an acceleration of the 
 stream, which is followed by a slackening of the circulation caused by a 
 loss of tone of the capillaries. The leucocytes (" wandering corpuscles ") 
 arrange themselves around the walls of the vessels, which, narrowing the 
 calibre of the tubes, causes a still greater retardation of the current until 
 it oscillates and then ceases, and the condition known as stasis results. 
 During the period that this stagnation takes place there is an exudation of 
 the liquor sanguinis and the migration of the white blood-corpuscles 
 through the coats of the vessels. The blood itself is also altered in the 
 surrounding vessels, it appearing to consist of the migratory cells, packed 
 together in agglomerated masses, which by some is attributed to the cohe- 
 siveness of the corpuscles themselves, and by others to a lack of tone found 
 in the vessels. 
 
 It is a matter of considerable discussion among pathologists, as to how 
 these white blood-corpuscles escape through the coats of the capillaries. 
 It is supposed by some that the walls are porous and thus allow the passage 
 of the leucocytes; others contend that these vessels possess "a certain 
 activity of life," and that shortly after injury, indeed, according to Professor 
 Strieker, on the second day an alteration occurs in the walls of these radicles, 
 
92 
 
 A SYSTEM OF SURGERY. 
 
 and that from the actual pressure of the white globules from within and a 
 fatty degeneration of the walls themselves, an opening is made for the 
 
 passage of the leucocytes. 
 FlG< 60 * This is again denied by 
 
 others ; all that it is neces- 
 sary for us to know at the 
 present is that the passage 
 takes place. In the annexed 
 cut, Fig. 60, Cohnheim's ex- 
 periment is seen. 
 
 L. Purves, to investigate 
 the place where the white 
 blood - corpuscles pass 
 
 through the wall of the ves- 
 sel in Cohnheim's experi- 
 ment on inflammation, in- 
 jected a solution of silver 
 into the vessels of a frog pre- 
 pared after the manner of 
 Cohnheim. 
 
 The colorless corpuscles 
 without exception wander 
 out between the boundaries 
 of the epithelioid cells. They 
 never pass through the sub- 
 stance or through the nucleus 
 of an epithelioid cell. Ac- 
 cording to the author, the 
 red corpuscles only pass out 
 by those channels which 
 have been previously made 
 for them by the colorless 
 corpuscles. 
 
 Changes in the Tissues. 
 (Edematous Infiltration. — 
 The tissues are rendered 
 more succulent and soft by 
 the quantity of the watery 
 blood matter which is ex- 
 uded ; this condition has re- 
 ceived the name of " cedema- 
 tous infiltration." In the 
 connective tissue are found 
 masses of white blood-cor- 
 puscles, and in some cases 
 entire blood elements. These 
 exudations contain, in cer- 
 tain cases, large proportions 
 of fibrin, which, under cer- 
 tain conditions, may become 
 in part coagulated, giving 
 rise to the condition known 
 as fibrinous dropsy, differing 
 from the mere effusion of 
 serum, which is produced by 
 an obstruction of venous 
 
 Cohnheim's experiment, showing the emigration of the leu- 
 cocytes out of a vein in the mesentery of a frog. The times of 
 the successive observations are marked on each figure, and the 
 individual leucocytes are distinguished by different letters ; r 
 and u denote two leucocvtes which were external to the vein 
 at the commencement of the observation, a was only just at- 
 tached to the outside of the wall of the vein at the commence- 
 ment, and was free from it at the second observation, c had 
 almost passed through the wall at the first observation, was 
 only just attached at the second, and was free at the third, b 
 had commenced to adhere to the interior of the wall of the 
 vein at the first observation, had partially penetrated it at the 
 second, was adhering to its outer wall at the third, and was 
 becoming pedunculated and preparing to detach itself at the 
 fourth.— From an experiment made for Mr. Holmes by Mr. J. 
 R. W. Webb.— (Holmes.) 
 
THE TISSUE METAMORPHOSIS THEOEY OF STEICKEE. 93 
 
 return, either by mechanical or other means, constituting anasarca or 
 ascites. 
 
 Effusion of Blood and Changes in the Fluid. — In some cases, in the sur- 
 rounding tissues we find that besides the masses of white blood-corpuscles 
 already mentioned, there are red blood-globules, which fact is attributed by 
 some to a rupture of the coats of the capillaries, but, as already mentioned, 
 Cohnheim asserts that these make their exit through the same apertures 
 that have given passage to the colorless corpuscles. 
 
 Blood, if it is present early, no doubt comes from the capillaries, if late, 
 it is conceded to be from the newly developed bloodvessels in the exuda- 
 tion. 
 
 Changes in the Mass of Inflammatory Blood. — Another peculiar change in 
 the body, is that in the mass of inflammatory blood, which mainly is found 
 in the increased quantity of fibrin, which varies from two to ten grains per 
 thousand. It is probable, however, that when there is so large an increase, 
 that a portion thereof may consist of white blood-globules, there being great 
 difficulty in separating them from the fibrin itself. 
 
 It has been ascertained by carefully conducted experiments, that the 
 blood of a person affected with inflammation is overloaded throughout with 
 fibrogeneous material as well as at the site of the pathological change, and 
 to this, which, as will be shown further on, is an old theory, inflammatory 
 fever is attributed. With the increase of fibrin it must be remembered that 
 there is found to be a diminution of albumen and a larger quantity of water. 
 
 Blood from a person suffering from a high degree of inflammation, forms 
 a much denser " crassamentum," or " clot" or ' ; cruor" than is found in 
 healthy vital fluid. When this clot has been allowed to stand for awhile, the 
 upper surface is covered with a whitish film, which is composed chiefly of 
 fibrin and white blood-corpuscles, and receives the well-known term t; buffy 
 coat." Many times the superior surface becomes concave, and then the 
 blood is said to be "cupped." 
 
 We have, therefore, thus far : 
 
 Changes having their seat in the vessels (contraction and relaxation) pro- 
 duced by the vasomotor system. 
 
 Changes produced in the blood-stream consequent upon the action of the 
 vessels. First increased velocity (a short stage), then diminution and 
 stasis. 
 
 Changes in the relative quantity and arrangement of the white blood- 
 globules. 
 
 Changes in the texture of the surrounding parts by the effusion of the 
 liquor sanguinis. 
 
 The Tissue Metamorphosis Theory of Strieker. — It will be seen from the 
 few foregoing remarks that though Strieker and Xorris have been earnest in 
 the promulgation of a part of the migration theory, that their more advanced 
 experiments bring them back again to the theory of Virchow, — which was 
 in reality one of tissue metamorphosis, but holding that the changes neces- 
 sarily produced by inflammation took place in the connective tissues. This 
 belief was upheld for a dozen years or more by many distinguished micro- 
 scopists. The doctrine held sway from 1855 to 1867, when it was entirely 
 upset by Cohnheim, who proved that the pus corpuscle was nothing but 
 an extra vascular white blood corpuscle, and established his migration 
 theory of which I have just given an outline. 
 
 In 1869 Strieker, chiefly from careful examination of inflamed corneas, 
 made the discovery that in no tissues of the body could inflammation and 
 suppuration be referred entirely to the migration of leucocytes, but that 
 there was also a certain alteration taking place in the capillaries which was 
 essential to the production of the inflammatory process. He says on this 
 
94 A SYSTEM OF SURGERY. 
 
 point : " However, in the year 1869, 1 had already found out, in conjunction 
 with W. F. Norris, that Cohnheim had examined the cornea imperfectly ; 
 that the cornea-corpuscles in fact did change; that their neuclei increased ; 
 that they became amoeboid in the course of the inflammatory process. True, 
 we said they do not all change at once ; they do not change everywhere in 
 the entire cornea, but only where a centre of suppuration is forming. But 
 in the rest of the cornea we see the old cornea corpuscles at the side of 
 single new cells, which look like pus-corpuscles. But, inasmuch as at that 
 period we likewise could not observe movements in the branched cornea- 
 corpuscles (in their normal condition) ; and inasmuch as we have learned 
 that they become amoeboid (like white blood-corpuscles) during inflamma- 
 tion, we said that the newly-revealed corpuscles had passed into this neigh- 
 borhood, and had become visible beside the unchanged branched corneal- 
 corpuscles. Norris and I have furthermore shown that suppuration does 
 -not always begin at the edge of the cornea as Cohnheim asserts, but that it 
 begins where the irritation has exerted its influence." After much more 
 research it was finally discovered, not only that the cells divide and sub- 
 divide, and thereby rapidly assist in the construction of new tissue, or to 
 increased pus formations, but they appear to resemble the true embryonic 
 oells in their behavior and life history. Strieker elaims that he can dem- 
 onstrate beyond cavil , that this cell division which has already been 
 alluded to, though occurring, does not take place according to the explanation 
 of Virchow (the nucleus being cleft into two parts, with a separation of 
 each), but that the cells become amoeboid before division, and that so soon 
 ^s inflammation commences, these independent movements begin, and from 
 this he was led to formulate his new and, as he declares, complete theory. 
 In the strong language of the German student, and forgetting in his enthu- 
 siasm all that has gone before, and what probably will be the fate of this, 
 his latest effort, he says : 
 
 " But the condition of affairs has now changed. In the year 1874 I began 
 to study keratitis in the mammalia, and here obtained results which ex- 
 plained the clinical phenomena satisfactorily. Starting from this point I 
 examined all kinds of tissue, and the results were of such a nature that I 
 also can now clothe the doctrine of inflammation in a simple form. Meta- 
 morphosis of tissue, return to the embryonic condition ; division into 
 amoeboid cells of the masses which have become movable ; hence the de- 
 struction and suppuration. This is briefly the outline of my new doctrine. 
 
 " On the other hand, all the details of my further researches were very favor- 
 able for my theory. It appeared that this theory was in harmony with results 
 of researches in the domain of comparative histology and histogenesis. It 
 appeared that in the pathological destruction of tissue by suppuration, not 
 only the cells, but also the entire tissue returned to the embryonic condition. 
 The machine was, as it were, separated into its parts again. In regard to 
 the pathological tissue, therefore, I was about in the position of the 
 mechanic, who takes apart the machine and finds that which the builders 
 have asserted to be present. It appeared, furthermore, that the return of 
 the tissue to the embryonic state at the same time included the conditions 
 requisite for a healing of the tissue. In every phase of inflammation 
 the destruction can cease, and a regeneration or a cicatrization can be 
 started. Anol this new formation is, throughout, similar to the embryonic 
 new formation. 
 
 " In consequence of such observations my conviction of the correctness 
 of my theory of inflammation has been so much strengthened that I believe 
 that I may now venture to publish it with all its deductions. But I must 
 finally remark that the opposition to this theory has only been heard in 
 moderate tones during the past five years." 
 
HEAT. 95 
 
 The Symptoms of Inflammation. — The most prominent symptoms that 
 denote the presence of inflammation are the well-known ones of pain, heat, 
 swelling, and redness. 
 
 Pain is the most characteristic symptom of inflammation, and is caused 
 by the compression of nervous filaments, from the encroachment of the 
 swelling upon them, which acts as a mechanical force; consequently, the 
 pain increases as the tumefaction advances, particularly if the surrounding 
 textures are firm and unyielding. The function also of the. sentient nerves 
 is perverted, and they become, themselves, one of the seats of inflammatory 
 action. Moreover, at each throbbing impulse of the heart and arteries, the 
 nervi vasorum of the distended and elongated vessels add something to the 
 general amount of pain. But such causes, as well as their results, are liable 
 to vary. The pain present in inflammation is not uniform. It is, as has 
 been before mentioned, in a great measure influenced by the elasticity of 
 the textures in which inflammation occurs. Thus, when a bone is affected 
 with disease, it is more painful than when the skin is attacked. The 
 intensity of the inflammatory action, and the sensitiveness of the affected 
 part also, to a great extent, influence the amount of pain, and, indeed, there 
 are occasional cases wherein no pain whatever is present. 
 
 The student must bear in mind that there are other varieties of pain 
 besides the inflammatory. With the agonizing pain of spasm, there is no 
 inflammation present ; in neuralgia, also, there is severe pain without the 
 slightest trace of inflammatory action. 
 
 The differential diagnosis is as follows : 
 
 In inflammation, pain begins slight, but continues gradually to increase. 
 
 In neuralgia or spasm, the pain begins generally with severity. 
 
 In inflammation, pressure invariably aggravates the suffering. 
 
 In spasm, colic, or neuralgia, the suffering is often relieved by pressure. 
 
 In inflammation there is bat one slight intermission, in the other diseases 
 there may be a distinct and even a periodical intermission. 
 
 In neuralgic diseases there is often a sudden intermission of the suffering ; 
 if this occurs in inflammation, it is always a suspicious symptom. 
 
 As a rule we find the most pain at the focus of the inflammation ; but this, 
 it must be borne in mind, is not always the case; for when parts are nearly 
 allied to one another in function, although separate in location, the pain may 
 be felt at a distance from the seat of inflammatory action. In inflammation 
 of the brain the most of the pain may be referred to the spine ; in the hip, 
 to the knee ; in the bladder, to the kidneys ; and in the liver, to the right 
 shoulder. 
 
 Heat. — " The symptoms and consequences of inflammation," wrote Mr. 
 Liston,* " and amongst others heat, are modified by the distance of the 
 affected part from the centre of the circulation. All actions, healthy as well 
 as morbid, proceed with more vigor in the superior extremities — the head, 
 the neck, and the trunk — than in the more remote parts of the body ; for 
 in the former the blood is transmitted more speedily, if not in greater quan- 
 tity, and is not so liable to be impeded in its return." This is evidently 
 true, as ascertained by the thermometer. The normal temperature of the 
 body, at the heart and upper parts of the trunk, varies from 981° to 100°, at 
 the extremities about 93°, f but there is a rise of the mercury from the heat 
 of an inflamed part, the patient complains of extreme heal, burning, and 
 throbbings, and the thermometer may indicate a rise of four or five degrees. J 
 This can be readily accounted for. During the inflammatory process the 
 nerves of sensation, partaking in the general abnormal action, become per- 
 
 * Liston's Elements of Surgery, p. 52. 
 
 f Cyclopaedia of Practical Medicine, p. 738. % ^ oc - cit - 
 
96 A SYSTEM OF SURGERY. 
 
 verted ; indeed, increased sensibility is one of the signs of inflammatory 
 action. This accounts for the sensation of heat so frequently noticed and 
 complained of by the patient ; and if we also remember that a very fruitful 
 source of animal heat is referred to the changes that take place in the blood 
 circulating in the capillaries, and as these changes are carried on with great 
 rapidity in inflammation, we can readily imagine that the heat of the part 
 which is the seat of the abnormal action may be elevated. 
 
 Heat must also be connected with other symptoms to assist in the diag- 
 nosis of inflammation, for we all know and are every day told of burnings 
 in different portions of the body, when there is not the faintest trace of any 
 inflammatory action. 
 
 A great many facts lead to the opinion that animal heat is the product of 
 increased sensibility. Whenever the vital powers are much excited it is 
 found in augmented quantity. The temperature of the hen's breast during 
 incubation, although divested of feathers, is much increased. Emotions of 
 the mind, as anger, hope, and joy, also develop heat, although it is rather a 
 sensation than a real increase of caloric ; experiments having shown that 
 the temperature in the mucous canals of animals is nearly the same in a 
 healthy or inflamed state. If the blood is accumulated unduly in a part, 
 there is found an increase of heat; and if a part is unusually heated, there 
 will be found an additional quantity of blood. 
 
 With regard to the fact already noted, that, an inflamed part actually 
 generates heat, Mr. John Simon has given us some most carefully conducted 
 thermo-electrical observations.* He finds, " 1st. That the arterial blood 
 supplied to an inflamed limb is less warm than the focus of inflammation 
 itself. 2d. That the venous blood returning from an inflamed limb, though 
 less warm than the focus of inflammation, is warmer than the arterial blood 
 supplied to the limb : and, 3d, that the venous blood returning from an 
 inflamed limb is warmer than the corresponding current on the opposite side 
 of the body." When this heat is reduced by perspiration or other critical 
 phenomena, there will be less of that disorder (hereafter to be mentioned) 
 known as inflammatory fever. 
 
 Swelling. — This effect arises from several causes ; first, the effusion of 
 coagulable lymph and serum ; secondly, the increased quantity of blood in 
 the vessels ; thirdly, the deposition of new matter ; fourthly, the interrup- 
 tion of absorption, particularly noticed by Soemmering. 
 
 The swelling is, for the most part, confined to the cellular texture, and is 
 commonly the greatest where the inflammation commences; but this 
 symptom, when viewed alone, cannot by any means, indicate the disease; 
 others must be conjoined with it. In the simplest form of oedema no in- 
 flammation is present. On the other hand, as noted by Stricker,f " we are 
 not sure whether the bones, for example, necessarily show any externally 
 visible swelling in inflammation. I must remark right here that inflamma- 
 tory swelling is distinguished by its hardness, and in many cases the hard- 
 ness, not the visible swelling, is the decisive characteristic. If I see a 
 reddened district in the skin ; if I palpate, and find it hot and hard, I say 
 it is inflamed, even though no swelling be visible. And it is indeed possible 
 that swelling at times may become unrecognizable — as, for example, when 
 the inflammation is in a nodular, uneven neoplasm. The inflammatory 
 swelling and hardness are, as I shall show, dependent on active tissue-meta- 
 morphosis. I say, therefore, that tissue-metamorphosis is a generally reli- 
 able symptom, and put in the place of swelling. The active tissue-metamor- 
 phosis likewise includes the symptom-impaired function ; for I shall show 
 
 * Holmes's System of Surgery, 2d ed., vol. i, p. 18. 
 f International Cyclopaedia of Surgery, vol. i, p. 33. 
 
THKOBBING 
 
 97 
 
 that the tissues, when undergoing inflammatory changes, have their func- 
 tion impaired." 
 
 The redness is evidently caused hy the increased quantity of blood con- 
 tained in the capillaries, and the introduction of the red globules into those 
 radicals which previously would not permit their admission. The color of 
 the blood, also, in inflammation assumes a deeper tint, but there are some 
 instances in which the inflammatory process may have been present to a 
 certain extent, and the parts be paler. This, however, is not generally the 
 case. The enlargement and engorgement of the capillaries were made 
 plainly distinguishable by Mr. Hunter. He says : " I froze the ear of a 
 rabbit and thawed it again; this occasioned considerable inflammation, an 
 increased heat, and thickening of the part. This rabbit was killed when 
 the ear was in the height of inflammation, and the head being injected, the 
 
 Fig. 61. 
 
 two ears were removed and dried. The uninflamed ear dried clear and 
 transparent, the vessels were distinctly seen ramifying through its sub- 
 stance, but the inflamed ear dried thicker and more opaque, and its arteries 
 were considerably larger." The different sizes of the capillaries are seen in 
 Fig. 61. 
 
 But redness is not absolutely essential to inflammation, which may take 
 place slightly in the cornea, for instance, without it, and also in the arachnoid 
 membrane of the brain. 
 
 The speedy appearance of the redness destroys the opinion advanced by 
 some that the red vessels are a formation of the inflammatory process. 
 
 Throbbing. — This depends upon the obstruction to the passage of the 
 blood through the capillary vessels, and is not owing to its increased rapid- . 
 ity of action. Throbbing, with a little attention, can generally be ascer- 
 tained. The larger vessels are incited into a strongei action, which again is 
 communicated to others, till the whole system may become involved. 
 
 The throbbing is particularly distinct in cases of paronychia. 
 
 There are many instances, however, when some of the local manifesta- 
 tions of inflammation cannot be appreciated, but the constitutional symp- 
 toms — quick full pulse, dry furred tongue, high-colored urine, thirst, etc. — 
 may, perhaps, lead to the detection of the disease, " but," says Mr. Fergus- 
 son, " some of these even are not entirely to. be depended on, seeing that 
 they may be present without the existence of inflammation ; whilst again, 
 that disease may be in full vigor, and yet the symptoms may be such that 
 the most experienced may be deceived.'''' Again, he says, referring to the same 
 subject, " exceptions to these observations must be familiar to every one 
 who has seen even a little practice." 
 
 7 
 
98 A SYSTEM OF SURGERY. 
 
 Symptoms, however, of the most unequivocal character, indicating the 
 existence of inflammation in some internal part of the body, may exhibit 
 themselves, yet a post-mortem examination may not detect its existence. 
 This is owing to the capillaries having emptied themselves into the veins 
 after death, or in consequence of the actual contraction of the vessels them- 
 selves, which is known to occur during the dying moments of the individual. 
 This fact is well worth remembering, as a correct diagnosis may have been 
 formed, and yet the physical evidence of it may be wanting. 
 
 Inflammatory Fever. — Some authors class inflammatory fever with pyaemia, 
 septicaemia, and traumatism in general, making, however, a classification 
 between the simple variety (that appearing immediately) and the more 
 alarming and profound symptoms which result after poisonous materials 
 have found their way into the circulatory system. 
 
 Every surgeon, however, knows that at certain times, especially in those 
 persons having a nervous temperament, in a very short period after an in- 
 flammation has appeared, all the symptoms of a high degree of fever are 
 developed. This has been explained by many, as resulting from general 
 overheating of the blood. 
 
 The more, however, I think over the subject, the more I am disposed to 
 believe that the views expressed long ago by John Fletcher* are correct, 
 and that inflammatory fever, properly so called, is due to a general perturba- 
 tion of the capillary system and a general disturbance of vital force. It 
 must be remembered that when Fletcher wrote, the inhibitory nerves had not 
 received attention, and that his conclusions were arrived at by reasoning, 
 observation, and analogy. He thus writes : 
 
 " It must be abundantly obvious that it is the first stage of fever which is 
 (as in inflammation) that of increased action, at least with regard to the 
 extreme vessels of the surface of the body (the essential seat of the morbid 
 change), and the second that of diminished action with respect to these 
 vessels ; and this, whether the exciting cause be stimulant or sedative. It 
 is true — the increased excitement of these vessels being always attended by 
 a diminished excitement of the rest of the body, and the diminished excite- 
 ment of these vessels by an increased excitement of the rest of the body — 
 it is difficult to divest one's self of the notion, that the cold stage of fever is 
 one of deficiency of action, and the hot stage of increase of it; and it was 
 this which gave occasion to Dr. Armstrong to call the three stages of con- 
 tinued fever (corresponding to the cold, the hot, and the sweating stage of 
 an intermittent) by the names of the stage of oppression, that of excitement, 
 iind that of collapse — names which, it must be remembered, apply only to 
 the state of the body in general, and not of the capillary vessels of the surface, 
 which, during the stage of oppression, are in a state of preternatural excite- 
 ment ; during that of excitement, in a state of corresponding collapse ; and 
 during that of collapse, in a state of reaction. ' Whenever,' says Dr. W. 
 Phillip, ' increased temperature, swelling, and redness appear, the capillary 
 vessels are debilitated, and preternaturally distended.' Now, in the hot stage, 
 the whole surface is affected with increased temperature, redness, and swell- 
 ing. The deduction is obvious, and the analogy of fever, in every respect, 
 with inflammation, is too manifest to require further comment. In fact, 
 inflammation and fever differ only in their seat and in their degree ; the 
 seat of inflammation being anywhere, and more or less circumscribed, and 
 its degree commonly considerable ; whereas, the seat of fever is in the 
 whole surface of the body, and its degree commonly slight. It is here, 
 however, meant that the degree of inflammation, in any given number of 
 
 * Elements of General Pathology, p. 176. Ed. J. J. Drysdale, M.D., and J. R. Russell, 
 Jtf.D. Edinburgh, 1842. 
 
RESOLUTION. 99 
 
 capillary vessels, is commonly slight in fever compared to that of inflam- 
 mation, properly so-called ; but the number of them much more than com- 
 pensates for the slightness of the inflammation of each, and the constitu- 
 tional affection is, of course, great in proportion." 
 
 Divisions. — Inflammatory fever has been divided into the sthenic and 
 asthenic; the former generally appearing in robust young people, the latter 
 in the aged and poorly nourished. It presents the usual stages of erethism, 
 beginning with the usual coldness or chill, as already explained, and fol- 
 lowed by frequent, full, and hard pulse, hurried respiration, flushed face, 
 dry mouth, hot head, restlessness, and often delirium. The tongue is 
 coated, the breath bad, the secretions deranged, and the temperature rises to 
 103° or 104°. These symptoms subside, with critical discharges from nose, 
 kidneys, lungs, or skin ; or if the focus of the inflammation continue high, 
 the nervous system becomes prostrated, and other symptoms of traumatism 
 develop themselves. These will be treated of in their proper places. 
 
 The Terminations of the. Process. — Inflammation has been made to cover 
 processes which were apparently directly opposed to each other. It embraces 
 the healing of wounds and their disastrous suppuration and ulceration ; the 
 mending of a broken bone, and the process which prevents the formation 
 of callus. In the consideration of the subject Mr. John Simon, the author 
 of the article on inflammation in Holmes's System of Surgery, thus writes : " As 
 regards the difference between these actions (formative and destructive), 
 when they occur in health and when they occur in inflammation, it may 
 suffice to observe empirically that the appreciability of the opposed results is 
 in itself a differential mark of inflammation. In healthy tissues, during 
 their normal self-mutation, the anatomist does not at any given moment 
 find either palpable detritus to express their waste of material or multiply- 
 ing embryonic forms to express their action of repair. The change of 
 matter, the degeneration and removal of what is effete, and the substitution 
 of what is useful, occur there so evenly and proportionably that separate 
 steps are not marked in the process, nor can any contrast be found between 
 the respective elements of declining and nascent tissues." 
 
 We therefore may arrange the terminations of inflammation under the 
 following heads : 
 
 1. Resolution and metastasis. 
 
 2. Repair (development of new formations). 
 
 3. Degeneration, including 
 
 a. Suppuration. 
 
 b. Textural softening. 
 
 c. Ulceration (molecular death). 
 
 d. Mortification (death en massed. 
 
 Resolution, also described as Delitescence by some authors, may be either 
 complete or incomplete. In this action the overloaded capillary vessels 
 give off a slight transudation, which relieves them of their engorgement, 
 and allows the agglomerated blood-corpuscles to move slightly in the over- 
 distended vessels. Absorption, also, which had been temporarily sup- 
 pressed, is again called into play, and the extravascular deposits are 
 removed ; by these two actions the tone of the capillaries begins to be 
 regained, and the heart continuing its action the circulation is gradually 
 restored, and healthy nutrition again established. But the sudden disap- 
 pearance of inflammatory action must always — as has been remarked of 
 pain — be regarded suspiciously, as other parts are very liable to take on a 
 similar action, and thus a metastasis is established, perhaps the organ more 
 recently attacked being of a far more important character than the one 
 primarily affected. 
 
 Although resolution cannot always be expected, still it frequently does 
 
100 A SYSTEM OF SURGERY. 
 
 occur; and when this is the case, it is the most desirable termination of the 
 inflammatory process ; at all events, the first treatment should be directed 
 to the establishment of resolution, which, if it does not prove sufficient for 
 this end,. may mitigate some of the after consequences of inflammation. It 
 frequently happens, however, that by the appropriate treatment the tendency 
 of parts to take on inflammatory action may be removed, and thus the 
 patient may be relieved of a considerable amount of suffering and the prob- 
 able tedium of a long and debilitating confinement, and the physician from 
 the harassing and perplexing complications that so frequently present 
 themselves as the sequelae of inflammation. 
 
 REPAIR. 
 
 Inflammatory New Formations. — To account for the varied new forma- 
 tions which are developed by the inflammatory process in the repair of the 
 tissues, many theories are at present under consideration. To explain them 
 Bennett founded his " Coagulable Lymph Theory" on the fact that all the 
 new tissues were formed from the blood plasma exuded from the coats of 
 the vessels. Goodsir, Virchow, and Redfern taught that new formations 
 could be developed from the tissues themselves; while Beale referred all 
 new formations to the subdivisions of the minute germs of living matter, 
 not especially, however, from the nucleoli or nuclei, but from invisible par- 
 ticles found in the blood. Then followed the migration theory of Cohnheim, 
 and the wonderful power of the wandering white blood-corpuscle appeared 
 to be demonstrated so satisfactorily that the process of repair was considered 
 as fully explained. But Strieker, who had also been industrious in discov- 
 ering this amoeboid motion of the cells, found that the new formations were 
 derived from active connective tissue metamorphosis without hyperemia. 
 For further information, however, the student is referred to the previous 
 section of this work which treats of the inflammatory process. 
 
 Whichever of these theories may be correct it is impossible for us to 
 determine at present, but we can form a fair conclusion that the develop- 
 ment of new formations may take place by the cellular infiltration under- 
 going a variety of modifications. It may be metamorphosed into primary 
 cellular tissue, then into granulation tissue, and thence again into connec- 
 tive tissue, which assumes more or less the conditions of healthy structure. 
 
 Adhesion. — A certain degree of inflammation was thought necessary to 
 the restoration of injured parts; hence called healthy inflammation, and 
 supposed to be an instinctive stimulus rather than a morbid action. Un- 
 healthy inflammation, on the other hand, was said to consist of many 
 species — influenced by the kind of disease or by the particular condition of 
 the part in which the inflammation took place. 
 
 Sir Astley Cooper expresses the opinion of the profession of his time. 
 He says : " Inflammation is a restorative process ; no wound can be repaired 
 without it ; even the little puncture made by the lancet would inevitably 
 destroy life if this salutary process did not prevent it." John Hunter, that 
 leviathan in physiology, as Johnson was in literature, in his great work on 
 Inflammation, has been supposed to hold the same opinion; but a more 
 critical examination has led us to believe that even he supposed wounds 
 might be healed without inflammatory action, to substantiate which, passages 
 from his writings can be adduced. For instance, when describing union 
 by the first intention, he seems perfectly aware of the ability of wounds 
 healing without inflammatory action, for he says the union in such cases is 
 without pain or constitutional disturbance, and proceeds as if nothing had 
 happened. Again, he says: "There is only a feeling of tenderness in the 
 part, and that is entirely from the injury done, and not from the operation 
 
REPAIR. 101 
 
 of union; also, that inflammation comes on as a necessary consequence of 
 parts being too weak to unite by the first intention, or not having the power 
 and disposition to heal." 
 
 Owing to Mr. Hunter's obscure phraseology, it is imagined by some that 
 he has been made to support opinions adverse to the great physiological 
 doctrines which he labored so much to establish. He considered inflamma- 
 tion as dependent upon increased circulatory action.* 
 
 As we descend in the order of vitality we find that inflammation is not 
 necessary to a restoration of health. When vegetables sustain injury no 
 such process is established, but the vacancy is filled by the regular and 
 gradual growth of the plant. 
 
 In polyps and gemmiparous animals incision and division are the means 
 of multiplying the species. The gray and green polypi have been united 
 into one animal. The injuries of insects, likewise, are repaired similarly 
 without inflammatory action. The oyster and mussel are said not to be 
 susceptible to inflammation, and the same may be said of serpents, toads, 
 salamanders, and others. 
 
 Of late we have a much more definite idea of the process of repair than 
 formerly. Now we can say that in every individual case the inflammatory 
 process is not necessary. The most perfect form of repair is that known as 
 k> immediate union" by which we understand that if parts, immediately after 
 severance, are placed in direct apposition, the capillary circulation may 
 be established, and union take place without inflammation, the conditions 
 through which such results occur being those most favorable for healthy 
 nutrition. 
 
 There are many other cases, however, in which the symptoms of inflam- 
 mation must and do present themselves; then we have a degenerative condi- 
 tion of the nutritive process, both in degree and in character, with a corre- 
 sponding breaking down of the very tissues which have a tendency to be 
 produced by the process. 
 
 In primary adhesive inflammation the older pathologists believed that 
 the connective tissue of a wound or surface about to be healed was formed 
 by the lymph exuded during the inflammatory process. According to 
 Virchow, however, the changes are now ascribed to the rudimentary cor- 
 puscles or leucocytes which are generated hy the cells on each side of the 
 cut or wound. These multiply and become packed into the interspaces 
 of the exuded fibrin, which is now merely a passive material. These cor- 
 puscles, however, undergo separate changes; in* the one instance they enter 
 into the new tissue about to be formed, and in other instances they become 
 pus-corpuscles. 
 
 According to Billroth, Cohnheim, and others, the changes that take place 
 in an incised wound are : 
 
 1st. Dilatation of the capillaries, which causes a retardation of the blood- 
 stream. 
 
 2d. The wandering white blood-corpuscles migrate into the margins of 
 the flaps, and may even pass into the connective tissue, which becomes 
 much infiltrated with serum. 
 
 3d. The leucocytes are then in part converted into the stable and per- 
 manent connective-tissue corpuscles, and the remainder either enter again 
 into the circulation or degenerate or soften to form pus. 
 
 4th. Together with this, an exudation of fibrogenous serum occurs, which 
 assists to hold the corpuscles firmly. 
 
 The ultimate firmness of the new formation is produced, according to 
 Schmidt, by a fibro-plastic substance, which arranges itself around the 
 
 * Lectures on the Principles of Surgery, by John Hunter, F.K.S., 1839, p. 149. 
 
102 A SYSTEM OF SURGES Y. 
 
 newly-formed corpuscles, forming for them a stratum in which further 
 growth and proliferation may occur, and which also may be removed by 
 absorption after the firmness of the parts is complete. During the healing 
 process, also, the blood-clots are broken up and absorbed. 
 
 The healing process, just described, was attributed by many pathologists 
 of old to the fibrin of the blood, which, according to the Hunterian theory, 
 was supposed to be necessarily present in the healing of wounds by what 
 was called per primam intentionem, or first intention ; and although there can 
 be no doubt that blood-clots may themselves become perfectly organized, 
 as is seen in the arteries after their occlusion, yet this method of organiza- 
 tion is at present believed to be only noticed in the smaller coagula, and 
 that, according to Billroth and some others, in the larger clots the organiza- 
 tion only occurs on the periphery, while disorganization takes place in the 
 centre of the clot. 
 
 Granulation and Cicatrization. — If a wound does not heal by the first in- 
 tention, it closes, by another process, by which new tissue is formed, known 
 as granulation. 
 
 The exuded white corpuscles, or the fixed inflammatory corpuscles, be- 
 come imbedded in fibrin from the liquor sanguinis, the serous portion of 
 which drains away or may be absorbed ; the capillaries assume a somewhat 
 tufted form, and are looped and twisted upon themselves, and finally 
 small, rounded, red, vascular points are seen scattered throughout the sur- 
 face. These cells are then called granulation-cells, and become numerous 
 and fill up the cavity which is being healed. It must be remembered that 
 new capillaries are also formed, which first are composed of a thin mem- 
 brane containing nuclei, arranged frequently in a longitudinal direction, 
 and arising from the sides of the permanent capillaries. These finally be- 
 come fully formed, and transmit an extra supply of blood as long as it is 
 needed ; when they are of no further use they diminish and disappear. 
 
 Healthy granulations are not very sensitive, are of a bright red color, 
 and ordinarily do not bleed easily; sometimes, however, they become sen- 
 sitive, and bleed from the slightest touch, or they may become flabby, pale 
 in color, and very luxuriant in growth ; these are, of course, deviations from 
 the normal or healthy process, and require treatment. 
 
 Finally, the granulation-cells gradually coalesce and become incorporated 
 with each other. (See Fig. 62.) During this process it must not be under- 
 stood that all the corpuscles take on the action we have described ; on the 
 contrary, there are many of them which undergo degeneration and soften- 
 ing, and become pus, and are thus carried away. After the granulations 
 have reached the surface of the body, provided they are healthy, they still 
 further join themselves together, and become glazed over, and as the nodules 
 next the healthy skin reach the surface they become dry and are paler, the 
 epidermal cells become flattened upon themselves, and thus the process 
 continues until cicatrization results. The annexed cut shows beautifully 
 the steps of the process just described. Rindfleisch says: ''The cicatricial 
 tissue is far from being a connective tissue of ideally high quality. On the 
 contrary, its fibres are stiff, inelastic, and misshapen ; its cells are repre- 
 sented by shrunken, staff-shaped nuclei, and its vital capacity is propor- 
 tionally reduced. Moreover, the cicatricial tissue exhibits an extreme 
 
 proneness to contract in all its dimensions It need hardly be said 
 
 that this general diminution in bulk is a physical rather than a vital phe- 
 nomenon. The removal of water has a great deal to do with it, for the 
 white glistening tissue of a cicatrix is dry, compact, and harder to cut than 
 anv other variety of connective tissue." 
 
 The scabbing process may be called nature's mode of healing wounds. We 
 often see the process in animals when they receive slight wounds, the blood, 
 
THE VARIETIES OF INFLAMMATION. 
 
 103 
 
 dirt, and other materials which collect on the outside form a thick scab, ex- 
 cluding the air ; when the' scab falls off, the wound beneath is healed. This 
 process takes place, however, only in slight wounds where there is little or 
 no suppuration. Dr. Hewson imitates this process in his earth treatment, 
 and I must confess I have seen wonderful results from this application in 
 
 Vertical section through the edge of a granulating surface in process of repair (after Rindfleisch).— a. 
 Secretion of pus. b. Granulation tissue (embryonic tissue) with capillary loops, whose walls consist of a 
 layer of cells longitudinally disposed : their thickness decreases as we approach the surface, c. Cica- 
 trization beginning at the base (spindle-cell tissue), d. Cicatricial tissue, e. Fully-formed cuticle, its 
 middle layer consisting of grooved cells. /. Young epithelial cells, g. Zone of differentiation — 
 (Holmes.) 
 
 recent wounds and burns. The process, however, does not appear to be 
 exactly understood. But it is probable that the pus and serum become 
 inspissated, and that the healing process takes place beneath them. 
 
 The Varieties of Inflammation. — It is rather difficult, strictly speaking, to 
 divide or classify inflammations, because in each the same actual pathological 
 conditions are found, viz., stasis and transudation; but there are marked 
 differences exhibited by different tissues when undergoing the process, and 
 from these we may differentiate the croupous or fibrinous, the parenchymatous, 
 the catarrhal, the phlegmonous, the scrofulous, the infective, and the chronic. 
 These terms scarcely need explanation. In the croupous, there is found to 
 be a coagulable exudation developed upon mucous surfaces, accompanied, 
 in the majority of instances, by a necrosis of the membrane beneath. The 
 catarrhal form differs from the above in the fact — an important one — that 
 the exudation is mucous and does not coagulate, and contains scattered leu- 
 cocytes. This variety is more liable to become chronic ; indeed, in some 
 instances the white blood-corpuscles become pus-corpuscles, and we have 
 the well-known purulent catarrh. 
 
 By the term parenchymatous inflammation, is understood those changes 
 
104 A SYSTEM OF SURGERY. 
 
 resulting from the inflammatory process taking place in the true tissue of 
 an organ, independent of its connective tissue.' It consists mainly in a 
 granular degeneration of the protoplasm of the cells, similar in most respects 
 with that variety of diseased action known as albuminoid, which often ends 
 with fatty degeneration. Parenchymatous inflammation therefore attacks 
 the true structure of a part, while interstitial inflammation affects the con- 
 nective tissue. 
 
 In the catarrhal variety of inflammation, the mucous surfaces suffer ; the 
 exudation that takes place is composed of mucus, containing scattered leu- 
 cocytes and epithelial cells ; the discharge does not coagulate, and some- 
 times, when the catarrhal inflammation is produced by a specific poison, as 
 in gonorrhoea, the mucous discharges rapidly become purulent. This is also 
 seen in the conjunctiva. 
 
 The so-called phlegmonous inflammation is nothing more than an acute in- 
 terstitial inflammation, generally resulting in the formation of abscess. 
 
 The term infective, as applied to inflammation, readily explains itself. 
 The passage of some infectious material into the blood (pus, ichor, or any 
 form of bacillus) will set up an inflammatory action which is decidedly in- 
 fective in its nature. Other terms sufficiently explain themselves, and need 
 no further mention in this place. 
 
 Other results of the Inflammatory Process. — Before proceeding to the con- 
 sideration of the other more important terminations of the inflammatory 
 process which demand separate treatment, a few remarks upon some of the 
 further results of the inflammatory process remain to be noticed. 
 
 In muscle the true texture disappears, and is replaced by granules and a 
 large quantity of " oil-drops;" even the strise in the surrounding muscular 
 fibre give way, and a semi-solid substance, composed chiefly of oil, 
 remains. 
 
 In glands and the mucous membranes, no matter where found, this tendency 
 to softening and disintegration, and the appearance in the debris of vast 
 amounts of oily material, is found. 
 
 In bone, the first trace of the destructive process is generally noticed be- 
 tween the animal and earthy constituents of the osseous structure. The 
 parts are disintegrated and discharged in larger or smaller particles, while 
 the chemical constituents are also materially changed. In ligaments and 
 the hard structures, again, are found liquefaction and tendency to fatty 
 degeneration ; and in nerves the very nerve-tubules themselves become filled 
 with depositions of oil. 
 
 The conversion of cells into this oily substance, which ultimately causes 
 fatty degeneration, is occasioned first by an accumulation of fatty particles 
 in the interior of the cells, which, being thus filled, lose their translucency, 
 and the cell-wall becomes thinned. 
 
 This degenerate body has been called by Gluge the " inflammatory glob- 
 ule," by others the " granule-cell." The cell-wall, as the process continues, 
 disappears, and the mass (" granule mass ") breaks up and is more readily 
 amenable to absorptive power. 
 
 This fatty degeneration is sometimes accompanied by the deposition of 
 calcareous material in the corpuscles. 
 
 The causes of inflammation are divided into the predisposing and exciting. 
 Among the former may be classed plethora, debility, either general or local, 
 intemperance, undue exertion of mind and body; the latter, comprising irri- 
 tants, pressure, heat or cold, excessive irritation, retention of secretions. 
 
 The duration of the inflammatory process varies according to the struc- 
 ture of the part, its situation, the temperament, age, sex, and habits of the 
 patient. In organs of a high degree of vitality, the progress is more rapid 
 than in those which are less highly organized. In the sanguine tempera- 
 
TREATMENT — LOCAL TREATMENT. 105 
 
 ment it is more severe than in the phlegmatic, and in the intemperate it is 
 more to be dreaded than in those who have led a regular and temperate 
 life. 
 
 Treatment. — In the treatment of inflammation, often the different charac- 
 teristics of the suffering are important, thus: Inflammation of the cellular, 
 osseous, nervous, and muscular tissues is circumscribed and the pain throb- 
 bing. In morbid growths and in tubercle the objective symptoms are dif- 
 ferent, nor is there much pain or increase of heat. In other varieties of 
 abnormal growth the appearances again are dissimilar, and the pains are 
 acute and lancinating. Inflammation of the lining membrane of the larynx 
 is admitted to be quite different from inflammation of the lining membrane 
 of the trachea. Inflammation, seated in the same tissue of the same organ, 
 assumes at different times different characters, as is observed in cutaneous 
 affections. How are these differences to be understood and encountered ? 
 Can they all be grouped together and treated as that pathological condition 
 termed inflammation ? If systems of medicine and not the law of simile be 
 true, they ought to be so understood and treated, and the successful result 
 of such practice would confirm the truth of the system. But they are not 
 treated upon any general principle. In diseases of the dermoid system, the 
 chief reliance is reposed upon what are termed specifics. An impartial mind 
 can entertain no other idea than that the different subjective symptoms — as 
 exhibited, for example, in different varieties of pain, such as tearing, burn- 
 ing, darting, lancinating, pressive, piercing, boring — are the result of essen- 
 tially different morbid actions ; each one, therefore, of necessity requiring 
 its appropriate remedy. To these differences a critical attention must be 
 given for the most successful application of means. It is unpardonable 
 ignorance at the present time, when the bright rays of progressive medicine 
 are illuminating our pathway, to have an imperfect knowledge only of 
 symptoms, and to confound all distinctions. 
 
 The following are the medicines that appear best adapted to remove the 
 tendency to inflammation. 
 
 1. Cham., graph., hepar, petrol., silic, staphis., sulph. 2. Baryta carb., 
 calc. c, lye, nit. ac, rhus, sepia. 
 
 Should these not be sufficient, and the inflammatory action appear to be 
 progressing, the medicines to be relied on are : 
 
 1. Aeon., ars., bell., bry., hepar., mere, phos., silic, sulph. 2. Asa., arn., 
 calc. c, china, graph., mang., natr. m., petrol., puis., rhus tox. 
 
 These, perhaps, it will be sufficient to name, although there are many 
 others of minor importance that are serviceable in treating the concomitant 
 symptoms of inflammation. 
 
 Of course, it would be highly improper to administer any of the above- 
 mentioned medicines merely for the few indications that have been men- 
 tioned ; the totality of symptoms must be considered ; but it would certainly 
 be a work of supererogation — indeed, it would be impossible to mention in 
 this chapter the medicines that are to be exhibited in every case of inflam- 
 mation, for the disease, as is well known, occupies not only the attention of 
 the surgeon, but constitutes a large proportion of those affections that are 
 encountered by the ordinary practitioner in the daily performance of his 
 duty. 
 
 Local Treatment. — In all cases, the first circumstance that must receive 
 attention is the removal of such exciting causes as happen to be present. 
 Of course, we could not expect to treat successfully any case of disease while 
 the exciting cause is still operating. A slight inflammation arising from a 
 small splinter cannot be cured until the extraneous body is removed. 
 
 In wounds, it is often found that foreign substances excite an unnecessary 
 degree of inflammation ; these should be taken away as speedily as possi- 
 
106 A SYSTEM OF SURGERY. 
 
 ble ; splintered pieces of bone often give rise to the abnormal action and 
 require removal. The head of a bone being out of its place may cause in- 
 flammation in the part in which it lies ; it, therefore, must be returned to 
 its natural position before inflammatory action can be subdued. There are 
 very many other exciting causes that may be detected, and the sooner they 
 are remedied the better. 
 
 Rest of the inflamed locality, if possible, should be absolute; when the 
 muscles are affected, they should be placed in such a position that they 
 may be entirely relaxed. 
 
 Position is all-important in the management of local inflammation ; the part 
 should be placed in such posture that gravitation will act as a sanguineous 
 drain, and at the same time oppose further injection of the inflamed part. 
 
 Moist Heat and Cold. — The efficacy of a poultice in the treatment of 
 inflammation is a disputed point in our school ; some, I believe in these 
 days a very few, practitioners discard the use of such adjuvants, while others 
 have recourse to them frequently, and speak loudly in favor of such means. 
 Among the latter I class myself. 
 
 I am in the habit of using a poultice composed of two parts of ground 
 flaxseed and one part of ground poppy leaves, encased in a bag made of 
 cheese-cloth, bobbin et, or some thin material, and applied hot, once in three 
 hours. Over the poultice a piece of oiled silk or thin india-rubber cloth 
 should be laid, and held in place by a turn or two of the roller, secured by 
 safety-pins. 
 
 If the pain is very severe, I add to this poultice, just before it is taken 
 from the cup, a teaspoonful of laudanum, having it thoroughly stirred 
 through the other ingredients. 
 
 Cold wet bandages, if they be properly applied, are also productive of much 
 benefit and relieve pain. They are more especially called for in the earlier 
 stages of acute or sthenic inflammation, and should be used in a careful 
 manner. Two folds of canton-flannel or patent lint, or a worn woollen 
 cloth, should be dipped into cold water, and wrung out sufficiently to pre- 
 vent dripping ; this compress should be placed upon the inflamed part, and 
 over it a dry flannel (large enough to extend two inches over the edges of 
 the wet compress) should be laid, over which again a piece of oiled silk, 
 mackintosh, or india-rubber gauze should be spread. No rule in regard to 
 changing this dressing can be laid down, for so soon as the compress be- 
 comes hot it must be again wrung out in the cold water and reapplied. In 
 some cases of acute inflammation the cloth may have to be changed every 
 ten minutes, in others not for an hour. Great care must be observed 
 not to allow any part of the clothing of the patient or the pillows and sheets to 
 become wet, for if such an occurrence be permitted, the patient will, in all 
 probability, take cold, and the efforts at relief be frustrated. 
 
 Many is the case of acute inflammation I have been able to subdue at its 
 outset by this treatment, and much severe pain I have speedily alleviated. 
 It must be remembered, however, that often upon a first application of either 
 the moist heat or the moist cold, a temporary aggravation of pain may re- 
 sult. This the surgeon must understand and explain to the patient. 
 
 Hot water alone is also to be used for the relief of pain and for the treat- 
 ment of the more chronic or fully established inflammations. In the use of 
 this agent the same precautions are necessary as have been given above as 
 applicable to the cold dressings. 
 
 Dry Heat and Cold. — Of late I have seen excellent results from the appli- 
 cation of dry heat and cold, which is accomplished in a most satisfactory 
 manner by an apparatus devised by a surgeon of Vienna, and which is seen 
 in the following cuts. The only objection I have to offer to this method is 
 the weight of the tubing (constructed of leaden pipes lined with tin). If the 
 
DRY HEAT AND COLD. 
 
 10: 
 
 parts are highly sensitive, as in peritonitis or acute inflammatory joint- 
 disease, the patient is often unable to bear the weight of the lead convolu- 
 tions, and in some cases I have been obliged to devise a temporary swinging 
 apparatus to assist in removing the heft. This has in a measure been obvi- 
 ated by having the coils constructed of india-rubber, the latter, however, 
 is open to the objection of not being readily bent to accommodate itself to 
 the inequalities of the surface to which the cold or heat has to be applied. 
 
 Fig. 63 shows the coil applied to the scalp ; 2 s represents the bottle con- 
 taining ice-water, into which the india-rubber tube, having a weight on its 
 
 Fig. 63. 
 
 end, is dropped. In place of the bottle, an ordinary tin pail containing 
 ice-water, answers a better purpose. Sp shows the leaden coil (to which the 
 india-rubber supply-tube is fixed) applied to the scalp and fastened under 
 the chin by the tape b ; as is the reservoir (it may be a bucket) into which 
 the waste water flows. The nurse is only required to fill the upper reser- 
 voir as it becomes exhausted. 
 
 For the application of the dry heat the apparatus is a little more compli- 
 cated. Fig. 64 represents its method of application. Cold water passes 
 from 2 s through the plate ps, in which is imbedded a spiral tube, which 
 is heated by the flame of the lamp L. From ps the water flows through a 
 vertical metal tube to which a thermometer is attached, indicating its tem- 
 perature. The latter is very important for the proper regulation of the size 
 of the flame of the lamp. The temperature of water can thus be raised 
 from say 45° to 140° Fahrenheit in three minutes. As the water should 
 pass through the heating-pan ps slowly, the lamp should stand about in the 
 
108 
 
 A SYSTEM OF SURGERY. 
 
 same height as the water-level. The thermometer should be observed during 
 the first ten minutes of the application, and in the meanwhile the flame 
 turned on to the necessary size for producing the desired degree of heat. 
 
 Fig. 64. 
 
 The lamp itself is seen in Fig. 65. z s is the tube supplying the cold 
 water. Under ps is the leaden coil (the arrangement of which is seen in 
 
 Fig. 65. 
 
 J. RSYXDZRS- 
 
 PS) exposed to the flame of the lamp, the set-screw of which controls the 
 movement of the wick. T, the thermometer fixed in its place, and / an 
 
DEGENERATION OF TISSUE. 109 
 
 eye-hole of colored glass, through which the attendant may notice the con- 
 dition and bearing of the flame upon the heated coil through which the 
 water is passing. 
 
 CHAPTER V. 
 DEGENERATION OF TISSUE. 
 
 Suppuration: Pus-Corpuscles — Varieties and Analysis of Pus — Fluctuation — 
 General Treatment — Abscess, Acute, Chronic, Diffuse, Eesidual: Time of 
 Operation — Treatment — Hyper-Distension with Carbolic Water — Sinus and 
 Fistula. 
 
 If resolution is not accomplished, or either of the methods of repair men- 
 tioned (vide pp. 99-103), then the white corpuscles, which, as we have seen, 
 are found in immense numbers, degenerate and become " pus-corpuscles," 
 or in some instances " the matter " may be de- 
 generate granulation-cells or connective-tissue FlG - 66 - 
 corpuscles. Pus-cells, when young, are small 
 punctated bodies, which, as has been already 
 remarked, possess the amoeboid motion (Fig. 
 66), especially at a high temperature. These 
 young cells send out offshoots, which separate 
 themselves, and rapidly proliferate, accounting 
 for the extremely rapid formation of pus which 
 is often seen after suppuration is once estab- 
 lished. After a time, however, as they grow „ „ . ... 
 
 -Pus-corpuscles * ct rroin 8. iiG&ltnv 
 
 older, thev assume the spherical form, and are granulating wound.' b. From an ab- 
 
 nhnnt a - th to * th ofan \r\oh in diampfpr scess ln the areolar tissue, c. The 
 
 aDOUt -2 5~o o m I0 Tinnr" 1 0I an mcn in diameter. same treat ed with dilute acetic acid. 
 
 " PllS-globuleS, as Seen OUt of the body, are d. From a sinus in bone (necrosis). 
 
 but little different in appearance from leuco- RiJdleKs p^dhdogki?H%tdo^° m 
 cytes. The leucocyte, when treated with acetic 
 
 acid, displays the appearance of a nucleus in its interior, that appearance 
 being usually regarded as the result of a shrinking of the protoplasm of 
 which it is composed. The pus-globule shows more distinct trace of a 
 membrane, and is frequently many-nucleated when treated with acid, a 
 condition which Rindfleisch regards as indicating a tendency to degenerate 
 and break down. But the same author says that many of the corpuscles 
 of pus display no difference whatever in character from the blood leuco- 
 cytes, having only single nuclei, showing the same amoeboid movements, 
 and being in fact obviously the same things, both in structure and function. 
 This should be borne in mind in connection with the fact that suppuration 
 is not in most cases wholly a destructive process, but serves also as one of 
 the usual modes of repair." — Holmes. 
 
 According to Virchow * " suppuration is a pure process of luxuriation, by 
 means of which superfluous parts are produced, which do not acquire that 
 degree of consolidation or permanent connection with one another, and 
 with the neighboring parts, which is necessary for the existence of the 
 body." .... Pus is not the dissolving, but the dissolved, i. e., transformed tissue. 
 A part becomes soft and liquefies while suppurating ; but it is not the pus 
 which occasions this softening ; on the contrary, it is the pus which is pro- 
 duced as the result of the proliferation of the tissues. 
 
 * Cellular Pathology, p. 489. 
 
110 A SYSTEM OF SURGERY. 
 
 Besides these degenerate corpuscles, there is a breaking down of the 
 intercellular substance, and a complete metamorphosis of tissue ; granu- 
 lation-cells, molecular debris, fatty particles, and blood-corpuscles, all being 
 commingled — in fact a general softening of the tissues. 
 
 To the eye, pus is a yellowish-white creamy liquid, sometimes of a slight 
 greenish tinge, with scarcely any peculiarity of odor, and heavier than 
 water. According to chemical examination, the pus-globule is said to be a 
 protein compound, consisting of the binoxide and tritoxide of protein, but 
 these bodies are included in regularly organized cellules, and they float in 
 a clear liquid called the liquor puris. This secretion is closely analogous to 
 the serum of blood, and differs from it chemically only in the fact that its 
 protein compounds are oxidized. 
 
 The chemical constituents of pus are alkali, water, albuminate, and three 
 other albuminoid substances. These substances differ in their powers of 
 coagulation and solubility. One of them requires from 48° to 49° C, and 
 is insoluble in a 0.1 per cent, of common salt and in a dilute solution of 
 soda. The second is insoluble in water, but dissolves in a 0.1 per cent, 
 solution of hydrochloric acid. The third is soluble in the latter solution, 
 insoluble in a solution of common salt. Besides, pus contains other sub- 
 stances, such as nuclein, albuminous constituents, cerebin, cholesterin, and 
 lecithin, which belong to the pus-corpuscles, as well as phosphuretted fats 
 and inorganic salts, the chief of which are chloride of sodium, phosphates 
 and carbonates of the alkalies, phosphate of lime, and the oxide of iron. 
 
 The abnormal constituents are mucin, chondrin, gluten, chlorrhodinic 
 acid, pyocyanin and pyoxanthosis (in blue pus), biliary acids, grape sugar, 
 and urea. After exposure to the air, pus undergoes acid fermentation, and 
 then contains leucin, formic, butyric, and valerianic acids. 
 
 According to Hoppe Seyler, pus-serum contains, in one hundred parts, 
 90.96 per cent, of water ; albuminoids, 7.02 ; lecithin, 0.10 ; fats, 0.04 ; 
 cholesterin, 0.07 ; alcoholic extract, 0.06 ; water extract, 0.92 ; inorganic 
 salts, 0.77.* 
 
 The whole amount of solid constituents in pus is 140 to 160 parts in 1000, 
 of which only 5 to 6 per cent, consists of mineral substances. 
 
 Pus, as has already been described, is what has been termed by many 
 writers laudable or healthy pus, and as such resists putrefaction for a length 
 of time ; but there are very many circumstances that may cause the matter 
 to assume different characters. It is a bland fluid, and can wash the most 
 delicate granulations without harming them. If, however, it is exposed to 
 the air, it becomes vitiated ; the albumen of the serum is converted into 
 the hydrosulphate of ammonia ; an offensive odor is given off, and then we 
 have unhealthy pus. 
 
 Specific pus is that variety which contains some specific virus, as the 
 syphilitic or vaccine. 
 
 Sanious pus is thin, acrid^and bloody, and receives also the name of 
 ichorous pus. 
 
 When it is mixed with serum it is called serous pus, and when it contains 
 flocculi or cheesy particles, it receives the name of scrofulous pus. 
 
 The terms sero-purulent and muco-purulent explain themselves. 
 
 Such are the changes that may be noticed in suppuration, and, by under- 
 standing them, the student and young practitioner will often be able to 
 trace more minutely the origin of the disease and render a more perfect 
 diagnosis. 
 
 Pus is rarely absorbed, and in the generality of instances, if not assisted 
 in its discharge by the surgeon, finds for itself an opening, leaving a scar, 
 that ever after denotes that disease has once been present in the system. 
 
 * Vide Lancet, March 16th, 1878. 
 
SUPPURATION. Ill 
 
 When suppuration is fairly established, the more acute sufferings of the 
 patient subside, the throbbing which was before frequent, disappears, and 
 the sharp piercing pains become more dull and constant. Generally about 
 the centre of the tumor a small conical eminence appears, that is most com- 
 monly of a paler hue than the surrounding textures ; when such appear- 
 ances present themselves the abscess is said to be pointing. 
 
 Fluctuation. — The fluctuation of a fluid can often be perceived beneath 
 the integument by careful examination with the fingers, but in some cases 
 it so happens that the presence of matter may be so deep-seated that this 
 sensation cannot be appreciated by the practitioner. The attendant occur- 
 rences and the presenting symptoms cannot be too carefully studied when 
 such a condition is suspected, for the discovery of the existence of deep- 
 seated matter is a circumstance of the highest importance, and one which 
 involves the practitioner's reputation, and frequently the life of the 
 patient. 
 
 Gentlemen of the highest reputation as surgeons have been, even after 
 minute examination of a case, entirely mistaken as to the presence of fluid. 
 Several instances are recorded in this work (one further on in this chapter), 
 in which three incidents in the life of Dr. Dease, of Dublin, are mentioned. 
 In the first his great skill as a diagnostician was shown; in the second, the 
 mistake ; the third, the suicide. 
 
 Mr. Cooper says : " In no part of the surgeon's employment is experience 
 in former similar cases of greater use to him than in the present ; and how- 
 ever simple it may appear, yet nothing, it is certain, more readily distin- 
 guishes a man of observation and extensive practice, than his being able 
 easily to detect collections of deepseated matter. On the contrary, nothing 
 so materially injures the character and professional credit of a surgeon as 
 his having in such cases given an inaccurate or unjust prognosis ; for in 
 diseases of this kind, the nature and event of the case are generally at last 
 clearly demonstrated to all concerned." 
 
 The only characteristic constitutional symptom that is said to denote the 
 formation of matter, is that of shivering. On this subject, however, as 
 there is some difference of opinion among the profession concerning its 
 usefulness as an indication of formation of pus, Mr. Fergusson is quoted. 
 " It is," says he, " in my opinion, less worthy of estimation than some seem 
 to imagine ; it frequently occurs in instances of disease where suppuration 
 never ensues ; it often occurs even in a state of health, and equally often 
 when it does happen it may be overlooked. Shivering is a symptom which 
 the surgeon is often deeply interested in, not so much, however, from the 
 dread of suppuration, as that it denotes some peculiar condition of the 
 system fraught with much danger to life; as, for example, if within the first 
 ten days after a capital amputation, or after lithotomy, a patient is seized 
 with shivering, there is much reason to anticipate a fatal result; and 
 although this may not occur in all such instances, every practical surgeon 
 must bear me out in the formidable estimation I have made of this symptom. 
 But whether it has preceded suppuration or not, the surgeon will seldom 
 be thus satisfied that matter has foVmed." 
 
 Treatment of Suppuration. — The more minute treatment of suppuration 
 will be detailed under those diseases in which it occurs. A few remedies 
 may however be mentioned. 
 
 The sulphate of iron has lately been used with great success in suppuration. 
 An account is given of a child who was burned all over the body, and in a 
 most terrible condition was brought to the Children's Hospital, at Lausanne. 
 It is stated that the suppuration was so profuse, that the ward in which he 
 was placed became absolutely uninhabitable. Upon placing him in a bath, 
 containing two handfuls of sulphate of iron, the pain ceased immediately. 
 
112 A SYSTEM OF SURGERY 
 
 The bath was repeated twice a day, and the patient allowed to remain in it 
 fifteen or twenty minutes at a time. The suppuration became very much 
 less, fetor vanished, and the child rapidly recovered. 
 
 Dr. Sidney Ringer recommends highly the sulphides of potassium, of 
 sodium, or of calcium, in the treatment of suppurative processes. After 
 their administration the discharge may become thin and unhealthy, but 
 afterwards assumes a " laudable " character. The dose is, for carbuncles, 
 y^th of a grain of sulphide of calcium, given every two hours. 
 
 Calendula Officinalis. — In this place it is proper to speak of the marigold, 
 and its power over suppuration. 
 
 Of all the varieties of topical applications which are recommended in 
 the treatment of suppurations and lacerations, and of all the different 
 medicinal substances which are supposed to possess an influence upon these 
 processes, there is not one that is entitled to a higher place than the calen- 
 dula officinalis. 
 
 The peculiar properties of this agent were some time back introduced to 
 the homoeopathic profession by Dr. Thorer, in the British Journal of Homoe- 
 opathy, and since that period many practitioners, through the periodicals, 
 have noticed its effects. 
 
 There can be no doubt that when homceopathists begin to devote them- 
 selves more exclusively to surgery, this plant will be as highly in vogue 
 after operations, in the treatment of wounds when large and exhausting sup- 
 puration is to be expected, in burns, in anthrax, etc., as the arnica has 
 become in the treatment of bruises. 
 
 According to the Pharmacopoeia, the flowers, buds, and young leaves are 
 used, the juice expressed after maceration in alcohol, and the tincture thus 
 obtained, when properly diluted, is used as a topical application. Dr. 
 Thorer prefers what he terms the aqua calendulas officinalis, and his directions 
 for its preparation are as follows : " Fill one-third of a clean bottle with 
 petals or leaves of the flowers, the remaining two-thirds with fresh pure 
 spring water. Cork the bottle well and expose it for two or three days to 
 the rays of the sun. The water is by this process rendered slightly aromatic. 
 It is then poured off from the leaves into a bottle, which must be sealed, 
 and placed in a lower temperature. While the liquid is being exposed to 
 the rays of the sun it must be narrowly watched, and as soon as there are 
 signs of incipient fermentation measures must be taken to arrest it." 
 
 This preparation is rather preferable to the dilute tincture, although the 
 latter has proved very serviceable in the hands of many practitioners. 
 When there is great suppuration, as in burns that have involved a consider- 
 able portion of the integument, the action of this medicine is wonderful. 
 The most convincing case of this kind came under the notice of Professor 
 Temple, of St. Louis, the details of which have already been given to the 
 profession in the North American Journal. I would also mention here its 
 usefulness in the treatment of anthrax, to assist in the separation of the 
 slough. I have had under my care many cases of carbuncle. In one 
 instance, the disease extended over the whole forehead. In another case, 
 a large, extremely painful anthrax appeared just over the tendon of the 
 quadriceps extensor, and involved the tissues beneath to such a degree 
 that an abscess formed underneath and threatened the joint. In a third, 
 three large and painful tumors developed themselves on the more usual 
 site, the nape of the neck. The internal treatment was arsenicum for the 
 intense burning, the part being constantly covered with a thick compress, 
 saturated with a hot solution of calendula and water. The effect of the 
 latter in hastening the generally tardy separation of the slough, in allaying 
 pain, and more particularly in bringing the disease to a speedy termination, 
 was surprising. Moreover, the solution of calendula can be poured into 
 
TREATMENT OF SUPPURATION — ABSCESS. 113 
 
 deep wounds with great benefit, and with much alleviation of pain. I have 
 used it freely in almost every variety of surgical operations, after many 
 kinds of amputation, in resections, removal of tumors, and in all classes of 
 wounds. I have experimented with it side by side with the carbolic acid, 
 now so much in vogue, and must give my testimony most decidedly in 
 favor of calendula. 
 
 A young lady, suffering from a contraction of a cicatrix (from a burn), 
 which drew down the eyelids towards the angle of the mouth, and partially 
 everted the lower lid, was brought to me by a student of the college. By 
 dividing the integument from the external canthus, towards the nose, for 
 about an inch and a half with the fascia and superficial fibres of the orbi- 
 cularis, the deformity was to a great extent relieved. The lids were then 
 closed and kept in apposition by straps of isinglass plaster. The wound, 
 from the efforts of the parts to regain their normal position (although de- 
 formity was of some years' duration) opened fully an inch, and to this raw 
 surface compresses saturated with calendula were applied. Rapid granula- 
 tion and cicatrization resulted, without the slightest tendency to erysipelas. 
 I sincerely trust that more of our profession will give to this agent the trial 
 it deserves in medicine and surgery. 
 
 Satisfactory cases, treated with calendula, are recorded by G. W. Camp- 
 bell, M.D.,* A. M. Cushing, M.D.,f and Dr. C. H. Lee. 
 
 J. G. Gilchrist, M.D., also speaks in favor of this substance as a vulner- 
 ary,^ and Dr. J. H. McClelland§ and Dr. L. H. Willard|| also mention cal- 
 endula as a favorite solution for external application. 
 
 Carbolic Acid. — In the chapter in which I treat of the present employment 
 of antiseptics, I shall give my opinion regarding the value of carbolic acid 
 as a vulnerary. It need not be referred to here, only in so far that I desire 
 to strengthen my statement, that it is not to the antiseptic properties alone 
 of carbolic acid that its value in the management of wounds can be ascribed 
 (for as an antiseptic, per se, it is really inferior to many other substances), 
 but that it possesses a specific power of its own of maintaining the integrity 
 of the leucocytes, and preventing their transformation into pus, thus arrest- 
 ing suppuration and assisting in the more rapid formation of new tissue. 
 This peculiar action I believe has been entirely overlooked by many, who, 
 in their anxiety to preserve intact the germ theory as the cause of all sup- 
 puration, forget that there are many influences at work in the production of 
 purulent formation. 
 
 Abscess. — When pus is fully formed, and collected into the parenchyma 
 of a part, the condition is termed abscess, which, on account of the frequency 
 of its occurrence and its numerous complications, is of great interest to the 
 surgeon. 
 
 Lining the cavity that contains the pus, especially if the abnormal con- 
 dition has continued for any length of time, is found a tissue having a 
 membranous appearance and a' membranous function, and possessing a 
 power of maintaining the formation of pus ; hence it is termed the pyogenic 
 membrane. It is not constant in all abscesses, and may be a sign of imper- 
 fect formation of the abscess wall, but is endowed with very considerable 
 capability of secretion, but as an absorbent surface it is comparatively 
 feeble. In regard to this latter point, however, it may be useful to re- 
 member that the pus-globule, when extra- vascular and complete, is of com- 
 paratively large size, not soluble in its own serum, and therefore but little 
 
 * American Homoeopathic Observer, vol. iii., p. 562. 
 
 f Log. cit., p. 563. 
 
 X U. S. Medical and Surgical Journal, vol. i., p. 121. 
 
 \ Transactions American Institute of Homoeopathy, 1868, p. 79. 
 
 || Pittsburg Hospital Cases. 
 
 8 
 
114 A SYSTEM OF SURGERY. 
 
 amenable to ordinary absorption ; the serous portion of the pus may be 
 taken up readily enough, but the solid part probably remains but little 
 affected. And thus the feebleness of absorbent power may depend, not so 
 much on defect of either structure or function in the pyogenic membrane, 
 as on the nature of the fluid on which it has to operate. 
 
 Sudden suppression of purulent formation is always to be regarded as an 
 untoward event. It is more liable to occur in the case of free and open sup- 
 puration than in an unopened abscess. It may be the result of some acci- 
 dental occurrence, the nature of which we may be unable at the time to 
 ascertain, or it may be caused by injudicious stimulation designedly applied 
 to the part ; but the suppression, no matter how it may be induced, is 
 always likely to be followed by disastrous consequences. 
 
 The process of pointing, and the great necessity of observing fluctuation, 
 have been alluded to in the chapter upon suppuration; but there remains 
 to be mentioned one of the most important circumstances connected with 
 abscess, which, if neglected, may be attended with fatal results, or at least 
 with great danger and trouble. 
 
 It sometimes happens that an abscess is situated directly in the course of 
 an artery, and when such is the case the greatest care and discrimination 
 should be exhibited in the diagnosis between the collection of pus and 
 aneurism ; the most experienced have been misled by circumstances, and 
 deceived by appearances. Dupuytren himself, whose ability and surgical 
 skill have always been regarded by the profession with the highest esteem, 
 failed in his diagnosis, and once plunged a lancet into an aneurism, mis- 
 taking it for an abscess. 
 
 The following is recorded of Dr. Dease, of Dublin : " He was called to see 
 a case, supposed to be one of aneurism by all the physicians who had 
 attended it, and upon careful examination determined it to be a large col- 
 lection of pus overlying an artery. Taking the responsibility, in spite of the 
 advice of those who had consulted with him, he plunged his knife into the 
 pulsating mass. There was a gush of matter, and the patient, who looked 
 a short time before upon his case as hopeless, was entirely relieved. Much 
 credit was justly the meed of Dr. Dease, and great gratification must he 
 have felt at thus relieving the unfortunate sufferer. Some time after, he was 
 sent for to another case, which, like that just mentioned, had been regarded 
 as an aneurism ; and, as in the other, he decided that it was a collection of 
 pus, and proposed relief in the same manner. This being assented to, he 
 penetrated the tumor with his knife, when out rushed a torrent of blood, 
 and with it the life of the patient. He had erred in his diagnosis. It was 
 an aneurism — not an abscess ! Dr. Dease returned to his home, and on the 
 next morning was found upon the floor of his chamber with his throat cut 
 from ear to ear by his own hand ! 
 
 The diagnostic signs between abscess and aneurism are : 
 
 From the earliest stage of abscess the tumor is hot, throbbing, hard, and 
 incompressible ; in aneurism the tumor is of natural temperature, and is 
 soft and fluctuating. 
 
 The skin covering an abscess is inflamed and discolored ; that which 
 covers an aneurism is of natural color, or perhaps paler. 
 
 In abscess the formation of the tumor is much more rapid than in aneurism . 
 
 In aneurism the tumor is pulsating; in abscess it is fluctuating, but has 
 no pulsation. 
 
 The enlargement in abscess cannot be diminished by pressure ; in aneu- 
 rism the contrary is the case. When, however, the diagnosis is sufficiently 
 established, it may become a question to the surgeon whether the pus shall 
 be evacuated by the lancet, or whether it would be proper to endeavor to 
 produce absorption. 
 
ABSCESS. 115 
 
 Acute abscess is one in which the inflammatory action runs a rapid 
 course, suppuration is soon established, the matter evacuated, and the 
 patient recovers. In this form of the affection the fever is high, the face 
 flushed, and sometimes, but rarely, there is delirium. Those patients who 
 suffer from acute or phlegmonous abscesses are generally dyspeptic, having 
 some disorder of the stomach or liver. The character of the pus varies in 
 this variety of abscess ; sometimes it is flaky, sometimes sanious, and often 
 laudable. If the inflammation has occurred in the neighborhood of se- 
 creting organs, and their texture has become implicated, then the discharge 
 may be mixed with the peculiar secretion of the organ affected ; there may 
 be bile, semen, or milk, as the liver, testicle, or mamma is implicated. 
 
 In many cases, especially in those accustomed to high living and de- 
 bauchery, or in those whose constitutions are broken down with exposure, 
 hard labor, deprivation, want of air, light, or food, the pus from the abscess 
 is not circumscribed by a pyogenic membrane, and burrows hither and 
 thither in the muscular tissues, giving rise to what is termed purulent 
 infiltration or diffuse abscess. The prognosis in such instances is bad, the 
 suffering intense, and the treatment rather unsatisfactory. The extensive 
 infiltrations of pus set up a terrible constitutional irritation, and the patient 
 may die, worn out with hectic. 
 
 Chronic abscess, or cold abscess.— In this, the symptoms are not as well 
 marked as we find them in the acute or diffuse variety, and those which note 
 the commencement of a chronic abscess are always obscure. There is no 
 fever, but a slight degree of pain ; no heat of surface ; on the contrary, the 
 part appears to be colder, hence the name " cold abscess." The suppurative 
 process is so slow that weeks and months elapse before fluctuation or point- 
 ing can be detected, during which time the general health of the patient is 
 not much impaired. In this variety of abscess, the pyogenic membrane is 
 said to be more clearly developed than in the more acute suppurative 
 process. 
 
 Residual abscess is the name given to the remains of a collection of pus, 
 the fluid portions of which have been absorbed. In such a case there 
 remains a tough or doughy texture, which has somewhat a " boggy " feel. 
 They are said to occur most frequentty after spinal abscesses. 
 
 Local Dangers. — The local dangers belonging to abcesses arise either from 
 the encroachment of the tumor on arteries or veins, or its proximity to 
 important cavities, into which the pus may be unexpectedly poured, or 
 when fasciae and bones become implicated. There are several cases on 
 record in which the coats of an artery have been ulcerated through, and 
 severe, if not fatal, haemorrhage has followed. A case, of the kind was 
 related to me by Dr. Zantzinger, in which upon opening a fluctuating 
 tumor of the neck containing pus a large amount of blood was discharged 
 per saltum. Mr. Liston, also, in opening an abscess, found a gush of blood 
 follow the incision. 
 
 Again, we have large abscesses, which, if they open into the great cavities, 
 would certainly be fatal. In abscesses of the liver, for instance, great care 
 should be taken to prevent such an accident. I attended, in consultation 
 with Dr. T. F. Allen, a gentleman who had an immense abscess in the ab- 
 dominal parietes. This, if it had not been laid open, would undoubtedly 
 have poured its contents into the peritoneal cavity. The patient could feel 
 the " bag," or pouch, as he expressed it, whenever he moved in his bed. 
 
 Again, abscesses are dangerous when they are bound down by strong and 
 deep fascia, as we find in the perinaeum, or beneath the fascia lata of the 
 thigh, in which case they are very likely to produce great devastation by 
 the burrowing of pus, or when suppuration has taken place beneath the 
 periosteum, and bone is likely to be destroyed. 
 
116 A SYSTEM OF SURGERY. 
 
 It is stated on the best authority that large abscesses have in a few in- 
 stances disappeared, and that there is, in certain cases, a physiological resorp- 
 tion of pus. This, however, must be explained, and the experiments of 
 Virchow have thrown much light upon the subject. " Pus as pus is never re- 
 absorbed" and when purulent formations have disappeared, which undoubt- 
 edly is the case in some instances, the process takes place in the following 
 manner : The pus-corpuscles are supplied with a great quantity of water, 
 which is both external to them and intercellular. This fluid part is absorbed, 
 leaving an inspissated form of pus, in which the corpuscles draw near to each 
 other and become very much shrivelled ; these may act as solid bodies, and 
 entering the circulation may give rise at a later period to ulceration. In 
 other instances a fatty metamorphosis of the cytoid corpuscles takes place, 
 in which a mass composed of a milky substance, fat, and an albuminous 
 substance is formed, sometimes even containing sugar, which can be taken 
 up by the absorbent vessels. 
 
 Time for Operation. — There is no doubt in my own mind that the tendency 
 of the surgery of to-day is to interpose operative interference too early, 
 especially in large abscesses. If the suppuration be deepseated, or, as has 
 been already mentioned, vital parts are in imminent danger from the rupture 
 of the sac, then the surgeon, so soon as he is certain that the pus has formed, 
 may proceed to evacuate it. Delay may be dangerous to the vitality, not 
 only of the part, but to the sufferer. Unless, however, some of the local 
 dangers attendant upon abscesses threaten, " delay " should be preferable to 
 speed. On this subject we have the high authority of Mr. Fergusson : " I 
 am of opinion that in ordinary abscess — a bubo, for instance — if an opening 
 is not made until the matter has approached near to the surface, the subse- 
 quent progress of the case is much more rapid and satisfactory, provided 
 that a proper opening be made. I have seen a good deal of the practice of 
 making early openings, and have invariably observed that more pain was 
 thereby induced, and I have often fancied an additional amount of suppu- 
 ration, whilst the after treatment has been remarkably tedious." 
 
 When it is deemed necessary to open an abscess, the incision should 
 always be made where the integument is thinnest, or, in other words, w T here 
 the abscess points ; at which place often a discoloration is manifest. 
 
 The practitioner must also bear in mind that various aberrations of puru- 
 lent collections take place in their progress to the surface, and that they 
 often proceed in a direction opposite to that of gravitation, owing to the 
 resistance of bones, fasciae, and aponeuroses ; which last oppose them in a 
 most remarkable manner, and cause their extension in various directions, 
 giving rise to the most severe local and constitutional sufferings. 
 
 A case of lumbar abscess came under my care after having been seen by 
 many physicians in the East and the West, in which there was an opening just 
 above the origin of the quadratus lumborum muscle, and two outlets in the 
 front of the chest, on the left of the sternum. In making a post-mortem 
 examination I found that the pus had burrowed in the intercostal spaces 
 between the external and internal intercostal muscles (the fibres of which, 
 it will be remembered, for the most part, cross at right angles), and thus 
 made for itself an anterior outlet. 
 
 In most cases the opening should be made freely, and the matter liberated 
 at one operation ; but when the abscess is large, and the constitution of the 
 patient feeble, the exposure of so large a surface and the speedy evacuation 
 of a quantity of matter, might be dangerous in the extreme ; it is then 
 recommended to ascertain to what degree the sac may be diminished, by 
 lessening gradually the quantity of fluid by removing portions of it by 
 means of the aspirator, or after the manner recommended by Abernethy. 
 That is, by making a small oblique opening, and allowing as much of the 
 
ABSCESS. 
 
 117 
 
 contents of the cyst to flow out, as the natural elasticity of the walls will 
 permit ; the wound will, perhaps, afterwards heal by the first intention, the 
 aperture may close perfectly, the patient not be injured by the operation, 
 and there will be much less fluid in the abscess ; this procedure may be 
 
 Fig. 67. 
 
 Fig. 68. 
 
 continued until the sac becomes sufficiently diminished in size to allow it 
 to be laid open in the same manner as smaller abscesses. When a lancet is 
 used, it should be held in the position represented in Fig. 67. 
 
 When the pus is deep-seated, the forefinger of the left hand, and perhaps 
 the middle also, being placed over the abscess with gentle pressure, the back 
 of the knife should be caused to rest against the side of the forefinger (as 
 seen in Fig. 68), the point should then be thrust through the skin, and the 
 coverings of the matter divided as far as may be deemed expedient ; the 
 blade may then be turned slightly on its long axis, when probably the .pus 
 will spring up along its surface. These methods are recommended by Mr. 
 Fergusson, who remarks, " In opening abscesses, whatever be the instrument 
 used, I invariably prefer puncturing first and then cutting from within out- 
 ward, to the method pursued by some, of making a sort of dissection, by 
 successive incisions, through the skin and other textures."* 
 
 In abscesses about the neck, especially those chronic formations of pus 
 beneath the deep cervical fascia, or when collections of deep-seated pus are 
 found in the abdominal cavity, or where such are even suspected, the aspi- 
 rator is without doubt the instrument to be employed. Since the general 
 application of this " suction method," if I may so term it, deep-seated collec- 
 tions of pus in locations which render the knife always hazardous, are 
 deprived in a great measure of their danger. As a means of diagnosis, also, 
 in abscess, the aspirator should never be forgotten ; if one is not at hand, 
 the exploring needle should be employed. Those now found in the ordinary 
 pocket instrument-cases answer the purpose admirably. 
 
 But the surgeon may be able, in many instances, to overcome the neces- 
 sity of operating, by the administration of appropriate medicines, by the 
 action of which the suppurative process may be hastened, and the abscess 
 allowed to open spontaneously. This should always be effected if prac- 
 
 * Practical Surgery, p. 
 
118 A SYSTEM OF SURGERY. 
 
 ticable, and the medicines that have been most efficacious in producing 
 such a result are hepar, mere, and silic. 
 
 When there is much constitutional disturbance on account of the violence 
 of the inflammatory action, aeon, and bell, are to be used, either separately, 
 or in complicated cases in alternation ; the doses to be repeated pro re nata ; 
 the proper antiphlogistic regimen also being observed. 
 
 Lachesis is pronounced an excellent remedy when there has been much 
 distension of the skin, which has a bluish tinge, or where the structure has 
 been destroyed by the magnitude of the abscess. 
 
 The medicines for abscesses are : (1) Bell., hep., mere, sil., sulph. (2) 
 Cale, lye, phos., puis., sep. 
 
 For Acute Abscesses : Ars., asa., bell., bry., cham., hep., led., mezer., phosph., 
 puis., sulph. 
 
 For Chronic Abscesses : Asa., aurum, cale, carb. veg., con., hep., iod., laur., 
 lycop., mang., mere, mere corr., nitr. ae, phos., sep., sil., sulph. 
 
 Silicea. — This remedy hastens suppuration, or restores it when it has be- 
 come arrested in consequence of the suppression of nervous influence. The 
 pus may be laudable or ichorous. It is also serviceable, after matter has 
 been discharged, to promote granulation and cicatrization. Calendula 
 officinalis is highly recommended by Dr. Thorer when the suppuration is 
 profuse and exhausting, especially in traumatic abscesses. 
 
 Sulphur is especially suited for chronic abscess, and for a tendency to 
 suppuration, depending upon a psoric or scrofulous diathesis. 
 
 The hypophosphate of lime appears to exercise a great influence over the 
 so-called " cold abscess." Its use in the treatment of purulent formations 
 has been of great assistance to the surgeon. Dr. Searle, of Brooklyn, called 
 the attention of the profession to this agent some years ago, and I have 
 reason to speak well of its efficacy. The dose, as recommended by Dr. 
 Searle, is 5 grains of the first decimal trituration repeated every three hours. 
 
 Hyperdistension with Carbolized Water. — Washing an abscess with car- 
 bolized water, according to the late Mr. Callender, is a recognized necessity ; 
 and to throw in such a quantity of fluid as will distend the abscess sac in 
 all its parts is equally recognized ; and this procedure is hyperdistension of 
 an abscess cavity. The operation is begun by cutting into the abscess (if 
 no sinus exists), the opening being made of sufficient size to admit a finger. 
 The* pus escapes, and the nozzle of a syringe is next passed through the open- 
 ing, the skin drawn around it, and the contents of the syringe are passed 
 into the sac. The amount of injection may be a little in excess of the quan- 
 tity of ejected pus ; sometimes a second injection may be given. Subsequent 
 treatment consists in renewal; and in a brief time the discharge of pus 
 ceases ; a limpid serous fluid drains off, and presently only a sinus remains. 
 
 Hence it will be observed that by hyperdistension of an abscess sac, the 
 carbolized water can be pressed into cavities implicated; and that treatment 
 can thus effect for such abscesses the same .result as an ordinary injection 
 will insure for a simple abscess. As for the result of this treatment, as far 
 as bone caries is concerned, at present, observations do not permit of abso- 
 lute conclusions ; but that abscesses can be reduced to non-suppurating 
 sinuses, whilst the health of the patient is improved, is clearly established. 
 
 Mr. F. Ash ton Heath records quite an interesting case of multiple abscess 
 treated by this method. 
 
 A woman (aged thirty-one years) had every symptom of chronic pyaemia, 
 and in the inner aspect of the left thigh there was a large abscess. This was 
 opened with a scalpel, and carbolic acid lotion, 1 in 20, mixed with half its 
 bulk of warm water, was injected per syringe into the cavity, until the fluid 
 returned almost pure ; a drainage-tube of rubber was then introduced, and 
 the abscess was dressed with " cere-cloth " soaked in glycerine and carbolic 
 
SINUS AND FISTULA. 119 
 
 acid, and covered with oil-silk ; this was renewed daily. Five weeks after- 
 wards the patient was up, had a good appetite, and was rapidly gaining 
 strength* In old cases, as well as in recent ones, this method is very ser- 
 viceable, and I have employed it often with very excellent success. It is 
 not at all necessary that the carbolized solution so highly spoken of by Mr. 
 Callender should be used. I have found calendula equally as efficacious, 
 and in one or two instances the bichloride of mercury, in a solution of 1 to 
 2000, productive of results which the carbolic acid failed to effect. 
 
 Dr. Marshall records an interesting case in which an old and obstinate 
 abscess was cured by the internal administration of hepar sulph. and injec- 
 tions of a strong tincture of hydrastis.f 
 
 Pressure. — The importance of applying pressure in the treatment of ex- 
 tensive abscesses was long ago recommended by Mr. Solly, J who wrote: " I 
 am not aware how far the plan, which it is my object in this paper to advo- 
 cate, is in general' use or not, but I am so convinced of its value, that I shall 
 venture to bring it forward. I refer to the careful application of pressure 
 over the surface of extensive abscesses after their contents have been dis- 
 charged, and the early disuse of the poultice and its congener, warm-water dressing. 
 I always prefer cotton-wool to any other kind of pad, as it fits better with 
 all irregularities of surface ; and I find that a greater amount of deep pressure 
 can be kept up by strips of plaster than by a roller. By these means the 
 surfaces of the abscess are kept well in contact, they adhere together and 
 the discharge soon ceases." 
 
 An excellent method of applying pressure in large abscesses, especially 
 where there are many sinuses, is through the medium of compressed 
 sponge. The pieces of sponge — which can generally be procured at any 
 reputable pharmacy— rare placed dry over the abscess, and held in situ by 
 means of adhesive straps applied at right angles. Care must be taken to 
 have a sufficient length of strap project beyond the margin of the sponge, 
 that a firm hold may be had upon the surrounding integument. As the 
 secretions are absorbed by the sponge, it naturally enlarges, and being held 
 firmly in its place by the adhesive straps, considerable pressure is exerted 
 upon the abscess and sinuses, and their walls, thus approximated, are much 
 more likely to heal than when constantly distended by accumulations of pus. 
 
 Sinus and Fistula. — These terms are used synonymously by most surgeons, 
 although, strictly speaking, a fistula should have two complete openings and 
 a sinus but one. Again, the term sinus conveys to the mind a somewhat 
 sinuous track which has more or less length. A fistula, in some instances, 
 has scarcely any length, and merely consists of an opening, as we find in 
 vesico-vaginal and recto-vaginal fistula?. When from any glandular organ 
 an unnatural passage is formed for the secretion, the term fistula is applied, 
 the kind being designated by the organ affected ; thus salivary fistula, biliary 
 fistula, etc. 
 
 If a fistula has but one opening, instead of receiving the name sinus as 
 it properly should, it is called incomplete, and it is this very jumble of terms 
 that gives rise to much misunderstanding among students of medicine. 
 
 These canals are lined by a membrane, more or less organized, or imper- 
 fectly formed granulation-tissue, from which is discharged unhealthy pus, 
 generally of a serous or flocculent character. The older the canal the more 
 callous are its walls. 
 
 We find that there are also sinuses that owe their existence to the presence 
 of some local cause, as portions of dead bone, bits of wood, bullets, or other 
 foreign material. 
 
 The course that a sinus takes is influenced by two causes : 1st, the position 
 
 * Braithwaite's Retrospect of Practical Medicine and Surgery, July, 1877, Part 75. 
 f Am. Horn. Observer, 1867, p. 244. J London Lancet, 1855. 
 
120 A SYSTEM OF SURGERY. 
 
 of the patient, thereby allowing the pus to gravitate in certain directions ;■ 
 and 2d, the density of the structures that intervene between the seat of the 
 disease and the external outlet. It is singular how a sinus may meander 
 through the textures, following the law of gravitation in the main, but 
 passing through tissues giving it the least resistance. The main cause of all 
 fistula? is suppuration : an abscess is formed, it bags or pouches, separates 
 tissues, and thus the canal is formed. The treatment will be mentioned 
 when considering the diseases of those parts most likely to be affected. 
 
 CHAPTER VI. 
 
 Traumatic Fever — Septicemia and Pyjemi a— Hectic — Treatment. 
 
 The confusion of terms (necessarily indicating a confusion of ideas) that 
 surround the subjects, traumatic fever, pyaemia, septicaemia, and phlebitis 
 is most surprising. In olden times pyaemia and phlebitis were considered as 
 synonymous terms, but this theory is now untenable. 
 
 It was supposed that the veins surrounding the seat of injury absorbed 
 the infectious material, which was carried into the circulation, but Tessier 
 proved in 1838, that in the majority of cases blood-clots were found above 
 the site of pus, and Gosselin and others, from careful dissections of bodies 
 of those having died of pyaemia, could detect no pus whatever in the vessels. 
 The microscope also proves that there are no more leucocytes in the blood 
 of pyaemic patients than in others. 
 
 It was not until the lamentable assassination of the President of this Re- 
 public, and during that treatment which was still more lamentable, that in 
 this country the profession arrived at anything like a precise knowledge of 
 these different affections. 
 
 For instance, Agnew, in his late Surgery, discards the term pyaemia en- 
 tirely, and regards all the conditions as belonging to traumatic fever, only 
 differing in degree. He classifies them as follows : 
 
 1. Simple traumatic fever. 
 
 2. Secondary traumatic fever. 
 
 3. Complicated traumatic fever. 
 
 Bryant* groups traumatic fever, septicaemia, and pyaemia together, and 
 says : " In septicaemia, ichoraemia, puerperal fever, and pyaemia, the ab- 
 sorption of putrid inflammatory products, or of pus and pus-forming mate- 
 rial, or of some other poison, whether from some other part or not, is the 
 undoubted cause of the disease, the poison being taken into the body, either 
 by the veins or by the absorbents from without." Traumatic or surgical 
 fever may, however, pass into septicaemia, and this into pyaemia, the first 
 being the mildest form of blood-poisoning, the last the most severe. 
 
 In this sweeping classification all the diagnostic marks between septi- 
 caemia and pyaemia are lost, for, as I shall attempt hereafter to show, there 
 are characteristic differences between the two affections. 
 
 In opposition to the ideas of Mr. Bryant are those of Mr. Holmes,f who 
 says : " Septicaemia is something even more fatal than ordinary pyaemia." 
 He believes, however, that they are the same disease under a different form. 
 Spence does not recognize septicaemia at all, and disliking to change surgi- 
 cal nomenclature, adheres to the old word pyaemia.J Pirrie§ adheres also 
 
 * Koberts's Edition. Philadelphia, 1881, p. 56. 
 
 f Surgery ; Its Principles and Practice. Philadelphia, 1876, p. 59. 
 
 j Lectures on Surgery. London, 1871, p. 33. 
 
 \ Principles and Practice of Surgery. London, 1873. 
 
TRAUMATIC FEVER — SEPTICEMIA. 121 
 
 to the term pyaemia, and qualifies his definition by saying : "The terms 
 ichoraemia and septicaemia would more appropriately express what is now 
 believed to be the exciting cause of the blood derangement, although for 
 convenience sake we will retain the use of the term pyaemia." 
 
 Erichsen, Grant, and Ashhurst are all about of the same opinion, and be- 
 lieve that the conditions are : 
 
 1st. Leucocytosis. 
 
 2d. Thrombic and consecutive abscesses. 
 
 3d. Absorption of poison, generating septicaemia. 
 
 It is not necessary to further multiply quotations regarding the various 
 opinions expressed by the surgical authorities of to-day. They all, however, 
 are agreed upon one point, that in both the disorders under consideration, 
 there is an absorption of poisonous material into the blood. 
 
 Upon the very outset of this question it would be appropriate to deter- 
 mine whether the putrefying process or the agents tfcat produce putrefaction 
 come entirely from without. If this be the case, then there are some cases 
 of pyaemia which are unexplainable. This, however, has already been dis- 
 cussed. No one at present denies that germs in the atmosphere will pro- 
 duce putrefaction, and no surgeon who has had any experience will not 
 admit that putrefactive changes result without the presence of an external 
 wound, although the absence of an exterior solution of continuity does not 
 necessarily preclude the absence of bacteria, as recent researches prove that 
 they are found in large numbers in acute bone disease. 
 
 I have looked somewhat into the literature of this subject, and I find that 
 but few writers arrange the two diseases separately. I have witnessed many 
 cases of both septicaemia and pyaemia (and have treated them where they 
 have been fully developed) and have been careful to study their course and 
 termination, and am prepared to say that septicaemia and pyaemia are in the 
 main separate and distinct affections, but that with complications the for- 
 mer may pass into the latter; and I do not agree with those authors who 
 class all these disorders under traumatic or surgical fever, or as a " systemic 
 affection." 
 
 TRAUMATIC FEVER. 
 
 After a patient has received a severe injury, whether accidental or at the 
 hands of the surgeon, the nervous system sustains a shock more or less se- 
 vere, the vital forces are prostrated, the skin is cold and blue, the pulse is 
 feeble, the respiration is quick, there is tendency to cold perspiration, the 
 heart's pulsation is feeble, or may cease from the action of the sympathetic 
 on the cardiac plexus, and every symptom plainly indicates depressed 
 vitality. If the remedies are properly chosen, and the patient's constitution 
 sufficiently strong, a reaction takes place in from one to six hours, which is 
 generally in exact proportion to the profundity of the depression, and the 
 new symptoms are all those of- vascular erethism, viz. : a bounding pulse, 
 red cheeks, dry mouth, restlessness, thirst, hot skin, and often delirium, 
 pulse 120, temperature 102? to 103? degrees. The latter condition is what 
 I call true surgical or traumatic fever. It is the direct result of the trau- 
 matism, and is the effort of nature to restore her lost equilibrium. This is 
 a distinct disease of itself. 
 
 SEPTICEMIA. 
 
 Let us however suppose that some decomposing animal matter, say in the 
 dissecting room, has gained access to the system. What happens? A 
 slight pain at the seat of injury, or no pain at all, or the appear- 
 ance of a small vesicle indicates the presence of the poison. For a day 
 or two, there may be a general feeling of malaise and sluggishness of 
 the circulation caused by zymotic changes taking place in the system. 
 
122 A SYSTEM OF SURGERY. 
 
 Suddenly the disease breaks forth with a severe chill, more perhaps coldness 
 than shuddering, followed by fever. The pulse beats from 120 to 130 strokes 
 per minute, the temperature stands at 104°, and is followed by profuse 
 sweating, with some delirium, with soreness, redness, and swelling of the 
 parts, which, upon examination, show slight red superficial lines, marking 
 the course of the inflamed lymphatics. Sometimes at the site of the gangli- 
 onic centres an enlargement and soreness of the glands are noticed. These 
 appearances are followed by severe constitutional symptoms. The temper- 
 ature even goes rapidly up to 105° (Fig. 69), while the nerve-power of the pa- 
 tient goes as rapidly down. All the symptoms pass rapidly from bad to worse ; 
 the body is continually bathed in perspiration ; restlessness, insomnia, and 
 mental aberrations are all present. At this period often a colliquative diar- 
 rhoea sets in with constant delirium, which, with rapid breathing and some- 
 times with hiccough, continue until the patient dies of profound asthsenia, 
 or sinks into coma from the toxsemic effects of the absorbed morbid pro- 
 ducts. After death the blood is found in a defibrinated condition, is darker 
 colored than natural, and contains much serum. This is a description of 
 the symptoms of a rapid or acute case of septicaemia. Sometimes the ma- 
 
 Fig. 69. 
 
 EaSHEHSa""' 
 
 Heat line in septicaemia, terminating in recovery. 
 
 jority of them may be almost entirely absent. I have known cases — one in 
 particular now occurring to my mind — in which the main feature was rapid 
 emaciation, so rapid indeed, that the loss of flesh was almost visible to the 
 lookers on. In another case the chief indications were periodical pains in 
 the intestines. 
 
 In the more chronic variety similar symptoms are noticed but their 
 sequence is more tardy. The conditions just described may be occasioned 
 by the absorption of any poisonous material from direct contact, whether 
 from an external wound, from a retained placenta, from diphtheria, from 
 sloughing ulcers, from cancerous discharges, and a variety of other affections. 
 
 A typical case has occurred to me within the past year. A lady ap- 
 plied to me for the removal of her right breast, affected with ulcerating 
 scirrhus, with enlarged axillary glands. She was a good deal emaciated 
 (which I always regard as a bad prognostic) but otherwise strong, and en- 
 dowed with uncommon nerve and moral strength. The breast was easily 
 amputated, and half a dozen large glands removed from the axilla ; two of 
 these were evidently undergoing degeneration. The operation was borne 
 well, and for ten days not a single untoward symptom occurred. There 
 was but slight suppuration from the axillary wound, which was supplied 
 with carbolized drainage-tubes, and the breast wound healed almost by first 
 intention. On the tenth day, without any premonitory symptoms what- 
 ever, a severe chill, followed by high fever, with the temperature at 105?°, 
 pronounced the disease. The arm of the affected side became red, painful, 
 and oedematous, and from it the lymphatics in red lines could be distinctly 
 
PYAEMIA. 123 
 
 seen. Tremendous sweating and muttering and low delirium followed, 
 and the patient died on the third day. I believe that the axillary glands 
 and lymphatics had been affected before the removal of the breast, and 
 that so soon as the patient began to recover from the shock and pros- 
 tration of the operation the old poison broke out afresh. In septicaemia 
 after death, besides the defibrinated condition of the blood, the liver will be 
 found softened, the mucous membranes reddened, and the salivary glands 
 engorged and softened. 
 
 PYEMIA. 
 
 Pyaemia in its distinctiveness is a disease bearing some resemblance to 
 that just mentioned, but having its own diagnostic marks. It is caused by 
 the absorption into the system of decomposing pus. I use the words with 
 care, " decomposing pus," because ordinary so-called healthy pus can be, and 
 has been injected into the circulation without disastrous effects, and because, 
 with our present knowledge of pathology, we consider the white blood-cor- 
 puscle and a pus-corpuscle as identical, one being, however, alive and for- 
 mative, the other dead and destructive. Mr. Spence, in his late lectures 
 upon surgery, confirms the statement that the injection of healthy pus into 
 the system is not found to produce those violent symptoms which were 
 hitherto ascribed to it, and that therefore the term pyaemia is an incorrect 
 one. This is a fact in the abstract, but it must not be inferred that the in- 
 troduction of healthy pus is not followed by any abnormal manifestations, 
 for from recent experiments made by Billroth, of injecting pure pus into 
 the circulation, fever was invariably produced, and in some instances in- 
 flammation and suppuration. Weber and SchifT found purulent pleuritis, 
 and Billroth subcutaneous abscesses after such injections. At present, how- 
 ever, it may be asserted that the pus serum, after undergoing a process of 
 change or decomposition, contains the elements FlG 70 
 
 which produce pyaemia. Again, the presence of 
 a thrombus or embolus may excite inflammatory 
 action, and give rise to suppurative inflammation 
 in the vessel, or the inspissated pus, which has 
 already been alluded to, or flocculent particles 
 may become poison to the circulation. By some 
 the term ichorrhaemia is employed to designate 
 this condition, as it is the ichor of the pus that is 
 found most generally to produce the disastrous 
 
 effects of the disease. My friend, Professor Liebold, Thermograph of pyemia. 
 has given to the profession an excellent article on 
 pyaemic fever.* There is no doubt, however, that when pus decomposes, a 
 contagiously miasmatic element is produced, which has a peculiar action on 
 the economy, producing a ferment having a tendency to thicken or coagu- 
 late the blood. 
 
 Let me, for the symptomatology of the affection, again describe a typical 
 case, also lately occurring to me. After an amputation of the thigh, between 
 the third and the sixth day, when the patient had been doing moderately 
 well, a severe chill, lasting for nearly two hours, set in, followed by a mod- 
 erate fever with a temperature at 102° or 102]°. The sweat was profuse but 
 not colliquative, and there was some prostration even early in the disease. 
 This condition lasted for some days, with regular intermissions of the par- 
 oxysms of chill, fever, and sweat ; indeed, so regular are these recurrences, 
 that I have known some cases to be mistaken for and treated as simple ma- 
 larial fever. The bowels of this patient were rather constipated, and the 
 urine high-colored ; the tongue was dry and covered with a yellow fur ; the 
 
 * Transactions N. Y. State H. M. Society, vol. viii., p. 571. 
 
 '£ 
 
124 
 
 A SYSTEM OF SURGERY. 
 
 complexion was icterode and the conjunctiva yellow. The symptom that 
 first placed me on my guard was the peculiar sweetish smell of the breath, 
 which I believe is almost pathognomonic. Examining the wound at this 
 time, the discharge of pus, which had been healthy and profuse, had ceased 
 entirely and there was an ichorous serum in small quantity exuding be- 
 tween the sutures. When the stitches were cut away, the surface of the 
 stump was glazed, of a brownish color, and covered with spoiled lymph. 
 The patient complained of great prostration. Every night there was an 
 accession of chill, fever and sweat, the temperature being about 103° (Fig. 70), 
 and the pulse 120. Occasionally there was delirium, but the patient could be 
 easily restored to consciousness. Shortly after the accession of these symp- 
 toms a bronchial cough set in with rales, especially on the left, side, with 
 severe aching pains in the bones. From these symptoms, however, the 
 patient made a slow recovery. 
 
 During the progress of pyaemia the poison (as already mentioned having 
 a tendency to cause viscidity of the blood) continues to increase these 
 zymotic products, and the stream circulating more slowly in the larger 
 vessels is arrested in the capillaries, which soon become clogged, and in- 
 farctions result. 
 
 Infarctions. — An infarction is a consolidated area of tissue discolored 
 and infiltrated by the rupture of the smaller vessels, in other words, the 
 result of an embolus. These points of rupture are found in various por- 
 tions of the body, and being caused by poisonous products, set up new foci 
 of inflammation, which soon terminate in abscesses in different parts of the 
 body, thus adding to the very grave constitutional symptoms already 
 developed, the additional and characteristic manifestations of the formation 
 of abscesses. If the lungs be the seat of these pus cavities, we get all the 
 physical manifestations of pneumonia or bronchitis. If the liver, the 
 jaundiced condition of the face, yellowness of the conjunctiva, and other 
 hepatic symptoms are present; sometimes a tumultuous beating of the 
 heart indicates either the nerve prostration or imperfect action of the cardiac 
 plexus, and very frequently albumen, pus and casts in the urine proclaim 
 that the renal apparatus is implicated. An especial symptom in pyaemia, 
 and one which I have seen in the majority of the cases that have fallen 
 under my observation, is pain of a fugitive character, flying from one part 
 of the body to another ; and, indeed, in several instances, I have known, 
 together with these pains, swelling and redness of the joints appear, w T hich, 
 with the fever and perspiration already alluded to, are very liable to lead 
 the physician to suppose that a true malarial rheumatism is present. 
 
 From these indications a differential diagnosis may be thus prepared : 
 
 Septicemia. 
 
 1. Caused by any poison absorbed by direct 
 
 contact. 
 
 2. Virus carried by the lymphatics. 
 
 3. A single chill. 
 
 4. No regularity of recurrence of fever. 
 
 5. Temperature 104° to 107°. 
 
 6. Paleness of face. 
 
 7. Rather offensive breath. 
 
 8. Rapid progress. 
 
 9. Delirium and exhaustion. 
 
 10. Pains not general. 
 
 11. No infarctions. 
 
 12. A single abscess or perhaps two ; gener- 
 
 ally superficial. 
 
 Pyemia. 
 
 1. Caused by decomposing pus or pus ele- 
 
 ments. 
 
 2. Carried by the veins. 
 
 3. Many chills. 
 
 4. Paroxysms of chill, followed by fever 
 
 and sweat, with regular intermission. 
 
 5. Temperature 102° to 103£°. 
 
 6. Jaundiced hue, with yellowness of scle- 
 
 rotic. 
 
 7. Peculiar sweetish odor of breath (like 
 
 new hay). 
 
 8. Slower progress. 
 
 9. Less delirium and more prostration. 
 
 10. Severe and fugitive pains in legs, abdo- 
 
 men, and back, with swollen joints. 
 
 11. Infarctions of the viscera; lungs, liver, 
 
 spleen, and kidneys. 
 
 12. Multiple abscess in internal organs. 
 
PYEMIA. 1 25 
 
 But it must also be remembered by the surgeon, that a septicaema may- 
 end in a pyaema, that is from septicemic infection abscesses may arise, 
 either at the point of entrance of the poison, or in the glands, or in the 
 serous membranes. If the pus be healthy and is the result merely of the 
 inflammatory process, its speedy evacuation may cure the patient ; if, how- 
 ever, the poison has not exhausted its toxic effects, or the pus become 
 putrid, either from the degenerate constitution of the patient, or from the 
 abscess being improperly managed, or from the discharges being allowed to 
 decompose, then the absorption of this secondary poison may give rise to 
 the symptoms as detailed as pyemic. I doubt, however, such a condition, 
 because in my own practice I cannot recall a single case of true septicaemia 
 even in those in which the inflammatory process has terminated in suppu- 
 ration, in which I have found multiple abscess, and this point has often 
 puzzled me. I have seen septicaemia follow ovariotomies, I have seen it 
 from dissecting-room wounds, I have suffered for weeks with it myself, I 
 have seen it after lithotomy, in large abscesses, in diphtheria, from retained 
 placenta, and from many other operations, and in many conditions in 
 which the septicemic inflammation has developed pus, and large quantities 
 of it, and yet in the post-mortem examination, multiple abscesses were 
 never found. I am not prepared to make an explanation of this fact, but 
 have thought that perhaps, when the poison is taken up by the lymphatics, 
 the lymph contained in the ducts may have a modifying power over the 
 blood stream, tending rather to liquefy that fluid, whereas when the pus 
 poison is taken into the blood itself, it produces, as I have alread}^ noted, a 
 thickening and viscidity of that fluid, tending to the formation of infarc- 
 tions, and thereby producing metastatic or multiple abscesses. 
 
 The tables of Bryant and Steele are here inserted : 
 
 Analysis of 217 Cases of Pycemia. 
 "Of 217 cases— 
 
 68 or 31.3 per cent, were after compound fracture as a whole. 
 24 or 11 per cent, not amputated. 
 44 or 20.2 per cent, amputated. 
 26 or 12. " were after amputation for disease. 
 
 28 or 12.9 " " after other operations. 
 
 21 or 9.6 " " after injury without operation. 
 
 60 or 27.6 " " after disease without operation. 
 
 f!2or 5.5 " " idiopathic. 
 
 \ 2 or .9 " " puerperal. 
 
 " Through the kindness of Dr. Steele, who has aided me in this statistical 
 investigation, I am able also to give the following interesting facts respecting 
 pyaemia : 
 
 " Out of 790 cases of compound fracture, 192 died, or 24 per cent. 
 68 of pyaemia, or 8.6 per cent. 
 Of 184 treated by amputation — 
 
 89 died, or 47.7 per cent. 
 44 of pyaemia, or 23.9 per cent. 
 Of 606 treated without amputation — 
 103 died, or 17 per cent. 
 24 of pyaemia, or 3.9 per cent. 
 Out of 324 cases of amputation of thigh, leg, arm, and forearm for disease — 
 126 died, or 38.8 per cent. 
 26 of pyaemia, or 8 per cent. 
 
 " Pyaemia is thus seen to be three times as fatal after amputation for 
 compound fracture as for disease. 
 
 " Out of 29,434 surgical cases admitted into Guy's during ten years, there were 1749 deaths, 
 or 5.9 per cent. 
 
126 A SYSTEM OF SURGERY. 
 
 " 203 of these were from pyaemia, or 11.6 per cent. ; about one in nine of the deaths being 
 from this cause. 
 
 " But of the whole number of cases treated, pyaemia was fatal only in .68 per cent." 
 
 The disease whenever found is one of the gravest importance, and re- 
 quires the most careful watching. In hospitals septicaemia is more frequent, 
 and said to be more fatal than in private practice, and, like hospital gan- 
 grene and hospital er} r sipelas, is apparently contagious when occurring in 
 crowded wards, or where many wounded are necessarily grouped together 
 within a small space. 
 
 At present, however, a new era has dawned upon the treatment of wounds ; 
 cleanliness, ventilation, disinfection, and drainage are considered as essen- 
 tial. Nowadays, when hospitals are built upon the more improved plans, 
 and the rules of antiseptic surgery rigorously followed, the appearance of 
 septicaemia is not nearly so frequent as in former years ; indeed, from very 
 careful examination of statistics, it was lately stated by no less an authority 
 than Sir James Paget, in a discussion at the Clinical Society of Great Britain, 
 " that there was quite as great a frequency of pyaemia after operations in 
 private as in hospital practice, and that not only with pyaemia, but with 
 other accidents, as they are called, of operations, he had seen no reason to 
 believe that hospitals are places of greater infection, as it is called, or of 
 greater unhealthiness than is met with in private practice." And Mr. T. 
 Holmes* states as his opinion, that the " popular impression as to the fre- 
 quency of pyaemia in our hospitals is extremely exaggerated." 
 
 Treatment. — From considerable experience in this disorder, I have no 
 hesitation in affirming that very often, if proper attention is paid to pro- 
 phylaxis, the disease may be averted. The first point of importance is 
 quiet. After a serious operation the surgeon must enjoin the utmost rest of 
 mind and of body. This is oftentimes very difficult to obtain, especially in 
 private practice. The friends and relatives are anxiously awaiting the 
 result of the ordeal to which the patient is being subjected. They watch 
 and listen with breathless anxiety ; the stillness is oppressive to them : there 
 is agony in the half-suppressed moan that issues from the operating-room ; 
 when finally the door is opened, the surgeon makes his appearance, and 
 informs them that the operation is completed, the patient survives, and is 
 doing as " well as could be expected ;" then, upon the impulse of the moment, 
 the sufferer may be surrounded by excited, though thankful, relatives and 
 friends, and amid the confusion and congratulations which ensue, the 
 patient, weak from the ordeal which he has just undergone, may be seriously 
 affected with nervous excitement. A change of position may produce 
 haemorrhage, or other untoward symptoms maj T be occasioned. Therefore, 
 quiet must be enjoined by the surgeon, and only one person, or at most two 
 at a time, be permitted to see the patient, and these must be admonished 
 not only to control, as well as they may be able, any mental emotion which 
 may arise, but also to remain but a few moments in the sick-room. 
 
 In the treatment of these diseases, of course, the first item of importance 
 is to remove the exciting cause, that is, if it can be done. When the septi- 
 caemia is produced by a few drops of virus, or from the presence of diph- 
 theritic poison, or from very large abscesses or sloughing wounds, this is 
 not possible. The cause remains, and the great desideratum is to antidote 
 it. Whether in septicaemia or pyaemia, we have circulating in the system a 
 virus which destroys life speedily, and the object should be to pour into 
 the current such substances as are known to be antidotal. 
 
 If the source of the infection is from an open wound or abscess, the care 
 in its treatment must be redoubled. I am speaking now with the belief 
 
 * St. George's Hospital Reports, vol. viii., London, 1877. 
 
PYAEMIA. 127 
 
 that every surgeon pays strict attention to cleanliness, disinfection and 
 drainage. The atmosphere must be purified, and any dressing, having a 
 tendency to prevent the increase of the formation of pus, should be em- 
 ployed. It may be carbolic acid ; if it is, a solution of one part to one 
 hundred is sufficient. If it be corrosive sublimate, which I now generally 
 use, it should be one to two thousand, or one to twenty-five hundred. If it 
 be iodoform it should be one part to eight of flour. 
 
 I have also used with benefit, an absorbent jute, saturated with the bichlo- 
 ride solution and then dried, which dressing should be changed twice during 
 the day. When the chill begins the tincture of the root of aconite in water 
 should be employed, and carbolic acid given internally. I formerly pre- 
 pared a first decimal dilution made with glycerine, mixing twenty or 
 twenty-five drops in half a tumblerful of water, giving a teaspoonful every 
 hour. Of late I have abandoned this treatment, and inject hypodermically 
 from forty to eighty minims of the nascent phenic acid of Declat every night 
 and morning. I cannot speak too highly of this method of treatment in 
 both septicaemia and pyaemia, and have employed it with signal success for 
 several years past ; it never fails to reduce the temperature, and appears to 
 possess complete antidotal properties. I have never known any bad results 
 to follow its use, and I have now in mind a case where sixty minims were 
 injected night and morning for four months, without pain, and without any 
 inconvenience either from the formation of local abscesses at the seat of 
 puncture. In this case the patient was verging upon seventy years, had 
 undergone supra-pubic lithotomy, and had suffered from all the symptoms 
 of double pneumonia. As I believe in the antidotal powers of quinine in 
 certain severe and pernicious intermittents, as I believe in the antidotal 
 effects of mercury and potash in the treatment of syphilitic fever, in the 
 same degree do I believe in the antidotal power of phenic acid in the treat- 
 ment of septicaemia and pyaemia. When the poison has been removed 
 from the system, and the prostration and exhaustion are extreme, arseni- 
 cum and muriatic acid are to be relied upon. In some cases, however, 
 when the patient is recovering from the disorders, there }^et remains a ten- 
 dency to induration of the surface, and sometimes to enlargement of the 
 glands; when such symptoms exist I have found the hyposulphate of soda 
 of most excellent service. It may be given in solution, ten to twenty grains 
 dissolved in six ounces of water, an ounce taken every two hours. 
 
 Another point which experience has fully demonstrated as valuable 
 is stimulation. The quantity of stimulant must be regulated by the ability 
 of the patient to bear it, and it must be given until its physiological action 
 is recognized. Some patients will be able to take half a bottle of brandy or 
 whiskey per day, while others can only bear half or a quarter the quantity. 
 I well recollect a patient in the hospital with two enormous abscesses on 
 the thigh and one on the abdomen, whom, when I saw, I thought was 
 dying ; the jaw was dropped, the eye hazy, the body covered with a cold 
 sweat, with a respiration of thirty -two, a pulse of 140, and temperature of 
 105°, who took half a tumblerful of whiskey every three hours for three days 
 and nights, and never showed any other signs than those of improvement, 
 and recovered after two months' treatment. As the convalescence progressed 
 the quantity of stimulant was diminished, until even a tablespoonful pro- 
 duced the ordinary effects of alcohol. 
 
 Of course, in pyaemia, as the symptoms indicating the development of the 
 internal organs arise, whether of pleuritis, bronchitis, pneumonia, hepatic, 
 or kidney derangement, they must be met with the proper homoeopathic 
 medicines, which, however, it is not the province of this chapter to discuss. 
 
 Muriatic acid is a medicine whose pathogenesis would indicate its applicability to sep- 
 ticaemia. I have used this medicine, and obtained from it apparently good effects. 
 Carbolic acid may also be employed, or the hyposulphite or sulphocarbolate of soda. 
 
128 A SYSTEM OF SURGERY. 
 
 Other medicines which may be called for in the disease are arsen., china, 
 carbo veg., lach., phosph., and veratrum viride. 
 
 Good results may also sometimes be had by the inhalation of oxygen gas. 
 In all large cities it can be obtained in iron cylinders, with the breathing- 
 bag. If the practitioner in the country desires its use, it may be prepared 
 in the ordinary manner.* 
 
 As a last resort in these most serious maladies, the operation of trans- 
 fusion may be performed. {Vide chapter on that subject.) 
 
 In the Transactions of the American Institute of Homoeopathy, for 1870,f Dr. 
 N. Schneider has published a very interesting article on pyaemia, in which 
 he narrates several cases. In one, after an amputation at the middle third 
 of the tibia, severe symptoms showing themselves, aconite, arsenicum, can- 
 tharides, mercury, and china were employed, and the patient recovered 
 after six months. In the second, the patient died; the treatment was 
 aconite, ipecac, arsenic, and veratrum. In the third case, aconite, cantha- 
 rides, china, and rhus were employed. In the fourth case the patient per- 
 ished from secondary haemorrhage. 
 
 Muriate of ammonia is also highly spoken of by some members of the 
 profession, and excellent results have been obtained from veratrum viride. 
 
 HECTIC FEVER. 
 
 The peculiarity of this variety of fever consists in its remissions from the 
 middle of the morning until the afternoon ; the reappearance of the symp- 
 toms at that time, their continuance throughout the earlier portions of the 
 night, and the profuse sweating in the morning. From these symptoms 
 I have known, especially in malarial districts, such fever to be mis- 
 taken for a simple intermittent. Although this regularity of type does 
 not always present, yet it is found in the majority of cases, and, indeed, 
 there are at times two distinct daily or quotidian paroxysms. 
 
 The main points by which the one form of fever may be diagnosed from 
 the other are : first, the exhaustion caused by the sweating and diarrhoea ; 
 second, the great emaciation of the patient; and, third, especially the severe 
 forms of organic trouble which are always to be found, and generally present- 
 ing in profuse suppuration. Another peculiarity of hectic consists in the fact, 
 that though the febrile condition may continue for a considerable time, 
 there is comparatively slight derangement of the assimilative powers. 
 
 Hectic may be diagnosed from typhoid fever by the absence of those 
 symptoms indicating that the nervous centres are affected. Throughout the 
 entire course of the disease the mental faculties do not fail, indeed, I have 
 often observed an increased power and an exaltation of the senses as the 
 physical condition is giving way. 
 
 "When hectic is fully established, every day there is a slight chilliness, or 
 even in some cases perceptible shuddering ; this is followed by a paroxysm 
 of febrile exacerbation, with dry mouth, hot skin and breath, the latter, 
 however, being devoid of the peculiar odor belonging to pyaemia ; the 
 palms of the hands and the soles of the feet burn, and the characteristic red- 
 ness, bright, circumscribed, and scarlet, upon one or both cheeks, with a 
 pulse about 110, and a temperature of 101°, indicate the fever at its height 
 (Fig. 71). This febrile condition lasts a few hours, and is succeeded by the 
 third or the sweating stage, called also by some the colliquative. Instead of 
 the sweat, a diarrhoea may supervene, but whichever results, the patient is 
 greatly debilitated. Between the paroxysms, however, the patient may, 
 
 * For an interesting paper on oxygen gas as a remedy in pyaemia, vide New York Medical 
 Journal, April, 1870, p. 165. 
 f Page 204. 
 
ULCERATION. 129 
 
 until the advanced stage, be comparatively comfortable, and at times may- 
 have some appetite. Finally, the emaciation becomes more rapid, the fea- 
 tures assume the hippocratic cast, the entire system is exhausted, and the 
 patient actually dies from asthsenia, the mental faculties continuing un- 
 impaired to the last. 
 
 Treatment. — The treatment of hectic fever is unsatisfactory, because the 
 surgeon is generally unable to remove the exciting cause. This, of course, 
 is first to be attended to, and if success crowns the effort, and the system 
 can be relieved of the constant source of irritation, the result will be 
 favorable. 
 
 Operative measures are, therefore, called upon, and often delay is danger- 
 ous. The removal of the affected part, even amputation or resection, has 
 
 Fig. 71. 
 
 
 
 
 
 
 : 
 
 
 
 
 
 w 
 
 
 jgj 
 
 
 
 
 
 
 HI 
 
 pBlBlBwnW 
 
 
 
 
 
 «ro 
 
 
 
 
 
 
 wmm 
 
 
 
 
 
 
 
 
 
 
 
 
 
 immmm 
 
 
 
 Hm 
 
 
 - 
 
 
 
 
 
 9l3 
 
 HK9B! 
 
 JSSSSSM 
 
 
 
 
 
 Thermograph of Hectic— (Holmes.) 
 
 often been followed by an immediate improvement in the condition, and 
 as I have elsewwhere remarked, waiting to " tone up " the system as it is 
 called is often to allow the patient to die. Every surgeon is aware, how, in 
 certain cases, after hectic has been wearing away the life of the patient, the 
 removal of the affected parts is at once followed by better appearances and 
 a better general condition. It is also a fact, that patients who have suffered 
 long from suppuration and hectic, bear the capital operations better than 
 those who are in robust health. There is less shock to the nervous system ; 
 indeed, in some most severe operations, I have observed that none whatever 
 has followed; the patient awaking from the anaesthesia with a refreshed and 
 animated appearance. 
 
 The different medicines for hectic can hardly be noted here, as the causes 
 from which it arises are most numerous. The symptoms must be studied, 
 the pathology regarded, and the organic disturbance receive careful atten- 
 tion in the selection of the medicines. 
 
 CHAPTER VII. 
 
 DEGENERATION (Continued). 
 
 Ulceration : Sloughing. — Ulcers : Simple — Irritable — Indolent — Varicose. 
 Treatment : Local — Straps — Bandages — Skin-grafting — Sponge-grafting — 
 Medical Treatment — Dry Earth. 
 
 Ulceration is that process by which a solution of continuity is effected in 
 a living solid ; it is of much more frequent occurrence in the cellular and 
 adipose tissues than in muscles, tendons, ligaments, nerves, or bloodvessels, 
 and is not generally applied to abrasions affecting only the epithelium. 
 
 The Hunterian theory regarded such breach of continuity as effected by 
 what was termed ulcerative absorption, or, in other words, that the absorb- 
 ent vessels were chiefly concerned in the establishment of the process ; 
 
130 A SYSTEM OF SURGERY. 
 
 modern pathologists, however, regard ulceration as the molecular death of 
 a part, a gradual softening and disintegration of tissue, molecule by mole- 
 cule, the effete matter being mixed with purulent and other secretions, and 
 thus carried out of the system. This process is generally one of true inflam- 
 mation, or connected in some degree with inflammatory action. 
 
 If the inflammatory process continue, suppuration, softening, disinte- 
 gration, and detachment of the tissues in minute portions follow in succes- 
 sion in the abnormal action ; the separated molecules become mixed with 
 the pus, and are removed with the discharge of the matter ; it would 
 appear, therefore, that with such a process absorption would be but little 
 connected. 
 
 It has already been mentioned that during the inflammatory process, 
 absorption is arrested either in toto or partially, and is only renewed when 
 resolution is taking place. If the process continue, and suppuration and 
 ulceration follow, the absorption is still held in abeyance. Again, there is 
 always a discharge accompanying ulceration, which need not exist if ab- 
 sorption were going on ; and when we add to this that many structures of 
 the body are peculiarly liable to ulceration, and particularly resistant of 
 absorption, it may be seen that the old doctrine cannot hold sway before 
 the new one of molecular death and disintegration. 
 
 There are several other circumstances which are opposed to the theory of 
 ulcerative absorption, and indeed form conclusive evidence that the absorb- 
 ents do not perform that action in ulceration that was attributed to them by 
 Mr. Hunter. 
 
 Ulceration is a step beyond suppuration. The inflammatory process 
 having reached its climax, in infiltration and partial softening of the tex- 
 tures, if ulceration supervenes the molecules become further softened, and 
 carried away with the discharge from the part. This is effected easily from 
 open surfaces, but when ulceration is progressing in an unbroken part, a 
 small abscess or pustule is formed, and after its contents are evacuated the 
 ulcerated surface is revealed. 
 
 The terms acute, inflamed, chronic, phagedenic, sloughing ulcer, are all modi- 
 fications of the process of ulceration, the severity of which is in proportion 
 to the grade of the inflammation and the vitality of the part. 
 
 If the inflammatory process is moderate, and the ulceration is established 
 steadily, it may be termed acute; if, however, the degree of abnormal action 
 is greater, the ulcer is said to be inflamed, on account of the unusual amount 
 of pain, heat, swelling, and redness that surrounds the part ; if the inflam- 
 mation is of a still higher grade, the destruction of the tissues is still more 
 rapid, and a phagedenic sore is produced ; and if still the inflammatory 
 action progresses, partial death to the part is effected, and a sloughing ulcer 
 is the result. 
 
 However, after ulceration has been established by inflammation, the latter 
 may subside, and the ulcerated surface be repaired in a short period ; but 
 if the inflammation is sluggish, the ulceration proceeds slowly and becomes 
 chronic in character. 
 
 The process by which an ulcerated surface is repaired, viz., granulation, 
 and the covering of these granulations with cuticular formation, or the 
 absolute healing of the part, viz., cicatrization, have been already considered. 
 
 The same causes that create inflammation are productive of ulceration. 
 These actions are portions of the same process, commencing with vital 
 tumescence, and terminating in gangrene. 
 
 Ulceration is the medium between suppuration and gangrene; in the 
 former the action does not proceed far enough to disintegrate the textures ; 
 and in the latter the death of the part is effected in mass, and not molecule 
 by molecule. 
 
SLOUGHIXG ULCERS. 131 
 
 Sloughing. — Death of a part, an undoubted termination of inflammation, 
 as well as of all other vital change, may be reached at once from intensity 
 of action, deficiency of power, or a combination of both. 
 
 The difference between ulceration and sloughing consists simply in the 
 fact, that in the former case the death is molecular, particle by particle 
 being cast off; in the latter the part dies in a mass and is detached, 
 the dead or decaying substance being denominated slough if the process has 
 taken place in the soft parts, and sequestrum if the dead structure is bony. 
 Sloughing occurs more rapidly or slowly in direct ratio with the intensity 
 of the inflammatory action. The textures broken up by the processes 
 of inflammation and ulceration are softened and infiltrated ; there is no 
 supply of blood, they die, and in obedience to the great law of nature are 
 cast off. 
 
 The medicines for different forms of ulceration will be found in the 
 sections upon ulcers. 
 
 ULCERS. 
 
 Those sores that are produced by the action of the ulcerative process — 
 or, in other words, solutions of continuity effected by ulceration — are termed 
 ulcers. 
 
 All the textures of animal life are liable to be attacked, although some 
 are more susceptible of invasion than others ; but it is more particularly 
 the formation of those sores that appear on the surface of the body that at 
 present demands attention. 
 
 The arrangement into classes of the varied forms of ulcers simplifies much 
 their description, and to a certain extent their treatment; but the classifi- 
 cation differs with different authors. Dr. Gibson mentions three varieties, 
 viz., simple, indolent, and irritable ulcers, arranging other ulcerated surfaces 
 under the diseases that cause them. Sir Everard Home forms them into 
 six classes : 
 
 1. Ulcers in parts that have sufficient strength to carry on the actions 
 necessary for their recovery. 
 
 2. Ulcers in parts that are too weak for that purpose. 
 
 3. Ulcers in parts whose action is too violent to form healthy granulations, 
 whether this arises from the state of the parts or of the constitution. 
 
 4. Ulcers in parts whose action is too indolent, whether this arises from the 
 state of the parts or of the constitution. 
 
 5. Ulcers in parts which have acquired some specific action, either from 
 a diseased state of the parts or of the constitution. 
 
 6. Ulcers in parts which are prevented from healing from a varicose state 
 of the superficial veins of the upper part of the limb. 
 
 Mr. Miller mentions ten varieties, viz. : 1. Simple purulent or healthy 
 sore. 2. The weak. 3. The scrofulous. 4. The cachectic. 5. The indo- 
 lent. 6. The irritable. 7. The inflamed. 8. The sloughing. 9. The pha- 
 gedenic. 10. The sloughing phagedena. 
 
 Probably the most simplified method of classifying ulcers is that of 
 arranging the whole into two divisions, the first comprising the simple, 
 indolent, and irritable ulcer, and the second embracing those sores that 
 have acquired a specific character from the diseases with which they may 
 be associated — scrofulous, syphilitic, cancerous, etc. — leaving the considera- 
 tion of these with the diseases themselves to be studied in their appropriate 
 places. This appears also the more requisite because there are many im- 
 portant symptoms that may present themselves in any or all the varieties of 
 ulcers, without regard either to name, classification, or the specific disease 
 upon which they may be dependent. 
 
 Simple, or Healthy Ulcer. — This is, in truth, an example of healthy granu- 
 
132 A SYSTEM OF SURGERY. 
 
 lation following a wound or abscess, or of inflammatory disintegration of a 
 part previously unbroken in its surface. 
 
 " The discharge is thick, creamy, easily detached from the granulations, 
 almost inodorous, and not profuse — in fact, it is laudable pus. The granu- 
 lations are numerous, small, acuminated, florid, sensitive, and vascular ; if 
 touched at all rudely, they bleed and are painful. The blood is arterial, 
 neither too profuse nor abnormal in quality, and the pain is but the just 
 appreciation of injury done to healthy tissues. The general sensation in 
 the part when riot injured is slight tenderness, or a feeling of rawness, rather 
 than actual pain — not unfrequently a sensation of itching is present to a 
 degree even troublesome. As soon as the granulations arrive at the surface 
 of the skin, cicatrization commences, and proceeds steadily until the part 
 is repaired." 
 
 The treatment of such sores is quite simple. The part should be kept at 
 rest, and in a position that may relax those muscles upon which the ulcer 
 is situated; and, above all, the strictest cleanliness enjoined. Milk and 
 tepid water commingled in equal parts should be allowed to dribble over 
 the sore from a sponge or piece of lint saturated with the liquid. This 
 appears to be the best abstersive method, as the frequent passing of a sponge 
 over the healing parts may prove a source of irritation, as well as causing 
 a destruction of the delicate granulations, and the healing process thereby 
 be retarded. 
 
 The simple ulcer generally heals rapidly, without the exhibition of any 
 medicine. Sometimes, however, after cicatrization has progressed for a 
 time, there appears to be a diminution of action in the healing process ; if 
 this be the case, a few doses of silicea, repeated every twelve or twenty-four 
 hours, will overcome the difficulty and complete the cure. 
 
 Irritable Ulcer. — This form of ulcer is generally preceded by an irritable 
 state of the system, or if such be not the case, the constitutional may be 
 produced by the local irritation. 
 
 The digestive function is frequently impaired in those persons afflicted 
 with irritable ulcer, and consequently the sore is often found among those 
 in the higher walks of life, who eat and drink to excess, or among de- 
 bauchees. 
 
 The appearances presented by an irritable ulcer are as follows : The edges 
 are ragged, undermined, and serrated ; the bottom appears deeper in some 
 points than in others, and the parts around are red, inflamed, and fre- 
 quently cedematous ; the discharge, which is always considerable, is a thin, 
 greenish, or reddish matter, which is frequently so acrid that it excoriates 
 the surrounding skin, and is sometimes mingled with solid matter. Granu- 
 lations are wanting, and in their place may be found a grayish film, or a 
 dark-red spongy mass, which is acutely sensible, and bleeds at the slightest 
 touch, the blood being of a dark grumous character. 
 
 The medicines that have proved most effectual in removing this form of 
 ulcer, are, arsen., asaf., carbo veg., lye, hepar,merc. sol., nit. acid, silic, mez., con., 
 sulph., thuja, staphis. 
 
 In addition to the internal treatment, when the granulations are very 
 exuberant and large, a local application of nitric acid, acid nitrate of mer- 
 cury, or lunar caustic may be made once or twice daily, and the parts 
 dressed with carbolated glycerin. 
 
 Indolent Ulcer. — This variety of ulcer is of much more frequent occur- 
 rence than either of those already described. It has received from several 
 authors the appellation " callous," and is the fourth variety in the classifi- 
 cation of Sir Everard Home. " Ulcers in parts whose action is too indolent 
 to form healthy granulations, whether this indolence arises from the state 
 of the parts or of the constitution." 
 
ULCERS. 133 
 
 The appearances presented are a complete contrast to those of the irritable 
 sore, although in the first instance it may have assumed the characteristics 
 of that variety of ulcer ; indeed, a healthy or simple sore may pass through 
 different stages, and ultimately become indolent, because cicatrization may 
 have been opposed or protracted by its situation, or other adverse circum- 
 stances. 
 
 From such reasons it is obvious that the ulcer must be most common 
 among individuals belonging to the laboring population, upon whose efforts 
 depend the subsistence of their families, and who therefore are unable to 
 make use of appropriate means, so necessary to be observed at the first 
 appearance of the sore, that the ulcerated surface may be repaired. As 
 long as the erect posture is practicable, the poor man must strive for the 
 maintenance of his household ; and finally a simple purulent ulcer be- 
 comes inflamed and irritable, and assumes those appearances which are 
 the sure characteristics of the indolent sore. But it is not among such 
 alone that this variety of ulcer is found, nor does it so frequently arise from 
 continued exertion, as from filthy and dissolute habits, or protracted in- 
 temperance. 
 
 An indolent ulcer presents the following appearances : 
 
 The edges are elevated, protruded, smooth, and rounded, giving to the 
 sore an appearance of deep excavation. The surface is smooth, glossy, 
 pale, and generally void of granulations, although in some instances there 
 is a feeble attempt at such formation ; or it is covered partly with a pellicle, 
 or crust, of a whitish or dark-gray color, so tenacious that it is inseparable 
 from the ulcer without considerable force. Sometimes the sore is dry, but 
 generally there is a profuse discharge of a thin and serous fluid, nearly 
 destitute of fibrin ; the surrounding integument is swollen and discolored. 
 
 The most striking characteristic of the indolent sore is the elevation of 
 the margins, which are very callous, and present a whitish appearance, 
 resembling a dense high ring of cartilage. The pain is so slight that the 
 patient frequently experiences but trifling annoyance, and is able to per- 
 form his usual vocation. 
 
 When an irritable ulcer has become indolent, the appearances vary from 
 those described above. The granulations are large, round, pale, and 
 flabby, extremely sensitive, and bleed from the slightest scratch, and some- 
 times rise into a fungous form above the skin. This is what is termed by 
 some writers the "fungous ulcer ;" by Mr. Home it would be denominated 
 as " an ulcer in parts too weak to carry on the actions necessary for its re- 
 covery," or by others as the " weak sore." " This fungus," writes Professor 
 Gibson, " may, and often does, accompany an ulcer with carious bone, 
 sprouts from the mouth of a sinus, or covers the surface of many specific 
 ulcers. From whatever source it springs, its characters are uniform, and 
 its disposition so truly indolent that it cannot without impropriety be referred 
 to any other head." 
 
 Varicose Ulcer. — There is another variety of indolent ulcer, which pre- 
 cedes or follows a varicose enlargement of the veins of the leg or thigh, 
 which has been denominated the varicose ulcer ; it generally makes its ap- 
 pearance on the inner side of the leg, and is often very difficult to cure. 
 It resembles an indolent ulcer in a somewhat advanced stage ; the edges of 
 the skin, however, bounding the sore are not tumid ; the part is blue or 
 purple ; the sore is seldom deep, usually spreads along the surface, and is 
 oval in shape. The branches and trunk of the vena sa/phena are enlarged, 
 and this varicose state prevents the healing of the ulcer. A varicose limb 
 becomes very much swollen, the coats of the veins are often thickened, the 
 vital power is much impaired, the temperature is diminished, the parts 
 assume that dark-blue appearance to which we have already alluded, and 
 
134 A SYSTEM OF SUKGERY. 
 
 are excessively prone to the inflammatory process, ending in ulceration, 
 which is generally of a tedious nature. Sometimes we find that the irritable 
 sore is accompanied with varicose veins. The pain appears to be deep-seated, 
 and extends up along the course of the veins, and is increased by maintain- 
 ing the limb in the erect posture. 
 
 Treatment. — In the treatment of indolent ulcers, it is necessary that the 
 utmost cleanliness be observed ; and if the patient be one whose constitu- 
 tion has been impaired by unwholesome diet, exposure to a foul atmosphere, 
 or by intemperance, these obstacles should be overcome by the substitution 
 of nutritious, easily digested food, proper ventilation, and regularity of 
 habits ; in fact, as far as possible, every effort should be made to effect the 
 removal of the predisposing cause. 
 
 The indolent sore is capable of cure under homoeopathic treatment; in- 
 deed, in some instances, without having recourse either to the bandage, 
 straps, or escharotics, but it is absolutely necessary that the patient be put 
 to bed, rest being a factor in the cure ; but in most instances such a favora- 
 ble termination is the exception, not the rule. 
 
 The restoration of continuity in the parts destroyed by the indolent sore 
 is often very gradual, and attended with variations in the healing process. 
 The ulcer may appear to be doing well, when, from some irritation, a retro- 
 grade action takes place; but if the practitioner have reason to believe the 
 medicine correctly chosen, it must perseveringly be administered, always 
 endeavoring not to interfere with its action by a too frequent repetition of 
 the dose. 
 
 The surgeon, if the sore progresses slowly, is often strongly tempted to 
 administer the medicine at too short intervals, and in a lower potency than 
 that which he is employing ; but when allowing himself to be thus led 
 astray, disappointment is invariably the result. So long as there is a per- 
 ceptible improvement in the appearance of the ulcer, the medicine must be 
 continued, as there is nothing that more retards the progress of cure than the 
 repeated change of the means employed for the accomplishment of that 
 purpose. 
 
 The medicines that are most serviceable in the treatment of indolent 
 ulcers are ars., carb. veg., lye, graph., phosph. ac, sang., sepia, silic, sulph. 
 
 Fig. 72. 
 
 Purely medical means will, according to my own experience, fail in many 
 instances unless accompanied with those surgical manipulations which I 
 wish to impress on the mind. 1st. A horizontal position of the limb ; 2d. An 
 even support given by a roller, applied from the foot to the knee ; and 3d. 
 In cases where the sore is rather of an indolent character, the application 
 of adhesive straps. One and all of these means can be used as follows : 
 Cleanse the sore with simple soap and water, and having raised the limb to 
 a horizontal posture (having previously prepared adhesive straps of suffi- 
 cient length to pass around the limb), apply the first strap from left to 
 right across the leg, the second from right to left, and so on ascend up the 
 limb, allowing each of the straps to slightly overlap the preceding. (Fig. 72.) 
 
TREATMENT OF ULCERS. 135 
 
 When the whole sore has been covered, a roller must be thus applied : 
 Having made a couple of turns around the ankle-joint, make several figure- 
 of-eight reverses, around the instep under the sole and back again to the 
 ankle, and having almost covered the foot, ascend on the leg, making the 
 circular and reverse turns from the ankle to the knee. (Fig. 73.) 
 
 The bandage must be re-applied every second day, and the straps twice 
 or thrice a week. I may remark that there are very few ulcers of the class 
 which I here mention, but will be at least very materially benefited in a 
 short space of time by this method of treatment. In fact, since I have 
 
 Fig. 73. 
 
 adopted this apparently simple procedure, and made the patient persist in 
 it, I have succeeded very much better than while using merely medical 
 means. 
 
 I have also used, in connection with this treatment, the application of the 
 first trituration of mere, dulc, with which the excavation may be filled, and 
 over which the straps may be applied. This has proved eminently suc- 
 cessful. 
 
 The sulphide of carbon has of late been much used in the treatment of 
 indolent ulcers.* Its disagreeable odor may be counteracted by either 
 iodine, essence of bitter almonds, or Peruvian balsam. 
 
 The formula is : 
 
 R. Carbon, sulphidi, fl. ^ss. 
 
 Tine, iodinii, fl. £j. 
 
 Essent. inentk. piper., ^iv. — M. 
 
 Local use. 
 
 For sloughing, or gangrenous ulcers, Dr. Brinton, of Philadelphia, uses : 
 
 R. Brominii, fl. 3J. 
 
 Aquae, . . gij. 
 
 Potassii bromidi, . grs. xix. — M. 
 
 Dr. Dowse, of London, applies the following to old atonic ulcers : 
 
 R. Chlorali, ^iv. 
 
 Sol. chlor. zinc., ziv. 
 
 Aquae, ^xvi. — M. fl. 
 
 I have also of late years had some success with the use of the subnitrate 
 of bismuth, and sometimes with iodoform and the balsam of Peru. These 
 two drugs may be employed together in a mixture of equal parts, the latter 
 in a measure destroying the disagreeable odor of the former. 
 
 Further on, the method employed by Mr. Critchett in preparing and ap- 
 
 * Naphey's Surgical Therapeutics, pp. 211, 212. 
 
136 A SYSTEM OF SURGERY. 
 
 plying straps is noticed. That gentleman gives most explicit directions, 
 and the method is also recommended in the British Journal of Homoeopathy* 
 as an adjunct to the treatment of the variety of ulcer under consideration. 
 It consists in tightly strapping the limb, in the manner presently to be de- 
 scribed ; the use of straps being considered preferable to the application of 
 the roller, as the bandage is liable to slip or become loose. 
 
 Instead of the plaster (empl. plumb.) recommended by Mr. Critchett, the 
 straps should be made from simple wax, or isinglass plaster, or, what is 
 still better, the surgical adhesive plaster of Mead. 
 
 The following are the words of Mr. Critchett : " You must seat the patient 
 opposite to you, and support his foot upon a small stool about a foot and a 
 half in height, and so constructed as to receive the print of the heel, and 
 leave the rest of the foot free. You should be provided with strips of plaster 
 about two inches in width, and varying in length from twelve to eighteen 
 inches, according to the size of the limb. 
 
 " You then take the centre of the first piece, and apply it low down to 
 the back of the heel, and then with the flat part of both hands press the 
 plaster along both sides of the foot. This plan is very preferable to taking 
 hold of the ends and endeavoring to apply them, as it insures a perfectly 
 smooth adaptation of the plaster to the part, and also because it enables 
 you to regulate that very important point, the amount of tightness you may 
 wish to employ. As you proceed with the remainder, you must always 
 remember the principle is to make one portion fold over another ; you must, 
 therefore, alternate them around the foot and ankle. Your second piece 
 should be placed in a similar manner underneath the heel, and then carried 
 upwards at a right angle to the last, so as to cover a portion of each malleo- 
 lus. The third piece should be again applied to the back of the heel, over- 
 lapping the first by about one-third. The fourth piece, under the foot, and 
 carried upwards, each piece being pushed along so as to allow it to take its 
 own course ; this must be continued until the foot and ankle are covered ; 
 the strips must then be carried in a similar manner up the leg, increasing 
 in length as the calf increases, and extended as far as the knee, and in some 
 few cases even above this." 
 
 Referring to this method of dressing, the editors of the British Journal re- 
 mark : " Over this a bandage is to be applied in the usual manner. Small 
 ulcers, situated in the hollow between the malleolus and the os calcis, require 
 more pressure than the rest of the limb, which may be produced by apply- 
 ing small pieces of plaster in a crucial manner over the wound before put- 
 ting on the strapping." 
 
 Twice a week, in the majority of cases, will be sufficiently often to renew 
 this manipulation. If there be a profuse discharge, a piece of dry lint may 
 be placed upon the sore. 
 
 Skin-grafting in Ulcers. — This process is said to be of French origin, and 
 has been largely practiced by Mr. Pollock, of St. George's Hospital, but later 
 researches bear evidence that Professor Hamilton, of New York, conceived 
 the idea of skin-grafting many years since. I have practiced it in many 
 cases with most excellent results. The method I employ will be found in 
 the following case : 
 
 Mrs. H. was admitted into the Hahnemann Hospital, New York, some 
 months since. The inside of the left leg, from above the centre of the calf 
 to the heel, was covered with ulcers of five years' standing, varying in size 
 from that of a half-dollar to that of a half-dime. The largest and deepest of 
 these unhealthy-looking sores was situated just below the internal malleolus. 
 The edges of the ulcers were jagged, uneven, and overhanging, with flabby 
 
 * Vol. vii., pp. 423-425. 
 
SKIN-GRAFTING IN ULCERS. 137 
 
 ana* readily-bleeding granulations. The integument was purple, and the 
 patient was in a bad condition generally. 
 
 June 18th. — I clipped with scissors several minute pieces of integument 
 from the left forearm, and having thoroughly cleansed the base of the ulcers, 
 inserted three grafts into the deepest parts of the largest sore, and in two of 
 the smaller ones, one each. The small particles of skin were kept in posi- 
 tion by a thin strip of isinglass plaster. On the second day there was not 
 much alteration in the grafts ; but on the third evening they appeared to be 
 reddened, and healthy granulations were perceptible. 
 
 June 21st. — After four days I proceeded to graft the remaining sores, de- 
 positing in the larger ones two or three " seeds of flesh," and in the smaller 
 but one. Some of these appeared to die away, but in all the ulcers healthy 
 action resulted, and in about three weeks the leg was healed. The skin, 
 however, although very much more natural in color, did not assume its 
 normal appearance ; but the sores healed in a comparatively short time. 
 
 July 25th. — Patient was discharged cured. November 3d, remained well. 
 
 It has been asserted that in certain cases the graft may be lost to view, 
 but that in the course of a few days the granulations will become healthy 
 and the cicatrization complete. Mr. Mason, however, who, in the Lancet for 
 
 Fig. 74. 
 
 Scissors for Skin-grafting. 
 
 October, reports nine cases — five still under observation — has not noted such 
 variations ; the graft in his cases always becomes the centre of healthy 
 growth. In some cases, in some of the ulcers the minute portions of integu- 
 ment did indeed disappear ; but in a day or two the ulcers began to assume 
 a healthy character and healed quite rapidly. 
 
 Messrs. Stohlmann & Pfarre have manufactured a scissors to facilitate the 
 operation of clipping the integument. (Fig. 74). 
 
 If such an instrument be not handy, pass a pin through the integument, 
 raise it gently, and snip off the portion thus raised below the pin, which 
 serves as a handle by which to apply the graft. 
 
 In the Medical Times, of Philadelphia, for December 15th, 1870, is a de- 
 scription of the changes which take place in the grafts, by Mr. Dobson. It 
 is as follows : 
 
 " At about the second day the cuticle begins to separate ; by the fourth 
 day only a faint pale spot marks the insertion, or there may be no evidence 
 left of it at all ; by the sixth day a faintly vascular tuft of granulation 
 appears. This becomes glazed, and in a few days more the usual covering 
 of cicatrix is formed. The patch is usually circular, and presents slight 
 ridges, and continues to increase in size circularly, until it reaches its maxi- 
 mum of growth, for it has a maximum of growth. I have never seen a 
 patch larger than a florin, and I have seen large numbers of them. I should 
 say that their average growth will not exceed the size of a sixpence." 
 
138 A SYSTEM OF SURGERY. 
 
 Dr. B. A. Watson,* in an able article on skin-grafting, insists on perfect 
 cleanliness, and the removal of " every particle of dead tissue," by the appli- 
 cation of emollient poultices, wet compresses, and the caustic (for which, per- 
 haps, ten days may be required). He applies the grafts in rows, about half 
 an inch apart, in order to dispense with the use of more plaster than is abso- 
 lutely necessary. By placing the grafts in rows a single strip of plaster may 
 cover half a dozen grafts, the line of direction depending upon the shape of 
 the ulcer. The grafts are allowed to remain undisturbed for forty-eight 
 hours, when the compress and bandage must be removed, and the grafts 
 examined through the plaster, which, being of isinglass, can easily be done. 
 The doctor observes a fact which has often presented itself to my notice, that 
 every trace of the graft may disappear, yet a healthy granulation may spring 
 up in the same point, which the author believes the " germ theory " will 
 fully explain. 
 
 He mentions, also, two other methods of healing ulcers by " germ-plant- 
 ing." One consists in " removing the epidermic scales from some portion 
 of the body, more frequently the thigh, which had been previously shaved 
 to remove fine hairs, after which the parts were scraped with a scalpel, and 
 the scales collected on a piece of writing-paper, and these carefully dis- 
 tributed on the surface of the ulcer." .... 
 
 The third method consists in applying a fly-blister to some portion of the 
 body, collecting the serum, transferring it to the ulcer, and retaining it in 
 contact. These methods may all be tried, but we see in this article the 
 peculiarity which is observed in most of the surgical essays of the old school, 
 viz., the great dearth of internal treatment. 
 
 Sponge-grafting. — Professor D. I. Hamilton f has given an idea which may 
 ultimately be of great service to the profession. Acting upon the fact that 
 blood-clots do become organized, which appears to be proven by the occlu- 
 sion of arteries in the cure of aneurism, Professor Hamilton filled several 
 ulcers with pieces of sponge prepared in the following manner. Fine 
 sponges were taken and washed, and then allowed to lie for 48 hours in a 
 solution of dilute nitro-hydrochloric acid, to dissolve the calcareous matter ; 
 they were then carefully washed in liquor potassse, and finally allowed to 
 remain until wanted in a carbolic acid solution, 1-20. 
 
 The sponges should be cut into small slices, the size varying with the 
 surface to be repaired, and placed in or upon the wound, and so allowed to 
 remain until the healing is complete. The process, as observed by Mr. 
 Hamilton, and which I have verified, is : first, that the interspaces of tbe 
 sponge become filled with connective tissue-cells, among which are found a 
 large number of giant-cells. In some of these cells the nuclei are very 
 numerous, each having a bright nucleolus. The cells are surrounded by 
 spindle-cells of the connective tissue type, and, as the experimenter writes : 
 " In fact, the appearance was like that of a typical giant-celled sarcoma." 
 Mr. Hamilton also remarks : " In order to carry out the inquiry still fur- 
 ther, I have performed certain experiments on animals. One set of experi- 
 ments consisted in placing pieces of sponge within the peritoneal cavity and 
 leaving them there for various periods of time ; while another set comprised 
 the introduction of the same into muscular parts. A third series of experi- 
 ments was made by inserting two thin glass plates with a layer of sponge 
 between them, into the subcutaneous tissues, while Ziegler's original experi- 
 ments,]: of inserting these beneath the tissues without any sponge interven- 
 ing, were also repeated. Whether the sponge was placed in the peritoneal 
 
 * New York Journal of Medicine, July, 1875. 
 f Edinburgh Medical Journal, November, 1881. 
 t Centralblatt, 1874, Nos. 57 and 58. 
 
SPONGE-GRAFTING. 139 
 
 cavity or in a muscular part, the result, where the case went on favorably, 
 was invariably the same, viz., that the sponge in a few days after insertion 
 began to organize in the same manner as I had found to occur in the human 
 subject." 
 
 Dr. C. B. Ball, F. R. C. S. I.,* reports four cases which are interesting in 
 this relation, as they show beyond doubt the organization of blood-clots, on 
 which, as I have before noted, Mr. Hamilton bases his practice of sponge- 
 grafting. 
 
 In a very interesting and instructive article on this subject by Kendal 
 Franks, M.D., and P. S. Abraham, M.D.,f may be found some remarkable 
 cases of this character, with plates illustrating the appearances of the cells 
 already described, and verifying many of Dr. Hamilton's observations. A 
 rather remarkable case in which sponge-grafting was employed occurred in 
 my practice not long since, and although not altogether successful on account 
 of accident, yet was very satisfactory as illustrating the sponge-grafting process. 
 A young lady presented herself to me with one of the worst cases of lacerated 
 perineum which I have ever seen ; not only was the perineal body (?) entirely 
 gone, but the recto-vaginal septum was split more than half way to the cer- 
 vix, which was, of course, very low down. All control of the bowel neces- 
 sarily was lost and her condition was most miserable. As frequently happens 
 in these cases, constant diarrhoea was present, which greatly excoriated the 
 parts. Digestion was much impaired, assimilation was very deficient, and 
 the consequent emaciation was great. Two operations had been performed 
 upon her, the last one by myself, in which I had taken great pains to bring 
 together the parts ; but not only did the diarrhoea (for the arrest of which I 
 had delayed the operation, and which I had thought cured) return on the 
 second day, but a severe uterine haemorrhage set in (which proved to be a 
 miscarriage) on the fifth day and completely ruined the operation. As soon as 
 she had sufficiently recovered from these mischances to allow an examina- 
 tion, I found that there had been an attempt at union which had failed ; that 
 the sides of the cleft as far up as the carunculae had not cicatrized, although 
 they had granulated and were evidently in process of skinning over, leaving 
 a very wide rent. I therefore had the bowels constipated ; I had some of 
 my sponges (prepared for ovariotomy) ready to graft, and my idea was to 
 cut a wedge-shaped portion of the sponge and fit it into the cleft of the peri- 
 neum, and having scarified the portions of the raw surfaces which were 
 disposed to cicatrize, to sew the sponge into the cleft with catgut. I was 
 called out of New York that afternoon and asked Dr. Wilcox to sew in the 
 sponge, which he did. On the morning of the second day the sponge was 
 saturated with pus, which was gently squeezed out, and the parts thoroughly 
 irrigated with carbolized water thrice a day. On the third day there was 
 such a putrid condition of the parts that I considered the operation must 
 be unsuccessful ; however, I gently squeezed out the pus and had the parts 
 irrigated again and vaginal douches given several times during a day. By 
 the fifth day, and very much to my surprise, the fetor diminished greatly, 
 the sponge seemed to be dry, and slightly protruding from the wound, and 
 when I took hold of the sponge with a pair of forceps and endeavored by gentle 
 traction to move it laterally, I found that I was quite unable to stir it with- 
 out applying more force than was consistent with safety. On the seventh 
 day the catgut sutures were all gone, and it was evident that the sponge was 
 protruding more and more from the opening, although there was a percep- 
 tible effort on the part of the integument to spread over the circumference, 
 as shown by a white line about y'g of an inch in width, around the margins 
 
 * Dublin Medical Journal, October, 1882. 
 
 f Journal of Anatomy and Physiology, April, 1882. 
 
140 A SYSTEM OF SURGERY. 
 
 of the wound. With a pair of curved scissors I cut off the small frag- 
 ment of the sponge which projected, and making a section of it, had it 
 placed under the microscope. Not only were the larger interstices filled 
 with giant-cells, but these appeared to lie in a network of smaller cells or 
 fibres, which branched out in all directions. What astonished me still more 
 was the vascularity of the sponge. Quite a little — say a few drops — of blood 
 of good color and consistence came from the cut sponge. I was, up to this 
 time, most sanguine of a cure, but a diarrhoea again came on, and although 
 the piece of sponge not vascularized was constantly filled with stinking 
 faecal matter, yet the deep portions remained firm until some parts of the 
 sponge had disappeared. Withal, there was some improvement in the case, 
 and I have mentioned it here to incite others to renew the experiment in 
 lacerated perineum. 
 
 Medical Treatment. — With arsenicum, calcarea carb., carbo veg., carbo an., 
 asafcet,, phytolac, mez., sulph., silicea, and other medicines, we may cure these 
 ulcers without the skin-grafting process, or if it be necessary to resort to 
 these means, the internal exhibition of the appropriate medicine has a ten- 
 dency not only to facilitate the " taking " of the graft, but also to promote 
 healthy granulations, and induce a condition of the constitution, which is 
 of the greatest possible importance in the healing of ulcers. A great deal 
 of success has also been attained in my hands, by packing the ulcer daily 
 with 
 
 R. Hydrarg. chlor. mit., 3j. 
 
 Cretse preparat., Jj. 
 
 M. ft. pulv. 
 
 Having previously sprayed the surface with calendula, and then evenly 
 strapping the part, as already directed. 
 
 When the ulcers are very old and have resisted all treatment for years, 
 being sometimes benefited by medical and surgical appliances and then 
 relapsing into their former indolent condition, a successful method has been 
 introduced which consists in making deep incisions on either side of the 
 sore in the sound skin, and keeping these open by means of pledgets of 
 lint. By this procedure the integument yields to the cicatrizing process in 
 the ulcer which had before been prevented from the hardness, inelasticity, 
 and torpor of the parts, and the new wounds heal as kindly as recent cuts. 
 
 Earth Treatment. — The treatment of varicose and indolent ulcers by the 
 application of earth is often followed with very remarkable results. Good 
 subsoil, dried and divested of grit, finely pow T dered and sifted, may be 
 applied directly to the part and held in situ by waxed paper, or gauze, the 
 ends of which are fastened to the integument by collodion, as recommended 
 by the late Paul Beck Goddard, of Philadelphia* or the gauze may be first 
 placed over the sore, and the earth applied over it to the thickness of half 
 an inch or more. The earth not only is comfortable and cooling to the 
 patient, but is a complete disinfectant. Many cases of the successful use 
 of this easily-obtained topical application are recorded, the effect being 
 immediately noticed. It is essential during the treatment that the patient 
 should be kept in bed, and if there be any large and varicose veins they 
 should be destroyed, either by subcutaneous incision between two pins 
 passed beneath the veins with a figure-of-eight suture of wire or silk above 
 them ; or the application of caustic lime and soda over the course of the 
 enlarged vessels. Vide Treatment of Varix. 
 
 * Earth as a Topical Application in Surgery, by Addinell Hewson, M.D., Philadelphia, 
 
 1872. 
 
GANGRENE AND MORTIFICATION. 141 
 
 CHAPTER VIII. 
 
 DEGENERATION (Continued). 
 
 Gangrene and Mortification — Line of Demarcation; of Separation — Question 
 of Amputation in Traumatic Gangrene — Dry Gangrene — Treatment — 
 Hospital Gangrene— Sloughing Phagedena. 
 
 Gangrene is but a step in advance of ulceration, and may be divided 
 into three stages : 1st. The death of the part. 2d. A period of arrest of 
 the plastic deposit. 3d. A period of separation and granulation. 
 
 Agnew* discards the title gangrene as having a tendency to mislead, but 
 it appears to me, that it will be difficult to exclude from surgical nomen- 
 clature, a term that has had a specific meaning for centuries past. 
 
 If the ulcerative process extends, then the dead particles of the ulcer are 
 still given off molecule by molecule, but if we have a larger portion thrown 
 off it is called a " slough." When gangrene is about to commence we have, 
 first, redness of the part ; after this it becomes of a bluish tinge, and above 
 this a mottled appearance ; blisters appear ; it becomes cold ; and has 
 a fetid odor. The constitution becomes weaker, the vitality of the parts 
 is less and less, and we have gangrene, which is death of the parts en masse. 
 The dead portion itself is called a " sphacelus " or " slough." If we take a 
 portion of the gangrenous mass and press it between the fingers we find 
 that it crepitates, because of the gas generated and contained in its sub- 
 stance. We always have this in the tissues where gangrene has appeared, 
 and it is an important fact to remember in connection with medical juris- 
 prudence, that wherever there is decomposition of the tissues we have a 
 lesser or greater accumulation of gas. 
 
 After a certain time, as the process of sloughing goes on, a " line of demar- 
 cation" forms, separating the healthy from the gangrenous part; this is 
 caused either by an arrest of the process itself, or because the healthy parts 
 are able to withstand the action of the process. There is severe pain and 
 hectic fever accompanying gangrenous ulceration, and during the time that 
 the line of demarcation between the dead and the living tissues is being 
 formed. After the line of demarcation, that of separation is begun (Fig. 75) ; 
 at this point the dead part is thrown off from the living. This line of 
 separation is always oblique. The line of demarcation forms the surface- 
 boundary of the "line of separation," which being oblique, leaves a stump 
 the reverse of that made by the surgeon in amputation. It either goes 
 through the limb, or it " scoops out " the dead portion ; and when the 
 slough comes away there is beneath a healthy granulating surface. 
 
 Internal organs are not very liable to gangrene ; the lungs being more 
 frequently attacked than any other. 
 
 Causes. — Among the causes of gangrene are injuries of all kinds, 
 especially crushed wounds. Clean cuts are never liable to be followed by 
 ulceration ; but such injuries as are occasioned by railroad and steamboat 
 disasters, congestions, and obstructions of circulation, give rise to mortifi- 
 cation. Sometimes gangrene is very rapid in its course, particularly 
 the traumatic variety. A man's limb may be crushed to-day; to-morrow 
 gangrene may set in ; and on the third day he may die. 
 
 Obstruction of the circulation is a frequent cause of gangrene. This ob- 
 struction may originate from a variety of conditions ; as embolism, tumors 
 pressing on the arteries, clots in the arteries from fibrin, etc. Heat and cold, 
 especially if excessive, are prolific causes of mortification. Frequently we 
 
 * Principles and Practice of Surgery, vol. i., p. 27. 
 
142 A SYSTEM OF SURGERY. 
 
 see this result from frostbite, as well as from the introduction of substances 
 into the system which have a tendency to contract the muscular coat of 
 the bloodvessels, as ergot of rye. 
 
 Tight bandaging in cases of wounds, fractures, and dislocations, has often 
 produced mortification, and many limbs have been sacrificed to this care- 
 less practice. The cut (taken from Druitt), Fig. 76, represents sphacelus 
 from starvation. 
 
 When gangrene does not involve the whole thickness of a limb, the line 
 of demarcation is formed around the sphacelated portion, and the part 
 
 Fig. 75. Fig. 76. 
 
 sloughs away, leaving an ulcerated surface beneath, in which the prDcess 
 still continues until the unhealthy structure is cast off. 
 
 The constitutional symptoms in mortification generally assume a typhoid 
 character. The pulse is quick and tremulous, the skin hot, tongue dry an I 
 of a brownish tinge, and the patient restless and uneasy. Delirium, sub- 
 sultus tendinum. nausea, and hiccough are frequently present. In general 
 the disease results from improper nourishment and inflammation. Gun- 
 shot wounds, fractures, dislocations, simple punctures, concentrated acids, 
 poisons, stimulating applications, infiltration of acrid fluids into the cellu- 
 lar membrane, lightning, burns, long-continued pressure, intense cold, all 
 operate, more or less, through the medium of inflammation) in producing gan- 
 grene and mortification. 
 
 There are also some specific causes of gangrene, which will afterwards be 
 noticed. 
 
 Mortification has been divided into acute and chronic, the former compris- 
 ing the humid, inflammatory or traumatic; the latter, the dry and idiopathic. 
 Generally speaking the acute is humid, and the chronic, dry — the fluids 
 being retained in the former, and gradually parted with in the latter : how- 
 ever, this is not invariably the case. 
 
 Acute or Moist Mortification. — In the acute form of mortification there is 
 always considerable swelling, which has been preceded by those symptoms 
 which have already been mentioned as belonging to inflammation. Then 
 the temperature of the parts diminishes, a slight blueness of surface attracts 
 attention, and the skin may be covered with vesicles ; there also may be a 
 species of crepitus felt by pressing upon the parts. At this stage the general 
 
DRY MORTIFICATION — TREATMENT OF GANGRENE. 143 
 
 condition of the patient suffers, the countenance expresses the death of a 
 portion of the body ; hiccough, delirium, and death supervene. This is the 
 ordinary acute gangrene, but there must be some distinction made between 
 this and true traumatic gangrene, which results from severe railway and 
 steamboat accidents. In these the parts are so crushed and the textures so 
 pulpy that they die almost immediately, and not only does the implicated 
 part suffer, but the gangrene spreads with alarming rapidity. To wait in 
 such cases for the line of demarcation would certainly consign the patient 
 to the grave. Every moment is precious, both to the surgeon and patient, 
 and immediate amputation must be performed. Delay is death. Prompt 
 action may be life. In this place, also, let me impress one truth upon my 
 readers. In amputating in traumatic gangrene always leave a considerable 
 space of healthy tissue between the gangrenous parts and the site of the 
 amputation, because it is remarkable with what facility gangrene will attack 
 the stump after the removal of the dead parts. 
 
 Dry Mortification — or as it has been termed, senile gangrene — is generally 
 seen in advanced years, and in many cases is the result of deficient circu- 
 lation. 
 
 This variety of gangrene may commence with a burning sensation, which 
 continues for a time, and ceases suddenly ; or without any well-marked 
 symptoms of inflammation, the toes and feet become cold, discolored, and 
 shrivelled, and finally converted into a hard dry mass, insensible, and 
 of a purple hue. Frequently there is no sloughing, and each part retains 
 its original form, the skin remains entire, the nails adhere to the toes, and 
 the part becomes hard and cold, and is perfectly free from fetor. Some- 
 times, however, the fetid odor and sloughing are considerable, and attended 
 by severe constitutional symptoms, although these are of rather rare occur- 
 rence. 
 
 It is frequently very difficult to assign any cause for this variety of the 
 disease. In some instances, however, it can be traced to diseased rye. 
 During very moist seasons secale cornutum, ergot, cockspur (a medicine whose 
 excellent qualities in many diseases is fully appreciated by the practitioner), 
 is generated in considerable quantities, constituting a disease in which the 
 grains of rye become larger, firmer, and of a much darker color than natu- 
 ral ; the diseased being mixed with the sound grain, is often eaten by fami- 
 lies, and for a time without producing any detrimental effect, but finally 
 dry mortification makes its appearance, and the population of entire dis- 
 tricts become afflicted with the disease. 
 
 Such aggravated forms of gangrene, arising from the continued use of 
 secale cornutum, is of much more frequent occurrence in European coun- 
 tries, particularly France, than in North America. 
 
 " The patients who have suffered from it have experienced pain and heat 
 with swelling, generally in the. lower limbs, though occasionally in the 
 upper. These symptoms abating, the parts became cold, insensible, and 
 discolored, and were gradually separated from the body. The disease 
 attacked patients of both sexes and every age; did not appear to be infec- 
 tious, and was frequently fatal."* 
 
 Canstatt, however, gives a much fuller description of gangrene caused by 
 the internal use of secale.f 
 
 Treatment. — The medicines best adapted to the treatment of gangrene 
 are : Ars., chin., crot., lach., sec. cor., silic, aeon., bell., carbo veg., euphorb., 
 hell., hyos., sabina, squill., sulph. 
 
 In threatened traumatic gangrene, when there is violent synochal fever, 
 
 * Liston's Elements of Surgery, p. 40. 
 
 t Hartmann's Chronic Diseases, vol. ii., p. 152. 
 
144 A SYSTEM OF SURGERY. 
 
 of course aconite should be prescribed, and calendula in solution applied to 
 the wounded part; or arnica diluted may be employed locally if there be 
 but little solution of continuity. The former medicine has been highly 
 recommended as a vulnerary, and it has been used with great success in 
 Europe in all kinds of lacerated wounds ; it has a powerful action over sup- 
 puration and its consequences ; indeed, its beneficial influence in wounds of 
 all descriptions is remarkable. This subject, however, will be again alluded 
 to when treating of wounds. 
 
 It may be useful also, in this affection, to wrap the feet or other parts 
 affected in carded wool. This practice was recommended by Sir B. Brodie in 
 his Lectures on Mortification, and is mentioned by Mr. S. Cooper in his First 
 Lines. There have been several cases treated successfully by this method,* 
 and no doubt it will assist in maintaining the warmth of the part, while 
 by the proper administration of medicine the cause upon which the disease 
 depends may be removed. 
 
 The following medicines have also been recommended : Chinin., mere, 
 mur. ac, plumb., sabin., scill., sulph. ac. 
 
 The American Columbo (Frasera carolinensis) is stated by Rafinesque to 
 have cured widespread gangrene after bark had failed.j 
 
 Dispascus sylvestris is used by Mr. Beullard, in certain cases of gangrene 
 with great satisfaction. He says : 
 
 " a. The wound is of some days' standing, has a ragged, irregular, anfrac- 
 tuous, black appearance ; exhales the well-known and repulsive odor of 
 gangrene ; this gangrene sometimes extends to quite a depth. With bistoury 
 or curved scissors I remove as much of the mortified tissues as I can, taking 
 care not to reach the quick, thus avoiding both pain and haemorrhage ; each 
 one must judge for himself if bridles (of sound tissue) may be spared. I 
 wash the wound with chlorinated water, in the proportion of one to ten, 
 then I fill it with the leaves cut very fine, so that all parts shall be fully in 
 contact therewith. I then cover with a compress, and all is kept in place 
 by a few turns of a roller. Here (he writes in France) I dress but once in 
 twenty-four hours ; under the tropics I think it would be necessary to renew 
 the dressing night and morning. Under the influence of this simple topical 
 application, in twenty-four or forty-eight hours, sometimes more (one must 
 not be discouraged — success is certain), the gangrenous becomes a simple 
 wound ; the black color has disappeared, a healthy suppuration is set up, 
 and the wound begins to granulate. 
 
 " b. The part has been contused, the skin remaining entire ; sooner or 
 later gangrene sets in ; it invades the skin or the subjacent parts to a con- 
 siderable depth. In this case I dissect away the mortified parts, taking 
 care, as above, to leave a slight layer over the quick to avoid pain and hae- 
 morrhage. This cavity is washed with the chlorinated water, dressed with 
 the dispascus, as above, and with the same result." 
 
 Dr. BlakelyJ reports five cases of traumatic gangrene treated very success- 
 fully by the internal administration of arsenic, lachesis, and iodine, with 
 the local application of calendula solution. The efficiency of this method 
 of treatment is remarkable. The following interesting case will show the 
 method I employ : 
 
 The patient was a deck-hand upon a ferry-boat, and accidentally caught 
 his foot between the wharf and boat as it was coming into the dock. The 
 contusion and laceration were very severe. Dr. Bayliss, of Astoria, was 
 called to see the case. Traumatic gangrene appearing on the second day 
 he sent him to the hospital. This was on Sunday, the first day of October. 
 
 * United States Medical and Surgical Journal, vol. ii., p. 318. 
 t Hale's New Remedies, p. 379. 
 
HOSPITAL GANGRENE. 145 
 
 When I saw him that afternoon, his foot presented all the appearances be- 
 longing to acute traumatic gangrene, which extended from the toes to about 
 the base of the first row of phalanges ; the color was purple ; the odor was 
 that peculiar to moist gangrene ; there oozed from the lacerated surfaces 
 an offensive sanies ; the sensation in the forepart of the foot was gone ; 
 and there was a reddish blush ascending over the instep, which indicated a 
 rapid spread of the disease. 
 
 The next morning I amputated the leg at its lower third, making the 
 circular operation, and forming a very large flap. It must be borne in mind, 
 that the ankle and heel presented no appearance of gangrene. On the next 
 day the patient was too well. I told him so. On the second day, when I saw 
 him, the odor, the discoloration, the oozing, pointed to the rather discour- 
 aging fact that the disease had attacked the stump. I cut open all the 
 sutures, turned the flap backward, and ordered the part to be washed every 
 three hours with water, and then carefully injected with carbolated glycerin. 
 A compress wet with the solution was applied, and arsenicum was given 
 every half hour. The effect of the treatment was magical. The gangrene 
 was entirely arrested, and I was enabled to cut away the dead portions of 
 the flap with scissors. The man made a good recovery. 
 
 In the treatment of gangrene, so soon as the line of separation begins to 
 form, the parts should be thoroughly wrapped in a disinfecting dressing. 
 Billroth covers the parts with lint saturated with chlorine water. I have 
 employed this method with success, but thoroughly sprinkling the surface 
 with iodoform or mineral earth is better. 
 
 The acetate of alumina used as follows is said to be most excellent : 
 
 R. Alurninis, £v. 
 
 Plumbi acetatis, jj. 
 
 Aquse, f^xiij — M. 
 
 Fiat lotio. Applied three times a day.* 
 
 Dr. Younghusband testifies to the especial value of arsenic in gangrene. 
 In his cases he used the ulmus as a poultice, made with yeast.f 
 
 Dr. John C. Morgan highly extols the topical application of white wgar to 
 the gangrenous parts; also, small quantities of glycerin. J 
 
 Hospital Gangrene — Hospital Sore — Sloughing Ulcer — Sloughing Phage- 
 dena. — There is a variety of gangrene known by the above names, which is 
 often so intractable, and spreads with such rapidity, that even a tendency 
 towards its appearance should cause great solicitude. The disease no doubt 
 was known from a remote date, Avicenna, Paulus, and others having written 
 concerning it. However, it is said by Dr. Gross that Poicteau, of Lyons, in 
 1783, was the first who generalized the disease, and gave a lucid and dis- 
 tinct account of its symptoms and treatment. Since then, it has been noticed 
 and commented upon by many surgical writers. 
 
 Its peculiarity is, that it generally appears in hospitals, or in apartments 
 where many persons are crowded together ; where there is not proper venti- 
 lation ; where there is abundance of filth and a lack of pure fresh water ; 
 where the drainage is imperfect, and there is want of cleanliness in dressing 
 wounds, ulcers, or abscesses. It is stated that few hospitals grow " old " 
 without the appearance, in some form, and at certain periods of time, of 
 this dreaded malady. It may follow scurvy, and may prevail on shipboard. 
 It existed to an extreme degree on board the ship " Prince of Wales " on 
 her homeward passage from Martinique. There was a serious epidemic of 
 this disease in Guy's Hospital in the year 1849. 
 
 * Naphey's Surgical Therapeutics, p. 103. 
 t American Homoeopathic Observer, 1868. 
 % Transactions American Institute of Komceopathy, 1869, p. 115. 
 
 10 
 
146 A SYSTEM OF SURGERY. 
 
 Thanks to the better systems of drainage, sewerage, ventilation, and hy- 
 giene in their varied departments, which are now introduced into hospitals, 
 this malady, at one time the scourge of charitable institutions for the sick, 
 is less frequent in its appearance and in its intensity. 
 
 Hospital gangrene may be also produced by direct contact, and appears 
 either on the surface without any previous abrasion — which, however, is rare 
 — or it attacks a wound or ulcer. 
 
 In its one form, and when on the surface, a pustule is developed, or a 
 vesicle makes its appearance, which bursts and discloses a dark and purplish 
 slough ; this slough is accompanied with a thin, ichorous, and extremely 
 offensive discharge, and separates rapidly, leaving, however, a jagged, ill- 
 conditioned sore, spreading speedily, with everted edges. The surrounding 
 skin is purple or mottled in appearance. The ulceration extends with great 
 rapidity, and has been denominated the black phagedena. During this time, 
 and even, in some cases, before the appearance of the sore, the constitutional 
 symptoms are alarming ; assuming the typhoid type, with great prostration 
 and tendency to collapse. Sometimes, and in rare cases, hospital-erysipelas 
 may coexist with hospital gangrene, making a grave complication. When 
 the tendency to this affection assumes an epidemic form, the matter secreted 
 is intensely contagious and is liable to infect nurses and others attending the 
 patients. The other inmates of the hospital are all liable to be attacked ; 
 the slightest abrasion of the surface, the scratch of a pin, or rubbing with 
 the finger-nail sufficing to produce a rapid development of the affection. 
 
 When sloughing phagedena attacks a wounded surface, the symptoms in 
 general are not so pronounced at the onset. The patient may have been 
 ailing, irritable, feverish, and thirsty, with anorexia, Upon examination 
 of the wound, it will be observed to be unhealthy, and gradually becoming 
 very painful. The discharge, which was once healthy, diminishes in quan- 
 tity and deteriorates in quality. The surface of the wound is of a grayish 
 or dirty white, with rather a spongy areola, which crepitates. Its base is 
 lardaceous, and from its color has received the name of gray pidtaceous 
 phagedena. Sloughs form and are cast away, the degeneration appearing 
 principally at the edges of the ulcer. Sometimes the sloughing parts are 
 infiltrated throughout with putrid extravasation. The pulse rarely shows 
 less than one hundred and thirty beats to the minute ; the patient becomes 
 debilitated, and, in some instances, is troubled with profuse perspiration, or 
 with colliquative diarrhoea. 
 
 The exact cause of this affection is unknown. It may be propagated by 
 an infected sponge, or by dirty instruments. It does not either find its 
 way universally in over-crowded hospitals, nor are the poorly nourished 
 always its subjects. There is some occult agency in all probability (a 
 bacterial one) which is necessary to the production of the disease. 
 
 The disease may be epidemic or endemic, and, occasionally, sporadic cases 
 occur. The disease appears to have no preference for sex, age, or tempera- 
 ment, climate or season, although, no doubt, in excessively hot weather its 
 course is more rapid and its effects upon the constitution much more severe. 
 In its more violent forms, or where the black phagedena attacks the wounded, 
 which it does as well as appearing upon unbroken surfaces, it spares no 
 tissue, and if unchecked, rapidly causes a fatal termination. In both varie- 
 ties the lymphatic glands in the neighborhood of the sore are affected, and 
 the joints may suffer from purulent formation. 
 
 Treatment. — The first thing to be attended to is the immediate removal of 
 the patient from the ward, leaving every ^ article of clothing behind. The 
 sloughs are then to be cut away ; and tHe parts washed every hour or two 
 with a solution of the bichloride of mercury (1 to 2000). 
 
 There are some medicines which appear to exercise over this malady a 
 
PREVENTION BY THE ANTISEPTIC METHOD — TUMORS. 147 
 
 powerful influence. The first of these is arsenic. The well-known patho- 
 genetic effects of this drug need not be repeated here to indicate its applica- 
 bility. It should be given, according to my belief, in the lowest potencies ; 
 and, indeed, sometimes Fowler's solution appears to be the preferable prep- 
 aration. Other medicines are crotalus, lachesis, kreasote, carbo veg., secale, 
 muriatic acid, nitric acid, rhus tox. Upon referring to the Materia Medica, 
 the specific uses of these drugs can be found, but space forbids further 
 notice. 
 
 In this fearful disease local measures must be employed at once, without 
 hesitation and without fear, and the best that can be applied is chloride 
 of zinc, which should be used in saturated solution and as an escharotic; 
 it has, besides its caustic properties, the advantage of great antiseptic virtues, 
 and, therefore, appears to be doubly applicable to the disease. After the 
 application of caustic, the free use of carbolic acid paste is the best dressing ; 
 which should be changed frequently, and the sore washed thoroughly with 
 tepid water and soap. All bandages and dressings used should be changed 
 frequently, and the patient allowed a certain amount of stimulus during 
 each day. The inhalation of oxygen gas also, if practicable, should be em- 
 ployed, and the strictest attention paid to free ventilation and appropriate diet. 
 
 With reference to local applications, the baptisea poultice is excellent, as is 
 also that made of charcoal. The free use of iodoform is also useful. 
 
 Prevention by the Antiseptic Method. — Von Nussbaum * relates the pre- 
 ventive power of Lister's antiseptic plan of dressing in the Munich State 
 Hospital, where hospital gangrene at once ceased, although at the period of 
 its use, eighty per cent, of the surgical patients had been affected. He holds 
 that the secret of its great success lay in a pedantic exactness of its mode of 
 application. Not even for a second should the wound be unprotected by 
 the carbolic acid spray. Other methods of dressing had been employed 
 without result. He states that during the prevalence of the disease, the 
 appearance of gangrene the following morning could be foretold by the rise 
 of the evening temperature to 104.8° or 105.8°. The actual cautery was 
 found most efficacious in staying the course of the gangrene, and he noticed 
 that a fall in temperature indicated a favorable change. He holds that hos- 
 pital gangrene is strictly a local affection.f 
 
 For accurate details in regard to the antiseptic method, the reader is re- 
 ferred to Dr. Thompson's chapter on antiseptic dressings. 
 
 CHAPTER IX. 
 TUMORS. 
 
 Introductory Remarks — Classification — Diagnosis— Characteristics. Histo- 
 logical Formation : A. Innocent Tumors — Types of Higher Tissues and Types 
 of Connective Tissues — Types of Epithelial Tissue. B. Sarcomata ; Types of 
 Embryonic Tissues— Connective Tissue. C. Carcinomata — Different Vari- 
 eties of Cancer. D. Cystic Tumors and their Varieties— Cysto-Sarcom a. 
 
 Since the time Abernethy attempted a classification of the varied tumors 
 which grow in and upon the body, there has been the widest difference 
 of opinion among pathologists concerning the divisions and subdivisions 
 
 * Monthly Abs. of Med. Science, March, 1876. 
 t Brit, and For. Med.-Chir. Rev., January, 1876. 
 
148 A SYSTEM OF SURGERY. 
 
 of these neoplasms, which indeed appears more confused since the intro- 
 duction of the microscope than settled by its wonderful powers. The fact 
 is, as the microscope presents actual appearances on its field ; as there are in 
 the world comparatively few experts in microscopy ; as the specimens exam- 
 ined are taken at varied stages of development, each specialist endeavors 
 in his own way to satisfactorily account for the results he obtains, which 
 may be very different at different times and under varying circumstances. 
 
 It has often struck me that, notwithstanding a great deal of care in ob- 
 taining and preparing microscopic sections, a slight alteration in such 
 preparation (in many cases unavoidable), which would be inappreciable to 
 our unaided senses, would render essentially different appearances in that 
 new world of life revealed to us by powerful lenses ; a film, a fibre, a little 
 bit of difference in the age of the specimen, a minimum of dissimilarity, 
 unobservable to our ordinary vision, must necessarily be magnified to such 
 proportions that attention is necessarily directed thereto, and so errors may 
 creep into descriptions and be rapidly promulgated by those who follow in 
 the lead of this or that pathologist. This may, in part, at least, explain why 
 opinions on these subjects are ever changing, and are ever likely to change. 
 Schiippel's " giant cells," so loudly spoken of ; Lostoffer's corpuscles, which 
 for a time set the syphilographers by the ears ; and the " typical cancer cell," 
 that was said to belong to the cancer discharges, and which turned the heads 
 of pathologists and surgeons, are monuments for our contemplation, on 
 which the microscopist of the present day may read, " Cave quid dicis, quand,o, 
 et cui." As a means of diagnosis between innocent and malignant tumors 
 (I mean, of course, primary diagnosis), the microscope is of little practical 
 use; after their removal from the body their characters and peculiarities are 
 better determined. How much better would be this condition vice versa. 
 
 I am therefore disposed to agree with Mr. Savage * in the introduction to 
 the third edition of his work, when he says : " The question of malignancy 
 is not to be determined histologically," and further when he writes : " In 
 regard to the question of malignancy, attended or not by recurrens in loco 
 eodem alioque, the experienced surgeon decides without much reference to 
 histology, and is generally right where the pure histologist is generally 
 wrong. The greatest benignity and the greatest malignancy may be united 
 in the sarcomatous group. ' I can assure you that two sarcomata of the most 
 similar histological qualities may differ entirely in course ' (Billroth)." Of all the 
 classifications of tumors which have been attempted, I think that of Virchow, 
 while it covers the greatest variety of species, and shows a vast amount of 
 experience and research, is the most unsatisfactory to the student, on ac- 
 count of the uncertainty of its expressions and its necessarily numerous dis- 
 crepancies, — for instance, his understanding of the terms " homology " and 
 " heterology." According to recent investigators of the English and French 
 schools, these terms have a definite and distinctive meaning: the former 
 applying to those tumors which in their structure bear a strong resemblance 
 to the normal tissues of the human body ; the latter, " heterologous," being 
 applied to those growths which are unlike any of these tissues ; of course it 
 is understood healthy and fully formed structures. Thus Holmes f writes 
 in his classification : " There is one class in which the substance of the tumor 
 has an exact anatomical resemblance to some tissue of the body (homologous 
 tumors) .... There is another class of tumors which do not present any 
 resemblance to the normal tissues, and which are therefore described as 
 heterologous." Sir James Paget % coincides in this view; he says : " The in- 
 
 * The Surgery, Surgical Pathology, and Surgical Anatomy of the Female Pelvic Organs, 
 London, 1876. 
 
 f Principles and Practice of Surgery, 1876, p. 348. 
 
 % Lectures on Surgical Pathology, English ed., pp. 382-387. 
 
TUMORS. 149 
 
 timate structure of malignant tumors is usually not like that of any of the 
 
 fully developed natural parts of the body Innocent tumors have not 
 
 a structure widely different from that of a natural tissue." It is, however, 
 unnecessary to multiply quotations. In Virchow's arrangement these terms 
 possess merely a relative meaning, and refer to the character of the tissue 
 from which the growth springs. It will be seen how confusing and uncer- 
 tain this must be, when a tumor presenting the same structural elements may 
 be homologous in one part of the body and heterologous in another. Besides this, 
 even Virchow himself is in doubt whether in the majority of instances his 
 cancerous growths are not heterologous ; and Green, * even while accepting 
 the classification of Virchow, says : " Heterology, however, is not limited to 
 the production of a tissue which is dissimilar to that from which it origi- 
 nates ; a tumor is said to be heterologous also, when it differs from the tissue 
 in which it is situated, and this may occur without its being a direct . pro- 
 duct of the latter. It is heterology in this sense that is so characteristic of 
 malignant growths." 
 
 Another obstacle encountered in describing certain tumors, is the dif- 
 ferent nomenclature adopted by different pathologists. Thus the " myeloid 
 tumor " of Sir James Paget is " the giant-celled sarcoma" of Virchow ; " the 
 recurrent fibroid " of Paget is the " spindle-celled sarcoma " of the German 
 pathologists, or the fibro-plastic of Lebert ; " the sero-cystic sarcomata " of 
 Brodie include " the glandular proliferous cysts " of Paget, to which w T e have 
 added a very great variety of sarcomata, as mucous sarcoma, net-celled sar- 
 coma, granulation sarcoma, alveolar sarcoma, pigmentary sarcoma, round- 
 celled sarcoma, and so on ad infinitum. 
 
 If we add to this the difference in the acceptation of the term " sarcoma," 
 another difficulty will be presented. The term may mean (and was for a 
 time so understood) " fleshy ;" then, again, it was used to express the myoma 
 or muscular formations ; afterward, a sarcoma was a species of growth com- 
 posed of an extraordinary preponderance of cell-elements, and deficiency of 
 alveolar substance; and, finally, the Germans especially apply it "to the 
 series of connective substances which are distinguished from the tumors 
 formed of the connective tissues, by the preponderating development of cell- 
 element." 
 
 By sarcoma should be understood a matrix or stroma, intermediate and 
 surrounding cells of varied character, the precise character of the cell-element 
 giving the peculiarity to the formation, hence the diversity of names. It is 
 from the great variety of these elements that Paget objects to the term, for 
 he says : " After a careful consideration of the matter, we are inclined to 
 think that the group is too vague, and is made to embrace tumors which are 
 too diverse, both in color, consistence, vascularity, structure, mode of growth, 
 seat, course, and effects on the patient, to be included under one common 
 term. We are not prepared, therefore, to employ the term sarcoma in the 
 classification of tumors, for we believe that the morbid growths which have 
 been ranked under that name may be more satisfactorily and precisely 
 arranged under one or other of the heads employed in these lectures." 
 
 Therefore, on account of the uncertainties at present realized, and those 
 which, no doubt, are yet to come, and in view of the great variety of terms 
 here and there introduced by the histologian, we shall attempt to classify 
 tumors somewhat in accordance with their clinical characteristics, and to 
 describe their structure also histologically, and may hope for a future when 
 the many discrepancies which now overshadow the magnificent classification 
 of Virchow and Billroth, will be removed, and a more simple arrangement 
 of these growths, at least for the student and practical surgeon, be arrived at. 
 
 * Pathology and Morbid Anatomy, Philadelphia, 18»4. p. 117. 
 
150 A SYSTEM OF SURGERY. 
 
 The fact is this, at least so far as I am able to get at it, the nearer a tumor 
 approaches in its structure to the perfectly developed formations of the human 
 body, in other words, the nearer its homology, the more likely it is to be 
 innocent ; the greater the departure from this standard, in other words, the 
 nearer the resemblance to imperfectly formed, embryonic, or abnormal struc- 
 ture, the more certain is the growth to be malignant. 
 
 We may therefore say that a tumor is a new growth, which is an addition to the 
 normal tissues of the body — not merely an increase in structure, which would 
 be a hypertrophy — " with," as Mr. Paget says, " appearance of inherent 
 power, irrespective of the growing or maintenance of the rest of the body, 
 discordant with the normal type and with no seeming purpose." 
 
 The exudations of inflammatory processes may be mistaken for tumors ; 
 but these generally disappear as soon as inflammation subsides ; or, if they 
 remain they constantly tend to assimilate themselves to healthy tissue. 
 Tumors, on the contrary, continue to grow more or less steadily, with or 
 without inflammatory action, and deviate more and more from the normal 
 type. In rare instances they may be confounded with aneurisms and ab- 
 scesses ; but the history of the case, a careful study of the symptoms, or, if 
 these fail, a cautious use of the exploring needle or the aspirator, will ren- 
 der the diagnosis more certain. We should, if we are prepared to be pre- 
 cise, exclude from the classification all retention cysts, extravasations, 
 tubercle, gummata, farcy buds, and effusions. 
 
 Clinical Classification. — Classifying tumors, then, clinically, we may say 
 that there are two great typical divisions, viz., innocent and malignant (car- 
 cinoma), with a third, or intermediate variety, which is known as the semi- 
 malignant (sarcoma), which latter, under peculiar circumstances, partake 
 partly of the nature of both. As a rule, and with an understanding of the 
 fact that one division may overlap the other : * 
 
 Innocent tumors may be distinguished by the following characteristics : 
 
 1. They are harmless in reference to surrounding structures. 
 
 2. With the exception of recurring fibroids, they are not liable to return 
 after proper extirpation. 
 
 3. In texture they resemble the normal tissues of the body. 
 
 4. As a rule, they are unattended by any marked constitutional disturb- 
 ance. 
 
 The following diagnostic marks characterize malignant growths : 
 
 1. In microscopic structure they completely differ from normal and 
 fully developed tissues of the body. " Many cells resemble bland or epi- 
 thelial cells, but can be distinguished from them by a practical eye. The 
 cells are grouped or heaped, one upon another, without any such definite 
 arrangement as we find in other tissues." (Paget.) 
 
 2. They are disposed first to soften, then to ulcerate; and there is great 
 tendency to infiltration and destruction of the surrounding matrix ; this in- 
 filtration may be either slow or rapid. 
 
 3. They do not enlarge continuously, but become irregular and lobulated 
 with offshoots ; innocent tumors, on the contrary, are generally round and 
 grow in one volume. 
 
 4. They are marked by persistent and often fatal haemorrhage. 
 
 5. The fetor is always easily recognized, and is sometimes intolerable. 
 
 6. They have a tendency to invade all surrounding structures, to produce 
 secondary deposits, and to sympathetically involve distant organs. 
 
 7. They are liable to return after extirpation. 
 
 8. They produce a marked constitutional cachexia. 
 
 * A very excellent chart, showing at a glance the recent classification of tumors, has been 
 prepared by Dr. G. F. Shears, of Chicago. I would commend its use to the student and busy 
 practitioner. 
 
TUMOKS. 151 
 
 To make the differences still more plain, I have prepared the following dif- 
 ferential diagnosis, premising, however, that there are certain forms of fibroid 
 tumor which may and do appear after removal (the recurrent fibroid), and 
 that a fungoid condition of a fibroid may exist, in which haemorrhage is 
 profuse, and often occurs with but slight irritation, and that enchondro- 
 matous formations may also recur. 
 
 DIFFERENTIAL DIAGNOSIS BETWEEN INNOCENT AND MALIGNANT TUMORS. 
 INNOCENT. MALIGNANT. 
 
 1. Harmless with reference to the surround- 1. The tumor is apt to destroy or involve sur- 
 
 ing structures. rounding structures. 
 
 2. Texture bears some resemblance to certain 2. Texture differs from the normal structure 
 
 of the surrounding structures. of the human body. 
 
 3. Non-liability to return (excepting recur- 3. Great disposition to return. 
 
 rent fibroid). 
 
 4. Absence of haemorrhage. 4. Liability to profuse bleeding. 
 
 5. Little disposition to soften. 5. Great tendency to soften. 
 
 6. Not much tendency to ulcerate. 6. Great tendency to ulceration. 
 
 7. Rarely accompanied by offensive dis- 7. Very offensive, ichorous, or bloody dis- 
 
 charges, charge. 
 
 8. Non-infiltration of surrounding struc- 8. Infiltration of the part on which they grow, 
 
 tures. which is often entirely transformed. 
 
 Innocent and malignant growths may coexist in separate tissues in the 
 same individual ; and the innocent may become malignant, if a cancerous 
 cachexia is present in any part of the body. Paget describes varieties of 
 fibrous and cartilaginous tumors, which returned after extirpation, caused 
 ulceration and sloughing, involved neighboring tissues and distant organs, 
 and finally terminated in death. He also states that in children of can- 
 cerous parents, tumors apparently innocent in structure are functionally 
 malignant. 
 
 Tumors may occur in any part of the body. As a rule, malignant 
 growths attack most frequently the glandular organs, while benign tumors 
 generally affect the skin, cellulo-adipose tissue, nose, uterus, and ovary. 
 
 Form. — In form they vary greatly ; they may be smooth, lobular, round, 
 conical, uneven, etc. Tumors involving lymphatics are generally nodular 
 and irregular ; encysted and fatty tumors, smooth and globular. Situation 
 may modify the shape, especially if the tumor be bound down by fascia or 
 muscular tissue. 
 
 Volume. — In volume they range from the size of a millet-seed to a bulk 
 greater than the patient's body. 
 
 Color. — The color varies with the number of bloodvessels contained in the 
 growth, and also with the amount of inflammatory action in the tumor 
 itself, or in the superimposed tissue. Nsevus is generally purple ; fatty 
 tumors, yellow; fibrous, whitish; cartilaginous, white and glistening. 
 
 Consistence. — In regard to consistence, tumors may be hard, soft, or semi- 
 solid ; fibroid and scirrhus are hard ; cystic, soft ; and the fatty tumor has 
 a " feel " between fibroid and cystic. Occasionally the position of a tumor 
 and its confinement by fascia gives it a sense of pulsation, which might 
 lead to the supposition of aneurism. 
 
 Mobility. —The mobility of a tumor depends upon its situation and the 
 character of the tumor itself. Some, like the fatty tumors, are freely 
 movable ; others, like the exostoses, are always firmly attached. Consist- 
 ence and mobility however can give us but little idea of the true character 
 of the tumor. 
 
 Metastasis.— Cohnheim has lately endeavored to settle the question as to 
 the metastasis of tumors by actual experiment, which consisted "in detach- 
 ing a small piece of periosteum from the tibia, and then introducing it in + o 
 
152 . A SYSTEM OF SURGERY. 
 
 the jugular vein. At first he found considerable difficulty from the ordinary- 
 mechanical and surgical results of such an operation, but, by using Esmarch's 
 method, combined with all antiseptic precautions, he succeeded, and the 
 animals lived quite well. They were killed after various periods, by bleed- 
 ing. In those killed from the third to the fifth day, only embolized perios- 
 teum was found ; in those from the tenth to the sixteenth day, a resistant 
 hard place on the lung parenchyma existed ; in those after the twentieth 
 day, the results were quite negative. Microscopically examined, the masses 
 found between the tenth and sixteenth days were truly growths of the 
 periosteum, with commencing formation of bone; but in cases where more 
 time had elapsed, the new growth was seen to be undergoing absorption, 
 and after a month had entirely disappeared. He considers this disappear- 
 ance to be due to that physiological capacity of the organism which shows 
 itself in the removal of callus, and he suggests that the real factor in the 
 generalization of new formations is the abolition of this function. So long 
 as the constitutional condition of the individual maintains this ability, 
 tumors remain merely local affections, although fragments are being con- 
 stantly detached and carried about by the circulation to distant parts of 
 the body. According to this view, the inoculation of healthy animals with 
 cancerous matter would remain without effect, as we know to be the case. 
 The explanation is hypothetical, but it is at least as comprehensible as the 
 malignity of certain growths."* 
 
 Growth. — The first formation that is noticed in the growth of a tumor is 
 a minute mass of protoplasm, consisting of a small round cell with an 
 irregular nucleus, the product of the connective tissue corpuscles — whether 
 however it is the stable or the mobile cells that are the factors in the pro- 
 duction of this protoplasm, or, whether both assist in the formation, has 
 not yet been determined. This protoplasm bears an exact resemblance to 
 the embryonic cell, and at this period of development, it is impossible to 
 decide whether the neoplasm is to be innocent or malignant; if, as the 
 tumor grows, it takes upon itself the nature of fat, fibre, flesh, or other 
 healthy adult tissue, the growth, without doubt, will be innocent ; if, on the 
 other hand, a proliferation of similar embryonic cells takes place, if they 
 do not proceed to any complete formation, if they are irregular broken- 
 down masses of embryonic tissue largely supplied with bloodvessels, then 
 the tumor will assume one of the many forms of carcinoma. If there is an 
 effort at organization, and here and there throughout the mass are the 
 •evidences of a higher development, then the growth may be set down as a 
 ■sarcoma. With these remarks, and with the previous understanding of the 
 terms " homology " and " heterology" the following histological classification 
 may be seen to correspond, and I think it is so simple that it may readily 
 be understood. 
 
 Cystic tumors will be considered by themselves, as (except in certain in- 
 stances where solid tumors become cystic through geodes in their substance, 
 as found in the uterus, ovary, and breast) they are generally either caused 
 by retention of secretion, or extravasation. 
 
 Histological Formation of Tumors. 
 A. Homologous or Innocent Tumors. 
 
 I. Type of forms of healthy adult tissue — of the higher class. 
 Type of muscle — myomata. 
 Type of nerve — neuromata. 
 Type of bloodvessel — angeiomata. 
 
 * London Medical Kecord, October 15th, 1877. 
 
TUMOKS. 153 
 
 II. Type of fully developed connective tissue. 
 Type of adipose — lipomata. 
 Type of fibrous — fibromata. 
 Type of mucous — myxomata. 
 Type of cartilage — enchondromata. 
 Type of bone — osteomata. 
 Type of lymphatics — lymphomata. 
 III. Type of fully developed epithelial tissue. 
 
 Type of skin and mucous membrane — papilloma and 
 
 horny tumors. 
 Type of gland — adenomata. 
 
 B. The Sarcomata (Semi-malignant). 
 
 Type of embryonic tissue. 
 
 {(a.) Spindle-celled sarcoma (recurrent fibroid.) 
 (b.) Giant-celled sarcoma (myeloid), 
 (c.) Round-celled sarcoma (glioma). 
 (d.) Lympho-sarcoma (alveolar). 
 
 C. The Carcinomata. 
 
 Type of the embryonic tissues, tendency to retrograde metamorphosis 
 rather than higher development. 
 
 (a.) Scirrhus. 
 (6.) Encephaloid. 
 (c.) Epithelioma. 
 (d.) Melanotic. 
 (e.) Colloid. 
 (/.) Osteoid. 
 (g.) Villous. 
 
 Epithelial tissue. 
 
 D. Cystic Tumors. 
 
 (a.) Cysts from expansion of spaces in the connective tissue— serous 
 cysts. 
 
 (6.) Independent cysts— in bone and cartilage. 
 
 (c.) Sanguineous cyst — from rupture of a bloodvessel. 
 
 (d.) Exudation cysts. 
 
 (e.) Congenital cysts. 
 
 (/.) Synovial cysts. 
 
 (g.) Mucoid cysts. 
 
 (h.) Colloid cysts. 
 
 («.-) Compound or proliferous cysts — cysto-sarcoma. 
 
 (k.) Retention cysts — sebaceous cysts. 
 
 A description of these neoplasms will now be given in detail. 
 
 A. Innocent Tumors (Homologous). 
 
 I. Type of healthy adult tissue of the higher class. 
 Type of muscle— my omata (a). 
 Type of nerve— neuromata (6). 
 Type of bloodvessel — angeiomata (c). 
 
154 A SYSTEM OF SURGERY. 
 
 (a.) Myoma. — A tumor composed of true striated muscular fibre is so very- 
 rare, that its existence is denied by many pathologists,* while others, as 
 Green,f allow them to have existed in a few cases, but as such, declare that 
 the growths were congenital. Tumors, however, are frequently found which 
 possess — often in considerable quantity — striped muscular fibre. These 
 neoplasms are generally located in the testicle and ovary, and being fre- 
 quently associated with the remnants of other tissue, such as cartilage, hair, 
 bone, etc., should be, according to the strict histological classification, placed 
 under the second division, or that variety arising from the fully-developed 
 connective tissue series. Smooth muscular tumors are often associated with 
 fibrous material, and are chiefly developed in the uterus, and it is a matter 
 of surprise how well the body tolerates the growth of these neoplasms ; the 
 size they attain is sometimes enormous ; the age at which they appear is 
 about the adult period, and colored women are peculiarly liable to them. 
 In some instances, there is a large association of bloodvessels, causing the 
 profuse bleedings which are characteristic, and from which they have been 
 termed myo-angeioma. In the majority of instances, the fibrous connective 
 tissue is predominant (Fig. 77), and from the specimens which I have had 
 examined, I am disposed to believe, that the true nature of these tumors is 
 rather that of myo-fibroma, than true myoma. The diagnosis is readily 
 made out, and the treatment is by the knife. Hysterectomy is now per- 
 formed with considerable success, but the operation is dangerous in the 
 extreme, and in inexperienced hands is sure to prove fatal. Batty 's opera- 
 tion, or that of Tait, is more readily performed, and offers much greater 
 chances of success. I have known these myo-fibroma gradually disappear 
 after the removal of the ovaries and tubes. In my last six cases I have lost 
 but one, the other five not only recovered from the operations, but the 
 haemorrhage ceased, the tumors all materially diminished in size, and the 
 patients were restored to usefulness. 
 
 (6.) Neuroma. — The neuromatous tumor "is also embraced under the 
 head of fibroma ; in such growth, according to Drs. Paget and More, it is 
 impossible to distinguish the fibrous neuroma from that composed of nerve 
 
 elements." It exists singly, or there 
 fig. 77. may be hundreds in different parts 
 
 of the body. In color, neuroma are 
 grayish or yellowish-white, and are 
 said to arisej from a deposit of lymph 
 around a single nerve fasciculus, 
 which becomes organized,while other 
 deposits take place, until a fibrous 
 growth results. These tumors are 
 sometimes excessively painful when 
 handled, but at others are not so ; 
 sometimes the pain shoots along the 
 course of the nerves, and at others 
 there is coldness of the part, and 
 section of Fibrous Tumor of the uterus. sometimes a great loss of sensi- 
 
 bility. 
 True neuromatous tumors are very rare, the ordinary variety nearly 
 resemble the cerebro-spinal nerves from which they often grow. 
 
 These growths, however, must not be confounded with the " Painful sub- 
 cutaneous tumor of Mr. Wood." This is a peculiar growth of fibrous struc- 
 
 * Heitzman: Microscopical Morphology of the Animal Body. New York, 1883, p. 517. 
 f Pathology and Morbid Anatomy. New York, 1884, p. 162. 
 j Holmes's System of Surgery, vol. i., p. 527. 
 
ANGEIOMA. 155 
 
 ture situated underneath the skin, occurring more frequently in women than 
 in men, varying in size from a pea to that of a chestnut. These tumors are 
 round, and rise a little above the surrounding integument, and are most 
 intensely painful, giving rise to hysterical symptoms of the most violent 
 character ; they are generally incased in a capsule of moderate firmness, 
 but are not imbedded between the fasciculi of nerves, or beneath the neuri- 
 lemma ; hence they must not be confounded with the neuroma just men- 
 tioned. On section, this variety of fibroid tumor presents fibres, matted 
 together and interlaced around a nerve trunk Sometimes there is a con- 
 centric arrangement of fibres, especially if treated with nitric acid. 
 
 Treatment. — Of the medicines internally administered, those which have 
 been productive of most good in my hands are undoubted^ conium and 
 calcarea, However, of late years, I have generally resorted to operative 
 measures. The internal administration of the muriate of ammonia has 
 been productive of good, and to relieve pain the hypodermic injection of a 
 few drops of a four per cent, -solution of cocaine has been very efficacious. 
 The application of veratrine ointment along the course of the nerve is often 
 of great service. 
 
 (c.) Angeioma. — Vascular tumors, as their name implies, are those com- 
 posed of bloodvessels. They are divided into three varieties by Mr. 
 Holmes : * capillary, arterial, and venous. In the first the tumor consists of 
 an enlargement of both venous and arterial capillaries ; in the second, the 
 arterial twigs predominate ; in the third, the venous. 
 
 Vascular tumors are found generally in the subcutaneous tissue, and then 
 are called naevi. When they are large and composed chiefly of arteries, 
 they receive the name cavernous angeioma, and, if large, they become aneu- 
 risms by anastomosis. This variety of tumor varies in size ; it is soft and 
 compressible, often distinctly pulsating, is irregular in shape, and if very 
 well supplied with bloodvessels gives a distinct bruit. As it grows the 
 skin may be so overdistended that imperfect nutrition results, and ulcera- 
 tion opens the tumor, from which there is often profuse haemorrhage. On 
 the scalp, in the lip, and about the face, they are often found. I have seen 
 them on the cheek, the forehead, and even on the back. The simple angei- 
 oma is generally a mark. 
 
 The diagnosis of this variety of tumor is usually easy, although Mr. 
 Holmes mentions a case in which a pulsating cancer of the skull (I suppose 
 a fungus nematodes) was mistaken for aneurism by anastomosis; the 
 patient was operated upon and nearly lost his life on the table. Sometimes 
 the tumors may be dissected out. The more complete treatment will be 
 found in the chapter on Diseases of the Capillaries. I may mention here, 
 however, that in the treatment of these tumors, even when there is consid- 
 erable pulsation, I have succeeded well by injecting from forty to sixty 
 drops of the fluid extract of ergot into the tumor, as recommended by Dr. 
 Hammond. In two instances the injection was repeated after a lapse of 
 eight days. 
 
 Innocent Tumors {Homologous). 
 
 II. Type of fully developed connective tissue, known as the connective 
 tissue series. 
 Type of adipose — lipomata (a). 
 Type of fibrous — fibromata (6). 
 Type of mucous — myxoraata (c). 
 Type of cartilaginous — enchondromata (d). 
 Type of osseous — osteomata {e). 
 Type of lymphatics — lymphomata (/). 
 
 * System of Surgery, vol. i., p. 542. 
 
156 A SYSTEM OF SURGERY. 
 
 (a.) Lipomata— Steatomata— Fatty Tumor.— These tumors are either ses- 
 sile, " continuous," or pedunculated, and are probably the fairest example 
 of homologous tumors. They grow from either superficial or deep-seated 
 fat, and are found wherever adipose tissue is deposited in the body. They 
 may occur at any period of life, and may remain for a considerable time 
 without growing, until from sudden appreciable or some inappreciable cause 
 they increase rapidly in size. They are not dangerous only so far as the 
 pressure symptoms are concerned, and do not return after extirpation. 
 
 When the fatty tumor is sessile or pedunculated it is encapsuled, when 
 it is continuous or appears as an outgrowth it* is not, as a rule, encapsuled. 
 I have only seen this latter variety on the nape of the neck ; it appears 
 like an agglomeration of fat-corpuscles, from the size of a small pea to that 
 of a bean, held loosely together with a delicate connective tissue, and bound 
 down by fascia. On the shoulders, arms, and legs, however, the masses of 
 fat are quite large and lobulated, and held in position by a distinct though 
 quite fragile capsule. 
 
 In the early stages of growth, this capsule is thin and delicate ; at a later 
 period, it becomes dense and hard. This fibrous degeneration of the capsule 
 constitutes the variety described by Rokitansky, Gluge, and Vogel, as " stea- 
 toma,"* and " lardaceous tumor," and by Muller as " lipoma mixtum." 
 Muller also distinguishes another variety u cholesteatoma," which is " appa- 
 rently composed of crystalline fat inclosed in meshes of cellular tissue. "t 
 
 Tn the diagnosis of this form of tumor, the student must first bear in 
 mind that there may be, indeed there often is, a deceptive appearance of 
 fluctuation, and this is more especially the case when the growth is pedun- 
 culated ; it must also be remembered that there is a peculiar tendency in 
 this form of tumor to drop down or shift its position, which fact will assist 
 in the diagnosis. Although as a rule it is not difficult to recognize this 
 peculiar growth, yet sometimes other tumors so nearly simulate it that 
 care is necessary to arrive at a correct diagnosis. A fatty tumor which 
 weighed, after its removal, twelve and a half pounds was mistaken for a 
 spina bifida ; the growth was situated midway in the lumbar region, and 
 had been present since infancy. 
 
 A fatty 'tumor situated directly in the course of the great vessels may 
 receive pulsation from the artery beneath ; this has occurred to me in two 
 cases, once in the neck over the subclavian, and once in the inner side of 
 the right thigh over the femoral. Drawing the growth away from the parts 
 beneath is generally sufficient to arrest the pulsation. 
 
 The following interesting case may show the action of internal medica- 
 tion. A young lady aged twenty-three years was sent to me by her medical 
 attendant, to examine a large tumor occupying the posterior surface of the 
 shoulder, and covering a space from the bend of the neck to the infra- 
 spinatus fossa of the scapula! The parents were averse to operation, and 
 desired that medical treatment should first be thoroughly tried before the 
 knife was resorted to. I knew of no medicine that was especially adapted 
 to fatty tumors, but was aware that Sir Benjamin Brodie had spoken 
 very highly of the liquor potassae in such cases, especially in that of a foot- 
 man who had an immense tumor extending from ear to ear, which was 
 cured by the medicine. I therefore prescribed that remedy, five drops in 
 a teaspoonful of sweetened water three times a day, gradually increasing 
 the dose until she took ten drops at a time. In seven weeks from the date 
 of commencing the treatment, the tumor had entirely disappeared. 
 
 Removal. — To remove the flat continuous growths, a single incision across 
 
 * The term "steatoraa" is applied by some authors to encysted tumors. Vide "sebaceous 
 cysts." 
 
 f Erichsen. 
 
FIBROMATA MYXOMATA. 
 
 157 
 
 the tumor, extending a little beyond its base, is generally sufficient ; but if 
 the growth is large, it may be necessary to make the cut either T, X or H- 
 shaped, then the dissection must be carefully continued around and beneath, 
 until the whole is removed. In the encapsuled variety the single incision 
 (being sure that it is made down to the capsule) is sufficient. The handle of 
 the scapel and the fingers will generally be sufficient to dislodge the lobes, 
 which often slip out in a most approved and cleanly fashion. 
 
 (b.) Fibromata, or as they are called, desmoid, chondroid, tendinous, or fleshy 
 tumors, possess all the characteristics of innocent growths, indeed, in many 
 cases, the body appears to tolerate this variety of tumor better than any 
 other, immense fibroids of the uterus being carried, with but little inconven- 
 ience, excepting their weight, for many years. A fibroid, in shape, is 
 spherical or ovoid, unless peculiarities of position or pressure alter this con- 
 dition. To the touch, fibromata are hard, elastic and firm, unless inflam- 
 mation attacks them, then, of course, the tissues soften; at times a profuse 
 haemorrhage results, and from the opening a fungoid growth may appear. 
 This must be remembered in making a diagnosis between it and cauli- 
 flower excrescence. 
 
 A fibrous tumor grows without pain, and can be handled with impunity ; 
 indeed, I have on several occasions removed tolerably large (six inches in 
 circumference) fibroid polypi from the uterus, the patient making little 
 complaint of pain, and not 
 being under anaesthetic influ- 
 ence. These growths again 
 may be sessile or peduncu- 
 lated; the latter receiving the 
 name of "polypi." As a rule, 
 also, we find the integument 
 over them movable, unless in- 
 flammatory action be present. 
 
 Very often the fasciculi of a 
 fibroma separate, and larger 
 or smaller cysts develop with- 
 in the Structure; the tumor Calcareous Deposit in a Fibrous Uterine Tumor, from 
 
 then receives the name "fibro- Desseau.— Paget. 
 
 cystic" and if calcareous mat- 
 ter has been deposited (Fig. 78), " jibro-calcareous." They are invested with 
 a capsule, which, however, is generally quite thin, and requires care in its 
 dissection ; but this is not always the case. In one or two instances I have 
 found quite a distinct and firm capsule, and this I have noted more particu- 
 larly in that variety of fibroma which was becoming cystic. 
 
 The uterus is most frequently affected with fibroma ; the jaws come next 
 in order, and after this, perhaps, the nerves, making the neuromatous tumor. 
 These growths also attack the subcutaneous tissue, the breast, the lobes of 
 the ears, and the bones. The fibroid tumor,*as it grows from the jaws, re- 
 ceives the name of epulis. This tumor is hard, but not to such a degree as 
 the ordinary fibroid ; it springs from the alveoli, and is connected distinctly 
 to the periosteum ; the tumor can be handled without pain, and often, nay, 
 generally, is pedunculated. When it is raised with the forceps, it sometimes 
 looks serrated along its edges, and is covered with mucous membrane. 
 Absence of disease in the subjacent glands, and also of the tendency to infil- 
 tration or to cachexia, diagnose it from malignant formations. 
 
 As a rule, time is lost in prescribing medicines for these tumors. The 
 knife is the only resort. 
 
 (c.) Myxomata or mucous tumors, known as fibro-cellular tumors, are, in 
 common medical nomenclature, considered as " soft polypi," and that is 
 
158 
 
 A SYSTEM OF SURGERY. 
 
 their best name ; nevertheless, they have received many others. According 
 to Rokitansky, a fibro-cellular tumor is " a gelatinous sarcoma;" according to 
 Voight, it is "a connective-tissue tumor;" according to Miiller, it is '"a cellulo- 
 fibrous growth" and according to Virchow, it is " a myxoma" one of the end- 
 less varieties of sarcoma. These tumors are composed, as their name well 
 indicates, of fasciculi of fibro-cellular structure, which are loose or otherwise, 
 in accordance with the softness or succulency of the growth ; in the meshes 
 of this tissue is a fluid resembling somewhat the synovial, in which are 
 found round or caudate cells or corpuscles (Fig. 79), which contain abun- 
 dant nuclei ; the more numerous these bodies, the denser the tumor ; in 
 some locations these growths are covered with a ciliated epithelium. 
 
 Myxomatous tumors have a soft and pulpy feel, are painless and grow 
 with rapidity, and may attain such considerable magnitude that parts may 
 be displaced by them ; they are generally continuous, are often lobulated, 
 and are pedunculated, hence the term "polypi." They are chiefly found 
 in the nose, ear, and uterus; they also may arise from the connective tissue 
 of* the organs, especially the mammas, and sometimes in the skin, when 
 they generally become papillary. This variety of growth is probably the 
 same as that spoken of by Paget as the true fibro-cellular tumors, which are 
 found in " the scrotum, the labium, or the tissues by the side of the vagina, 
 and the deep-seated intermuscular spaces in the thighs and arms." Polypi 
 
 Fig. 79. 
 
 Fig. 80. 
 
 Cells of a Myxomatous 
 Tumor. 
 
 Microscopic appearance of a Myxoma with cells in various 
 stages of elongation and attenuation. 
 
 present " opaque white bands intersecting a shining, succulent basis sub- 
 stance of serous-yellow or greenish-yellow tint ; the whole mass closely re- 
 sembles ' anasarcous cellular tissue.' Examined under the microscope, they 
 are found to be composed of parallel or interlacing filaments and fasciculi, 
 interspersed with nuclei and cells like those of granulations." (Fig. 80.) 
 
 Secondary Changes. — These tumors vary in the color, consistence, and 
 nature of their contents; they are also subject to cartilaginous and ossific 
 degeneration, and in some cases may ulcerate and slough. 
 
 These morbid growths, however, sometimes yield to remedies. 
 
 Professor Dunham reports cases cured with calc. carb., teucrium, and 
 staph. I have also seen excellent results from the injection of acetic acid, 
 pure, four or five minims, directly into the tumor. The injection may be 
 repeated once a week. 
 
 Dr. John Pattison has used successfully a snuff of powdered rad. sangui- 
 naria canadensis. 
 
ENCHONDROMATA. 
 
 159 
 
 Polypi may sometimes be cured by puncture and evacuation of the 
 tumor. 
 
 I have very often succeeded in diminishing the size of polypi, and in one 
 or two instances of curing them with calc. carb. andteucrium, but have most 
 frequently been obliged to resort to operative measures. 
 
 There are other soft and succulent tumors which have been described, 
 but which are all of the same character, and according to Yirchow consist 
 of " the embryonic tissue or Whartonian jelly of the cord." 
 
 The cylindroma of Billroth are those in which " are found cylindrical 
 structures of a clear and transparent appearance, arranged like a series of 
 anastomosing branches, which terminate often in bulbous ends, and contain 
 numerous spindle or round cells, though they appear clear and structure- 
 less." At other times little flask-like bodies are discovered, which are sup- 
 posed to be some peculiar modification of the rudimental connective tissue. 
 These tumors are sometimes classed as the semi-malignant, but there is not- 
 much actually known of them. 
 
 (d.) Enchondromata is but another name for cartilaginous tumors, and 
 is also synonymous with osteo-chondroma, chondroma, and benign osteo- 
 sarcoma of some authors. I believe the simple expression " cartilaginous 
 tumor " is preferable to any of these ambiguous terms. 
 
 It must be remembered that these tumors, though classed as innocent, 
 occasionally recur after their removal, although I believe in most cases their 
 reappearance is owing to admixture of imperfectly developed cells. 
 
 These tumors present many peculiarities, among which may be noticed 
 the difference in structure which is presented in a single enlargement. In 
 the case related below, the surface of the swelling was very soft, nay, 
 almost fluctuating ; while its base was extremely cartilaginous. We find, 
 also, in this (which is a general characteristic of the affection), the parts 
 firmly adhesive to the adjacent bones. 
 
 Sir James Paget* gives an accurate description of enchondroma. 
 
 " To the touch, cartilaginous tumors may be very firm or hard, especially 
 when they are not nodular and their bases are ossified. In other cases they 
 are firm, though compressible, and extremely elastic, feeling like thick- 
 
 FlG. 81. 
 
 Fig. 82. 
 
 Microscopic Characters of Enchon- 
 droma. 
 
 Enchondroma of the Hand. 
 
 walled, tensely-filled sacs. Many a solid cartilaginous tumor has been punc- 
 tured in the expectation that it would prove to be a cyst." 
 
 In the specimens in my possession, the different properties, as to touch 
 and the eye, are appreciable. The base of the excrescence is particu- 
 larly cartilaginous, while the superficial parts are much more elastic, and 
 
 Surgical Pathology, p. 422. 
 
160 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 83. 
 
 this difference is to a greater degree apparent immediately after an operation 
 than after the immersion of the tumor in spirits. In enchondroma all the 
 intermediate gradations, from the hardest cartilage to the softest consist- 
 ency of ordinary fatty tumors, are present, and, necessarily, the microscopic 
 characters of each of these different portions present a different cell forma- 
 tion. The cartilage corpuscles, however, in the more dense structure are 
 said to bear no resemblance to those that exist in the normal cartilages of 
 man or any of the vertebrata. (Vide Fig. 81.) According to Mr. Quekett, 
 however, whose authority in cytology is acknowledged to be very high, the 
 natural cartilage of the cuttle-fish possesses corpuscles of a similar character 
 to that of enchondroma, which fact in itself is certainly a point of interest, 
 showing that the abnormal character in the higher order of the animal 
 species may constitute a normal characteristic of the lower creatures. 
 
 Rokitansky,* speaking of cartilaginous growths, has, as usual, a full and 
 at the same time a very conscise description of them. 
 
 " Wounds of cartilage are not reunited by means 
 of cartilaginous substance, nor is this substance 
 regenerated when destroyed. Nevertheless, new 
 growths of cartilaginous texture are both frequent 
 and voluminous. The structure of the growths or 
 tumors was first ascertained with the aid of the 
 microscope by Johannes Miiller, who applied to 
 them the term ' Enchondroma.' These excepted, 
 not a single new growth, whether designated as 
 cartilage-like or as cartilaginescence, chondroid, 
 or fibro-chondroid, has more than a seeming 
 
 analogy with true cartilage texture 
 
 " The capsular case of the enchondroma is un- 
 essential, and is common to many other heterolo- 
 gous growths Many of the so-called cases 
 
 of spina ventosa of older observers were probably 
 of the nature of enchondroma." 
 
 These growths have also been known to have 
 their seat upon the lower jaw, but the general site 
 is upon the fingers (Fig. 82) or thighs (Fig. 83). 
 The surgeons whose names are chiefly associated 
 with the removal of enchondromatous tumors are 
 Diffenbach, Muller, John Bell, Sir Astley Cooper, 
 Hodson, Lawrence, Paget, and Hunter. 
 Prof. Miller says of these growths : 
 " Cartilaginous formations (enchondroma of 
 Muller) occur more frequently in bone than in the 
 soft textures ; their nature and tendency are sim- 
 ple, yet degeneration is possible, while discussion 
 is impossible, and therefore early extirpation is expedient." 
 
 The following interesting case came under my observation in the Good 
 Samaritan Hospital, St. Louis, and was removed by Dr. Fellerer, myself, 
 Dr. Comstock, and others assisting. 
 
 This tumor occupied a space from shoulder to shoulder of the unfortunate 
 possessor, and from the nape of the neck to below the angles of the scapulae. 
 Portions of it were purplish, and other parts presented the natural color. 
 Throughout the whole cutis a number of enlarged and tortuous veins were 
 distinctly seen. To the touch this tumor presented all those sensations 
 which belong to fatty enlargements, excepting at its base, where the structure 
 
 Bony Skeleton of Enchondroma. 
 
 * Pathological Anatomy, vol. i., p. 143. 
 
ENCHONDROM AT A . 
 
 161 
 
 appeared more dense. This hardness extended also to the right clavicle, and 
 to some distance below it. On the vertebral column, immediately under the 
 posterior margin of the enlargement, were several well-marked cicatrices. 
 
 The history of the case was given by the patient as follows : Some years 
 since, at a wine shop in Berlin, the man became engaged in an altercation, 
 which resulted in a quarrel, and he was stabbed several times in the back 
 by his assailant. For many weeks his life was despaired of by the attend- 
 ing physicians, but a tolerable recovery resulted, and the duties of life were 
 resumed. After a time, however, a small swelling appeared on the region 
 of the spinal column, at the site of one of the late wounds. This tumor 
 was not accompanied with any very severe suffering, and was allowed to 
 remain and grow undisturbed, until its rapidly increasing size induced the 
 patient to apply to a physician, who declined taking any steps towards its 
 removal. The man then came to this country, and during the voyage the 
 tumor increased in volume very considerably. He travelled through differ- 
 ent portions of the United States, and finally came to St. Louis. For nearly 
 a year he had been obliged to sleep upon his belly, with his head bent over 
 the edge of his bed or supported on his hand. He had suffered great pain, 
 and in a state of desperation demanded a removal of the tumor. He was 
 plainly told at the hospital that the chances of such an operation would be 
 decidedly against him ; but rather than drag on such a miserable existence, 
 and finally succumb to the disease, he begged that no delay should be used, 
 but at once his suffering should be terminated. 
 
 Accordingly he was placed prone upon his abdomen, his head projecting 
 beyond the edge of the table, and chloroform administered. A crucial in- 
 cision was then made, and Dr. Fellerer dissected up the two left-hand flaps, 
 while I turned over those on the right side, by such a procedure saving 
 considerable time. The tumor Avas then raised up, and with the greatest 
 difficulty dissected from the transverse and spinous processes of the ver- 
 tebras, to which it was most firmly attached. Portions of this attachment 
 were almost ossific. 
 
 The haemorrhage was very profuse, 
 but all venous, and occurred chiefly 
 during the dissection of the flaps ; that 
 resulting from raising the tumor from 
 its bed not being excessive. 
 
 The operation lasted two hours, and 
 the man to all appearances appeared 
 to rally from the chloroform very well. 
 About three hours after the perform- 
 ance he took some wine and appeared 
 quite rational, then turned upon his 
 side and died in a few moments. 
 
 Fig. 84 represents from Druitt the 
 bony skeleton of enchondroma. 
 
 Cartilaginous tumors are subject to 
 degenerative liquefaction, which may 
 occur either on the periphery or in the 
 interior. The central softening often proceeds to the formation of cysts ; 
 the skin covering the tumor inflames, ulcerates, and sloughs; fistulous 
 openings form, and a viscid ichorous fluid is discharged. It is a some- 
 what singular fact that these two processes — ossification and disintegration 
 — may coexist in different parts of the same tumor. Calcareous and fatty 
 degeneration may also occur. 
 
 Dr. John Pattison reports that he has successfully enucleated an enchon- 
 droma of the index finger with a saturated solution of sulphate of zinc. 
 
 11 
 
 Fig. 84. 
 
 Groups of various Cartilage Cells— Magnified 
 400 times. 
 
162 A SYSTEM OF SURGERY. 
 
 The usual and best surgical treatment is excision of the tumor, or ampu- 
 tation of the affected part. 
 
 (e.) Osteomata. — As has been already noticed, ossific deposit may be found 
 in cartilaginous and other tumors, but growths undergoing such change do 
 not receive the name osteoma, it being applied to fully developed bony for- 
 mations. Osseous tumors are homologous, or, in other words, innocent ; 
 their resemblance to healthy bone formation of the body being perfect, both 
 anatomically and chemically. 
 
 These tumors are generally outgrowths, and partake either of the nature 
 of the compact or cancellated structure. In the compact or ivory or eburnated 
 exostoses (which chiefly are found connected with the cranial bones) the 
 structure is firm and of different shapes. These tumors are attached either 
 within or without the cranium, and when in the latter position are very 
 difficult to diagnose. " This exostosis," says Rindfleisch, " is so remarkable 
 a phenomenon, just because quite divergent from the usual schema, namely, 
 without regard to the vessels and their course, the osseous tissue is depos- 
 ited layer by layer about one of the smallest tubers as a nucleus. This 
 gradually becomes a warty, polypus-like, white formation, which may at- 
 tain the size of a man's fist, and nevertheless consist throughout of compact 
 bony structure. This entire kind of growth undoubtedly reminds us of 
 dentine."* 
 
 It is worthy of remark also, that there often exists between the compact 
 layers of bone, a cancellated structure, and that in very many cases the tumors 
 have a small base, are round, smooth, and hard, and sometimes rise to a 
 considerable height above the surrounding bones. The pain they occasion 
 is generally that of pressure. 
 
 The second variety or cancellated exostoses, as the name indicates, are 
 formed of structure exactly resembling the cancellated structure of healthy 
 bone. They usually arise from cartilaginous tumors, are round, lobulated, 
 sometimes presenting spiculse or angles. These tumors grow in most pecu- 
 liar locations, and Mr. Paget calls especial attention to those found at the 
 lower end of the femur, above the insertion of the adductor magnus.f 
 
 These tumors grow often by stems or peduncles, which, when broken, do 
 not appear to be reproduced. A peculiarly hard species of this variety 
 is that growing from the last phalanx of the great toe, giving severe pain, 
 pushing up the nail, and rendering the parts around sensitive. During 
 the past winter, at the college, I removed two of these subungual exostoses, 
 and found them hard, unyielding, perfectly cancellated, and being direct out- 
 growths from the last phalanx of the toe. Mr. Paget has seen such tumors 
 growing from the little toe, and also from the dorsal surface of the last 
 phalanx. 
 
 The upper jaw is often affected with exostosis, and in some cases there 
 appears to be an hereditary tendency to the production of these tumors. 
 
 The medical management of osteoma will be found in the chapters upon 
 diseases of the bones, and in other parts of the volume treating on the sur- 
 gery of those regions where they most frequently appear. Suffice it here to 
 say, that some very remarkable cures have been made. In many instances, 
 however, removal of the parts is necessary. 
 
 (/.) Lymphomata, Lymphoma, Lympho-sarcoma, are terms used to designate 
 a peculiar hypertrophy of the lymphatic glands, which has been so accu- 
 rately described by Dr. HodgkinJ that it is now named " Hodgkin's Dis- 
 ease." Wilks calls the disease lymphatic anxmia, Cassy, general hypertrophy 
 
 * Textbook of Pathological Histology, p. 602. 
 f Surgical Pathology, p. 532. 
 
LYMPHOMATA, LYMPHOMA, LYMPHOSARCOMA. 163 
 
 of the lymphatic glands, and Wiinderlich, multiple lymphadenoma. The cer- 
 vical glands are those most generally affected, but the axillary are also not 
 unfrequently attacked, as may be other of the glandular tissues. The dis- 
 ease does not depend on zymotic influences, and bears in many respects a 
 resemblance to phthisis. In some cases it may be caused by traumatism. 
 The glands gradually enlarge, with their connective tissue, and these appear- 
 ances may result from a bruise or a strain, or may appear without any ap- 
 preciable cause, A small swelling may be the first indication of the disease. 
 Acute pain, neuralgic in its character, accompanies the growth, or may ap- 
 pear in the locality before the tumor is noticed. The neoplasm at first 
 appears movable, but grows rapidly without seriously inconveniencing the 
 patient. A peculiar and frequent accompaniment of ihe disease is leucocy- 
 thsemia, the white blood-corpuscles being always in excess, and often in 
 enormous quantities. There is also the usual bruit de souffle which accom- 
 panies the condition. A single gland may be thus affected, or, as is more 
 frequently the case, several become seats of the disorder, and finally tumors 
 in the lungs, liver and cellular tissue are developed, Lymphadenoma is not 
 always accompanied by leucocythaBmia, as is noted by Mr. Haward, and 
 offers a better opportunity for treatment when uncomplicated. M. Jaccoud 
 concludes, that this disease is occasioned by a twofold condition of the 
 blood. In the one the red globules are much reduced ; in the other, this 
 condition coexists with a vast increase in the leucocytes. According to this 
 view the anatomical constitution is different in each variety. He is of 
 opinion that in the latter cases, viz., where there is a great increase in the 
 amount of the white blood-corpuscles, the new growth is altogether ex- 
 panded in the cellular elements, but when both conditions noted above are 
 combined, the capsule of the glands and the connective tissue are much 
 thickened. At present, operative interference is scarcely considered just- 
 ifiable, as most of the cases reported have proved fatal.* 
 
 Mr. Warrington Haward f presented at the Clinical Society of London, 
 the following interesting case of lymphadenoma. " The patient, a child of 
 four years, had on the left side of the neck an immense mass of enlarged 
 glands, extending from the ear above, to the clavicle below, and from the 
 spine behind, to the trachea in front. The glands were elastic, and mode- 
 rately firm, and not adherent to the skin. There was no evidence of disease 
 in any other part of the body, and the number of the white globules in the 
 blood was not increased. There was a family history of phthisis on the 
 mother's side. The child was pale and rather thin ; the growth was of a 
 year's duration, and commenced soon after an attack of small-pox. As the 
 disease of the glands appeared to be confined to those visible in the neck, it 
 was determined to remove these, in the hope that the general infection 
 might thus be prevented or delayed. As the removal of the disease involved 
 the dissection of the whole of one side of the neck, it was effected in two 
 operations. At the first the affected glands were removed from the anterior 
 triangle of the neck ; at the second, from the posterior triangle. The child 
 recovered well from the operation, and soon gained flesh and color to a 
 remarkable extent. Subsequently, however, the disease returned in the 
 upper part of the left anterior triangle of the neck, and tumors afterwards 
 appeared in the axilla and groin. The child died, pale and emaciated, and 
 post-mortem adenoid growths were found in the abdominal viscera in addition 
 to the enlargement of the glands. No recurrence occurred in the posterior 
 triangle of the neck, and it was thought that possibly some diseased glands 
 might have been left in the upper part of the anterior triangle, where the 
 growth first reappeared." 
 
 * Vide Medical Times and Gazette, January 27, 1877. 
 
 f Medical Times and Gazette, December 25, 1875. Reported also in the Monthly Abstract 
 of the Medical Sciences. 
 
164 A SYSTEM OF SURGERY. 
 
 M. Trelat* mentions two cases of removal of lymphadenomata, attended 
 in each case with similar growths in other parts of the body. In both these 
 cases there was a recurrence and a fatal issue, and lymphomatous growths 
 were found in the vertebrae, sternum, spleen and liver. It is held that 
 there are forms of lymphadenoma which are malignant, and others which 
 are not, but the definite histological criteria for determining between the 
 two varieties is not pointed out. The conclusion drawn from these cases is 
 that the removal of these tumors is not advisable when there is any sus- 
 picion of visceral implication. 
 
 There are certain indications for treatment in lymphadenoma which 
 should be remembered. I have had several cases of the disease and have 
 observed the course generally taken by the enlarged glands, — often tending 
 to suppuration, — always obstinate to treat. The medicines are mercury, 
 baryta carb., calcarea, conium mac, arsenicum, and the iodide of potas- 
 sium. 
 
 To the enlarged glands I apply the mineral earth, as prepared by the Bal- 
 timore Company, made into a paste. This is put on every night and 
 retained in position by an appropriate bandage. I have had perhaps the 
 most satisfactory results from the prolonged use of calcarea and arsenic, giving 
 the former in the 2 X trituration, three grains night and morning for a week, 
 and a drop of the tincture of arsenic, night and morning, after meals, for the 
 succeeding week, continuing this treatment for several months. As the 
 glands soften and suppuration comes on, mercury and calcium sulphide 
 are given, and if these means, after being persistently tried, fail, extirpation 
 of the glands, if practicable, can be practiced. 
 
 Innocent Tumors (Homologous). 
 
 III. Type of fully developed epithelial tissue. 
 
 (a.) Mucous membrane and skin: papilloma, horny tumors. 
 (6.) Glandular: adenomata. 
 
 (a.) Papilloma. — By those familiar with the histological formation of the 
 skin and mucous membrane, the appearances and structure of papillomata 
 will readily be understood. These growths have always some connective 
 tissue mingled with the epithelial elements, and are divided into two classes : 
 1st. The hard or horny papilloma, in which there is a preponderance of con- 
 nective tissue, and which grow upon the skin, embracing warts, horny 
 growths and nail tissue ; and 2d. Those in which epithelia are very numerous, 
 embracing soft outgrowths which spring from the mucous membranes of 
 the mouth, the larynx, the rectum, bladder, and sometimes from the uterus. 
 The so-called " painful caruncle " of the female urethra comes also under 
 this classification. 
 
 The soft or myxomatous papilloma are well supplied with bloodvessels and 
 bleed readily, while the former are not vascular. The color often noticed in 
 the hard growth is derived from pigment deposited in the deepest layer of 
 the epithelia. 
 
 Often in the myxomatous papilloma, shreds and bits of membrane are 
 cast off with the natural secretions of the part. 
 
 It is stated by some authorities that from constant irritation of these 
 growths, they may develop a myeloid or round-celled formation, which, 
 from recent observations, I am disposed to believe. 
 
 Horny Tumors. — These curious morbid growths generally occur in con- 
 nection with sebaceous follicles, and their origin can frequently be traced to 
 injuries or chronic inflammation. 
 
 * American Journal of the Medical Sciences, July, 1877, page 256. 
 
SPINDLE-CELLED SARCOMA RECURRENT FIBROID TUMORS. 165 
 
 They are usually found about the head and face, but may also exist in 
 other parts of the body. They first appear as soft, semi-transparent masses 
 enclosed in complete cysts ; as they increase in size, they become dense and 
 hard, and assume all the characteristics of horny structure. 
 
 They grow slowly, and frequently attain considerable magnitude ; one 
 case has been reported in which the tumor measured eleven inches in length 
 by two and one-half inches in circumference ; and in another instance the 
 horn was fourteen inches around the base. 
 
 They are more or less flexible, and of an almost cartilaginous hardness. 
 The surface is marked by rough rings, indicating the different stages of 
 growth ; sometimes it is knotted or covered with small pearl-like scales. 
 
 In shape they are usually conical, and twisted upon themselves like the 
 horns of a sheep ; their color varies from a dingy yellow to brown or black. 
 
 Under the microscope they exhibit flattened epithelial cells and nuclei. 
 
 The only treatment for these tumors that I know of is excision. 
 
 (b.) Adenoma, or Glandular Tumors. — These tumors are most commonly 
 found in the breast, in the prostate, in the thyroid gland, and sometimes in 
 the lip, the name of the part in which they grow generally being added, to 
 determine their locality, thus, labial glandular tumor, mammary glandular 
 tumor, etc. In the majority of cases, the growths occur within the glands, 
 but sometimes they are found external to them. 
 
 These tumors are more frequent in adult life ; they grow slowly and may 
 attain considerable size without much inconvenience; they are smooth, 
 round, and sometimes lobulated. When they are cut into, their structure 
 appears to be separated by interstices, in which a small quantity of fluid 
 is found ; they are, especially in the breast, encased in a distinct capsule, 
 and generally may be dissected out with ease. They are painless unless 
 from pressure, or, as in the mammary gland, from dragging the parts down- 
 ward. Occasionally cysts are developed in the substance of these tumors, 
 which appear to contain a serous fluid, resembling that spoken of above, 
 as found in the interstices of the tumor. 
 
 The microscopic elements of adenoma resemble true glandular structure 
 arranged in a lobular form, each lobe containing more or less glandular epi- 
 thelium. The septa are formed of fibrous tissue which is often concentric 
 in form, sometimes, however, radiating from the centre to the circum- 
 ference. 
 
 These tumors are amenable to treatment, and I have seen them disappear 
 under calc. carb., conium, and especially phosphorus. In the breast they 
 are likely to enlarge during the menstrual period. In operating they may 
 be taken out by removing the capsule and enucleating the morbid mass. 
 Sometimes, however, the gland must also be extirpated, especially when 
 much of its substance is involved. 
 
 B. The Sarcomata (Semi-malignant). 
 
 (a.) Spindle-celled sarcoma (recurrent fibroid). 
 (b.) Giant-celled sarcoma (myeloid), 
 (c.) Round-celled sarcoma (glioma), 
 (d.) Lympho-sarcoma. 
 (e.) Alveolar sarcoma. 
 
 (a.) Spindle-celled Sarcoma — Recurrent Fibroid Tumors.— The chief charac- 
 teristics of the spindle-celled sarcoma appear to be as follows : First. Their 
 almost invariable tendency to recurrence after removal, such reappearance 
 not being attributable to any portions of the tumor which may have been 
 accidentally allowed to remain in the parts. Second. They generally appear 
 at the site of the former wound, as well as in other portions of the body. 
 
 Connective tissue 
 series. 
 
166 
 
 A SYSTEM OF SURGERY. 
 
 Third. Their growth is slow at first, but afterwards they enlarge with greater 
 rapidity. Fourth. They give but little pain, and life is not threatened by 
 them for along time, unless (which most frequently happens) local pressure 
 causes danger and death. Fifth. The superjacent skin is not involved, nor 
 does it proceed to ulceration, unless such solution of continuity is produced 
 by tension and consequent deficiency of circulation. Sixth. They are 
 hard, lobulated, and often immovable, appearing to be firmly attached to 
 the aponeuroses and fibrous sheaths. Seventh. They do not infiltrate the 
 tissues surrounding them, nor do they produce the cachexia found in can- 
 cers. Eighth. Their structure appears to resemble somewhat the natural 
 tissues of the body, but the cell-element is rudimentary, incomplete and 
 preponderating. Ninth. The oftener they recur the more succulent and soft 
 do they become, and the more rapid is their growth. Tenth. The cells com- 
 posing them are spindle-shaped and caudate, often with attenuated processes, 
 with large nuclei (vide Fig. 85). There may be also, free nuclei scattered 
 
 Fig. 85. 
 
 Microscopic elements of a Spindle-celled Sarcoma, magnified 400 times. 
 
 throughout the intermediate cellular substance. Eleventh. The hardness or 
 softness of spindle-celled sarcoma consists in the deposit of fatty particles 
 in the one variety, and their absence in the other. 
 
 The secondary changes which take place in these tumors give rise to many 
 difficulties in diagnosis. The most frequent is fatty degeneration, but there 
 may be deposits of calcareous matter, and even pigmentation may occur; 
 in the former case giving rise to the supposition that the tumor may be a 
 fibro-calcareous growth, and in the latter that it may be melanotic, which 
 also, if a rupture of a bloodvessel should occur, would be easy to mistake 
 and diagnose as a simple sanguineous cyst. The surgeon should be upon 
 his guard in making a diagnosis. 
 
 Many cases of this variety of tumor have come to my notice, but the one 
 I here record is of considerable interest, because of the simultaneous appear- 
 ance of three tumors, after the complete extirpation of the first, and of the 
 train of pressure symptoms which were gradually developed. The patient, 
 Ella S., was about twenty years of age, and healthy in appearance. Her 
 father partook of the rheumatic diathesis ; her mother died of phthisis (the 
 disease being hereditary in that branch of the family). She had enjoyed 
 average health from childhood, excepting a severe attack of scarlatina, occur- 
 ring during her fourth year, from which she is said to have made a com- 
 plete recovery. From a careful inquiry I could not find that she ever 
 received an injury of the neck, or that there was an appearance of any 
 abnormal growth, until about two years prior to the date of operation. 
 About that period a tumor appeared near the centre of the right side of the 
 neck ; it gave but little inconvenience and no pain, and scarcely attracted 
 notice. After a time, however, as it slowly enlarged, occasional difficulty 
 of deglutition called more critical attention to the growth, which had con- 
 siderably increased in an upward direction. In addition to the above 
 
SPIXDLE-CELLED SARCOMA — RECURRENT FIBROID TUMORS. 167 
 
 unpleasant symptom, there were paroxysms of great dyspnoea ; both of 
 these symptoms being produced by pressure on the oesophageal branches of 
 the vagus and the inferior laryngeal or recurrent nerve. The suffocative 
 paroxysms increased until life was in peril, the growth of the tumor also 
 proceeding with marvellous rapidity. 
 
 In consultation with Dr. Banks, of Englewood, whose patient she was, it 
 was decided that nothing but operative measures could prolong her life, and 
 though the season of the year was rather unpropitious (it being midsummer), 
 the day was appointed for the operation. 
 
 The tumor at this time extended from the mastoid process of the tem- 
 poral bone, bordering closely the ramus of the inferior maxilliary, to the 
 margin of the clavicle, and from near the mesian line of the neck to a point 
 about half an inch beneath the anterior border of the trapezius. The sterno- 
 mastoid muscle crossed it diagonally, and from the pressure consequent upon 
 the protrusion of the growth had become much attenuated. The external 
 jugular vein, from the same cause, was reduced to a thread. The tumor 
 was distinctly lobulated, hard, and most firmly fixed, a condition which 
 renders every surgeon more careful in his methods of procedure ; in fact, it 
 is recommended by some distinguished authorities that this immobility 
 should decide the question of surgical interference, especially in parotid 
 tumors. 
 
 The patient was placed on the table about noon, and ether administered. 
 There were suffocative paroxysms during the first period of anaesthesia, 
 which, however, gradually passed away. 
 
 The head was placed in a position similar to that for ligation of the ca- 
 rotid, and an incision of three inches made along the anterior attenuated 
 border of the sterno-mastoid, from the angle of the jaw to the lower border 
 of the thyroid cartilage. The tumor was so immovable that I determined, 
 on account of its peculiar situation, to give myself all the room that I could, 
 and to make a crucial incision, if necessary, to afford facility in getting 
 underneath the growth. 
 
 The fascia was cut through and the sterno-mastoid held aside ; finding, 
 however, that the tumor lay beneath the deep cervical fascia, and that the 
 sterno-mastoid was attached, I divided it with a transverse incision. The 
 next step was a transverse division of the anterior fibres of the trapezius, 
 which was accomplished upon a director. This allowed a free and full 
 exposure of the upper surface of the tumor, which was laid bare after a 
 tedious dissection. The next step was to dislodge it from its base ; begin- 
 ning with the posterior border, the handle of the scalpel was introduced 
 beneath it. The adhesions were extremely dense, and repeated touches of 
 the knife, the use of the director, the fingers, and the handles of instruments, 
 gradually raised the tumor until we discovered its connection with the 
 sheath of the great vessels. Having, thus far, loosened the growth from the 
 posterior side, the adhesions on the anterior border were attacked in the 
 same manner ; they gradually gave way until it was free, excepting its line 
 of connection with the sheath of the carotid and internal jugular. Having 
 then a finger placed on the carotid, as it passed under the tumor, ready for 
 compression, if necessary, the dissection was carefully continued from below 
 upward, until the growth was removed, taking with it the external portion 
 of the sheath of the great vessels of the neck. 
 
 It is unnecessary to say that this was both a trying and tedious dissec- 
 tion. It occupied nearly two hours, and the heat was overpowering. There 
 were six ligatures applied, but there was no serious haemorrhage, excepting 
 for a short time, from a prick of the internal jugular ; continued compres- 
 sion stopped this. The wound was brought together with silver sutures, and 
 the patient progressed without untoward symptoms, excepting a slight con- 
 
168 
 
 A SYSTEM OF SURGERY. 
 
 vulsive cough, for three weeks, when a swelling showed itself in the site of 
 the wound. In a few days a second growth was developed on the left side of 
 the neck, in a position 'precisely similar to that occupied by the first tumor, viz., 
 beneath the sterno-mastoid. Then were presented a train of peculiar and 
 most unfavorable symptoms. Ptosis of the right lid; insensibility of the 
 pupils and diplopia ; then numbness of the right side of the face, which was 
 followed by deafness of the right ear; these symptoms increased, until 
 finally the eyeball began to protrude from the orbit. Distressing paroxysms 
 of cough then were present, and to add to the suffering of the poor girl, diffi- 
 culty of deglutition again ensued. At this time bulimia, of an actually fierce 
 character, superseded with rapid and great emaciation. The tumor on the 
 right side grew to a considerable size, but was much softer than the former 
 growth (a characteristic of this variety of neoplasm). The eyeball was pushed 
 
 Fig. 86. 
 
 Section from a spindle-celled sarcoma of the femur, taken from the exterior of the tumor, a shows the 
 " indifferent granulation material" or "adenoid tissue" stretching out from the tumor structure (b) into 
 the adipose tissue (c) separating its cells. The tumor was of a malignant character, and contained in 
 other parts of its substance cartilaginous and osteoid material. Path. Soc. Trans., vol. xxi., p. 341, and 
 pi. viii., Fig. 1.— (HOLMES.) 
 
 out from a tumor of the orbit until it lay upon the cheek. Severe neuralgic 
 pains and sleeplessness were present, and she died in great agony, which 
 opiates were powerless to relieve. 
 
 Fig. 86 represents the appearance of the different cells in a section of a 
 recurrent fibroid. 
 
 (b.) Giant-celled Sarcoma — Myeloid Tumors (Paget) ; Fibro-plastic (Lebert). 
 — These tumors are of rather rare occurrence, and there is no better method 
 of describing them, or indeed any varieties of abnormal growth, than by 
 the history of a typical case. The following is one in which I removed the 
 superior maxillary and turbinated bones for the disease in question. 
 
 Joseph Vogl, aged forty-nine, entered the Good Samaritan Hospital, at 
 my suggestion, on account of a peculiar tumor involving the upper jaw of 
 the right side, extending downward and forward into the mouth, forcing 
 forward the alveoli and the teeth contained therein, and growing, according 
 
GIANT-CELLED SARCOMA — MYELOID TUMORS — FIBRO-PLASTIC. 169 
 
 to the statement of both the patient and his wife, with amazing rapidity. 
 The tumor was turned toward the left side, and the lower eyelid drawn 
 somewhat downward. The mass that could be seen by drawing the cheek 
 aside, resembled in many respects the gum from which it appeared to grow ; 
 never bled excepting after severe handling, and then but slightly ; had a 
 peculiar odor, but not that which belongs to encephaloid disease, and ap- 
 peared to involve the whole bone, excepting the orbital plate, extending 
 upward to the articulation of the nasal bones. The patient's health was 
 rapidly failing, and I advised an operation as soon as the system could 
 sustain the shock. 
 
 The diagnosis was difficult to make out. There was an absence of symp- 
 toms which generally belong to malignant tumors, and that part of the 
 growth which was capable of being examined presented many appearances 
 of epulis. My first impression was that it was the latter-named disease, 
 but in reading over The Surgical Observations of John Mason Warren, I 
 recollected a passage which I think led to the correct diagnosis of this case. 
 The lines were as follows, page 64 : " Myeloid tumors in the jaw are rare, 
 and at a late stage of their existence are often distinguished with difficulty from 
 that external affection called epulis." Further research justified the opinion, 
 and the examination of the diseased mass after its removal put the ques- 
 tion beyond doubt. 
 
 The question as to the malignancy of the tumor was first to be considered, 
 and many of the features which I have found to belong to the so-called 
 heterologous growths were absent; thus there was entire absence of hsemor- 
 rhage ; lack of proneness to ulceration (which is very ■ characteristic of 
 malignant formations), together with the appearance presented by those 
 parts which could be examined (which in homologous growths is, as a rule, 
 similar to some of the textures of the body on which the formation is found), 
 which was normal in both color and consistency. On the other hand there 
 was an amazing rapidity of growth, some fetor, general depression of vitality, 
 and other symptoms which were of serious import. A myeloid tumor 
 is one which, in appearance, resembles, after slight maceration, common 
 suet. The growths generally occur in bones and in cancellated structure ; 
 on section they present reddish or even purple spots in their texture, and 
 present a similar external appearance to epulis. According to Mr. Paget, 
 " they grow slowly and without pain ; generally commence without any 
 known cause, such as injury or hereditary predisposition ; bear consider- 
 able injury without becoming exuberant; they are not apt to recur after 
 complete removal, nor have they, in general, any features of malignant 
 disease." 
 
 Dr. Gross differs somewhat in his opinion regarding these growths, and 
 his words are so expressive that I shall quote them. He states " that the 
 myeloid tumor is rather rapid in its growth, occurs in both sexes at different 
 periods of life, but more commonly in the young and middle-aged than in 
 the old, and is capable of attaining considerable bulk. From its tendency 
 to destroy the structure in which it is developed, and from the fact that it 
 occasionally displays a malignant tendency, recurring after extirpation, and 
 ultimately causing death, there is a strong reason to conclude that it is 
 merely a modified form of encephaloid or fibro-plastic growth. Neverthe- 
 less, in the existing state of science, we are not warranted in expressing a 
 very positive opinion regarding the true nature of the disease." These 
 remarks are very applicable to the case in question, and the appearance of 
 several fibrous polypi attached to the nasal bones would appear to demon- 
 strate the fibro-plastic nature of the disease, with a tendency to degeneration. 
 After a careful consideration of the facts, and some consultation as to the 
 advisability of the operation, I felt myself justified in removing the bone. 
 
170 A SYSTEM OF SURGERY. 
 
 On the 13th of March, the patient was laid upon a bed, with his shoulders 
 and head elevated, with the affected side towards a good light. This is the 
 position advised by Dr. Gross, and one which I always prefer, the upright 
 position formerly employed being unfavorable for prolonged anaesthesia. 
 After this the patient was thoroughly brought under anaesthetic influence, 
 and an incision was commenced at the angle of the mouth, and carried 
 around the cheek to the zygomatic arch ; a second cut was then made 
 parallel to the border of the lower lid, to the lateral margin of the nasal 
 bone on the right side, and the flap dissected up. The zygomatic arch 
 was then divided, partly with the saw, and partly with the bone pliers. 
 The mass was then separated from the orbit, and the division effected 
 through the palate with the pliers. By seizing the tumor with Fergus- 
 son's forceps, and depressing it, the growth was taken away. Parts of 
 it, however, were found adhering to the under surface of the nasal bones, 
 and indeed had invaded the left alveolar processes. These were cut away 
 with the pliers, and several polypi, one of them quite large, were removed 
 from the upper part of the fauces. The appearance presented by the wound 
 was rather revolting, and a considerable quantity of blood was lost during 
 the operation, though there were but three vessels (the largest being a 
 branch of the internal maxillary) which required ligature. I was in con- 
 siderable doubt whether the patient would survive the operation. The 
 wound was brought together by several points of suture and the patient 
 put to bed. 
 
 The patient succumbed to the disease about six months after the opera- 
 tion was performed. The growth reappeared and grew with frightful 
 rapidity. The sufferings of the man were terrible, and he died in great 
 agony. 
 
 When a section of a myeloid tumor is placed under the microscope, the 
 characteristic poly-nucleated cells are plainly visible ; they are large and 
 
 Fig. 87. 
 
 " Giant-celled Sarcoma," or Myeloid Tumor.— After Billroth, a, points to a part where cysts were being 
 formed by the softening of the tissue of the tumor ; o, to a focus of ossification. 
 
 contain often very many nuclei floating in a clear and granular fluid (Fig. 
 87). Sometimes the spindle-shaped cells, so well known as belonging to 
 Paget's " recurrent fibroids," are seen. 
 
 It is quite probable from the embryonic and heterologous nature of the 
 cellular elements in glioma, cylindroma, and myxoma, that these tumors 
 
ROUND-CELLED SARCOMATA — CARCINOMA. 171 
 
 would recur after removal, and, therefore, might well be placed among the 
 semi-malignant growths. 
 
 (c.) Round-celled Sarcomata are softer to the touch than the spindle- 
 celled, and it is sometimes difficult to diagnose them from encephaloid 
 cancer. My experience shows me two great differences which are always 
 well marked in cases of true sarcomatous tumors, and these are the absence 
 of haemorrhage and the non-infiltration of the parts. 
 
 Glioma. — This is a peculiar form of round-celled sarcoma, but differs 
 materially from the myeloid formation in the character of its cells, and the 
 localities it occupies. The cells of glioma are round and small, and the 
 cell-elements resemble those found in the brain ; some of the cells show 
 prolongations, which tend to the formation of a reticulated substance. The 
 seat of the tumor is generally in the retina, and in the gray, sometimes in 
 the white substance of the brain. 
 
 (d.) The Lympho-sarcomata have been mentioned in the section on 
 lymphadenoma. 
 
 (g.) Alveolar Sarcoma is but another form of the round-celled variety, 
 and was first described by Billroth ; it adds another to the innumerable list. 
 These sarcomata appear in the muscles and bone, but frequently in the 
 skin, where they may become very numerous, and proceed to ulceration, 
 giving rise to considerable deformity. Like all other sarcomata, they recur 
 frequently, and the treatment is complete removal by the knife or cautery. 
 
 The author has purposely excluded from this chapter, of a work designed 
 especially for students, the many varieties of sarcoma which are constantly 
 being described. The more he has studied the subject, and the more ex- 
 tended his experience, the more he arrives at the fact, that as all these 
 tumors overlap, or rather intermingle their anatomical and histological 
 elements, there may occur to every surgeon, and to the same surgeon 
 many times, cases of sarcomata, with more or less development of other 
 tissues, and it has been the endeavor to name each of these classes, that 
 has given and will give forever, an unlimited field for the cultivation and 
 production of every variety of sarcoma under heaven. 
 
 C. Carcinomatous Tumors. 
 
 (a.) Scirrhus. 
 
 (b.) Encephaloid. 
 
 (c.) Epithelioma. 
 
 (d.) Melanosis. 
 
 (e.) Colloid. 
 
 (/.) Osteoid. 
 
 (g.) Villous. 
 
 Carcinoma. — Under this head, will be classed those tumors which are 
 essentially malignant in their nature, and possess those characteristics 
 which have been already mentioned, the chief peculiarity of the disease 
 being unusual, nay, often tremendous cell production. These cells are 
 often found crammed into the tissues without order or regularity ; they 
 float in a liquid known as the " cancer juice," and not only have the ten- 
 dency, but the power under certain circumstances, being heterologous and 
 ungovernable, to rush upon any tissue, infect, and destroy it. 
 
 The great distinction between true cancer and the innocent tumor with 
 reference to auto-infection is this : in the latter the parts are pushed asunder, 
 a separation of tissue taking place ; in the former the surrounding tissues 
 are infiltrated with the cancerous material. 
 
 Again, another of the peculiar marks of cancer consists in the glandular 
 enlargements which follow its growth. If we find a tumor which is appa- 
 
 Epithelial embryonic tissue. 
 
172 A SYSTEM OF SURGERY. 
 
 rently innocent in its characteristics, accompanied during its life with lym- 
 phatic or neighboring adenoid swelling, it must at least be regarded as 
 suspicious in its character. 
 
 With reference to the actual pathology of this affection, the following 
 most appropriate language is used by Mr. Bryant* 
 
 " Pathologically, a cancerous tumor is not composed of any definite or 
 characteristic elements, such as at once stamp it as being a cancer ; it does 
 not contain any distinct cancer-cells which mark its nature, for the cells, 
 nuclei, and fibres, which enter into the formation of a cancer, may all be 
 traced in other and in innocent morbid growths. ' But neither in tumors 
 of innocent character, nor in natural tissue, do these elements combine in 
 such variety as is common in a single cancer' (Moore). It does not appear, 
 however, to be incorrect to assert that the more the cell elements predomi- 
 nate in a growth, and the more they approach an epithelial type, the greater 
 is the probability of its being malignant, and therefore cancerous ; for the 
 soft cancers, which are undoubtedly the most virulent, are made up almost 
 entirely of cells and nuclei, only enough fibre tissue existing to bind and 
 hold these cells together." 
 
 It has been supposed by some, that the primary origin of cancer is to be 
 looked for in a deviation from the healthy standard of nutrition, and that 
 there exists in some an hereditary predisposition to this abnormal action ; 
 that though this tendency may exist for years latent in the system, yet it 
 ultimately develops itself either from known or unknown causes in the form 
 of one or other of those tumors known as cancerous. Certain I am that in 
 the majority of cases of cancer that have come under my own personal 
 supervision during the last fifteen or twenty years, I have been able to 
 trace a cancerous disease somewhere in the family. At first this predispo- 
 sition may be denied on the part of the patient, from ignorance of the 
 actual facts ; but upon carefully inquiring it has been found that " cancer " 
 somewhere existed more or less remotely. I think I may say that this 
 heredity may sometimes skip a generation, and appear again with redoubled 
 violence in the same family. 
 
 With the peculiarity just noticed there is another which should be ob- 
 served, which consists in the fact that those causes which produce ordinary 
 diseases do not appear to have much influence in the production of cancer; 
 and that all classes are more or less liable to its invasion ; nor, indeed, does 
 impaired health appear to be a factor in its production. I have known in 
 several instances, a true scirrhous tumor to exist for years, in the person 
 of a wretchedly poor, ill-fed, dyspeptic, and hysterical woman, and, with the 
 exception of occasional pain, be of no inconvenience. 
 
 Cancer is a disease of adult life and old age. It occurs generally between 
 the ages of thirty-eight and sixty, and is more frequent in women than in 
 men. I have only seen one case of cancerous disease in the male breast, 
 and that was of a most aggravated character. The patient was a clergyman, 
 the founder of the Good Samaritan Hospital in St. Louis, and was attended 
 by Dr. Comstock and myself. 
 
 As I have already mentioned on two occasions, there is believed at 
 present to be no typical cancer-cell; it is the whole history of the case, the 
 multiplicity, the proliferation, the heterology of the cells, which have to be 
 considered in making the diagnosis. On general principles it may be 
 said that the cancer-cell is oval, with a large, double, or concentric nucleus. 
 Water clouds the cell ; acetic acid acts in a somewhat similar manner as is 
 noticed when applied to the pus-corpuscle — it clears it up. Another 
 form of cell discovered in cancerous formations is the " mother " or the 
 
 * The Practice of Surgery (Am. ed.), p. 666. 
 
CARCINOMA. 173 
 
 " brood " cell, which receives its name from the fact that it contains in its 
 interior several apparently perfectly formed cells. 
 
 The " cancer juice " is a milky-white, sometimes glairy fluid, which lies 
 between the stroma ; it is often quite limpid, though from being loaded 
 with disorganized products it may sometimes be more or less dark or bloody. 
 This cancer juice must not be mistaken for the oil-globules which run away 
 frequently during an operation for cancer (a fact that should warn the 
 operator that he is cutting into and not around the growth). Cancer-cells 
 are exceedingly liable to undergo fatty degeneration, and, indeed, what is 
 called the " saponification " of cancer is the fatty degeneration of the stroma 
 and cells. Sometimes the fat deposition stretches along the connective 
 tissue, giving rise to a peculiar appearance known as " reticular cancer." 
 
 I give here the different types of cancer, with the microscopic structure 
 of different varieties, which I have taken from Dr. Moxon's celebrated 
 chapter on the microscopic anatomy of tumors in Bryant's Surgery. His 
 classification is as follows : 
 
 " Five leading types of carcinoma may at present be conveniently distin- 
 guished. 
 
 " 1st. Those in which the fibrous meshwork is in preponderance, and the 
 epithelioid contents of the alveola are scanty, and perhaps, also prone to 
 perish early, so that they are found more or less degenerate within the 
 fibrous meshes — hard carcinoma, or scirrhus. 
 
 " 2d. Those in which the fibrous meshwork is in smaller proportion, and 
 the epithelioid contents are plentiful, making large collections of cells, but 
 with no evident approach in the form of these collections to the shapes of 
 gland acini, and no evident resemblance of the component cells, either to 
 the columnar epithelium of mucous glands or the squamous epithelium of 
 cuticle — soft carcinoma. This kind occurs especially in glands, and the 
 transformation of the glandular tubes or follicles to cancer alveoli can be 
 seen in all its stages in the growing margin of the tumor. 
 
 " 3d. A structure essentially such as that last described, but with this 
 difference, that the epithelioid cells have a quantity of mucus between them, 
 which is regarded as arising from a transformation of them. This change 
 to mucus may be carried to such an extreme that scarcely any cellular 
 elements are left, while the alveolar meshes in which the mucus is contained 
 becomes very strikingly visible from its nakedness and the pellucidity of 
 the mucus — colloid, or alveolar cancer. A common seat of this is the wall 
 of the alimentary canal, where it may be traced arising from Lieberkiihn's 
 follicles. 
 
 "4th. A structure in which the epithelial cells resemble squamous epithe- 
 lium, and form masses which are very like the follicles of cutaneous glands, 
 or occasionally like rudimentary hairs ; the tubular and bulbous forms may, 
 however, be seen ramifying like the lymphatic vessels of the skin, as if their 
 form were moulded to the lymphatic plexus. In these cancers peculiar 
 bodies are found, composed of flattened cells disposed concentrically so as to 
 form a scaly-walled globe, whose appearance is like the section of an onion, 
 or like a bird's nest ; these are so large as often to be visible to the naked eye ; 
 when they are numerous and well characterized, they are diagnostic; some 
 authors (Billroth) distinguish a variet}^ of this cancer in which the stroma 
 preponderates over the epithelial part, calling it scirrhus of the skin — 
 squamous epithelial carcinoma. 
 
 " 5th. A structure in which the epithelial cells resemble ordinary columnar 
 epithelium, and the structure itself is quite like normal mucous membrane, 
 in which it always' primarily arises (alimentary canal, especially colon, 
 uterus) ; the secondary formations which occasionally occur in these cases, 
 in the liver especially, have the same structure, and thus a tissue like the 
 
174 A SYSTEM OF SURGERY. 
 
 glandular mucous membrane of the colon may be found in the liver — 
 cylindrical epithelial carcinoma. 
 
 " The fourth and fifth varieties are distinguished from the first three as 
 epithelial cancer or epitheliomata. Some authors have used the term can- 
 croid for the fourth variety, as though it were not completely cancerous. 
 These are less likely to infect the viscera than the first two varieties, which 
 are the most infectious of all tumors, though they are very far from being 
 the only kinds of infectious tumors." 
 
 Mode of Death. — Cancer patients die in many cases because their systems 
 are actually poisoned, the blood becomes scanty, the organs break down, 
 the secretions alter. The entire lymphatic system appears to be filled with 
 the poison, which often manifests itself in many parts of the body at the 
 same time. Those individuals who possess a strong constitution of course 
 give greatest resistance, although this may not always be the case, for I have 
 known patients who have been suffering from other diseases offer more re- 
 sistance to the inroads of cancer than those who to all appearances were 
 much more robust. 
 
 Cancer patients also die indirectly from the poison ; some are carried off 
 by effusions, and some with pyaemia. Again, cancers entirely obstruct the 
 bowels, cancers eat out the oesophagus, cancers destroy the air-passages, 
 cancers tear open arteries, cancers perforate the organs, in fact deaths from 
 cancers are effected in all parts of the body and in many ways, and, sad to 
 say, medicines are not of much avail against their inroads. 
 
 The different varieties of cancer are as follows : (a.) Scirrhus, (b.) Enceph- 
 aloid,(c.) Epithelioma, (d.) Melanosis, (e,) Colloid, (/.) Osteoid, (g.) Villous. 
 
 (a.) Scirrhus — Hard Cancer.— It is said that scirrhus is the most frequent 
 form of cancer ; in my own experience I have not found it so. I think that in 
 America, at least in those sections in which I have had an opportunity of ob- 
 serving the disease, epithelioma is the more frequent. The occurrence of 
 fibroma and adenomain the female breast may have given rise, in part, to the 
 statement regarding the frequency of scirrhus, the one being mistaken for 
 the other. A scirrhus tumor is hard, nodulated, and circumscribed ; its 
 chief peculiarity and its diagnostic mark, is its tendency to contraction, or 
 the drawing around it of all the tissues. (,Fig. 88.) Who has not seen in a 
 female affected with this disease, a healthy, well-developed breast on the one 
 side, and a shrivelled, drawn, potato-like excrescence on the other? This 
 mark, its contraction, together with its tendency to adhesions to the under- 
 lying and superincumbent structures, may be said to be pathognomonic of 
 the disease. No other tumor posseses these peculiarities to such a degree. 
 
 There is often noticed in the growth of a scirrhus tumor a peculiar in- 
 crease, either in the middle, the one side or the other ; by careful observa- 
 tion it will generally be seen that the most marked increase in structure 
 is found at that point where there is most nutrition ; in other words, near 
 the nutrient artery. There is another point to which attention should be 
 directed, and that is, the undoubted fact that scirrhus withers of itself; espe- 
 cially is this true of breast cancers. This withering of scirrhus has been 
 found by most careful observers not to consist in its transformation into 
 other tissues, nor in its conversion into healthy structure. It is merely a 
 breaking up of the cells and nuclei, and the escape of oil-globules and debris. 
 
 A somewhat peculiar feature of scirrhus is the " cupping " of its surfaces. 
 When cut into, after its removal from the body, the sections become concave, 
 the surface shining, the substance elastic and glistening. This pitting is 
 explained by the tendency, which has been before noticed, to contraction 
 inherent to the growth. 
 
 The pain of scirrhus is not severe in the early stages, indeed, a tumor 
 may exist for a time, and be by accident discovered. There is, however, 
 
ENCEPHALOID CANCER. 
 
 175 
 
 always soreness of the lump when handled, and sharp, lancinating pains, 
 which are peculiar. As the disease advances, these darting paftis become 
 more frequent and severe ; these, though peculiar to most forms of carci- 
 noma, are much more severe in scirrhus, being probably due to the pressure 
 exerted by so firm a growth on the nerve-fibres. Glandular enlargement 
 also is another most prominent symptom, which is more peculiar to scirrhus 
 than perhaps the other forms of cancer. 
 
 After a time ulceration sets in, as has been noticed, and the action is then 
 rapid, the discharges are thin and offensive, the ulcer is jagged and ill-de- 
 
 Fig. 88. 
 
 Fig. 89. 
 
 Hard cancer, extending from a border lobe 
 of mammary gland to the skin, affecting in- 
 tervening tissues.— Paget. 
 
 Ulcerating Scirrhus of the Breast. 
 
 fined. (Fig. 89.) With these symptoms the cachexia is well marked, and 
 the usual manifestations of decline are present. 
 
 The yellow lines through scirrhus have already been noted ; besides these, 
 there are often whitish bands which extend into the substance of the growth, 
 which resemble the tissue of lacteal ducts. The cells are round and oval, 
 and are about T oVoth of an inch in diameter. There are often two nuclei 
 in each cell, and each has one or more large nucleolus. There are also 
 often present withered cells, undergoing either fatty or calcareous degen- 
 eration. 
 
 (6.) Encephaloid Cancer. — This form of carcinoma has received several ap- 
 pellations, chiefly from the appearances it presents. The fungus nematodes 
 and fungus melanodes of the old writers and the soft or medullary cancer 
 of the more recent authors are synonymous. There are two distinct forms of 
 encephaloid disease ; the one appearing as a round and defined growth, the 
 other being nothing more than intense and perfect infiltration ; the latter is 
 often found in serous membranes, and also in the bones. The former are 
 " boggy " in their feel, and generally inclosed within a delicate capsule, 
 which sends trabecular into the substance of the tissue, dividing it into com- 
 partments, each of which may also have a covering of connective tissue. 
 In the other variety the tumor is not so distinctly marked, though the eleva- 
 tion rises above the surrounding structure, and presents such elasticity that 
 fluctuation is apparently present. On more than one occasion these fluctu- 
 
176 
 
 A SYSTEM OF SURGERY. 
 
 ating tumors have been punctured with the expectation of finding either 
 serum or ptis. 
 
 Encephaloid cancers are always profusely supplied with bloodvessels, 
 which have exceedingly delicate walls, and which are in size much out of 
 proportion to the structure through which they ramify. Besides this inter- 
 nal vascularity, the veins on the surface of the tumor are enlarged and tor- 
 tuous. It is from this profuse supply of vessels, especially if the cancerous 
 growth is bound down by dense tissue, that there may be distinct pulsation 
 in the tumor. 
 
 A peculiarity of this variety of cancer is found in the fact that it may 
 exist with scirrhus in the same patient, and that all ages are liable to its 
 invasion. It has been found in the foetus at birth. The sufferings of those 
 affected with encephaloid are, as a rule, not so great as is found in scirrhus, 
 particularly if the disease appears in soft and yielding structures ; there is 
 often extreme suffering, however, when bone or periosteum is affected. 
 
 The most frequent seats of the disease are bone, testicle, uterus, eye, and 
 female breast ; the bladder and the face are also often affected. 
 
 As the disease progresses, a bluish spot near the surface becomes visible. 
 The integument becomes thinner and thinner, until it ulcerates, generally 
 with profuse hsemorrhage. Almost immediately 
 from this opening there sprouts a red, soft, fungoid, 
 readily-bleeding mass, which grows with great 
 rapidity and undermines the health of the patient 
 with marvellous speed. The cancerous cachexia is 
 more marked in this variety of cancer than in 
 almost any other, and is noticeable even in the 
 earlier stages. 
 
 The " cancer juice " pressed from an encephaloid 
 is of yellowish or milky hue ; the stroma is reticu- 
 lated and spread out like a net, within the meshes of 
 which are found the cancer-cells already mentioned 
 floating in a liquid intercellular substance. The 
 cells vary in form, being caudate or pyriform, and 
 have many nuclei. (Fig. 90.) The progress of soft cancer is rapid, the du- 
 ration of life under its ravages not often exceeding two years. Death often 
 occurs from actual exhaustion. The following, from Gross, is the differen- 
 tial diagnosis : 
 
 Fig. 90. 
 
 Nuclei of Medullary Cancer 
 magnified 500 times. 
 
 ENCEPHALOID. 
 
 1. The tumor is soft and elastic, not uni- 
 
 formly, but more at some points than 
 others. 
 
 2. It grows rapidly, and soon acquires a 
 
 large size — perhaps ultimately attain- 
 ing the bulk of an adult head. 
 
 3. The pain is slight and erratic, until 
 
 ulceration sets in, when it becomes 
 more severe and fixed. 
 
 4. There is always marked enlargement of 
 
 the subcutaneous veins. 
 
 5. The ulcer is foul and fungous, with 
 
 thin undermined and livid edges, and 
 is subject to frequent and copious 
 haemorrhages. 
 
 6. There is generally early lymphatic in- 
 
 volvement. 
 
 7. Occurs at all periods of life. 
 
 SCIRRHUS. 
 
 1. Uniformly hard and inelastic, feeling 
 
 like a marble beneath the skin. 
 
 2. Growth is slow, and bulk comparatively 
 
 small ; the tumor rarely, even in the 
 worst cases, exceeding the volume of a 
 double fist. 
 
 3. The pain begins early ; is distinctly 
 
 localized, and is of a sharp, darting, 
 burning or lancinating character. 
 
 4. In scirrhus these vessels retain their 
 
 natural size, or are only slightly en- 
 larged. 
 
 5. The ulcer is incrusted with spoiled 
 
 lymph, and has steep, abrupt edges, 
 looking as if it had been scooped out 
 of the part; bleeding little and sel- 
 dom. 
 
 6. Usually not until late, or just before 
 
 ulceration is about to occur. 
 
 7. Seldom before the age of forty-five. 
 
EPITHELIOMA. 
 
 177 
 
 ENCEPHALOID. 
 
 8. Is most frequent in the eye, testicle, 
 
 mamma, lymphatic ganglions, bones, 
 skin, and cellular tissue. 
 
 9. The disease usually terminates fatally in 
 
 from nine to twelve months. 
 
 SCIRRHUS. 
 
 8. Never occurs in the eye and testicle, and 
 
 rarely in the bones, skin, and lym- 
 phatic ganglions. 
 
 9. Seldom sooner than eighteen months or 
 
 two years. 
 
 Fig. 91. 
 
 (c.) Epithelioma. — Epithelioma, as its name implies, is that form of cancer 
 which bears some resemblance to the epithelial structure of the human 
 body. It%>ossesses all the characteristics of the ordinary malignant forma- 
 tions, and is found especially in the lip, the tongue, the penis, the os uteri, 
 and rectum. 
 
 It generally begins as a wart, or a fissure, or a tubercle, and spreads by 
 infiltration. It in many cases becomes fungoid, and then the peculiar 
 papillary structure can be discerned by the naked eye. There are two 
 peculiarities which I have carefully noted in this disease, and those are : 
 1st. The length of time that the disease may rest locally in the system with- 
 out harm being done ; and 2d. Speaking 
 purely from my own experience, it is less 
 likely to return than any other form of 
 carcinomatous disease; at all events the 
 patients have a longer immunity from it 
 when the growth is early and thoroughly 
 removed. 
 
 There is one peculiar method in which 
 it may make its appearance which de- 
 serves attention. It is when there appears 
 to be formed over an abrasion of the skin, 
 or a round red spot, a hypertrophied epi- 
 thelial structure (Fig. 91), a dry scale, 
 which, upon being removed, again de- 
 velops ; when this scurf is removed a 
 small quantity of moisture shows beneath, 
 but nothing more. Gradually, however, the papillae are enlarged, and, in- 
 deed, often become enormous ; then there appears to be considerable ichor 
 exuded, and the structures show symptoms of infiltration, which soon 
 ravage the parts around. This may be called the second stage of epithe- 
 lioma. In some cases it has been noticed that as the ulcerative process 
 goes on, there is a deposition of new growth at the sides and borders of 
 the chasms. Men are said to be more liable to epithelioma than women, 
 though I have seen many cases in the female, especially in the uterus and 
 vulva. 
 
 In this variety of cancer there seems to be also a local irritation existing 
 in most cases. Thus, the heat of the clay pipe on the lip of smokers, the 
 
 Microscopic appearance of three papillae of 
 Epithelial Cancer. 
 
 Fig. 92. 
 
 Epithelial Cancer cells magnified 350 times. 
 
 soot in the scrotum of the chimney-sweep, or the irritation of old warts or 
 moles, often, indeed in the majority of instances, lead to the development 
 of epithelioma. 
 
 The cells which have already been described, are irregular in shape, and 
 
 12 
 
178 A SYSTEM OF SURGERY. 
 
 vary from ^th to ^th of an inch in diameter (Fig. 92). The nucleus 
 contained is small and round. There are also " brood-cells," and laminated 
 corpuscles. 
 
 A peculiar fact is also noted by microscopists, that the nuclei of these 
 cells become excessively enlarged, and appear as clear spaces. 
 
 (d) Melanosis— Melanotic Cancer.— The synonyms of this variety of cancer 
 are " black cancer " and " carcinoma melanodes." 
 
 Melanosis is undoubtedly encephaloid or medullary cancer, with a de- 
 posit of pigment throughout its substance. The history and symptoms 
 are therefore very similar to those already noticed as belongmg to that 
 disease. The colors of this kind of cancer constitute its peculiarities ; they 
 are brown, bronze, and even black. In those cases of melanosis which have 
 come under my observation the color was rather a dark plum color, and 
 was interspersed throughout the growth without regularity, and in masses 
 varying in size from a pea to that of a kidney-bean. It is understood that 
 the pigment bears no especial relation to the malignancy of the disease, and 
 that parts of an encephaloid may be entirely free from coloring-matter, 
 while others may be very melanotic. 
 
 In primary melanotic cancers the structure is softer than other malig- 
 nant growths of the same age. They make their appearance as infiltrations, 
 but also may be circumscribed. The peculiarities of melanosis are, besides 
 that of color, just noted, according to Sir James Paget, their proneness to 
 appear near cutaneous moles, and their profuse multiplication. The color 
 is due to the pigment cells, which are similar to those of the choroid coat, 
 or to those found above the basement membrane of the skin in the colored 
 races. From the similarity which exists between the coloring matter of this 
 form of cancer and that found in the lungs of aged people, some have sup- 
 posed that melanosis is "a pigmental degeneration of cancer." The second 
 and third peculiarities are not well understood, although the last may be 
 more apparent than real, the pigmentary deposit having a tendency to draw 
 out and color many cells which otherwise would be unobservable. 
 
 Ganghofner and Pribram* have given especial attention to the character 
 of the urine in patients suffering from melanotic cancer, and find it contains 
 a peculiar substance, chromogen, which varies with the specific gravity, viz., 
 the solid constituents of the urine. 
 
 (e.) Colloid or Gelatiniform Cancer — Alveolar Cancer — Gum Cancer. — Ac- 
 cording to Lebert this form of cancer is found oftener in men than in women, 
 and appears most frequently in middle life ; it is, however, rarer than either 
 scirrhus, encephaloid, or epithelioma. It attacks chiefly the mamma, 
 stomach, and intestines, and may be present in the system with other forms 
 of the disease. 
 
 This form of cancer is essentially infiltrating, and sometimes attains con- 
 siderable size, and from being in dense structure presents the sensation of 
 fluctuation. Its name " alveolar cancer " is derived from the arrangement 
 of the fibres of its stroma in large open meshes of transparent fibres, in 
 which are seen rounded or oval nuclei. Lying in the interstices of these 
 fibres is a transparent jelly-like substance, in which will be seen, under the 
 microscope, cells of various sizes and shapes, the most characteristic being 
 large, round, and flat, formed of a nucleus, around which are numerous 
 concentric laminae, very much like an oyster-shell, besides which there are 
 others which approach more or less closely to the forms usually seen in 
 epithelioma (Fig. 93). — Holmes. 
 
 The colloid matter itself varies greatly in different parts of the body. 
 It generally resembles boiled starch, which has been strained, but not 
 
 * London Medical Eecord, January 15th, 1877. 
 
OSTEOID CANCER. 
 
 179 
 
 allowed to become cool. It is slightly bluish in color, although its variations 
 are very great. Sometimes it is greenish, sometimes pink; at others it may 
 be opaque and brown, and resembles decomposing tuberculous matter. 
 
 The growth and multiplication of colloid is most remarkable. I have 
 removed two pailfuls of the substance from one patient, and in a second 
 case, in which there were also many tuberculous deposits, about sixteen 
 quarts. In several other cysts of the ovary, I have taken away quite 
 enormous quantities of this material. 
 
 The main points of this peculiar formation are, that it presents structure 
 which is most unlike the usual protein compounds, and is so dissimilar in 
 structure from ordinary cancerous growths that some have denied it a place 
 in the classification of that disease. Of this latter point Mr. Paget says 
 
 Fig. 93. 
 
 Colloid Cancer : a, epithelioid type ; 6, " round or oval" oyster-shell cells. Very characteristic— Holmes. 
 
 that its locations are the same as medullary cancer ; that it infiltrates, it 
 supersedes, and replaces the natural textures ; it repeats itself in the lym- 
 phatic glands and lungs ; it is often associated with other forms of cancer ; 
 it recurs after removal, and is often hereditary. 
 
 (/.) Osteoid Cancer. — The appearance of true cancer, and in different varie- 
 ties, in the osseous system, appears to contradict the opinion advanced by 
 some pathologists that true cancerous growths are produced from external 
 or glandular epithelia. There can be no doubt of the fact that cancer does 
 attack the osseous system, and often develops first within the bones. It 
 appears also that certain bone cancers are liable to occur in the same locali- 
 ties, and to present the same histological species. The extremities of the 
 
180 A SYSTEM OF SURGERY. 
 
 humerus and femur are often affected with cancer ; sometimes the cancel- 
 lated structure appears to be the seat of the disease, while at others the 
 periosteum is first involved. As soon as these parts are thoroughly infil- 
 trated the cancer grows with great rapidity, and a delicate framework of 
 ossific matter is formed, which is filled with soft rapidly-growing cancer- 
 nodules. Sometimes the tumor begins in the diploic structure, and may 
 extend both within and without, perforating the bone both ways. 
 
 The form of these tumors is generally oval, and can be traced with the 
 finger down to the bone from which they grow. The tissues around are in 
 most instances in a healthy condition, although scattered throughout them 
 small masses of well-developed cancerous formation may be found. 
 
 According to Sir James Paget " the unossified part of an osteoid cancer 
 appears fasciculated or banded, and it is always very difficult to dissect. 
 In some specimens, and in some parts, it has only a fibrous appearance, due 
 to marking and wrinkling of a nearly homogeneous substance, in which 
 abundant nuclei appear when acetic acid is added." After an osteoid 
 cancer has been macerated for a time, its central portion is found to be 
 very dense and hard, difficult to cut, and incapable of being triturated. 
 Around this the substance is more succulent. The duration of bony cancers 
 is shorter than any other, and males are said to be more subject to the 
 disorder than females. Amputation is generally all that can be done. 
 
 (g.) Villous Cancer — Dendritic Vegetation.— In some cases there are found 
 projecting from a fibrous or a mucous surface, sprouts of tissue in clusters 
 and rows, or the stem may send out branches containing round protuber- 
 ances, which are filled with cancer-cells. These are called by Eokitansky 
 " dendritic vegetations." 
 
 This vegetation, according to Rokitansky, is composed of a structureless 
 membrane, which is hollow and often attached to a fibrous stem. This may 
 gradually enlarge until it becomes a sac ; this sac contains a serous fluid, 
 from which new vegetations are likely to spring. 
 
 Bloodvessels run in loops around the stems of these vegetations, and also 
 in some instances loop themselves around the protuberances and branches 
 in an arborescent form. The villi themselves contain, besides the ordinary 
 cancer-cell and nuclei of medullary and melanotic cancer, true epithelial 
 cells. The gums and the bladder are the sites at which it is most frequently 
 met. 
 
 Treatment of Cancer. — Gross, speaking of the curability of this disease, 
 says : " All internal remedies of whatever kind and character have proved 
 unavailing. The vaunted specific of the empiric, and the enchanted draught 
 of the honest but misguided enthusiast, have alike failed in performing a 
 solitary cure ; and the science of the nineteenth century must confess, with 
 shame and confusion, its utter inability to offer even any rational suggestion 
 for the relief of this class of affections."* Scarcely less strong are the 
 words of Mr. Moore, f who writes : " No remedy is at present known to have 
 a specific power of eradicating cancer, of neutralizing its taint, or alter- 
 ing the nature of its growth. Scarcely less, in our present ignorance of the 
 causes from which it springs, are we in a position to rely with confidence 
 on any means for obviating its outbreak." 
 
 Mr. Thomas Bryant says, in his work:! "The general treatment of 
 cancer resolves itself into the improvement of the general health, and the 
 nutrition of the body by hygienic means, good nutritious diet, and tonic 
 medicines. No medicine has any special influence on the disease." 
 
 * System of Surgery, vol. i., p. 257. 
 
 f Holmes's System of Surgery, vol. i., p. 593. 
 
 j Practice of Surgery, p. 738. 
 
TREATMENT OF CANCER. 181 
 
 It is not necessary to multiply quotations on this subject from the allo- 
 pathic authorities of to-day ; and I may remark, that the three that have 
 been given were not selected on account of any peculiar force of expression, 
 but were those that first came to hand in consulting works for the facts in 
 the case. 
 
 We may turn then with some feeling of satisfaction to our own literature, 
 although at the outset we must regret that while throughout our periodicals 
 there are many cases of " cancer " reported cured, in very many of these 
 the specific variety of the disease is not diagnosed. Cancer is, by the 
 majority of surgeons, considered as a generic term, and has several important 
 species. To group the scirrhus, medullary or encephaloid, melanotic, epi- 
 thelial, and osteoid, as " cancer," and in the report of a case to omit to 
 diagnose the variety, is not sufficiently precise, leads us astray in our ideas, 
 has a tendency to throw distrust upon our records, and gives us but little 
 information for the treatment of subsequent cases. For instance, in a 
 " Report of the Homoeopathic Institute of Leopoldstadt,"* there is a case 
 of " cancer of the womb." The variety of the disease is not mentioned, 
 whether epithelial, scirrhous, vegetating epithelioma, or other. Bryonia 
 removed the severe pains, and belladonna was given for the uterine tenes- 
 mus ; " the discharge diminished, and became less fetid, sleep and moderate 
 appetite were established, and the patient felt so much stronger that she 
 was enabled to undertake a journey." Such a record really counts for 
 nothing in the establishment of the superiority of homoeopathic treatment. 
 Many such ulcerations are temporarily arrested by hygienic influences and 
 the tonic system of treatment, as it is called, of the old school. This case 
 is merely selected as one from many that are found in our literature, and 
 can only be accepted as indicating that relief for a cancerous ulcer was 
 obtained. So again, Dr. Bayesf speaks of a case of " cancer of the lip " 
 (probably ulcerating epithelioma), which was arrested ; cancer of the left 
 breast, in which the tumor had almost entirely disappeared ; and an " open 
 cancer of the left breast," which from the size of a half crown diminished 
 to that of a pea. 
 
 These and many cases that might be cited prove conclusively that there 
 are certain medicines employed homoeopathically that can arrest "can- 
 cerous " formations, but it is, as before stated, much to be lamented that 
 more precise diagnoses have not been given in the cases. Chief among 
 the medicines referred to in Dr. Bayes's paper is hydrastis can. I have used 
 it frequently with excellent success, and from cases of my own, may affirm 
 that its efficacy in cancer is chiefly in the epithelial variety ; also that its 
 action in other forms of the disease is correctly indicated by Dr. Bayes, 
 who says : " My experience has thus led me to infer, that the remedial 
 sphere of hydrastis is confined to the arrest and removal of scirrhus in its 
 early stage, and chiefly when its situation is in a gland or in the immediate 
 vicinity of a gland." 
 
 We have other reports, however, which are more conclusive. The 
 remarkable case of Field Marshal RadetskyJ is one that it is fair to set down 
 as a cure of encephaloid of the eye. So also we find that Dr. Hughes § has 
 a most excellent case, quoted from Petroz, in which a woman under the care 
 of Dr. L. Herminier had a suspicious ulcer of the tongue, involving the 
 parts deeply. The doctor, distrusting his own diagnosis, sent her to Pro- 
 fessor Mardolin, who returned the following : " Cancerous ulcer ; no chance 
 
 * British Journal of Homoeopathy, vol. xix., p. 144. 
 f lb., vol. xix., p. 150. 
 
 t lb., vol. i., p. 147. Being a series of letters which appeared in the Horn. Zeitung, July, 
 1841, by Dr. Hartung. 
 I Therapeutics, p. 219. 
 
182 A SYSTEM OF SURGERY. 
 
 of cure but from operation, and this is impossible, for the base of the 
 tongue is involved." This case, which was probably one of epithelioma, 
 was cured by the hydrocyanate of potassa, T ^th of a grain at a dose, 
 repeated every fourth day. Eighteen years afterward there had been no 
 relapse. 
 
 Stapf * reports a most interesting case of fungus hsematodes oculi, which 
 was completely cured. Belladonna, removed the excessive photophobia 
 and inflammation in six days ; calcarea carb, cleared the cloudiness of the 
 cornea ; lycopodium, sepia, and silicea removed the fungous growth. The 
 cure was complete. 
 
 Muhlenbeinf gives also a case of the same disease so diagnosed by several 
 allopathic physicians and an experienced surgeon, in which belladonna, 
 one drop at intervals of a week for four weeks, together with nux vomica, 
 euphrasia, and aconite, completed the cure. 
 
 Dr. von Vietiunghoff, { among his cases, has recorded one of encephaloid 
 of the breast which is interesting. The pain was relieved by belladonna 
 and bryonia in alternation. Phosphorus and hepar, also in alternation, 
 materially improved the character of the discharge ; arsenic caused sepa- 
 ration and discharge of the tumor. After persevering with the latter for 
 several months the cure was perfected. 
 
 Other cases of this variety (encephaloid) of cancer are found throughout 
 our literature.§ 
 
 Dr. G. M. Pease,|| in a short and practical paper on "Cancer," mentions 
 three cases, in two of which operations had been performed, and these are 
 merely noted here, inasmuch as being under the carbolic acid treatment, 
 one was alive five years, the other four years after operations had been per- 
 formed. The third, however, a case of hsematoid cancer, located on the right 
 cheek, and extending to the ala of the nose, was cured by carbolic acid 
 internally and externally with no return in three years. 
 
 Dr. A. G. Beebe^[ gives a case of melanotic cancer, cured chiefly by car- 
 bolic acid and sanguinaria, the former for the specific disease, the latter for 
 gastric disorders. During the first three weeks of treatment, the tumor was 
 reduced to the size of a pin's head, and all suffering relieved. Ultimately, 
 there was complete recovery. 
 
 Dr. Leon** relates a case of carcinoma uteri which had not recurred after 
 three years. The medicines were : arsenic, a dose night and morning for 
 one week; conium 3 night and morning for one week. These medicines 
 were continued four months in alternation, with an occasional dose of china 
 as an intercurrent for haemorrhage. 
 
 We must now turn to the consideration of Dr. Bayes's essays,ft written 
 especially with reference to the use of hydrastis can. in the treatment of 
 cancer ; and for brevity's sake will merely introduce his table appearing at 
 the end of his second paper. He also includes in these statistics Dr. Brad- 
 shaw'sJJ cases, offering additional testimony to the beneficial effect of the 
 "Goldenseal." 
 
 These papers certainly show (although the percentage of cures is small) 
 that this medicine does possess more or less influence over the disease ; but 
 
 * Archiv. fur die Hornoepathische Heilkunst, vol. vii. 
 
 t Log. tit. (both these cases are recorded in Dr. Jeanes's Homoeopathic Practice). 
 \ British Journal of Homoeopathy, vol. xvii., p. 53. 
 
 | British Journal of Homoeopathy, vol. xxvi., p. 658. Dr. Quinn's case in the Annals, vol. 
 i , p. 177, quoted by Hughes. Fungus hsematodes, Dr. Hughes, British Journal of Homoeop- 
 athy, vol. xxviii., p. 795. 
 
 || Transactions of the American Institute of Homoeopathy, 1872, p. 390. 
 X Medical Investigator, vol. xi., p. 549. 
 ** United States Journal of Homoeopathy, vol. i., p. 41. 
 ft Hydrastis can. in Cancer, B. J., vol. xix. ; also, loc. cit., vol. xx., p. 1. 
 XX A Few Kemarks on Hydrastis, B. J. H., 1861, vol. xviii., p. 598. 
 
TKEATMENT OF CANCER. 
 
 183 
 
 when the question arises as to the comparative efficacy of homoeopathic 
 treatment combined with surgical operations, I think it may be shown that 
 a better result is obtained with the knife than without it. 
 
 Of the following twenty- three cases, six are diagnosed as scirrhus, thirteen 
 as cancer (ulcerated or otherwise), one as fungus hsematodes, and three as 
 cancerous tumors. The results of the treatment are as follows : three were 
 cured ; in six others there was " improvement ;" in three " arrest of develop- 
 ment ;" and in six, relief from pain was noticed; while again in five others 
 " no effect " was produced. It would be interesting to the operating sur- 
 geon to ascertain how long the three cases remained cured ; and if in any 
 there was a recurrence of the disease, at what time the symptoms were de- 
 veloped. Until this point be clearly settled, the vexed question as to the 
 expediency of operative interference with the knife, cannot be satisfactorily 
 determined. Few operations for cancer, especially of the lip and mamma, 
 are not followed by a more or less complete exemption from the disease 
 for one, two, or even three years ; but even then the conscientious sur- 
 geon would scarcely be justified in announcing a complete cure of the 
 affection. 
 
 O 
 1 
 
 be 
 41 
 
 Sex. 
 
 Disease. 
 
 Location. 
 
 Result. 
 
 Female. 
 
 Scirrhus. 
 
 Breast. 
 
 Cured. 
 
 2 
 
 42 
 
 1 ' 
 
 Tumor. 
 
 Ovary, right. 
 
 Relieved. 
 
 3 
 
 46 
 
 " 
 
 Cancer. 
 
 Right breast. 
 
 Much improved. 
 
 4 
 
 77 
 
 1 ' 
 
 ' ' 
 
 1 ' ' ' 
 
 Arrested. 
 
 5 
 
 25 
 
 " 
 
 Scirrhus. 
 
 Cervical glands. 
 
 Much improved. 
 
 6 
 
 55 
 
 " 
 
 Hard nodulated tumor. 
 
 Dorsum of foot. 
 
 Almost cured. 
 
 7 
 
 45 
 
 ' ' 
 
 Scirrhus. 
 
 Breast. 
 
 Pain relieved. 
 
 8 
 
 50 
 
 " 
 
 Ulcerated cancer. 
 
 Left breast. 
 
 Greatly improved. 
 
 9 
 
 37 
 
 ' ' 
 
 Cancer. 
 
 ii it 
 
 Cured. 
 
 10 
 
 48 
 
 • ' 
 
 1 ' 
 
 Right breast. 
 
 Pain relieved. 
 
 11 
 
 38 
 
 ' ' 
 
 Tumors (cancerous). 
 
 Both breasts. 
 
 Much improved. 
 
 12 
 
 48 
 
 ' ' 
 
 Scirrhus. 
 
 Os uteri. 
 
 No effect. 
 
 13 
 
 56 
 
 1 ' 
 
 Cancer— ulcerated. 
 
 Os uteri.vagina, and rectum. 
 
 ' ' 
 
 14 
 
 42 
 
 1 ' 
 
 Scirrhus. 
 
 Uterus. 
 
 ' ' 
 
 15 
 
 60 
 
 " 
 
 Fungus hsematodes. 
 
 Right thigh. 
 
 " 
 
 16 
 
 22 
 
 ' ' 
 
 Cancer. 
 
 Left breast. 
 
 Cured. 
 
 17 
 
 50 
 
 ' ' 
 
 Ulcerated cancer. 
 
 ii ii 
 
 Relieved. 
 
 18 
 
 50 
 
 Male. 
 
 < ' " 
 
 Lip. 
 
 Arrested and improved. 
 
 19 
 
 40 
 
 Female. 
 
 Carcinoma. 
 
 Left breast. 
 
 Relieved. 
 
 20 
 
 58 
 
 1 ' 
 
 Scirrhus. 
 
 ii ii 
 
 Arrested. 
 
 21 
 
 40 
 
 " 
 
 Ulcerated cancer. 
 
 Os and cervix uteri. 
 
 Slight and temporary relief. 
 
 22 
 
 60 
 
 ' ' 
 
 « ( (i 
 
 ii ii 
 
 No relief. 
 
 23 
 
 37 
 
 
 
 
 Arrested. 
 
 This phase of our subject brings us directly to the consideration of the 
 cases of Marsden and MacLimont,* in which the. " enucleation treatment" 
 was adopted. In the ten cases they record, the subsequent histories of the 
 patients have not been given, obviously from the many difficulties sur- 
 rounding dispensary and hospital practice. In stating these cases here they 
 must be considered in a measure operative ; as nitric acid, chloride of zinc, 
 hydrastis in powder and tincture, and stramonium ointment, would scarcely 
 be called by the pure homceopathicians, homoeopathic medicines, especially 
 when in combination and applied locally. Yet the success of these appli- 
 cations may in a measure be attributed to constitutional treatment with 
 medicines exhibited according to the law of similia ; and such being the 
 case, does not the operator, whether with knife or caustic, who, throughout 
 the entire duration of the case (before, during, and after operative measures), 
 prescribes homoeopathically for the presenting symptoms, possess a most 
 decided superiority over those who rely chiefly on hygienic and general 
 constitutional treatment? In other words, does not homoeopathy even here 
 
 * B. J. H., voL xxi., p. 616. 
 
184 A SYSTEM OF SURGERY. 
 
 exercise a beneficent influence upon operative surgery ? The answer may- 
 be given in the affirmative. 
 
 In June, 1873,* I reported to the New York Homoeopathic Medical Society 
 fifty cases of cancer, and since that period have operated with knife and the 
 enucleating paste on a great many others. Of the latter I only preserved 
 the records of twenty -three cases, then from lack of time was obliged to dis- 
 continue my investigations. Many of these cases I watched with consider- 
 able care, and kept them under treatment for a long period of time. I 
 will merely state that eleven of the twenty-three have died between the 
 date of my last report and the present. Two of the cases were scirrhus 
 of the breast ; one advanced epithelioma of the penis ; one scirrhus of the 
 parotid, in which I may say that I think electrolysis did decided harm ; 
 four encephaloid of the mamma, and three from general dissemination 
 of the disease. Of the fifty cases I then placed upon record, five of the 
 epithelioma cases are now alive — in one instance, thirteen years having 
 elapsed since the treatment ; in another, ten years ; and both of these were 
 locally treated by Marsden and MacLimont's paste. Another has lived six 
 years, and is at present enjoying good health. Five years have elapsed 
 since another was operated upon, the patient being well, and the fifth also 
 has survived five and a half years. A sixth case might also be reported as 
 cured, as the patient died of gall-stones two years after the operation. Of 
 the encephaloid of the mamma subjected to the knife, four survived ; the 
 longest time elapsing being four years. Three have died. Of the scirrhus, 
 of which twelve were operated upon with the knife, one is alive nine years 
 after ; two have died. The others I have been unable to hear from, although 
 I have made many attempts, to ascertain their condition. (These statistics 
 remain unchanged from the last edition). 
 
 Many quotations of cures have been omitted ; but it is to be hoped that 
 sufficient facts have been given to prove that in a disease considered beyond 
 the reach of medicine by the old school, well-directed homoeopathic medi- 
 cine can and has effected cures ; and that when operative interference be- 
 comes necessary, the beneficial influence of homoeopathic medication cannot 
 be denied. It may modify the cachexia, or postpone the recurrence of the 
 disease. It would be ridiculous, however, even with this knowledge, to 
 make the broad assertion that all cases of cancer may be cured, or that re- 
 turn after extirpation is not to be expected. The facts remain, that cases 
 are and have been cured, and such facts encourage every surgeon in his 
 endeavor to select the proper homoeopathic medicine, and avoid, if possible, 
 the performance of operations ; and still further, if the knife be deemed 
 necessary, or the caustic treatment seem advisable, he has certainly in the 
 homoeopathic Materia Medica, agents which will assist him to prevent re- 
 currence and alleviate suffering. 
 
 Looking at the matter with these proofs before us, endeavoring to view the 
 testimony as impartially as we are able, and referring to the written opinion 
 of the best allopathic authorities of to-day, it may safely be claimed that 
 homoeopathy has exerted a most beneficial influence over this department of 
 surgery, whether the knife be employed or internal medicines exhibited. 
 
 Of all medicines in the Materia Medica, Arsenic is probably the most 
 reliable in cancerous formations, and next to it in point of efficiency, conium 
 is to be placed. 
 
 In an old number of the London Monthly Review, dated 'August, 1763, I 
 find a very interesting article by Dr. Hoffman,f in which he recommends 
 
 * New York Journal of Homoeopathy, vol. i., p. 146. 
 
 f Observations on the internal and external use of hemlock, ss. ; in a letter from Dr. Hoff- 
 man, Professor of Physic at the University at Steinfort, to his friend at Munster. London 
 Monthly Review, 1763, p. 170. 
 
TREATMENT OF CANCER. 185 
 
 highly baths of Hemlock, arguing — and truly, too — that he believes the 
 system would be thoroughly saturated with Conium by the bath, without it 
 having to undergo changes incident to the processes of digestion or assimi- 
 lation. The bath must be warm (not hot), and must contain " twelve large 
 handfuls of hemlock leaves." The patient must be placed in the tub, and 
 the person covered with a sheet or blanket drawn around the neck, and 
 allowed to remain in the water about 30 minutes ; the patient is then put to 
 bed. The bathing should be continued at intervals of two or three days for 
 the space of about six weeks. At all events, the case cured was remarkable. 
 I tried this treatment, but only twice, but I must say in both, although 
 the cases were aggravated to a degree, having been under the enucleation 
 treatment of quack cancer doctors, the method was troublesome to carry out, 
 and was followed by indefinite results. 
 
 Galium aperinum has been known for some time to exercise a powerful 
 influence upon certain cutaneous diseases, and also to possess some curative 
 virtue in cancer and nodulated tumors of the mouth and tongue. Cases 
 are upon record where it has certainly proven of great efficacy. Mr. F. A. 
 Bailey, F.R.S.C, records a case* in which a cure was apparently effected. 
 The preparation used was — 
 
 Extract Galii aperini solidi, ^ij. 
 
 Aquae, Oss. 
 
 M. ft. extract fluid. 
 
 Of this a drachm and a half was given twice a day in a wineglassful of water, 
 and as a warm lotion applied to the parts several times during the day. 
 
 Phytolacca appears to have some influence on cancer, especially scirrhus 
 of the breast. Not long since there was a good deal written concerning the 
 action of acetic acid upon cancer-cells, and Mr. Bencef reported a very in- 
 teresting case of cancer of the breast, treated by Sir Henry Thompson at 
 the University College Hospital, with the examination of the morbid speci- 
 men. The method of treatment was first suggested and employed by Dr. 
 Broadbent. 
 
 Dr. Hastings X also has employed the treatment successfully in cancer of 
 the liver, stomach, and mammae. The acid was given in the latter case in 
 three-drop doses three times a day, after which an interval of two days was 
 allowed to elapse, and the medicine resumed. A compress saturated with 
 an acetic acid solution, was worn over the breast. This case was apparently 
 cured. 
 
 I have tried this method, and also injected the tumor with the acid, but 
 am sorry to say that I have derived no positive benefit from its use. 
 
 Cedron was introduced to my notice by Dr. E. M. Kellogg, of New York, 
 who had used it successfully as a palliative to the severe sufferings, especi- 
 ally the lancinating pains in the- advanced stages of cancer. Drop doses of 
 the tincture, frequently repeated, are necessary to produce relief. 
 
 Lapis albus. — This medicine, introduced by Dr. Grauvogl, was kept secret 
 for a while by him, in order to prove to Liebig that the power of medicines 
 might be ascertained, and the position of the science secured, without in all 
 cases the aid of chemistry. This substance is the white primitive calcium 
 gneiss, found in the lower Ache valley, abounding in the mineral springs 
 of Gastein. The cures said to have been made by this drug are remarkable. 
 It was given in the first to the sixth decimal trituration. 
 
 Resorcin. — This medicine has been highly extolled by Dr. G. I. Gatch- 
 
 * Medical Times and Gazette, July 30th, 1864. 
 
 f Medical Times and Gazette, February 16th, 1867. 
 
 X Cancer, with Cases Cured. London; Henry Turner, 1869. 
 
186 A SYSTEM OF STJKGERY. 
 
 kovsky* as an application to " cancer-like " growths. It is applied either 
 in substance or in the shape of a 50 per cent, vaseline ointment. When 
 used in powder, the remedy was dusted freely over the part, and the oint- 
 ment was applied twice a day. The cases recorded are of interest. 
 
 Hypodermic Injection of Nascent Phenic Acid. — Though I must say that I 
 have never known a cure of cancer in any of its varieties produced by the 
 Declat method, yet I am bound to affirm that I have known very great 
 amelioration of pain, arrest of hemorrhage, and increase of strength follow its 
 use, and I have employed it a great deal. The dose is 80 minims twice a day, 
 generally injected with a Declat syringe into the cellular tissue of the abdo- 
 men. With this, I give the patient internally the syrup of the Iodo-phe- 
 nique twice a day, and two drops of Fowler's solution after the mid-day 
 meal. 
 
 It' is surprising in some cases to note the rapid improvement by this 
 method, and hopes are immediately entertained that by steady perseverance 
 the disease may be eradicated. The hope, according to my own experience, 
 is deceptive. The case progresses favorably for some time, then after several 
 months remains in statu quo, and finally slips back gradually to its devastation. 
 
 The treatment, however, ought to be tried ; it generally is productive of 
 very much relief. 
 
 Enucleation. — The system of enucleation was first introduced by Justa- 
 mond, an English surgeon of the last century, who employed an arsenical 
 paste. The pastes generally used consist mainly of arsenic and chloride of 
 zinc. 
 
 Marsden and MacLimont's treatment, as reported in the British Journal of 
 Homoeopathy, is essentially as follows : 
 
 " The method of removal varies as the disease is in a state of ulceration 
 or otherwise. When the skin is entire, the site, size, and bearing of the 
 tumor are ascertained and marked out on the skin with nitrate of silver or 
 vermilion paint ; then a mixture of ice and salt is applied to deaden sensi- 
 bility ; the affected parts are then dried and the skin destroyed by applica- 
 tion of pure nitric acid, and this action of the acid is kept up until the skin 
 assumes a tawny or yellow aspect. The skin is then douched with cold 
 water, and a piece of lint applied soaked with the following paste : a decoc- 
 tion of hydrastis root, powdered hydrastis, chloride of zinc and flour, equal 
 parts, one of this mixture to one part stramonium ointmentf On removing 
 the dressing at the end of twenty-four hours, a yellow, hard, dry eschar is 
 produced, surrounded by a slight amount of erythema. The pain caused 
 by this application varies with the amount of surface destroyed, and is 
 generally lessened by congelation of the part. Through the eschar make 
 vertical parallel incisions one-twentieth of an inch in depth, and one-half 
 of an inch apart ; into each incision insert a slip of calico smeared with 
 the paste ; cover with adhesive plaster, and apply over all a light dressing. 
 Repeat the process every day, until the tumor is percolated. Do not use 
 the knife too freely, but cut deep enough to get through the eschar, being 
 careful not to draw blood. We can tell when we reach the base of the 
 scirrhus by the feeling, — the cancer is hard and cuts with difficulty, and 
 when the knife pierces sound tissues, it feels as though it had entered a 
 cavity or an abscess. It is important that the slip of calico should be carried 
 to the bottom of the incision, and extend its whole length, or even one- 
 
 * The Medical Eecord, August 8th, 1885. 
 
 f I use the following preparation and find it of much service : 
 
 Zinc, chlor., 
 
 Hydrast. submur., 
 
 Ung. stram., aa gij. 
 
 M. ft. ung. — Use externally for three hours. 
 
ENUCLEATION. 187 
 
 quarter or one-half an inch below on each side, but care should be taken 
 not to let the paste run down on the sound skin. In the process of enu- 
 cleation it often happens that a cavity containing disintegrating cancerous 
 matter is opened ; expose the cavity freely, evacuate the contents, and pro- 
 ceed through the floor of the cavity, the same as before. At the end of a 
 fortnight, a line of demarcation forms around the tumor, beginning at its 
 most dependent portion; the living healthy tissues beneath granulate and 
 push the tumor out, and the entire mass sloughs away in from four to seven 
 weeks. Remove all unhealthy granulations, diseased glands, etc., and allow 
 no cicatrization so long as cancer-cells can be distinguished in the discharges. 
 After the slough has come away, dress the sore with lint spread with stra- 
 monium ointment." 
 
 Marsden and MacLimont claim for this mode of treatment the following 
 advantages : that it obviates all danger of pyaemia, " the chloride of zinc 
 acting as an antiseptic ;" that it produces no constitutional disturbance ; that 
 it is equally applicable to all forms of malignant growths, and may be em- 
 ployed when the use of the knife is inadmissible ; and that " it gives rise 
 to such drawing or contraction as to bring within reach of the paste portions 
 somewhat deeply imbedded in the surrounding tissues." 
 
 Dr. John Pattison,* of London, employs an enucleating paste composed 
 of equal parts of powdered hydrastis root, chloride of zinc, flour, and water. 
 The method of application is the same as that already described. This 
 treatment gives rise to slight constitutional symptoms, which are met by 
 the appropriate remedies. 
 
 The following is Michel's f process for removing external tumors, for 
 a knowledge of which Dr. Bell paid 25,000 francs, and which, in a spirit 
 of true liberality, he has made public. It is worthy of careful considera- 
 tion. 
 
 " The preparation used in all cases where the tumor can with safety be 
 reached externally is made in the following way. Asbestos, as soft and free 
 from grit as possible, is reduced by rubbing between the hands to the finest 
 possible fleecy powder ; it is then mixed thoroughly with three times its 
 own weight of strong sulphuric acid (S0 3 HO). A mass is thus formed 
 which may be easily worked with a silver or gold spatula into any size or 
 shape, corresponding with the tumor to be destroyed. Any malignant 
 growth of the breast which is detached and solitary, with the submaxillary 
 glands unaffected, is suitable for treatment, whether open or not makes no 
 difference. In the application of the caustic the adjoining healthy parts of 
 the skin are carefully protected by applying a zone of collodion and pads 
 of linen, and the patient is so placed that the surface of the tumor is per- 
 fectly level. The saturated acid asbestos is then laid on the surface, to the 
 thickness of half an inch, for a tumor the size of a hen's egg. Rapid de- 
 struction of the tissues follows, with, after the first half hour or so, but little 
 pain. An oozing of clear watery fluid appears, which must be carefully 
 sopped up. After twelve or fourteen hours' action, the first application is 
 to be removed, and a new portion of smaller size adapted to the sore. 
 After this has been applied for twelve hours the operation is complete, and 
 the healing of the deep excavation alone requires to be attended to ; for the 
 details of which we must refer our readers to the pamphlet. Dr. Bell does- 
 not pretend to say that this mode of operation will effect a permanent cure 
 of cancerous cases, but he thinks that the plan presents various and consid- 
 erable advantages over extirpation by the knife, as in producing much less 
 shock to the system, in removing the tumor alone with but little of the sur- 
 
 * Vide Pattison on Tumors. 
 
 f Practitioner, June, 1871, p. 377. 
 
188 A SYSTEM OF SURGERY. 
 
 rounding breast, and in postponing, in malignant cases, for a longer period, 
 the recurrence of the disease." 
 
 Dr. Broadbent recommends injections of the first dilution of acetic acid. 
 The pain is slight, and haemorrhage is checked by the use of styptics. 
 
 Dr. Routh, of the " Samaritan Hospital," London, reports two cases of 
 scirrhus cured by the topical application of bromine. 
 
 Professor J. C. Morgan, of Philadelphia, has cured a case of epithelioma 
 of the lower lip by local application of carbolic acid. 
 
 Dr. James Arnott has advised continued application of cold, by means 
 of some freezing mixture applied to the surface of the tumor. This may 
 check the growth for a time, but can never effect a radical cure. The same 
 may be said of Mr. Young's treatment by compression. 
 
 W. Neftel, M.D., reports* that he has used electrolysis successfully in 
 cases of scirrhus. From his experiments, he is inclined to believe that 
 this treatment exerts a positive beneficial influence upon the cancerous 
 diathesis. 
 
 The iodide of arsenic has been partially proved, and from the symptoms it 
 has produced, and from certain cases in which it has been productive of 
 great benefit, is highly recommended, as has been also the phosphate of 
 iron; the latter is said to have produced "the most happy results;" by its 
 administration the pain is lessened, and the ulcer takes on a more healthy 
 appearance. 
 
 In a case where cancerous ulceration had invaded the left half of the 
 upper lip, and the soft parts upwards to the bone, and outwards to the 
 angle of the mouth, arsenicum repeated every eight days, effected a 
 cure. 
 
 In a case of scirrhus and prolapsus of the uterus, in which, in the earlier 
 stages of the disease, there was metrorrhagia, in varying quantity and 
 quality ; still later the discharge of a fetid, whey-like matter, pain in the 
 back, flying stitches in the pubic region, costiveness, the uterus in a state 
 of scirrhous induration, bell. gtt. 1.20 every forty-eight hours, for two weeks, 
 and a dose of arsen. every four days, for some time afterwards, together 
 with the local application of a weak infusion of bell, by means of a sponge, 
 effected a cure. 
 
 The following medicines have been recommended for encephaloid and 
 other malignant growths:! Ars., carb. an., carb. veg., phosph., sep., silic, 
 thuja, calc. carb., crot, lye, mere, sol., nit. ac, sulph. 
 
 Fungus hsematodes of the eye, with chronic ophthalmia, complicated 
 with ulcers on the cornea, great photophobia, burning, lancinating, and 
 boring pain in the eye, the sight fast diminishing, calc. c. as the chief 
 remedy, with lye, sep., silic, was cured.J 
 
 An elderly negro man in Surinam had a bleeding tumor on his knee, 
 which was removed by excision. Some time afterward a tumor formed in 
 each hip near the trochanter major ; that on the right was much larger than 
 the one on the left hip. Two years and a half after the operation it had a 
 diameter of four inches, was of a conoidal shape, slightly movable, hard, 
 elastic, of the natural temperature, and without pain or pulsation. After 
 being ruptured by a blow, it bled slowly, but almost incessantly, and be- 
 came slightly painful and somewhat warm. On wiping the blood, which 
 was apparently venous, from the opening, " the structure of fungus hsematodes 
 could be clearly discerned. Cinchona 1.12, and shortly afterward phosph. 1.30, 
 
 * Richmond and Louisville Medical Journal, July, 1870. 
 
 f Jahr's and Possart's Manual, p. 620. 
 
 X See Guide to Practice of Homoeopathy, p. 155. London, 1844. 
 
REMOVAL BY THE KNIFE. 189 
 
 were given. About the same time the patient filled the wound with tinder. 
 The tumor continued to increase in size, as also did a fungous growth from 
 the opening, which had made its appearance previously to the administra- 
 tion of the medicine, and the haemorrhage was considerable till the four- 
 teenth day, when there was a slight fever, which disappeared without 
 medicine. After this period the tumor began gradually to diminish in size, 
 and the haemorrhage ceased until the thirtieth day, when it occurred sud- 
 denly, but soon ceased of itself. After the second or third week the patient, 
 being very much debilitated, was allowed to take a glass of wine occasion- 
 ally. The tinder remained adherent in the opening till after the fiftieth 
 day. On the sixtieth the wound was unclean, of a bad odor, and again 
 bled a little ; but the tumor had greatly diminished, as had also that on the 
 left hip. By the eightieth day the improvement had advanced much farther, 
 which advancement was attributed by the patient to a common adhesive 
 plaster which had been applied to gratify him with the idea of active local 
 treatment. By the ninetieth day there only remained an indurated cicatrix. 
 The induration gradually diminished, and at the end of four months had 
 entirely disappeared."* 
 
 Dr. Marsden recommends the following, which I have used with some 
 success in the treatment of epithelioma. His formula is two drachms of 
 arsenious acid to one drachm of mucilage of gum acacia, well mixed into a 
 thick paste. The success of this method is highly spoken of, but I must 
 refer the student for details to his work.f 
 
 Removal by the Knife. — A great diversity of opinion obtains regarding 
 the extirpation of the diseased mass. Dr. Gibson writes : " Even extirpa- 
 tion of the tumor, and that, too, in its very incipiency, answers so little 
 purpose that there is hardly a case on record where this operation has suc- 
 ceeded. "J The futility of operation in this affection is well illustrated by a 
 case detailed by Mr. Allan. § The patient suffered during thirteen years 
 from a very large tumor which occupied the left hip. When it attained the 
 size of a child's head it was dissected out by Mr. Newbigging, of Edinburgh, 
 apparently with success, for the wound healed and the patient felt perfectly 
 well. At the end of nine months, however, it grew again, and in seventeen 
 months from the first operation, a second was performed by Mr. Russel, 
 upon a tumor as large as the two fists. The wound soon closed, but in 
 nine months following, the tumor recurred, and soon equalled in size a very 
 large mamma. A third operation was now undertaken by Mr. Allan, and 
 so extensive was the dissection that the wound was as large as the crown 
 of a hat. In a few weeks it healed perfectly, but the tumor appeared again 
 in seven months. The late Mr. John Bell was then consulted, and per- 
 formed a fourth operation upon it, the tumor at the time being as large as 
 the head of a child eight years old. Several months after the diseased 
 mass was reproduced, and from-the surface a fungus sprouted, in shape and 
 size resembling a large cauliflower. This Mr. Allan removed by ligature, 
 and the patient for the time was relieved. His constitution, however, was 
 completely ruined, and although he lived for several months afterward, he 
 died at last from long-continued discharge from the fungus, nearly eight 
 years having elapsed from the time of the first operation. " This case," 
 continued Dr. Gibson, from whose work it is taken, " plainly shows how 
 little we are to expect from extirpation." 
 
 Notwithstanding, however, the liability of these malignant growths to re- 
 
 * See Jeanes's Homoeopathic Practice of Medicine, p. 236. 
 
 f A New and Successful Mode of Treating Certain Forms of Cancer, by Alex. Marsden, 
 M.D., F.E.C.S.E. London, 1874. 
 
 X Institutes and Practice of Surgery, vol. i., p. 314. 
 | Allan's Surgery, vol. i., p. 364. 
 
190 A SYSTEM OF SURGERY. 
 
 turn again and again after removal, yet there are cases in which the 
 surgeon may deem it both prudent and proper to resort to the knife. Life 
 may be prolonged for months, or even for years, as in the case above, by an 
 early eradication of the mass. A vast amount of suffering may be saved ; 
 business may be settled, which, if left undone, would cause great discom- 
 fort or even poverty to a family ; and, therefore, it becomes important to 
 ascertain when operative measures should be resorted to. 
 
 When the tumor is not amenable to remedies, and the patient is unwil- 
 ling to await the somewhat tedious process of enucleation ; or when the 
 morbid growth occurs in the osseous structures, then exsection of the dis- 
 eased mass, or amputation of the affected part, is the last resort. Excision 
 may be practiced under the following circumstances : the patient must not 
 be over sixty years of age ; the general health not much impaired ; appetite 
 and other functions remaining normal ; there should be no extension of the 
 disease to neighboring lymphatics ; and the patient possess sufficient vitality 
 to react from the operation. But as has been before noticed, even under 
 the most favorable conditions, excision is rarely, if ever, successful in effect- 
 ing a radical cure ; sooner or later the disease returns and progresses rapidly 
 to a fatal issue. 
 
 The power of arsenic as a prophylactic after these operations, is very highly 
 spoken of by the celebrated ovariotomist, W. L. Atlee, of Philadelphia. At 
 a meeting of the American Medical Association, held in Philadelphia in 
 May, 1872, the subject of cancer being under discussion, the doctor made 
 the following remarks :* 
 
 " My experience with arsenic is unusually large, and each year has in- 
 creased my confidence in it. I have now patients in the city — and if it 
 nad occurred to me, I could have brought you four or five — whose breasts 
 have been amputated from five to twenty-five years, and who are examples 
 of the protective power of arsenic, and of its extinguishment of the cancer- 
 cell. 
 
 " Twenty-five years ago a lady presented herself to me with a large breast 
 of soft cancer, which we denominated fungus hsematodes, because the great 
 mushroom mass, almost black, looked ready to burst and let the patient 
 bleed to death. I had no idea that she could be saved ; but I put her im- 
 mediately upon small doses of Fowler's solution — the maximum being 
 three drops three times a day — and when her system was thoroughly satu- 
 rated with it I extirpated the breast. It healed up readily ; and, according 
 to my observation, the wound from extirpation of cancer commonly heals 
 more quickly than a like wound under other circumstances. I kept her 
 under the influence of arsenic for one year after the cicatrization, and to 
 this day she is a living example of perfect freedom from cancer." 
 
 He details other cases with a similar result, and observes that his maxi- 
 mum dose of Fowler's solution was three drops. He records cases of re- 
 moval and non-return which were considered incurable by celebrated 
 surgeons of Philadelphia. 
 
 D. Cystic Tumors. 
 
 (a.) Cysts from expansion of spaces in connective tissue. 
 
 (b.) Independent cysts — in bone and cartilage. 
 
 (c.) Sanguineous cysts — from rupture of bloodvessel — hsematoma. 
 
 (d.) Exudation cysts. 
 
 (e.) Congenital cysts. 
 
 (/.) Synovial cysts. 
 
 (g.) Mucoid cysts. 
 
 * Medical Kecord, New York, June 15th, 1872, p. 261. 
 
CYSTIC TUMORS. 191 
 
 (h.) Colloid cysts. 
 
 ^ i. ) Compound proliferous cysts. 
 
 (k.) Retention cysts — sebaceous, etc. 
 
 Cysts, in the majority of instances, cannot properly be classed as tumors. 
 If they were, they should be placed under the head of the adenomata, be- 
 cause they so frequently develop from glandular substance. Cysts are 
 formed and grow, 1st, from a retention of the normal secretion of a gland, 
 caused by a stoppage of the excretory duct, or, 2d, by the preternatural 
 secretion of a gland, which is not provided with a duct, or, 3d, by the rupture 
 of a bloodvessel into a gland thus distended. In the first instance we 
 might have a sebaceous cyst ; in the second, a bursa ; in the third, a sam 
 guineous cyst would be produced. Then again we may find cysts, and 
 hundreds of them, independently produced by the formation of a cyst 
 wall around an accumulation of blood, or a parasite (as echinococcus), or 
 by the softening or liquefaction of tissues from mucoid or fatty degenera- 
 tion. There are also cysts that are formed from the divergence or expansion 
 of the spaces of connective tissue (hygroma). 
 
 Cysts are therefore sacs with walls of widely different texture, and with 
 their contents varying greatly. They may, in their many forms, occur in 
 every portion of the body. I have myself seen them in almost every organ 
 in the cavity of the abdomen. I have found many in the same patient, 
 varying in size from that of a pea to a diameter of four and a half inches. 
 There is a remarkable case upon record* in which the liver, spleen, mesen- 
 tery, and omentum were studded with cystic tumors. Large cysts were 
 found in the bladder and sigmoid flexure of the colon, and were distributed 
 everywhere. They could, indeed, be counted by thousands. This was a 
 true case of taenia echinococcus. 
 
 As a general rule, there is no special difficulty in diagnosing cystic tumors ; 
 the chief symptoms which lead to their detection are fluctuation, and a 
 smooth, oval surface, with absence of pain, and with a healthy integu- 
 ment, which, however, may assume a bluish appearance from tension when 
 the tumor is large. The diseases with which they are most likely to be 
 confounded are cold — or, as they may be termed, subacute — abscesses ; 
 fluctuation is perfectly apparent in both cases, and there is no very high 
 degree of inflammation manifested in either. The history of the case may 
 be of great service, and the manner of growth of the tumor also assists ; 
 there is a great degree of inflammation in the abscess, and its apparent 
 pointing will be a guide to the surgeon ; but where the tumors are covered 
 by layers of tense muscles, it is almost an impossibility to recognize the cyst, 
 and, at best, only the general conditions can be relied upon in the diagno- 
 sis. The question here arises with the present understanding of the forma- 
 tion of cysts, whether an abces froid is not a true cyst itself. 
 
 Cysts may be primitive vesicles and form singly, attaining, in some in- 
 stances, great magnitude, and in others varying from the size of a millet- 
 seed to that of a walnut. Billroth, in his classification, places the cyst 
 among those " tumors which seldom return after their extirpation, but some- 
 times occur distributed in great numbers over the whole surface of the 
 body." He then subdivides them according to the contents of the sac, 
 thus : 
 
 (a.) Cysts with serous fluid; found in the spermatic cord and in the 
 neck. 
 
 (b.) Cysts with mucous contents (colloid), which contain a soft gelatinous 
 
 * Western Homoeopathic Observer, vol. iii., pp. 154, 162. 
 
192 A SYSTEM OF SURGERY. 
 
 substance or mucous tissue ; they are discovered on the neck, in the ovary, 
 and in the thyroid gland ; they may be very numerous. 
 
 (c.) Cysts with a pultaceous or fatty matter ; these occur in great numbers, 
 often in connection with sebaceous glands or hair-follicles. He says that 
 their walls sometimes present a cutis-like construction on their internal 
 surface ; a rete Malpighii, hairs, and sebaceous and sudoriferous glands (der- 
 moid cysts). These cysts, when found in the ovary, sometimes contain 
 pieces of bone, teeth, hair, and the like, and are known as dermoid. 
 
 In 1876, I removed an immense dermoid cyst from a woman aged twenty- 
 seven years. There were, besides immense colloid accumulation, large 
 masses of lime ; many tufts of hair, from one to three inches in length ; per- 
 fectly formed teeth ; a bone resembling the superior maxillary, holding two 
 molars and an incisor ; a second bone of the shape and size of the first rib ; 
 and a third, looking like the scapula ; besides other small ossific deposits. 
 The solid parts of this tumor weighed twenty -three pounds, while the colloid 
 and fluid substance must have amounted to thirty or forty more. 
 
 I have also seen several cysts containing hair, bone, and large quantities 
 of sebaceous material. 
 
 Paget 's classification of cysts may here be noticed. He divides them 
 into : (1) Simple or barren ; (2) Compound or proliferous ; and (3) An in- 
 termediate variety, which may contain substances more highly organized 
 than are found in the simple or barren, and less organized than those of 
 the compound or proliferous. 
 
 Among the simple cysts are (a), those containing serum, mucus, and 
 other substances ; (6), the transition cysts, containing synovia, milk, semen, 
 or the like ; while (c), the proliferous cysts contain still more highly or- 
 ganized structures. Holmes, in his System of Surgery, follows much the 
 classification adopted by Paget, and arranges them thus : 
 
 A. Simple or barren : serous and hygromatic ; synovial ; mucous ; sangui- 
 neous; oily; colloid; seminal. 
 
 B. Compound or proliferous : complex cystoid, with intracystic growths, 
 cutaneous or dentigerous. 
 
 It will be seen that here, class A is subdivided according to the contents 
 of the sacs ; but in class B the position they occupy determines the subdivi- 
 sion into groups, which we need not enumerate. Billroth* disregards 
 " the retention cysts of large canals," leaving them, as he says, " to internal 
 medicines and obstetrics," and confines himself surgically " to those tumors 
 that Virchow has grouped under the term ' follicular cysts.' " He gives the 
 name " composite cyst, or cystoma," to a combination of such cysts, and 
 designates those containing more solid substance as " cysto-fibroma, cysto- 
 sarcoma, cysto-chondroma, cysto-carcinoma," etc. 
 
 With reference to the formation of the walls of cysts, the principles laid 
 down by Thomas Bryant hold good. He says : " All tumors with the ex- 
 ception of the hydatid, are made up of one or more of the natural elemental 
 tissues of the body, and in no single example has any extraneous or new 
 element been ever detected." So we find, as already noted, that cystic 
 tumors, excepting the hydatid, are formed sometimes by the expansion of 
 the walls of natural ducts, as in the case of sebaceous cysts, and those of 
 the lactiferous tubuli ; others are formed from an expansion of the areolar 
 spaces, in which fluid collects ; and others still by the enlargement of bur- 
 sas, or in ovarian tumors of the cystoid variety. In very many cases — and 
 in almost all cysts of any magnitude which have come under my own 
 observation — the true capsule, or wall of the tumor, has been covered with 
 a network of bloodvessels, most of them capillary in size, but involving here 
 
 * Surgical Pathology, p. 619. 
 
CYSTIC TUMORS. 193 
 
 and there one of larger magnitude. Cysts may also contain gas ; such are 
 denominated " gaseous cysts." Again, in some instances, cysts in the neck 
 appear to be a transformation of erectile or vascular tumors. Paget's classi- 
 fication is decidedly simple and most readily understood. 
 
 All varieties of cystic tumor have come under my observation, and 
 from the lessons which the cases have taught me, I would lay down the 
 general rule, that the simplest and safest method of dealing ivith them is to extir- 
 pate the sac by dissection. The treatment by puncture and injection is un- 
 satisfactory, and should only be tried when excision cannot be performed. 
 
 (a.) Cysts from Expansion of Spaces in Connective Tissue. — The neck ap- 
 pears to be the seat of many simple serous tumors — hygroma — as well 
 as of the other varieties. 
 
 Hygroma of the Neck. — This case was one of rather a critical nature, and 
 deserves even more minute mention than can be given to it here. 
 
 The patient, a lady about forty years of age, after being caught in a snow- 
 storm in March, 1868, felt an uneasy sensation in the right side of her neck, 
 and on putting up her hand discovered a tumor. From this time it con- 
 tinued gradually to increase. Within a few months a second growth ap- 
 peared just above the first, and finally a third. She applied to Dr. Dunham. 
 Under his medical treatment the two smaller growths disappeared, and the 
 larger one remained stationary until March, 1871, when it began to rapidly 
 increase, and in a short time attained twice its former size. It occupied, 
 when I saw it, the whole of the posterior triangle of the right side of the 
 neck, and extended behind the clavicle, and in front of it, so that the bone 
 appeared to be saddled with the tumor. 
 
 After two hours' careful dissection the entire cyst was removed. Dr. 
 Jernigen, now of Boston, and Dr. Bayliss, of Astoria, assisted me during 
 the prolonged operation. After the integument, platysma, and deep fascia 
 had been divided, the mass beneath looked so dark and purple as to lead 
 me to conclude that the cyst was of the sanguineous variety. But the color 
 proved to be due to a coating of dilated vessels, chiefly veins. This was 
 divided upon a director, and the true cyst then came into view. With such 
 a dissection as is made in hernia, I succeeded in exposing the whole super- 
 flees of the sac without rupture. It was as thin and delicate as the perito- 
 neum. In getting behind it, however, at the anterior margin of the trapezius, 
 the sac gave way, and a dark, brownish, thin fluid was discharged. By 
 drawing up the sac, enough of its contents was retained to form a guide to 
 its entire removal. In its very centre, was found a second cyst of the size 
 of a pigeon's egg. A third, which was discovered behind and below the 
 clavicle, was also removed. When the operation was completed, the ante- 
 rior border of the trapezius, the sterno-mastoid, the omohyoid, and the 
 scaleni muscles were perfectly exposed. The third portion of the subcla- 
 vian, the transversalis colli, and the transversalis humeri arteries, were dis- 
 tinctly seen, and the pneumogastric nerve and the brachial plexus were also 
 plainly visible. Eight vessels were ligated, and considerable blood was 
 lost. The external jugular was divided also, and bled pretty freely. 
 
 The patient was very much exhausted after the operation, suffering more, 
 however, from the effects of chloroform than from any other cause. The 
 wound was perfectly adapted, and in two weeks had almost entirely healed. 
 The ligatures came away between the tenth day and the twelfth. A small 
 portion of the surface, that over the deep section toward the back, neces- 
 sarily had to granulate. The tumor measured six inches and three-quarters 
 in its long diameter, and four and a quarter inches in its transverse. 
 
 Serous ovarian cysts, and cysts of the broad ligament, are treated, and 
 their differential diagnosis pointed out, in the chapter on Ovariotomy. 
 
 Case II. — A gentleman having four or five fluctuating tumors on the 
 
 13 
 
194 A SYSTEM OF SURGERY. 
 
 right side of the neck, in the direction of the sterno-mastoid muscle, applied 
 to me for relief. The tumors were punctured, and a clear serum issued 
 from them. After a time the cysts refilled, and again the fluid was evacu- 
 ated and the sacs scarified. The site of the tumors became inflamed, and 
 they again filled, not with serum, but with a glairy substance, which 
 constantly oozed from them. Suppuration finally ensued, and after a long 
 period the openings closed. This happened in my practice some years ago, 
 and since that period I have always extirpated the walls of such cysts, by 
 dissection if possible, if not, by including the whole mass in a ligature. 
 
 (6.) Independent Cysts — Cysts in Bone. — A young lady desired relief from 
 a tumor in which fluctuation was apparent, and which was situated on the 
 left side of the os frontis. I at first diagnosed a simple sebaceous cyst, but 
 found afterward that I was in error, and that it was a cyst seated within the 
 bone. It made its appearance first in the diploe, and gradually pressed the 
 external table forward, until finally the bone substance was absorbed, and 
 the periosteum assisted to form its anterior wall. The appearance pre- 
 sented after the removal of the tumor was very similar to that which obtains 
 in the os frontis when the external table has been cut cleanly away by a 
 trephine. Every portion of the sac was removed, and the bone thoroughly 
 scraped. The cure was complete. 
 
 (c.) Sanguineous Cysts, the " haematoma " of Bennett and other writers, 
 are nearly related to serous cysts. According to Paget, they may be formed 
 in three different ways, either by haemorrhage into a previously existing 
 serous cyst ; by partial obliteration and transformation of a naevus ; or by 
 the occlusion and dilatation of a vein. These tumors occur most frequently 
 in the neck, and contain a bloody fluid. The cyst-wall varies in thickness, 
 according to locality. In subcutaneous cysts it is membranous, and pre- 
 sents a columnar or fasciculated appearance, due to the unequal rupture of 
 the membrane. 
 
 Sometimes a bloodvessel opens into a sero-cystic tumor, and forms a 
 sero-sanguineous cyst, which is described by some writers as a separate 
 variety of cystic growth. Mr. Paget, however, makes no such distinction ; 
 on the contrary, he expressly states that a sanguineous cyst may be formed 
 by " accidental haemorrhage into the cavity of a serous cyst."* I therefore 
 prefer to regard it as a mere subdivision of the preceding variety. 
 
 (d) Exudation Cysts — Thyroid Cysts. — An infant was recently brought to 
 me with an obscurely fluctuating tumor directly over the thyroid cartilage. 
 The growth was not exactly of an erectile nature, or a naevus, but I was 
 rather of the opinion that it was connected with deep-seated veins or vessels. 
 By grasping the tumor and pulling it forward, and passing beneath it three 
 needles crossed at angles, and then strangling the mass with waxed silk 
 passed behind the pins, the whole tumor sloughed off. It was, as I had 
 supposed, in close connection with bloodvessels, and at its base presented 
 somewhat of a honeycomb appearance. Tapping and injection of iodine 
 generally cures. 
 
 (e.) Congenital Cutaneous Cysts are sometimes found on the foreheads of 
 infants soon after birth. They are round, flat, or oval ; the cyst-wall con- 
 sists of " membranous connective tissue, lined with tessellated epithelium," 
 and contains an oily fluid. These tumors may also occur in other parts of 
 the body. They are evidently synonymous with the variety described by 
 Mr. Paget as oily cysts. 
 
 Congenital Serous Cysts of the Orbit.f — Congenital serous cysts of the orbit 
 are said by Dr. J. Talko, from his observation of six cases, to be situated 
 
 * Paget's Surgical Pathology. 
 
 f London Medical Record, July 15th, 1877 ; Monthly Abstract of Med. Science, September, 
 
 1877. 
 
CYSTIC TUMORS. 195 
 
 between the eyeball and the lateral wall of the orbit, to be commonly cov- 
 ered with conjunctiva, to increase in the direction of the lower lid, causing 
 ectropion, to vary in size, and prevent the development of the eye, pro- 
 ducing micro-ophthalmus. They contain a yellow serous fluid, rich in 
 albumen, and are not formed after birth. They are not usually intimately 
 united with either the conjunctival fold or eyeball, and should be extirpated. 
 
 (f.) Of Synovial Cysts we may distinguish two varieties, those formed by the 
 enlargement and transformation of bursse, and those which occur in the 
 sheaths of tendons, and which " appear to be the cystic transformation of 
 the cells, inclosed in the fringe-like processes of the synovial membrane of 
 the sheaths." (Paget.) The cyst-wall may consist of a thin membranous 
 expansion, or it may be thick, fibrous, and lined with a pasty-looking lami- 
 nated growth of imperfectly organized fibrin. The contained fluid is serous, 
 and of a yellowish or brown color. Attached to the walls and floating in 
 this fluid, are sometimes found small grayish or yellowish granular bodies, 
 irregular in shape, and closely resembling granulation-cells. These often 
 exist in such numbers as to completely fill the cyst, and convert it into a 
 solid mass.* These tumors often show a tendency to inflame and suppu- 
 rate. Paget classes synovial cysts as a variety of simple cysts ; but it will 
 be seen from the preceding description, that in some instances they might 
 with equal propriety be ranked among the proliferous. In fact, it is im- 
 possible to accurately define their position. 
 
 Case. — A woman twenty-seven years of age, had suffered much from an 
 enlarged synovial bursa of the knee-joint, immediately above the tubercle 
 of the tibia. Iodine and pressure were applied without any benefit ; she 
 suffered patiently and long. A careful dissection removed the mass, which, 
 when opened, contained a fluid exactly resembling the vitreous humor of 
 the eye. The tissues surrounding the bursa, from the lasting inflammatory 
 action, had become thickened and agglutinated together into a mass. Syno- 
 vial bursse of the wrist are so frequent and have come under observation so 
 often, that it is unnecessary to mention them here. 
 
 Concerning gaseous cysts comparatively little is known. According to 
 Hunterf they consist of air-bladders, and are " frequently found upon the 
 intestines of hogs that are killed during the summer-time." Whether they 
 ever occur in the human structure is not known ; upon this point neither 
 Hunter nor Paget give any information. 
 
 (g.) Mucous Cysts. — Under this head may be included all cysts found in mu- 
 cous tissue. They occur in various parts of the body, but attack most fre- 
 quently the female sexual organs. They grow either singly or in clusters, and 
 are generally oval. The cyst-wall is sometimes thin and membranous, in other 
 cases thick and tough ; the contents vary greatly ; generally they consist of a 
 transparent or opaline viscid fluid ; at other times this fluid is dark, turbid, 
 greenish or nearly black ; and Mr. Caesar Hawkins relates a case in which 
 it closely resembled fluid faeces. By microscopical analysis it is found to 
 contain corpuscles, granular molecular matter, and cells. (See also " Ka- 
 nula.") 
 
 (h.) Colloid Cysts. — The term " colloid " is applied to those cysts which con- 
 tain gelatinous substances ; the contents " may range between pellucidity 
 and the thickest turbidness, and may be of all hues of yellow, olive-green, 
 orange, brown, pink, and nearly black." J These cysts occur in the thyroid 
 gland and the kidneys, and, according to Professor Tobold, are occasionally 
 found in the larynx. 
 
 Colloid Tumor beneath the Eye. — A girl of about fifteen years of age suffered 
 
 * Vide Erichsen's Surgery, p. 392. f Paget's Surgical Pathology, p. 349. 
 
 X Vol. iv., page 98. 
 
196 A SYSTEM OF SURGERY. 
 
 from a fluctuating and rapidly-growing tumor on the right side of the face, 
 over the malar bone. It was easily removed by a single straight incision. 
 The contents of the sac were peculiar, being oily and of a semi-fluid 
 consistence. Erysipelas followed this operation, but the recovery was com- 
 plete. 
 
 I have mentioned elsewhere the cases of proliferous cysts that have come 
 under my observation. Very many other cystic tumors of the classes which 
 I have now given have been successfully removed, but they presented 
 nothing worthy of record. 
 
 The last variety of simple cysts are those formed by the inclosure and 
 dilatation of a duct and the transformation of its contents. Under this head 
 may be included " milk tumor," " seminal cysts," or " encysted hydrocele 
 of the cord," and some forms of ranula. The walls are generally composed 
 of " fibrous tissue, lined with tessellated epithelium." 
 
 The contents are either a serous fluid or the natural secretion of the part ; 
 par example, seminal cysts may contain either semen or spermatozoa. In 
 the latter case, the cyst seems to acquire a secreting power of its own, for it 
 is entirely unconnected with the proper secretory apparatus. 
 
 (i.) Compound or Proliferous Cysts have been already defined as those " which 
 contain highly organized substances, and possess the power of producing 
 more highly organized and even vascular structures." 
 
 Cysto-sarcoma is a peculiar disease, and has given rise to considerable dis- 
 cussion among pathologists. It consists, however, in cyst-formation devel- 
 oped in different or heterologous parenchyma, and it is said to occur much 
 more frequently in females than in males. The mammary gland is pecu- 
 liarly liable to be attacked with it, although it may occur in bone, within 
 the medullary canal, or in the compact structure. 
 
 According to Johannes Miiller, we find three varieties, which he describes 
 thus: 
 
 u 1. Cysto-sarcoma simplex, in which the cradle mass does not intrude at 
 all into the cavity of the cyst, is of the rarest occurrence. 
 
 " 2. Cysto-sarcoma proliferum is engendered by the development, within the 
 terminal excrescence bulbs of the acinus-like cavities, into filial cysts, and 
 the intergrowing of the cradle mass is here repeated. 
 
 " 3. The cysto-sarcoma phyllodes of Johannes Miiller, with its amply devel- 
 oped warty cauliflower and foliated or cock's-comb-like ingrowths, has 
 nothing to mark it beyond the size and development of the excrescences. 
 The cyst-membrane is here no longer demonstrable, having coalesced with 
 the cradle mass of the cyst. 
 
 " It has been stated that the dendritic intrusions into the cyst may occur 
 at one point only of the cyst, at several points, or, lastly, at all points sim- 
 ultaneously. In the last case they converge, coalesce, and eventually fill 
 the entire cyst, determining thus its aggregate lobulated structure." 
 
 It will readily be seen how well the last description answers to the case 
 about to be mentioned. It is asserted that the " chronic mammary tumor," 
 so often spoken of by Sir Astley Cooper— the " imperfect hypertrophy of the 
 mammary gland," of Mr. John Birkett — are somewhat analogous tumors to 
 the cysto-sarcoma of Miiller.* 
 
 Mr. Paget, f in his lecture on compound or proliferous cysts, embraces 
 under this head the sero-cystic sarcomata, mentioned by Sir Benjamin Bro- 
 die in his lectures on pathology and surgery, the tuberous cystic tumors of 
 Mr. Caesar Hawkins, and cysto-sarcoma phyllodes and proliferum of Miiller, 
 and describes the cysts as having abundant power of producing more highly 
 organized and even vascular structures. 
 
 * Rokitansky, Pathological Anatomy, vol. ii., p. 194. 
 f Surgical Pathology, p. 352. 
 
CYSTIC TUMOES. 
 
 197 
 
 It appears to me, however, that the proliferous cystic structures are made 
 by Mr. Paget to include too great a variety of growths, and that the sur> 
 divisions adopted by Miiller and Rokitansky are much more readily un- 
 derstood by the student, as by their classification he is enabled to detect 
 the true pathology of the cases when he meets them in practice. 
 
 These tumors grow to great extent, sometimes rapidly, sometimes slowly, 
 often with long intervals of rest. They generally appear upon the breasts 
 of unmarried and childless women, but cases occur sometimes in the child- 
 bearing woman ; a few have been known to occur in the breast of the 
 male. They are nearly all spherical in form, the large ones irregular, 
 knobbed, lobulated, and* tolerably resistant, elastic, and feeling like a cyst 
 filled with fluid ; the small ones are smooth, even and regular in shape. 
 The skin sometimes adheres to the tumor, and has a dark livid appearance, 
 and is filled with enlarged veins. The mammary gland wastes and dies. 
 
 These tumors are painless, but multiply rapidly, and often reappear 
 several times after removal. In many respects they are similar to the 
 fibrous tumor of the uterus and enchondroma. 
 
 The case of cysto-sarcoma illustrated in Fig. 94, is one which, in many 
 respects, is very interesting. The patient, a lady sixty-eight years of age, 
 
 Fig. 94. 
 
 The author's case of Cysto-Sarcoma. 
 
 about twenty years ago, noticed a tumor in the right breast, the size of a 
 hickory nut. This was shown to many surgeons, many physicians, and 
 many quacks, with just as many different opinions ; some declaring it was 
 scirrhus, others that it was fibrous, others that it was serous, and some pro- 
 posing an immediate operation. 
 
 To this latter proceeding she was utterly averse, and never, throughout 
 the twenty years' duration of the tumor, could she be prevailed upon to. 
 have a scalpel brought near to the diseased mass. 
 
 Daring a number of years other growths made their appearance, and she, 
 during this period, made a visit to Europe for the purpose of placing herself 
 under the care of the most distinguished physicians and surgeons. She 
 
198 A SYSTEM OF SURGERY. 
 
 saw many eminent medical men of both schools, and finally placed herself 
 under the somewhat notorious Lutze, who promised a cure. After three or 
 four years of travel — the tumor continuing to enlarge — she returned to 
 America and applied a variety of salves, washes and ointments, and was 
 visited by spiritualists, soothsayers, astrologists, and charmers, many of 
 whom promised to remove the now enormous mass, and some in an in- 
 credibly short space of time. 
 
 I was called to see her about six or eight months before her death, and 
 found the following characteristic symptoms and appearances: The tumor 
 extended from the clavicle to below the waist, and from beyond the centre 
 of the anterior wall of the thorax, under the axilla and around by the back, 
 and was growing steadily. It presented an uneven surface, and portions of 
 the integument rising over the nodulations were bluish in color. These 
 eminences were circumscribed ; fluctuation was very evident in them, and 
 they were not only scattered over the surface of the gland itself, but were 
 appearing above the clavicle and under the integument along the lower 
 margin of the mammary gland. 
 
 She then was suffering from some dyspnoea, and complained of occasional 
 rigors. On the surface of the larger cysts a slight bluish tinge had formed, 
 and the base — apparently fixed to the thorax — was very hard, firm, and 
 nodulated. The general health was somewhat impaired, although at times 
 she would appear almost as well as usual. There was profuse perspiration 
 and some cough. 
 
 After a careful investigation of the case and a minute examination of the 
 tumor, at the same time taking into consideration the age of the patient, 
 I gave the opinion that very little could be expected from any treatment, 
 whether medical or surgical, and that the only indications for relief con- 
 sisted in endeavoring to prevent the further extension of the morbid growth, 
 and to keep up the general strength of the patient. I gave her many medi- 
 cines, among others calc, silk., kali iod., mix, sulph., etc., without much 
 benefit, and then remembering the peculiar action of kali bromatum in many 
 forms of cystic disease, and having no especial indications to guide in the 
 selection of other medicines, and no surgical interference being allowed, 
 even if it had been deemed necessary, I concluded, at a venture, to place 
 her under the action of the bromide of potash. I began with two grains 
 three times daily, and continued it for two weeks, when a most remarkable 
 action took place in the tumor. Two of the larger cysts opened, and the 
 amount of discharge that passed away was so large and so long continued 
 as to utterly surprise all who beheld it. Three smaller cysts which lay 
 beyond the internal margin of the gland disappeared ; one on the apex of 
 the shoulder also disappeared, and the balance of the tumor shrunk per- 
 ceptibly. The medicine was still continued, lessening the dose, however, 
 when two other large cysts at the inferior surface of the tumor gave way 
 and freely discharged. After the evacuation of the liquid, in the bottom of 
 the cavities were huge masses of decomposed substance resembling the 
 cores of decayed apples or of bulbous vegetation. This I scraped away in 
 large quantities, the tumor, meanwhile, growing smaller, but the patient 
 evidently very much weaker. The decayed masses which were removed 
 were very fetid, and it was only by the use of constant injections of carbolic 
 acid, and the application of disinfectants, with careful attention to proper 
 ventilation and cleanliness, that she could be kept at all comfortable. She 
 had from time to time many symptoms which would indicate the occur- 
 rence of paralysis of the affected side, but these would gradually subside. 
 
 After several months of this treatment, she finally succumbed to the 
 disease. Although an urgent request was made no autopsy was allowed. 
 
CYSTIC TUMORS. 199 
 
 This case is recorded not only from the rarity of its nature but to mark 
 the action of the bromide of potash. 
 
 Whether the rupturing of some of the cysts and the disappearance of 
 others were merely coincidences occurring after the bromide had been given, 
 or whether it was the true action of this important medicinal agent, I am 
 at a loss to determine, although I am disposed to place the changes which 
 took place in the morbid mass to the action of the medicine, and I think 
 I may do this with some confidence, when it is remembered what peculiar 
 action this medicine has been known to possess in other forms of cystic 
 disease. 
 
 In Proliferous Ovarian Cysts we find two principal varieties of endogenous 
 cystic growths ; those that are spheroidal have broad bases, and are similar 
 in structure to the parent cyst ; and those that are slender have thin walls, 
 are attached by pedicles, and occur in clusters. In- 
 termediary and mixed forms also occur in which FlG> 95 
 the characteristics of each class are present to a 
 certain degree. 
 
 Cysts of the Chorion — " the hydatid mole " of some 
 writers — are developed, according to Paget, in the 
 following manner : certain cells of the villi degen- 
 erate, enlarge, and form cysts, upon whose surface 
 new villi spring up, which, in their turn, undergo 
 a cystic transformation ; and this process may be 
 repeated indefinitely. As the result of these changes, 
 the chorion becomes covered with oval, pellucid vesi- 
 cles, which contain a limpid fluid, and are attached A 
 by " long, slender, and often branching pedicles," Hydatid Cysts of the chorion, 
 as represented in the accompanying cut (Fig. 95). 
 
 Hydatid Tumors are composed of cysts containing entozoa or hydatids. 
 The cyst-wall is strong, composed of fibrous tissue, possesses considerable 
 vascularity, and contains a dirty-looking pulpy substance, in which the 
 parasite is found. The hydatid itself contains a limpid saline fluid, odor- 
 less and incoagulable. These entozoa " perish in a few years from suppu- 
 ration, gangrene, or gradual drying up of their contents. Under such 
 circumstances, the inclosing cyst is often remarkably thickened and even 
 transformed into fibrous tissue."* These tumors vary in size "from a 
 mustard seed to a small orange ;" are globular in shape, and of a whitish 
 color. They generally occur in the liver, uterus, and ovaries, and are occa- 
 sionally found in the testicles, mamma?, and serous cavities. By the irrita- 
 tion of their presence they sometimes produce fatal inflammation. 
 
 Hydatid tumors may also occur in the cancellated tissue of bones. When 
 existing near articular extremities,. they may cause destruction of the joints, 
 giving rise to intense pain, and often inducing hectic fever. 
 
 (&.) Retention Cysts — Sebaceous Cysts have been variously described by 
 different authors, as encysted, atheromatous, melicerous, and steatomatous 
 tumors ; when situated on the scalp they are generally known as wens. 
 Most surgical writers hold with Sir Astley Cooper, that these cysts are com- 
 posed of enlarged and obstructed sebaceous follicles ; but Paget claims that 
 in many cases they are essentially new formations. They occur most fre- 
 quently on the scalp, face, and neck, are generally subcutaneous, and may 
 be either single or multiple. In many instances they seem to be hereditary. 
 The cyst-wall may be thin and delicate, or thick, tough, fibrous, and even 
 calcified ; the contents usually consist of a semi-liquid, yellowish-white 
 substance, which, in old cysts, is hard, dry, laminated, and of a brown, 
 
 * Gross's Surgery, vol. i., p. 232. 
 
200 A SYSTEM OF SURGERY. 
 
 green, or blackish color. Examined under the microscope, they are found 
 to contain epithelial scales, granular matter, crystals of cholesterin, and 
 rudimentary hairs. 
 
 When small, they are round, smooth, non-adherent, semi-fluctuating or 
 elastic, grow slowly, and are painless. As they increase in size, they adhere 
 to surrounding tissues, and show a tendency to become pedunculated. 
 Encysted tumors of the scalp, when fully developed, may induce inflam- 
 matory action in the pericranium, causing adhesive and cartilaginous de- 
 generation of that portion of the pericranium lying next the sac. In rare 
 cases the tumor may cause absorption of the outer table of the skull, form- 
 ing " a cup-shaped cavity, with rough, slightly elevated edges." In some 
 instances the cysts inflame and suppurate ; the skin adheres, ulcerates, and 
 the tumor is either thrown off in the discharges, or "the sebaceous matter, 
 exposed by the ulceration of the integument, undergoes a process of putre- 
 faction. In other cases, again, large granulations are thrown out in it ; the 
 atheromatous mass appears to vascularize, becoming irregular and nodu- 
 lated, rising up in tuberous growths, with everted edges, exuding a fetid foul 
 discharge, becoming adherent to subjacent parts, and assuming a semi- 
 malignant appearance. " — (Erichsen. ) 
 
 Paget describes two other varieties of compound cysts : the " cutaneous 
 proliferous," and the " dentigerous." They contain skin, hair, teeth, and 
 other outre substances ; are found most frequently in the ovaries, but may 
 also occur in various other parts of the body, and exist either in connection 
 with other tumors, or as independent growths. 
 
 Treatment. — Homoeopathic remedies sometimes prove successful in re- 
 moving the different varieties of cysts. 
 
 I have seen great advantage from the internal administration of kali 
 brorn., given in two-grain doses three times a day. 
 
 Calc. carb. is recommended by Professor Dunham for encysted tumors of 
 the head and neck, with fluid or semifluid contents. 
 
 Apis, arsen., graph., hepar, iod., kali bichr., lye, mere, phos., sil., and 
 sulph., may be tried. 
 
 Electrolysis is also recommended by various authors, and may prove useful 
 in some cases. 
 
 A seton may occasionally be efficacious, and in a few instances a radical 
 cure has been effected by subcutaneous puncture and evacuation. 
 
 The cysts may also be punctured and injected with a strong solution of 
 iodine, sulphate of zinc, or some other irritating substance, to produce 
 adhesive inflammation. 
 
 Dr. John Pattison, of London, reports several brilliant cures by enuclea- 
 tion ; he cuts down upon the cyst, evacuates its contents, and fills the cavity 
 with cotton-wool, smeared with an enucleating paste, composed of equal 
 parts of powdered hydrastis root, chloride of zinc, flour, and water. 
 
 If these various methods fail, the only resource is complete extirpation 
 both of the tumor and the wall of the cyst. Great care must be taken to 
 remove the cyst-wall entire, for if the slightest trace of it be suffered to 
 remain, the cyst may probably be reproduced. 
 
 Sebaceous Cyst of the Prepuce. — A unique case of this kind came recently 
 under my care. The patient was one of Dr. Bartlett's, of New York. He 
 was a healthy boy of about eighteen months. He had an enormously 
 enlarged prepuce, on the rignt side of which, at birth, was noticed a small 
 round tumor, about the size of a pea. This remained stationary for some 
 time, but after a period of months it began to grow rapidly. Circumcision 
 was all that was necessary. The tumor had a firm envelope, and contained 
 a substance resembling cottage cheese in texture, and smelling exactly like 
 the secretion from the glands of Tyson. 
 
SCROFULA. 201 
 
 Cysts with Mixed Contents. — An elderly lady had upon the top of her 
 head a large tumor, which had been there for very many years ; latterly it 
 had begun to grow, and presented such evident signs of suppuration that I 
 cut into it. There was a considerable discharge of pus ; afterwards a large 
 amount of cheesy-looking substance was removed with a sac, which at its 
 base was of a cartilaginous hardness. 
 
 For serous and hydatid cysts in bones, the following methods of treatment 
 have been proposed : 
 
 1. Cutting down upon the tumor, evacuating its contents, and painting 
 the cyst-wall with iodine. 
 
 2. Trephining and evacuation ; opening and counter-opening with pres- 
 sure ; in bad cases, resection or amputation. 
 
 CHAPTER X. 
 SCROFULA— STRUMA— TUBERCULOSIS. 
 
 Definition — Treatment— Scrofulous Ulcer — Division of Tubercle— Gray and 
 
 Cheesy Granulations. 
 
 The term scrofula is supposed to have derived its origin from the circum- 
 stance that swine were said to be subject to the disease, though the correct- 
 ness of this etymology has been rendered very questionable by the remarks 
 of Dr. Henning* and the statement that these animals are really liable to 
 be attacked appears to be erroneous. The disease received likewise the 
 appellation of struma, or king's evil, from the custom of submitting patients 
 affected, to the royal touch. It is an affection, one of the chief or most pal- 
 pable symptoms of which, is a chronic swelling of the absorbent glands in 
 various parts of the body, with a gradual tendency to imperfect suppu- 
 ration. Our ideas of scrofula, however, would be very indefinite, were we 
 to define the disorder as a morbid condition of the lymphatic glandular 
 system; for, as a judicious author observes, f "the system of absorbent 
 glands, it is true, seldom or never fails to become affected in the progress of 
 the disease ; but there is reason to believe that scrofula appears for the first 
 time in parts that do not partake of a glandular nature." There are, per- 
 haps, but few of the textures or organs of the human body that are not 
 liable to attacks of scrofula, even as an original idiopathic disease. 
 
 Scrofula is a constitutional affection, which is generally developed early 
 in life, and exhibits its presence by many and varied signs. The glands, 
 the bones, the joints, the skin and mucous membranes may suffer by turns 
 or simultaneously, at the same time many constitutional symptoms pre- 
 senting, both difficult to manage and liable to recur. Indeed, in scrofulous 
 persons, we know not when to foresee a new outbreak of the disease. 
 
 Throughout the body tubercles may develop themselves, and all the 
 structures be invaded and infiltrated by them. 
 
 The disease may be hereditary or it may be acquired ; it may descend 
 from generation to generation, or may develop in an apparently healthy 
 child, born of unhealthy parents. Exposure, want, privation, poor venti- 
 lation, abuse of mercury, and other causes develop the disease. Struma, 
 however, must be considered a vague term, and it must not be allowed to 
 
 * Critical Inquiry into the Pathology of Scrofula, 
 f Thompson's Lectures on Inflammation, p. 134. 
 
202 A SYSTEM OF STTRGEKY. 
 
 cover too wide a field. It was formerly the custom to attribute all diseases 
 of the bones and the glands to this affection, but at the present day the term 
 is more restricted. 
 
 On this subject. Mr. Paget writes : " Scrofula or struma is generally under- 
 stood as a state of the constitution distinguished in some manner by pecu- 
 liarities of appearance even during health, but much more by peculiar 
 
 liability to certain diseases, including pulmonary phthisis Little 
 
 more can be said of them than that, as contrasted with other diseases of the 
 same appearance and parts, the scrofulous diseases are usually distinguished 
 by mildness and tenacity of symptoms. They arise from apparently trivial 
 local causes, and produce, in proportion to their duration, slight effects ; 
 they are frequent, but not active."' 
 
 The glands show the most marked disposition to the disease, and it is not 
 infrequent to find children in whom the cervical, axillary, and mesenteric 
 glands are enlarged, infiltrated, and tuberculous. Fig. 96, from Mr. Druitt's 
 
 Fig. 96. Fig. 97. 
 
 Elements shown by teasing ont a miliary tubercle (after Eind- 
 fleisehi. 1. The large tuberc-re-cells. 2. The small tuberele-oells. 
 3. Endogenous cell development. 4. Delicate reticulum from 
 the interior of a miliary tubercle, the cells partly removed by 
 pencilling. 
 
 work, represents the enlargement of the mesenteric glands of a scrofulous 
 patient. Males are more liable to external scrofula than females ; * while 
 in the latter, the phthisical diathesis is more frequent. + 
 
 There are said to be two varieties of tubercle ; the miliary, or. as they are 
 termed, the " gray granulations " of Bayle. and the " yellow " or " chees-y.'' The 
 first are small (Fig. 97). and, as their name implies, bear a close resemblance 
 to millet seed; they have irregular borders and possess no moisture; 
 whereas the latter are soft like cheese or putty. Many, and indeed most 
 pathologists, regard these two varieties as but different stages of the same 
 deposit ; the hard being the early stage of life, the soft the more advanced. 
 This, by analogy, would certainly appear to be a reasonable deduction. The 
 question, however, is by no means satisfactorily determined. 
 
 Tubercles possess a very low grade of vitality, and are composed of an 
 aggregation of granules and corpuscular bodies of various forms and shapes. 
 about 210 o tn °f an mcn i n their long diameter, and are composed, chemi- 
 cally, chiefly of nitrogenous substances, albumen, cholesterin, and many of 
 the ordinary salts : they are very prone to degenerate, and show a great 
 tendency to infiltration, making the ordinary "tubercular infiltration." The 
 
 * Scrofula and its Nature, by Sir B. Phillips. 
 
 f Dr. Walsh's Eeport on Phthisis. British and Foreign Med.-Chir. Rev., Jan., 1S49. 
 
TREATMENT OF SCROFULA. 203 
 
 formation of these peculiar bodies is now supposed to arise from the degen- 
 eration of inflammatory exudation, and Virchow thinks they originate from 
 degenerate cell proliferation. 
 
 Villemin demonstrated that tubercles may be transmitted from man to 
 the inferior animals by inoculation, and from this a transmitted specificity 
 was argued, but it has been also proven that tuberculous deposit may take 
 place from the mere introduction of non-specific matters into the body. 
 Billroth states that a very small amount of irritation applied to rabbits and 
 guinea pigs can establish tuberculosis. 
 
 Treatment. — The treatment of the various diseases which either directly 
 arise from scrofulous cachexy, or are dependent thereon, would comprise 
 more space than can be allowed here ; the following medicines, however, may 
 serve as an outline to guide the student in the selection of others, which may 
 prove appropriate to each presenting case. Many of the diseases dependent 
 upon struma will also be mentioned in different portions of this work. 
 
 The medicines are in general: ars., asaf., baryta c, bell., calc, cina, con., 
 hepar, iod., lye, mere, rhus tox., silic, sulph. ; also aur., bromine, carb. an., 
 carb. veg., cist., dulc, graph., kreos., mere, iod., staphis. 
 
 At the commencement of the disease, when children exhibit a tardiness 
 in learning to walk, the principal medicines are : bell., calc, silic, sulph., 
 and perhaps ars., china, cina., ferrum, lye, magnesia mur., pinus, puis., sep. 
 
 In the second stage, when there are glandular affections, the medicines 
 especially indicated are : bary. c, bell., bro., calc, cist., con., dulc, hepar, 
 lye, mere, phosph., rhus t., silic, staphis., sulph. 
 
 Cutaneous affections : aur., met., bary. c, calc, cist., clem., con., dulc, 
 hepar, lye, mere, mur. ae, rhus t., silic, and sulph. 
 
 For affections of the osseous system : aur. met., calc, lye, mere, phosph., 
 phosph. ae, puis., silic, sulph. 
 
 Atrophy — marasmus : ars., calc, and sulph., or perhaps baryta e, lye, 
 nux, puis., rhus. Sycamore bark has also been found useful. 
 
 Dr. A. R. Clement, of Hannibal, Missouri, communicated to me the 
 
 following remarkable case : " Henry V , set. nineteen, of a strumous 
 
 habit, had been for several years unable to leave the house from the 
 effects of an ulcer situated on the anterior inferior part of the tibia. 
 This ulcer would slough and heal alternately, and discharge a fetid and 
 ichorous matter. His appearance was cadaverous; when walking, his 
 spine assumed the form of a bow, making one think that a posterior curva- 
 ture existed ; assistance was necessary to sustain him in a semi-upright 
 position ; when reclining this curvature did not retain its form, or only 
 partially ; abdomen sunken ; fever, with a pulse of 94. The cuticle pre- 
 sented a pale ashy aspect, and, with the symptoms enumerated, there were 
 others indicative of wasting disease. This was the state of affairs when the 
 sycamore bark infusion was administered. It was given as a dernier ressort 
 by the patient's friends, not that they had confidence in it as a curative 
 agent, but merely to palliate the morbific advance. The change was radi- 
 cal from the start, and after a thorough course of bathing with and drink- 
 ing this infusion, persisted in for one month, the patient was able to leave 
 the house." 
 
 In this case and in others where the sycamore bark has been used, it has 
 been made into an infusion, and taken often in large quantities, the parts 
 also being bathed therein. 
 
 A Scrofulous Ulcer is distinguished from other sores by its inert, pale, and 
 torpid appearance, and the peculiar character of the pus, which at first con- 
 tains many cheesy flocculi, but after a time becomes thin and corrosive. 
 The state of the atmosphere is remarked by some authors to possess influ- 
 ence upon the appearance of the ulcer. In fair weather it may appear dis- 
 
204 A SYSTEM OF SURGERY. 
 
 posed to heal, but in damp, cloudy, and rainy seasons it presents a most 
 unhealthy appearance. The bottom of the sore is uneven, watery, fungous, 
 or ash-colored ; it is extremely difficult to heal, but sometimes after suppu- 
 rating for years the sore closes, leaving a disfiguring cicatrix. These ulcers 
 frequently arise in glandular parts, after inflammation and suppuration. 
 If the gland is merely swollen when the surgeon is called, by the exhibition 
 of mercury, potash or ferrum phos., aur., baryt. c, cistus can.,con.,dulc, or 
 rhus t, in accordance to presenting symptoms, suppuration may be pre- 
 vented. 
 
 Hartmann writes : " To judge by the symptoms the cistvs canadensis seems 
 to be a highly important remedy for scrofulous ulcers. It has swelling of 
 the glands, also with suppuration ; scrofulous ulcers, and other scrofulous 
 ailments ; violent chilliness, with shaking, followed by heat, with redness 
 and swelling of the ears, and swelling of the cervical glands ; discharge of 
 moisture and badly smelling pus from ears; inflammation and painful 
 swelling of the nose ; caries of the lower jaw ; even the swollen, loose, readily 
 bleeding, and sickly-looking gums. The frequent nausea, the diarrhoea 
 after eating fruit, and the pains in the larynx, are indications of the anti- 
 scrofolous nature of this drug."* 
 
 Dr. Hempel relates a case in which the ulcerative process had invaded 
 the nose, and one whole side of the face, threatening to totally destroy all 
 the surrounding parts, and to relieve which American and European physi- 
 cians of the highest standing had exhausted all the resources of their skill 
 without any apparent effect, — that was radically healed by using an infusion 
 of cistus canadensis internally, and embrocations of the same plant externally. 
 The patient was an interesting young lady of eighteen years of age.f 
 
 The ulmus rubra, bayberry, the cornus circinata, phytolacca and trillium 
 have all been used, especially throughout the western portion of our coun- 
 try, for the varied ailments arising from scrofula. 
 
 The more minute treatment of scrofulous diseases will be detailed in other 
 chapters. 
 
 Dr. E. M. Hale! nas found cistus canadensis better than calcarea when the 
 patient is thin and scrawny, and stillingia should be used if a syphilitic 
 taint is suspected. 
 
 I must here, however, in conclusion, say that the use of cod-liver oil freely 
 given, with the different preparations of lime (calc. carb. and hepar) together 
 with iodide of potash is the most beneficent treatment. I have seen, indeed, 
 marked improvement after its employment. This method, however, must 
 be continued steadily for a length of time. 
 
 The diet is also of very great assistance in the cure of tuberculosis, and 
 . must be rigorously attended to. I have been successful in many cases with 
 a system of diet which is simple and easily carried out. I give the patient, 
 if a child, the juice of a lemon, pure, every morning and night; if the 
 patient be an adult, I administer double the quantity. During the day, 
 nothing — absolutely nothing — but milk is allowed, and this taken suffi- 
 ciently often to appease hunger; water occasionally as a drink is permitted. 
 During this period the appropriate medicine is given. The skin is kept in 
 good condition by frequent bathing, and as much sunlight and fresh air 
 allowed as possible. 
 
 * See Hartmann's Diseases of Children, p. 379. f Loc. cit., p. 380. 
 
 % New England Medical Gazette, vol. xii., p. 446, 1877. 
 
SYPHILIS. 205 
 
 CHAPTER XI. 
 VENEREAL DISEASES. 
 
 History of Syphilis— Gonorrhoea — Gleet — Balanitis — Gonorrhoea in Women 
 — Gonorrheal Rheumatism — Gonorrhoeae Ophthalmia— Sycosis. 
 
 History of Syphilis. — Under the name venereal disease we find gonor- 
 rhoea, blennorrhea ; the soft chancre or chancroid ; and the " true chancre," 
 or " hard chancre," or " indurated chancre," of Hunter, together with the 
 many symptoms and appearances known as syphilis. 
 
 The question concerning the origin of syphilis, has given rise to much 
 argument, and to many learned discussions. The three suppositions that 
 appear most worthy of notice are : 
 
 1st. That the disease was brought from America by the Spaniards. 
 
 2d. That it originated in Europe. 
 
 3d. That it has been observed from the earliest periods of human exist- 
 ence. 
 
 The first of these suppositions was promulgated to a great extent by 
 Oviedo, a Spaniard; indeed, he received from writers upon this subject the 
 entire credit of having traced the course of the disorder. To whatever 
 reputation, however, may attach to such research, Oviedo was not entitled, 
 inasmuch as Leonhard Schmauss, Professor at Salzburg, in the year 1518, 
 had declared the same fact. The opinion of Schmauss was adopted by 
 Chevalier Uirich von Hutten (known afterwards for his zeal and attachment 
 to the cause of Luther) A.D. 1519. The assertion, nevertheless, of its 
 American origin did not find very many supporters, notwithstanding it was 
 strenuously advocated and enforced by Oviedo. Among those, however, 
 whose minds were impressed with its truth, were several individuals of 
 much celebrity. If Oviedo was quite sincere in the opinion he expressed, 
 it is certain that feelings of a personal nature very much contributed to 
 augment the warmth and energy with which he maintained his position. 
 
 Among the distinguished opposers of the American origin of this dis- 
 order was Van Helmont, who oelieved it to be a new disease, supposed its 
 birthplace to be Europe, and that it was generated in the army of Charles 
 VIII. at the siege of Naples. Howard, at a later period, supported the 
 same opinion. 
 
 In the year 1680, Samuel Jansen, who had resided for some years in the 
 West Indies, not having observed the appearance of syphilis endemically, 
 supposed that it was brought by the slaves from Africa. It is well known 
 that both Sydenham and Boerhaave favored this opinion, and the latter 
 defended it warmly in 1751. But slaves were not carried to America pre- 
 vious to the year 1503, and at that time the disease was prevailing over all 
 Europe. 
 
 An Italian alchemist propagated, also, a very curious idea concerning the 
 origin of this disease. Lord Bacon credited the story, and endeavored by 
 his writings to render it more plausible. " The length of the siege of 
 Naples," says Leonardo Fioravanti, " having caused a famine among the 
 French and Spanish troops, the merchants who brought food to the soldiers 
 sold them various articles prepared from human flesh, and all those who 
 made use of the horrible aliment were soon affected with syphilis, which 
 was disseminated by contagion through Italy, France, and Spain." Finally, 
 J. Astruc,* a man of much learning and great natural talent, but whose 
 
 * De Morbis Veneris, Libri Sex, Paris, 1736. 
 
206 A SYSTEM OF SURGERY. 
 
 acquirements, according to Jourdan, have been greatly exaggerated, endeav- 
 ored, and succeeded in many instances, in convincing the world that the 
 disease was imported from America. He was supported, also, by Christopher 
 Girtanner, a person of many and varied literary and scientific attainments. 
 But Jourdan, taking up the arguments that were brought forward, disposes 
 of them one by one in a most satifactory manner. His pamphlet* bears 
 the impress of deep thought, and of a vast amount of learning, toil, and 
 research, and should be perused by every student who is interested in this 
 subject. He thus writes: "The question is generally put, did syphilis 
 appear for the first time towards the end of the fifteenth century? The 
 terms are not sufficiently explicit, since, as a preliminary matter, it is neces- 
 sary to explain what is meant by syphilis. Now this definition, which has 
 been neglected by all writers, is the only way of duly appreciating, judging, 
 and reconciling the different opinions successfully advanced on this subject. 
 By the term syphilis, therefore, is to be understood : 1st. A general affection 
 of the system, which presents itself under a most frightful aspect, with 
 many particular modifications, assuming a real epidemical character. In 
 this sense the word designates the disease which broke out towards the end 
 of the fifteenth century. 2d. It may serve to express morbid symptoms 
 arising from an intercourse with a disordered person, communicated in the 
 same way to other individuals, and having with each other a more or less 
 intimate connection. Now, if we use the word syphilis in this last sense, 
 it can be incontestably proved, that from the remotest antiquity the diseases 
 which it designates were known." 
 
 He then proceeds to prove his above statement in a concise manner, 
 and mentions among others who have noted the disease, Guy de Chauliac. 
 Peter Argelata says that pustules arise on the penis " ex materia venenosa 
 quse retinetur et remanet inter prseputium et pellem cutis ex actione viri cum fseda 
 muliere." In the thirteenth century, Lanfranc, Salicet, and others, spoke of 
 the same disease in terms which prove how far they considered it worthy 
 of attention. There have been also many passages collected by Becket 
 from manuscripts which make mention of it. What likewise proves that 
 the diseases of that period were considered of a serious and formidable 
 character is, that the authorities in order to prevent their propagation 
 enacted severe laws, the penalties for the violation of which were rigidly 
 exacted. Hence the regulations for the houses of pleasure in London in the 
 years 1162 and 1430. Similar establishments and regulations existed in 
 most of the large cities of Europe from the time of Charlemagne. Medical 
 and historical writers make mention of diseases contracted at such houses, 
 called clapiers. Jourdan quotes many authorities in favor of the affection 
 having been noticed and mentioned by writers at a very early date,f but it 
 is unnecessary that they should be named here. 
 
 He is also of opinion that the terrible epidemic which prevailed about 
 the close of the fifteenth century, originated with the Marranes (hogs). This 
 term was applied to those Moors and Jews who had entirely disregarded the 
 teachings of Christianity, and refused to enlist under its banner ; for this 
 offence they were expelled from Spain by an edict of King Ferdinand, dated 
 March, 1492. The persecutions were unremitting, and the tortures to which 
 this unfortunate class were subjected were horrible in the extreme; to avoid 
 which they concealed their belief, but secretly practiced those rules that 
 were prescribed by their religion. They are described as living in the most 
 disgusting and loathsome manner, and leprosy among them was alleged to 
 be common. They were driven from their homes, not allowed to carry with 
 
 * Historical and Critical Observations on Syphilis. 
 f See Leviticus, chap, xv., 2-27. 
 
SYPHILIS. 207 
 
 them any of their property, and very many of them retired to the northern 
 coasts of Africa, where they propagated a disease so terribly contagious, 
 that of 170,000 families who crossed to Africa, 30,000 were destroyed. 
 Jourdan says :* " When we compare the testimonies of the most veridical 
 historians and physicians, we think it impossible to doubt its being derived 
 from the Marranes, who were expelled from Spain before the discovery of 
 America." Fulgosi, among others, tells us that it originated in Ethiopia, 
 " quse pestis, ita enim visa est, primo ex Hispania in Italiam allata, et ad Hispanos 
 ex Ethiopia." At that time all the parts of Spain occupied by the Moors 
 were called Africa, and afterwards Ethiopia. Infessura, who noticed the 
 first ravages of the epidemic at Rome, calls it pestis Marranorum : Mortui 
 sunt quam plurimi ex peste et contagione Marranorum. Beniveni, Benedetti, 
 and Trascatorius derive it from Spain. John Trithamius, abbot of Span- 
 heim, likewise informs us that it originated in that country : habet suae infec- 
 tionis pestiferse principium in Hispania. The period of its appearance exactly 
 corresponds to that of the expulsion of the Marranes. Fulgosi announces 
 its existence in Lombardy as early as 1492. We find it among the Germans 
 in 1493 and 1494. John Pomarus says it appeared in Saxony in 1493. 
 Henry Bunting affirms the same thing for Brunswick and Lunenburg. 
 According to John Sciphover, it broke out in 1494 in Westphalia, from 
 whence it soon spread from the coasts of the Baltic Sea to Pomerania and 
 Prussia ; and, as mentioned by Linturius, it manifested itself in 1494 on the 
 borders of the Rhine, in Suabia, Franconia, and Bavaria. The expul- 
 sion of the Marranes dates from the year 1492. These unfortunate wretches 
 who left Spain, according to Fabricius, to the number of 124,000 families, 
 or of 170,000, as mentioned by Mariana, lost, according to the same Fabri- 
 cius and John Mariana, 30,000 families of a most fatal epidemic, which 
 appeared to be of a peculiar nature. The disease not merely spread to 
 Rome, as mentioned by Infessura, but also infected Naples, according to 
 Zureta and Collenuccio, and even was propagated to the coasts of Barbary. 
 Leo, the African, says, that the disease anterior to the landing of the Mar- 
 ranes was unknown in Africa. Paul Jovious attributes also the extension 
 of the disease to these exiles. Finally, some passages from Peter Martyr, 
 Francis de Villaloros, and Peter Pinctor, which, owing to their want of 
 clearness, have been refuted by the partisans of the American origin, seem 
 to indicate that the epidemic already existed in Spain during the last twenty 
 years of the fifteenth century, consequently before 1490. It is not surpris- 
 ing that such considerable collections of people, whom the avarice of Fer- 
 dinand had deprived of all the necessaries of life, and consequently thrown 
 into the most disgusting filth, the inseparable attendant on misery, should 
 have spread wherever they passed a contagious cutaneous disease, compli- 
 cated with scorbutic symptoms, which were necessarily produced by the 
 dampness and the excessive heat of the weather. This is the idea we natu- 
 rally form of the terrible epidemic of the fifteenth century. 
 
 The epidemic thus spread over all portions of Europe. In Germanyf the 
 propagation of the disease was principally attributed to the Lansquenets, a 
 military rabble, who were constantly ready to sell their lives and bjood to 
 the highest bidder. In the latter end of the fifteenth century, the whole of 
 Europe being engaged in war, the disease once propagated among the 
 common soldiers, readily spread over the whole continent. A similar con- 
 fusion prevailed in regard to the mode in which the disease was propa- 
 gated. It was believed by many that the virus could be carried in the 
 atmosphere, or that any article which a person afflicted with the disease 
 
 * Loc. cit.y p. 99. 
 
 f See Gollmann, on Diseases of the Urinary and Sexual Organs, p. 45. 
 
208 A SYSTEM OF SURGERY. 
 
 had touched, was capable of imparting the disorder. Fallopius supposed 
 that the disease might be propagated by the holy water into which a 
 syphilitic patient had dipped his ringer. 
 
 In the year 1556, Fernet proved that the disease originated from a specific 
 cause, emanating from some affected individual, and acting upon one in 
 health ; he opposed the idea of the transmission of the virus by the atmos- 
 phere, and denied the belief in cosmic or astrological influences ; he also 
 described with tolerable accuracy its mode of transmission. After a lapse 
 of three hundred years, Fernel's picture of the syphilitic disease is still true, 
 as is shown by the descriptions of the most enlightened and learned physi- 
 cians of the present day. 
 
 Gonorrhoea, or a contagious secretion from the urethra in the male and 
 from the urethra and vagina in females, is a disease of very ancient date. 
 It arises from impure connection, from contact of inflammatory secretions, 
 introduction of instruments, etc., and may be divided into three stages: 1. 
 That of incubation. 2. The inflammatory. 3. The subacute stage. When 
 the discharge ceases, burning and pain disappear, and the parts regain their 
 original condition ; or if not properly managed a gleet may remain, which 
 may last for months, nay, even for years. 
 
 The presence of a specific germ in this affection is claimed by Neisser and 
 others, and has received the name gonococcus. True gonorrhoea, it is said, 
 may thus be diagnosed from other forms of urethritis. 
 
 The symptoms are as follows : A few days, generally from four to six, or 
 even more,* after copulation, a tickling or slight itching is felt in the urethra 
 near the frsenum ; this sensation continues one or two days, when the mouth 
 of the urethra acquires an increased sensibility, becomes red and swollen, and 
 there oozes or is discharged a limpid or yellow matter which stains the linen. 
 When the running occurs, the titillation increases and becomes more 
 painful, especially during the emission of urine, which is followed by a 
 smarting and burning in the affected part. In some persons the first 
 symptom observed is the discharge of thick mucus ; in these cases the 
 patient experiences a painful scalding when passing water. 
 
 These symptoms usually increase for three or four days; sometimes, 
 however, not sensibly, for eight to twelve days. The glans penis acquires a 
 dark-red livid color ; the discharge becomes more profuse, the matter be- 
 coming of a yellowish-green color, the swelling of the glans and sometimes 
 even of the whole penis becomes considerable, the patient experiences a 
 frequent desire to void urine, and suffers, particularly when he has been 
 some time in bed, lying on his back, from involuntary erections, so frequent 
 as to disturb his rest. 
 
 In many cases the inflammation extends to the reticular substance of 
 the corpus spongiosum ; the erections, when this is the case, become ex- 
 tremely painful ; the frsenum being drawn down, while the body of the 
 penis is forced upward, from extreme turgescence; such a condition is 
 termed chordee. When in this state the vessels of the urethra are often 
 ruptured, occasioning considerable haemorrhage, while at other times the 
 discharge is only streaked with blood. The prepuce is also at the same time 
 so inflamed and swollen that it cannot be drawn back (acquired phimosis), 
 or when retracted it cannot be returned (paraphimosis). 
 
 In some instances the urethra discharges small clots or even fluid blood, 
 and there are evident marks of an ulceration of the canal. 
 
 The inflammation may increase to such an extent that there will be no 
 
 * Gonorrhoea may lie dormant in the system for a considerable time, or it may be retarded 
 in its course by some other disorder attended with fever. For corroboration of this, see Lon- 
 don Lancet, June, 1845, p. 526. I also omit from the definition the term " specific," on ac- 
 count of the present unsettled nature of the question. 
 
GONORRHOEA. 209 
 
 secretion from the glands and the membranes lining the canals. All dis- 
 charge then ceases, and it is to this form of the disease that some authors 
 have improperly applied the term gonorrhoea sicca, or dry clap. 
 
 But the symptoms, their time of appearance, and their violence, vary 
 greatly in different individuals. Mr. Hunter has well remarked* that " the 
 variety of symptoms in a gonorrhoea, and the difference of them in different 
 cases, are almost endless. The discharge often appears without any pain, 
 and the accession of pain is not at any stated time after the appearance of 
 the discharge. There is often no pain at all, though the matter thrown out 
 may be considerable in quantity and of bad appearance. The pain often 
 goes off while the discharge continues, and will sometimes return again. 
 An itching in some cases is felt for a considerable time, which sometimes is 
 succeeded by pain, though in many cases it contfnues to the end of the dis- 
 ease. On the other hand, the pain is often troublesome and considerable, 
 even when the discharge is trifling or none at all. In general, the inflam- 
 mation in the urethra does not .extend beyond an inch or two from the 
 orifice ; sometimes it runs all along the urethra to the bladder, and even to 
 the kidneys ; and in some cases spreads in the substance of the urethra, 
 producing a chordee. The glands of the urethra inflame, and often suppu- 
 rate. The neighboring parts sympathize — as the glands of the groin, the 
 testicles, and the pubes — with the upper parts of the thighs and abdominal 
 muscles." 
 
 In the worst cases, small indurations may often be felt in the course of 
 the urethra, and the prostate gland partakes of the inflammation ; in which 
 event a sense of heat, weight, and fulness is experienced in the perinseum, 
 with pain in the hypogastrium, dysuria, and tenesmus, particularly when 
 the disease has spread to the bladder or its cervix. Abscess, fistula, and 
 permanent disease of the prostate, or stricture of the urethra, are the occa- 
 sional results of such complications. Phimosis, orchitis, and bubo, not 
 infrequently take place from the extension of the inflammation to the pre- 
 puce, testes, and glands of the groin, during the course of gonorrhoea. 
 
 In the majority of instances gonorrhoea is occasioned by impure coitus ; 
 but there are many discharges from the urethra (urethritis) which are occa- 
 sioned by copulation with menstruating women, or those having leucorrhcea 
 or some acrid discharge from the genitals. This, no doubt, is of frequent 
 occurrence, and should be remembered by the surgeon before giving a posi- 
 tive diagnosis. The symptoms presented when the disease has been occa- 
 sioned by the causes just mentioned are not different from those occurring 
 from true gonorrhoea! virus, and are often very intractable, and followed by 
 a gleety discharge of very long duration. 
 
 On this subject Ricord, in his Letters,! says : " But when we go back in 
 the most rigorous manner and with the severest criticism to the determining 
 causes of the best characterized gonorrhoeas, we are forced to acknowledge 
 that a variety is most usually wanting. Nothing is more common than to 
 find women who have communicated blennorrhagias the most intense, the 
 most persistent, the most varied and of the gravest character, who were only 
 affected with uterine catarrhs, which sometimes were scarcely purulent. In 
 other cases the menstrual flux seems to have been the only cause of the 
 communicated disease. Finally, in a great number of cases, we find nothing 
 at all, or only simple changes in diet ; fatigue ; excesses in sexual connec- 
 tion ; the use of certain drinks— beer ; of certain food — asparagus. 
 
 " From this arises that frequency of belief on the part of patients, a belief 
 very often legitimate, that they owe their clap to a perfectly healthy 
 woman. 
 
 * Hunter on the Venereal, p. 61. f Ricord's Letters on Syphilis, p. 47. 
 
 14 
 
210 A SYSTEM OF SUBGERY. 
 
 " On this point, I assuredly know all the causes of error, and I have the 
 pretension to say, that no one more than myself holds himself on his guard 
 against frauds of every kind, scattered in the path of the observer ; but it is 
 with knowlege of the cause that I advance this proposition : women frequently 
 give gonorrhoea without having it. I do not think I go too far in saying that 
 women give twenty claps for one they receive." 
 
 Masturbation is also another frequent cause of urethritis ; the passage of 
 bougies; the internal administration of both mercury and cantharides; 
 worms in the rectum, are other causes. I know of an instance in which 
 sea-bathing invariably produced an attack of urethritis in a gentleman 
 living far in the interior of the country, who occasionally visited the seaside 
 during the heated term. 
 
 An outbreak of secondary syphilitic symptoms often occasions a discharge 
 from the urethra. In such cases as these, particular attention should be 
 given to the case, as the secondary secretions are virulent in the virgin sub- 
 ject, and would produce chancre. 
 
 Gleet, or the existence of a serous or muco-purulent, pale green or color- 
 less discharge from the urethra, is not an unfrequent occurrence after an 
 attack of acute inflammation. It is commonly attributed to chronic in- 
 flammatory action. The most trifling errors in diet, and particularly the 
 use of spirits, wine, and pungent condiments, are generally followed in those 
 affected with the disease by a frequent inclination to void water, a degree 
 of ardor urinse, and increased oozing of matter. This state often continues 
 for years, and grows more and more aggravated, until at length a permanent 
 stricture is formed, or thickening of the bladder, disease of the prostate, or 
 even of the kidneys, becomes established. 
 
 Treatment. — There is a prophylactic treatment of gonorrhoea which is often 
 serviceable. It is also termed the " abortive treatment." The difficulty in 
 adopting it chiefly arises from the fact, that in eight out of ten cases, the 
 physician does not see the patient until the period of incubation has passed 
 away, and the inflammatory condition appears. 
 
 If the virus or irritating substance can be neutralized, or otherwise dis- 
 posed of before it excites its train of distressing symptoms, the sooner it is 
 antidoted the better. 
 
 An injection composed of nitrate of silver, ten grains to the ounce of water, 
 and used once, or at most twice, will destroy a gonorrhoea ; but such treat- 
 ment must not be attempted if the symptoms of the inflammatory stage are 
 beginning to show themselves ; then other means must be used. 
 
 Some authorities, among whom are Bumstead, greatly prefer the applica- 
 tion of a weaker solution of the nitrate, one or two grains to the ounce, the 
 solution being used more frequently. This with me has not been marked 
 with such good results as one single strong caustic injection. 
 
 The best syringes are constructed of hard rubber, able to hold an ounce 
 of fluid. The instrument should be twice filled, and the whole surface of 
 the urethra be washed with the injection. 
 
 Glass or metal syringes are objectionable ; the former are too easily broken ; 
 the latter are liable to vitiate the solution employed. 
 
 Before the use of the syringe the patient should urinate, or I frequently 
 direct that a stream of water be thoroughly injected before having recourse 
 to the medicated solution. By this the discharges are washed from the 
 urethra, and the injection comes in more direct contact with the mucous 
 surface. There is no doubt of the efficacy of this treatment, if it be em- 
 ployed at the proper time, nor, on the other hand, can there be a question 
 of its hurtfulness if it be used after the inflammatory stage has commenced. 
 I have known men who, living irregular and dissipated lives, after a suspi- 
 
TREATMENT OF GONORRHOEA. 211 
 
 cious coitus, immediately employed an injection of nitrate of silver, ten 
 grains to the ounce, and for years never experienced a symptom of gonor- 
 rhoea. A typical case of this kind recently occurred : Two men had con- 
 nection with the same woman on the same night, one took the precaution to 
 use the injection ; the other, somewhat overcome with stimulus, neglected to 
 use it, and in three days was attacked with virulent gonorrhoea. The other 
 escaped. 
 
 I have practiced this method of treatment for twenty-five years. At 
 that time of course the gonococcus described by Neisser was unknown. 
 
 The newer abortive treatment, especially for true gonorrhoea, is the irri- 
 gation of the urethra with large quantities (two quarts) of a watery solution 
 of the bichloride of mercury, 1 to 40,000. If this solution is borne well, a 
 stronger may be employed, say 1 to 20,000, or vice versa, 1 to 60,000. This 
 treatment is highly spoken of by Dr. S. O. Vander Poel, Jr.* To be effective, 
 a fountain syringe holding a quart should be employed, and suspended at 
 a height sufficient to insure a good stream. 
 
 When the inflammatory stage has begun, the most reliable medicine in 
 the Materia Medica is aconite. It must be given in the first or second 
 dilution, and frequently. This medicine does not allay the discharge, which 
 often increases during its exhibition, but it subdues the inflammatory 
 symptoms and gives the patient rest. 
 
 When burning begins, cannabis should be administered, and there is no 
 doubt that it has a specific influence upon the disorder, and, according to a 
 tolerably large experience, the second or third dilution acts better than 
 the tincture often employed. Cannabis in tincture relieves the burning and 
 itching, but has not so much influence on the discharge. I recollect once 
 curing a case of gonorrhoea, which had not yielded to injections and other 
 treatment, with a few large-sized pills of cannabis. There are many cases 
 that neither aconite nor cannabis will reach ; in such, if there is much ardor 
 urinas, copaiba should be prescribed. This may be given in five-drop doses 
 of the first dilution, and taken until the odor is perceived in the urine. If 
 the burning is excessive and cannabis has not relieved, sepia and mercurius 
 are often indicated by corresponding constitutional symptoms. 
 
 Petroselinum is efficacious in claps, in which the ardor urinse is very dis- 
 tressing. It has a remarkable influence over the urinary organs, and in 
 cases of strangury, in which cantharides has failed, it has proved successful. 
 Capsicum and cantharides are also useful medicines when there is strangury. 
 If the inguinal glands are enlarging, and there is a greenish muco-purulent 
 discharge, mercurius sol, second or third trituration, given once in three or 
 four hours, will produce good results. Very often during the administration 
 of these medicines, it may be necessary to give a few doses of sulphur, or 
 hepar stdphuris may be more strongly indicated. 
 
 Sandalwood Oil. — This medicine in five-drop doses in the inflammatory 
 stage is most useful, after aconite, when the burning is intense. It must 
 not, however, be taken for more than four or five days in this dose, other- 
 wise the physiological action of the medicine may be manifested. 
 
 With reference to the use of injections, as there are very many of our 
 school who employ them, and I have frequently had from them good 
 results, it is proper to notice them in this place. In the early stages injec- 
 tions of hot water every two hours (if the patient can so employ them) have 
 been known in a couple of days to completely arrest the disease. My 
 friend Dr. William H. Holcomb, of New Orleans, employs the following 
 formula : 
 
 * Medical Kecord, March 27th, 1886. 
 
212 A SYSTEM OF SURGERY. 
 
 R. Plumbi acet., grs. iv. 
 
 Morph. acet., grs. iv. 
 
 Aquae font., |;iv. 
 
 M. ft. sol. S. Inject every six hours. 
 
 In addition to this he prepares a solution of two drops of the tincture of 
 copaiba in one ounce of alcohol, and orders ten drops three times a day.* 
 This treatment I have never employed, but Dr. Holcomb speaks well of its 
 efficacy. 
 
 Hempel, in his Materia Medica, recommends the chloride of platina. 
 
 A solution of the chlorate of potash, one drachm of the salt to eight 
 ounces of water, injected every twelve hours, is also alleged to be a specific. 
 
 The following treatment has also been recommended: During the first 
 stage the injection of 
 
 R. Ext. acet. opii, grs. xxx. 
 
 A( iu*, • , • 3y- 
 
 M. ft. sol. 
 
 After the inflammatory action has been subdued, the internal adminis- 
 tration of the biniodide of mercury in the second trituration, and in the 
 third stage, copaiba given until diuresis is produced. 
 
 Other injections are : 
 
 R. Argent, nitrat, 
 
 . grs. iij. 
 
 Aquae destil., 
 
 %v'i 
 
 R. Acid, nitrat. mere, . 
 
 . grs. ij. 
 
 Aquae, .... 
 
 • Jij- 
 
 R. Liq. zinci chlor., 
 
 . grs. ij. 
 
 Aquae destil., 
 
 ftj- 
 
 R. Vini rubri, 
 
 
 Aquae purae, aa, . 
 
 . #v 
 
 R. Acid, tannic, . 
 
 . grs. xx. 
 
 Aquae destil., 
 
 £v 
 
 A successful treatment by injection, as reported by Dr. Bachelder, is a 
 solution composed of 
 
 R. Liquor zinci chlor., gtt. xxiv. 
 
 Aquae font., ^iv. 
 
 M. ft. sol. 
 
 He states that the cure is generally made in five or six days, and that 
 the patients need no other medicine; he recommends the continued use 
 of cold water injections for six or eight days after ceasing with the zinc 
 solution. 
 
 I frequently have recourse to injections in gonorrhoea, but never during 
 the inflammatory stage. I have had occasion, when the subacute period was 
 approaching, and when I had tried many medicines in vain, to use injec- 
 tions, and I have employed many. Those which I use most satisfactorily 
 are the following : 
 
 R. Zinci sulph., grs. iv. 
 
 Zinci acetat., grs. iv. 
 
 Vini opii, gij. 
 
 Aquae destil., ^vj. 
 
 M. ft. sol. S. Use three times a day. 
 Or, 
 
 R. Hydras, sub. mur., 3j. 
 
 Aquae font., ^v. 
 
 M. ft. sol. S. Use three times a day. 
 
 * Vide United States Medical and Surgical Journal, vol. i., p. 231. 
 
TREATMENT OF GONORRHOEA. 213 
 
 Dr. T. C. Gruber, of Lawrence, Kansas, reports* nine cases of gonorrhoea 
 cured by erigeron can. He gives the medicine in tincture, and uses injec- 
 tions of the same. 
 
 My friend, Dr. Kenyon, of Buffalo, has given a detailed account of some 
 remarkable cures made by gelseminumrf in cases in which the discharge had 
 been suddenly and prematurely arrested by improperly used injections. In 
 several cases constitutional symptoms were benefited as the discharge re- 
 turned. I have observed a similar train of symptoms result from the use 
 of the .oil of sandalwood. 
 
 Capsicum is recommended when the discharge is whitish and purulent, 
 and ardor urinae experienced when making water. Ferrum, pulsatilla, and 
 also nux vomica are stated to be useful, when capsicum failed to relieve the 
 symptoms quoted. Sulph and mere, are considered the most useful in cases 
 where the patient has previously been under a course of copaiba or cubebs. 
 Nit. ac. is often very serviceable in gonorrhoea as soon as the inflamma- 
 tory stage is over, but generally requires to be followed by sulph. if the pain 
 has subsided but the discharge continues. When the inflammation has 
 evidently extended far down the urethra, much benefit has been derived 
 from the use of canth. and cann., and in some cases from nux vom. when 
 the discharge is serous and scanty, the desire to pass water frequent and 
 urgent, the act of urination painful and difficult, the stream of urine broken 
 or forked, in short, when symptoms present the appearance of the formation 
 of stricture or a tendency thereto. 
 
 In addition to the above medicines, nit. ac. may be mentioned as useful 
 in gleet ; likewise sep., lye, cub., silic, calc, thuja, nat. mur., and dulc. When, 
 in consequence of errors in diet, the use of wines, spirits, acids, etc., an 
 increased discharge takes place, accompanied with frequent desire to urinate, 
 with scalding pain, nux vom., or one or more of those medicines enumer- 
 ated above, must be employed. 
 
 Tussilago petasites has been recommended as an efficacious remedy in 
 recent as well as in chronic gonorrhoea.;); If aggravation follow the first 
 dose or two of the medicine, it must be given in a weaker or more dilute 
 form. When there is a complication of gonorrhoea and chancre, or when 
 the discharge from the urethra is found to proceed from chancres within the 
 tube, mercury should be prescribed. And when there are condylomata on 
 or in the vicinity of the genital organs, or there is reason to suppose that 
 the discharge from the urethra is of sycotic origin, thuja and nitric acid, or 
 cinnabar, mere, or sulph. are the principal medicines with which the cure 
 is to be accomplished. Against symptomatic buboes, carb. an. is considered 
 as one of the most efficacious remedies. Silic. and mere, may also be 
 named as likely to be useful in some cases. 
 
 If cystitis ensue in consequence of the extension of the inflammation to 
 the mucous membrane of the bladder, canth. and cann. will claim the 
 principal attention. ( Vide treatment of cystitis.) 
 
 During the treatment of gonorrhoea, wine, spirits, and malt liquors should 
 be abstained from. Pure cold water is the best diluent, and may be freely 
 partaken. Active exercise should be shunned during the inflammatory 
 stage, and when it cannot be wholly avoided, a suspensory bandage worn. 
 If the inflammation be extensive, or the parts much swollen, confinement 
 to the recumbent posture becomes requisite. 
 
 In regard to cannabis, it may be observed in this place that it is a medi- 
 cine which accords in its pathogenesis with very many of the symptoms of 
 
 * Western Homoeopathic Observer, vol iv., p. 172. 
 
 f Vide Western Homoeopathic Observer, 1869. 
 
 % British Journal of Homoeopathy, vol. iii., p. 125. 
 
214 A SYSTEM OF SURGERY. 
 
 gonorrhoea. Its specific suitableness to the complaint is attested by numer- 
 ous physicians. In further corroboration of its efficacy, the author is assured 
 by a practitioner who has had much experience in the treatment of gonor- 
 rhoea, that he has been not only gratified, but surprised at its efficacy in 
 subduing the disorder. The symptoms which point to its use may be 
 present at any period, but exhibit themselves in cases somewhat advanced, 
 as well as in those more chronic. In the latter especially is its power appa- 
 rent ; cases that for two, three or more months, which had fruitlessly been 
 tampered with by phj^sicians of high station, were immediately arrested and 
 speedily cured. In truth, the disorder was checked by the first dose, con- 
 sisting only of a few drops of the medicine, and a few more doses, at 
 intervals regulated by the symptoms, accomplished complete cures. The 
 attenuation, however, of the medicine is an important consideration in the 
 treatment, the exhibition of the tincture causing disappointment, while 
 a successful result is obtained from the 2d, 3d, and 6th potencies. 
 
 The gentleman whose testimony has just been given, commenced with 
 the tincture and first dilutions, but failed ; and it was only by resorting to 
 higher dynamizations, that he learned that the sphere of curative action 
 for gonorrhoeal disorder, exists in the preparations even as highly attenuated 
 as the twelfth, the latter being the strength of the medicine which he then 
 always administered. 
 
 Facts like these, attested by gentlemen of high social position, as well as 
 of acknowledged ability, certainly convert the childlike smile of incredulity 
 into that of imbecility, as expressed upon the countenances of individuals 
 who, with so much pleasant self-sufficiency, fancy themselves the sole 
 depositaries of all medical science. 
 
 During the treatment the strictest cleanliness must be observed. The 
 penis should be often washed with tepid or cold water, and the rags that 
 are used to prevent the discharge from staining the linen should be fre- 
 quently removed and fresh ones substituted. 
 
 In his work on the new remedies, Dr. Hale records many medicines as 
 useful in gonorrhoea and gleet ; among them we find eryngium aquaticum, 
 Hydrastis, phytolacca, sanguinaria, erigeron canadense, and stillingia. The man- 
 agement of gleet is one of the opprobrium medicorum. There is scarcely a phy- 
 sician in either school of ten years' practice who has not been troubled with 
 the persistency of gleet. A drop or two of discharge will be found every 
 morning agglutinating the lips of the meatus urinarius, and no matter what 
 treatment be adopted, " a drop or two " will still appear. The medicines 
 which apparently,' with me, have answered best in this unsymptomatic 
 complaint, are sulphur, silicea, thuja, fluoric acid, cimicifuga, and sepia. Dr. 
 Hastings* speaks very highly of an injection composed of a solution of 
 agnus castus, and records cases in which the treatment was efficacious. 
 I have not been so fortunate with it, having given it in many cases a careful 
 trial without perceptible results. 
 
 Dr. L. J. Williamson states that he has employed with " magical effect " 
 a No. 6 bougie smeared with a solution of carbolic acid and glycerin, eight 
 grains of the former to half an ounce of the latter. 
 
 Injections of bismuth, one drachm to one ounce of water, have also been 
 employed. 
 
 The frequent introduction of sounds has afforded me at times satis- 
 factory results, but this, like other remedies, often fails. I am acquainted 
 with a gentleman who was troubled with this disorder for nearly three 
 years, who cured himself permanently by using for two months an injec- 
 tion of equal parts of claret and water. Many methods of treatment, and 
 
 * British Journal of Homoepathy, vol. xiii., p. 590. 
 
GONOEEHCEA IN WOMEN. 215 
 
 a variety of substances have been used and lauded, but I frankly confess 
 that as yet gleet is one of the most incorrigible affections the surgeon or 
 physician is called upon to treat. 
 
 Balanitis — Gonorrhoea Praeputialis — Spurious Gonorrhoea. — This disease is 
 called also gonorrhoea prdsputialis, or external blennorrahgia, and is caused by 
 impure coitus, and those discharges which give rise to gonorrhoea of the 
 urethra. Persons who have an unusually elongated prepuce, or those who 
 are not cleanly in their habits, are very liable to be attacked. There is 
 first a sensitiveness of the glans penis, with itching, burning, and sore- 
 ness, increased by friction from walking ; the inflammation may be quite 
 severe, and the swelling so tense as to prevent the escape of the discharge, 
 which finally may give rise to a distressing abscess. The mucous surfaces 
 of the glans and prepuce secrete a fluid which varies in quantity and in 
 consistency, and gives rise to excoriations in different parts of the impli- 
 cated surfaces. The system does not suffer from this inflammation of the 
 glans, and the disorder is more amenable to treatment than that previously 
 described. 
 
 Treatment. — The first requirement is absolute cleanliness. If the swelling 
 of the prepuce be so tense as to prevent its retraction over the corona glandis, 
 the nozzle of a small syringe must be introduced underneath the fold, and 
 the parts thoroughly cleansed ; this ought to be done at least three times a 
 day. A warm sitz-bath is very beneficial. As soon as the inflammation has 
 subsided, which the internal administration of aconite generally assists, the 
 prepuce must be carefully retracted, and the first trituration of mercurius 
 vivus sprinkled upon the part. This must be repeated after each washing. 
 I have rarely found other medicines necessary. Some authorities recom- 
 mend washing the surfaces with a weak solution of either the nitrate of 
 silver, the acetate of lead, or sulphate of zinc, and Mr. Langston Parker rec- 
 ommends the following formula for local application : 
 
 R. Cerati siraplicis, vel mellis, 
 
 Olei olivse, aa, %j. 
 
 Hydrarg. chloridi, ^ss. 
 
 Ext. opii £j. 
 
 M. 
 
 The patient to be kept as quiet as possible, and should confine himself to 
 light and wholesome food. The various complications of gonorrhoea, as 
 orchitis, stricture, and ophthalmia, are noticed in another place. 
 
 Gonorrhoea in women is more difficult to detect than in men, for many 
 reasons, chiefly, however, from the fact that there is so large a mucous sur- 
 face lining the vagina, the uterus, and urethra, which often secretes a puru- 
 lent discharge, with burning during micturition, in females who have never 
 had sexual intercourse. Another cause of difficulty of diagnosis, and one 
 which is alluded to by Bumstead, is the difficulty in obtaining a true his- 
 tory of the case. He says : " The history of women seeking advice from 
 gonorrhoea, can rarely be ascertained with certainty, or the disease traced 
 with accuracy to its source. It is notorious that a woman often receives the 
 embraces of several men within a short space of time, and there are many 
 reasons for her concealing important facts which a man would readily con- 
 fide to his physician. Women also can have more intercourse than men, 
 and fabulous stories are told of Messalina, who used in one night one hun- 
 dred and sixty men, without having her passion gratified." Bechand Rival 
 relates " that during the first French Revolution, a beautiful and modest 
 girl was ravished by twenty-eight hussars, and that the only bad effects of 
 this violence were a slight irritation of the vagina, and a few scratches, which 
 soon healed."* 
 
 * Vide Gollniann's Chapter on Sexual Excesses, p. 209. 
 
216 A SYSTEM OF SURGERY. 
 
 I have seen a purulent discharge with inflammation of the vulva in young 
 children of seven to ten years of age, in two instances accompanying ver- 
 minous affections, and in three others appearing without any assignable 
 cause. Several of these young girls were in such social position and were 
 of such ages that the slightest shade of suspicion could not be entertained. 
 From all these facts, in many cases there is an impossibility to pronounce 
 positively as to the presence of gonorrhoea in the female. 
 
 The symptoms of gonorrhoea resemble those of other inflammations of 
 mucous surfaces, — heat, burning, itching, swelling, and discharge, which 
 latter varies at different times ; it may be bland and without odor, or it may 
 be and often is, as the disease advances, muco-purulent and offensive ; often- 
 times with swelling and irritation of the clitoris, and with increased sexual 
 desire ; coitus is very painful. If the inflammation extend into the vagina, 
 the speculum should be employed to ascertain if chancre, either hard or 
 soft, be present. The urethra may be implicated and the cervix uteri also 
 by extension of the abnormal action. Thus we may have a urethritis, a 
 vaginitis, a vulvitis, or an inflammation of the cervix uteri, either separately 
 or coexistent, in gonorrhoea of the female. The shortness of the urethra and 
 the passage of urine over the labia often prevent the surgeon from ascer- 
 taining where the discharge arises, but by careful watching the point may 
 be discovered. 
 
 The most patent symptom of gonorrhaea in women is most undoubtedly 
 urethritis ; in fact, when this is noticed, contagion may generally be sus- 
 pected. The diagnosis, however, as to cause is very difficult, if not impos- 
 sible. On this head, Bumstead writes : "Toa surgeon of the present day, 
 acquainted with modern methods of investigation, mistakes are not likely 
 to occur. With the recognition of the disease, however, our power, so far as 
 diagnosis is concerned, ceases. It is impossible to go further and determine 
 its origin. Many authors have attempted to give diagnostic signs as between 
 gonorrhoea originating in contagion and that arising from other causes ; but 
 they have most signally failed to produce any that are at all satisfactory, simply 
 for the reason that none such exist ! ' The microscope fails to furnish us with 
 a means of distinguishing between gonorrhceal and simple vaginitis, and no 
 
 symptom or combination of symptoms 
 FlG - 98< is absolutely conclusive on this point ' 
 
 (West). Acute inflammation and the 
 presence of urethritis may render im- 
 pure intercourse probable, but cannot be 
 regarded as decisive ; and what is wanting 
 in the physical diagnosis must be sought 
 for in the history of the case."* 
 
 Treatment. — The management of gonor- 
 rhoea in the female is not materially different 
 from that in the male. Frequent ablution 
 and injections of warm water must be em- 
 ployed, and in the earlier stages of the dis- 
 ease aconite or belladonna given according 
 to the presenting symptoms. Cannabis, 
 mercurius solubilis, cantharides, Phyto- 
 lacca, sepia, sulphur, thuja, and zinc are 
 all often applicable. In employing ene- 
 mata, the old-fashioned blunt syringe is of very little service. The vaginal 
 douche, or fountain syringe No. 3, or the kind represented in the cut (Fig. 
 98) is far preferable. 
 
 * Bumstead on Venereal, p. 179. Dr. West was of course unaware of Neisser's investigations, 
 which indeed are yet to be verified. 
 
GONORRHCEAL RHEUMATISM. w 217 
 
 This douche is used as follows : Having prepared the solution about to 
 be injected, the vessel must be set upon an elevated shelf or mantel. To one 
 end of the india-rubber tube is attached a metallic cover, which must be filled 
 with water and immediately dropped into the basin or uppermost tub. The 
 lower end of the tube is attached to a hard rubber shield, from which pro- 
 jects the vaginal tube. It will be seen that this siphon-like arrangement 
 draws the water from the upper vessel, sends it into the vagina, from which 
 it finds exit through the tube that empties into the lower tub. 
 
 Gonorrhoeal Rheumatism. — This peculiar affection follows upon one or 
 more attacks of gonorrhoeal urethritis, and differs from ordinary rheumatism 
 in several particulars. It is characterized by pain, weakness, and rigidity 
 of the larger joints and surrounding muscles, the articulation of the knee 
 being decidedly the most liable to the disorder. 
 
 The pains are increased by motion and the affected parts readily grow 
 cold ; the fever and swelling are not so marked as in ordinary acute ar- 
 thritis ; indeed, in some cases, these symptoms are almost imperceptible. 
 The pains may become fixed in the loins, in the hips, or knees, but seldom 
 in the thorax, although the heart cannot be said to be entirely free from the 
 disease ; the temperature of the body is not much increased, and the pulse 
 seldom, after the first few days, exceeds eighty beats per minute. The dis- 
 ease continues for an indefinite period, and sometimes becomes chronic and 
 even incurable. In such cases, patients are rarely free from pain, and are 
 very sensitive to damp and changeable weather. The affected joint is occa- 
 sionally so debilitated that it is powerless, resembling the condition pro- 
 duced by paralysis; or in some cases the joint presents the appearance 
 familiarly known as white swelling. The latter, however, generally is noted 
 in persons of a strumous habit. In gonorrhoeal rheumatism it is rare to find 
 suppuration of the bursse or that thickening and rigidity of the ligaments 
 which belong to ordinary chronic rheumatism, although cases are upon 
 record where suppuration and death have occurred. The eye is liable to be 
 affected with the disease, and gives rise to very troublesome symptoms. 
 Fuller says, as quoted in a foot-note by Bumstead : " In true rheumatism 
 the eye seldom suffers, so seldom that I find no record of any affection of 
 that organ in more than 4 out of 379 cases of acute and subacute rheuma- 
 tism admitted into St. George's Hospital during the time I held the office of 
 Medical Registrar. But in rheumatic gout the eye is not unfrequently 
 affected." 
 
 Treatment. — The best medicines for gonorrhoeal rheumatism are aconite 
 in the first stage, if the attack be ushered in with much sexual excitement. 
 This must be followed by clematis erecta, sarsaparilla, thuja, or the iodide 
 of potassium, which latter possesses a wonderful power over the disease. 
 The clematis has been found almost specific in cases in which there has 
 been a tendency to orchitis, and'in which the rheumatic symptoms succeed 
 rapidly an attack of gonorrhoea. 
 
 Thuja is called for when the pains are tearing and pulsative, or as from 
 subcutaneous ulceration, with a sensation of coldness or torpor of the part, 
 with aggravation during repose, or in the warmth of the bed. 
 
 Veratrum pains are increased by the warmth of the bed, and by wet 
 weather. There is a bruised feeling in the joints, which is lessened by walk- 
 ing; the affected part is weak and trembling. Sepia, euphorbium, mercu- 
 rius sol., stannum, and rhus, are also of service. I have used all these 
 medicines with more or less effect, but, according to my experience in gon- 
 orrhoeal rheumatism, the actsea racemosa is preferable to all of them. Phy- 
 tolacca also is useful. In some cases all medicines appear ineffective ; in 
 such instances, if we have reason to suspect the suppression of the gonor- 
 rhoeal discharge, gelseminum will be serviceable. My attention was called 
 
218 m A SYSTEM OF SURGERY. 
 
 to this medicine by Dr. Kenyon of New York, who prepared a paper on its 
 action for the Western Homoeopathic Observer. One case is especially typical ; 
 a portion of it reads thus : " In the evening I was sent for again, and found 
 him with violent pain in the left ankle and foot, especially through the in- 
 step; with considerable redness but not much swelling; exceedingly sore ; 
 violent fever, pulse 140, and sharp ; tongue very dry ; considerable pain in 
 back of the head and left shoulder, with some pain in the le£t wrist. He 
 then told me that he had gonorrhoea for two weeks, and the glands in the 
 groin were considerably swollen ; had been taking mercurials, and two days 
 previous, by the advice of a druggist, he had used an injection of the per- 
 manganate of potash, which in six hours entirely arrested the discharge. I 
 found the prepuce enormously swollen, the glands very red and inflamed, 
 and the orifice of the urethra dry and hot. Since the injection he had in- 
 tense pain and burning on urinating. I gave him gelseminum tincture, two 
 drops every hour, and in the morning found the gonorrhoea re-established 
 in full bloom, and all the other symptoms correspondingly improved. Two 
 days after his rheumatism was well, and he had no more chills or fever. 
 Sulphur soon cured gonorrhoea." 
 
 The doctor further states that after the discharge had been re-established 
 by the gelseminum, in no case was there the usual burning or scalding dur- 
 ing micturition, nor any tendency to pass into gleet. 
 
 Kalmia latifolia I found useful in a very obstinate case, where the pains 
 were aggravated by movement, and when the patient was not relieved by 
 bryonia. Daphne, assafoetida, and the iodide of potash are sometimes in- 
 dicated. 
 
 In some cases, notwithstanding the best directed efforts of the physician, 
 the pains and stiffness remain, the lameness becomes almost constant, and 
 every accession of cloudy, damp, or rainy weather renders the patients mis- 
 erable. They become sick both in mind and body ; they grow irritable and 
 morose, the appetite disappears, and all the functions of the body are more or 
 less impaired. For this condition I believe there is a means of cure ; it is 
 expensive, but more certain than any other with which I am acquainted. 
 It is a visit for two successive seasons to the Hot Springs of Arkansas. 
 These waters possess a wonderful effect over gonorrhoeal rheumatism, as well 
 as over syphilitic, and I have known patients who had, when starting, to be 
 carried to their conveyance, or hobbled painfully on crutches to the steam- 
 boat, return, to the best of my knowledge, cured. 
 
 Gonorrhoeal Ophthalmia somewhat resembles the purulent variety, and is 
 occasioned either by the direct application of gonorrhoeal matter or by me- 
 tastasis. The mucous membrane of the eyeball and lids is the seat of* vio- 
 lent inflammation, and there is a profuse discharge of purulent matter, 
 resembling that which issues from the urethra in gonorrhoea. This variety 
 of ophthalmia is said to be the most violent and destructive to which the 
 eye is subject. It often destroys the sight in a short period, and frequently 
 when the patient applies for relief, the disease is so far advanced that the 
 organ is irreparably injured. 
 
 In this affection there is a great degree of vascular congestion, chemosis, 
 excessive tumefaction of the conjunctiva and palpebrse. In the first stage, 
 which is generally short, the inflammation is confined to the conjunctiva, 
 and the usual symptoms of such pathological condition are present, — sore- 
 ness, stiffness, photophobia, etc. After a time, however, the disease extends 
 to the cornea, and the patient experiences severe, often excruciating pain 
 in the orbit and head, which is aggravated by exposure to light ; there are 
 also constitutional symptoms present, — shivering, fever, delirium, etc. If the 
 disease still advance, the inflammation extends from the mucous membrane 
 to the cornea and globe of the eye. The tumefaction of the orbicular con- 
 
GCXNORRHCEAL OPHTHALMIA. 219 
 
 junctiva is often so great that it overlaps the cornea, effusion takes place in the 
 lids, and the swelling may be so great that it is impossible to obtain a view 
 of the cornea ; this tumefaction declines after a time, and both eyelids may 
 become everted, the convex edge of the tarsal cartilage being pushed for- 
 wards by the swollen conjunctiva. The effects of gonorrheal ophthalmia 
 are as follows : suppuration, ulceration, and sloughing of the cornea, inter- 
 stitial deposit, escape of the humor, obliteration of the anterior chamber, 
 staphyloma, prolapsus iridis, corneal opacity, and obliteration of the pupil. 
 
 According to Hastings, three distinct forms of ophthalmic inflammation 
 occur in conjunction with, or dependent on, gonorrhoea, viz., acute inflam- 
 mation of the conjunctiva; mild inflammation of that membrane; inflam- 
 mation of the sclerotic coat, sometimes extending to the iris. 
 
 Treatment. — As the same tissues are affected in the first stages of gonor- 
 rhoea! ophthalmia as are primarily involved in ophthalmia neonatorum, 
 the medicines that are adapted to the one disease are in a measure suited 
 to the other. The great activity of the inflammation, and the more intense 
 febrile disturbance accompanying it, render the employment* of aconite in- 
 dispensable at the commencement of the disease, and the most strikingly 
 beneficial results are said to have followed its administration. 
 
 Arg. nit., sulph., mere, cham., puis., rhus, and, perhaps, ignat. or bry. 
 may be indicated. 
 
 When the tissues that are more deeply seated become involved, when the 
 pains are pressive, and there is throbbing in the eye, bell, should be em- 
 ployed. This medicine may also be used in alternation with aconite. 
 
 Arsenicum is indicated when the pains are severe, occurring in paroxysms; 
 then there are violent stabbings in the eye ; the eyeball feeling like a coal 
 of fire. Dr. Dudgeon recommends highly a solution of nitrate of silver as 
 homoeopathic to gonorrhceal ophthalmia, as well as to the severe forms of 
 catarrhal ophthalmia. The solution he recommends is composed of from 
 two to four grains of arg. nit. to an ounce of distilled water : a small quan- 
 tity of this solution is carefully introduced beneath the eyelids with a 
 camel's hair brush once a day, every two, three, or four days, according to 
 the severity of the symptoms. 
 
 Besides this topical application, he has derived advantage from the local 
 use of weak solutions of euphrasia, arsenicum, rhus, and mercurius. On 
 this subject Dr. Dudgeon writes that, judging by analogy, equal advantage 
 might be derived from the local use of the other medicines in these local 
 diseases. He says, further : " The mode in which I usually employ the 
 remedies locally, is to mix a drop or two of the mother tincture, or of the 
 1st, 2d, 3d, or 4th dilution, or of the dilution taken by the patient internally, 
 with a teacupful of water, to be applied one, two, or three times a day to 
 the eye with a soft rag." 
 
 Tussilago petasites is said by Dr. Rosenberg to have proved effectual in 
 gonorrhoea! ophthalmia ; but Dr. Dudgeon remarks that the case given by 
 the former in illustration of the virtues of tussilago was not a genuine oph- 
 thalmia gonorrhoeica, but a species of blepharophthalmia, with scrofulous 
 or other dyscrasic complication. 
 
 Acid. nit. is useful when the anterior chambers look as though filled with 
 a dirty-looking pus, and the whole eye appears to threaten disorganization. 
 If symptoms of iritis develop themselves, aconite in alternation with cor- 
 rosive mercury is very useful. Thuja and macrotin have also been em- 
 ployed, but the argenti nitras, both internally and externally, as used above, 
 is the most certain treatment. 
 
 * Dudgeon on Diseases of the Eye, British Journal of Homoeopathy, vol. vii., p. 4. 
 
220 A SYSTEM OF SURGERY. 
 
 Sycosis— Condylomatous Venereal Disease — Vegetations. — By these terms 
 are understood a certain cutaneous affection, distinguished by warty and 
 condylomatous excrescences ; these morbid growths making their appear- 
 ance in males upon the glans and under the prepuce, and in females about 
 and in the pudenda ; most frequently, however, on the inner surface of the 
 labia majora, or at the junction of the labia minora. They may arise from 
 impure coitus, though the idea of their independent nature has been dis- 
 puted by many scientific men of both schools. They present different ap- 
 pearances, sometimes resembling warts, figs, cauliflowers, cock's combs, or 
 are of a pear or raspberry shape. Their pathological condition is a morbid 
 thickening of the chorion, rete mucosum, and epidermis, with great enlarge- 
 ment of the papillary body. 
 
 The genitals are not their only site, but they sometimes appear at the verge 
 of the anus, the wrist, navel, the neck, the angles of the mouth, and the 
 perinaBum. 
 
 In the majority of cases they are spongy, soft, and readily bleeding, and 
 are liable to return after cauterization or ligature. After their removal by 
 these methods, secondary disease has been known to arise, particularly a 
 variety of pseudo-rheumatism, or whitish sensitive elevations appear in 
 the mouth, on the tongue, palate and lips, or tubercles in the arm-pits, 
 about the cephalic region, and other parts. 
 
 These morbid growths are often accompanied with a gonorrhoeal or gleety 
 discharge, and secrete a fetid fluid, the odor of which is sui generis, resem- 
 bling herring pickle, and has a sweetish taste. 
 
 Many homoeopathic, physicians agree with Hahnemann in opinion, that 
 sycotic growths constitute a disease distinct in its nature and not a sequence ; 
 although the majority believe them to be venereal. Kaue mentions having 
 treated three cases of the kind, two young men and a girl, the latter aged 
 nineteen. The males were treated unsuccessfully for a gonorrhoeal affection, 
 and in two weeks condylomata appeared. The growths manifested them- 
 selves in the girl without her having had any previous affection, and they 
 were cured with thuja. 
 
 Treatment. — Thuja is no doubt the specific for this disease, and many 
 cases I have cured with it. I have always prescribed it in the third potency, 
 and have directed the warts to be touched with the tincture every night. 
 The exhibition of this medicine must be steadily continued for at least 
 three weeks. It has been necessary in some cases to give for a week cal- 
 carea carb., the third potency, every night and morning, and then return 
 to thuja. 
 
 Flat condylomatous growths with rather broad bases, and those accom- 
 panied by gonorrhoeal discharge, are especially acted upon by thuja; it is 
 also well adapted for cauliflower growths. 
 
 Nitric acid is applicable for pedunculated and pen-shaped condylomata. 
 
 Sabina is also employed successfully in some cases, especially when there 
 is burning and itching. Raue gives the following characteristics : 
 
 Fig warts complicated with gonorrhoea require : thuja, mere, corr., cinna- 
 bar, nit. acid, sulphur, lycopodium. 
 
 With chancre : cinnabar, nit. acid, phosph. acid, staphis., thuja. 
 
 Flat: magn., nit. acid. 
 
 Exuberant, like cauliflower : thuja, staphis. 
 
 Fan-shaped: cinnabar. 
 
 Pedunculated : lycop., nit. acid. 
 
 Conical : mere. sol. 
 
 Dry : thuja, staphis., mere, sol., mere. corr. sub., nit. acid, lycop. 
 
 Moist, suppurating : nit. acid, thuja, sulph., euphrasia. 
 
 Soft and spongy : sulph. 
 
CHANCROID. 221 
 
 If sycosis be complicated "with other chronic affections, the remedies for 
 such diseases are to be selected. A radical cure is to be expected only from 
 a precise and prolonged treatment. 
 
 CHAPTER XII. 
 CHANCROID— SOFT CHANCRE. 
 
 Definition— Characters of — Seat — Phagedenic — Chancroids in the Urethra. 
 
 The variety of appearances presented in different persons affected with 
 syphilis, has, since the time of Hunter, been ascribed to a sort of reaction 
 of the organism upon the virulent principle — the chancre being the seed, 
 the constitution the soil, and in proportion to different conditions of the 
 latter was the product of the former. In other words, the doctrine of the 
 unity of the virus was that generally accepted and acknowledged by Ricord 
 himself although not without some conditions or modifications. He 
 says*: " Up to the present time we are justified in denying the existence of 
 more than one virus." This idea, however, appears not to have been cer- 
 tainly believed even by the great syphilographer himself, for, on one occa- 
 sion, when he was reproached by M. Auzias Turenne with having aban- 
 doned '' the flag of Hunter," although he defended himself, he was not 
 positive in his assertions as to the unity of the syphilitic virus. 
 
 In a later work, however, he tells us, " The chancre is no longer a morbid 
 unit, but a mixed manifestation belonging to two distinct pathological 
 species." The one of these being the simple chancre, the other, the indu- 
 rated or infecting chancre. The latter creates constitutional symptoms, the 
 former is one " with soft base, an affection purely local, which limits 
 its effects to the region which it attacks, which never exercises a general influ- 
 ence upon the system, which is never accompanied by constitutional affections. In 
 other words, it is a chancre zohich does not affect the economy — a chancre without 
 syphilis." This is the chancroid. 
 
 We are now enabled to say to the unfortunate father, who comes in trepi- 
 dation and exhibits a chancroid, " Sir, be not alarmed ; the disease will not 
 be transmitted to your own constitution, or to those children hereafter to be 
 begotten by you." It will also be of service to many practitioners, if it will 
 cause them to desist prescribing massive doses of mercury, which are not 
 necessary. With this understanding, let us return for a moment to the 
 question of the origin of syphilis, and recollect the statement of Jourdan, 
 viz., that the disease existed at an early period, and also originated epidem- 
 ically in the fifteenth century. This theory of a double virus is also received 
 and criticised by Bassereau. The simple chancre, then, is the u issue," the 
 il uncleanliness " mentioned in Holy Writ ; "the contagious ulcer of the 
 genitals " of Celsus, Galen, etc., and the new disease that appeared about 
 the fifteenth century, is the infecting chancre and its constitutional mani- 
 festations. 
 
 At the International Medical Congress, held in Philadelphia in September, 
 1876, of which Dr. F. J. Bumstead was reporter on syphilis, the following 
 conclusions were arrived at, after a full and comprehensive discussion : 
 
 1. The virus of venereal sores is dual. 
 
 2. Venereal sores may be due to the inoculation of the syphilitic virus, 
 and also to the inoculation of products of simple inflammation. 
 
 * Eicord's Lectures on Syphilis, p 149. 
 
222 A SYSTEM OF SUKGERY. 
 
 3. These two poisons may be inoculated simultaneously. 
 
 4. (Additional.) The present state of science has demonstrated that sup-, 
 purating inflammatory lesions resembling chancroids, may be produced on 
 various portions of the body by inoculation with simple pus from various 
 lesions. 
 
 With such an understanding as this, it must become a matter of the 
 utmost importance to the physician to be able readily to distinguish between 
 these two varieties of ulceration ; and in the last work of Dr. Ricord we 
 have minute details as to the appearance of soft chancre. He says : 
 
 " The simple chancre is one whose base remains soft, or only presents an 
 inflammatory thickening, which does not react upon the glands, or which 
 influences them in a peculiar manner, by producing almost certainly an in- 
 flammatory adenite, acute, mono-glandular, suppurating and furnishing 
 most generally an inoculable pus. 
 
 " Chancre with edges neatly shaped and cut perpendicularly, the floor 
 irregular and wormeaten. 
 
 " Chancre ordinarily multiple or multiplying itself by a series of inocu- 
 lations of the neighboring parts. 
 
 " Chancre with virulent pus, contagious par excellence, pursuing during a 
 long period the characters which constitute its specificity. 
 
 "Chancre with secretion free and purulent; surface covered with pulta- 
 ceous deposit. 
 
 " Lastly, a chancre with a destructive and invading tendency ; the form 
 of ulceration the most apt to experience the phagedenic complication." 
 
 These directions are explicit ; and when we come to remark the characters 
 of the indurated variety, and the greater frequency of occurrence of simple 
 chancre — that there are some parts of the body where simple chancres do 
 not appear, and the infecting have been discovered, and also the relative 
 frequency of bubo in the different varieties, — I believe that more light than 
 has yet been thrown upon the diagnosis of these venereal ulcers, and more 
 systematic treatment will be the inevitable result. M. A. Fournier states 
 that the statistics collected by himself during three months among the 
 patients at the Midi show the following : 
 
 Number of chancres seen, 341 
 
 Chancres indurated and infecting, 126 
 
 Chancres simple, non-infecting, 215 
 
 And again: 
 
 Patients affected with simple chancre, 207 
 
 Simple chancre with bubo, 65 
 
 Simple chancre without bubo, 142 
 
 The above statistics should be carefully treasured for diagnosis. 
 
 Simple chancres are not generally found upon the head. Indeed, Ricord 
 has asserted that they are never found in that locality. Indurated chancre 
 can be generated anywhere on the surface of the body. Here, again, is a 
 remarkable fact, a curious circumstance in the history of chancre, which 
 cannot be explained. Ricord himself most positively states the fact of the 
 immunity of the cephalic region from soft chancre; and if we even 
 may suppose him to err in regard to the invariability of location, it still 
 remains an unexplained mystery, that during twenty-five or thirty years 
 of constant daily attendance upon the numbers of patients presenting them- 
 selves for treatment, with all varieties and forms of syphilis, he should not 
 have been able to detect a simple cephalic chancre. He is very positive on 
 this subject. He remarks : " I have shown to you in my wards numerous 
 
CHANCROID. 223 
 
 examples of the soft chancre developed upon different regions of the body, 
 upon the genital organs, upon the thighs, upon the legs, the arms, the 
 abdomen, the back, the chest, etc. I have shown them to you everywhere 
 except on one point, — the cephalic region. It is a fact, gentlemen, that 
 during five-and-twenty years of practice, I have never met with a single 
 well authenticated case 'of soft chancre developed upon the face or upon 
 the head." 
 
 Mr. Fournier has drawn up a table of observations made upon 824 
 patients, in whom the seat of the chancre has been noticed with precision. 
 This is so interesting that it is given in full : 
 
 Patients affected with,— Indurated. Simple. 
 
 Chancres on glans and prepuce, 314 296 
 
 Chancres on integument of penis, 60 15 
 
 Multiple chancres on the penis, that is to say, presenting sim- 
 ultaneously chancres on the prepuce and integuments, the 
 
 integuments and glans, etc 11 17 
 
 Chancres on the meatus urinarius, 32 9 
 
 Intra-urethral chancres, which cannot be perceived by the 
 forced separation of the lips of the meatus ; diagnosed by in- 
 oculation, by the touch, by lymphangitis, .... 17 3 
 
 Chancres on the scrotum, 7 
 
 " " peno-scrotal groove, 4 
 
 " " arms, 6 2 
 
 " lips, .12 
 
 " " tongue, 3 
 
 " nose, ; 1 
 
 " " palatine membrane, 1 
 
 " evelids, 1 
 
 " fingers, 1 
 
 " leg, 1 
 
 The above is a curious table, and when carefully studied, will assist in 
 the establishment of a correct diagnosis, not, probably, with the utmost 
 precision, but may prove indicative of the nature of the sore, when other 
 symptoms are perhaps obscure. It may in other cases add another confir- 
 matory evidence to a doubtful diagnosis. 
 
 A peculiarity of the chancroid, also, is found in the fact, that its admix- 
 ture with another virus does not impair its power, and that, as has been 
 before said, it is very likely to assume a phagedenic complication. 
 
 A Phagedenic Chancroid is usually very rapid and destructive in its prog- 
 ress, increasing in extent but not in depth, and accompanied with severe 
 pain. Its extension is irregular and serpiginous. It occurs generally in 
 constitutions worn out by intemperance, and follows very often irritating 
 dressings which have been injudiciously applied to irritated or inflamed 
 chancres, especially .mercurial ointment. It was called the black slough, in 
 England. 
 
 There is a form of phagedenic sore called the diphtheritic or pultaceous, 
 which is exceedingly chronic (Ricord has seen it last for seven years) ; it 
 is covered, either entirely or partially, by a pultaceous diphtheritic secre- 
 tion. The base is cedematous, and the edges are elevated, irregular, and 
 serrated ; it is surrounded by a dull purple areola, and it increases by 
 successive ulceration of the depending parts. The constitution becomes 
 seriously implicated and the patient finally sinks. This form of chancre 
 occurs in ill-fed, badly-lodged individuals, in whom there is previous organic 
 disease. 
 
 In some cases, chancroid becomes gangrenous. In such a case the destruc- 
 tion of the tissue proceeds so rapidly that the whole glans is destroyed in a 
 short period. 
 
224 A SYSTEM OF SURGERY. 
 
 Chancroids of the Urethra.— The presence of the virus in the urethra gives 
 rise to chancroids, which are generally found at the fossa navicularis, and 
 may in some instances be visible by stretching widely apart the walls of the 
 canal, or by the use of the endoscope. When lower down, they are some- 
 times very difficult to diagnose. The discharge is generally not so profuse 
 as in gonorrhoea, and by pressing the ringer along the under surface of the 
 urethra, a distinct spot will be indicated more painful than others. If with 
 these symptoms a symptomatic bubo be present, additional light is thrown 
 upon the diagnosis. 
 
 Treatment. — It necessarily follows from the above detailed account of 
 chancroid, that a merely local treatment is necessary, unless there be some 
 indications by symptoms, for the administration of internal medicine. The 
 sooner the sore is cauterized the better, and the less likelihood will there be 
 to the formation of bubo. 
 
 I believe it was the general practice of homoeopathic practitioners some 
 years back, adhering to the doctrine of immediate constitutional contami- 
 nation, and not being acquainted with the duality of the virus, to commence 
 with the internal treatment of the disorder, the medicines most generally 
 used being the mercurial preparations, administered both internally and 
 externally ; the latter by sprinkling mercurius solubilis upon the ulcerated 
 surface. Since, however, a new pathology has been adopted, a different 
 method must be resorted to; for the chancroid, a local treatment; for 
 chancre, as before, immediate constitutional medication. 
 
 It is impossible for thinking, reading, and observing men to ignore all 
 the teachings and experience of those who have devoted so much time in 
 examining, testing, and treating the disorder under consideration and 
 I cheerfully receive this accumulated evidence of large experience and 
 accumulated facts, with that thankfulness which all should experience who 
 are desirous for the progress of truth and science. Therefore, in acknowl- 
 edging the correctness of Ricord's views of the nature of chancroid, no 
 want of faith in other medical doctrines should be imputed, nor in the 
 treatment of the simple venereal ulcer upon the principle of Ricord, can the 
 Hahnemannian be charged with deviating from the law of similia. 
 
 Let us examine this matter thoughtfully. Let us test it with our judgment 
 and with our daily experience. 
 
 We are informed by a man of acknowledged reputation and talent, who 
 has spent thirty years in investigating all the minutiae of venereal disorders, 
 who has been placed by governmental direction as the chief of a hospital 
 devoted to the treatment of the disease, and who is supported by many of 
 the most competent and learned men of the times, that the simple chancre 
 is a local sore — that it is the product of a virus highly contagious in char- 
 acter — nothing more, nothing less. Thousands of cases can be brought 
 forward to establish the truth of this assertion, and the records of the hos- 
 pital furnish evidence of the fact, which is confirmed by successful treat- 
 ment, and this treatment is par excellence the abortive. "Ah!" says the 
 opponent, "where is your principle of similia similibusf — where are your 
 medicines given in infinitesimal doses ?" In reply to which I would say : 
 " Recollect, in the treatment of the simple chancre — of the local sore (and 
 of this only I am speaking), we have not an ordinary ulcer ; we have locally 
 poisonous pus to encounter." The treatment is essentially surgical in its 
 character. 
 
 What sane man, when called to a case of poisoning with arsenic or corro- 
 sive sublimate, or lead, or zinc, would commence with the administration 
 of homoeopathic medicines before he had antidoted or destroyed the noxious 
 substance in the stomach ? And would he be less the homoeopathic physi- 
 
TREATMENT OF CHANCROID. 
 
 225 
 
 Fig. 
 
 cian because he administered, to neutralize the poison, tablespoonful doses 
 of the hydrated peroxide of iron, or the sulphate of soda, at five or ten 
 minute intervals ? The treatment of the simple, or the non-infecting chancre, 
 must tend to the rapid destruction of the poison, or in the words of the 
 Syphilograph, " To reduce the specific ulceration to the state of a 
 common ulcer, and to transform a wound possessing a special principle for 
 its maintenance, into a wound which has no longer such a resource." With 
 the indurated chancre the treatment must be different. 
 
 In reference to the caustic to be employed, Ricord says : " Reject at once 
 all mild caustics, which only act more or less as anodynes. That which is 
 required in this instance, is a destructive agent. To which, then, should we 
 give preference ? I have successively tried the Vienna paste, 
 potash, nitric acid, the actual cautery, etc. All these have 
 inconveniences which I need not point out to you, as I have 
 to propose to you a new agent particularly efficacious. This 
 caustic consists of sulphuric acid, mixed with powdered vege- 
 table charcoal, in the proportions necessary to form a half-solid 
 paste." Here, then, is the substance to destroy a poison, to 
 convert a chancre into a simple wound, which will proceed 
 rapidly to cicatrization. I believe this treatment to be the 
 correct one ; and since the first perusal of these clinical 
 lectures in July, 1860, I have had opportunities to test its 
 efficacy in very many cases of chancroid, in both private and 
 hospital practice, and with satisfactory results. Define well 
 the chancroid, find it to be certainly the non-contagious 
 ulcer, and no internal medicine will be required. 
 
 Professor Bumstead employs nitric acid, which may be 
 used with a glass rod, or with a small piece of wood. 
 
 Canquoin's paste is used by Diday, and is made of chlo- 
 ride of zinc and flour in equal proportions. 
 
 An excellent application can be made of chloride of zinc, 
 flour, and the submuriate of hydrastin, after the manner 
 recommended by Marsden and MacLimont for the removal 
 of tumors. 
 
 As soon as the eschar has separated, lint saturated with 
 aromatic wine may be used as a dressing. I have also used 
 with advantage a preparation of glycerine and carbolic acid, 
 in the proportion of ten drops of the latter to an ounce and 
 a half of the former. 
 
 Whatever application be made, a most essential part of 
 the treatment is cleanliness — frequent washings of the part 
 with castile soap and water, and the frequent substitution of clean for soiled 
 dressings. 
 
 For this purpose, if we have reason to believe that the ulcer is deep in 
 the urethra, the syringe of Bumstead, modified by Dr. R. W. Taylor, of the 
 New York Dispensary, vide Fig. 99, is very efficacious. It consists of a 
 hard-rubber tube, and is six inches long, having a longer curve than the 
 short one of Thompson, at the end of which is an acorn-shaped bulb or 
 head. This bulb is perforated upon its tapering sides by twelve very minute 
 holes, which are arranged in four rows of three holes each, placed equidis- 
 tantly around the head. The apex of the bulb is somewhat rounded, so 
 that in introduction the folds of the urethral membrane are not wounded ; its 
 base also rounds off, and presents a shoulder before it merges into the shaft. 
 The tubes are made of various sizes, corresponding to Nos. 4, 6, 8, and 10 
 of the English scale, while the widest portion of the bulb is two sizes larger 
 
 15 
 
226 A SYSTEM OF SURGERY. 
 
 than the shaft. There is also a button of hard rubber which slides upon 
 the shaft, by means of which precision of injection is obtained.* 
 
 There are many advantages gained by the use of this excellent instru- 
 ment in those cases which require direct apjjlications to deep portions of 
 the urethra. 
 
 CHAPTER XIII. 
 
 Syphilis — General Considerations — Chancre— Differentiae Diagnosis between 
 Chancre and Chancroid — Bubo— Constitutional Syphilis— Affections of 
 the Skin— Tertiary Forms— Syphilitic Iritis — Syphilis of the Larynx — 
 Syphilization — Fumigation — Inunction — Infantile Syphilis. 
 
 Syphilis is a disease caused by a morbid principle or poison, which, 
 applied under certain conditions to any portion of the human body, will 
 produce definite and characteristic phenomena; this principle being ab- 
 sorbed and carried into the system will, during the existence of the local 
 or primary symptoms, and for an indefinite period subsequent to their ces- 
 sation, contaminate the economy ; and, finally, this principle is capable of 
 being transmitted hereditarily, and that, too, at a period when its presence 
 in the system is not revealed by any external sign. This capability of quie- 
 tude for a number of years within the organism, without producing in the 
 meantime any appreciable effect upon it, is a character not peculiar to the 
 syphilitic poison. Another feature also is that one attack of the disease, in 
 the majority of instances, will protect from another. 
 
 Mr. Hutchinson and many others believe that syphilis is a specific fever, 
 which has a period of incubation, an exanthematous stage, and sequelae ; 
 that it is a disease of the blood during the exanthematous stage (secondary), 
 as shown by the s^ymmetrical eruption ; that the sequehe (tertiary symptoms) 
 are not due to a disease of the blood, as is shown by their being non-sym- 
 metrical and non-contagious ; that the secondary stage is due to the multi- 
 plication of germs ; that the tertiary growths are due to the development of 
 some localized products left by the secondary stage; that the tertiary de- 
 posits differ from the secondary, in being purely local affections ; and that the 
 pathology of syphilis is only to be explained by the hypothesis of a syphil- 
 itic yeast. To these views, Sir James Paget says, that the action of specific 
 remedies on tertiary symptoms, and the inheritance of syphilis by children 
 begotten by parents in the tertiary stage, show that it is a blood disease in 
 all stages ; that blood diseases do not necessarily show symmetrical erup- 
 tions — typhoid fever, for example ; that the " cryptogamic germ poison " is 
 purely hypothetical; that there is no evidence that deposits are left over 
 from the secondary stage from which gummata can develop, and that his 
 explanation of syphilitic inheritance, upon the theory that germs still hold 
 possession of the testis and ovary when they no longer exist free in the 
 blood, is purely imaginary, and has no basis of observation. 
 
 Fessenden N. Otis, M.D.,f speaking of the transference of syphilis by con- 
 tagion, thus remarks : 
 
 The assumption is warranted that the disease germs of contagious dis- 
 eases are degraded cells (bioplasts), originally derived from the healthy 
 elements of the human organism, but which by degradation have lost their 
 capacity for proper development into useful tissue. Germinal cells from 
 
 * American Journal of Svphilographv and Dermatology, October, 1870. 
 f The Medical Kecord, August 17th, 1878, No. 406. 
 
SYPHILIS — GENERAL CONSIDERATIONS. 227 
 
 one source cannot come in contact with those of an independent organism 
 without a breach of tissue. The modes of transference of syphilis from the 
 diseased to the healthy are three : 
 
 1. By direct contact of the diseased surface with an abrasion, or other breach 
 of tissue on a healthy person. 
 
 2. By immediate contagion. 
 
 3. By hereditary transmission. 
 
 Communication of the disease by direct contact (as in the act) is the most 
 frequent mode of the acquirement ; yet it may be produced by many inci- 
 dental causes, as through the act of simply kissing ; by pipes passing from 
 syphilitic to healthy persons; canes, pencils, and even sticks have been 
 known to bring the contagion. Medical students, from contact with bodies 
 tainted with the disease, nave been known to be infected ; and cases have 
 been known in which the only clue to the acquirement of the disease was 
 the habit of passing among numerous clerks and occasionally transferring a 
 lead-pencil from the desk to the mouth, doubtless belonging to an infected 
 person. 
 
 Mr. Hutchinson * affirms that a mother can be infected from the foetus in 
 utero, and become syphilitic without symptoms ; thus communicating the 
 disease to a second child without showing any manifestations herself. 
 
 Dr. F. J. Bumstead, in an articlef criticizing Mr. Hutchinson's expression 
 of views on this subject, asserts that the term "duality of syphilis" really 
 signifies a duality, not in syphilis, but in what had been known as syphilis 
 and called by that name. Otherwise, he observes, we must adopt the ridicu- 
 lous supposition that so-called " dualists " believe in two kinds of syphilitic 
 virus, whereas they have simply maintained that there exists, independent 
 of the syphilitic virus, another contagious principle, giving rise to a local sore 
 known as chancroid. If Mr. Hutchinson intends to limit the power of pro- 
 ducing the soft chancre to contagion with inflammatory products arising 
 from syphilis, Dr. Bumstead considers him in error, since sores precisely 
 similar to the chancroid have been produced by other inflammatory pro- 
 ducts. Mr. Hutchinson's view, however, that the chancroid, instead of 
 being dependent upon a distinct specific virus, incapable of spontaneous 
 generation, is the result of inflammatory products, and hence, that if every 
 chancroid now existing were exterminated, new chancroids would arise ; 
 this, Dr. B. thinks, has strong arguments in its favor, and may be looked 
 upon as a step in advance, suggesting an interesting analogy with the his- 
 tory of gonorrhoea during the last fifty years. Finally, Dr. Bumstead 
 declares his belief that " dualism " still lives, and that Mr. Hutchinson is, in 
 fact, one of its most advanced apostles. 
 
 The classification of venereal diseases is as follows: 1. Primitive or 
 direct, when they occur at the inoculated spot, from the immediate action 
 of the virus. 2. Successive, when they originate in the latter, and are pro- 
 duced elsewhere by absorption, or contiguity of tissue, or accidental contact, 
 as chancrous bubo, and the conversion of neighboring abrasions, or leech- 
 bites, into chancres. 3. Secondary, when the skin and mucous membranes 
 are affected after the reception of chancrous matter into the system ; and 4. 
 Tertiary, when the cellular, fibrous, and bony structures are the seat of the 
 constitutional symptoms. 5. Diseases unconnected with syphilis. 
 
 Concerning this classification, however, it has been remarked that it is 
 unphilosophical and wanting in simplicity, and that many of the grounds 
 on which it is founded are incorrect and untenable. The first two may cer- 
 tainly, without violence, be included under one head ; the second and third 
 
 * Month. Abstract of Medical Science. May, 1876. 
 t N. Y. Med. Record, June 17th, 1876. 
 
228 A SYSTEM OF SURGERY. 
 
 divisions are not susceptible of separation on the grounds given by Dr. 
 Ricord. The so-called tertiary symptoms may arise without the necessary 
 intervention of the secondary. Dr. Ricord asserts, that whilst the former 
 may be transmitted hereditarily, the latter cannot be, except in a degen- 
 erated form, as scrofula. This, however, is not well substantiated, and many 
 of the profession believe both secondary and tertiary syphilis equally liable 
 to propagation by inheritance. With regard to the fifth class, viz., " diseases 
 unconnected with syphilis," it is difficult to understand what is meant. 
 
 The whole subject may be much simplified by dividing it into primary, 
 secondary, and tertiary. 
 
 Before proceeding further, it is well to mention here a peculiar fact ; that 
 great and multiform as are the effects of the syphilitic virus ; acknowledged 
 as it is by the whole profession to possess a power so mighty that almost 
 every structure of the human body is obnoxious to its effects — skin, bone, 
 muscle, tendon, and periosteum; that it is not confined to the person 
 attacked, but may be transmitted hereditarily from generation to generation, 
 yet the most powerful microscope cannot find it, nor can the most carefully 
 conducted chemical analysis detect it. This may be an argument in favor 
 of infinitesimal power, and certainly is one that cannot fail to be acknowl- 
 edged by every physician and surgeon. 
 
 Syphilis, as a general rule, occurs but once in the same person during a life- 
 time, although there may be, no doubt, exceptions (which, however, prove 
 the rule), as are noted in measles, whooping-cough, scarlatina, and other 
 disorders ; but it must be here borne in mind that a person who has suffered 
 from a syphilitic attack, is not protected from another from the chancroid, 
 nor, on the other hand, does a succession of chancroids prevent syphilitic 
 inoculation. Diday, as quoted by Bumstead, says : 
 
 " 1. As a general rule, the syphilitic, like other kinds of virus, does not 
 exercise the same action twice in succession upon the same individual. 
 
 " 2. When applied (under such conditions as to permit absorption) to a 
 syphilitic subject, this virus produces no effect. Applied to a subject who 
 has had, but who no longer has, syphilis, it produces a modified form of 
 syphilis. 
 
 " 3. The more feeble the first attack, and the longer the time that has 
 since elapsed, the more energetic will be the action of the virus, and the 
 more severe will be the second attack of syphilis, and vice versa" 
 
 True chancre is often superficial, and is then rather more difficult to diag- 
 nose, especially in the earlier stages, but the induration and hardness of the 
 ganglia assist materially in the case. 
 
 The true chancre is excessively indolent; the surface is smooth and larda- 
 ceous ; the parts seem to have been taken out with a gouge ; the edges of 
 the chancre are gradually lost in the floor of the ulceration, and the indu- 
 ration extends above and around it. The solution of continuity is generally 
 single, although this is not invariably the case ; it has no disposition to in- 
 vade the neighboring structures, but soon defines its limits, and always has 
 enlargement of the inguinal glands, which become in a short period indu- 
 rated, although rarely proceeding by themselves to suppuration. Among 
 the indurated chancres treated by M. Ricord during the whole year 1856, 
 three only were found accompanied with suppurating buboes. In these 
 three cases, the suppuration was only produced consecutively to a strumous 
 degeneration of the glands, the pus being twice tested by inoculation, and 
 found negative. 
 
 Ricord says : " There can be no infecting chancre without an indurated 
 symptomatic bubo. This may be called without hesitation a pathological 
 law." And again : " Never neglect, therefore, when examining a patient 
 affected with constitutional disease., who denies suspicious antecedents of 
 
DIAGNOSIS OF CHANCRE* 
 
 229 
 
 every kind, to interrogate the glands. Specific adenopathy is, for the in- 
 fecting chancre, an effect which follows its cause." 
 
 With regard to the earlier symptoms of syphilis, Dr. F. N. Otis says :* 
 " The only constant feature of all lesions, during the active stage of syphilis, 
 is shown by microscopic examination to consist in a localized cell-accumu- 
 lation. Neither inflammation nor ulceration are essential features in syphilitic 
 inoculation. It is the local conditions at the point of inoculation that 
 must be looked to for the earliest evidences of syphilitic action ; where, 
 through the microscope, densely packed non-inflammatory cell-accumulation 
 may be discovered. The same cell-accumulation is seen to occur in the 
 lymphatic vessels connecting the initial lesion with the adjacent lymphatic 
 glands. In all cases possible, the person from whom syphilis may have been 
 acquired should be examined. Search should be made, not only for initial 
 lesion, but for possible secondary manifestations." He cites a case in which 
 a man (set. 23), " on the 14th day after his first and only connection, had a 
 slight urethral discharge, which was found entirely purulent — no pain on 
 urination. It was evidently not gonorrhoeal. A syphilitic inoculation was 
 suspected. The woman on examination was found to be passing through 
 the active stages of syphilis. Patient entirely recovered, and up to the 
 present has not had the slightest evidence of syphilitic trouble." 
 
 These, then, are the chief points in the differential diagnosis of the two 
 great divisions of chancre, and so far as they can be gleaned from a careful 
 study, backed by considerable experience, they have been concisely ex- 
 pressed. The establishment of a correct diagnosis between the chancre and 
 chancroid is however of such importance to those who expect to treat chancre 
 successfully, that the distinguishing marks have been arranged and placed 
 side by side ; and, at the same time, the peculiar nature of the adenite follow- 
 ing each is also embraced in the classification, to facilitate, if possible, their 
 more ready recognition. It must be remembered that the appearances pre- 
 sented by the two varieties of chancre are similar in their very early stages. 
 We then have the following : 
 
 DIFFERENTIAL DIAGNOSIS OF CHANCRE. 
 
 SIMPLE NON-INFECTING CHANCRES. 
 
 1. No period of incubation. 
 
 2. Never, excepting in exceptional cases, 
 
 noticed upon the cephalic region. 
 
 3. Develops rapidly. 
 
 4. Surface irregular; floor fretted, or worm- 
 
 eaten. 
 
 5. Edges neatly shaped, cut perpendicu- 
 
 larly, as if cut out with a punch. 
 
 6. Edges undermined. 
 
 7. Border abrupt. 
 
 8. No induration. 
 
 9. No induration. 
 
 10. Suppurates profusely; the suppuration 
 being one of the most fertile sources 
 from which the poison is derived. 
 
 INDURATED INFECTING CHANCRES. 
 
 1. Period of incubation from seven days to 
 
 seven weeks. 
 
 2. Every part of the body liable to inva- 
 
 sion (therefore chancre on the head 
 may be pronounced infecting). 
 
 3. Develops slowly. 
 
 4. Surface smooth ; floor lardaceous. 
 
 5. Edges sloping, as though made by a 
 
 gouge. 
 
 6. Edges adherent. 
 
 7. Border gradually lost in the floor of the 
 
 ulceration, giving to the ulcer the ap- 
 pearance of a cupola. 
 
 8. Induration surrounding the ulcer on 
 
 all sides, forming for it a kind of bed 
 (pathognomonic). 
 
 9. Induration commences from the first (if 
 
 not produced in a few days, will not 
 become so). 
 10. Suppurates little, producing but a small 
 quantity of serosity, most frequently 
 sanious and ill-formed. 
 
 The Medical Record, August 31st, 1878, No. 408. 
 
230 
 
 A SYSTEM OF SURGERY. 
 
 SIMPLE NON-INFECTING CHANCRES. 
 
 11. Pus in the highest degree contagious; 
 
 persisting during the entire existence 
 of the chancre. 
 
 12. Generally multiple from its origin, or 
 
 becomes so by inoculation. 
 
 13. Tendency to invade the neighboring 
 
 structures. 
 
 14. The simple chancre is most likely to un- 
 
 dergo the phagedenic complication. 
 
 15. In virgin subjects, transmitted in its form 
 
 — that is a simple chancroid. 
 
 16. Transmitted to syphilitic subjects, either 
 
 as a simple or an indurated chancre ; 
 the form which is reproduced probably 
 depending on the nature of its origin 
 — that is to say, the chancre which 
 gives birth to it. 
 
 INDURATED INFECTING CHANCRES. 
 
 11. Pus rapidly loses its specificity, at all 
 
 events for the infected subject, who 
 in a few days becomes refractory to 
 inoculation with his own virus. 
 
 12. Generally solitary; in most cases a 
 
 single chancre giving rise to conta- 
 gion. 
 
 13. Inverse disposition ; its limits soon de- 
 
 fined. 
 
 14. Rarely assumes the phagedenic devia- 
 
 tion. 
 
 15. Transmitted in its species in virgin 
 
 subjects, that is to say, an indurated 
 chancre. 
 
 16. Transmitted to previously infected sub- 
 
 jects, under the form of a chancre with 
 a soft base, analogous in appearance 
 to the complication. 
 
 SIMPLE NON-INFECTING CHANCRE. 
 BUBO. 
 
 17. Not necessarily present. 
 
 18. Monoglandular. 
 
 19. Suppurating almost certainly, and fur- 
 
 nishing generally an inoculable pus. 
 
 20. No fixed period of development. 
 
 INDURATED INFECTING CHANCRE. 
 BUBO. 
 
 17. No infecting chancre, without an indu- 
 
 rated symptomatic bubo. 
 
 18. Affecting several or all the glands. 
 
 19. Extreme hardness ; independent of each 
 
 other ; no tendency of themselves to 
 inflammation or suppuration. 
 
 20. Produced in course of first or second 
 
 week ; rarely noticed later ; generally 
 coincident with induration. 
 
 A peculiar feature in chancre is the rapid zymosis that takes place, which, 
 however, is in the main denied by some syphilographers, among whom is 
 Ricord. He says,* " Of all the chancres which I have seen cauterized, or 
 cauterized myself, not one has ever been followed by the special symptoms 
 of constitutional syphilis. From this it would appear that during the first 
 four days which follow contagion the syphilitic seed has not sufficiently 
 implanted its roots in the economy, and that, if you are in time to destroy 
 it, you ward off the general intoxication — you kill the syphilis in its germ." 
 The last few words of this quotation give evidence that Ricord believes the 
 chancre to be the primary cause, and not an effect. Would cauterizing the 
 bite of a mad dog when the hydrophobic virus had been circulating in the 
 system for months prevent hydrophobia? Would cauterizing the snake- 
 bite when the system showed evidence of a thorough zymotic influence re- 
 lieve the patient? There is at present the greatest amount of evidence to 
 show that the application of escharotics immediately after the introduction 
 of the poison does not prevent syphilis. Diday, Bumstead, and Langston 
 Parker have proved by experiments, that a most thorough cauterization, 
 even to the depth of half an inch, but two hours after the appearance of the 
 ulcer, was followed by severe syphilitic symptoms. 
 
 Treatment. — The treatment of chancre is in direct contrast with that rec- 
 ommended for chancroid ; the former was antidoting a local poison by the 
 application of caustics, which are hurtful to the true chancre. The ulcera- 
 tion gives the evidence of the constitutional disease ; it tells us that the 
 system is affected, and that constitutional means must be employed. 
 Syphilis being immediate after the impure coit, and the chancre the evidence 
 
 Work on Chancre, p. 147. 
 
TREATMENT OF CHANCRE. 231 
 
 of the poison, the sooner the treatment is begun the better. In the majority 
 of instances, however, relief is not sought until the initial lesion has devel- 
 oped itself. I have been very successful with a comparatively simple 
 method of treatment. In the first place great attention must be paid to 
 cleanliness, the chancre must be carefully washed with castile soap and 
 water, and upon it a pledget of lint laid, moistened with calendula solution, 
 one part of the tincture to four of water. This must be changed three times 
 a day. I then administer two grains of the first decimal trituration of the 
 protoiodide of mercury every night and morning for one week. The next week, 
 every night ; the third week, every other night, and then continue at intervals 
 until the sore has healed, which will generally take place in about six or 
 eight weeks. The patient must be told to have patience, the case be thor- 
 oughly explained to him from the commencement, and, I believe, in the 
 majority of cases, the treatment will be successful. I have experimented 
 with the deutoiodide and red oxide, with cinnabar and Hahnemann's solu- 
 bilis, but must give the preference to the preparation I have recommended. 
 In many cases of syphilis the patient is excessively weak, and morbid states 
 of the appetite and spirits manifest themselves, for which appropriate medi- 
 cation, as symptoms present, must be resorted to. As a general rule, the 
 first trituration of ferrum, three grains given every morning, and a similar 
 quantity at night, will be of great service. When the chancre appears to 
 remain in statu quo, I am in the habit of touching the sore w T ith the oint- 
 ment of nitrate of mercury, mixed with five parts of simple cerate ; or of 
 applying lightly nitric acid. When there is a tendency to phagedena, then 
 the bichloride of mercury must be used as low as the second decimal, given 
 often, and, perhaps, if there be a tendency to gangrene, alternated with the 
 second trituration of the iodide of arsenic, and the sore cauterized with 
 fuming nitric acid or the actual cautery. This must be done fearlessly. 
 I am guided by a somewhat large experience in the disease, and am forced 
 to the conclusion that medicines must be given materially, and repeatedly, 
 if we desire to effect cures. No one can deny that the pathogeneses of the 
 preparations of mercury and arsenic resemble in almost every particular the 
 diseases we are expecting to combat, and I would have all interested give 
 the mercury treatment just recommended a fair trial. 
 
 Dr. Attomyr observes : " Syphilitic patients, with very few exceptions, are 
 young unmarried men, who either board at the hotels or sit at table with 
 their relations or probably superiors. In either case it is unfortunate for 
 the observation of homoeopathic diet. To this must be added the fact that 
 patients conceal their disorders, and in order not to excite suspicion, dare 
 not venture on the slightest aberration from their accustomed diet. In 
 consequence of these adverse dietetic circumstances, I resolved in treating 
 such patients to administer larger doses than usual. 
 
 " I am still of opinion that the lower dilutions recall reaction quicker, but 
 that their effects are less extensive and permanent than the higher. Four 
 grains of calomel in the space of a few hours operate violently and excite 
 diarrhoea, while the same four grains, if taken in minute portions, result in 
 an indisposition, which continues several days, and in more intense com- 
 motion of the organism. I moreover concluded from these premises that 
 the larger doses could be repeated more frequently, which would seem 
 essential, on account of the necessary dietetical errors. Within the period 
 of two years I treated one hundred and fifty-six patients laboring under 
 venereal disease. Every physician knows how it is with office practice, 
 how difficult to learn anything, or obtain any certain experience in this 
 manner. Generally one half of this class of patients stay away, so that it is 
 impossible for us to decide with certainty upon the termination of their dis- 
 orders. The one remains away because the effects of the treatment did not 
 
232 A SYSTEM OF SURGERY. 
 
 fulfil his anticipations, the other (and among syphilitic patients the major- 
 ity), because he is approaching convalescence, and is desirous of avoiding 
 the burdensome thanksgiving of his cure." Dr. Attomyr also states that out 
 of the one hundred and fifty -six patients, so many did not return to men- 
 tion the success of the treatment, that only eighty-four can be cited as 
 being perfectly cured. 
 
 The medicines that have been found most efficacious in the treatment of 
 syphilis are, besides the protoiodide of mercury already mentioned : Merc. 
 sol., mere, corr., mere, biniod., acid, nit., hepar sulph., acid, phosph., lye, 
 sulph., silic, ars., carbo. veg., thuj., and sepia. 
 
 I am aware that there are some who positively assert that mercury and its 
 compounds are not applicable to syphilis ; that the disease is aggravated by 
 their exhibition, and that many of those disastrous conditions character- 
 istic of the later stages of the affection, are attributable to the use of this drug. 
 
 From an extended experience I must positively say, that there is, in my 
 opinion, no drug in the pharmacopoeia that can compare with mercury in 
 the treatment of primary syphilis, even when the rash is present. That 
 the disease is augmented and the secondar}^ and tertiary symptoms compli- 
 cated by the injudicious use of mercury is also a fact, but I think it may 
 be stated, that since the days of massive doses of mercury have passed, and 
 those of minute doses of the drug have succeeded, the treatment of syphilis 
 has been much more satisfactory in all its stages. As years have added 
 experience to my method of practice, I must, after watching patients who 
 have undergone this method of treatment, again assert positively, that mer- 
 cury possesses great power over syphilis in all its stages. 
 
 There are, however, some cases in which mercury must be considered 
 entirely inapplicable. It should never be given in the doses mentioned, 
 when the patient suffers from tuberculosis, whether in the active or passive 
 form. In such cases the 3d or 6th decimal dilution should be given, and 
 when Bright 's disease is present, either in its incipient or advanced stages, 
 the 1st or 2d trit. of the bichloride should take the place of the protoiodide. 
 
 Of the different preparations of iodine, the potassium iodide is remark- 
 able for its efficacy in the treatment of the more remote symptoms of syph- 
 ilis. The action of the drug is not nearly so profound as that of mercury, 
 but will not disappoint the practitioner, especially in the secondary stages. 
 My favorite prescription is the following very simple one : 
 
 R. Kali hydriod. 
 [ua cinnamc 
 M. ft. sol. S. Seven drops in half a tumblerful of milk three times a day. 
 
 Aqua cinnamomi, aa, ^s 
 
 da 
 
 Seven drops of the above solution represent just five grains of the salt, 
 and after the patient has taken this dose for about a week, ten drops are to 
 be given at each dose for a second week, and fourteen for the succeeding 
 week. The patient is always told that if symptoms of catarrh, or the ap- 
 pearance of pimples upon the forehead and shoulders should result, the 
 medicine must be stopped for a week and then resumed. 
 
 At the present, some syphilographs recommend the employment of the 
 iodide of potassium in tremendous quantities — 100 to 150 grains a day, and 
 even more, being given. Of this I shall say a few words at the end of the 
 chapter, when again referring to the effect of the potassium iodide. 
 
 In some old and obstinate cases, mercury and potash may be combined, 
 and then it is better to employ the biniodide of mercury. 
 
 A peremptory duty of the surgeon after he has recognized the undoubted 
 presence of syphilis, is to explain to the patient the contagiousness of the 
 disease, and prohibit all sexual communication during the existence of the 
 initial lesion, and for some time after the sore has disappeared. Precise 
 
bubo. 233 
 
 directions should be given to avoid all risks of communicating the disease 
 by kissing, and in the use of cups, tumblers, or other articles, which are 
 used by those suffering from lesions of the lips and throat ; as has already 
 been mentioned pencils, pens, paper-knives, etc., having been held in the 
 mouths of syphilitic patients, can propagate the contagion, and, therefore, 
 care in the use of such articles must be impressed upon the patient. 
 
 The frequent use of the bath is another item in the treatment which is of 
 especial import. Daily ablutions, not only of the parts, but, if practicable, 
 of the entire person, should be practiced. Turkish baths once or twice a 
 week are often very serviceable. The treatment by inunction and fumigation 
 will be found at the end of this chapter. 
 
 Aur., caust., china, dulc, and staphis., may also sometimes be requisite 
 in the treatment of chancre. 
 
 Bubo. — After what has been already written regarding buboes and their 
 relative frequency and appearances in the chancroid and chancre, the sub- 
 ject will receive but a limited notice. The proper study of these adenoid 
 troubles must be in connection with the disorders of which they are con- 
 comitants. 
 
 Bubo always takes place in those lymphatic glands in the immediate 
 neighborhood of chancre, while the deeper-seated and remote glands remain 
 uncontaminated, or at least do not enlarge or suppurate. As chancre gener- 
 ally occupies some part of the penis, the glands of the groin are the ones 
 most commonly affected. Sometimes several glands are enlarged and form 
 a cluster ; but according to Mr. Hunter one gland only is usually affected. 
 A suppurating bubo does not invariably follow a chancre, and yet the 
 system is not less liable in such cases to contamination. This circumstance, 
 amongst others, has induced some surgeons to believe that bubo does not 
 arise, as is commonly imagined, from the absorption of venereal virus, but 
 from an inflammation in the extremities of the lymphatics excited by 
 chancre.* Bubo seldom arises from a chronic chancre, but usually makes 
 its appearance soon after the sore is established. It is more frequently 
 observed to follow venereal ulcers on the prepuce or frsenum, than those 
 situated on the glans penis,f and is late or early in its appearance according 
 to the degree of inflammation existing in the sore. Oftentimes a bubo 
 remains stationary for weeks, neither tending towards resolution nor suppu- 
 ration ; in general, however, it is of a bright scarlet color, exceedingly painful, 
 and suppuration is speedily established. Sometimes erysipelatous inflam- 
 mation is present. 
 
 The ulceration which follows a bubo does not differ from that of common 
 chancre, and the matter from it is equally infectious. The bottom of the 
 ulcer is hard and solid to the touch, and the surface either of a dark-red or 
 brownish color, or of a yellowish cast. 
 
 Very extensive ulcerations now and then follow a bubo. I have seen 
 instances in which each groin and the greater part of the pubes have been 
 laid bare by the severity of the affection. In certain constitutions buboes 
 degenerate into insensible and very troublesome fistulse tliat are exceed- 
 ingly perplexing to treat. In some instances the skin covering a bubo 
 entirely closes, but not uniting with the parts beneath, leaves a hollow from 
 which in a short time a thin serum is discharged through small holos or 
 pores formed in the skin. In such cases, the integuments generally assume 
 a leaden or bluish color, and present an unhealthy aspect. 
 
 Swelling of the inguinal glands also, frequently arises from other 
 causes than the absorption of syphilitic virus. For example, from wounds 
 
 * See Allan's Surgery, vol. i., p. 200. 
 
 f Gibson's Institutes and Practice of Surgery, vol. i., p. 339. 
 
234 A SYSTEM OF SURGERY. 
 
 or injuries of the foot, from colds, fevers, and from irritating applications. 
 Such swellings are very difficult to distinguish from the true venereal bubo. 
 The surgeon, therefore, must carefully inquire into the history of each indi- 
 vidual case before he ventures to give a decided opinion respecting its nature. 
 
 In the treatment of syphilitic buboes, there are three objects to be attained : 
 1st. To prevent their development (prophylactic treatment). 2d. To dis- 
 perse the tumors. 3d. To heal the ulcers after suppuration and discharge of 
 the pus have occurred. The prophylactic treatment implies : 1st. A rapid 
 cure of the primary chancre. 2d. The prevention of a return of the ulcer. 
 3d. Perfect rest of the diseased part. To accomplish these objects the prin- 
 cipal medicines are mere, sol., kali hydriod., silic, calc. carb., acid, nit., 
 graph., and thuja. 
 
 When the swellings are either small or of considerable size, but neither 
 excessively painful, mercury has been of great service, administered in 
 the second decimal trituration, five grains night and morning, until im- 
 provement is manifest. 
 
 If the bubo be excessively painful, bright red, with intense inflammation, 
 belladonna a few drops of the tincture in water will in all probability allay 
 the sufferings. 
 
 After suppuration is established, silic. frequently cures the complaint. 
 
 If the patient has been subjected to the abuse of mercury, and the tumor 
 is hard, hepar and a poultice of flaxseed may hasten suppuration. If the 
 mouth and gums of the patient are affected by previous drugging, and there 
 is lancinating pain in the hard tumor, staphis. will be an excellent medicine. 
 Nitric acid or the muriate of gold may be beneficial, spongia officinalis and 
 spongia palustris have proved of striking efficacy in some cases of indurated 
 glands, either of a scrofulous Or venereal origin. 
 
 Asaf., hydriod. pot., or nitric acid may particularly be called for in cases 
 which have evidently been aggravated by the previous injudicious use of 
 mercury in massive doses. 
 
 Bell., hepar, silic, sulph., carb. an. are important medicines in treating 
 sympathetic bubo ; the indications for their administration may be found 
 in the Materia Medica * 
 
 So soon as suppuration has been fully established, the matter should be 
 freely evacuated, and this is best done with a fine sharp-pointed curved 
 bistoury, the point to be inserted with the cutting edge upward, and a free 
 incision made. Sometimes in making the operation, an arterial twig may 
 be severed, which may be generally secured by torsion, or the bleeding 
 arrested by pressure. Care must be taken not to allow any of the pus to 
 come in contact with abrasions, or any mucous surfaces. The cavity must 
 then be freely syringed, thrice a day, with a solution of calendula, one part 
 to three, and a compress placed over the wound, and held in situ by a 
 bandage. An indolent bubo takes a long time to heal, and requires a careful 
 internal as well as local treatment. 
 
 Constitutional Symptoms of Syphilis present themselves in several forms, 
 and usually develop in regular succession. The parts that appear to be 
 first affected are the skin and throat; in the generality of instances the 
 latter is earlier attacked. After these, periosteum, bones, fasciae, tendons, 
 eyes, and ears become involved. 
 
 There has been a good deal of discussion among syphilographers as to the 
 contagion of the secondary symptoms. There is, however, incontestable 
 proof that some of these appearances, especially the pustular eruptions, are 
 capable of inoculation, and also, that this secondary contagion will produce, a 
 chancre; that constitutional syphilis will pursue its regular course of evolution, 
 
 * For an excellent description of inguinal bubo see Hannemann's Lesser Writings, p. 76. 
 
CONSTITUTIONAL SYPHILIS. 235 
 
 whether it originates from a primary or secondary symptom — in the latter case, as 
 in the former, the chancre being the primary manifestation. 
 
 The first development of constitutional symptoms will, in many cases, 
 be ushered in by syphilitic fever or by pallor of countenance, swelling of the 
 submaxillary glands, and shifting pains, apparently of a rheumatic or neu- 
 ralgic character, in different portions of the body. When the tonsils are 
 examined, they may be found to be the seat of an ulcer, which is coated 
 with an ash-colored or brownish matter, that causes the sore to present a 
 foul and unhealthy appearance, while the surrounding edges are slightly 
 inflamed and of a coppery hue. In the more advanced stages the ulcer is 
 excavated, or, as Mr. Hunter has expressed it, " dug out ;" if the ulceration 
 still advance, one or both tonsils, the velum palati, membranous portion of 
 the Eustachian tube, and even the epiglottis may be entirely destroyed, 
 giving rise to permanent deafness, incessant cough, and endangering the 
 patient's life from suffocation, by permitting food and drink to enter the 
 larynx. In many instances, a communication is established between the 
 nose and mouth, from the ulceration having destro} T ed the soft parts and 
 bones of the palate. At other times the disease travels along the Schnei- 
 derian membrane, undermines the septum and cartilaginous portion of the 
 nose, destroys the periosteum covering the thin and delicate bones, which 
 are soon rendered completely carious, and crumble away, destroying the 
 nose, and thereby causing pitiable disfiguration, and reducing the patient 
 to a condition often loathsome, with foul and fetid matter flowing perpet- 
 ually from the nostrils or into the throat, and a breath so extremely offen- 
 sive as to render the sufferer hateful to himself and disgusting to others — 
 Ozsena syphilitica. 
 
 Syphilitic Fever. — This peculiar eruptive fever generally precedes, with 
 more or less distinctness, the appearance of constitutional affections of the 
 skin and mucous membranes. In many instances, the whole skin becomes 
 discolored, or mottled, or covered by an efflorescence ; at other times, cir- 
 cular patches appear in distinct spots on different parts of the body, each 
 of which proceeds from an indurated lump of a pale-red color. The patch 
 slowly enlarges, and in a little time its centre becomes flat, and incrusted 
 with whitish scales. These gradually desquamate and are succeeded by 
 others of a similar appearance, until finally the skin cracks and discharges 
 a puriform secretion, which, hardening on the surface, is converted into a 
 copper-colored scab. This seldom extends beyond half an inch in diameter, 
 and after a time drops off, exposing an ulcerated surface, which gradually 
 spreads and deepens, and becomes covered with a thick, fetid, greenish 
 matter. 
 
 The parts of the body most liable to be attacked by venereal eruptions, 
 are the back of the neck, the forehead, breast, and groin ; sometimes, how- 
 ever, the palms of the hands and the soles of the feet are affected. 
 
 Exanthemata Syphilitica. — Roseola is one of the most frequently occur- 
 ring of the exanthematous eruptions, and may accompany other secondary 
 symptoms ; the spots are of a " coppery red" and are scattered over the 
 trunk and extremities without any very determinate figure. They become 
 very apparent after exertion, bathing, or sweating, but can easily be made 
 to disappear by the pressure of the finger. The eruption is not generally 
 accompanied with much itching, makes its appearance without constitu- 
 tional disturbances in the space of a few hours, and in a few days the spots 
 fade and become of a yellowish hue. 
 
 Syphilitic Maculae. — These " spots " are more frequently seen on the face 
 and head, although I have noticed them on the trunk and extremities. 
 They are oval or sometimes irregular in shape, and of a yellow coppery 
 color, differing from the exanthemata in the latter, being of a redder hue. 
 
236 A SYSTEM OF SURGERY. 
 
 These spots are often darker in the centre than at the circumference, and 
 they do not entirely disappear upon pressure ; they may become extremely 
 dark when they have existed for some time. 
 
 Syphilitic Pustules. — There are several forms of pustular disease which 
 follow constitutional syphilis, and among them we find syphilitic rupia. 
 These pustules, the bases of which are bullous, become covered with large 
 and prominent incrustations, which are black and rise in the shape of a 
 cone. The scab finally splits, and becomes loosened irregularly around its 
 circumference, and finally drops ofT, leaving an open sore, secreting a pecu- 
 liarly offensive pus. The skin surrounding becomes of a purple hue, but 
 is not ulcerated. The ulceration, if unchecked, continues to extend beneath 
 the scabs, upon pressing which, the discharge exudes. Very many of these 
 may appear on one patient, and they are often very intractable. I recollect 
 a woman whom I attended in consultation with my friend Dr. Comstock, 
 who had at least a dozen of these sores upon her person. 
 
 Syphilitic Papulae. — This form of cutaneous disease has been noticed to 
 appear suddenly with erethism or in a successive and slow manner. The 
 elevations are firm and solid, contain no fluid, and are of a yellowish or 
 coppery color. They are sometimes crowded together and present the 
 appearance of confluence. They do not itch and desquamate often. In 
 other instances they are of a brownish, livid, or violet color, and may ulcerate 
 at their summit. These eruptions are generally circumscribed. 
 
 Syphilitic Squamae are more or less round in shape, like the other erup- 
 tions, of a coppery color, and appear in patches ; there is slight itching in 
 some cases ; in others none. The patches are from six to eight lines in 
 diameter, and appear from six to eight weeks after the cure of the primary 
 sore. They are distinct, irregularly rounded, slightly prominent, and cov- 
 ered with a thin scale, which, when detached, shows the skin beneath them 
 smooth and shining. In the palms of the hands and soles of the feet the 
 syphilitic psoriasis is distinct. A number of spots, three or four lines in 
 diameter, not very prominent, appear, and small scales of epidermis are 
 regularly thrown oft from the palms of the hands and soles of the feet. 
 Where the disease has existed for a considerable time, the skin cracks in 
 different directions, and rhagades form, which are very much increased by 
 the motions and constant uses of the hand. This disease is often accom- 
 panied with somewhat similar eruptions about the axillae, the thighs, scro- 
 tum, labia, and on the margins of the anus and the commissure of the lips. 
 
 Syphilitic Tubercles are of a livid and coppery red color, smooth, and 
 sometimes covered over with dry or moist scales. They appear in clusters, 
 or are scattered and degenerate into open sores ; they are from the size of a 
 small pea to that of a walnut. 
 
 These tubercles are found about the alse of the nose, and in this position 
 rarely ulcerate. The scrotum, also, is often affected, and in this locality 
 they are generally isolated, are quite circular, and more prominent than in 
 other portions of the body. This form of growth may also exist with 
 sycotic disease. Sometimes there exist beneath the skin, and deep in the 
 cellular tissue subcutaneous syphilitic tubercles, which may perforate the skin 
 and form ulcers with ragged edges and a whitish base. 
 
 Gummatous Products. — It is a difficult matter to draw a line of demarca- 
 tion between what are termed the secondary and the tertiary symptoms 
 of constitutional syphilis. The division is, it appears, merely arbitrary. 
 The time of the appearance of secondary symptoms is generally fixed at 
 six or eight months from the healing of the chancre ; symptoms appearing 
 thereafter being considered as tertiary syphilis. The deeper structures are 
 then invaded by the poison, and the periosteum, bones, eyes, testicles, and 
 other parts give evidences of the disease. 
 
GUMMATA, ETC. 237 
 
 The most peculiar formations, however, are known as gumma. A gumma 
 is a nodule in the connective tissue, which, according to Green,* presents 
 the following appearances : 
 
 " The gummata consist of atrophied and degenerated elements imbedded 
 in a scanty and obscurely fibrillated stroma. The central portions of the 
 growth are composed almost entirely of closely packed granular d6bris, fat- 
 granules, and cholesterin, amongst which there may be an exceedingly 
 scanty fibrillated tissue. Surrounding this, and directly continuous with 
 it, is a more completely fibrillated structure, while the peripheral portions 
 of the growth, which are continuous with the surrounding tissue, consist 
 entirely of small round cells resembling granulation-cells and lymph- 
 corpuscles. The bloodvessels, which only exist in the external portions of 
 the growth, are very few in number." 
 
 The main difference between the secondary and tertiary stages appears to 
 exist in the fact, that in the former, the new formations are composed of 
 fibrin, or a very similar element, while in the latter, the gummata resemble 
 granulation-tissue prone to break down and to ulcerate. 
 
 Syphilis of the Periosteum and Bones. — All the bones do not appear to be 
 equally susceptible of impression from absorption of the virus ; those thinly 
 covered by integuments, or situated near the surface of the body, as the 
 cranium, clavicle, sternum, tibia, radius, and ulna, are most liable to suffer. 
 The first evidence that the patient experiences, as indicative that the dis- 
 ease has reached the bony structure, is an enlargement or a tumor, called 
 sl node; this increases slowly, never attains much magnitude, and is seldom 
 painful until it has existed for a considerable time. Finally, however, the 
 integuments covering the tumor become red and inflamed ; deep-seated 
 and acute pain is felt in the part, and extends from it to a considerable 
 distance, often throughout the limbs; the sufferings are extremely aggra- 
 vated at night when the patient becomes warm in bed. In a greater or 
 less time the swelling loses its hard and solid consistence, becomes soft and 
 fluctuating, ulceration takes place on the most prominent part and soon 
 opens a communication with the interior, and a discharge ensues of an ill- 
 conditioned glairy matter. The bone may now be felt rough and bare, and 
 it may become completely carious. When the node is seated on the skull, 
 both tables are often perforated with numerous holes, and resemble in some 
 respects a piece of wormeaten wood. When a node proceeds from in- 
 flammation of the periosteum alone, the swelling may be frequently 
 removed. 
 
 Patients who have suffered from repeated attacks of syphilis, and have 
 taken large quantities of mercury, often have the veins greatly enlarged 
 and thickened throughout their whole extent. When examined, also, such 
 veins have been found to be much heavier than usual. 
 
 Venereal Warts, " Sycosis Hahnemanni," often follow chancres, and usually 
 are found in the same situation. They arise by a narrow neck or pedicle, 
 and are expanded on the surface, resembling a mushroom. They are some- 
 times exceedingly painful, and bleed profusely on the slightest touch. 
 Frequently the whole glans penis or vulva is completely covered by these 
 excrescences. 
 
 Condylomatous Tumors usually occupy the verge of the anus. They are 
 firm and fleshy, broad at their bases, irregular on the surface, and often 
 ulcerate and become very troublesome. 
 
 Alopecia does not invariably follow the secondary symptoms of syphilis, 
 even when the system is thoroughly contaminated. In many cases, how- 
 
 * Pathology, p. 120. 
 
238 A SYSTEM OF SURGERY. 
 
 ever, large quantities of scurfs or scales form about the roots of the hair, 
 which are soon loosened and drop out, leaving the scalp perfectly bare. 
 The eyebrows also not unfrequently fall off, and are seldom regenerated. 
 
 The further details of diseases of the bones, phimosis, paraphimosis, 
 orchitis, etc., will be found in chapters on those diseases. 
 
 Treatment. — Syphilitic sore throat, which generally arises from the con- 
 tinued abuse of mercury in the primary disease, is successfully combated by 
 nit. acid, aurum, carbo veg., or lycopodium. 
 
 When the patient complains of dryness and scraping in the throat, with 
 swelling and inflammation of the tonsils, calcium sulphide is an excellent 
 medicine ; when, however, there are superficial ulcers of a grayish color situ- 
 ated within the buccal cavity, nit. acid may be employed. After the exhibi- 
 tion of these medicines, when the more violent inflammatory symptoms are 
 mitigated, silic. or sulph. will often complete the cure. 
 
 If, during the first stages of the disease, mercury has not been used in 
 massive doses, this medicine is frequently sufficient in itself to produce the 
 desired effect. Kali hydriod. and mere. iod. are also useful in this affection, 
 as are also ars., iod., aurum, bell, and staphis. 
 
 In the treatment of secondary syphilis, mercury is the chief medicine, 
 particularly for the syphilitic eruptions. " Allopathic physicians,' 1 writes 
 Hartmann, u use iodium and sarsaparilla for these eruptions, which homoeo- 
 pathic physicians only use for syphilis complicated with mercurial symp- 
 toms." The principal mercurial preparations which are of service in the 
 treatment of these secondary syphilitic diseases, are mere, prsecip. rub., 
 mere, corr., cinnabaris, mere, nitras ; though the other preparations may 
 likewise be useful. Besides mercurials, we have thuj., nit. ac, hepar, 
 clematis, staphis., phos. acid, mez. 
 
 The selection of the remedy does not depend upon the seat of the sore, 
 but upon the nature of the ulcer. A mercurial preparation will have to 
 be used, and the medicine be given in much larger doses than ordinary, 
 otherwise the fauces, mouth, nose, etc., may all be destroyed. The 
 medicine required is sometimes indicated by the attendant syphilitic ap- 
 pearances in other parts of the body ; for instance, mere, prsecip. rub., 
 cinn., mere, nitras, nit. ac, and thuja are demanded, when out of the sec- 
 ondary exanthematous ulcer, whether it be indurated or phagedenic, con- 
 dylomata have developed themselves. If accompanied with bullae, mere, 
 corr. is the principal remedy, unless mere, prsecip. rub. or viv. is more spe- 
 cifically indicated ; if complicated with mercurial ulcers in the mouth and 
 throat, iod. and nit. ac. and potassium iodide deserve the preference. 
 
 If, after the secondary syphilitic ulcer is cured, there should be still a 
 remnant of the secondary syphilitic eruption, some other medicine must be 
 chosen. Lepra and psoriasis syphilitica will frequently yield to dulc, 
 clem., lye, mez. or calc. The scurfy eruption to lye. and calc, or to co- 
 nium, graph., ranune 
 
 The tuberculous require often argent, nit., thuj.,kreas., zinc, if deep-seated ; 
 ars., thuja, especially if spongy, or clematis. The exanthemata ; bella., apis 
 mel., mere, nit. acid, canthar. 
 
 The symptoms, however, in each case, must be thoroughly studied, by 
 means of the repertory and codex. 
 
 The medicines for Venereal nodes are asaf., acid. phosph.,aur.,calc, mez., 
 silic, and sulph. The intolerable aching pains in the bones are relieved 
 by mez., acid, staphis,, aurum, sulph. or kali hydroid. 
 
 Dr. Hale recommends, phytolacca dec, corydalis, rumex, sanguinaria, 
 stillingia, and other remedies for syphilis. I have not employed them, and 
 must refer the reader to his work on the New Remedies, 
 
SYPHILITIC IRITIS. 239 
 
 For alopecia, lye. is said to be almost a specific ; if its use is not followed 
 by success, nit. acid., petrol., or phosph. may be serviceable. 
 
 Condylomata are controlled by mere, sol., thuj., or sabina, and also with 
 aurum, causticum, and phosphoric acid. 
 
 To onychia syphilitica the following medicines are adapted : ars., graph., 
 hepar, mere, lye, and petrol. 
 
 When the skin appears unhealthy, the slightest cut degenerating into pain- 
 ful rhagades or ulcerated fissures, mere, sulph., lye, acid, nit., hepar, are 
 very useful medicines. 
 
 I desire here to mention a fact which has occurred to me in regard to 
 the exhibition of iodide of potassium. I cannot obtain any result from 
 it in any potency above the second and third, and find the farther away I 
 go from the substance, the less are its effects visible. This I am bound to 
 admit, nor can I explain it. It is impossible, in my experience, to suc- 
 cessfully manage the varied manifestations of constitutional syphilis 
 without the use of the kali hydriod. Its action is most wonderful in many 
 instances, and what mercury is to the primary, so kali iod. is to constitu- 
 tional or general syphilis. In these latter days a great deal has been said 
 concerning massive doses of iodide of potash. I have made some ex- 
 periments myself, regarding the toleration of the drug by patients suffering 
 from constitutional syphilis. I have seen given sixty grains three times a 
 day, and continued for a length of time, and patients, though they are 
 rather disposed to become melancholy, otherwise improve under the use of 
 the drug. I write this by no means to justify such enormous doses but 
 that the young practitioner may not think he is overdosing his patients 
 when he orders five or ten grains of the iodide three times a day. The 
 treatment which has been recommended on a previous page is safe and 
 efficient, and unless the disease has attacked the nervous system, larger 
 doses than there recommended are not, in my opinion, necessary. The 
 medicine is then entirely discontinued for a week and again renewed. 
 I speak with a great deal of confidence of this method of treatment, because 
 I am positive of its efficacy. For other indications for the use of medicines 
 the student must consult the repertory and symptomen codex. 
 
 Podophyllum is most highly lauded by Dr. Adrian Stokes in all the forms 
 of syphilis. " In recent as well as in the secondary and tertiary forms of 
 syphilis, he ivho fails with podophyllum judiciously used need not hope to get any 
 help oid of mercurials"* 
 
 Syphilitic Iritis. — This affection is intermediate between secondary and 
 tertiary syphilis. By Ricord it is supposed to belong to the former, and 
 Gollmann coincides in this opinion. 
 
 The iris is the primary seat of the disease, although, if the symptoms are 
 violent, the other tissues of the eye may be involved ; in most cases but one 
 eye is affected, and the organ presents many of the properties and appearances 
 of common iritis. When syphilitic ophthalmia is accompanied with scler- 
 otical injection, the latter is said to depend upon an accidental rheumatic 
 complication ; however, sometimes among the anatomical signs of ophthal- 
 mia syphilitica is noticed a zone of violet red, from a line to a line and a 
 half in width, of uniform tint, and in which cannot be observed any dis- 
 tinct vessels. This zone is called the dyscrasic circle. In the commencement 
 of the disease the iris becomes duller, and presents a grayish appearance, 
 the radii being more or less effaced ; the small circle of this membrane is 
 livid or copper-colored ; its tissue is tumefied, and forms an elevated ring 
 composed of thick downy flakes. The pupil is more or less contracted, 
 and assumes an irregular or angular shape ; the cornea is somewhat dimmed, 
 
 * B. J. H., vol. xxii., p. 80. 
 
240 A SYSTEM OF SURGERY. 
 
 and on its inner surface, careful examination detects small fasciculi of con- 
 gested vessels ; the tunica albuginea is of a rose color, which at its juncture 
 with the cornea is converted into a dark-red hue. As the disease advances 
 the iris becomes more discolored, its surface is covered with exudation, its 
 free margin is tumefied, and upon its anterior surface there are elevations 
 of a yellowish or gray tinge. The pupil at length becomes perfectly im- 
 movable ; pedunculated excrescences, termed condylomata of the iris, sprout 
 from the membrane, and adhesion takes place between the iris and the 
 lenticular capsule. In such cases, the pupil still remains open, and presents 
 a gray, instead of its usual black appearance. At the bottom of the ante- 
 rior chamber, through the dim cornea, a more or less elevated layer of pus, 
 sometimes mixed with extravasated blood, can be perceived. The patient 
 experiences in the suborbital region of the affected side, violent constrictive 
 boring pains, which radiate sometimes to the neighboring regions of the 
 head, are increased towards evening, most violent at midnight, and abate 
 towards morning. The visual faculty is more or less altered, by reason of 
 the intensity of the inflammation, and of the plastic exudations formed in 
 the pupillary opening. Photophobia is rarely present in true syphilitic 
 ophthalmia, and when the symptom is noticed other complications are 
 often the cause of its appearance. 
 
 The terminations of the disease are — resolution, condylomata of the iris, 
 exudation within the pupil, or obliteration of this aperture. 
 
 This variety of ophthalmia, although it is sometimes met with alone, is 
 generally accompanied with other symptoms of secondary syphilis, such as 
 eruptions of the skin, ulceration of the fauces, or pains in the periosteum. 
 
 Treatment. — The object in this form of iritis is to allay inflammatory 
 action, as well as eradicate the virus, and to arrest further extension of 
 its effects. As the disease is most frequently met with when the inflamma- 
 tion has threatened to close or obliterate the pupil, a resort must be had to 
 artificial means to dilate the same, which is best accomplished by dropping 
 into the eye, three or four times a day, or even more frequently if there is 
 a high degree of inflammatory action, a few drops of the following : 
 
 R. Atropia, grs. viij. 
 
 Aquae font., ^ij. 
 
 M., ft. collyrium. 
 
 This dilates the pupil and allows perfect rest to the muscular fibre. 
 
 A resort to the external application of either atropia, belladonna, or hyos- 
 cyamus in the concentrated form to dilate the pupil, is equivalent to a 
 mechanical force, the object being to irritate muscular fibre into unnatural 
 contraction — very different from exhibiting an infinitesimal dose to produce 
 curative action. 
 
 Rhus tox. is adapted to the earlier stages when there is profuse lachryma- 
 tion. Petroleum for pain, heat, and throbbing in the occiput, with heat in 
 the eyes. Cinnabar for pain in the supra-orbital region. The latter is the 
 best mercurial in this form of disease. 
 
 When abscess forms in the iris, hepar, mere, silic, and sulph. are valuable 
 medicines. 
 
 For the chancrous ulceration that sometimes attacks the cornea, besides 
 mercurius, arsen. and calc. should not be forgotten. 
 
 In those cases in which mercury has been abused, nit. ac, hepar, sulph., 
 mez., and dulc. will prove useful. 
 
 Colchicum will be of service when there is an exudation of lymph or the 
 inflammation is of a very chronic character. 
 
 Syphilis of the Larynx is another manifestation of the presence of the virus, 
 which generally appears late after the primary infection. It is not, however, 
 
SYPHILIZATION. 241 
 
 a very uncommon affection, and is easily recognized. The patient has but 
 slight difficulty in deglutition, and the erosions on the mucous membrane 
 may remain stationary for a time, or be subject to periods of extension, and 
 to quietude. There is a dry hacking cough, hoarseness, and expectoration 
 of a sticky and tenacious mucus. Finally, however, the ulceration spreads 
 to the cartilages of the larynx, and, in some cases, destroys them either in 
 part or entire ; the voice, from being husky, disappears in toto; the cough 
 becomes worse, the patient emaciates, deglutition is accompanied by 
 fits of suffocation, hectic fever and debilitating sweats supervene, and 
 the patient finally dies a miserable death. The prognosis is in most cases 
 bad. 
 
 Treatment. — I have had under treatment at different times some very 
 difficult cases of syphilitic laryngitis, and have found that the ordinary 
 medicines, as laid down in the books, are not at all satisfactory in their 
 action — I mean phosphorus, hepar, sulphur, etc. The medicines which 
 have produced decidedly beneficial action are the bichromate of potash, the 
 second trituration given twice or thrice a day, and continued for a length 
 of time ; also, the kali hydriodicum, in substance, given thrice a day ; or if 
 the indications for mercury be present, the bichloride acting better than 
 others. Arsenic, iodine, macrotys, and podophyllum have been given from 
 time to time with benefit. I have used also the atomizer, containing a 
 weak solution of iodine, with excellent results ; but in its application, care 
 must be taken that the solution is not too strong, as very disastrous effects 
 have followed such inhalation. Ten drops of the first decimal dilution of 
 iodine, placed in a gill of water, will be found of sufficient strength for 
 most cases, and need not be repeated more than twice during the week. 
 
 Syphilization for the cure of syphilis has been practiced from time to time 
 and has had some warm advocates, while many are very much opposed to 
 the practice. It«consists in inserting under the skin the syphilitic virus. 
 " The inoculations are performed first on the sides of the thorax, then on 
 the arms, and lastly on the thighs. Six such punctures are made every 
 three days in symmetrical positions ; the matter for each inoculation being 
 always taken from its predecessor as long as it takes effect ; a fresh supply 
 being only used when the former has entirely lost its force." Dr. Boeck, 
 of Norwa}^ is a great advocate for this method of cure, but is particular not 
 to have recourse to it until the general symptoms manifest themselves. 
 With this method I have had no experience, but find that it has been prac- 
 ticed in this country by Professor Boeck. At a meeting of the New York 
 Academy of Medicine, on June 6th, 1872, Dr. Hutchinson, of Brooklyn, read 
 a paper on this most interesting subject. He related cases in which Profes- 
 sor Boeck, while on a visit to this country in 1869, practiced syphilization. 
 The cases were three in number, and, as the report read, " went from bad to 
 worse under the various treatments adopted, and were regarded as utterly 
 hopeless. The first of these cases died. The detail of the second* is given 
 here in full, not only to show the method, but to observe the time occupied 
 and the symptoms manifested, and because the operation was conducted 
 by Professor Boeck himself. 
 
 Case 2. James C , set. twenty-one ; sailor ; admitted August 16th, 1869. 
 
 Patient stated that his health had been good. Five months previously, ten 
 days after an exposure, a small sore appeared near the meatus urinarius, 
 followed soon after by other sores upon the glans. These healed rapidly, 
 to be followed by another in April, without fresh exposure ; this also healed 
 speedily. Early in May he began to have sore throat, and the cervical 
 glands became enlarged. 
 
 * Medical Eecord, July 15th, 1872, p. 306. 
 16 
 
242 
 
 A SYSTEM OF SURGERY. 
 
 June 8th. An eruption made its appearance on the forehead, and since 
 that time it has spread to the face, trunk, and limbs. 
 
 Examination, on admission, discovered patches of ulceration in fauces 
 and pharynx ; the epitrochlear and inguinal glands were enlarged and in- 
 durated. A very extensive rupial eruption was noticed in various parts 
 of the body ; was emaciated and very feeble. Treatment by means of mer- 
 curials (internally and by fumigation), iodide of potassium, sarsaparilla, 
 etc., was instituted. 
 
 Sept. 2d. No improvement having taken place under the usual treatment, 
 syphilization was, with the consent of the patient, inaugurated. 
 
 Nov. 30th. Inoculations with matter from a soft chancre, on chest, were 
 systematically practiced every third day, and were invariably successful. 
 
 Dec. 14th. No further effect was produced by inoculation on chest, by 
 matter from whatever source. Large crusts formed on the sites of inocula- 
 tions ; they increased in size and became confluent. Kupial crusts on face 
 diminished in size. General condition was somewhat improved. 
 
 Feb. 1st. Reinoculations had been practiced successfully on arms and 
 thighs, which were covered with extensive crusts, while the chest was com- 
 paratively free from them. Large ulcers continued in the throat, and there 
 was a constant fetid discharge from the nose. Although the patient ap- 
 peared to be in better physical condition, he was yet too feeble to leave his 
 bed. 
 
 Feb. 21st. Inoculations were seldom effectual ; they were accordingly 
 discontinued, and the iodide of potassium, with a vegetable bitter, was pre- 
 scribed. 
 
 March 8th. Recommenced inoculations, but the patient was no longer 
 susceptible to virus taken from any source. 
 
 March 28th. The general physical condition was improved ; the patient * 
 left his bed for the first time in five months ; ate and slept^well. The ulcer- 
 ations in throat and pharynx had 
 healed. 
 
 May 3d. The crusts following 
 inoculations had nearly all dis- 
 appeared. The patient weighed 
 one hundred and eighty pounds 
 — more than at any previous 
 period. Said he was a "well 
 man." 
 
 July 9th, 1870. Had continued 
 to improve in health and strength, 
 and was discharged cured. 
 
 Mercurial Fumigation has also 
 been employed and I have in a 
 few instances tried it myself, but 
 have not found it equal to my 
 expectations. 
 
 This method of treatment is 
 highly recommended by Mr. 
 Langston Parker, and can be 
 made easily by filling a shallow 
 vessel with boiling water, thor- 
 oughly heating a brick and plac- 
 ing it in the water, which must not be of sufficient depth to overflow the 
 top surface, on which is sprinkled from thirty to sixty grains of the mild 
 chloride of mercury. This vessel is then placed on the floor underneath 
 a cane-bottomed chair upon which the patient, having been previously 
 
 Fig. 100. 
 
 Lee's Lamp modified by Bumstead 
 
INFANTILE SYPHILIS. 
 
 243 
 
 Fig. 101. 
 
 rubbed off with a towel, is seated. He is then covered closely with a 
 blanket, which is secured around the neck, and its folds allowed to reach 
 the floor on all sides. The bath may last a quarter of an hour, when the 
 patient must retire to bed. 
 
 Mr. Lee has constructed a lamp for this purpose, which has been modified 
 by Bumstead, of New York, and which I have used and found convenient 
 for the purpose. It is represented in the adjoining cut (Fig. 100). Upon 
 the small saucer, A, is placed a scruple or thereabouts of calomel, or of 
 the black oxide of mercury. The groove surrounding the saucer, B, is 
 filled with boiling water, and the alcohol lamp, C, lighted. The patient 
 arranged, is seated upon the chair, and the bath conducted as already 
 described. In a short time perspiration is produced. 
 
 Dr. Maury has invented a very complete fumigating apparatus, which is 
 represented in Fig. 101. It is arranged in such manner that it can be used 
 with gas, and the burners are those known as Bunsen's. 
 
 Inunction. — With regard to the inunction treatment of Sigmund, of Vienna, 
 consisting of rubbing the gray ointment of mercury successively on the 
 arms, forearms, thorax, abdo- 
 men, thighs, and legs each 
 night, and using a tepid water- 
 bath every morning, keeping 
 the patient perfectly quiet and 
 upon strict diet, I may say that 
 I have known of its good effects 
 in the hands of Dr. Comstock, 
 of St. Louis, in a case of rupia 
 syphilitica which had been un- 
 der my care, and had resisted 
 all other treatment. The doc- 
 tor, I believe, employed in this 
 case the citrine ointment. 
 
 Infantile Syphilis. — Nothing 
 is more pitiable to the humane 
 surgeon than the sight of an in- 
 fant developing symptoms of 
 syphilis. Nothing more for- 
 cibly illustrates the words of 
 holy writ, — a child ushered into 
 this world, bearing at birth the 
 marks of serious disease con- 
 tracted by its parent or parents. 
 
 Congenital syphilis presents 
 the most remarkable phe- 
 nomena in regard to its origin. 
 It may be communicated from 
 the mother alone, or from the 
 father alone, or from both parents. It may be contracted from the paternal 
 side without the mother being infected, and what is still more remarkable, 
 the father having been infected years before marriage, may have every reason 
 to believe himself cured, and yet may transmit the disorder to his offspring. 
 It may also be present, though latent in the mother, and yet will develop 
 in the child. 
 
 From these facts, it will be seen that it is not at all necessary that the 
 mother should have contracted the disorder during her pregnancy, for 
 a woman being married twice may have contracted syphilis even from 
 
 Maury's Fumigator. 
 
244 A SYSTEM OF SURGERY. 
 
 her first husband, and the second being healthy, may yet have syphilitic 
 children. 
 
 Again, a healthy woman having nursed a syphilitic child, contracts the 
 disease, and then transmits it to other children gotten by a husband who is 
 healthy. In both cases the blood, the source of life, growth, and nutrition, 
 is completely poisoned, and hence all its products, whether solid or fluid, 
 must necessarily participate in the evil effects to which such a state gives 
 rise. But in the female these effects are still greater than in the male ; the 
 whole function of the male in the process of reproduction consists in the 
 deposition of a certain amount of semen, perhaps a solitary spermatozoon, 
 while the female is also obliged, not only to furnish a fluid, but after con- 
 ception has occurred, she is compelled to nourish the new being, the most 
 intimate connection being established between them by means of the pla- 
 centa. 
 
 With regard to the time at which a woman suffering with general syphilis 
 may communicate the disease to the child, there is no certainty. Professor 
 Gross says : " The probability is that it is very short. This is proven by 
 the circumstance that such a woman frequently aborts within a few months 
 after conception, evidently in consequence of the deleterious effects of the 
 virus upon the foetus. I suppose that the contamination is coeval with 
 conception, occurring at the moment of the commingling of the two seminal 
 fluids ; for if it be assumed, as we have a right to do from the facts of the 
 case, that the male can communicate the poison in this manner, why should 
 a similar faculty not be ascribed to the female ? She, too, furnishes an im- 
 pregnable substance, a seminal liquor, which can no more escape contami- 
 nation when her system is affected with secondary syphilis through the 
 seminal fluid of the male." 
 
 A syphilitic child at birth does not usually present symptoms of infec- 
 tion, but after the first few months an eruption upon the face or scalp, 
 mucous patches about the arms, spots of dark reddish hue over the body, 
 which are all more or less inveterate in their nature, indicate the presence 
 of the disorder. 
 
 Diday, to throw more light on the subject, has tabulated 158 cases. In 
 these the disorder showed itself: 
 
 Before the end of one month in 86 
 
 Before the end of two months in .45 
 
 Before the end of three months in 15 
 
 At four months in 7 
 
 At five months in 
 
 At six months in . . 
 
 At eight months in 
 
 At one year in . 
 
 At two years in 
 
 Total, ."'.'-•-.. 158 
 
 Treatment. — The first step in the treatment, if the child is nursed by the 
 mother, is to remove it from the infected parent and substitute a healthy 
 wet-nurse ; great attention being paid to bathing and fresh air. Then the 
 administration of such medicines as are indicated, must be carefully attended 
 to. Of these, the preparations of mercury will generally be found most ad- 
 vantageous, and of these, according to my own experience, the corrosive 
 sublimate or bichloride is decidedly preferable. Whether it be that these 
 compounds have a more searching action, and permeate the system more 
 deeply than others, I am not prepared to sa}', but certain I am, that when 
 other mercurials have failed in obstinate cases, these have been of decided 
 benefit. Next to these we have kali hydriodicum, which may be given 
 
wounds. 245 
 
 during alternate weeks. The preparation of the bichloride which I use is 
 the third, that of the potash, the first. I am aware that these drugs are 
 considered antidotal to each other, and are considered " incompatible," 
 according to pharmacologists ; but in the treatment of the varieties of syphilis 
 many distinguished surgeons have found from experience that the two 
 agents may be combined with excellent results. It is a common practice 
 nowadays (I cannot say whether it be entirely scientific or no) to mix a 
 few grains either of the protoiodide or the deutoiodide of mercury with 
 iodide of potash and sarsaparilla, and use the same in syphilitic affections. 
 
 The iodide of iron (ferri iodidum) is a valuable medicine in the syphilitic 
 cachexia of children, and is particularly adapted to those forms of the dis- 
 ease where there is a constant tendency to indigestion and diarrhoea ; it may 
 be given in alternation with other medicines. 
 
 Nitric acid, phytolacca, sanguinaria, thuja, iris versicolor, and other 
 medicines are called for. In the majority of instances, however, it will be 
 found that when the symptoms can be traced to hereditary syphilis, the 
 preparations of mercury and potash are best adapted to the cases. 
 
 CHAPTER XIV. 
 
 Wounds : Definition — Classification — Dangek of — Dressings for — Sutures — 
 Straps — Antiseptic Treatment— Methods of Heading — Incised — Punctured — 
 Contused — Lacerated— Poisoned Gunsk ot. 
 
 Wounds are solutions of continuity in any texture of the body, or divi- 
 sions of the tissues caused by mechanical violence, and weapons of every 
 variety, and are produced in innumerable ways. For convenience of de- 
 scription, however, they are divided into six general classes, this classifi- 
 cation being based upon the appearance or general characteristics of the 
 wound, and upon the agent or material which produced it. We have, 1st, 
 Incised; 2d, Punctured; 3d, Contused; 4th, Lacerated; 5th, Poisoned; 6th, 
 Gunshot wounds. There are also superficial and deep wounds, these, terms 
 explaining themselves. Wounds are also named according to the part of 
 the body in which they occur, as wounds of the head, face, chest, abdomen, 
 and extremities. Wounds in the direction of the long axis of a muscle or 
 limb are called longitudinal, those passing directly across, diagonal or trans- 
 verse wounds; the latter class generally gape much more than the former, 
 which fact should be remembered in making incisions in surgical operations. 
 Wounds are also divided into penetrating and non-penetrating, or those en- 
 tering joints or the cavities of the body, and those which enter but a short 
 distance from the surface ; the former are again subdivided into wounds 
 with injury of the organs — or viscera contained in the cavity — and those 
 without injury to the viscera. There are also flap wounds, found most fre- 
 quently about the scalp, or made by sharp cutting instruments in other 
 parts of the body. The flap is connected to the body by a neck of tissue, 
 called "ike bridge;" if the bridge be very narrow, and the flap very large, 
 the probabilities are it will perish, because the only means of nourishment 
 is through this pedicle. After a time, however, adhesions form other con- 
 nections with the main surface of the body, and the circulation is thus re- 
 established. By ivounds with loss of substance, we understand those in which 
 masses of tissue are entirely cut away. These are the general definitions, 
 and will answer sufficiently for the purposes of this work. 
 
 The Healing of Wounds depends not only upon their proper treatment, but 
 
246 A SYSTEM OF SURGERY. 
 
 also upon the constitution or condition of the person at the time the injury 
 is received. The more depraved or broken down the constitution, the longer 
 will it take to repair the wound, and vice versa. These solutions of conti- 
 nuity occurring in persons who are ill-fed, who are improperly clothed, or 
 are uncleanly in their habits, who live in crowded and badly-ventilated 
 apartments, heal with much difficulty, as do also those found in scrofulous 
 or syphilitic individuals. 
 
 Danger. — The danger attendant upon a wound depends upon its extent, 
 and the physiological importance of the organs involved. Wounds of the 
 heart, aorta, or medulla oblongata, produce almost instantaneous death, while 
 quite severe lacerations of the extremities often recover rapidly. Penetrating 
 wounds are critical, their danger being increased by injury inflicted on the 
 lung, liver, stomach, intestines, kidneys, or bladder, in which case they are 
 often rapidly fatal. Wounds of the brain or spinal cord rarely heal. Divi- 
 sion of large nervous trunks produce paralysis of the parts supplied by 
 them, and punctured wounds of the hands and feet frequently produce 
 tetanus. The danger of poisoned wounds depends principally upon the 
 virulence and amount of poison introduced into the system ; in very many 
 instances their prognosis is bad. 
 
 Dressings. — There are various appliances to facilitate the healing of 
 wounds. These consist mainly in sutures, various kinds of adhesive plaster 
 and bandages, the object of all being to maintain the parts as nearly as pos- 
 sible in apposition, and to give support to the mutilated structures. 
 
 Sutures. — There are several varieties of suture, viz., the continued, the inter- 
 rupted, the twisted, the quilled, and the india-rubber : these are most constantly 
 in use; the "clamp-suture" of Sims, the "button suture" of Bozeman and 
 the " plastic suture " of Professor Pancoast are sometimes employed by those 
 who are adepts in the use of the varied instruments with which they are 
 made. 
 
 The substances employed for sutures are either the ordinary saddler's 
 silk, or a more costly article manufactured in England for surgeons' use, 
 and coming to the market either in skeins or wound upon spools; it is a 
 most excellent fabric, and is called "patent ligature silk;" it does not kink 
 or curl, and is remarkably strong and pliant. (See pages 38 and 39.) 
 
 The description of the needles which I now generally employ is found 
 upon page 40 of this volume, and the needle-holder on page 35. I desire, 
 however, here to call especial attention to the newer form of needle and 
 needle-holder invented by Hagedorn. 
 
 Dr. Hagedorn's Xeedles. — The advantages claimed for these new needles, 
 which are graded from 1 to 19 (see Fig. 102), are : 
 
 1. Being curved on the edge, they are more resistant, and the point fol- 
 lows without deviation, the intended direction of the puncture. 
 
 2. The eye, perforating the flat side, can be made larger and tapering at 
 the terminal end ; in consequence of which, even a stout double thread will 
 pass without difficulty through the puncture, an advantage which no sur- 
 geon will fail to appreciate. 
 
 3. The needle, owing to its equal thickness, can be firmly and safely taken 
 hold of at any point, whereby its direction will be much facilitated. 
 
 4. The cutting-edge being on the convex side, cannot be injured or blunted 
 by the needle-holder, and may be easily resharpened by the surgeon himself. 
 
 5. The incision made by the needle is at a right angle to the edge of the 
 wound, similar to a button-hole. The two edges of the stitch-wound, on tying 
 the suture, are drawn into close apposition, whereby their union is favored. 
 (Fig. 103.) 
 
 6. The flat needles cause less injury, which is of great importance, espe- 
 cially in sutures of nerves and tendons. 
 
SUTURES. 
 
 247 
 
 Hagedorn's needle-holder differs from the usual kind. It is so construc- 
 ted that it is made to hold the needle at the flat side; its jaws open and 
 close parallel to each other, and every size of needle, of whatsoever curve, 
 is held with equal firmness. The breaking of a needle is rendered impos- 
 sible, even when the strongest pressure is applied. In using it, the needle- 
 holder is held in such a position that the little finger is near the ratchet, ready 
 for releasing its hold by slightly pressing against it. Attention must be paid 
 that the needle is placed in the longest diameter of the jaw with the inner 
 curve close to the stem of the fixed rod. Only when the needle has been 
 grasped in this manner will its perfectly firm position be secured. 
 
 Tiemann & Co. have constructed a needle-holder, a combination of Hage- 
 dorn's and the Russian needle-holder, combining the advantages of both. 
 
 In wounds of considerable extent we may employ both suture and adhe- 
 sive plaster. In making an interrupted suture, the stitches should be placed 
 
 Fig. 102. 
 
 Fig. 103. 
 
 C 
 
 a, b, Wound of Old Needles. 
 c, d, Wound of New Needles. 
 
 Hagedorn's Needles. 
 
 not more than half an inch apart, and in some particular cases at a less dis- 
 tance ; they should be inserted at regular intervals, and great care should be 
 taken to have the edges of the wound so adapted that there shall be no 
 puckering. One lip of the wound should be seized with the fingers of the 
 left hand, or a pair of forceps, whichever the operator finds the more con- 
 venient ; the needle, threaded with silk or silver wire, is then passed from 
 without inwards through the centre of the tissue ; the other lip is then 
 seized, and the needle passed from within outwards, inserting it at the same 
 depth, and passing it out at the same distance from the edge or lip of the 
 
248 
 
 A SYSTEM OF SURGERY. 
 
 wound as it was passed in on the opposite side. A space of two to six lines 
 from the margin of the cut will generally be found sufficient to hold the 
 suture. 
 
 In threading a needle with wire, care should be taken to have the wire 
 lodge in the grooves running back from the eye ; the end should be pressed 
 tightly down behind the end of the needle, and twisted about the long end 
 of the ligature. This may appear a trivial matter, but the accomplished 
 surgeon does not so regard these apparent trifles. Many surgeons of the 
 present day make the metallic stitches in the following manner, which was, 
 I believe, first introduced by T. Addis Emmet, of New York : An ordinary 
 sized needle is threaded by passing the two free ends of a loop of silk 
 through the eye. The extremities are then tied firmly, leaving the loop 
 free ; upon this loop is placed the wire, which is simply bent over it. By 
 
 Fig. 104. 
 
 Hagedorn's Needle-Holder. 
 
 introducing the needle, thus armed, it will be readily seen that the flexi- 
 bility of the silk will allow a considerable degree of manipulation with the 
 needle, which could not otherwise be accomplished without twisting or 
 
 Fig. 105. 
 
 Tiemann & Co.'s Modification of Hagedorn's Needle-Holder. 
 
 knotting the wire. After the metallic threads have been introduced, they 
 may be seized with a pair of strong straight pliers and twisted, and the 
 extremities cut off. 
 
 Fig. 106 (on next page) shows the wire supported and in process of being 
 twisted. 
 
 Fig. 107 (on next page) is a silver wire carrier, which works with a spring 
 and a slide. 
 
 After the introduction of the wire some surgeons prefer to tie it in a 
 square knot, and to cut the ends short off. 
 
 The twisted or figure-of-eight suture, is made by introducing pins or needles 
 through the lips of the wound, and twisting over them, in the figure-of-eight 
 form, silk, thread or cotton. The pin should be placed in the pin or 
 needle forceps, and introduced about one-eighth to one-quarter of an inch 
 from the margin of the wound ; care must be taken to pierce the tissue at 
 least to the middle of its thickness. When the point is seen emerging from 
 the raw surface, it is made to enter the opposite lip of the wound, and 
 
SUTURES. 
 
 24fr 
 
 brought out on the surface at the same distance from the margin as it was 
 entered on the opposite side. After the introduction of several pins, the 
 
 Fig. 106. 
 
 Fig. 107. 
 
 v/~> 
 
 vX~ 
 
 «./M,«J*A-CQ. 
 
 Fig. 10S. 
 
 Fig. 109. 
 
 Fig. 110. 
 
250 
 
 A SYSTEM OF SURGERY 
 
 Fig. ill. 
 
 silk is to be applied by placing its centre part over the first pin, and making 
 two or three turns in the shape of a figure-of-eight ; the ligature is then 
 carried to the next pin, and the same process gone through. The cut (Fig. 
 108) gives a good idea of the interrupted and (Fig. 109) the twisted suture. 
 In tying either the silk, the thread, or the wire, the knot should never be 
 placed over the line of approximation, but to one or the other side. The 
 ends of the pins are then cut off with the pliers, and if there is a tendency 
 to laceration from pressure, small pieces of wax may be placed upon the 
 extremities of the pins, or a small strip of adhesive plaster be laid under 
 them. The latter is the plan which I usually adopt. As a rule, the pins 
 should not be allowed to remain more than three days, as sufficient adhe- 
 sion has generally taken place in that period of time. To remove the suture 
 the thread must be carefully snipped on both sides of the pins, and lifted 
 away ; one extremity of the pin is then grasped by a forceps, rotated slightly, 
 and withdrawn. 
 
 The continued suture, or that known as the glover's suture, is made by pass- 
 ing the needle, properly threaded, diagonally from one lip of the wound to 
 the other, making, as it is called, the over and under stitch. 
 
 The india-rubber suture (Fig. 110) was introduced by Washington L. Atlee, 
 of Philadelphia. It consists of small sections of gum-elastic tubing, which 
 
 are stretched over the pins, as seen in the 
 figure. This suture may answer well in some 
 cases, but is liable from its elasticity to cut into 
 the tissues. 
 
 The quilled suture (Fig. Ill) is merely an in- 
 terrupted suture, with the extremities of the 
 thread tied over pieces of quill or bougie, which 
 are laid parallel with the lips of the wound. 
 
 It is especially applicable to lacerated 
 wounds, where the parts will not bear the trac- 
 tion of single threads. 
 
 Gauze and Collodion. — This method of draw- 
 ing together the lips of wounds, especially where 
 there is much laceration, was first suggested 
 by Dr. Paul B. Goddard, of Philadelphia, and 
 has been extensively used in the Pennsylvania 
 Hospital. I have employed it with good re- 
 sults. The method of application is as follows: 
 Having prepared strips of gauze, or tarlatan, or 
 bobbinet, of the requisite width, one end of the 
 strap is placed upon one side of the wound on 
 healthy texture. Over this collodion is painted, 
 care being taken that none of this substance 
 touches the wounded part! By the rapid evaporation of the ether the solu- 
 tion soon dries, and in so doing fixes itself and the fabric securely to the 
 integument. The surgeon then draws the gauze, over the wound, the edges 
 of which are nicely adapted, and fastens the other end of the gauze on the 
 opposite side in the same manner. This method of securing wounds has, 
 besides the firmness with which it brings the parts together, the additional 
 advantage of allowing the free application of any medicated substance to 
 the wound without disturbing the dressing, and the surgeon can observe 
 at any moment the progress of the case. 
 
 The Dry Suture in closing long wounds, is recommended by Dr. John 
 H. Packard* He uses strips of Seabury & Johnson's porous plaster, two 
 
 * Medical Eecord, February 1st, 1879, No. 430. 
 
ADHESIVE PLASTER — HEALING OF WOUNDS. 251 
 
 and a half inches wide and the length of the wound. These are applied 
 on each side of the incision and then the sides laced together, using the 
 holes in the porous plaster. 
 
 Adhesive Plaster. — There are several kinds of adhesive plaster. We have 
 the old-fashioned adhesive, composed of resin, lead, and a little soap ; 
 Isinglass. Robbins's, Behrle's, Surgeon's, etc. There are other varieties, 
 composed of resin, lead, litharge, and turpentine, in various proportions, 
 said to possess advantages, but they are generally rather irritating to sensi- 
 tive skins. The india-rubber plaster and that variety known as Mead's 
 has already been mentioned in the article on dressings in the first chapter 
 of this volume. 
 
 Cutting the Plaster. — The plaster, whichever kind is used, should be cut 
 into strips sufficiently wide for the purpose, generally from one-quarter to 
 half an inch in width, and in the direction of the long fibres of the cloth : 
 if it be divided transversely it is very liable to stretch and allow the wound 
 to gape. To apply adhesive straps, that is if the old-fashioned plaster is 
 used, the free or unspread surface of the cloth must be laid on the outside 
 of a smooth tin vessel, filled with hot water, until the adhesive surface is 
 sufficiently sticky ; it should then be carefully and evenly laid upon the 
 part, sufficient traction being used to bring the cut surfaces in apposition. 
 The traction or tenseness of each strap must be graduated in such a manner 
 that an even support is given to the part, and to do this properly requires 
 considerable experience. In the removal of straps, or even in changing them, 
 there should be no haste; so long as they are fulfilling the purpose for 
 which they were applied they should be allowed to remain, and when taken 
 off, considerable care is necessary to prevent tearing the edges of the wound 
 apart. One extremity of the strap should be carefully raised and drawn 
 towards the edges of the wound. As soon as it has been raised to this point, 
 the other extremity must be dealt with in like manner. In wounds of the 
 scalp or parts covered with hair, the razor should be used, and the surface 
 rendered perfectly smooth. 
 
 Collodion. — This substance is also used with advantage in small wounds, 
 or it may even be applied after the use of sutures or straps. When there is 
 a tendency to haemorrhage, the styptic colloid of Richardson is of good service, 
 the tannin acting as a styptic, while the collodion forms an impervious 
 covering to the wound. It is necessary to mention here, that some surgeons 
 have objected to the use of these preparations of ether, on the ground that 
 they cause too great contraction or shrinkage of the tissues. For my own 
 part, however, I have not observed that untoward results have followed their 
 application. 
 
 Healing of Wounds. — For a more accurate description of this process the 
 student may refer to Part II., Chapter IV., a brief recapitulation being only 
 necessary here. 
 
 There are several methods which nature adopts in healing wounds : the 
 first of these is what is termed immediate union, or that method in which 
 the parts are brought into immediate contact and the continuity of the ves- 
 sels restored, there being no inflammatory action or no deposit of lymph. 
 This, however, is rarely the case, although there may be instances in which 
 it can occur. 
 
 The scabbing process may be called nature's mode of healing wounds. We 
 often see the process in animals when they receive slight wounds : the blood, 
 dirt, and other materials which collect on the outside form a thick scab, ex- 
 cluding the air ; when the scab falls off the wound beneath is healed. This 
 process takes place, however, only in slight wounds, where there is little or 
 no suppuration. Dr. Hewson imitates this process in his earth treatment, 
 
252 A SYSTEM OF SURGERY. 
 
 and I must confess I have seen wonderful results from this application in 
 recent wounds and burns. 
 
 Healing by first intention, as it is called, is the desideratum to be ob- 
 tained in all varieties of recent wounds. This is the manner in which 
 incised wounds generally heal, and takes place by the adhesive inflamma- 
 tory process, if the edges are well coaptated, and there are no constitutional 
 causes to operate against the healing process. The changes that occur are 
 chiefly in the so-called connective tissue, composed of cells and intercellular 
 substance. The cells multiply and form themselves in numbers about the 
 divided tissues. These gradually form themselves into " scar tissue," by first 
 becoming spindle-shaped, then infiltrating the intercellular substance, and 
 finally, the cells become changed into connective-tissue corpuscles. These 
 latter are flattened and in a measure disappear, leaving their nuclei. This 
 tissue gradually contracts until the scar is compact. There is a considerable 
 difference of opinion regarding the action of the capillaries in this pro- 
 cess, Billroth assuming that these minute radicals occupy a secondary im- 
 portance, the changes being made by the cells themselves, while Cohnheim 
 regards the capillaries as the main factors, as through them are exuded the 
 white corpuscles. 
 
 However this may be, we find after a time that circulation through the 
 tissue is again re-established. In the present state of pathology it is quite 
 impossible to state with any degree of certainty, what power the nerves of 
 the part play in the reparative process. Wounds with loss of substance, 
 such as contused and lacerated wounds, cannot be expected to heal per pri- 
 mam intentionem, because the vitality of the bruised tissue is destroyed to 
 such a degree that it can never again regain the normal standard. It dies 
 and must be thrown off, and replaced by granulation-tissue, which consti- 
 tutes the process adopted by nature to restore lost substance. All wounds 
 in which there is loss of substance, or contusion sufficient to destroy the 
 vitality of a part, must result in sloughing, and therefore the lost tissue 
 must be supplied or replaced, which is accomplished by the process of granu- 
 lation. It is as follows : 
 
 Small red granules or points are seen at the bottom and sides of the 
 wound, and increase rapidly in number, inosculate with one another, and 
 fill up the cavity from the bottom and sides towards the surface. 
 
 Healthy granulations are not very sensitive ; are of a bright-red color, and 
 ordinarily do not bleed easily ; sometimes, however, they become sensitive, 
 and bleed from the slightest touch, or they may become flabby, pale in 
 color, and very luxuriant in growth ; these are, of course, deviations from 
 the normal or healthy process, and require treatment. 
 
 In a healthy granulation there is a single vessel and within each are ar- 
 ranged nuclei parallel to the sides of the vessel, or in some cases transversely. 
 The granulations must be well supplied with blood, by means of which 
 their many transformations are accomplished. When the granulations 
 have reached the surface, around the margins of the wound or sore, the epi- 
 dermis grows towards the centre, exhibiting a white line around the border 
 of the cavity to be repaired. In this manner the reproductive material will 
 partake of the nature of the part to be reproduced : bone in bone, muscle in 
 muscle, nerve in nerve. ( Vide Part II., Chapter IV.) 
 
 Incised Wounds are inflicted with sharp cutting instruments, and are gen- 
 erally considered the simplest of all the varieties previously mentioned, but 
 the latter feature must depend to a certain extent on the parts that are in- 
 jured. The most troublesome symptom is haemorrhage, and this aside, there 
 is but slight danger connected with them, — fibres have been simply divided, 
 they have suffered no contusion or laceration, and consequently they are 
 less likely to inflame severely, or to suppurate or slough. 
 
TREATMENT OF INCISED WOUNDS. 253 
 
 Simple incised wounds pour out more blood than the contused or lacer- 
 ated, although in the latter, much more important bloodvessels may be 
 injured, but their coats not being divided entirely or fairly, they recede, 
 owing to the size of the instrument by which the wound is produced, or to 
 their inherent elasticity or contractility. 
 
 If the haemorrhage be arterial, the blood has a florid, bright-red color, and 
 if vessels of any magnitude are severed, it spouts in jets ; if the blood be 
 venous, it is a dark-red or purplish, and flows gradually. 
 
 This variety of injury may heal by the first intention, but there are fre- 
 quently causes that operate to prevent such a desirable result. Among these 
 may be the inability to coaptate the wound, or the effusion of blood between 
 the margins of the cut, which may interfere with the healing process in 
 several ways : first, by acting as a foreign body ; secondly, by decomposing 
 and furnishing a further source of irritation. Again, contusions of the 
 wound-flaps may produce death of certain parts of the wound, or foreign 
 bodies, as sand and dirt, etc., remaining in the cut may prevent the process 
 of healing. Thus we see that there are a number of causes besides the con- 
 stitutional ones, which may operate against the speedy closure of incised 
 wounds. It may not be amiss here to ask the question, how do wounds 
 heal by first intention ? What is the modus operandi of the process ? When 
 a wound is first united, either by the interrupted suture or otherwise, its 
 edges may at first appear pale from the pressure produced by pins or su- 
 tures, or they often assume a purplish hue, owing to an obstruction to the 
 return of the venous blood. Sometimes within a few hours, or at most 
 within a day, local reaction is established, the edges of the wound become 
 red, it pains slightly, swells to a certain extent, and feels warmer to the 
 touch, though in reality the temperature is but little increased. These 
 symptoms indicate the presence of inflammation, which may be termed 
 traumatic inflammation, or the adhesive inflammatory process. So long 
 as this inflammation remains, so to speak, normal, it does not extend far 
 from the wound, does not increase in severity after the first twenty-four 
 hours, and begins to subside from the third to the fifth day. If all goes 
 well, at the end of the fifth or sixth day, the infiltrated or exuded plasma 
 will have become totally firm, the edges of the wound will be found quite 
 solid, even firmer than the surrounding tissues. This induration, sooner or 
 later, disappears. If the wound be now cleansed, the new cicatrix will be 
 seen as a red stripe along the track of the original wound; indeed, it is 
 slightly elevated. In course of time it loses its redness and hardness, and 
 finally becomes white and s jft, even whiter than the surrounding skin. 
 
 Treatment. — In the treatment of incised wounds, the surgeon should 
 endeavor to accomplish three objects, viz. : 1st. Arrest the haemorrhage. 2d. 
 Remove all extraneous matter from the wound. 3d. Coaptate the edges in 
 the manner most favorable for their union. 
 
 Arterial haemorrhage is most effectually checked by the application of a 
 ligature to the ends of the vessels (it is frequently necessary in the treat- 
 ment of incised wounds to ligate both extremities) : when the bleeding is 
 slight, it may be arrested either by compressions or twisting the divided 
 ends of the artery.* 
 
 After the first and most important object has been effected, attention must 
 be directed to the second consideration, " removal of all extraneous matter/' 
 The wound should be carefully examined, and all such substances, which 
 by their presence would prove a source of irritation (glass, dirt, clots, etc.\ 
 should be gently removed, as it is impossible for the wound to heal by the 
 first intention if such be allowed to remain. 
 
 * See Chapter on Arresting Hemorrhage. 
 
254 A SYSTEM OF SURGERY. 
 
 Haemorrhage having been stanched, and the wound cleansed, the third 
 consideration, coaptation, is to be thought of. In former days it was deemed 
 advisable to effect the union immediately and completely, but the expe- 
 rience of modern surgery teaches the expediency of moderate delay and in- 
 completeness. 
 
 If the external wound be put together while oozing blood continues, even 
 though slightly, especially if the part be covered with lint and bandages, 
 adhesion is necessarily thwarted on account of the oozing blood, which, 
 being unable to escape, accumulating, forms a coagulum between the lips 
 of the wound, and this, acting as any other extraneous body, prevents the 
 union. 
 
 All attempts at closure should, therefore, be delayed for a time, in wounds 
 of moderate extent, and in those of large dimensions the approximation of 
 the edges should be incomplete. In cases where the wound is not exten- 
 sive, a few moments' delay suffices; and when the cut surfaces present a 
 glazed appearance, they should be nicely adapted, and retained either by 
 straps or sutures. 
 
 If the oozing from the lips of the wound continue for some time, and if 
 a considerable amount of blood is thus discharged, the local application of 
 a saturated solution of tannin and alum, of the liquor ferri persulph., of the 
 dry Monsel's powder, or the perchloride of iron, or the ether spray, or the 
 xylostyptic ether of Richardson, will generally arrest it ; the best dressing, 
 however, I have found to be the prepared styptic cotton of Ende, as men- 
 tioned in the chapter on haemorrhage. In connection with this, arnica, 
 crocus, diadema, creasote, or phosphorus, should be internally administered. 
 If the patient's strength appears to be failing very rapidly, the countenance 
 becomes deadly pale, or assumes a livid appearance, china off. should be 
 prescribed, and the close repeated every ten or fifteen minutes, until the 
 symptoms commence to disappear. 
 
 After the bleeding has entirely ceased, adhesive plaster and position are 
 frequently sufficient to complete the cure ; this method, if practicable, is 
 much preferable to any other for promoting union ; but there are cases in 
 which the wound is so situated, or so extensive, as not to admit of the ap- 
 plication of adhesive straps, and when such is the case, recourse must be 
 had to sutures. Those most commonly employed are the interrupted, or 
 twisted, as already noted in the prefatory remarks on wounds. 
 
 For wounds that are slight, M. Vidal introduced small spring forceps, 
 
 which at their extremities are provided with hooks, sufficiently sharp to 
 
 hold the integument, without transfixing or laceration (Fig. 112, serra- 
 
 fines); when they have been allowed to remain from ten to 
 
 fig. 112. fourteen hours, the wound may have sufficiently healed to permit 
 
 fns) their removal, after which all other means required for retention 
 
 ^Hf are unnecessary. 
 
 Jjyj When strapping is deemed sufficient to produce adhesion, the 
 
 CTjy part should be placed in the position that relaxes the fibres of 
 
 ^T those muscles which, if remaining tense, would tend to retard 
 W^ union. The surrounding skin should then be perfectly freed from 
 
 serrafines. moisture, and if there be any hair upon the part, it should be 
 carefully shaved. If we expect to use the water-dressings, such 
 as solutions of calendula, or arnica, the old-fashioned adhesive plaster is to be 
 preferred ; if not, the Isinglass plaster, or Robbin's adhesive, or the Surgeon 
 adhesive plaster should be used. The straps should be long, and extend 
 some distance from the wound, in order that they may supply the place of 
 the bandage, in supporting the surrounding parts. Spaces should be left 
 between the straps to allow the escape of the serous discharge that passes 
 off during the process of adhesion. 
 
PUNCTURED WOUNDS. 255 
 
 Alcohol has been highly recommended by Dr. Dolbeau as a dressing for 
 wounds. He applies to the surfaces and fills the cavities with charpie 
 saturated with alcohol, and covers the dressing with a gutta percha envel- 
 ope. This application at first gives considerable pain, but in time the 
 parts appear to become insensible to the action of the spirit. I have never 
 had occasion to use the dressing, and, therefore, can say nothing in its 
 favor. 
 
 The application of dry earth is also a good dressing to wounds, and may 
 be used advantageously either to the recently cut surfaces or to suppurating 
 wounds. 
 
 If metallic sutures have been employed together with the plaster, they 
 should be allowed to remain uncovered, in order that they may be easily 
 removed when their aid is no longer essential. The sooner they can be dis- 
 pensed with, the more rapid will be the adhesion. Animal sutures are 
 absorbed. 
 
 After the wound has been dressed, the patient should be placed in bed, 
 all stimulating diet should be prohibited, and all causes of excitement be, 
 if possible, removed ; arnica should then be administered internally. If 
 the patient be robust, and there is a tendency to fever or delirium, aeon, or 
 belladonna may be employed. According to my own experience the tinc- 
 ture of hypericum in water is the best medicine to allay pain. 
 
 For more complete instructions for dressing wounds, the student may 
 refer to Chapter XIV., and also to Chapter I. 
 
 After surgical operations, aeon, has been very highly recommended. Dr. 
 Wurtzler writes: "After amputations, extirpations, and other surgical opera- 
 tions, I have invariably derived the most important service from the em- 
 ployment of aconitum. In most instances a complete cessation of pain 
 took place three hours after its * administration ; traumatic fever never 
 supervened, and the patients almost always fell into a placid and refreshing 
 slumber ; but rarely was it found necessary to have recourse to opium, and 
 that only when startings from sleep took place from local or general con- 
 vulsive jerkings or twitchings." 
 
 Punctured Wounds are inflicted by sharp and narrow instruments, as 
 needles, pins, thorns, nails, splinters, etc., which bruise and tear as well as 
 cut. They are, when slight, attended with little danger, but when of any 
 considerable extent the injury is always serious. Much also depends upon 
 the constitution of the patient and the situation of the wounded part. A 
 superficial wound along the integument, and not involving the textures 
 beneath it, is of trivial importance; but when the direction is from the 
 surface internally, there is always some danger to be apprehended, either 
 from the injury inflicted upon some internal organ, or from inflammation 
 occurring in the deep part of the'wound, inducing the formation of matter, 
 which being confined, infiltration of the surrounding textures is likely to 
 supervene, giving rise to much constitutional and local disturbance. Large 
 collections of matter have formed beneath the fasciae, giving rise to exces- 
 sive pain, and even permanent contraction or extension of the limbs, by 
 uniting the muscles or their cellular texture together. 
 
 Dr. Gibson mentions a case of a young man whose forearm was covered 
 with sinuses, from which matter could be pressed in every direction. The 
 fingers were permanently contracted, and consequently useless. The dis- 
 ease arose from a very trivial wound inflicted by a needle fixed in the end 
 of an arrow. 
 
 The lymphatics often swell from punctured wounds. A wound in the 
 foot may produce a sympathetic bubo, or a wound in the hand may give 
 rise to inflammation and swelling of the axillary glands. 
 
 If a punctured wound is made with a clean sharp instrument, and does 
 
256 A SYSTEM OF SURGERY. 
 
 not penetrate the viscera, the wound may be regarded more favorably than 
 when a rough, rusty or dirty weapon has inflicted the injury ; therefore the 
 surgeon should, if possible, inquire and examine the instrument before a 
 definite prognosis is given. There is, generally, slight hemorrhage from 
 punctured wounds, because the parts soon begin to swell, and the blood 
 clots over the mouth of the vessels, there being but small space for exit. 
 
 Treatment. — It was formerly the custom among surgeons to endeavor, by 
 immediately dilating punctured wounds, to convert them into incised, and 
 treat them as that variety of injury ; but this cruel practice is fast becoming 
 obsolete, although dilatation may be necessary under peculiar circum- 
 stances, viz. : If a portion of the weapon that inflicted the wound be im- 
 bedded in the injured textures, its removal requires that incisions be made 
 to permit the introduction of instruments used in extraction. If an artery 
 be punctured, it must be ligated, and this requires a certain degree of dila- 
 tation. Or, again, when by the formation of matter infiltration of the sur- 
 rounding tissues is threatened, free incisions must be employed. 
 
 But in many cases of punctured wounds, after ascertaining that there is 
 no extraneous substance present, by the use of isinglass plaster, and by 
 placing the part at rest and in the proper position, union by the first inten- 
 tion takes place, and the wound in a short time heals. If, however, inflam- 
 mation appear and suppuration threaten, hepar, mercurius, or silicea should 
 be administered. If the local inflammation is excessive, cham., bell., or rhus 
 will prove serviceable ; but by the judicious and early exhibition of arnica 
 or aconite the above symptoms may be prevented. Nit. acid and cicuta 
 vir. have been recommended in the treatment of this variety of wounds. 
 
 Ledum is said to be one of the most serviceable medicines in punctured 
 wounds and affections attendant upon them. The characteristic symptom 
 for its exhibition is coldness during the fever. M. Teste remarks : " Ledum is 
 for wounds inflicted with sharp instruments, what arnica is for contusions." 
 
 The above writer mentions instances in which this medicine was produc- 
 tive of most beneficial results. 
 
 " 1st. In several whitlows caused by the pricks of a needle. 
 
 " 2d. Violent bite of a water rat. 
 
 " 3d. In a serious wound inflicted upon a young lady who fell with an 
 embroidery needle in her hand, which pierced through and through. No 
 haemorrhage occurred, but I observed the intense cold which accompanies 
 and characterizes ledum fever."* 
 
 If, as a consequence of punctured wounds, tetanus supervene, aeon., am., 
 angust., and cicuta may be employed.f 
 
 Contused Wounds. — In every contusion there must be a certain degree of 
 injury inflicted upon the parts beneath, though the integument from its 
 elasticity may remain unbroken. 
 
 Ecchymosis, in the generality of instances, occurs from the rupture of 
 smaller bloodvessels, their contents being poured into the surrounding 
 cellular tissue. If larger vessels have been torn, danger is to be appre- 
 hended from the extensive infiltration of blood, giving rise to inflammation, 
 suppuration, and gangrene. 
 
 If, together with the contusion, the integument is broken, the injury is 
 then termed a lacerated wound. Such wounds, when first inflicted, give rise 
 to little pain, because the nerves of the part have suffered from the concus- 
 sion ; but after a time, when the part has to a certain extent recovered its 
 nervous power, the pain increases in proportion to the inflammation that 
 is established. 
 
 The degree of violence of contused wounds is in proportion to the velocity 
 
 * Teste, Mat. Med., p. 77. f See Chapter on Tetanus. 
 
LACERATED WOUNDS. 257 
 
 with which the contusing weapon is carried against the parts, and the 
 resistance of the textures to which it is applied. If the parts yield, the 
 shock is diminished, and consequently the injury is less considerable. 
 
 Treatment. — In simple bruises, or in the most violent contusions, pro- 
 vided there is no abrasion of the integument, the remedy is arnica, admin- 
 istered internally, applied as a lotion externally, or both. 
 
 The extraordinary virtues of this " panacea lapsorum " is not only appre- 
 ciated by the whole medical profession, but as a domestic medicine its 
 excellent qualities are fully understood, and the frequency with which it is 
 employed with success, bears testimony to its usefulness in all manner of 
 bruises. 
 
 As an external application, the tincture should be diluted according to 
 the sensitiveness of the skin of the patient, but in the generality of cases 
 one part of the pure tincture to ten or twelve parts of water will be suffi- 
 cient. If ecchymosis be present to any extent, the internal administration 
 of arnica or sulph. ac. will generally suffice. 
 
 If, however, by the use of the diluted arnica there be any aggravation 
 of pain, or if any of the pathogenetic effects of the drug are manifested, 
 calendula officinalis must be employed. Helianthus and Symphytum have 
 also been recommended. 
 
 If contused wounds be slight, and the vitality of the affected part not 
 much impaired, union by the first intention should at least be attempted, 
 inasmuch as partial agglutination may prevent deformity and other ill 
 consequences ; but if the injury be of any considerable extent, adhesion is 
 impossible, for the bruising is such that the texture is immediately deprived 
 of life, or its vitality is so much diminished that death is inevitable. 
 
 In all cases sutures should be dispensed with, and antiseptic adhesive 
 straps employed to retain the edges of the wound as nearly in situ as possi- 
 ble. Rest and perfect relaxation of the muscles of the part are indispensable. 
 
 When the ligaments or tendons are implicated, rhus tox., as adapted 
 particularly to contusions of such tissues, is preferable to arnica as an 
 external application, and should also be administered internally. 
 
 If gangrene threaten, china off. should be immediately prescribed, but 
 if the wounded part assume a bluish tint, and the patient's strength sink 
 rapidly, arsen. or carb. veg. must be administered. 
 
 When there has been considerable loss of substance in contused wounds, 
 the parts can only heal by granulation, and if there be present any dead 
 or dying tissue, it must first slough away. When such is the case, the 
 patient must be kept at rest, and hepar or mercurius sol. be administered 
 to aid nature in her efforts to cast off the slough, and when this has been 
 effected, calendula, silicea, or sulphur may be administered to forward the 
 granulations and complete the cure. If bone or periosteum has been 
 affected by the injury, mez., phos. ac, or ruta should be employed ; the 
 latter is especially serviceable when the wound has involved the tarsal or 
 metacarpal joints. 
 
 In all injuries where there is great contusion, arnica should be immedi- 
 ately administered internally, and if high fever and delirium supervene, 
 it may be alternated with aeon., bell., hyos., or stram., according to the 
 indications for each medicine. If the fever assume a lower grade, and 
 typhoid symptoms are present, rhus, ars. or carb. veg. must be employed 
 agreeably to the presenting symptoms. 
 
 Lacerated Wounds. — A wound is said to be lacerated when its edges 
 present a torn and ragged appearance. 
 
 In this variety of injury there is generally but little haemorrhage, and it 
 is this circumstance that frequently leads inexperienced practitioners to 
 establish a false prognosis regarding the termination of the case, but the 
 
 17 
 
258 A SYSTEM OF SURGERY. 
 
 experienced surgeon does not allow himself to be deceived by the absence 
 of haemorrhage ; on the contrary, in proportion as there is little bleeding, 
 the violence that the fibres and vessels have received is estimated. Whole 
 limbs have frequently been torn from the body without the occurrence of 
 profuse haemorrhage. 
 
 In La Mott's Traite des Accouchements can be found an interesting account 
 of an injury of this kind that happened to a lad, who, while playing near the 
 wheel of a mill, entangled his arm and forearm in the machinery. The limb 
 was violently torn away from the shoulder-joint, but the haemorrhage was so 
 trivial that it was stopped with a little lint, and the boy very soon recovered. 
 
 The indisposition to haemorrhage manifested by lacerated wounds is 
 owing to the following circumstances : The orifices of the bleeding vessels, 
 from the laceration, become drawn together, or, as it were, puckered ; conse- 
 quently the stream of blood is diminished in volume ; they also retract to a 
 greater degree than when they have been evenly divided ; the sheaths of the 
 vessels are drawn, at the lacerated extremity, to a point, which also tends to 
 retard the flow of blood, and the arterial coats being divided at different 
 times contract separately, the internal and middle being the first that are 
 separated. These circumstances, as will be perceived, tend greatly to arrest 
 the haemorrhage which otherwise would necessarily occur. 
 
 Any irregular bod}^, driven with violence, may produce a lacerated wound. 
 It may also be caused by falling from a height upon uneven surfaces ; 
 but machinery, when in full motion, produces, perhaps, the most fearful 
 and disastrous lacerations. 
 
 There are cases of this description recorded by Carmichael, Morand, 
 Cheselden, and also in many of the medical and surgical journals, that are 
 highly interesting, as denoting from what frightful laceration the system 
 may ultimately recover. 
 
 Complete union by the first intention is impossible in lacerated wounds ; 
 inflammation and suppuration are certain, and the dead tissues must be 
 thrown off in the form of a slough, and if this be large, severe constitu- 
 tional symptoms are likely to supervene ; but this is not the only difficulty 
 which has to be encountered ; gangrene often spreads rapidly in the sur- 
 rounding textures, thus increasing the danger to both life and limb ; or 
 tetanus may threaten with its alarming symptoms. 
 
 Treatment. — The first attention of the surgeon when called upon to treat 
 a lacerated wound, must be directed to the removal of all extraneous bodies, 
 and if it be present, arresting haemorrhage. It sometimes happens that dirt 
 or sand are begrimed in the wound, and this is particularly the case when 
 the injury has been occasioned by the patient falling from a height upon 
 uneven ground and loose stones. After all such foreign matter has been 
 extracted and the wound cleansed carefully, the most important blood- 
 vessels that have been implicated must be searched for and ligated, and a 
 dose of arnica administered internally. 
 
 It is advisable never immediately to cut away any of the lacerated soft 
 parts, because it frequently happens that some portion of them may heal 
 by adhesion, thus leaving a less amount of surface to be repaired by the 
 reproductive process (granulation and cicatrization). 
 
 Adhesive straps should then be loosely applied, and in such a manner 
 that a free exit be allowed for the matter. Calendula officinalis, prepared as 
 before directed, should be applied to the part, and also administered inter- 
 nally in the usual form, as it is known to prevent, in many instances, that 
 prolonged suppuration that so frequently occurs in extensive lacerations, 
 and also exercises a powerful influence over granulation and cicatrization. 
 If, however, the expectation of the practitioner be disappointed and suppu- 
 ration is excessive, calcium sulphide 1-10 should be substituted. 
 
POISONED WOUNDS INSECT WOUNDS. 259 
 
 If the patient is restless, uneasy, and excited by the least emotion, and 
 the local pain is severe, cham. will prove serviceable ; or, if together with 
 the pain there is high fever and delirium, aeon, or bell, should be resorted 
 to, the latter, particularly, if the patient is of a robust habit of body. Either 
 of the above may be alternated with arnica or calendula. 
 
 If the patient become extremely weak, with thirst, hot dry skin, and 
 gangrene threatens, ars. must be substituted ; or, if the symptoms correspond, 
 carbo veg., china, or lach. are to be employed. 
 
 While the ulceration and sloughing are progressing, the wound must be 
 narrowly watched, as there is danger of haemorrhage ensuing. Tetanus 
 may also be present, the proper medicines for which will be found in another 
 portion of this work. (See Tetanus.) 
 
 In some cases, however, notwithstanding the best-directed efforts in both 
 constitutional and local treatment, gangrene appears to be spreading rapidly ; 
 in such, the question of amputation must be seriously considered. 
 
 Poisoned Wounds are characterized by the presence of some poisonous 
 material, which is itself the principal source of danger, the wound being 
 generally a mere puncture or scratch. The prognosis in such injuries must 
 depend upon the extent of the wound and the virulence of the poison in- 
 troduced into the system. 
 
 The nervous system is reacted upon by the virus which is received into 
 the blood; and the great nervous centres suffer in proportion as the poison 
 is introduced either remote or near them. In some instances it would seem 
 that the nervous system is immediately affected, as death has been known 
 to follow the bites of the more venomous serpents in a very short period of 
 time. In the majority of instances, however, in poisoned wounds, some 
 time intervenes between the introduction of the poison and the symptoms 
 indicating its presence in the system. 
 
 By the term zymosis, is understood a process of fermentation, which is 
 supposed to take place in the circulating fluid after the introduction of virus, 
 whereby the whole system becomes contaminated, and most alarming symp- 
 toms present themselves. 
 
 Some poisons after being introduced into the system have a period of in- 
 cubation, then develop their characteristic mark in the shape of pustule or 
 ulcer, and from this the entire system becomes inoculated. This process is 
 called the double zymotic process. 
 
 Insect Wounds. — Among insects, the bee, wasp, hornet, and yellow jacket, 
 inflict a slight wound, and infuse into it poison contained in a bladder situ- 
 ated at the base of the sting. The virus flows from the vesicle through the 
 sting at the instant this passes into the flesh. Such wounds are, in this 
 country * generally trivial, and their effects pass off in a short time ; but 
 sometimes they are productive of intense pain and violent inflammation. 
 
 * Insects are the curse of tropical climates. The bete rouge lays the foundation of a tremen- 
 dous ulcer. In a moment you are covered with ticks. Chigoes bury themselves in your 
 flesh, and hatch a large colony of young chigoes in a few hours (p. 404). They will not live 
 together, but every chigo sets up a separate ulcer, and has his own private portion of pus. 
 Flies get entry into your month, into your eyes, into your nose ; you eat flies, drink flies, and 
 breathe flies. Lizards, cockroaches, and snakes get into the bed ; ants eat up the books ; 
 scorpions sting you on the foot. Everything bites, stings, or bruises. Every second of your 
 existence you are wounded by some piece of animal life that nobody has ever seen before, 
 except Swammerdam and Meriam. An insect with eleven legs is swimming in your teacup, 
 a nondescript with nine wings is struggling in the small beer, or a caterpillar with several 
 dozen eyes in his belly is hastening over bread and butter. All nature is alive, and seems to 
 be getting all her entomological hosts to eat you up as you are standing, out of your coat, 
 waistcoat, and breeches. Such are the tropics. All this reconciles us to our dews, fogs, 
 vapors, and drizzle, to our apothecaries rushing about with gargles and tinctures, to our old 
 British constitutional coughs and swelled faces.— Sid. Smith's Works, vol. ii., p. 147. 
 
260 A SYSTEM OF SURGERY. 
 
 The virus of the hornet or of the yellow jacket is more highly acrimonious 
 than that of the common bee, and there are instances on record in which 
 both human beings and inferior animals have lost their lives from wounds 
 inflicted by these insects. Dr. Gibson records a case of a female who died 
 in fifteen minutes after having been stung by a yellow wasp. Another case 
 is also mentioned by the same author, of a young woman who lost her life 
 from swallowing a bee inclosed in a piece of honeycomb. 
 
 The mosquito, certain varieties of spider, and some species of fly, inflict 
 severe and oftentimes dangerous wounds. In unhealthy constitutions, or 
 in individuals whose skin is very susceptible to inflammation, the sting of 
 the mosquito will degenerate into a troublesome sore. Dr. Dorsey * men- 
 tions a case where gangrene and death supervened from a bite of this insect. 
 The patient was previously enjoying good health. There is also recorded 
 by Dr. Mease, in the Domestic Encyclopaedia, an instance in wdrich the sting 
 inflicted by a spider was productive of fatal results. 
 
 The tarantula, a species of spider that is found in South America, Mexico, 
 and in Europe, particularly in the neighborhood of Naples, inflicts a sting 
 which has been pronounced by some authors to be exceedingly severe, 
 while others deny that ill consequences of any severity result from the 
 virus injected into the system. 
 
 The scorpion is an insect whose sting in warm climates is so severe that 
 death frequently ensues. It attains its largest growth in Persia, India, and 
 Africa, where it is termed the scorpio afer. The reservoir that contains 'the 
 poison is situated near its tail, and is ejected from two small orifices on each 
 side of the tip of the sting. The symptoms produced in animals after they 
 have been bitten, are swelling, convulsions, retching, vomiting, and death 
 soon supervenes. 
 
 The appearances presented w T hen individuals have been bitten by the 
 scorpion, are related by Mr. Allan to be similar to those produced by the 
 stings of bees, but much more aggravated.! 
 
 Wounds of Venomous Snakes. — The two species of American serpents that 
 are the most venomous, are the copperhead and rattlesnake. Of the latter 
 there are ten species. The oldest naturalists mentioned but eight, but the 
 two others, crotalus cumanesis and the crotalus Iceflingii, were discovered by 
 Humboldt and Bonpland. All are poisonous, but those whose virus is most 
 malignant are the crotalus hori'idus, miliarius, and durissus. The poison of 
 the rattlesnake is of a yellow color, tinged slightly with green ; during the 
 extreme heat, particularly in the procreating season, it becomes of much 
 darker hue.J 
 
 Mr. Catesby § informs us that the Indians, who in their constant wander- 
 ings in the woods are liable to be bitten by snakes, know immediately if the 
 wound will prove fatal. If it be on any part at a distance from the large 
 bloodvessels, or where circulation is not vigorous, they at once apply their 
 remedies ; but if any artery or vein of considerable magnitude is involved, 
 they quietly resign themselves to their fate. 
 
 Sir Everard Home, in some observations on the poisons of the black- 
 spotted snake of St. Lucia, the cobra de capello, and the rattlesnake, remarks : 
 
 " The effects of the bite of a snake vary according to the intensity of the 
 poison. When the poison is very active, the local irritation is so sudden 
 and so violent, and its effects on the general system are so great, that death 
 soon takes place. When the body is afterward inspected, the only alteration 
 of structure met with, is in the parts close to the bite, where the cellular 
 
 * Elements of Surgery, vol. i., p. 68. 
 
 t Allan's Svstem of Pathological and Operative Surgery, vol. i., p. 370. 
 
 X Gibson's Practice of Surgery, vol. i., p. 108. 
 
 I Preface to Natural Historv of Carolina. 
 
WOUNDS BY BABID ANIMALS. 261 
 
 membrane is completely destroyed, and the neighboring muscles very con- 
 siderably inflamed. When the poison is less intense, the shock to the gen- 
 eral system does not prove fatal. It brings on a slight degree of delirium, 
 and the pain in the part bitten is very severe. In about half an hour swell- 
 ing takes place from an effusion of serum in the cellular membrane, which 
 continues to increase, with greater or less rapidity, for about twelve hours, 
 extending, during that period, into the neighborhood of the bite. The blood 
 ceases to flow in the small vessels of the swollen parts; the skin over them 
 becomes quite cold ; the action of the heart is so weak that the pulse is 
 scarcely perceptible, and the stomach is so irritable that nothing is retained 
 by it. In about sixty hours these symptoms go off; inflammation and sup- 
 puration take place in the injured parts; and when the abscess formed is 
 very great it proves fatal. When the bite has been in the finger., that part 
 has immediately mortified. When death has taken place, under such cir- 
 cumstances, the absorbent vessels and their glands have undergone no 
 change similar to the effects of morbid poison, nor has any part lost its 
 natural appearance, except those immediately connected with the abscess. 
 In those patients who recover with difficulty from the bite, the s}~mptoms 
 produced by it go off more readily and more completely than those pro- 
 duced by a morbid poison which has been received into the system."* 
 
 The viper is a serpent whose bite is exceedingly venomous. It is the 
 virus of the lance-headed viper {trigonocephalus lachesis) with which the 
 members of our school are so familiar by the labor, research, and the self- 
 sacrificing investigations of Dr. Hering. 
 
 This poison has somewhat the appearance of saliva, but it is less tenacious. 
 It readily forms into drops and falls without threading. It is slightly greenish 
 in color, and when exposed to the air concretes into a dry yellow mass.f 
 
 Wounds by Rabid Animals. — The bite of rabid animals produces, in many 
 instances, that disease termed rabies canina, or hydrophobia, although this 
 affection does not necessarily follow ; for it has been certainly ascertained 
 that out of numerous persons bitten by dogs, undoubtedly mad, few have 
 sustained material injury. 
 
 The first symptoms of hydrophobia generally manifest themselves between 
 the seventh and fortieth day ; but there are cases recorded of the virus re- 
 maining latent in the system for months and years. The wound is often 
 slight and heals readily, and may never again re-open, but sometimes at the 
 onset of the disease, it inflames, becomes painful, breaks open afresh, 
 assuming a livid and spongy appearance, and secreting an ichorous humor. 
 The patient complains of pain extending from the wound or cicatrix along 
 the nerves. The part bitten feels numb, becomes stiff and immovable, or it 
 may be convulsively moved. 
 
 The patient is troubled with excessive apprehension, the countenance in- 
 dicates great anxiety, or the features may assume a melancholy expression. 
 The sleep is restless and uneasy, interrupted by frequent startings, or there 
 is complete sleeplessness. There are also present drawing pains in the nape 
 of the neck, burning in the fauces and stomach, sensitiveness to draughts of 
 air, with vertigo, nausea, and vomiting of green bile. Constant urging to 
 urinate, the urine passing in drops, or an irresistible desire for copulation, 
 are symptoms that are not unfrequently encountered. In some cases vesi- 
 cles appear under the tongue, which are said by some to be pathognomonic 
 of the disease. 
 
 When the convulsive stage sets in there is that frightful aversion to liquids 
 which characterizes this disease, and from which it derives its name.J 
 
 * Case of a man who died in consequence of the bite of a rattlesnake. 
 f Jahr's Pharmacopoeia and Posology, p. 221. 
 
 J Ina letter published in the Lancet the following remarks occur;: u Drinkmg water is 
 now no criterion by which we can judge of the existence or not of rabies. The name of hy- 
 
262 A SYSTEM OF SURGERY. 
 
 Although the patient is tormented with violent thirst, even the thought of 
 fluid at once excites most painful and distressing symptoms. If the attempt 
 be made to swallow a few drops of water, the throat and chest become con- 
 stricted, and the most violent suffocative convulsions of the facial, thoracic, 
 and abdominal muscles ensue. The convulsions are excited by the most 
 trivial incidents. The movement of a curtain, contact, etc., give rise to 
 spasm. There is also often present another very distressing symptom, — the 
 collection of thick, ropy, viscid phlegm, adhering with such tenacity to the 
 throat that it is extremely difficult and often impossible to eject it. Dr. 
 Marcet, in the Medico- Chirurgical Transactions, records a case of this disease 
 in which the phlegm was thrown off with such extreme torture that the 
 patient exclaimed, " do something for me ! I would suffer myself to 
 be cut to pieces ! I cannot raise the phlegm ; it sticks to me like bird- 
 lime !" 
 
 Finally, tetanic or epileptic convulsions take place, and the appearance 
 presented by the sufferer during these spasms is most horrible and appall- 
 ing. The face expresses intense anguish and despair; the eyes are pro- 
 truded, bloodshot, and roll wildly in their sockets ; the delirium is furious, 
 during which muscular strength increases to such a degree that the patient 
 is with difficulty controlled. He howls, bites, and spits, or endeavors to 
 tear himself to pieces. This attack continues about fifteen minutes, and 
 subsides for a short period, leaving a state of complete exhaustion. It is 
 during such intervals that consciousness is sometimes present, and often it 
 happens when a slight gleam of reason returns, that the patient warns his 
 attendants to what danger his rage may expose them, or prays them in 
 earnest tones to terminate his sufferings. 
 
 Sometimes vomiting occurs. Men may be attacked with priapism, and 
 women with furor uterinus. The beats of the pulse are small, irregular, and 
 very frequent, about 130 to 150 per minute, with temperature at 105°. 
 
 As the disease progresses, the paroxysms increase in frequency and vio- 
 lence, and death ensues in from two to eight days, generally from exhaustion 
 (apoplexia nervosa), or the patient may die, suffocated, in convulsions. These 
 are the symptoms that occur in most cases of hydrophobia ; but there are 
 modifications in this as well as in other diseases. In some instances, the 
 patient may be able to swallow some liquids, and not water ; or the symp- 
 toms may only appear during a paroxysm ; or they may be purely nervous. 
 
 This disease is said to originate and develop itself spontaneously among 
 the canine or feline race. The virus can be transmitted to men and to all 
 warm-blooded animals. Youatt has noticed the disease in the horse. 
 
 Several severe cases of this horrible disease have been brought to my 
 notice, one in particular deserving some attention. A man had a pet dog, 
 which regularly slept in the same bed with his master. The dog was seized 
 with rabies and died ; shortly after the man was also attacked with hydro- 
 phobia, and died, no wound being detected upon his person. This is a 
 singular but undoubted case. In another instance, a mad dog had been 
 killed upon the steps of a public institution; shortly after a man, in a state 
 of intoxication, fell upon the same step, striking his head violently on the 
 spot where the dog had been killed. In a short time symptoms of hydro- 
 phobia manifested themselves, and the patient died in all the agonies of 
 the disease. 
 
 Rabies in the dog is said to be of two varieties. " The first is characterized by 
 augmented activity of the sensorial and locomotive functions, continued and 
 
 drophobia is now universally allowed to be incorrect, there being no dread of water itself, but 
 of the horrible spasms which the attempt to swallow liquids induces. Even this is not so 
 constant an attendant on the disease as it was formerly supposed to be. There are many 
 well-marked cases of rabies without either a horroi' of fluids or difficulty of swallowing ." 
 
"WOUNDS BY EABID ANIMALS. 263 
 
 peculiar barking, and a strong disposition to bite. The affection commences 
 with some alteration in the peculiar habits and disposition of the animal, 
 who, as the case may be, is more tractable, more irritable, more lively, or 
 more sluggish than usual ; or these several conditions may alternate in one 
 and the same animal. An early symptom consists in the inclination to 
 lick, or carry in the mouth, various inedible substances, especially such as 
 are cold. The animal after a time gets restless ; snaps in the air, as if at 
 flies ; frequently leaves the house, but soon returns ; and is obedient and 
 seems attached to its master. According to Blaine, constipation constantly 
 exists. There is usually complete loss of appetite ; but the animal seems 
 to suffer from thirst, drinking eagerly, until, as indeed usually occurs, the 
 mouth and tongue become swollen. The eyes are red, and become dull, 
 haggard, and half-closed, the skin of the forehead being also wrinkled, 
 which gives the animal a peculiar aspect. The nose, tongue, and throat 
 now usually become swollen, and the coat becomes rough and staring. 
 According to Hertwig, the mouth is generally very dry ; but Blaine has con- 
 stantly observed a flow of thin saliva. After some time the gait becomes 
 unsteady and staggering, and finally the extremities are paralyzed. The 
 tail, in this form of the disease, is not drawn between the legs ; and the 
 head is carried erect, the nose being pointed upwards. A disposition to 
 bite sooner or later, invariably occurs. It is not, however, permanent, but 
 recurs periodically. It is directed against both inanimate and animate ob- 
 jects — most especially against the cat — less so towards other animals, and 
 least of all towards man. When the animal bites, he does not previously 
 bark, or fly at the object of his attack, but approaches in a quiet or evert 
 friendly manner, and makes a sudden snap. 
 
 " The second form of the disease is distinguished by inactivity and 
 depression. There is no disposition to bite — probably from the lower 
 jaw being paralyzed — nor is there any indication for change of place mani- 
 fested. The first symptoms are unusual quietness and apparent depression 
 of spirits. The voice is peculiarly altered, as it is in the foregoing variety ; 
 but there is much less disposition to bark. The mouth is open, the lower 
 jaw hangs as if paralyzed, and is raised only under the influence of strong 
 excitement. There is a constant flow of saliva from the mouth. The 
 animal either does not drink at all, or does so with difficulty, but manifests 
 no fear of water ; and, on the contrary, willingly immerses the nose in that 
 fluid. The tongue is almost constantly protruding from the mouth."* 
 
 The anatomical changes that are noticed in the bodies of those persons 
 who have died from hydrophobia are as follows : The subject decays 
 rapidly; the blood is dark, fluid, and quickly imbibed by the system. The 
 veins are engorged, air is frequently found in the larger vessels, and emphy- 
 sema develops itself rapidly. The whole surface of the body is blue-red; 
 the epidermis is very dry ; all the muscles are dark red, and, like the ten- 
 dons, they are rigid and tight. 
 
 Flemingf refers to some curious experiments in relation to hydrophobia 
 and sexual excitement. 
 
 " A cross-bred spaniel, 5} months old, had never left its mother, never went 
 out and was quiet. When the mother became in rut, the young dog refused 
 food and became agitated, and was excited by the odor. After a sleep it 
 flew savagely at the attendant and was removed. On the fifth day it died 
 from rabies, all the time refusing food." 
 
 Another case of what Fleming calls spontaneous rabies occurred under 
 similar conditions : "Ina box adjoining a kennel of the male, was placed 
 
 * British and Foreign Medical Review, No. xxv., p. 50. 
 f The Medical Record, July 6, 1878, No. 400, 
 
264 A SYSTEM OF SURQERY. 
 
 a female in rut, the effluvia from which caused the most ardent veneric ex- 
 citation. After fifteen clays the animal went furiously mad. Similar results 
 have often occurred." 
 
 The introduction of morbific matter into the system is sometimes productive of 
 the worst results. One of the most deleterious poisons seems to be engendered 
 in the body during the puerperal disease, and when by any accident there 
 has been inoculation with this virus, results the most fatal have followed. 
 Anatomists, or those engaged in macerating or making preparations, have 
 suffered severely from accidental wounds inflicted by the instruments they 
 were using. Violent inflammation frequently follows such casualties ; 
 the axillary glands inflame and suppurate ; the whole limb is painful ; ab- 
 scesses form, and gangrene and death may result. Many examples of such 
 cases are on record. 
 
 Treatment of Poisoned Wounds. — The bites of the mosquito and other 
 insects, which are common in our climate, are often quite painful, and 
 cause considerable annoyance. However, a lotion composed of a weak 
 solution of arnica tincture, if applied to the bitten part, eases almost imme- 
 diately the pain and itching. Camphor and lemon juice,* as external 
 applications, are also highly recommended for this purpose. Dr. Gibson 
 writes :f "The aqua ammonia? applied to a part stung by bees, I have 
 known to act like a charm." The internal administration of ledum is also 
 recommended by M. Teste.! He says : " Against mosquito bites, a single 
 teaspoonful of a tumblerful of water in which a few globules of the 15th 
 dilution of ledum has been dissolved, quieted completely in a few minutes 
 — I might even say a few seconds — the itching caused by the bite." This I 
 quote, though I can scarcely credit the miraculous, and would recommend 
 the application to the part of common laundry soap as much more certain 
 and efficient to allay the itching. 
 
 If, after the sting of any insect, the part becomes swollen, tense, hot, 
 with erysipelatous blush, bella. should be administered, and if fever super- 
 vene, aeon, may be used in alternation. Arnica is also an important rem- 
 edy, and should be used, both internally and as an outward application, 
 when the swelling assumes a bluish cast, and there is a bruised sensation 
 around the part. If the pain is stinging, and there is itching, and a thin 
 discharge from the wound, creas. should be administered. This medicine has 
 also been recommended as a lotion, composed of about ten drops of the 
 tincture to a pint of water. 
 
 The following medicines have also been found very serviceable ; the indi- 
 cations for their use will generally be shown in the constitutional symptoms 
 that present themselves: Ant. crud., calad., lach., mere, seneg., sep. 
 
 In Morocco, where the scorpion is very common, most families keep a 
 bottle of olive oil in which the bodies of several of these reptiles have been 
 infused, and when bitten, apply it to the wound, and with reputed success. 
 A ligature is also generally placed above the wounded part, to interrupt the 
 progress of the poison, and the wound is afterwards scarified. " In Tunis, 
 when any person is stung by a scorpion," says Mr. Jackson,§ " or bit by 
 any venomous reptile, ihey immediately scarify the part with a knife, and 
 rub in olive oil as quickly as possible, which arrests the progress of the 
 venom. If oil is not applied in a few minutes, death is inevitable, particu- 
 larly from the sting of a scorpion. Those of the kingdom of Tunis are the 
 most venomous in the world." According to the same author, the coolies, 
 
 * Laurie's Homoeopathic Practice of Physic, p. 541. 
 
 .f Institutes and Practice of Surgery, p. 119. 
 
 J Materia Medica, p. 77. 
 
 | Jackson's ^Reflections on the Commerce of the Mediterranean. 
 
TREATMENT OF POISONED WOUNDS. 265 
 
 or porters who work in the oil stores, have their bodies constantly saturated 
 with oil, and on this account not only never suffer in the slightest degree 
 from the bites of scorpions, and other reptiles which creep over them at 
 night, as they sleep on the ground, but there is not a single instance known 
 of one of these people ever having taken the plague, although the disease 
 frequently rages in Tunis in the most frightful manner. 
 
 Dr. Hammond, of New York, has called the attention of the profession to 
 Bibron's solution in antidoting the poison of the rattlesnake. The formula 
 for its production is : 
 
 R. Bromine, 3 V \. 
 
 Hydrag. bichlor., gr. ij. 
 
 Potass, iodidi, gr. iv. 
 
 M. ft. sol. 
 S. Ten drops every twenty to sixty minutes, in accordance with the violence of the symptoms. 
 
 Dr. Hammond has used this preparation with success. 
 
 The use of olive oil has been highly extolled by many writers as a remedy 
 for the bites of poisonous serpents. Dr. Miller,* of South Carolina, relates 
 the case of a man who was bitten in the sole of the foot by a very large 
 rattlesnake. Although very little time elapsed before he reached the patient, 
 his head and face were prodigiously swelled, and the latter black. " His 
 tongue was enlarged and out of his mouth ; his eyes as if starting from their 
 sockets; his senses gone, and every appearance of immediate suffocation." 
 Two tablespoonfuls of olive oil were immediately got down, but with great 
 difficulty. The effect was almost instantaneous; in thirty minutes it oper- 
 ated freely by the mouth and bowels, and in two hours the patient could 
 articulate, and soon after recovered. The quantity of oil taken internally 
 and applied to the wound did not exceed eight spoonfuls. In the course of 
 twelve years Dr. Miller has met with several similar cases in which the oil 
 has proved equally successful. 
 
 The application of dry heat has also been highly lauded for the neutraliza- 
 tion of the virus inflicted by serpents. 
 
 In the western parts of our country, where rattlesnakes abound, and 
 persons frequently are bitten, the treatment consists in forcing the patient 
 to swallow from a pint to a quart of some alcoholic stimulant — generally 
 common whiskey. Although this method of treatment may appear novel 
 and strange, still the effects produced are recorded as most wonderful. In 
 the iron regions of Missouri, among the mountains, the rattlesnake is fre- 
 quently found, and the inhabitants, although they fear the reptile, are 
 destitute of that dread which generally connects itself in our minds regard- 
 ing the crotalus ; this probably arises from the belief that their remedy is 
 infallible. 
 
 Case, — A boy was chasing a squirrel in the locality above mentioned, 
 when the animal, as the child supposed, ran into a hollow tree. The boy 
 immediately thrust his arm into the opening, and was bitten by a large 
 rattlesnake. The hand and arm soon after commenced swelling, and the 
 glands in the axilla had become somewhat enlarged, when medical assist- 
 ance was procured. Common whiskey was immediately administered by 
 the half tumblerful, until the child must have swallowed nearly a pint and 
 a half. The stimulus did not appear to produce any exhilarating effect, 
 but drowsiness came on and the patient slept for some time ; on awaking, 
 though the arm was still considerably swollen and painful, it was more 
 natural in color. From this time improvement continued, and the patient 
 ultimately recovered. The author witnessed this case. 
 
 * New York Medical Repository, vol. ii., p. 242. 
 
266 A SYSTEM OF SURGERY. 
 
 The late Professor Brainerd, of Chicago, extolled very highly the follow- 
 ing treatment in snakebites : Saturate the parts with a solution composed 
 of five grains of iodine and fifteen grains of iodide of potassium in a fluid 
 ounce of distilled water, and paint the limb with the tincture of iodine ; at 
 the same time administering five grains of the iodide of potash every five 
 hours. 
 
 Dr. Perkins, in the Galveston (Texas) Medical Journal, states that the im- 
 mediate application of a coal of fire is a specific treatment for the bite of 
 the rattlesnake. 
 
 In the western parts of Missouri a very popular remedy for the bites of 
 all venomous serpents is a plant vulgarly called " the snake weed," the 
 " snake infallible," or " rattlesnake master." In the Western Homoeopathic 
 Observer an interesting account of it can be found. It belongs to the class 
 Pedicularis Canadense, or lousewort. 
 
 Professor Halfour, in the Pacific Medical and Surgical Journal, gives some 
 very interesting cases treated by the injection of liquor ammonise into the 
 veins. Two drachms of a solution of this medicine were employed. He 
 gives some remarkable cases, from which we select the following : 
 
 A robust man, aged twenty-three years, was bitten in the palm of the 
 right hand. The part was immediately excised. Arriving at Dr. Rae's 
 soon after, he employed suction and cauterization, and no symptoms of 
 poisoning appearing sent the man home. In three hours, drowsiness, nausea, 
 numbness of right arm, intolerance of light, and oppression in the chest, 
 came on, and increased so rapidly, that it became difficult for the man to 
 ride alone. Upon arriving again at Dr. Rae's the stupor was so great that 
 shouting would scarcely elicit monosyllables in answer. The surface was 
 cool and clammy, breathing quiet and slow, pulse feeble and intermittent, 
 pupils widely dilated and scarcely responding to the stimulus of light. 
 Twelve minims of liquor ammonise fortior with two drachms of warm water 
 were injected into the median cephalic vein. Within a minute the man 
 moved himself in his chair, and in ten minutes had so recovered as to walk 
 out in the open air unassisted. He resumed work the next day. Dr. Rae 
 wrote that he had had no faith in the treatment, but adopted it because 
 there was nothing else to do. He could scarcely believe his eyes in regard 
 to the result, which seemed incredible, though nevertheless true. 
 
 In some concluding remarks Professor Halfour speaks of the great 
 value of ammonia injections in the depression resulting from the inhala- 
 tion of large quantities of chloroform, also in opium poisoning and in cholera. 
 
 It appears, however, from some further experiments that the treatment by 
 injection of ammonia is not always free from danger, and has to be very 
 carefully conducted. 
 
 The best method of practice, however, if the surgeon is present when the 
 bite is inflicted, or is called immediately after, is the free excision of the 
 part. The indications for treatment are to prevent absorption of the virus, 
 and obtain its expulsion from the body. Therefore, a ligature must be 
 thrown immediately around the limb, in order to obstruct return of venous 
 blood, and if the part be favorably situated, free excision be instantly prac- 
 ticed ; if the latter is impracticable, incision should be made and the flow of 
 blood caused by every means. Suction by the mouth is also exceedingly 
 beneficial after either operation, and should never be neglected. The suc- 
 tion must be continued long and repeated often. It is of the greatest im- 
 portance to ascertain whether the snake that has inflicted the wound is 
 venomous or not. Dr. Hering writes, " All venomous snakes have in the 
 upper jaw but two teeth, very long and large. All snakes that have two 
 rows of teeth above and below are not venomous. After the bite of a venom- 
 ous snake, a cutting and sometimes a burning pain is experienced. Im- 
 
TREATMENT OF HYDROPHOBIA. 267 
 
 mediately after sucking the wound, rub into it fine kitchen salt until the 
 part is saturated with it ; or, if that cannot be obtained, gunpowder, ashes 
 of tobacco, or wood : ashes may be used as a substitute. The patient should 
 be kept as quiet as possible ; the greater the motion or anxiety, the worse 
 will be the consequences." 
 
 If there be vomiting, giddiness, or fainting, and blue spots make their 
 appearance, ars. or carbo veg. should be administered. The former of these 
 medicines has been used with considerable success by the old-school physi- 
 cians. Dr. Gibson* writes, " As an internal medicine arsenic has been lately 
 found more decidedly beneficial than any other." 
 
 Mr. Irelandf has recorded five cases, in all of which the most violent 
 symptoms produced by the bite of the coluber carinatus, a poisonous serpent 
 very common on the island of St. Lucia, were speedily arrested, and cures 
 finally effected, by the use of this medicine. The supposed efficacy of the 
 Tanjore pill, a medicine very commonly employed in India against the bites 
 of serpents, the chief ingredient of which is arsenic, first led Mr. Ireland 
 to employ Fowler's mineral solution. He gave it to the extent of two drops 
 every half hour, and repeated for four hours, with the best effects. Severe 
 vomiting and purging followed the exhibition of the medicine, and the 
 patients were soon after relieved. 
 
 The administration of the above-mentioned medicine in smaller doses, 
 would probably prove more serviceable, and save the patient an immense 
 amount of additional suffering. 
 
 A person bitten by a dog, under suspicious circumstances, writes Mr. 
 Miller, " is usually much alarmed, and applies for relief without delay. 
 The first business of the surgeon is to inquire into the history of the acci- 
 dent ; the disposition of the dog ; its apparent condition at the time ; whether 
 loose or chained ; whether provoked or not. For it may happen that the 
 animal was not to blame, having either been provoked to assault, or having 
 inflicted the bite with the idea of discharging a supposed duty on an 
 aggressor. Such a wound is not supposed to contain any virus." 
 
 If there be any reasonable grounds for doubt, concerning the state of the 
 animal, at the time when the bite was inflicted, the treatment should be 
 conducted as though the person had been inoculated with the virus. The 
 best method is immediate and free excision of the parts, and at the same 
 time, if there be any presenting symptoms, those medicines best adapted 
 to them should be administered. If there was unquestionable and unde- 
 niable authority concerning the efficacy of homoeopathic treatment of 
 hydrophobia, it would undoubtedly be wrong to subject the patient to an 
 operation, and although the cases recorded, particularly those by Mr. Leadam 
 and Mr. Ramsbotham, have the appearance of genuine hydrophobia, and 
 are evidences of the powerful action of several drugs in this affection ; still 
 the disease is so terrible in its nature, that the surgeon has indeed necessity 
 for being doubly armed against it, for if excision fail, he has medicines at 
 his command, the symptoms of which are very nearly allied to those mani- 
 fested by hydrophobic patients. Moreover, the poison is an extraneous 
 matter introduced into the system, and surely the conscientious surgeon 
 may be justified in using mechanical means for its removal. My friend, 
 Dr. T. G. Comstock, of St. Louis, has reported a case of undoubted hydro- 
 phobia, which was permanently cured. J; He was called on May 14th, 1852, 
 and the patient was discharged at the end of the month. The medicines 
 were chiefly : rhus tox., bella., hyoscyamus, and lachesis. But let it be 
 
 * Gibson's Surgery, vol. i., p. 123. 
 f Medico-Chirurgical Transactions, vol. ii., p. 394. 
 
 X Philadelphia Journal of Homoeopathy, 1852-5 d, p. 315 ; also Medical News Letter, St. 
 Louis. 
 
268 A SYSTEM OF SURGERY. 
 
 remembered, that if some time has elapsed between the infliction of the 
 bite and the application of the patient for relief, excision of the part will 
 prove of no avail, and immediate recourse must be had to medicines, the 
 chief of which are belladonna, hyoscyamus, lachesis, stramonium, and 
 cantharides. 
 
 Drs. Hartlaub and Trinks recommend cantharides as a preventive of 
 hydrophobia. 
 
 Although much reliance cannot be placed on the many popular remedies 
 for this dreaded malady, it would seem proper to mention one which has a 
 very great reputation in certain localities, which is the elecampane. Many 
 persons are said to have been cured by it. The directions for its use are as 
 follows, as given by Mr. Fry : 
 
 The patient is to be kept free from excitement of every sort, especially 
 from that caused by the visits of sympathizing friends. The medicine is 
 to be prepared by taking one ounce of elecampane root, powdered, one 
 tablespoonful of madder, and one quart of new milk, and boiling them all 
 together, slowly (in a water-bath, if possible), until reduced to a pint. The 
 dose is one wineglassful once a day for three days ; then intermit three days, 
 then repeat and intermit again, and again repeat. That is, nine wineglass- 
 fuls are taken in all, and there are three intermissions. 
 
 In support of the efficacy of this treatment it is stated that thirty years 
 ago Mr. Reed and Daniel Mershon were bitten at Germantown by a rabid 
 dog; that Mr. Reed was treated by an eminent physician and died of 
 hydrophobia, while Mershon, under this treatment, never suffered at all. 
 A young man and a young woman, under similar treatment, recovered from 
 the dreadful disease about twenty years since. In 1858, a policeman, so far 
 gone with hydrophobia as to have to be held in the carriage, in which he 
 was driven through Germantown to Mr. Fry's residence, was also treated 
 with entire success. A number of additional cases are quoted, in all of 
 which the remedy described is claimed to have effected complete cures. 
 
 Nitrate of Amyl. — Dr. W. S. Forbes* has been making successful experi- 
 ments on the use of Nitrate of Amyl in cases of hydrophobia, and states : 
 
 In each case the first applications of the amyl relieved the patient of that 
 dreadful feeling of impending dissolution, a striking feature in this malady. 
 It calmed them, but did not stay the advance of death. In the two cases 
 of which the Dr. speaks, the sufferings preceding the last paroxysm were 
 relieved. The pulse fell, the sense of choking vanished, the breathing 
 became regular, the function of swallowing was restored, and sleep obtained. 
 In both cases death took place while the patient was in spasms, which came 
 on every fifteen minutes. There was total inability to use fluids, the men- 
 tion of which would produce spasms. After giving £ a grain of morphia 
 without effect, 24 drops of the nitrate of amyl were administered by inhala- 
 tion, when the patient complained of numbness in the extremities, and said 
 if the room were quiet she could sleep. When she awoke after four hours 
 and a half, the spasms began again and continued to her death. No post- 
 mortem was permitted. The application of the amyl in the second case had 
 much the same effect as in the first — this, like the former patient, went 
 also into convulsions, and died. No post-mortem. 
 
 pasteur's method of treating hydrophobia. 
 
 Inoculation. — As this portion of the work is passing through the press, 
 the treatment of hydrophobia by inoculation as produced by M. Pasteur, 
 is exciting the attention of the medical profession throughout the world. 
 It is known that M. Pasteur alleges that he has discovered a cure for hydro- 
 
 * The American Journal of the Med. Sciences, April, 1878, No. cl., New Series. 
 
269 
 
 phobia by perfecting a method of inoculation by which human beings can 
 be rendered unimpressionable to the virus of rabies canina. This treat- 
 ment is based on the discovery, that one attack of hydrophobia in the dog 
 protects against another, and from analogy Pasteur claims that by such 
 method human beings may be so protected. It may be well in this place 
 to state the method by which Pasteur prepares the virus. A portion of the 
 spinal cord of a mad dog is injected into a rabbit. It is said that after the 
 space of fifteen days the rabbit perishes with all the symptoms of hydro- 
 phobia. A part of the cord of this dead rabbit is prepared and a second 
 rabbit inoculated. This animal dies in a shorter space, or, in other words, 
 with a shorter incubation than the first. A part of the cord of the second 
 rabbit is prepared and injected into a third, and this process is continued 
 until no less than sixty rabbits have been inoculated. It is said by this 
 process that after such inoculation, the period of incubation shortens and 
 the virus tecomes more powerful. Portions of these diseased cords from 
 the whole series of the sixty rabbits are placed in bottles of dried air, which 
 somewhat weakens the poison. 
 
 M. Pasteur claims, that by taking a person bitten by a mad dog and 
 inoculating that person with a less virulent virus, and gradually increas- 
 ing the number of injections, each of an increasing strength, such a person 
 will be protected. All this may be very well, but as yet no tangible 
 proof has been exhibited that the process cures hydrophobia. The fact 
 that a person bitten by a clog undoubtedly mad, after going through a 
 series of inoculations by Pasteur, succumbs to the disease, necessarily raises 
 a doubt in the minds of the profession in reference to the efficacy of the 
 treatment. 
 
 The children who were taken from Xewark to be inoculated by Pasteur, 
 and were said to have been bitten by a mad dog, and who thus far have 
 developed no symptoms of hydrophobia, can in no way be adduced as 
 authentic proof of the reliability of Pasteur's method, from the simple 
 fact that there is no proof that the dog was afflicted with rabies. The 
 seven other dogs which were bitten, and which were taken care of, and care- 
 fully watched by the authorities at Xewark, have, up to the present date, 
 presented no symptoms of hydrophobia ; therefore, although Pasteur's 
 method may prevent the recurrence of rabies in the dog, there is no proof 
 that it can cure hydrophobia in the human being. 
 
 " In a late meeting of the Academy -of Medicine at France, after a thorough 
 explanation by M. Pasteur, M. Jules Guererin placed on record the following 
 protests : 
 
 " 1. That M. Pasteur made his inoculations with the virus of an artificial 
 rabies, there being no proof that his rabbits really had the genuine disease. 
 
 " 2. The person on whom M. Pasteur had experimented was not a proper 
 one, since his patient had been treated with carbolic acid, and since the 
 bites of rabid dogs are not always followed by hydrophobia. 
 
 u 3. M. Pasteur had only found a preventive for rabies in the remedy 
 declared." This method of course will take time for its thorough devel- 
 opment. 
 
 There is a species of hydrophobia, not arising from the inoculation of 
 virus, but proceeding from some violent mental emotion; the disease is 
 termed symptomatic hydrophobia. Fear and imagination, after a bite from 
 a perfectly healthy animal, may give rise to symptoms that very nearly 
 resemble those of the genuine affection. Sometimes very serious trouble is 
 occasioned by large doses of bella., canth., or mercury, the drug disease 
 assuming as it were the form of a medicinal hydrophobia. The treatment 
 of these affections is generally simple, when their cause is correctly ascer- 
 tained. 
 
270 A SYSTEM OF SURGERY. 
 
 When putrid animal matter has been received into the system by means 
 of wounds, as in dissection, there should be a ligature worn for a time, and 
 suction by the mouth be immediately resorted to, after which, collodion 
 should be applied over the wounded surface ; if the wound after a time 
 presents rather a bluish appearance with swelling, china off. or arsenicum 
 should be given ; if mortification or abscess ensue, the treatment has already 
 been mentioned. 
 
 Gunshot Wounds. — Before entering into the consideration of the wounds 
 occasioned by firearms, it will be necessary to make a few remarks upon 
 the general principles of firing and the motion of projectiles, for it may often be 
 of service to the surgeon, in his endeavors to discover the course of a ball 
 or a bullet, and to determine other questions of import in gunshot injuries. 
 
 There are three imaginary lines upon which the general principles of 
 firing are grounded. These are : 
 
 1st. The line of fire or projection. 
 
 2d. The line of metal or aim. 
 
 3d. The line of trajectory, or flight of the bullet. 
 
 By the first is understood the primary direction of the centre of the 
 bullet, or the axis of the barrel, indefinitely prolonged, indicating the course 
 the ball would take if it were subject alone to the explosive force of the 
 powder. 
 
 The line of aim, or the line of metal, is an imaginary line drawn from the 
 centre of the back sight and the top of the front one, directly to the object 
 of aim. 
 
 By the third, or line of trajectory, is meant the flight of the bullet, and is 
 the curve described by the missile from the barrel of the gun to the object 
 of aim. It must be obvious that so long as the bullet is passing along the 
 barrel of the gun, the line of fire and that of trajectory are the same ; but 
 the moment the bullet leaves the muzzle, the trajectory leaves the line of 
 fire, and the divergence becomes greater and greater as the bullet passes 
 through the air. 
 
 Fig. 113. 
 
 This may be illustrated by the cut, Fig. 113. A to D is the line of fire ; 
 A to Cis the line of aim; A to B is the line of trajectory. The course of 
 a bullet is urged downwards by several forces, as inertia, friction, gravity, 
 and its rotation, the latter being occasioned by the grooves or the twists in 
 the barrel of the gun. These points are useful in ascertaining the velocity 
 and revolution of balls. In order to find the velocity and rotation of a 
 bullet, divide the velocity in feet by the number of feet in which one com- 
 plete turn is made by the bullet. Thus : " The initial velocity (that of the 
 bullet as it leaves the muzzle) of the Enfield rifle being twelve hundred and 
 sixty-five and one-tenth feet per second, and the turn (rotation) one in six 
 and a half feet, the initial velocity of rotation of the bullet fired from the En- 
 field, is one hundred and ninety-four and six-tenths revolutions per second." 
 
 The bullet, therefore, as it leaves the gun, must be under the action of 
 three separate and distinct forces — that of the gunpowder exploding, that 
 of gravity, and that of resistance of the atmosphere — and it is discovered 
 that in the first second it falls sixteen feet ; at the end of the second second 
 
GUNSHOT WOUNDS. 
 
 271 
 
 it will have fallen sixty-four feet; and at the end of the third second, one 
 hundred and forty-four feet. It is from a knowledge of these facts, and 
 many more, that the science of gunnery teaches accuracy of aiming. Robins 
 says " he found that when a twenty-four pound shot was impelled by its 
 usual charge of powder, the opposition of the air was equivalent to at least 
 four hundred pounds weight, w r hich retarded the motion of the bullet so 
 powerfully, that it did not range one fifth part of what it would have done 
 if the resistance of the air had been prevented." With a knowledge of the 
 power obtained by rotation given to bullets by the shape of the barrel, and 
 the uncertainty of smooth-bore guns, very many remarkable improvements 
 in the construction of firearms and cartridges have been adopted ; certain 
 grooves have been constructed, 
 
 and certain twists made in the FlG - 114 - 
 
 barrels, which make the guns 
 of to-day a marvel of inge- 
 nuity, accuracy, and execution. 
 Among many of these Ameri- 
 can guns we have " Wesson's 
 improved American rifle ;" 
 " Colt's," which is in high favor 
 in the service; "Sharp's," the 
 "Maynard," the " Burnside," 
 the " Spencer," the " Ballard," 
 the " Peabody," '* Reming- 
 ton's," " Cochran's," and many 
 others, w r hich are mostly 
 breech-loaders, and using coni- 
 cal balls. And among the Euro- 
 pean the " Needle-gun," in- 
 vented by Herr von Dreyse; 
 the " Chassepot breech-loader," 
 the " Snider-Enfield rifle," the 
 
 11 Cornish breech-loader," and the "Grenade rifle;" in the latter the ball is 
 hollow, and is filled with two and a half grains of pow r der ; it explodes when 
 it strikes w r ith great certainty, and sends its fragments three feet in every 
 direction. It is reputed to do as much damage as three or four ordinary 
 balls, and to create the utmost dismay. 
 
 Some experiments have been made to show the relative number of shots 
 that may be made by some of 
 these remarkable guns. FlG - 115 - 
 
 Spencer— A little less than 
 twelve shots per minute. 
 
 Peabody — Fourteen and two 
 hundredths per minute. 
 
 Ballard— Fifteen per min- 
 ute. 
 
 Berdan — Sixteen and four 
 hundredths per minute. 
 
 The "Mitrailleuse" is an- 
 other most powerful weapon, 
 which produces serious devas- 
 tation and dismay. 
 
 The "Chassepot rifle" can 
 be fired, the men taking aim, 
 about eight or ten shots per minute, and fourteen without shouldering the 
 gun. 
 
 Ball for needle- 
 gun, 451 grs. 
 
 Wesson Large ball for 
 slug, 28 to Spencer 
 pound, breech-loader. 
 
 A, U. S. round musket-ball, calibre 69, weight 387 grs. ; B, 
 Springfield rifled musket-ball, calibre 58, Aveight 500 grs. ; 
 C, Enfield rifled musket-ball, weight 450 grs. ; D, Austrian 
 rifle ball, weight 460 grs. 
 
272 A SYSTEM OF SURGERY. 
 
 Great improvements have also been introduced in the manufacture of the 
 balls, most of which are conical in shape, with hollow bases. Fig. 114 
 shows the shape of the different missiles of various guns ; and Fig. 115, 
 taken from the Surgeon-General's Circular, shows the round and conical 
 bullets now much used in the army of the United States. 
 
 Of the varieties of gunshot wounds, none are more terrible in their 
 effects than those that are produced by the peculiar bullet invented 
 by M. Etienne Minie, of Paris. These terrible implements of war are 
 cylinclro-conical in shape, with a hollow base, an.d they cover every 
 requisition, viz. : 1st. When the explosion of the powder takes place, 
 they fill exactly the bore of the gun. 2d. When projected they proceed 
 with a rotary motion. 3d. They are so formed as to present as little resist- 
 ance as possible to the air. 4th. The forward portion of the ball is solid, 
 to cut through whatever opposes its progress. The Minie bullet is for rifles, 
 and is made of lead ; the base of the ball is nearly the diameter of the rifle, 
 and is hollowed out. The effect of the powder when firing is to expand the 
 thin portion of lead around the recess at the base of the ball, making it 
 fit tightly the grooves of the rifle. W T ith these advantages the missile may 
 be projected to immense distances with unerring precision, and the effects 
 are truly terrible ; bones are ground almost to powder, muscles, ligaments, 
 and tendons torn away, and the parts otherwise so mutilated, that loss of 
 life, certainly of limb, is almost an inevitable consequence. None but 
 those who have had occasion to witness the effects produced upon the body 
 by these missiles, projected from the appropriate gun, can have any idea 
 of the horrible laceration that ensues. The wound is often from four to 
 eight times as large as the diameter of the base of the ball, and the lacera- 
 tion so terrible that mortification almost inevitably results. 
 
 Quite a number of men wounded at the Camp Jackson affray were brought 
 to the Good Samaritan Hospital at St. Louis immediately after the skirmish, 
 which was one of the first of our late war. I watched these cases, and made 
 careful dissections of the limbs after amputation. In one case the ball 
 passed directly through the inferior maxillary bone, cutting loose the pala- 
 tine and glossi muscles, fearfully smashing the bone and forcing the tongue 
 from the mouth. This man could neither speak nor swallow for some 
 weeks, but finally recovered. 
 
 In another case, the ball entered about the middle of the forearm, coursed 
 down on the surface of the radius, and emerged at the wrist-joint. Although 
 every possible attempt was made to save the arm, untoward symptoms 
 presented, and amputation at the upper third of the forearm was necessary, 
 and was performed by the surgeon to the hospital. The muscles on the 
 anterior face of the forearm were soft, but not much out of place or tume- 
 fied ; but those (particularly the deep layer) on the posterior aspect were 
 decayed, black, and filled with extravasation ; the radius was shivered into 
 about ten or twenty pieces, the medullary matter being thrown out into the 
 surrounding textures ; the ulna was not broken, except the styloid process, 
 which was torn away, the semilunar bone of the carpus was divided, the 
 os pisiforme separated from the joint, and the head of the os magnum 
 driven forward and split open. With such a wound as this, mortification 
 was a result to be expected. 
 
 In the third case amputation was resorted to above the knee-joint. In 
 this instance, the extravasation was ver} T remarkable, the fluid being ex- 
 tremely dark and very offensive. Here the fibula was only slightly touched ; 
 but the tibia was broken near the knee-joint, and split longitudinally for 
 two-thirds its length, very many small fragments of bone being imbedded 
 in the tissues. The fetor from the wound was intense, and the laceration 
 of the soft parts, along the whole track of the ball, severe and remarkable. 
 
GUNSHOT WOUNDS. 273 
 
 In the fourth case, a wound was inflicted immediately below the knee- 
 joint, smashing the fibula, and tearing the structures to a considerable 
 degree. The course of the ball was under the gastrocnemius and through 
 the soleus. Every effort was adopted to save the leg of this man, a cap- 
 tain in the service. An attempt was made to resect the fibula; upon 
 cutting down, however, upon the bone, it was found that the external 
 lateral ligament of the joint had literally been destroyed, that the head of 
 the fibula was gone, and that in its place there existed a black, gritty mass 
 of decayed muscle, bone, and ligament. All hope of saving the limb was 
 therefore abandoned, the patient still kept on the table and under the influ- 
 ence of chloroform, and the limb amputated above the knee-joint at about 
 the middle third of the femur. It is worthy of observation, that on the 
 morning of the operation, pain was complained of in the popliteal space. 
 On examining the limb after amputation, the tibio-fibular articulation was 
 found to be involved ; and upon inserting the scalpel through the transverse 
 ligaments, a large amount of fetid fluid, containing flocculi of a cheesy 
 character, issued from the joint. Upon inspection, marks of disease were 
 found upon the left condyle of the femur, sufficient evidence that a serious, 
 if not fatal disease of that most complicated joint, the knee, was about 
 being established, and that amputation was necessarily the only resource 
 left to preserve life. 
 
 Such is a brief account of effects produced by the Minie ball upon the 
 organism. 
 
 The preceding cuts will give an idea of the different shapes of the balls 
 and cartridges. Fig. A, the Whitworth bullet. Fig. B, the ball of the 
 needle-gun, weighing 451 grains. Fig. C, the slag of the Wesson cavalry 
 carbine, twenty-eight to the pound. Fig. D, represents the cartridge (full 
 size) for Spencer's army and navy rifles. 
 
 Cannon-balls inflict sometimes the most severe injuries, carrying away an 
 entire limb, or severely bruising the parts without breaking the integu- 
 ment. 
 
 The total number of gunshot injuries in times of war is appalling to the 
 civilian. In the British army during the Crimean war there were 12,094 
 wounded and 2755 killed, making a total of 14,849. In the French army 
 in the Crimea there were 39.868 wounded, 8250 killed, or a total of 48,118. 
 In our own war the reports from about three-fourths of the regiments, for 
 the year ending June 30th, 1863, were 55,974 gunshot wounds, and according 
 to the circular Xo. 6, from which these figures are taken, " the battle-field 
 list of wounded for the years 1864-65 include 114,000 names." Such is the 
 sacrifice of life and limb in war. 
 
 The following figures, taken also from the Surgeon-General's circular, as 
 corrected from the register on September 30th, 1865, shows the classification 
 of wounds and injuries and results during the civil war in the United 
 States : 
 
 Of gunshot fractures and injuries of the cranium there were 1108 ; of gun- 
 shot fractures of the bones of the face, 1579 ; gunshot fractures of spine, not 
 involving chest or abdomen, 187; gunshot fractures of ribs, 180; of pelvis, 
 397 ; of scapula and clavicle, 389 ; of the humerus, 2408 ; of the radius and 
 ulna, 785; of the carpus and metacarpus, 790; of the femur, 1957; patella 
 and knee-joint, 1220; tibia and fibula, 1056; tarsus and metatarsus, 629 ; 
 gunshot penetrating wounds of the chest, 2303 ; of abdominal viscera, 565 ; 
 scalp wounds, 3942; flesh wounds of face, 2588; of the neck, 1329; of the 
 thoracic parietes, 4759; of the back, 5195; of the abdominal parietes, 2181 ; 
 of the genito-urinary organs, 468; of the upper extremities, 21,248; of the 
 lower extremities, 25,152 ; wounds of arteries, 44 ; wounds of the veins, 3 ; 
 of nerves, 76: sabre wounds, 106; bayonet wounds, 143." Simple fractures 
 
 18 
 
274 A SYSTEM OF SURGERY. 
 
 and miscellaneous wounds and injuries, 2883 ; tetanus, 363 ; of secondary 
 hemorrhage, 1035 ; pyaemia, 754 ; making a total of 87,822. The following 
 is the classification of the surgical operations : 
 
 Amputation of finger, 1849 
 
 " of wrist-joint, 46 
 
 " of forearm, 992 
 
 '* of elbow-joint, 19 
 
 " _ of arm, 2706 
 
 Amputation of shoulder-joint, 437 
 
 " of toes, 802 
 
 " of foot (partial), .160 
 
 " of ankle-joint, 73 
 
 of leg, 3014 
 
 " of knee-joint, 132 
 
 " ofthigh, 2984 
 
 " of hip-joint, 4 .... 21 
 
 Excision of head of humerus, 575 
 
 " of elbow, 315 
 
 " of wrist, . . . 34 
 
 11 of ankle, m .22 
 
 " in continuity of upper extremity (shafts, humerus, radius, ulna, 
 
 radius and ulna), 695 
 
 " of shafts of tibia and fibula (tibia, fibula, tibia and fibula), . 220 
 
 of knee, 11 
 
 " of shaft of femur, 68 
 
 " of head of femur, , 32 
 
 " of bones of face or wrist, . ...... . 101 
 
 Trephining, : 221 
 
 Ligation of arteries, 404 
 
 Extraction of foreign bodies, 726 
 
 Operations for surgical diseases, 443 
 
 Operations not classified, .23 
 
 Gunshot injuries partake more or less of the nature of contused and lacer- 
 ated wounds, and are often accompanied by extreme danger, the patient 
 being either immediately or remotely destroyed; or there may exist exten- 
 sive mutilations, giving rise to abscesses, sinuses, or diseased bones, which 
 are frequently extremely tedious and difficult to heal. Indeed, the after- 
 life of the patient may be fraught with such intense suffering that the 
 approach of death is hailed with joy as the only relief. The kind and ex- 
 tent of the injury must depend upon the form and size of the instrument inflict- 
 ing the wound, upon the velocity with which it is carried, and a variety of 
 other circumstances. 
 
 A ball moving with great rapidity and striking the body, enters readily, 
 and pursues its course generally in a straight line, either passing through 
 the part or lodging at a greater or less depth. On the contrary, a ball which 
 moves slowly enters with difficulty, and instead of following a direct line, 
 is diverted by the slightest obstacle, always taking an angular course. 
 Owing to this circumstance, it often happens that a bullet strikes some part 
 of the body and apparently passes through, but upon examination it will 
 be found that it has taken a circuitous route, or traversed the head between 
 the bone and the scalp, or passed entirely around the abdomen or neck. 
 When such is the case the superficial track is marked by a discolored line, 
 sometimes slightly emphysematous. Other instances there are in which 
 the ball strikes an extremity, runs beneath the integument or among the 
 muscles, and is lodged many inches — or even two or three feet — beyond the 
 point at which it entered.* 
 
 * In one instance, which occurred m a soldier with his arm extended, in the act of endeav- 
 oring to climb up a scaling ladder, a ball, which entered about the centre of the humerus, 
 
GUNSHOT WOUNDS. 275 
 
 The aperture made by the bullet's entrance is small, and with margins 
 inverted ; often it appears of much less dimensions than the foreign body 
 which has passed through it, and sometimes it may even simulate the in- 
 cised character. In such cases the ball has come from some distance, and 
 has struck with considerable force and velocity ; the aperture, consequently, 
 is made with comparatively little bruising or tearing, and the elastic tex- 
 tures close upon its track. 
 
 The aperture of exit, on the contrary, has its margins ragged and everted ; 
 and is of larger dimensions than that which marks the entrance. There has 
 lately been some discussion concerning the size of the wound of entrance 
 and that of exit. The French surgeons, and particularly M. Roux, of Paris, 
 contend that in gunshot wounds, it frequently happens that the aperture of 
 entrance is larger than the opening made by the ball as it passes from the 
 body. When the injury has been inflicted at a short distance, the aperture 
 of entrance is comparatively large, has no smoothness in its edges, and is 
 obviously of a lacerated character; then, too, portions of the wadding are 
 usually impacted in some part of the track, and the surface may be marked 
 by the grains of powder. There are many instances in which there are not 
 two openings. In such cases, the ball, after having entered, lodges under 
 the integument, in the muscle, or in a bone. 
 
 Extraneous substances may be carried before a bullet — such as buttons, 
 coins, keys, etc. These always produce irritation in proportion to the 
 irregular shape of the foreign matter. 
 
 In other cases, portions of clothing may be driven before the ball, and be 
 imbedded deeply in the wound. When such is the case, it frequently hap- 
 pens that when the cloth is removed, the bullet is discharged with it. 
 
 Balls have been buried and never been found. They become, in such in- 
 stances, inclosed in a cyst, or surrounded by bony formation, the patient 
 experiencing little or no inconvenience from them ; or they may change 
 their position and traverse the body, giving rise to pain, long suppuration, 
 haemorrhage, convulsions, or paralysis. 
 
 Dr. Franklin records a very interesting case, " in which a bullet was driven 
 into the upper part of the thigh ; all efforts for its removal were unavailing. 
 The wound healed, and the patient attended to his ordinary duties as if 
 nothing had happened, when suddenly (four years after the injury) he was ; 
 attacked with loss of motion in the leg. Having placed himself under the 
 care of a surgeon, and getting no better at the end of five weeks, the case 
 was submitted to my care. Upon examination I discovered the cause of the 
 difficulty, and learning the position when struck, examined carefully the 
 inner and upper part of the thigh, where I felt the ball lying in contact 
 with the crural nerve. The ball was removed, the patient improved in 
 strength, and in a short time fully recovered the use of his limb, and up to 
 this time enjoys uninterrupted health,"* 
 
 Again, balls by striking forcibly the edge of a sharp bone, may be divided, 
 each portion of the bullet taking for itself a separate route. 
 
 " It is no uncommon thing," writes Mr. Thompsonj " for a ball in striking 
 against the sharp edge of a bone, to be split into two pieces, each of which 
 takes a separate direction. Sometimes it happens that one of the pieces- 
 remains in the place which it struck, while the other continues its course 
 through the body. Of a ball split by the edge of the patella, I have known 
 
 passed along the limb, and over the posterior part of the thorax, coursed among the abdomi- 
 nal muscles, dipped deep through the glutei, and presented in the forepart of the opposite 
 thigh, about midway down. — Hennen's Principles of Military Surgery, p. 34. 
 
 * Science and Art of Surgery, vol. i., p. 676. 
 
 f See Thompson's Reports of Obs. in Military Hospitals in Belgium. 
 
276 A SYSTEM OF SURGERY. 
 
 one-half pass through at the moment of the injury, and the other remain in 
 the joint for months, without its presence there being suspected. In the 
 same manner I have known a ball divided by striking against the spine of 
 the scapula, and one portion of it pass directly through the chest, from the 
 point of impulse, while the other moved along the integuments till it reached 
 the elbow-joint. But the most frequent examples of the division of bullets, 
 which we had occasion to see, were those which were produced by balls 
 striking against the spherical surface of the cranium. It sometimes happens 
 that one portion of the ball enters the cranium, while the other either re- 
 mains without, or passes over its external surface. Not infrequently, in 
 injuries of the cranium, the balls are lodged between its two tables, in some 
 instances much flattened and altered in their shape, and in other instances 
 without their form being changed." 
 
 The course which bullets take is at all times uncertain, for very slight 
 obstacles cause a retroversion from the rectilinear direction. A shot may 
 rebound from the water, and a button or a handkerchief has been the means 
 of preserving life. " Although," says M. Chevalier, " in many cases a mathe- 
 matical explanation of the course of a ball cannot be given, this arises 
 entirely from the want of data, the laws of matter being fixed and immu- 
 table. But when the data are known, as, for instance, the velocity and direc- 
 tion of the shot, the position of the patient, or of the wounded part at the 
 time of the accident, and the structure of the parts penetrated, a much more 
 probable conjecture of the course of the ball may generally be formed than 
 if these circumstances had not been regarded." 
 
 Dr. Franklin, during his service in the army, saw many remarkable 
 " evidences of the strange and anomalous course of balls in various parts of 
 the body. In one case the bullet passed over more than two-thirds of the 
 circuit of the neck, and was cut out just beneath the skin. 
 
 " In another, a ball entered at the crest of the ilium, passed downward 
 parallel with the thigh, and emerged just above the knee-joint."* 
 
 The opening by which the ball has made its exit is frequently very near 
 the aperture of its entrance. Indeed, there are cases on record in which the 
 aperture of exit and that of entrance were the same. Dr. Hennen mentions 
 an instance in which a ball entered the pomum Adami, and, after running 
 •completely around the neck, was found in the very orifice at which it 
 •entered. 
 
 Gunshot wounds, partaking of the nature of contused and lacerated 
 ivounds, seldom bleed profusely externally, and for the same reason ; but 
 •often, though the bleeding is not manifest, a fatal haemorrhage may be 
 taking place internally. Secondary haemorrhage is also of frequent occur- 
 rence in this variety of wound, from the detachment of the slough, etc. But 
 it must also be remembered, that though immediately after the injury the 
 bleeding may be but slight, in a short time the haemorrhage may become 
 profuse, and particularly if the wound be inflicted in vascular parts, like the 
 face and neck, and this may occur even though the larger branches of the 
 artery may not be opened. 
 
 When a large artery is only partially divided, the bleeding is more pro- 
 fuse and dangerous than when the vessel is completely severed ; and in such 
 ^cases the haemorrhage often continues until the patient expires. 
 
 Mr. Guthrie f mentions three cases in which life was lost from wounds of 
 the carotid, femoral, and humeral arteries, no means having been adopted 
 to arrest the haemorrhage. 
 
 Shock. — There is a peculiar shock which attends upon gunshot wounds — 
 
 * Science and Art of Surgery, p. 675. 
 f On Gunshot Wounds, p. 8. 
 
GUNSHOT WOUNDS. 277 
 
 an extraordinary perturbation or agitation, which the bravest are not able 
 to resist. This, however, is not invariably present; " for," says Dr. Hennen* 
 11 the effects of a gunshot wound differ so materially in different men, and 
 the appearances are so various, according to the nature of the part wounded 
 and the greater or lesser force with which it has been struck, that no inva- 
 riable train of symptoms can be laid down as its necessary concomitants. 
 If a musket or pistol ball has struck a fleshy part, without injuring any 
 material bloodvessel, we see a hole about the size of, or smaller, than the 
 bullet itself, with a more or less discolored lip, forced inwards ; and if it 
 has passed through the parts, we find an everted edge, and a more ragged 
 and larger orifice at the point of its exit. The haemorrhage is in this case 
 very slight and the pain inconsiderable, insomuch that, in many instances, 
 the wounded man is not aware of his having received any injury. If, how- 
 ever, the ball has torn a large vessel or nerve, the hemorrhage will generally 
 be profuse, or the pain of the wound severe, and the power of the part lost. 
 Some men will have a limb carried off or shattered to pieces by a cannon- 
 ball without exhibiting the slightest symptoms of mental or corporeal 
 agitation ; nay, even without being conscious of the occurrence ; and when 
 they are, they will coolly argue on the probable result of the injury ; while 
 a deadly paleness, instant vomiting, profuse perspiration, and universal 
 tremor, will seize another on the receipt of a slight flesh wound. This 
 tremor, which has been so much talked of, and which, to an inexperienced 
 eye, is really terrifying, is soon relieved by a mouthful of wine or spirits ; 
 but, above all, by the tenderness and sympathizing manner of the surgeon, 
 and his assurance of the patient's safety." 
 
 A rather peculiar case representing the fatality of shock present in gun- 
 shot wounds was related to me at the time of its occurrence by Dr. Com stock. 
 The gentleman, a patient of Dr. C, was serving at Camp Jackson near St. 
 Louis, when the United States troops demanded surrender. A slight 
 skirmish ensued, and the gentleman received a wound on the anterior face 
 of the inferior third of the thigh, shattering the bone. Dr. Comstock not 
 being at hand, a physician was called who prescribed a large dose of 
 morphia, and sent for a surgeon to amputate the limb. In the meantime 
 Dr. Comstock arrived and found the patient just expiring, no reaction having 
 followed the shock. 
 
 Surgeons at the present day deny the existence of the so-termed wind 
 contusion, or the effects produced by the wind of a ball ; and explain the 
 injuries heretofore attributed to it, as produced by spent balls, which have 
 really struck, yet with so little quickness of force as to merely bruise, with- 
 out inflicting an open wound. 
 
 The nerves also suffer to a great extent in gunshot wounds, especially 
 those of the extremities. Even after the wound has healed, there may be 
 very distressing sensations around and in the cicatrix, which pains are 
 generally aggravated in damp cloudy weather, or from cool moist easterly 
 winds. 
 
 The progress of cure in gunshot wounds is often extremely tedious, from 
 the numerous accidents that are likely to ensue. Excess of inflammation, 
 erysipelas, abscess after abscess, excessive suppuration, sloughing, gan- 
 grene, non-union of fracture, caries, necrosis, hectic, and tetanus, are some 
 of the untoward events that may occur to prevent the healing of a gunshot 
 wound. 
 
 As " deduced conclusions," from considerable experience in gunshot 
 wounds, I have condensed from the concise and practical work of P. L. 
 Appia some most pointed observations on gunshot wounds. They are a 
 
 * Principles of Military Surgery, p. 33. 
 
278 
 
 A SYSTEM OF SURGERY. 
 
 resume of what I have written in the preceding pages, and are inserted here 
 chiefly for the use of the student and young practitioners. 
 
 Delusions. — I. It is wrong as a precautionary measure, to lay open a wound 
 under the impression that it changes the gunshot wound into one of a simple 
 character. 
 
 II. There are no such things as wind contusions. Heavy projectiles, espe- 
 cially balls, can produce deep and serious injuries of the soft parts, and 
 even to bones, without necessarily breaking the skin, and these undeniable 
 facts were accounted for by the extreme pressure which the air in front of 
 the projectile underwent. But one need not be a natural philosopher to see 
 that air is too delicate and elastic a medium not to separate on either side 
 of a convex and limited surface, like that of a bullet, rather than undergo 
 extreme compression from it. 
 
 III. Internal injuries, in former times, would have been attributed to the 
 wind of the ball. 
 
 Dr. Quesnoy saw an engineer officer who had his forearm broken without 
 any external symptoms of injury. At Alma they took into the ambulance 
 a soldier whose forearm was in its interior a mere mass of pulp, though his 
 skin was unhurt. 
 
 Shock. — I. The general shock to the system is not a constant symptom in 
 gunshot wounds. 
 
 II. In general, pain is a late symptom of a gunshot wound. 
 
 Elustrations. — In the Crimean war, men with their upper and lower jaws 
 crushed, were known to walk from the trench to the ambulance. One of 
 these men, from whose pharynx some fragments of bone were removed, 
 although unable to speak, could write what he wished with a steady hand. 
 At Alma, men whose limbs hung by a mere shred of skin, were in full 
 enjoyment of all their senses. 
 
 Varieties of Gunshot Wounds. — I. Wounds from firearms are of infinite 
 variety, according to the velocity of the projectile, its bulk, shape, and 
 direction with regard to the body, and also the numberless changes of 
 posture which the latter may assume at the very moment when the accident 
 occurs. 
 
 II. The relative frequency with which the different parts of the body are 
 struck by the bullet may be seen by the following table : 
 
 Legs, 
 
 Thigh, . 
 
 Face, 
 
 Arm, 
 
 Hand, 
 
 Chest, 
 
 Abdomen, 
 
 Shoulder, 
 
 Skull, . 
 
 Forearm, 
 
 100 
 97 
 61 
 60 
 57 
 53 
 52 
 42 
 37 
 36 
 
 Knee-joint, 
 Foot, . 
 Elbow-joint, 
 Neck, ' . 
 Genitals, . 
 Ankle-joint, 
 Shoulder, . 
 Hip, . 
 Vertebra, . 
 Wrist, 
 
 Cases. 
 54 
 29 
 22 
 22 
 18 
 15 
 13 
 6 
 10 
 2 
 
 Total, 
 
 . 786 
 
 III. It has generally been remarked that the orifice of entrance is smaller 
 than that of exit, its margins more sharply cut than the latter, which is 
 usually smaller and with everted edges. In the Parisian hospitals, where 
 in 1848 hundreds of wounded were collected, I sought often to establish 
 this difference, but I did not find it so well marked as has been usually described. 
 
 IV. According to the velocity of the projectile, a wound presents either : 
 a. A simple bruise without laceration of the skin. 6. A wound with a 
 
GUNSHOT WOUNDS. 279 
 
 single orifice, r. A wound with a double orifice, d. When it has carried 
 off a limb. 
 
 V. A cylindn -conical ball produces a terrible shock, and splits and tears 
 the bone. This comminution of the bone has no parallel in former surgical 
 annals. 
 
 VI. The most serious consequences of wounds from conical balls depend 
 on three causes : 1. The conical ball is never turned by a hard or elastic 
 body, but passes straight through it. 2. It may, nevertheless, in its course 
 through the body change its longitudinal position, so that it strikes the 
 organs with its long axis, causing very considerable damage. 3. It is 
 probable, from the pointed shape of the conical ball, that it causes less 
 actual loss of substance, but at the same time more lateral separation of tissue 
 from its wedge-like form. 
 
 VII. The surgical experiences of the Crimean war have been rather dis- 
 couraging, as regards the resources of art for preserving limbs which have sustained 
 comminuted fractures. 
 
 Foreign Bodies. — I. The foreign bodies which complicate and aggravate 
 gunshot wounds are : 1. The destroyed tissues. 2. Bone splinters. 3. The 
 ball itself. 4. Pieces of clothing, woollen, or other objects encountered by 
 the ball. 
 
 II. External injury may be insignificant, compared to the internal de- 
 struction of parts, and from external examination one might be led to under- 
 estimate the mischief which has occurred within, and from a superficial view 
 entertain hope of a cure, which turns out detrimental to the patient, and 
 from which one is only warned by repeated disappointments. 
 
 III. The velocity of a ball influences the extent of its injuries to a bone, 
 and it is generally thought that these effects are less in inverse proportion to 
 its velocity. 
 
 IV. The character and shape of a ball are influenced by its encounter 
 with hard substances. 
 
 Illustrations. — Laroche relates a curious case of one of his relations, who 
 had twenty Napoleons in his pocket, which, struck by a ball, were driven 
 into his belly. In the Crimea, fragments of a shell were found lodged in 
 the abdominal parietes, in the thigh, and in the leg. 
 
 The following is a list of some of the foreign bodies found in thirty-one 
 cases, in the Revolution of 1848 : 
 
 Cases. 
 
 Small bits of ball, 5 
 
 Small shot, 2 
 
 Pieces of wadding, 3 
 
 Pieces of shoe, 3 
 
 Pieces of cloth and shirt, 6 
 
 Wadding and tow, 4 
 
 Worsted, 2 
 
 Bundle of hair, 
 
 Many hogs' bristles, 
 
 Pieces of cast iron, 
 
 Small pieces of wood, 
 
 Copper ornament from shako, 
 
 Nail, 
 
 With reference to the alterations in the form of the bullet some very 
 curious cases are mentioned. 
 
 1. A ball split on the edge of the petrous bone. 
 
 2. A ball split in two by the crest of the tibia, which broke the latter, and 
 half remained in the periosteum. 
 
 3. A ball divided by the orbital arch into two parts, the larger of which 
 lodged behind the eye at the bottom of the orbit. 
 
280 A SYSTEM OF SURGEKY. 
 
 4. A ball split in three parts by the orbital arch. 
 
 5. Division into three parts by the edge of the clavicle. 
 
 6. A ball shot into the skull of a subject, which spread out on the internal 
 table of the skull like a piece of tin. 
 
 7. A ball divided into two parts upon the femur. 
 
 8. In another soldier, a bullet which had struck the great trochanter, was 
 divided into three separate pieces. 
 
 9. The oddest example is related by M. Servier. In Algeria a ball broke 
 into five fragments on a rock, five or six paces from a grenadier; the first 
 fragment struck and broke the right ankle, two others pierced further down ; 
 the fourth wounded his right thigh, and the fifth lodged in the skin on the 
 back of the hand. 
 
 Torrey relates the case of an artilleryman who was struck by a ball in 
 the right thigh. The femur was broken ; as for the ball, it pierced the 
 thickness of flesh, turned around the bone, and ended near the anus, by 
 dipping into the hollow of the thigh. When he was brought to the ambu- 
 lance, neither he nor his surgeon suspected the presence of a foreign body ; 
 the patient was even of the opinion that the same ball had passed on and 
 struck another bombardier. It was only when performing amputation that 
 Torrey discovered a ball five pounds in iveight. 
 
 Dupuytren relates, that a ball, nine pounds in weight, was so completely 
 concealed in a patient's thigh, that the surgeon did not at first discover its 
 presence. 
 
 On the morrow after the taking of the Mamelon Vert, a soldier applied 
 at the ambulance, said to be wounded in his left thigh ; about its middle 
 was found a small circular aperture, like that of a round ball. Not a wound 
 of exit. On examination they could feel an obscure swelling in the popli- 
 teal space, but otherwise there was no swelling, redness, or special amount 
 of pain. A large incision enabled them to discover and extract an enor- 
 mous shot, which had run around the limb without breaking it. 
 
 Twisting Course of the Ball. — I. A ball may enter at one part of the body, 
 and pass out at another, leaving two apertures apparently quite independent 
 of each other. 
 
 II. Two apertures may be found opposite to each other, including between 
 them in the straight line, which must unite them, organs important to life, 
 which, if the ball had touched, must have inevitably been followed by death. 
 Whence one naturally concludes that the ball must have passed around 
 these organs. 
 
 III. The wandering course of a ball cannot, in the majority of instances, 
 be known by the condition of the wounds. 
 
 IV. Spitting of blood is not a pathognomonic sign of penetrating wounds 
 of the lung, simple contusions and superficial wounds being complicated 
 with it. 
 
 V. One is forced to admit very often, that there has been a deviation in 
 the course of the ball, in cases when the patient's progress has been too 
 favorable to allow the belief that the ball has traversed any vital organ, 
 and so to suppose that it penetrated in a direct line, when the severity of 
 the symptoms seems more in proportion to the importance of the organs 
 injured. 
 
 Illustrations. — Roeng mentions a case of simple perforation of the right 
 shoulder, with no trace of fracture, but, nevertheless, a line drawn between 
 the two apertures passed straight through the head of the humerus. Hennen 
 declared he saw a case, in which the ball entered near the thyroid cartilage, 
 and which, after going around the neck, returned to the same point at which 
 it had entered, and was extracted at that spot. A soldier was struck at the 
 moment he extended his arm to mount a ladder. The ball entered the 
 
GUNSHOT WOUNDS. 281 
 
 middle of the humerus, passed along the limb above the posterior aspect 
 of the thorax, opened for itself a passage in the abdominal muscles, pierced 
 those of the buttock, and passed again upwards to the anterior aspect of the 
 opposite thigh. 
 
 Diagnosis. — I. In order to determine the treatment of a wound, it is neces- 
 sary to know its depth and direction. This cannot always be accomplished 
 by drawing a direct line between the apertures. 
 
 II. It is necessary in such cases to assume that the wounded man was 
 in a particular position, which he sometimes remembers, and can assist in 
 diagnosis by telling the surgeon. 
 
 III. The inferior extremities being, during action, less frequently approxi- 
 mated to the trunk, never present the same complications as the arms. 
 There are but few cases where the ball has broken both thighs, or even 
 both legs. 
 
 IV. It is useless and wrong even to have an inclination to determine with the 
 probe the depth of a wound of the splanchnic cavities. This practice, which 
 some surgeons delight in, to enhance the apparent importance of their own func- 
 tions, should be especially repudiated. 
 
 V. In examining wounded limbs, the probe becomes an invaluable guide, en- 
 abling us to ascertain the presence of splinters, etc., and should be used as 
 early as possible. 
 
 VI. The introduction of the finger, or especially of the probe, is always 
 a painful operation, so it is well to perform it when the limb is still numbed 
 by the shock of injury. 
 
 Illustrations. — In one case, at St. Louis, the ball had traversed the left 
 biceps muscle, then had penetrated the chest by the axilla, and had gone 
 out again by the left lumbar region. To understand the course of the ball 
 one must imagine the body much bent forward and the left arm extended 
 to the utmost. A ball entered in the upper third of the right arm and went 
 out just above the nipple. If the arm is hanging, the straight lines uniting 
 these two wounds to the body would in a manner seem to indicate four skin 
 wounds. But as there were only two, we must imagine that the arm was 
 stretched out when struck. 
 
 Surgical Prognosis. — I. Wounds of the heart, of the lungs, and the brain* 
 will generally be fatal when they reach the centre of the organ, as the base 
 of the brain, the root of the lung. As to the heart, however, although a 
 wound of it appears incompatible with life, yet cases are upon record to the 
 contrary. 
 
 II. The spinal marrow cannot be wounded without causing death, whether 
 from its importance to life, or from the extensive osseous injuries which of 
 necessity accompany it. 
 
 III. Penetrating wounds of the abdomen are almost always fatal, owing 
 to the impossibility of retaining the edges of the wounded intestine in a 
 suitable position for cicatrization. 
 
 IV. Wounds of the liver can recover with a hepatic fistula. 
 
 V. Lacerations of the bladder are almost always followed by fatal results 
 from urinary infiltration. 
 
 VI. Fracture of Bones. — The prognosis depends upon several causes ; upon 
 the degree of splintering, the rapidity with which new bone is thrown out, 
 and the extent of suppuration. Fractures of the skull owe their unfavorable 
 prognosis, independently of the extent of injury, to the inflammation which 
 
 * In the American Journal of the Medical Sciences, for July, 1879, page 146, will be found 
 an interesting case of gunshot wound of the brain, in which" the ball passed through both 
 hemispheres, and was retained in the cranial cavity. Kecovery, with the persistence of all 
 the cerebral faculties, resulted. The case is reported by Dr. P. F. Harvey, U. S. A. 
 
282 A SYSTEM OF SURGERY. 
 
 they set up, often slowly and insidiously, from without inward, through the 
 thickness of the cranium to the cerebral mass. 
 
 VII. Wounds of the pelvis admit a much more favorable prognosis than 
 fractures of the long bones. 
 
 Treatment. — Gunshot wounds are, to a certain extent, amenable to the 
 rules of treatment that have been mentioned as applicable to contused and 
 lacerated wounds. 
 
 The symptoms of shock must be treated according to the indications laid 
 down in the Chapter upon " The Nervous System after Operations and 
 Injuries." 
 
 The suppression of haemorrhage (vide chapter on that subject), and the re- 
 moval of the foreign body, should be attended to immediately. If blood 
 be poured out copiously the vessel must be ligated, even though incisions 
 be necessary. As soon as the haemorrhage has ceased it is of much impor- 
 tance to ascertain if foreign substances have lodged in the wound. If the 
 opening be large enough to admit the finger, it may be inserted ; or if the 
 wound be small, or if the finger be too short to reach the bottom, a probe 
 must be used. The best of the kind is the long gunshot probe (Fig. 116% 
 which, from its length, is preferable to the ordinary instruments carried in 
 the pocket case. It should be ten or twelve inches in length, and should 
 be much thicker than usual. 
 
 Dr. Gross is a great advocate of this large probe, and I believe has one 
 constructed which bears his name. 
 
 The probe with which the celebrated Nelaton discovered the ball in Gari- 
 baldi's wound was tipped with porcelain, in order to detect the presence of 
 the metallic body. 
 
 The electric bullet probe consists of a steel probe connected at one extremity 
 with an electric chain ; when the other end comes in contact with the 
 metallic substance the chain announces the fact. Staff surgeon Nemperdick, 
 at Berlin, succeeded, at the first trial of the instrument, in detecting a bullet 
 lodged in the bones of the foot, which had eluded observation for six weeks. 
 
 It is well, however, before commencing any operation to administer to 
 the patient aeon, and arnica in alternation ; or if there is excessive prostra- 
 tion, china may be employed, as such treatment may tend to expedite the 
 disappearance of the shock and relieve pain. 
 
 The patient should then be placed as nearly as possible in the position 
 that he occupied at the time the wound was received, and the probe passed 
 along the wound gently, but with determination. If from any circumstance 
 the surgeon has reason to believe that extraneous matter is imbedded any- 
 where in the track of the ball, probing should be instituted as soon as 
 practicable after the infliction of the injury. If this operation be delayed 
 for a time, the lips of the wound close, the whole track becomes so swollen 
 and painful that it is not only frequently impossible to ascertain the direc- 
 tion the foreign body has taken, but the operation, slight as it may appear, 
 causes intense suffering. But immediately after the wound has been in- 
 flicted, the probe carried, through the recently made passage, glides along 
 with comparative ease to the bottom of the wound, where it may encounter 
 the foreign body, which may, if practicable, be withdrawn by the forceps, 
 or removed by a counter-opening made just over it. In every case, however, 
 in which the ball is not easily discoverable, all examinations should be aban- 
 doned, and the extraneous body allowed to remain in its situation until its 
 locality is better known. Mr. Hunter disapproved of making counter- 
 openings, excepting when the integuments under which the ball was lodged 
 were so contused that sloughing was inevitable ; in such cases the parts 
 might be considered as already dead, and an opening might be made for 
 
TKEATMENT OF GUNSHOT WOUNDS. 
 
 283 
 
 extraction, but it is the more modern practice to cut down upon the foreign 
 body and extract it, if it is not too deeply imbedded. 
 
 In wounds of the abdomen, probing should only be instituted to ascer- 
 tain the track of the ball in the parietes ; any further search in the cavity of 
 
 Fig. 116. 
 
 Fig. 117. 
 
 Fig. 118. 
 
 Fig. 119. 
 
 American bullet forceps. 
 
 Bullet scoop. 
 
 the abdomen would be extremely dangerous, and productive of no good to 
 the patient or surgeon. 
 
284 A SYSTEM OF SURGERY. 
 
 Guthrie mentions that he has cut out a number of bullets that were more 
 than an inch below the surface. However, the surgeon should always be 
 guided by the locality and texture of the wounded part; if the ball be deep 
 and firmly impacted, it is preferable to wait for the relaxation of the tex- 
 tures that occurs during suppuration, before attempting its removal, as at 
 that time the foreign body itself, in obedience to the general law, has begun 
 to seek the surface. It should always be remembered, as has been before 
 stated, that a ball may be inclosed in a cyst, or surrounded by bony forma- 
 tion, and remain for years in such a condition that the patient experiences 
 little or no uneasiness from its presence. 
 
 For extracting the ball, many bullet forceps have been made, some of 
 them very much more highly thought of than others. 
 
 The cut, Fig. 117, represents an excellent one, made by Messrs. Tiemann 
 & Co., of this city. It was used abroad during the late French war, and 
 was much lauded, receiving the name of the " American bullet forceps." 
 The instrument, however, known as Weisse's (Fig. 118), is better adapted 
 to the seizure of the ball than any other, it can readily be introduced into 
 the track of the bullet, and the claws are so sharp that they " take hold " 
 of the offending mass at once. I have used this instrument for other than 
 bullet wounds with great satisfaction. Sometimes a scoop (Fig. 119) is 
 very useful in removing the ball. 
 
 When a bone has been struck, or even grazed, very careful examination 
 is necessary — assisted by incision, if need be — in order to ascertain if splin- 
 tering has occurred. Late experience in Paris seems to have shown, that 
 unless all bruised and splintered fragments are thoroughly removed at 
 the time, these portions become necrosed, and serious consequences by 
 inflammation and suppuration are likely to ensue. 
 
 The remainder of the treatment should be conducted on the same plan as 
 that noticed under contused and lacerated wounds. 
 
 If the wound has been inflicted in a vascular part, and there is consider- 
 able oozing of blood from the smaller vessels, the medicines that will 
 frequently subdue such haemorrhage, if arnica has not proved efficacious, 
 are crocus, phosphorus, or diadema, the latter being recommended " for 
 haemorrhage from every orifice of the body. /or violent bleeding from icounds;'''' 
 or perhaps sabina may prove useful, provided the remaining symptoms 
 correspond. 
 
 If there is a contusion caused by a spent ball, arnica is the specific. After 
 the extraction of the foreign matter, not only to mitigate suffering, but also 
 to prevent exhausting suppuration, calendula must be prescribed. Or if 
 the patient complain during the suppurative process of boring pain in the 
 head, particularly in the forehead, whizzing and throbbing in the ears, 
 chilliness, particularly of the extremities, hepar will be the best medicine. 
 
 If the fever be high, with delirium, aeon, and bell, in alternation ; or one 
 of the above with some other medicine, may be employed. 
 
 If the fever exacerbate at night, and also the other symptoms, and if 
 suppuration proceed slowly, mercurius should be given. 
 
 Creasote may be employed if the discharge from the wound is thin and 
 sanious, or consists of decomposed blood, and the patient is debilitated. 
 Nit. acid should also be administered in somewhat similar cases. 
 
 Silicea is also another predominant medicine, and should be exhibited, if 
 the wound is very difficult to heal, and the suppuration very profuse ; if the 
 inflammation has a tendency to spread, and there are drawing pains in the 
 limbs ; also, when the patient is constantly chilly, with insufferable thirst 
 and frequent flushes of heat in the head. 
 
 Sulphur must be employed when the patient complains of frequent inter- 
 
DISSECTION WOUNDS. 285 
 
 nal chilliness, or there may be spasmodic jerkings through the limb ; when 
 the pains in the wound are aggravated by change of weather, and the patient 
 sleepless and very restless; also for profuse suppuration and unhealthy 
 pus. This medicine is also very well adapted to promote granulation and 
 cicatrization, as is also silicea, or according to Thorer, calendula off. 
 
 There are also other medicines that may be valuable in the treatment of 
 gunshot wounds, but the practitioner must in all cases select the medicine 
 the symptoms of which correspond to the most of those that are experienced 
 by the patient, always, however, bearing in mind the pathological condition 
 of the part, as it is an index to the genus of the remedies from which the 
 appropriate medicine must be selected. 
 
 If gangrene threaten, or to prevent the spreading of such disease, the 
 best medicines are ars., carb. veg., china off., lachesis or crotalus. 
 
 Very frequently, the first care of the surgeon is to determine whether to 
 amputate the limb, or to endeavor to save the part. Of course, whenever 
 there is a reasonable hope that the wound may be healed without the per- 
 formance of a painful operation, it is the duty of the surgeon to endeavor 
 to produce such favorable result. There are cases, however, when ampu- 
 tation is absolutely necessary. 
 
 Tooth Wounds. — The wounds that are inflicted by the teeth of men and 
 of the inferior animals are always serious. The popular impression prevails 
 that because the animal or man is not rabid from disease the wounds in- 
 flicted by the teeth are not serious. This is a great error. I have seen many 
 of these wounds, and have noticed that those inflicted by man are generally 
 more troublesome to manage and produce more serious constitutional 
 disturbance than those of dogs or cats. In every instance save one that 
 came to my notice, where the wounds were on the fingers, amputation 
 was necessary; and in the one exception the recovery was lingering. 
 Parts of the ear and nose are sometimes bitten off in those horrible encoun- 
 ters of man, when he becomes more beastly than the brute, and death has 
 been known to result in some cases from the bites of these " rabid " human 
 beings. 
 
 An accidental blow upon a tooth at times is followed by inflammation, 
 erysipelas, and sloughing. 
 
 In the treatment of these wounds, a first object of attention is to thoroughly 
 cleanse them. They should be washed with soap and water, and then 
 bathed with a solution of carbolic acid ; if they should begin to inflame, 
 and symptoms of erysipelas develop, aeon., apis, bell., rhus, lachesis, can- 
 tharides, or crotalus may be given. If there is a disposition to ulceration, 
 the ointment of the carbonate or oxide of zinc will be productive of satis- 
 factory results. 
 
 Sometimes a solution of the carbonate of potash tends much to relieve 
 the pain and soothe the part. 
 
 Arsenicum and china and veratrum relieve ; pr^tolacca and carbo veg. 
 may also be called for according to the symptoms. 
 
 If there be evidences of the formation of pus, the sooner it is evacuated 
 the better. Other symptoms may require treatment according to directions 
 already pointed out in the management of the various kinds of wounds. 
 
 Dissection Wounds. — Under this head may be included those wounds 
 which infect the body by the presence of poison received into the system 
 (generally by accidental inoculation), while dissecting the cadaver, or oper- 
 ating for malignant tumors. Students of anatomy, in the dissecting-room, 
 frequently scratch or cut their fingers, yet considering the number thus 
 engaged, unfortunate results are not frequent ; occasionally, however, most 
 melancholy or even fatal consequences occur. 
 
286 A SYSTEM OF SURGERY. 
 
 In some individuals there is greater susceptibility to the action of virus 
 from the dead body than in others, and, moreover, this susceptibility varies 
 at different times in the same individuals. I have known a student who, 
 during one winter, from careless handling of the scalpel, pricked and cut 
 his fingers without being injured, while during the second session, he was 
 made so severely ill by receiving a scratch in the dissecting-room, that he 
 had to abandon his studies and return home, where he remained several 
 months before recovering. 
 
 The poisonous virus of dead bodies has its period of incubation, which 
 period varies in different individuals, from three to ten days. A vesicle 
 first appears containing a limpid fluid, which gradually degenerates into a 
 pustule, which opens, leaving an unhealthy sore beneath. At other times 
 the hand inflames, the skin is hot, tense, and shining, the pain very severe, 
 the axillary glands enlarged ; the arm becomes stiff and painful during 
 motion, and, if examined, streaks of a reddish hue are visible, extending 
 upwards. There is a high degree of constitutional disturbance; fever, deli- 
 rium, jactitations, and prostration ; entire loss of appetite ; coma may super- 
 vene, and death take place. 
 
 In other instances suppuration takes place beneath the thecse and apo- 
 neuroses, giving rise to excruciating pain. If the matter is not evacuated 
 caries of the bone may result. Again, the ulceration may become phleg- 
 monous, and gangrene require speedy amputation. Erysipelas also may 
 appear in some cases, thus complicating the case and increasing the suffer- 
 ings of the patient. 
 
 My friend Dr. Jernigen, during the winter of 1872, while demonstrating 
 the triangles of the neck to the class, in a subject very much decayed, be- 
 came inoculated with the virus from the body, and for months suffered in- 
 tensely from thecitis in the palm of his hand and the index and middle 
 finger. He finally recovered with a stiffened joint. In this case the consti- 
 tutional symptoms were well marked and of a typhoid nature, and the 
 aspect of the hand so serious that at one time it was feared that amputation 
 might be necessary. 
 
 Persons dying of puerperal fever, septicaemia, cancer, malignant pustule, 
 and that class of ailments, at an autopsy should always be carefully dis- 
 sected, as the poison from such bodies is always more virulent than from 
 other subjects. What the poison is which generates in the human body 
 after death is unknown ; like the vaccine, the syphilitic, the hydrophobic, 
 it eludes the search of the chemist and microscopist. 
 
 Most severe wounds and dangerous symptoms are also induced from the 
 introduction into the body of matter from cancers, suppurating sores, and 
 abscesses. 
 
 I recently attended a boy who died from septicaemia and synovitis, occa- 
 sioned by poisoning of the rhus radicans, which I believe he ate. The 
 bandages from his ankle were changed frequently by his mother, uncle, and 
 other attendants. Shortly after his death his mother began to suffer from 
 a small vesicle on the knuckle of the index finger of her left hand. This 
 went through the usual stages of inflammation, the arm was much swollen, 
 the axillary glands enlarged, fever and prostration followed, suppuration 
 took place beneath the tendon of the extensor indicis, and the matter was 
 evacuated. The uncle of the boy also suffered from several similar evidences 
 of the poison. The person who washed the dressings, w T hich were many 
 and frequently changed, likewise had several pustules on the finger, and 
 two others of the household, who had nursed the lad and handled the band- 
 ages, had several places on their fingers cauterized to prevent further exten- 
 sion of the poison. 
 
EQUINIA — GLANDERS — FARCY. 287 
 
 The surgeon in operating for malignant carcinoma should always be on 
 his guard, as instances are upon record where disastrous effects have speedily 
 followed inoculation from such virus. 
 
 Treatment. — There are some prophylactic means which should be ob-^ 
 served to prevent inoculation while dissecting or making post-mortem ex- 
 aminations, one of the best of which is to anoint the hands freely with olive 
 oil, vaseline, beef or mutton tallow. Olive oil is considered in many coun- 
 tries a preventive of the unpleasant symptoms arising from the stings of 
 venomous insects, and that it has such power is well known. It is so readily 
 obtained that it can always be employed. 
 
 The practice of using gloves during dissections is scarcely to be coun- 
 tenanced, although gloves of india-rubber gauze are now manufactured for 
 the purpose. 
 
 A favorite custom of students when they have either pricked or cut them- 
 selves, is immediately to wipe off the spot with a wet towel, suck out the 
 poison, and then cauterize the injured place with the nitrate of silver, or 
 some prefer to place upon the wound a piece of tobacco. These means are 
 really productive of good results. Dr. Gross prefers the acid nitrate of mer- 
 cury as a caustic, and Dr. Comstock speaks highly of the hamamelis as a 
 local application. 
 
 I believe the best caustic is the actual cautery, which may be applied 
 secundum artem, by the iron, or in a more homely manner with a lighted 
 cigar, the latter being generally more easily obtainable than the former. If, 
 however, the patient is not seen until the formation of a vesicle or pus- 
 tule, it may be immediately opened, and a poultice of linseed applied, 
 and carbolic acicl given in the second dilution, fifteen or twenty drops in half 
 a glassful of water, of w T hich a tablespoonful should be taken every two 
 hours. For the nervousness and sleeplessness which follow, the bromide of 
 potash is the best medicine, not only as a sedative, but from its action in 
 the various forms of toxaemia. Other medicines are those which are men- 
 tioned in the treatment of erysipelas, gangrene or poisoned wounds. In 
 the case of Dr. Jernigen, after the parts had been well opened, there was 
 not the slightest disposition to heal, the hand remained swollen, and the 
 tendons very rigid. Dr. Liebold, with whom I saw the patient in con- 
 sultation, applied to the hand, red precipitate ointment with the very best 
 result. 
 
 For the further and more precise treatment of septicemia and pysemia, 
 the student is referred to Chapters VI. and XV., where the different materials 
 and medicines for local and constitutional treatment are described. 
 
 Equinia — Glanders— Farcy. — This horrible disease was formerly con- 
 founded with malignant pustule, but further researches have proved their 
 distinctness. It received the name equinia from Elliotson, on account 
 of its being transmitted from the horse. It is denominated by some 
 farcy. ^ 
 
 It is occasioned in man by the introduction into his system of a specific 
 animal poison derived from the horse, the ass, or the mule. 
 
 Glanders has a period of incubation of from three to eight days, and is 
 divided into the acute and chronic varieties. When the zymosis begins to 
 be apparent, a rigor generally announces the contamination of the system. 
 There is severe aching in the bones, fever and delirium, accompanied with 
 profuse and offensive sweats and discharges. During this period the inocu- 
 lated part becomes painful, red, and swollen, the lymphatics and glands 
 are inflamed and enlarged, and abscesses form in the joints and cellular 
 tissue. The face becomes shining and livid, and the very characteristic 
 viscid and offensive discharge from the nostrils appears. Pustules form, or 
 
288 A SYSTEM OF SURGERY. 
 
 in some instances, blackish bulla? on the face and on the body, which soon 
 assume a gangrenous appearance, coma and subsultus tendinum supervene, 
 and the body sinks into death, overpowered by the poison. In the chronic 
 variety of the disease the symptoms, though they do not follow with such 
 alarming rapidity, yet are almost as fatal. The nasal discharge is profuse 
 and accompanied with considerable tumefaction of the nose and eyes. The 
 pustules, both on the integument and Schneiderian membrane, soon degen- 
 erate into foul and ill-conditioned ulcers, the ulcerative process extending 
 along the mucous lining of the pharynx, larynx, and lungs ; these symp- 
 toms may not appear to progress rapidly, when an unexpected aggravation 
 takes place and the patient is rapidly carried off, or great exhaustion with 
 excessive perspiration may terminate life. The duration of the disease is 
 from ten to twenty days. 
 
 Glanders in the horse can either arise spontaneously or be transmitted 
 by inoculation. About forty years ago the fact of its transmission to man 
 was undoubtedly proven. Though the disease per se requires for its devel- 
 opment inoculation with the virus, yet the miasm arising: from the disease 
 may produce in man symptoms of malignant and fatal fever. The horse, 
 the mule, and the ass, are all liable to the disease, and it is probable that 
 the zebra, jaghatai, quagga, and other solipeds are also susceptible to the 
 poison, while it is asserted that ruminating and carnivorous animals are not 
 affected by it. 
 
 If a horse be inoculated with the virus either from man or from another 
 animal of the equine species, the symptoms of glanders will be produced in 
 from three to four days. 
 
 Treatment. — The treatment of this malignant disease is not satisfactory. 
 In some of the veterinary manuals, the only direction given is to destroy 
 the animal at once, to prevent further infection. Mr. Moore, however, has 
 suggested that kali bichromicum is a medicine of great power in the disease, 
 and I can see no reason why, if it is beneficial to the animal, it should not 
 be so to man. Mercurius, lachesis, and arsenicum are adapted to certain 
 symptoms of the affection. The sixth volume of the North American Jour- 
 nal of Homoeopathy contains an article on glanderine and farcine, in which 
 the writer strongly urges the use of these animal poisons in diseases of 
 peculiarly malignant type, and, perhaps, under certain circumstances, 
 they may be serviceable in true glanders. In the treatment of glanders, 
 great attention must be paid to cleanliness, diet, ventilation, and disinfec- 
 tion. 
 
 Maggots in Wounds. — In spite of the utmost cleanliness, maggots some- 
 times appear in wounds and among the dressings. They are especially 
 found in wounds which have not received proper attention as to cleansing 
 and changing of dressing, and in those where there is a large amount of 
 suppuration combined with heat. 
 
 In some cases it appears impossible to assign a cause for them, while in 
 others their presence may be readily accounted for. When they are once 
 noticed they multiply with most singular rapidity and give considerable 
 trouble. In cases of resection, especially of the knee-joint, where suppura- 
 tion is profuse and the pus liable to gravitate around the limb and be sub- 
 jected there to the heat of the body, maggots are often found. In compound 
 and comminuted fractures we sometimes find them. 
 
 In civil practice these maggots in wounds are the exception ; indeed, of 
 late years they are not even found in hospitals, excepting in occasional 
 cases, the antiseptic treatment having completely abolished them. 
 
 The treatment is very simple and very effective. Remove entirely all the 
 soiled dressings, — that is, all that can be spared, and cut away others ; with 
 
AMPUTATION OT WOUNDS. 289 
 
 a good syringe or douche, send a stream of water into the wound and 
 thoroughly cleanse the part. Wipe now all the wound and dry the parts 
 well with " marine-lint " (oakum). With a Richardson's local anaesthesia 
 apparatus, spray on the parts a solution of carbolic acid and water in pro- 
 portion to ten drops of C. A. to water one ounce. This having been done, 
 apply clean dressings, and over these a cloth saturated with the carbolic 
 acid. This treatment with me leaves nothing to be desired. The dressings 
 should be changed twice a day for two days; after that period, once in 
 twenty-four hours. 
 
 Question of Amputation in Wounds. — This is a subject of the greatest im- 
 portance to the surgeon as well as to the patient, and one in which there are 
 so many arguments pro and con, that a conscientious practitioner is often 
 placed in a most unenviable position. I have experienced such feelings as 
 these. Perhaps there is a severe lacerated wound occasioned by a railroad 
 or steamboat accident, the bones are broken, and part of the flesh is pulpy 
 and must die. It is impossible to ascertain the exact amount of injury 
 done, although there is an appearance of traumatic gangrene. Under- 
 standing the power of conservative surgery, and the action of medicine, the 
 great desire of the surgeon, as well as of the patient, is to save the limb, 
 and the preference should be given always to conservatism. Sometimes 
 cases which appear desperate are cured, perhaps with a stiff joint and 
 some deformity. If, however, gangrene threaten to extend, the medicines 
 and treatment appear to be of no avail, and the constitution suffers, the 
 knife must be at once resorted to. 
 
 There are other cases in which the experienced surgeon can see in a 
 moment that there is no hope to resuscitate the member ; then amputation 
 must be immediate. 
 
 When masses of substance are carried away, when large arteries and veins 
 are implicated, when the cavities of large joints are opened, when tendons, 
 ligaments, and bones are severely crushed, then a primary amputation should 
 be performed. On the other hand, if the attempt be made to save the limb, 
 and that effort appears unsuccessful, then, after a fair trial, not allowing the 
 patient to suffer too greatly from the irritation produced upon his system, 
 a secondary amputation must be made. 
 
 In gunshot wounds, there has been much discussion as to primary and 
 secondary amputation. In military practice, the majority of surgeons are 
 in favor of primary or immediate operation. Dr. Franklin is of opinion that 
 the operation should be performed during the shock. He says, " Whenever 
 I could get access to the wounded during a battle, my judgment was always 
 to operate immediately, using the time of shock, or nature's anaesthesia, as 
 the most opportune period, without reference to the reaction upon which so 
 much stress is laid in surgical works. "* He says, farther, " that when he 
 has waited for reaction, the patients have not gotten on nearly so well as 
 those who were subject to the knife earlier." 
 
 Other surgeons prefer the period of systemic repose between the subsi- 
 dence of shock and excessive reaction. These questions, however, should 
 be settled in the mind of every military surgeon, and I have no doubt that 
 many circumstances would influence the performance of amputation in 
 either case. Primary amputation may then be considered to mean: ampu- 
 tation performed during the presence of shock, or between the subsidence 
 of shock and establishment of reaction. What is now understood by sec- 
 ondary amputation ? It means, in some instances, to defer the operation, 
 though the surgeon may be convinced that it will have to be performed, in 
 order to allow a better state of the constitution, to give greater hopes of 
 
 * Science and Art of Surgery, vol. ii., p. 719. 
 19 
 
290 
 
 A SYSTEM OF SURGERY. 
 
 £ 
 
 
 s 
 
 8 
 
 o 
 
 
 <a 
 
 op 
 
 <w 
 
 1 
 
 k^ 
 N 
 
 § 
 
 ^ 
 
 Cb 
 
 >8 
 
 g 
 
 S 
 
 © 
 
 ss 
 
 I 
 
 i 
 
 o 
 
 
 *c 
 
 
 1 
 
 "^^ 
 
 r-l 
 CO 
 
 ^ 
 
 
 6 
 
 w 
 
 •\ 
 
 ©H 
 
 !i 
 
 1 
 
 ^ 
 
 
 CO 
 
 ^ 
 
 >>< 
 
 r© 
 
 
 
 "s» 
 
 o^ 
 
 CO 
 
 PS 
 
 ?-. 
 
 E§ 
 
 
 <£, 
 
 «; 
 
 co 
 
 
 ^ 
 
 
 6i 
 
 
 
 
 t~ 
 
 CO 
 
 i <M CO CO 
 
 
 Aggregate. 
 
 OS 
 
 O iO l>- CO o 
 
 CO IO CO rH 
 
 
 
 
 
 
 
 i-H CO 
 
 
 
 
 i-H CO CO CI 
 
 3 CO 
 
 BJ 
 
 Mortality rate. 
 
 © 
 
 GO TJH CO t 
 rH lO CO c 
 
 i-H 
 
 
 
 o 
 
 t> IQ 1Q 
 
 t^ 
 
 
 1— 1 
 
 
 
 
 
 
 1 
 
 
 T* 
 
 OS CO t- Ci 
 
 3 ^ 
 
 3 
 
 Undetermined. 
 
 r-4 
 
 OS -^ CO -^ 
 r-l i— 1 r-t r 
 
 H CO 
 
 
 
 >• 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 GO 
 
 t^ <N 
 
 1 O 
 
 CO 
 
 Died. 
 
 CO 
 
 CO CO © U 
 
 3 OS 
 
 
 
 <M r- 
 
 4 rH 
 
 3 t- 
 
 O 
 
 
 
 
 
 
 
 
 09 
 
 
 
 
 
 
 
 
 a 
 
 
 
 
 
 
 
 
 o 
 o 
 
 
 O 
 
 co co oq c 
 
 > rH 
 
 Recovered. 
 
 
 OS O l>» tf 
 
 i— 1 
 
 3 <N 
 
 CO 
 
 
 
 CO 
 
 
 CO 
 
 
 CO 
 
 
 Mortality rate of 
 
 CO 
 
 
 CO 
 
 . 
 
 CO 
 
 
 determined cases. 
 
 CO 
 
 <M 
 
 > OS 
 
 in 
 
 g 
 
 
 CO 
 
 t-- GO IO O 
 
 t t^ 
 
 Undetermined. 
 
 r-l 
 
 CO O O i- 
 r-l 
 
 S CO 
 
 O 
 
 3 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 o 
 
 
 
 
 
 
 
 
 
 Died. 
 
 o 
 
 r-l 
 
 CO CO i-l 
 i— 1 tH 
 
 S r-l 
 kO 
 
 Recovered. 
 
 <N 
 
 t> (M tH t- 
 
 4 CO 
 
 rH 
 
 
 
 
 
 CO OS p 
 
 5 CO 
 
 
 Mortality rate of 
 
 
 
 GO o o 
 
 ^ IN 
 
 
 determined cases. 
 
 © 
 
 o 
 
 lO T* CO C 
 !>. IO Tt< t- 
 
 5 co 
 
 CO 
 
 fl 
 
 
 I— 1 
 
 
 
 
 
 
 
 o 
 
 i-( t» t>. C£ 
 
 ) rH 
 
 o 
 
 1 
 
 Pi 
 
 Undetermined. 
 
 
 rH T*i rH « 
 
 5 T*4 
 1 ^ 
 
 
 <N 
 
 rti i-H <M r- 
 
 H O 
 
 a 
 
 Died. 
 
 
 <N iO T- 
 
 i <y 
 
 5 <M 
 
 < 
 
 
 
 
 
 
 i V 
 
 5 »C 
 
 
 o 
 
 CO <M i-H r- 
 
 * (M 
 
 
 Recovered. 
 
 
 
 t* CO o 
 
 J O 
 
 
 
 
 
 
 
 
 < CO 
 
 
 
 <M 
 
 t>- CO GO C 
 
 > CO 
 
 
 Total terminated. 
 
 GO 
 
 GO "# r-t f 
 CO CO ""Cft £> 
 
 o 
 o 
 
 
 
 
 
 
 
 
 
 
 
 .2 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 *o 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 G- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rC 
 
 
 
 
 
 
 
 
 bO 
 
 
 
 
 
 
 
 
 c 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 oj 
 
 
 
 
 
 
 
 
 O 
 
 
 7= 
 
 
 
 
 
 
 '3« 
 
 a 
 
 
 
 12 
 
 1 
 
 
 
 
 *h 
 
 i. 
 
 
 
 |c 
 
 
 
 
 3 
 
 a 
 
 •r 
 
 4 
 
 
 ■> 
 
 
 
 
 
 
 £ 
 
 ^ 
 
 a 
 
 a 
 
 c 
 
 
 
 
 «*H 
 
 «+- 
 
 «*^ 
 
 e«— 
 
 
 
 
 o 
 
 c 
 
 o 
 
 C 
 
 
 
 
 
 s 
 
 s 
 
 3 
 
 3 
 
 ac 
 
 
 
 
 fn 
 
 s- 
 
 ^ 
 
 !h 
 
 "G 
 
 
 
 
 =3 
 
 
 s 
 
 £ 
 
 a 
 
 
 
 
 *a 
 
 
 ■u 
 
 
 
 
 
 CJ 
 
 t 
 
 O 
 
 c 
 
 s 
 
 
 
 
 S3 
 
 a 
 
 as 
 
 7 s 
 
 o 
 
 
 
 
 £ 
 
 ,*4 
 
 * 
 
 £ 
 
 £ 
 
 
 
 
 
 ■«J 
 
 -W 
 
 ■*J 
 
 -<f 
 
 
 
 
 o 
 
 O 
 
 o 
 
 o 
 
 o 
 
 
 
 
 .J3 
 
 r3 
 
 ^5 
 
 rC 
 
 ^5 
 
 
 
 
 00 
 
 00 
 
 GO 
 
 OS 
 
 CO 
 
 
 
 
 fl 
 
 E 
 
 G 
 
 c 
 
 a 
 
 
 
 
 3 
 
 
 3 
 
 3 
 
 3 
 
 
 
 
 o 
 
 1 
 
 o 
 
 o 
 
 o 
 
 
THE VAEIED METHODS OF DRESSING WOUNDS. 291 
 
 success ; or it may mean, when there is uncertainty in the mind of the sur- 
 geon whether the loss of the limb is necessary, to wait and ascertain what 
 conservative means may accomplish. In the one case the surgeon is certain 
 amputation must be made, but hopes for a better state of the body for its 
 performance. In the other, he is undecided whether he can save the limb 
 or not, and awaits the development of symptoms. This has given rise to 
 considerable confusion. We may, however, say that a secondary amputa- 
 tion is one in which, from any cause, the operation is delayed. 
 
 In 1689 cases of gunshot fractures of the humerus, the complete records 
 of which have been obtained, amputation or excision was practiced in 996, 
 and conservative treatment adopted in 693, with a rate of mortality of 21 
 per cent, in the former and 30 per cent, in the latter. 
 
 In gunshot fractures of the humerus, the tables of statistics in the late 
 war were rather in favor of operation than against conservative measures. 
 
 The unsuccessful nature of the treatment of gunshot fractures of the 
 femur has given rise to the opinion of some surgeons, that when the acci- 
 dent occurs, amputation should be immediately resorted to. This, however, 
 is not the proper method to pursue in all cases, because instances are upon 
 record wherein fractures of the femur from gunshot injuries have united, 
 and the cure been complete. ( Vide table on page 290.) 
 
 The primary operation so far gives the best results, and should be adopted 
 when there is no hope of rescuing the limb. A secondary amputation 
 should be performed when the hope of saving the limb, which dictated 
 the delay, is deferred and weakened by the untoward progress of the case. 
 
 The surgeon, however, should bear in mind one fact, that no matter how 
 decided the local injury may be in calling for amputation, the operation 
 should not be performed unless there is a reasonable hope of success ; and 
 that secondary amputation is generally called for in cases of prolonged sup- 
 puration, hectic, non-union of broken bones, gangrene, sloughing, caries, 
 and necrosis. 
 
 CHAPTER XV.* 
 
 THE VARIED METHODS OF DRESSING WOUNDS.f 
 
 As it becomes the daily duty of a surgeon to apply dressings to wounds 
 and sores, it is also his duty to understand a variety of methods by which 
 cicatrization may be attained, so that in case one method does not pro- 
 duce the desired results, some other may be resorted to. In many cases, 
 however, the healing process will go on without hindrance under the use 
 of almost any emollient application, therefore the principal object to have 
 in view is to give the wound a covering, and so protect it from external 
 influences ; thus frequently the method adopted for this protection is unim- 
 portant. 
 
 In the case of superficial incised wounds, the tendency, in good consti- 
 tutions, is to primary union. Still, even in these cases, foreign bodies 
 should be looked for, as they often have forced into them either hairs, 
 gravel, glass, or some portions of the clothing, or even some articles neither 
 
 * This chapter has been written by Dr. John H. Thompson, Lecturer on Minor Surgery 
 in the New York Homoeopathic Medical College. 
 
 f In the preparation of this chapter, I have availed myself of Prof. Gosselin's lectures on 
 the dressings for wounds, and the excellent articles on the subject of the antiseptic treatment 
 of wounds, by A. C. Girard, M.D., and K. F. Weir, M.D.- J.'H. T. 
 
292 A SYSTEM OF SURGERY. 
 
 visible nor capable of detection by the touch. All of these should be care- 
 fully removed, either by washing, suction, or the forceps, before applying 
 any dressing. 
 
 Unfortunately, however, wounds do not always present this simple char- 
 acter. It then becomes necessary to apply some method which will bring 
 about the most favorable results ; union by first intention, if possible, if not, 
 to favor cicatrization by granulation. 
 
 In order that this most desirable result (primary union) may be attained, 
 the wound should be clean, without having been severely contused, and 
 without loss of much substance. 
 
 If only a short time has elapsed since its infliction, the edges may be 
 brought together and maintained in proper apposition either by some 
 kind of suture, or the application of strips of plaster, with the addition 
 of a light bandage ; the parts should always be placed in an uncon- 
 strained position and kept immovable ; this latter is essential to primary 
 union. 
 
 Should it be impossible to obtain union except by second intention or 
 granulation, either on account of a severe contusion or suppuration having 
 already become established, or in the case of gunshot wounds, which are 
 quite certain to suppurate, it then becomes important to inquire which is 
 the proper method to dress these different varieties of wounds. In all cases 
 great attention must be given to the progress of the general symptoms, and 
 those dressings selected which afford the best protection, and at the same 
 time have a tendency to reduce the process of inflammation. Thus, for 
 local application, poultices, water-dressing, simple cerate, cold cream, etc., 
 may be used. 
 
 Poultices, when required, should be used warm. 
 
 Water may be applied either warm or cold, and often the feelings of the 
 patient will be the best guide, although water as hot as can be well borne 
 will generally reduce an inflammation more effectually than cold. When 
 cold water is applied, the compress which holds the water should be covered 
 with a piece of oiled silk, or thin india-rubber or impervious paper may be 
 used, to prevent evaporation. 
 
 Another excellent method is that of irrigation, or the application of a 
 continuous stream of water upon an inflamed part. 
 
 Thus in a few words are described some of the antiphlogistic methods 
 which are of much benefit during the inflammatory period of those wounds 
 which are destined to suppurate. 
 
 All dressings should fulfil two important indications, — not to produce 
 pain, and not to convey subjects of contagion to the wound. 
 
 There are many salves and other articles for local application under the 
 use of which, if the general constitution is good and the hygienic conditions 
 favorable, the wound will heal. When, however, the granulations become 
 too exuberant and rise above the surface, the application of nitrate of silver 
 as a caustic, or powdered sulphate of copper, will generally reduce the sore 
 to a more healthy condition. When, on the other hand, it becomes pale 
 and anaemic, often with lardaceous spots, the pus transformed into a serous 
 discharge, the reparative process has ceased, and stimulation becomes requi- 
 site. In addition to general treatment and hygienic measures, the appli- 
 cation of an ointment of balsam of Peru may be made, or the sulphate 01 
 copper applied in solution, or the pure pulverized, and allowed to remain 
 on until its caustic effect becomes apparent. An electric battery may be 
 made of a thin plate of silver and another of zinc, connected with a copper 
 wire, the silver being applied to the sore, and the zinc over a healthy part. 
 Care must be taken to change the locality of the zinc frequently, or another 
 sore will be produced. 
 
THE VAEIED METHODS OF DKESSING WOUNDS. 293 
 
 Enough, perhaps, has been said concerning superficial wounds. Atten- 
 tion must now be given to a more important subject. I mean deep and 
 more extensive wounds, and those which are connected with osseous struc- 
 tures, whether consequent upon an operation or traumatism. In the case 
 of narrow deep wounds which compound a fracture, all the means at com- 
 mand should be resorted to in order to obtain primary union of the integu- 
 ment, and such an adjustment of the deeper parts that they may become 
 united in the most speedy manner. This treatment would rarely be suc- 
 cessful in the case of an amputation of a limb, or a gaping wound, the 
 result of an operation for the removal of a large tumor ; therefore it becomes 
 necessary to be familiar with several methods of dressing, so that in the 
 event of a failure in any stage of the method of dressing which may be 
 adopted, some other may at once be substituted : for no matter how highly 
 lauded each variety of dressing may be by its author or adherents, each 
 may be followed by failure in some case or other, either on account of its 
 being misunderstood by the surgeon, or a want of adaptability to the 
 case. 
 
 Open Method. — The first method to which attention is called is the open 
 treatment of wounds. It was first introduced to notice in the early part of 
 this century by Kern, a Vienna surgeon, whose name is sometimes attached 
 to this method. It was revived in 1856, in Germany, by Bartscher and 
 Vezin. It consists simply in leaving the wound just as it is after the opera- 
 tion and the arrest of haemorrhage, with a simple dressing of cloths wet with 
 water, without sutures, strapping, or anything of the kind, until granulation 
 takes place ; the sides of the wound are then adjusted and brought together 
 with straps of plaster or bandages, so that the union is always that of second 
 intention. 
 
 The advantages claimed for the open treatment are as follows : 
 
 1. The dressings do not cause undue pressure. 
 
 2. Danger of conveying contagion to the wound by impure applications 
 is avoided. 
 
 3. As adhesion to primary union is abundant from the first, as many 
 ligatures as are desirable may be applied to thoroughly avoid secondary 
 haemorrhage. 
 
 4. The wound may be inspected at any time by simply removing the cloth 
 covering it. 
 
 5. There are no foul emanations from dressings to vitiate the surrounding 
 atmosphere. 
 
 6. There is but slight danger of the retention of pus. 
 
 7. Irritation of the wound by changing the position, and making the ex- 
 ternal applications, is avoided. 
 
 8. Less material is required for the dressings. 
 
 These advantages should certainly be a recommendation for this method 
 when frequent observation is to be made by the surgeon ; also for the in- 
 struction of students in the wards of a hospital, and for practice in war when 
 materials are scarce. 
 
 There are, however, two considerations against the open method; one 
 is the renunciation of healing by primary union, and the somewhat more 
 frequent occurrence of erysipelas. This may be somewhat avoided by 
 due regard to sanitary protection. And if in a particular case the sur- 
 geon may expect union by first intention, some other method may be 
 selected. 
 
 Occlusive and Compressive Dressing. — This second method of dressing 
 wounds with wadding was originated in France by Dr. Alphonse Guerin, 
 and used by him at St. Martin's Hospital in 1870, where it became quite 
 successful and gained excellent results. I will now explain the method 
 
29-4 A SYSTEM OF SURGERY. 
 
 of its application. Take for instance an amputation ; the operation having 
 been performed and the ligatures applied, the bleeding having ceased, and 
 the wound thoroughly cleansed and dried ; a large bundle of new wadding 
 must then be prepared by having it heated in an oven to as high a tem- 
 perature as possible. The wound should then be filled with this warm 
 wadding, and secured in position by layers extending up on the limb sev- 
 eral inches above the site of the operation. A sufficient quantity of the 
 wadding should be applied to make the limb about three times as large 
 as the other. The whole dressing is to be retained by an ordinary roller 
 bandage, which should exert considerable pressure; this of course must 
 be applied with great care. 
 
 The dressing should remain on from twenty to twenty -five days. At the 
 end of this time it should be removed and a similar one put on. It is gene- 
 rally necessary to reapply it two or three times. 
 
 The inflammation which supervenes is but slight, and frequently the pa- 
 tient will sleep and rest as well as before the operation, as the pain is usually 
 very slight. 
 
 Upon renewing the first dressing the cotton will be matted together and 
 as the wound is exposed a small amount of thick, creamlike, laudable pus 
 will be found. The wound itself is usually of a healthy reddish color covered 
 with granulations. 
 
 The principle upon which this dressing is applied is the complete exclu- 
 sion of atmospheric germs. First the cotton is made as hot as possible to 
 destroy any germs which it may have contained when procured ; it is then 
 applied in thick masses, and bound on tightly with a bandage. It might 
 be supposed that this dressing would be impervious to germs, but vibriones 
 have been found in the pus under this dressing on the twenty -fifth day ; 
 still they did not appear to interfere with a favorable result, as the wound 
 afterward healed well. 
 
 Without either embracing or discarding the germ theory, this will often 
 be found to be an excellent dressing, though like all others it will sometimes 
 fail, even under the most favorable circumstances. 
 
 Alcohol Dressings. — Professor Nelaton was the first to make recognition of 
 this agent as a dressing for wounds, the discovery of which was the result 
 of investigations for some method to obviate the dangers of pyaemia. Quite 
 a number of distinguished surgeons have since used it, and some very favor- 
 able results have been obtained. 
 
 The wound should be dressed with a compress of lint, which is saturated 
 with about ninety per cent, alcohol. The effects are quite remarkable in 
 many cases, though of course not absolutely certain in all. The period at 
 which its inefficiency is most apparent is during suppuration, when it ap- 
 pears to delay the formation of a definite cicatrix. 
 
 The most markedly beneficial effects are that during its use it prevents 
 the symptoms of inflammation ; there is no redness, swelling, or heat, and 
 the pain is of a very moderate nature. The wound does not become putrid 
 in any of its parts, and constitutionally the patient has but slight febrile 
 reaction. 
 
 Bordeaux Dressing, so called by the professor of clinical surgery in 
 that city, Dr. Azam, who in 1874 described his method for the reunion 
 of wounds after amputation, which he claimed would cure the patient as 
 certainly as the occlusive method just described, and in a much shorter 
 space of time, the former taking from fifty to sixty days, while the method 
 of Dr. Azam occupied for the same purpose Only from ten to twenty-five 
 days. This is certainly an important point, and worthy of our earnest 
 attention. 
 
 After the operation has been performed, and all haemorrhage controlled 
 
lister's antiseptic method. 295 
 
 in the usual manner, a good-sized drainage-tube is laid in the deep portion 
 of the wound and fastened to the limb. The bases of the flaps are then 
 united with quilled sutures of fine silver wire, as many as are necessary to 
 hold the wound firmly, each from one and a half to two inches from the 
 edges of the flaps. The edges of the wound are then held together with the 
 figure-of-8 suture or harelip pins, supported by strips of charpie dipped 
 in collodion. The limb is then wrapped in wadding, except where the 
 drainage-tubes emerge, the ends of which are covered with charpie to absorb 
 the discharge. 
 
 The harelip pins may be removed on the second or third day, and the 
 deep sutures may be loosened then, or a day or two later. The dressings 
 should be renewed as in ordinary cases, and cicatrization will usually be 
 perfect in from ten to twenty -five days. Under Dr. Azam's care an ampu- 
 tation of the leg healed in eleven days, and one of the thigh in ten days. 
 
 There are, therefore, three important points to be observed in the applica- 
 tion of this method. 
 
 1st. A drainage-tube at the bottom of the wound, through which the blood 
 and serum run out. 
 
 2d. The deep sutures which are to hold in contact that portion of the 
 wound. 
 
 3d. The superficial sutures for the approximation of the margins of the 
 wound. 
 
 These latter had been used by the English surgeons towards the end of 
 the last century. Dr. Langier had proposed and applied the deep suture 
 twenty years before for the same purpose. The drainage system had also 
 been used by Drs. Broca, Fochier, and Courty previous to its adoption by 
 Dr. Azam, but he is entitled to the credit of having united the three methods 
 of drainage, deep, and superficial sutures, and originating a method which, 
 on account of its success, is certainly entitled to much respect. 
 
 The manner in which a wound heals by this method is as follows : The 
 margins and deeper parts unite by first intention. The inflammation 
 which is developed in the site occupied by the drainage-tube is quite mod- 
 erate, granulation becomes established upon the surface of the cavity, and 
 unites the muscular to the osseous structures, generally after quite a limited 
 amount of suppuration, and with a good chance of freedom from serious 
 complications. 
 
 In 202 amputations, 63 of which were of the lower limbs, there were but 
 12 fatal cases. 
 
 Lister's Antiseptic Method. — This method was introduced by Prof. Joseph 
 Lister, and first used by him in his hospital in Glasgow in 1868. Since that 
 time he has made some alterations and improvements, and still further 
 changes may be made in the course of time. It is only lately that attention 
 has been given practically in this country to the teachings of Prof. Lister in 
 regard to antiseptic surgery. 
 
 Much interest was elicited by his appearance at the International Medical 
 Congress in Philadelphia, in 1876, when he gave practical demonstration of 
 his treatment. Also from the fact that highly satisfactory results have been 
 obtained in the practice of many German surgeons with large hospital prac- 
 tice, it has come to be used by many of our surgeons. 
 
 There are some reasons, perhaps, why American surgeons, who have the 
 credit of eagerly adopting all improvements, have not earlier tested this 
 mode of treating wounds. One reason given is that it is " too much trouble," 
 another that " other modes of treatment give good results." 
 
 To these two objections Prof. Lister answers, "that the trouble is more 
 imaginary than real, and is one of the necessary results of a want of proper 
 
296 A SYSTEM OF SURGERY. 
 
 apparatus and appliances, together with inexperience as to their use, etc."* 
 To the second objection he grants " that they give good results but not the 
 best attainable." f 
 
 Still another objection might be given, namely, that it was declaring 
 one's self in favor of the germ theory. X 
 
 Thus Lister's definition of the antiseptic system is, " the dealing with 
 surgical cases in such a way as to prevent the introduction of putrefactive 
 influences into wounds."§ 
 
 However, " Thompson, Weitzelbaum, and others have stated that they 
 found living bacteria in the carbolic solutions as used by Lister, and Lin- 
 hart, Fischer, Ranke, Schuller, and Volkmann, who, in several hundred 
 observations, have found bacteria in the discharges of wounds that had been 
 most carefully and satisfactorily treated by the antiseptic method. 
 
 " It was noticed, however, that the presence or absence of these bacteria 
 (and such were only considered as present when chain bacteria were found), 
 did not influence the progress of the wounds, and Fisher gives the opinion, 
 in which many of his countrymen join, that the object of the dressing is 
 not so much to keep the germs away as to keep the secretions in such a 
 condition as to be as unfavorable as possible to the development of bacte- 
 ria, and thus prevent decomposition taking place." || 
 
 Mr. Lister says in reply to the observations above quoted : " The statement 
 that cell-forms have been found beneath antiseptic dressings must be re- 
 ceived with caution. I have recently met a gentleman who was with Ranke 
 in Halle when he found, as he supposed, these organisms beneath antiseptic 
 coverings, and when this gentleman pointed out to me the bacteria, which 
 he called putrefactive, I at once recognized them as of the non-putrefactive 
 variety, and the gentleman was forced to admit that they differed from those 
 found in decomposing masses. 
 
 " The germ theory of putrefaction is the foundation of the whole system 
 of antiseptic surgery, and if this theory is a fact, it is a fact of facts that 
 the antiseptic system means the exclusion of all putrefactive organisms."^" 
 
 It is desirable therefore that in the interests of science all possible knowl- 
 edge may be brought to bear upon the pathological and physiological changes 
 in connection with it. Be this as it may, we cannot afford to wait until it is 
 fully explained, but must acknowledge that the antiseptic method is one full 
 of marked success. On this point the voice of those who have successfully 
 used it is unanimous. 
 
 Hagedorn, of Magdeburg, says that in every failure the surgeon himself 
 is to blame, and not the method, and Lindpainter, representing the expe- 
 rience of Munich with nearly a thousand cases treated antiseptically, states 
 that it must be considered a precept that the minutest directions must be 
 followed, and that he who does not get the results desired must certainly 
 have made some mistake.** 
 
 We must constantly bear in mind that the principal object of this method 
 
 * Trans. International Medical Congress. f Ibid. 
 
 J The following is an excellent and concise explanation of the germ theorv as given by 
 K. F. Weir, M.D., in the K Y. Journ. of Med., December, 1877. That in the dust of the 
 atmosphere, and in matter with which it is in contact, there are germs of minute organisms, 
 which under favorable circumstances induce putrefaction in fluids and solids capable of that 
 change, in the same manner as the yeast plant occasions alcoholic fermentation in a sacchar- 
 ine solution ; that putrefaction is not occasioned by the chemical action of oxygen or other 
 gas, but by the fermentative agencies of these organisms ; that the vitality or potency of the 
 germs can be destroyed by heat or by various chemical substances which in surgery are called 
 " antiseptics." 
 
 \ Trans. International Medical Congress, Philadelphia, 1876, p. 536. 
 
 || Antiseptic Treatment of Wounds and its Results. — Weir. 
 
 \ Lister, Trans. International Medical Congress, p. 538. ** Weir. 
 
LISTER'S ANTISEPTIC METHOD. 
 
 297 
 
 Fig. 120. 
 
 is to prevent the entrance of germs into wounds, to destroy them if already 
 there, and to guard against the accumulations of wound secretions. In 
 order to accomplish this, Mr. Lister has instituted a method of treatment, 
 upon which he has on different occasions made some improvements, by which 
 he proposes to prevent the injurious effect of these germs upon wounds. 
 
 The various articles and the manner in which they are to be used will 
 now be taken carefully into consideration. 
 
 1st. A solution of carbolic acid crystals in water in the proportion of 1 
 to 20. This is used to carefully cleanse the surface before operations or the 
 neighborhood of wounds, to disinfect the hands of the surgeon and his assis- 
 tants, to wash out septic wounds, inject into compound fractures, and clean 
 drainage-tubes. A basin of the solution of this strength should contain all 
 the instruments which are to be used in the operation. " A solution of 
 this strength is also required for the spray when a steam atomizer is used."* 
 
 2d. A solution of carbolic acid crystals in water in the proportion of 1 to 
 40 " for the sponges during the course of an operation,"* to wet the " loose 
 layer of gauze, and for the lotion when changing the dressings. "f 
 
 3d. A Steam Spray Apparatus. — In order to prevent the entrance of living 
 germs during an operation or dressing, a spray of the solution of carbolic 
 acid in water is used directly and 
 constantly upon the parts. Some 
 instrument which throws a large 
 and finely divided spray should 
 be used. A steam atomizer (Fig. 
 120) is indispensable on account 
 of the necessity of keeping up an 
 uninterrupted application of the 
 spray; for one worked by hand 
 would become too fatiguing. A 
 boiler containing 20 to 24 ounces 
 will give a spray for about two 
 hours. It is said that atomizing 
 the solution renders it weaker, so 
 that some use a 1 to 30 solution, 
 which, when in the form of a spray, 
 will be about 1 to 40. 
 
 It is often necessary to be pro- 
 vided with two apparatuses, so 
 that if for any reason one should 
 cease working, the other will be at 
 hand. Fig. 121 represents the 
 atomizer of Dr. Weir. 
 
 4th. The Protective is ordinary 
 oiled silk, coated with copal var- 
 nish to render it impermeable to 
 carbolic acid, which gutta-percha 
 is not ; it is then covered with a 
 thin coating of dextrin, 1 part ; starch 
 1 to 20, 16 parts. 
 
 Hank's Atomizer. 
 
 2 parts ; and carbolic acid solution, 
 After this last application the disinfecting solution will 
 
 * Vide Letter from Prof. Lister to J. L. Little, M.D., of New York, in Hosp. Gaz., May 
 9th, 1878. 
 
 f Although Mr. Lister and many of his followers have discarded the spray, yet, as there 
 are still some in the profession who employ it, I have thought best to allow the directions for 
 generating it to remain in this edition, although in my own practice 1 now never employ 
 it ; substituting therefor a carbolic vapor from a large kettle containing a boiling solution 
 1 to 40 carbolic acid water. 
 
298 
 
 A SYSTEM OF SURGERY. 
 
 the better adhere to the protective. It should always be immersed in a 1 
 to 40 solution previous to being used after an operation. The object of the 
 protective is to prevent the irritating effect of the carbolic acid contained 
 in the antiseptic gauze to the part operated upon. The protective should 
 slightly overlap the wound. 
 
 5th. Antiseptic Gauze. — This is made of a coarse-meshed, unstarched cotton 
 cloth, which in Scotland is called " mull," but here is called dairy or cheese 
 cloth. This was selected by Mr. Lister on account of the facility with which 
 the secretions are absorbed by it. Mosquito-netting has also been put to 
 the same purpose after a careful preparation. 
 
 The mode of preparation is to heat the cloth for several hours beyond 
 212°, it is then sprinkled with a hot mixture, composed of carbolic acid, 
 1 part ; resin, 5 parts ; paraffin, 7 parts. The cloth is then submitted to 
 
 Fig. 121. 
 
 Weir's Atomizer. 
 
 pressure so that the mixture will be equally distributed through it. The 
 resin is excellent to hold the carbolic acid, and prevents its too speedy 
 evaporation, and the paraffin prevents it from being sticky. 
 
 In using the gauze, it should be wet with the carbolized solution, 1 to 40, 
 folded in eight thicknesses, placed next above the protective, and slightly 
 overlapping it. Between the seventh and eighth layers from the skin, should 
 be inserted a piece of mackintosh. 
 
 Dr. W. T. Bull has recommended, that thymol should be used instead 
 of carbolic acid, principally on account of its being less irritating ; but one 
 solution is required, and that is, thymol, 1 part ; alcohol, 10 parts ; glycerin, 
 20 parts ; water, 1000 parts. 
 
 The gauze is also prepared with it as follows : thymol, 16 parts ; resin, 50 
 parts ; spermaceti, 500 parts. In using this gauze " the protective " oiled silk 
 may be omitted ; the other minutiae are the same. 
 
 6th. Mackintosh is common rubber cloth ; this prevents the secretions from 
 coming immediately to the surface, so that the whole dressing is saturated 
 with the discharge, which is thus kept in contact with the antiseptic. 
 
 This should be cut an inch smaller than the gauze, so that when the se- 
 cretions come to its outer layers they may be detected while they are still 
 in the antiseptic gauze. 
 
 It is not necessary to have a new piece of mackintosh at each dressing 
 but it may be washed off with carbolized water and used again, but it 
 should be held up to the light each time, so as to detect any holes or im- 
 perfections. 
 
299 
 
 7th. Drainage-tubes are small tubes of soft rubber, made of different sizes. 
 They should have several openings on the sides to facilitate the egress of 
 the secretions from the parts which they are intended to drain. Two small 
 ones will be better to use than one large one, as they will not cause the 
 wound to gape so much. Each pocket or angle of the wound should have 
 its drainage-tube, and it should extend down to the bone ; they should be 
 cut off on a level with the skin, either square or bevelling, and sewed with 
 a piece of silk drawn through the end, which should be fastened externally 
 with a piece of plaster, so that the tubing may not be lost by slipping into 
 the wound. Several strands of catgut may be used for drainage instead of 
 the rubber tube ; these can be withdrawn one or two at time, if desirable, 
 as the wound closes. A small bundle of horse-hairs is the latest article 
 used for drainage by Prof. Lister.* (See page 43.) 
 
 8th. Catgut, as used for ligatures and deep sutures, is one of the principal 
 articles in antiseptic dressings. The edges of wounds approximated by this 
 substance heal readily; the catgut becomes absorbed without producing 
 any irritation. 
 
 It is prepared by putting it in a mixture of carbolic acid, made liquid by 
 one-tenth its weight of water, to which is added five parts of olive oil. The 
 catgut should be kept separate from the watery part of the mixture, and 
 this is best done by placing some marbles or pebbles in the bottle and laying 
 a piece of glass on them ; this will raise the catgut above the water ; they 
 should remain in this manner two months without being disturbed. 
 
 At the meeting of the International Medical Congress, held in 1876, Mr. 
 Lister announced that he had made more satisfactory ligatures by a mixture 
 of carbolic acid, glycerin, chromic acid, spirits of wine, and water ; the exact 
 formula has not yet, however, been made known. 
 
 9th. Antiseptic Silk. — The catgut is used for ligatures and the deep 
 sutures, but as it does not retain its firmness long enough for superficial 
 sutures, silk antiseptically prepared is preferable. It may be prepared by 
 immersing the silk for an hour in a mixture of hot beeswax, 10 parts ; car- 
 bolic acid crystals, 1 part. It should then be drawn through a cloth to 
 remove the superabundant wax. It may then be kept in a well-stoppered 
 bottle. 
 
 10th. The Sponges used in Lister dressings, whether during the operation 
 or for the absorption of secretions, should be thoroughly beaten, then washed 
 in warm distilled water, and kept covered in a jar filled with a carbolized 
 solution 1-20 until needed. After being used they may be washed out in 
 a solution and replaced in the vessel. In this manner they can be used re- 
 peatedly. In addition to small sponges used during the operation, it is 
 well to have some larger ones, which may be applied to wounds the first 
 day after the operation, to absorb the secretions, which are made copious 
 by the application of the spray. 
 
 11th. Carbolized Olive Oil, lto 20, is used to oil catheters and other in- 
 struments ; or the fingers, when necessary to introduce them within the 
 body. 
 
 It is also useful where a direct and continued application of the antisep- 
 tic is required to the wound, as, for instance, in cases of caries, or where it 
 would not be possible to apply the gauze dressing ; also in order to avoid 
 some of the irritating and caustic effects of the spray upon the operator's 
 hands. 
 
 12th. Liq. Zinci Chlor., 1 part mixed with 12 parts of water, may be used 
 in cases of compound fracture, or in any case where a wound has been ex- 
 posed to atmospheric influences, or where a wound which has been dressed 
 
 * Medical News and Library, February, 1878. 
 
300 A SYSTEM OF SURGERY. 
 
 antiseptically has become septic, it may then be rendered aseptic by being 
 washed out with this solution ; but great care is necessary in its use, and it 
 is generally a more successful way to scrape out sinuses or caries in bones 
 before applying this article. 
 
 The writer has purposely omitted mentioning the varied preparations of 
 boracic and salicylic acids, as used by Prof. Lister, in order not to unneces- 
 sarily extend the limits of this chapter. 
 
 After all of the articles above described have been made ready,, if there 
 be any hair on the part to be operated upon, it should be cleanly shaved off. 
 The skin should then be washed with soap and warm water with a brush. 
 The anaesthetic may then be administered, and, when complete, the spray 
 should be directed upon the part. The surgeon's and assistants' hands are 
 now to be thoroughly immersed in the 1 to 20 solution, and a final washing 
 given to the skin. The instruments, having been immersed in a basin of 
 the same solution, should be carefully wiped and returned to it after being 
 used. The blood is wiped away with the prepared sponges, which are 
 ready in another basin of the solution, and after being thoroughly squeezed 
 should be put in the basin again. 
 
 Care must be taken by the operator and the assistant who has charge of 
 the spray apparatus not to allow any one's hands to come between the cone 
 of spray and the wound. 
 
 The bleeding vessels are secured in the usual manner, and tied with the 
 antiseptic catgut ligatures, and both ends cut off close. 
 
 A piece of gauze should be lying in carbolized water, so that in case the 
 atomizer for any reason ceases to work, it would be ready to throw over the 
 wound until the spray could be resumed, and for this reason it is always 
 well to have two instruments at hand. 
 
 After the operation is completed, the tourniquet or Esmarch's bandage, 
 whichever has been used, may be removed. There is generally some haemor- 
 rhage, owing to the fact that the spray prevents the formation of clots. All 
 bleeding must be stopped, the wound carefully washed out with the 1 to 
 40 solution, the drainage-tubes may then be put in their places and secured 
 as before directed, and the sutures introduced ; the deep with carbolized cat- 
 gut, the superficial with the antiseptic silk. 
 
 The wound is then to be covered with a piece of the protective which has 
 been lying in the carbolic solution of 1 to 40, and this covered with a single 
 layer of gauze, wet in the same solution ; this should be a little larger than 
 the protective, so as to overlap it on all sides ; if much depression exists, as 
 after the removal of a tumor, one of the large sponges which has been pre- 
 pared may be placed between the protective and loose layer of gauze. The 
 spray may now be dispensed with. The eight layers of gauze are then to be 
 applied, either wet or dry, as may be desired, remembering to insert between 
 the seventh and outer layers, a piece of mackintosh, with the rubber side 
 down, cut one inch smaller on all sides than the gauze. The whole of this 
 dressing is to be retained with bandages made of strips of the gauze. When 
 the wound is large, or the discharges are likely to be excessive, a thicker 
 dressing may be put on. 
 
 The first dressing should generally be removed not later than twenty-four 
 hours, sooner than that if the discharge appears anywhere on the surface ; 
 but Mr. Lister says that when the oiled silk protective is used, " a wound 
 need not be opened for a week ;" however, when there is an oozing at any 
 part, undue pain, or an increase in the patient's temperature, the dressings 
 should at once be removed, always under the spray, which should be care- 
 fully directed towards the parts until the wound is covered again. " If the 
 protective is unchanged in color, the wound is certainly aseptic ; if it is not, 
 
301 
 
 it will show dark-brownish spots, the result of the action of the liberated 
 sulphur upon the lead in the oiled silk. This only holds good of incised 
 wounds. In contused wounds the changes of color are met with, even 
 though the wound is doing well." (R. P. Weir, op. cit.) Whenever the 
 protective is discolored, the wound must be treated like a septic wound, 
 either with the carbolized solution or the chloride of zinc. 
 
 If the wound has remained aseptic, washing it is to be carefully abstained 
 from, and the drainage-tubes not removed until the third or fourth day, 
 unless one becomes choked up, when it should be carefully taken out and 
 washed with the 1 to 20 solution, and replaced according to the granulation 
 of the wound ; the surrounding parts may be gently cleansed with a sponge. 
 The feelings of the patient and the staining of the dressing are good indi- 
 cations of the necessity for making changes, but the best is the temperature 
 of the body. When this is normal and the protective unspotted, we may be 
 certain that our dressings are correctly applied, that the wound is doing 
 well, and needs no interference. 
 
 When the patient shows an increase of temperature over the preceding 
 examination, it becomes positively necessary to remove the dressings and 
 examine the wound, when it will be found that the drainage-tubes have 
 either become clogged, or else that they have not perfectly drained the 
 wound, and the introduction of another tube, or washing the wound out 
 with the carbolic solution, by means of a syringe, will correct the septic 
 condition, and the relief will be shown by a fall in the temperature. 
 
 Prof. Lister keeps the drainage up until the wound is nearly if not quite 
 healed, shortening them as often as is necessary. In reapplying the dressing 
 everything had better be changed. The piece of mackintosh may be used 
 again, after having been thoroughlv washed in a carbolic solution of 1 
 to 20. 
 
 For wounds to which this method is to be applied, and which have ex- 
 isted for some time before coming under observation, such as compound 
 fractures and lacerated wounds, the procedure must be somewhat different 
 from that already described. If it is a compound fracture, the external 
 parts must be thoroughly cleansed, and the wound explored under the 
 spray, the loose fragments of the bone removed, and the cavity syringed 
 out with the carbolized solution 1 to 20, or, as Mr. Lister has lately used, 
 carbolic acid, 1 part to 5 of alcohol, thrown into the wound with a syringe. 
 Drainage-tubes are then inserted up to ends of the bone and the bottom of 
 the wound ; after this the protective and other dressings are to be applied as 
 usual. In all cases the spray is to be continued until the parts have been 
 covered by the protective. For wounds which have been brought to the 
 surgeon in a suppurating condition, or those which " have failed to remain 
 aseptic," it is necessary to resort to another procedure, and that is the appli- 
 cation of the solution of chloride of zinc, as already described. However, 
 when wounds treated from the first by this method have become septic, the 
 experience of those who have used this method extensively, goes to show 
 that there has been some error in making the dressing. 
 
 The presence of pus is not decisive of the failure of this method ; but the 
 odor that arises from it, also the brownish spots on the protective, indicate 
 that a septic action has taken place, for dressings which remain aseptic are 
 always without any odor. The antiseptic treatment does not always pre- 
 vent the formation of pus, though it may be desired, and Mr. Lister himself 
 does not regard putrefaction as the only cause of suppuration. 
 
 The results which have been obtained by this method of dressing wounds 
 is a matter of the deepest interest to surgeons, and much has been written 
 on the subject The views of Prof. Lister are not confined to his pupils 
 
302 A SYSTEM OF SURGERY. 
 
 alone, but are embraced by men of high standing as surgeons, like Volk- 
 mann, Thiersch, Locin, Nusbaum, and many others. 
 
 Its advantages, therefore, are sufficiently vouched for to render it the duty 
 of every one having, the charge of surgical cases to give it a careful trial, 
 especially in hospital practice. 
 
 CHAPTER XVI. 
 
 A CONCISE REVIEW OF THE ANTISEPTIC SURGERY OF 
 
 THE PRESENT. 
 
 Having gone over the varied methods of dressings in the last chapter, and 
 having considered the subject of antiseptics in the chapter upon " Disinfec- 
 tion and Antiseptics," and having also occasion to allude to them in both 
 the chapter on "Minor Surgery" and the "Ligation of Arteries," as well 
 as in the manner of " dressing wounds," and in view also of the many 
 changes in opinions and practice in regard to antiseptic surgery, it would 
 appear eminently proper that a chapter bearing the above title should be 
 inserted in this place. 
 
 With the varied discussions relative to the germ-theory and the labors 
 of Pasteur, Schwan, Schroeder, Dusch, Roberts, Drysdale, Koch, Spina, 
 Peter, and many others, this chapter has nothing to do, nor will its author 
 undertake to detail the many very careful and prolonged experiments that 
 have been made to ascertain the true nature of the micro-organisms that 
 inhabit the atmosphere (whose presence yet causes and has heretofore de- 
 veloped such disastrous effects during the treatment of wounds), only in so 
 far as the opinions of the distinguished authors bear upon the question 
 which forms the subject of this chapter. 
 
 In the outset, then, we draw a distinct line of demarcation, between what 
 is known as " antiseptic surgery " and " aseptic surgery ;" the former being the 
 treatment of all wounds by the best methods of preventing putrefaction and 
 the consequent infectious diseases, the surgeon employing any of the so- 
 called antiseptics in any way most in accordance with his opinion; while 
 the latter (the " aseptic method "), will be considered as synonymous with 
 " Listerism" the sheet-anchor of which is carbolic acid, and main-stay, " com- 
 plete occlusion of the wound." This portion of the subject, with its details, 
 has been fully considered in the last chapter. 
 
 The majority of surgeons at present, I think, are of the opinion that most, if 
 not entirely all germs come from without, either by the means of instruments, 
 the hands of the operator, or by floating from the surrounding atmosphere, 
 and that if these be perfectly excluded many complications will be avoided, — 
 perfect disinfection of the whole wounded surface and the complete exclusion 
 of air being the two main conditions upon which the aseptic treatment rests. 
 
 There are three parties, however, at present in dispute regarding the 
 theory of both the antiseptic and aseptic methods, and although all appear 
 to agree that the introduction of the aseptic (Listerian) method, has been 
 productive of a vast amount of good, the one side are disposed to believe 
 that these results are obtained by simply care and cleanliness, while another 
 attributes them to the distinctive power that carbolic acid has upon bac- 
 teria, spores, micro-organisms, and germs of all kinds, while again a third 
 are of the opinion that the acid itself has some peculiar inherent power over 
 the varied processes of repair. 
 
 There is, however, another point which is claimed by true antiseptic sur- 
 
THE THEORETICAL ASEPTIC METHOD. 303 
 
 gery, which exists in the fact that a really true antiseptic not only should 
 exclude all septic ferments from the wound, but should be capable (as Dr. 
 Chein says *) of rendering inert the causes of putrefaction. 
 
 Let us first, then, consider the aseptic method as briefly as possible. That 
 the entire surgical world is indebted to Mr. Lister for the antiseptic method 
 of treating wounds, there can exist no doubt, and that, following his ex- 
 ample and his teaching, most minute carefulness and perfect cleanliness 
 have succeeded carelessness and filth, especially in hospital practice, is also 
 well authenticated. That the results he has obtained in the treatment of 
 wounds under his care, are remarkable when compared to the older method, 
 is true. The practical value of his teaching in saving human life and pre- 
 venting an immense amount of human suffering, is a fact which cannot be 
 gainsayed. While, therefore, I think the majority of the profession at the 
 present day are willing and ready to accord to the aseptic method a vast 
 practical improvement in its results, yet there is a wide difference of opinion 
 regarding what I may term " Theoretical Listerism." 
 
 The first main proposition in this system is the perfect and complete 
 acceptance of the germ-theory of putrefaction, viz., that bacteria floating in 
 the dust of the atmosphere not only infect the wounded surfaces, but enter 
 into the tissues, deeply poison the whole mass of blood, and produce rap- 
 idly those infectious diseases known as septic ; that these micro-organisms 
 are the only sources of putrefaction, and that carbolic acid is the substance 
 par excellence which is to be relied upon as most potent in preventing the 
 entrance of these destructive bacteria, and offering obstacles more or less 
 complete, to the fermentations which these particles would otherwise occa- 
 sion. This, in a word, is the theoretical Listerism, practioal Listerism being 
 the preparation of no less than twenty-one articles, which, as Mr. Chein in 
 the Encyclopaedia of Surgery says, will be necessary for each dressing. Many 
 of the articles mentioned are in the plural, which in themselves cumber 
 very materially the room, and require a long time for their preparation, and 
 considerable expense for procuration. 
 
 The Theoretical Aseptic Method. — It is in this, as I have already said, that 
 a wide discrepancy of opinion prevails, for while no one at the present day 
 can deny the germ-theory of certain diseases (and it appears from very recent 
 experiments that additional evidence can be adduced in its favor), yet many 
 do deny that germs are the sole agents of putrefaction. I may here by way 
 of parenthesis remark that one of the best received and most carefully pre- 
 pared works on the germ-theory of disease has issued from the pen of my 
 esteemed friend, Dr. Drysdale, of Liverpool, for a long number of years one 
 of the editors of the veteran British Journal of Homoeopathy. 
 
 The question now is, are there no other influences than the presence of 
 germs to account for the obstreperous deportment of wounds, and does this 
 bad behavior always arise (as Mr. Lister and his followers strictly contend), 
 solely from the presence of bacteria ? 
 
 In the present status of antiseptic surgery, it can be shown without doubt 
 that these very bacteria, instead of being in all cases hurtful, are indeed 
 beneficial, and while they may be in many instances the essential agents in 
 fermentations, decompositions and putrefactions, at the same time they 
 may be important factors in the maintenance of health. 
 
 A large proportion of our food is prepared by saprophytes. To bacteria 
 we are indebted for butter, cheese, vinegar, and even bread, wines, beers, 
 and spirituous liquors. In fact, the tremendous influence of these organ- 
 isms in consuming the waste thrown off from the animal and vegetable 
 kingdom is indeed astounding ; were it not for these, the debris would not 
 
 * Chein, Antiseptic Surgery, p. 13. 
 
304 A SYSTEM OF SURGERY. 
 
 be consumed, and would accumulate as a tremendous load upon the earth. 
 Animals would be overburdened by their own excrement, and plants die 
 for want of nutriment. Therefore, looking at the germ theory in this light, 
 there is reason to doubt theoretical Listerism. 
 
 Again, certain varieties of bacteria, under peculiar circumstances, are 
 absolutely of service in the process of repair. At the present time, there are 
 many renowned surgeons who, I think, would give testimony in favor of such 
 a statement. 
 
 Dr. William Hunt, senior surgeon to the Pennsylvania Hospital, thus 
 speaks : " Having noticed wounds healing kindly under masses of maggots, I 
 reflected that they were scavengers, eating only dead materials, and so con- 
 verting harming matter into harmless living substance. We have to get rid 
 of them, it is true, because they will persist in getting into wrong places, 
 and so give an infinite amount of trouble. To my mind" further says Dr. 
 Hunt, and he italicizes the words, " there is no positive proof as yet of the or- 
 ganisms being specific and primary in their operation" and further on he says, 
 and backs up his opinions by no less authorities than Formad and Dr. Joseph 
 Leidy, " No micro-necrosis, no micro-maggots ; that is food mostly in the 
 shape of necrotic products precedes the advent of the micro-organisms ; 
 however these may originate, whether animal or vegetable, and in disease 
 these necrotic products, first, plus the micro-organisms, second ; play havoc 
 with their environment." Formad says, "The presence of bacilli (so far 
 as our present research goes) is secondary, and appears to condition the 
 complete destruction of the tissue already diseased and infested by them, 
 and this destruction is in direct proportion to the quantity of the organisms 
 which thus regulate the prognosis." 
 
 According to this view of the theory, bacteria are useful in some instances 
 and hurtful in others, and a still more singular fact has been noted by 
 Kocher, who says, u In different forms of inflammation different forms of 
 organisms come into action, and the different changes in a wound cannot 
 be laid to the same coco-bacteria." And again, our friend, Dr. Drysdale, 
 also has proved that there is a specific parasite for almost every human 
 tissue. Therefore, to account for every variety of septic poisoning by the 
 presence of micro-organisms cannot at the present be tenable. This may 
 be proven by the fact that the most minute attention to all the details of 
 Listerism does not completely exclude bacteria, for they have been found 
 ici the best dressed and healthiest wounds, even, I believe, in carbolized cat- 
 gut ligature ; they have also been discovered in wounds proceeding rapidly 
 to adhesion. " Billroth and Ehrlich, after careful experiments, declare that 
 no difference is discoverable in the putrefaction of blood drawn directly 
 from an artery and sealed up under spray and that taken without such 
 protection." Besides, if mere bacteria acted as a pyaemic poison as self- 
 producing and in the minimum dose, like the poison of rabies, syphilis, and 
 small-pox, nobody could survive the smallest cut or abrasion, and vaccina- 
 tion and subcutaneous injection would be certain death.* As Dr. Hunt 
 also says, if these organisms are specific and primary, " I do not compre- 
 hend how any of us are alive." 
 
 Dr. Bryant also writes in his latest work, " I am no convert as yet to the 
 theory on which it (Listerism) is based, nor to the great value of the special 
 practice based upon it, neither is it yet proved. It is much to be regretted, 
 that the originator of the system should not have listened to the repeated 
 requests of surgeons to publish the results of his practice as a whole, since 
 it can be by such alone that the value of the method is to be estimated. "f 
 And again, Markoe, of our country, in a valuable paper on " Through 
 
 * Drysdale, Protoplasm, p. 45. f Bryant, Practice of Surgery, p. 792. 
 
THE THEORETICAL ASEPTIC METHOD. 305 
 
 Drainage in the Treatment of Wounds,"* says that, though he is a firm be- 
 liever in many of the most important doctrines connected with the germ 
 theory, he certainly is of opinion that there are very many other causes 
 which may excite "the ill-behavior of wounds." 
 
 Dr. Lawson Taitf writes : " The basis of Lister's theory of putrefaction 
 by means of bacteria had long ago been proved beyond dispute as regards 
 dead matter. But Mr. Lister assumed for living matter the same sequence 
 of events as in the case of the dead." 
 
 Again, it has been proven that symptoms in appearance, progress, dura- 
 tion, and results exactly similar to septicaemia, have been produced by in- 
 troducing fibrin ferment into the blood in considerable quantities, that 
 pepsin and ptyalin produced similar symptoms, and from these facts Dr. 
 W. T. Bellfield, in his valuable Cartwright Lecture,! states positively that 
 recent experiments have demonstrated " that the aetiology of the growth of 
 clinical and anatomical appearances, known as septicaemia, is by no means 
 restricted to putrid infection." 
 
 These references are sufficient to show that there are wide differences of 
 opinion regarding the theoretical aseptic or Listerism methods ; let us look 
 to that which concerns us more closely, viz., the practical results of the 
 method. 
 
 Those at all conversant with surgical literature must acknowledge 
 that Mr. Lister has roused the medical and surgical world to the proper 
 application of thorough disinfection and perfect cleanliness, and by his 
 praiseworthy and persevering efforts has wrought a complete revolution 
 in the treatment of wounded and abraded surfaces. The most skeptical 
 as to the theory are compelled to acknowledge the beneficial results of the 
 practice, and I think I may say, that in private or in hospital routine 
 work at the present day, any surgeon would appear derelict in his duty did 
 he not employ some variety of the antiseptic method. 
 
 The details of Listerism, however, as I have already stated, are cumber- 
 some and trying, both to the patient and to the time of the surgeon, and 
 therefore many of the minutiae, which at one time were deemed essential, 
 are now omitted altogether, or applied in a very modified form, with most 
 excellent results. Notably is this the case in the application of the spray, 
 which has been not only abolished by many, but by some is deemed abso- 
 lutely hurtful. 
 
 Lister, himself, has modified his opinion with regard to the strength of 
 his carbolic acid solutions, using first a spray of 1 to 100, and now 1 to 20 ; 
 for sponges, a solution of 1 to 40, and it is stated by Delacroix that 10 per 
 cent, of carbolic acid is required to destroy bacteric life. He says :§ " It 
 would not at all break my heart if I were told that I should never be allowed 
 to use the spray again in my life,*and I am satisfied I could, by other means, 
 get equally the same results." He also goes on to express himself very 
 much in favor of corrosive sublimate dissolved in glycerine, which prepara- 
 tion, he thinks, has never been mentioned before, and which he considers 
 " a new fact in chemistry." It may be said, therefore, that as there are 
 means of causing putrefaction other than the bacteria floating in the dust 
 of the atmosphere, and as (as already has been stated) different inflamma- 
 tions are attended by different forms of bacteria, and as the resistant power 
 of bacteria is not always the same (that of the reproductive spores being 
 much greater than fully developed bacterial products), and as also Dr. 
 
 * American Journal of the Medical Sciences, April, 1880, p. 309. 
 
 f Loc. tit., July, 1882, p. 267. 
 
 % Medical Record, March 3d, 1883, p. 227. 
 
 I British Medical Journal, February 23d, 1884. 
 
 20 
 
306 A SYSTEM OF SURGERY. 
 
 Weir writes, " it must be admitted by the most devoted advocates of the 
 Listerian system, that the dressings applied with the strictest attention not 
 infrequently fail in arresting the progress of putrefaction," — that the good 
 results so widely acknowledged, must be explained by other than the Lis- 
 terian theory. Again, Kocher, Volkman's assistant, is of opinion that the 
 same antiseptic measures cannot be used in the treatment of all varieties of wounds* 
 and the same surgeon after fully admitting that many wounds heal well by 
 the carbolic acid treatment, says : " I have seen colleagues who tena- 
 ciously hold to the spray with all the attributes which hold to the Lister- 
 Volkman technique, have here and there the most grave cases of infection 
 after complicated operations ;" and as Drs. Hunt and Formad have stated 
 that in many instances the micrococci seem to be increased in the proportion 
 to the necrosis of the tissue ; may it not be a fact that carbolic acid (as 
 indeed do many medicinal substances) has a peculiar action upon certain 
 forms of bacterial life, in the one case causing the total annihilation of the 
 organisms, in another but partially affecting them, while perhaps in a third 
 variety they resist the action altogether ? In other words, a specific action 
 of carbolic acid is found in one class of cases, and, perhaps, these are in the 
 majority, while in another, it is of no avail. 
 
 In looking over Mr. Chein's work on Antiseptic Surgery, and comparing 
 Mr. Lister's own statistics, it will be found that the best and most surprising 
 results were obtained by Mr. Lister in his method of treating diseases of the 
 joints. Why, then, as different micro-organisms belong to different inflam- 
 mations and tissues, may not carbolic acid be particularly applicable to 
 those affecting the synovial tissues of joints ? 
 
 Again, there are other thoughtful men, who, believing, in a measure, as I 
 do myself, in the bacterial agency in the production of putrefaction, see 
 in the good results that are often observed from the use of carbolic acid, 
 something more than the mere destruction of bacilli, and give a large share 
 of the efficiency of the drug to its action upon the tissues themselves. 
 
 Dr. Markoef says, " My attention once directed to this point, I think I 
 have verified this power which I claim carbolic acid possesses, of modifying 
 vital action in many striking instances. I have watched many commencing 
 surface inflammations rapidly diminish and disappear under carbolic dress- 
 ing, when no exclusion of germs was attempted. I have seen wounds of all kinds 
 and degrees of severity go through their stages of repair without a trace of 
 inflammatory complication, and even when inflammatory complications 
 had not been prevented. I have seen the morbid actions which threatened 
 infinite mischief, so modified and controlled by carbolic acid constantly 
 applied as to be practically robbed of their usual power to inflict damage." 
 It is needless here to note the opinions of Oilier, Tillaux, Weir, Beal, and 
 others, but I may say that these views have been for the past six years 
 entertained by myself, indeed, since the perusal of a pamphlet by John 
 Dougall, M.D., of Glasgow.]; I immediately endeavored to look for some other 
 power in carbolic acid in the treatment of wounds besides its virtues as a 
 mere germicide. In his paper, Mr. Dougall says, " If, as is alleged, germs 
 are the source of putrefaction, then the strongest preventives must be the 
 best antiseptics, and vice versa. Now, as seen in the table, carbolic acid 
 
 occupies a very mediocre place, and although unable to formulate 
 
 the change that takes place, when it unites in large proportion with organic 
 bodies, for which it has a strong affinity, still the result of such change 
 certainly is the formation of a compound capable of resisting the attacks of 
 
 * Volkman's Klinische Vortage, November, 1882. 
 f American Journal of the Medical Sciences, April, 1880, p. 314. 
 
 X The Relative Power of various substances in Preventing the Generation of Animalculse, or 
 the Development of their Germs, with Special Reference to the Germ Theory of Putrefaction. 
 
ANTISEPTIC METHOD. 307 
 
 oxygen, of water, and consequently of germs. In other words, a compound 
 is formed which is proof against putrefactive tendencies." 
 
 If, now, we take also into consideration the valuable experiments of 
 Prudden,* which appear to show that strong solutions of carbolic acid cause 
 immediate cessation of amoeboid motion and death of the cells, and that 
 very dilute solutions may cause a temporary cessation of the movement, 
 and not the death of the white blood-corpuscles, it would appear that the physio- 
 logical action of carbolic acid may have a great deal to do with the results 
 which have been obtained by its use in the treatment of wounds. It would 
 be interesting to enter upon the details of " carbolic acid poisoning" but want 
 of space forbids. 
 
 Antiseptic Method. — Having now given sufficient consideration to the 
 aseptic method, the second division of the subject, viz., u The Present Status 
 of Antiseptics," claims serious attention. 
 
 Here at once a wide field opens to the student, and a cursory glance at 
 medical literature for the past three or four years will show beyond cavil, 
 that the universal antiseptic has not yet been discovered, nor will such a 
 panacea lapsorum, in my mind, ever be revealed. I have no doubt, however, 
 that the time will come when a more thorough understanding of the actions 
 of the so-called antiseptics will be arrived at, and that the surgeon may then 
 be enabled to select certain drugs or certain chemicals which, beside having 
 antiseptic properties, may be peculiar^ adapted to the process of repair as 
 taking place in the different structures of the human body. 
 
 I think it may be affirmed at the present that while the aseptic or Listerian 
 method, or certainly portions of it, which were formerly deemed essential, 
 are gradually being done away with, yet that antiseptic treatment is being 
 more thoroughly investigated. This may be judged even by a cursory 
 review of the treatment of wounds in hospitals as well as in private prac- 
 tice. 
 
 The spray, I think, is almost abolished in the majority of hospitals, and 
 many antiseptics, other than carbolic acid, are employed by surgeons in all 
 parts of the world. It is well known that Mr. Savory, senior surgeon to St. 
 Bartholomew's, the largest of the London hospitals, rejects the antiseptic 
 treatment and relies upon cleanliness alone, and very ably has defended his 
 position, although Mr. Chein, in his work, states that the Savory treatment 
 was in some degree antiseptic. 
 
 Mr. Lawson Tait, as has already been mentioned, is no advocate for the 
 antiseptic method in ovariotomy, and we find, so late as May of this year, 
 1886,f a most surprising record, viz., one hundred and thirty-nine consecu- 
 tive cases of ovariotomy performed in a year without any Listerian details, 
 without a single death. Mr. Tait states that he would stuff his pads with 
 germs properly prepared. His increased success he attributes to the im- 
 proved methods of operating, to his more extended experience, and espe- 
 cially the complete abandonment of the use of carbolic acid or any other disinfect- 
 ant, and the establishment of hospital discipline and hygiene on the best 
 known principles. 
 
 Bantock,! also of the Samaritan Hospital, operates without spray. 
 
 Dr. Keith,§ it is well known, spoke his mind in the surgical section of 
 the London Congress when he said, that after having a succession of eighty 
 successful cases, he had five deaths in the next twenty-five cases, two of 
 which were from carbolic poisoning, one from septicaemia, and two from 
 acute nephritis. He had abandoned the spray in all operations, and in 
 
 * American Journal of the Medical Sciences, January, 1881, p. 96. 
 
 f British Medical Journal, May 15th, 1886. 
 
 X Medical Eecord, March 10th, 1883. 
 
 | Lancet, August 13th, 1881. 
 
308 A SYSTEM OF SURGERY. 
 
 the last twenty-seven ovariotomies without any antiseptic treatment, he had 
 lost but one patient. 
 
 Holmes, at St. George's Hospital, discards the use of antiseptics except in 
 disease in the joints. 
 
 Hutchison, at the London Hospital, also works without Listerism. 
 
 In the hospitals in New York they are constantly investigating substances 
 with a view of ascertaining their antiseptic properties, the spray being in 
 very many of the institutions entirely abolished, and even by some con- 
 sidered as being pernicious. Sands, Stimson, Markoe, Weir, and many 
 other surgeons are, in the hospitals to which they are attached, constantly 
 experimenting with the newer dressings, some oi* which as bearing upon 
 this subject will be mentioned shortly. In Belle vue Hospital the dressing 
 is as follows, as communicated to me by my former pupil, Dr. Fuller, 
 late house surgeon in that institution: He writes me: "The form of 
 dressing now in use in our wards is one introduced by Dr. Lange, and is 
 practically the antiseptic dressing that is being used in Germany almost 
 entirely. The wound dressing, however, is only one element in the treat- 
 ment of the case, the secret is absolute cleanliness and antisepsis. Say the 
 case is one of amputation, or excision of a joint, the parts are first washed 
 with soap and water, with ether, if necessary, and the hair shaved off. 
 Then towels wet with an antiseptic solution, generally ^ carbolic acid, are 
 spread around the limbs so that the operator's hands or the instruments 
 may not touch the parts unnecessarily. Instead of a spray the wound is 
 frequently irrigated with a solution of corrosive sublimate, four grains to 
 the pint of water, the instruments are absolutely clean, and are lying, when 
 not in use, in a solution of ^ carbolic acid. The hands of those engaged 
 in the operation are wet with the same. For ligatures we use carbolized 
 catgut or fine carbolized silk. We keep it in pots, wound on spools. In an 
 amputation we use absorbable drains of decalcified bone, in other cases, 
 rubber tubes. After the final washing, the wound is sprinkled with iodo- 
 form and protected by rubber tissue, which is placed over the sutured mar- 
 gins of the wound, and the outside dressing is then applied, it may be peat, 
 borated cotton, or gauze. Peat is the best absorbent, but is expensive. We 
 generally dress within thirty-six hours. When the oozing of blood and 
 serum will have ceased, the tubes are then removed or not, according to 
 circumstances. This dressing must be made under the same precautions 
 as the operation, irrigation, guards, etc. The second dressing may remain 
 on a week or longer. If the discharge comes through the outside dressing, 
 the part is to be dusted with iodoform, or an extra amount of cotton or gauze 
 applied. The only indication for the removal of the entire dressing is a 
 higher temperature. With this dressing we have treated in the last two 
 months over a dozen excisions of joints, half a dozen osteotomies, excisions 
 of tumors, compound fractures, etc., without a bad result, and with a re- 
 markably low range of temperatures. In all the wards we do not treat anti- 
 septically, but there have been no results to equal these I speak of. Dr. 
 Weir tried full Lister dressing with good results ; Dr. Keys also. Dr. Wood 
 used the open method entirely. Dr. Lange employs the one I have just 
 mentioned." 
 
 In a somewhat late periodical * Dr. Henry C. Simes, assistant surgeon to the 
 Episcopal Hospital, thus writes of the general treatment of wounds in the 
 Philadelphia hospitals. He says that Listerism is far from being accepted, and 
 thus continues : u In this city ( Philadelphia) I know of no hospital in which 
 its surgeons have fully and thoroughly carried out the details necessary to 
 give their treatment the name of antiseptic, that is to say, that they have not 
 
 * Medical News, Philadelphia, June 13th, 1880. 
 
IODOFOKM. 309 
 
 attended to the minute directions, and in many cases the principal features 
 have been omitted ;" and then further states, that in the same hospital, when 
 antiseptically treated cases were compared with those not subjected to the 
 method, theresults of the former were much more satisfactory. 
 
 From these facts, selected from an immense amount of material, it may be 
 judged that antiseptic surgery, as we now regard it, is being more thoroughly 
 investigated and improved, while the details of Listerism are being gradu- 
 ally abolished. 
 
 The constant search for new antiseptics in the treatment of wounded sur- 
 faces, may be regarded as indicative of the fact that there are none which 
 have as yet proved entirely satisfactory, and, as much has been written and 
 many experiments made during the past three years in regard to new sub- 
 stances said to be antiseptic in their nature, I therefore shall give the most 
 important, with as much detail as the limits of the work allow. 
 
 Iodoform. — Iodoform must take the precedence, not only because it has 
 been very much used by many distinguished surgeons, but because the 
 results obtained have been very surprising. In fact, I recollect reading not 
 very long since, that Billroth had stated that the reason that he had not 
 published his cases treated with iodoform, was that the results he had ob- 
 tained were so very surprising that he feared they would not be credited. 
 
 Iodoform contains about 96 per cent, of iodine, and when decomposition 
 is going on, the iodine is evolved, which, by actual experiment, has been 
 proved to be one of the best disinfectants. 
 
 After the wound has been cleansed, the powder of iodoform may 
 be dusted over the part, and covered with a piece of protective. This 
 substance is very useful in regions of the body where carbolic acid could 
 not be applied, as in cancers of the rectum, tumors of the tongue and 
 mouth. 
 
 Billroth made twelve consecutive amputations of the tongue, and treated 
 the wound with iodoform without a fatal result. Dr. Sands* of New 
 York, mentions cases of strangulated hernise, trephining for fracture of the 
 skull, colotomy, enterotomy, castration, ligature of the external carotid, 
 peri-nephritic abscess, enucleation of suppurating inguinal glands, excisions 
 of the breast, and amputations, all of which made prompt recovery, treated 
 with iodoform. 
 
 Among the German surgeons, especially Esmarch, Billroth, and Langen- 
 beck, the use of this drug has produced surprising results — out of thirty- 
 four resections, thirty-two were cured with a dressing once applied and 
 allowed to remain thirty -five days. Billroth 's method of applying iodoform 
 is to powder the wound thickly with the substance, or, in some instances, to 
 fill it ; surround this with a piece of cotton wool or iodoform gauze, then a 
 water-tight dressing is put on and held in position by a bandage. From a 
 paper entitled " The Use of Iodoform in the London Hospitals " f we read 
 that it is a favorite dressing in almost every institution. It must, how- 
 ever, be borne in mind that iodoform is highly poisonous, although the 
 iodine is taken up slowly ; indeed Kcenig, of Gottingen, has published a 
 special warning on this subject, and, therefore, the dressing ought not to be 
 allowed to remain for over five days, and then for a time some other anti- 
 septic should be employed. 
 
 The symptoms of iodoform poisoning chiefly show themselves in intoxi- 
 cation of varying degree and intensity, and often in mental derangement. 
 It can be detected in the urine by adding starch and nitric acid and shak- 
 ing well, when the blue color will appear. The lethal dose for a guinea pig 
 
 * Medical Record, March 25th, 1882. 
 f Medical Record, April 15th, 1882. 
 
310 A SYSTEM OF SURGERY. 
 
 is three grains, in rabbits forty-five grains, in the dog one drachm, and in 
 man according to his susceptibility to the drug. 
 
 Bichloride of Mercury in dilute form is employed, especially by some of 
 the metropolitan surgeons. I have used it in amputations, resections, and 
 the removal of tumors with excellent, and in some instances surprising 
 results. 
 
 Delacroix dilutes one part with 2525 of water, and Dr. Weir and Sands 
 in about ^Vtfj ^ u ^ °f ^ n ^ s Weir says, bacteric life is found under such 
 dressings, and therefore, following the experience of Kiimmel and Schede, 
 of Hamburg, he uses it stronger and with a uniformity of good unknown to 
 Listerism. 
 
 In preparing this dressing, the sponges, compresses, etc., are wet with 
 solution No. 1 (as it is called), consisting of 8 grains to the pint. The liga- 
 tures are made of silk dipped for two hours in a solution of 8 grains to the 
 pint, and catgut immersed in 8 grains to the pint of water for 12 hours, 
 then rolled on bobbins and kept in an alcoholic solution of 20 grains to 
 the pint. The gauze is prepared by immersion in a solution of 20 grains 
 to the pint of alcohol with 3 iss of glycerine. It is to this variety of dress- 
 ing that I give the preference over all others. I think by this time (July 
 27th, 1886) I have tested it sufficiently in surgical practice to warrant the 
 assertion that so far it is superior to all other substances. 
 
 It has been found by Koch that the anthrax spores, the most resistant of 
 all varieties, are completely destroyed by moistening the parts with one 
 to five thousand of water, and if immersed for a longer period, a solution of 
 one to twenty thousand parts is sufficient for their destruction. 
 
 Turf. — As Dittle discovered the elastic ligature by accident, so Neuber, a 
 few years ago, recorded the case of a man brought to his clinic who had sus- 
 tained a wound and fractures of both forearms, ten days before : a comrade 
 had surrounded the wound with a turf mould, and upon its removal the 
 cut surfaces were found healing beautifully. It has since been discovered 
 that the dust resulting from the sawing of the turf into moulds, possesses 
 a very great affinity for ammonia, carbonate of ammonia, and odors gen- 
 erally; and in the infantry barracks at Brunswick, the turf mould is used 
 to disinfect privies, etc. 
 
 This dust, besides being a great disinfectant, possesses wonderful absorb- 
 ent properties, taking up nine times its weight of water. A great many ex- 
 periments have been tried regarding its efficiency as an antiseptic dressing 
 with satisfactory results. The turf mould is used as follows : Bags are made 
 of two sizes, 12 and 24 centimetres square. The turf dust is placed in these, 
 the smaller one having besides 2i per cent, of iodoform. This is laid on 
 the wound, which has also been disinfected ; over this the larger bag is 
 laid, the mould of which is saturated with a five per cent, solution of car- 
 bolic acid. 
 
 Its absorbent powers, its cheapness — a pennyworth being sufficient for a 
 dressing — and its antiseptic virtues, render it an excellent dressing in those 
 countries where the mould is readily obtained, and so much has been said 
 of its efficiency that it is now being used by surgeons in this city, and I am 
 informed with excellent results. 
 
 The Peroxide of Hydrogen. — The Peroxide of Hydrogen has received great 
 eulogiums from many and varied quarters, and C. T. Kingsett, of London, 
 made a report of a series of experiments with the material in 1876. In 1878, 
 Guttman and Fraenkel, in Germany, and Baldy, Best, and Regnard, in 
 France, made many demonstrations of the value of the material, and under 
 the name of " Eau oxygene " it has been widely used. It is employed as 
 spray, as a washing for wounds, ulcers, etc., and is devoid of all odor. 
 Kingsett has lately announced a preparation called " Sanitas oil," which he 
 
NAPHTHALIN— CALENDULA OFFICINALIS. 311 
 
 claims to be an organic peroxide, which will continually yield peroxide of 
 hydrogen to water, on being placed in contact therewith. If laid on sur- 
 faces it is said to keep them in a completely antiseptic atmosphere. 
 
 There are a great many other of the so-called disinfectants and antiseptics, 
 among which may be mentioned boracic and salicylic acids ; eucalyptus 
 oil, by Bassini ;* resorcin, which belongs .to the phenol group, and has 
 been noticed especially with reference to its substitution for carbolic 
 acid ;f 
 
 Naphthalin, — which according to Fischer, of Strasbourg,^ is superior to 
 carbolic acid; and 
 
 Subnitrate of Bismuth, which Kocker § claims as a new and better anti- 
 septic than any yet discovered. He discards drainage tubes and closes the 
 wound its entire extent by suture. 
 
 During the operation the parts are sprinkled with water holding bismuth 
 in solution. The wound is then closed by suture and the line of incision 
 covered with bismuth paste. Then the dressings wet with bismuth water 
 are applied. 
 
 As the sutures are removed, bismuth is again applied ; this method is 
 called healing by second adhesion, but there have been also some drawbacks 
 to this substance when applied to extensive abraded surfaces ; if bismuth 
 in powder was largely employed, it was found to produce diarrhoea, ne- 
 phritis, stomatitis, and other disturbances; it was then employed in a 
 solution of 10 per cent., and sprinkled on the parts with great benefit. 
 The astringency of bismuth is said also to add to its effective healing 
 powers. 
 
 Oxidized Oil of Turpentine.— This is announced || as a valuable antiseptic. 
 It is prepared by passing air for a long time through the ordinary oil of 
 turpentine. Mr. Lister was said to be experimenting with the substance, 
 but as no report has as yet been given, it is reasonable to suppose that the 
 results were not as satisfactory as Mr. C. T. Kingsett had anticipated. 
 
 Chloral Hydrate. — This substance has also been used in Russia, with 
 benefit, as an antiseptic, especially in the treatment of ulcers and open 
 wounds. Dmitrieff demonstrated in St. Petersburg that an equal quantity 
 of a one per cent, solution of chloral hydrate destroyed in twenty minutes 
 all mobility of the bacteria in a putrefying infusion of flesh. 
 
 Calendula Officinalis.— While on this subject I must say," as far as I have 
 observed by actual results in the treatment of wounded surfaces — for I 
 have never given any microscopical trial to ascertain its value as a germi- 
 cide — that the calendula officinalis has given me equal, if not better results 
 than carbolic acid, and while I acknowledge the fact, that since the "bac- 
 teria craze," and the " carbolic excitement," I have yielded to the popular 
 cry and used carbolic acid in different proportions and in different solu- 
 tions, yet I am convinced, that, other things being equal, calendula, 
 from its peculiar action on suppurating surfaces, is a medicine that- sooner 
 or later must receive the attention which its virtues deserve. I am quite 
 sure of the following facts, that in the past five years, when I have been 
 employing carbolic acid preparations upon wounded surfaces that have 
 not appeared to be progressing as favorably as I thought they should, I 
 have substituted calendula with surprising results. In many cases of 
 breast amputations and large wounds, I have employed merely cleanliness 
 
 * Medical News, February, 1881. 
 
 f American Journal of the Medical Sciences, January, 1883. 
 
 X Glasgow Medical Journal, November, 1882. 
 
 1 Volkman's Klinische Vortage, No. 224, 1882. 
 
 || Lancet, 1881, p. 971. 
 
312 A SYSTEM OF SURGERY. 
 
 and the solution of calendula, one per cent, to four of water, with a most 
 satisfactory termination of the cases. 
 
 Dr. Charles M. Thomas* speaks well of calendula, but after some experi- 
 ments he writes : " I find that, casteris paribus, wounds treated with it follow 
 a more favorable course than under non-medicated dressings, but in com- 
 parison with corrosive sublimate, iodine, iodoform or even carbolic acid, 
 the results are decidedly inferior." 
 
 But a sufficient number of these substances have been enumerated to 
 show, as I have already stated, that as yet all of them have some disadvan- 
 tages. It is my belief, as already stated, that there must reside in any ap- 
 plication adapted to a wounded surface, something besides its germ-killing 
 properties, which after all is merely mechanical. I am justified in assert- 
 ing that because a substance is really a germicide, it is no reason that it is a 
 perfect vulnerary. There must reside in the drug a power to act upon the 
 leucocytes, to either hasten their amoeboid motion to the cut surfaces of the 
 capillaries, which are endeavoring to repair waste, or to retard this very 
 migration, and by so retarding, prevent the dying of the leucocytes, which 
 in the majority of instances means their conversion into pus. 
 
 Comparative Results. — In conclusion, it is most important to look at the 
 results of antiseptics in surgery — and this also must be briefly considered, 
 although on this point, viz., the welfare of humanity, the whole subject 
 must rest. 
 
 First, I will note MacEwen's cases, because they were treated in Glasgow, 
 where Mr. Lister began his investigations and treatment; and second, be- 
 cause the experiments were made under the preconceived idea that hygienic 
 treatment was all-sufficient in the treatment of wounds. In the years 1875, 
 1876, 1877, 1878 (four years), there were 1706 cases treated by the aseptic 
 method, of which fifty died, giving a mortality of 2.93 per cent. During the 
 same period, in the same number of wards, Dr. Morton treated 1884 cases 
 without aseptic precautions, and of these 110, or 5.84 per cent., died. 
 
 After Mr. Lister went to Edinburgh, from the end of 1871 to the middle 
 of 1877, a period of about five and a half years, he treated aseptically 533 
 cases, of which 29 cases died. Mr. Spence, during the same time (five and 
 a half years), was operating in the same hospital, using no very decided 
 treatment — sometimes water dressing, sometimes boracic lint, and some- 
 times none whatever. In the 328 cases operated upon there were 58 deaths, 
 showing again a large percentage in favor of the antiseptics. 
 
 Again, if we turn to Mr. Lister's figures, after he had changed his resi- 
 dence from Edinburgh to London, where, in King's College Hospital, from 
 November, 1877, till November, 1880, a period of three years, he performed 
 207 operations, of which 14 died, a fair estimate of his success may be ar- 
 rived at. As these last were performed by Mr. Lister after he had studied 
 and improved upon his method for a period of thirteen years and in three 
 hospitals, the results as bearing upon the present status of antiseptic sur- 
 gery, are of the utmost importance, and therefore it may be well to mention 
 the character and kind of operations performed. Thus : 
 
 There were three amputations of the hip-joint for disease, with one death. 
 There were four amputations of the thigh for disease, of which three died. 
 There were two amputations of the forearm, no death. There were sixteen 
 excisions of the mamma, with two deaths. There were thirty-one operations 
 upon healthy bones for deformity ; no deaths. There were eight abscesses, with 
 one death. There were four cases of strangulated hernia, with three deaths. 
 There were three operations for the radical cure of hernia ; no death. There 
 
 * American Homoeopathist, June, 1886. 
 
COMPARATIVE RESULTS. 313 
 
 were three cases of acute necrosis, and one death. There were twenty -three 
 large abscesses ; no death. Two cases of empyema ; no death. There were 
 also cases of nerve stretching, castration, varicocele, and tumor. 
 
 From a careful examination of these cases, it will at once be seen that in 
 the same hospitals, with the ordinary run of cases, with the same surround- 
 ings, and in the same atmosphere, the percentage in aseptic treatment is 
 almost double in its favor. This fact cannot be gainsaid, but we must 
 noiv consider whether the aseptic method, Listerian in theory and practice — 
 the carbolic-acid treatment in its minute details — gives better results than 
 the ordinary antiseptic methods as employed without the Listerian minutiae 
 by the majority of the profession at the present day. This is difficult to 
 accomplish, and the best way for me to place the subject properly is to give 
 the statistics of the Hahnemann Hospital. These figures I have copied 
 from the case book, and extend over a period from September, 1878, to June, 
 1883, being four and three-fourths years. 
 
 Among these were 17 amputations of the breast, and 1 death. There were 
 
 15 amputations, 1 of the thigh, 5 of the leg, 3 Syme's, 2 Pirogoff's, 1 Chopart's, 
 3 fingers, with 1 death. There were 3 excisions of the rectum for cancer, 
 with 1 death. There were 2 cases rectotomy, no death. There were 9 re- 
 sections — tibia, 3 ; ankle joint, 1 ; elbow, 1 ; wrist, 1 ; coccyx, 1 ; ribs, 2 — with 
 no death. There were 11 ovariotomies, with 4 deaths. There were 17 
 abscesses, some of very large size, and no deaths. There was 1 case of 
 empj^ema, and 1 death. Laceration of the perinseum 22, with no death. 
 External urethrotomy 11, with 1 death. There were 2 cases of internal 
 urethrotomy, no death. There were 9 cases of lipoma, some of large size, 
 no death. There was 1 fistula of the thorax, 1 vesico-vaginal fistula, 1 recto- 
 vaginal fistula, 1 perineal fistula. There were 2 cases of Battey's operation, 
 no death ; 2 cases cystocele, no death. There were 9 rhinoplastic operations, 
 1 death. There were 3 cases of supra-pubic lithotomy, 1 death. There were 
 5 cases of lithotrity, no death. Removal of superior maxillary 2 cases, no 
 death. There was 1 extirpation of the uterus, 1 death. There were 56 cases 
 of laceration of the cervix, no death. Besides these were 10 cases of hernia, 
 
 16 cases of fistula in ano. Varicocele, tracheotomy 1 each, and others, making 
 a sum total of 201 operations performed in the Hahnemann by the visiting 
 surgeons, with the loss of 11 cases. There is no absolute Listerism prac- 
 ticed at the hospital, but antiseptics, are used in the shape of carbolic acid 
 solutions, carbolized instruments, and calendula, balsam of Peru, the 
 bichloride of mercury, or any other antiseptic used that the operator may 
 deem proper. One feature in the dressing is the marine lint, which I regard 
 as an agent of the greatest value. The parts to be operated upon are washed 
 with carbolized solution, the floor of the operating room is scrubbed, and 
 the " ovariotomy room also ventilated and disinfected after each operation." 
 The instruments are first laid in carbolized oil overnight, and then in 
 shallow pans containing carbolic acid. An assistant is at hand to imme- 
 diately wash an instrument which has been laid asicte and replace it in the 
 pan. Sponges are immersed either in a solution of corrosive sublimate, 1 
 to 2500, or in carbolic solution 1 to 60. The wounds are closed with silver 
 sutures carbolized. The silk is rendered aseptic and catgut is often em- 
 ployed. Salicylated India rubber plaster is the only kind used in the house, 
 and after it has brought the edges of the wound in contact, a wad of marine 
 lint is laid over the entire wound, spreading some distance around it; over 
 this the protective gauze, and again over that a bandage is placed. These 
 dressings are not touched until some indication for their removal is. noticed, 
 and often remain in position for days together. It will be seen, therefore, 
 that our statistics without the minutiae are even better than those of Mr. 
 Lister. 
 
314 
 
 A SYSTEM OF SURGERY. 
 
 If, now. we compare all these statistics, we can formulate the present 
 status of antiseptic surgery : 
 
 Operator and Location of Hospital. 
 
 Cases. 
 
 Deaths. 
 
 Per cent. 
 
 Glasgow. 
 McEwen, 5 Years 
 
 1.706 
 1,884 
 
 50 
 110 
 
 2.93 
 5-84 
 
 Aseptic Treatment. 
 
 Same Hospital. 
 Morton 5 Years 
 
 Xon-aseptic Treatment. 
 
 Edinburgh. 
 Lister. o\ Years 
 
 553 
 328 
 
 29 
 58 
 
 5.2 
 17.7 
 
 Aseptic Treatment. 
 
 Same Hospital. 
 Spence, 5 J Years 
 
 Xon-antiseptic. 
 
 London. 
 Lister. 3 Years 
 
 207 
 
 14 
 
 6.76 
 
 Aseptic Treatment. 
 
 New York. 
 Hahnemann Hospital, 1 Years 
 
 201 
 
 „ 
 
 5.47 
 
 
 It will be found that in most hospitals the aseptic treatment, viz., 
 Ldsterism, is abolished or greatly modified, and that the a nt i -septic treat- 
 ment will probably give as good results as the a-septic, especially with proper 
 hygienic surroundings. 
 
 In conclusion I will state here that all appliances for antiseptic dressings, 
 whether prepared with carbolic acid, with salicylic acid, with the bichloride 
 of mercury, with iodoform, or with iodine, are most carefully manufactured 
 by Mr. C. Am Ende, of Hoboken. I have used these in both hospital and 
 private practice and have been always satisfied with their efficacy. 
 
 As the proof-sheets of this portion of my work are passing through the 
 press, I find that Prof. Lister appears to have become somewhat dissatisfied 
 with carbolic acid, and now uses a double mercurial salt, called salaern- 
 broth. It is formed by the sublimation of a mixture of the perchloride of 
 mercury and chloride of ammonium. All the dressings, gauze, wool, lint, 
 bandages, etc.. are prepared with a solution of this substance 1-100. After 
 the dressing is applied, it is covered with aniline blue 1 to 10.000. When- 
 ever an alkaline discharge comes in contact with the blue, the color changes 
 to red. thus immediately indicating the presence of pus and the points from 
 which it comes.* 
 
 * Medical Record, JuIy 17th, 18S6. 
 
THE MEA2SS AND INSTRUMENTS FOR ARRESTING HEMORRHAGE. 315 
 
 CHAPTER XVII. 
 
 HEMORRHAGE. 
 
 The Means and Instruments fob Arresting Hemorrhage — Definition — Hemo- 
 philia — Hemostatics. Naturae and Artlficiae — Internal Medication— Styp- 
 tics — Flexion* — Compression— Percutaneous Ligation — Acupressure — Various 
 Instruments— Ligature — Esmarch's Method — Dittel's Elastic Ligature. 
 
 The means and instruments with which to arrest haemorrhage constitute 
 a topic of grave import to the physician as well as the surgeon, because in 
 the panic which generally accompanies every case of haemorrhage, and of 
 the uncertain and inopportune times at which bleeding may occur, the 
 nearest medical man is summoned, whether he profess surgery as a specialty 
 or otherwise. 
 
 The most fearless and bold operators have more or less dread of those 
 great losses of blood which may either immediately or secondarily prove 
 fatal to the patient ; indeed, in the majority of operations, it is '" the bleed- 
 ing " which is most feared. The fact that in a few moments the life of a 
 human being may pass away with the crimson tide which bursts from an 
 open vessel, causes such occurrence to be regarded with much apprehension, 
 and, added to this, the heart-sickening scene presented by a person dying 
 from loss of blood, the horror-stricken faces of bystanders, and the disorder 
 and confusion which are often present on such occasions, have taught us to 
 regard haemorrhage always with certain feelings of anxiety. The appear- 
 ances presented by a person " bleeding to death " are appalling. The ashy 
 paleness of the face, the pinched nose, the blanched and drawn lips, the icy 
 brow, the clammy skin, the intense nausea, and that hazy vacancy that 
 gradually steals over the eye. together with the absolute depression of all 
 those forces which render us cognizant of the great world without, indicate 
 too plainly that vitality is giving place to death ; that the wonderful life- 
 giving current is rapidly being withdrawn from the organism which it 
 nourished, and that light and life are soon to be extinct. 
 
 It is not, therefore, surprising, that those men who are supposed to be 
 familiar with the means which will save life when it is threatened from loss 
 of blood, should be regarded with feelings almost akin to reverence, and it 
 is in these times that all the self-possession, knowledge, skill, and mechanical 
 tact of the operator will be called into requisition. 
 
 Such was the confidence placed in the skill of Ambrose Pare in arresting 
 haemorrhage, that he is said to have infused new life into the French army 
 by his appearance in the midst of a sanguinary contest. 
 
 I have in my possession a treatise on surgery written a century and a 
 half ago by Samuel Sharp, a pupil of the renowned Cheselden. and sur- 
 geon to Guy's Hospital.* On page 221 he has the following paragraph : 
 " There are in armies a great many instances of gunshot wounds of the 
 arm near the scapula, but the apprehension of losing patients on the spot by 
 haemorrhage has deterred surgeons from undertaking amputation.'' Fabricius ad 
 Aquapendente appears to have had such horror of haemorrhage that he 
 recommended all incisions for amputation to be made in mortified, and 
 therefore, bloodless structures. O'Halloran, speaking of amputation of the 
 leg, alludes to the " bleeding " as the most troublesome and alarming symptom, 
 
 * A Treatise on the Operations of Surgery, with a Description and Representation of the 
 Instruments Used in Performing Them, ete., by Samuel Sharp, Surgeon to Guy's Hospital, 
 London. 
 
316 A SYSTEM OF SURGERY. 
 
 that and most reproachful to the surgeon, " the haemorrhage often proving 
 fatal to the patient." Professor Thompson, the preceptor of the distinguished 
 Simpson, thus speaks : " The suppression of haemorrhage and the reunion 
 of divided surfaces are, in every wound and in every operation, the first and 
 ultimate objects of the surgeon's attention." It is unnecessary to multiply 
 quotations to establish facts that are so universally acknowledged, and 
 although by some of the newer means for arresting haemorrhage the occur- 
 rence is deprived of some of its terrors, yet it still remains in every opera- 
 tion to demand the serious attention of the surgeon. 
 
 Definition. — By the term haemorrhage is understood the escape of blood 
 from bloodvessels. If this discharge takes place from open surfaces or from 
 organs communicating with the atmosphere, the simple word " haemorrhage " 
 is used. When it occurs within the cavities of the body, we have " internal 
 haemorrhage." When the discharge of blood is not very great and remains 
 beneath the surface, Cl extravasation " is produced. When the blood flows 
 freely and in streams, or is profuse in quantity, we use the term " active 
 haemorrhage ;" " passive" being applied to slow and irregular discharges gen- 
 erally emanating from the capillary vessels. When the blood flows " per 
 saltum " and is bright red, we recognize the characteristics of " arterial haem- 
 orrhage" and when it is of darker color and a more continuous flow, the 
 haemorrhage is said to be " venous." Let me here, however, remark that an 
 arterial haemorrhage may occur, in which the blood does not flow u in jets." 
 I have seen this in amputations where a vessel — perhaps of the third calibre 
 — has contracted behind muscular or tendinous substances, and in instances 
 in which a longitudinal incision has been made in the coats of an artery ; 
 in the latter instance a portion of the blood passing through the tube, the 
 remaining portion issuing through the opening in the coats. In such cases, 
 which are always more or less embarrassing, the color of the blood, and a 
 knowledge of the anatomical relations of the parts must chiefly be our 
 guide. Sometimes also there may be an apparent pulsation or u jetting " to 
 the stream flowing from a good-sized vein, owing to its proximity to a large 
 or pulsating tumor or arterial trunk. 
 
 Again, surgeons denominate "primary haemorrhage" as that occurring 
 during the performance of an operation ; " intermediary haemorrhage" so I 
 believe designated by Butcher, as that which takes place within a few hours 
 after operative procedure, either from the relaxation of tissues or the increased 
 power of the circulation as reaction is taking place ; and " secondary haemor- 
 rhage" that which results from the separation of ligatures, or the removal of 
 pins or dressings, which have been used to prevent the primary flow of blood. 
 
 Haemorrhages, even extravasations, are always looked upon with appre- 
 hension. The gradual flow of blood into the meshes of a tissue is serious. 
 If it take place within the globe of the eye, it may cause disorganization of 
 the entire ball. If within the cardiac structures, imminent peril results ; 
 if within the brain, coma and death may supervene ; while the dangers from 
 active, arterial, or venous haemorrhage are well known to every one. 
 
 Hemorrhagic Diathesis— Haemophilia. — It may be well here to remark 
 that some persons are much more prone to haemorrhage than others, and a 
 circumstance still more peculiar is found in the fact that the so-termed 
 " hemorrhagic diathesis" appears in many instances to be hereditary or con- 
 genital. In the medical periodicals and text-books, many interesting cases 
 may be found, furnishing abundant testimony of the fact. 
 
 Those who are afflicted with this peculiar and distressing constitutional 
 defect are called " bleeders," and in such (whether it be a weakness of the 
 capillary vessels, or a loss of their contractile power, or a diminished quan- 
 tity of plastic material in the blood, or other unknown circumstance), a very 
 slight and trivial cause, even a pin-scratch, may give rise to a dangerous or 
 
HEMOSTATICS. 317 
 
 fatal loss of blood. The diathesis generally is found among the male sex, 
 and in the earlier years of life, the tendency disappearing toward adult age. 
 When it is acquired it is usually among the poorer classes, who are poorly 
 fed, with lack of light, pure water, exercise, and fresh air. There are in this 
 affection many symptoms that are analogous to scorbutus, the blood being 
 thin and defibrinated, and the haemorrhage taking place often without any 
 assignable cause. Often it occurs beneath the integument, giving rise to 
 dark purple spots, or those of a slightly reddish hue. I have known an 
 almost fatal haemorrhage occur from the gums of a patient without any as- 
 signable cause. Children have perished from loss of blood consequent upon 
 lancing the gums, dividing the "frsenum linguse" excising the tonsils, extract- 
 ing a tooth, and other minor operations. 
 
 Some very remarkable cases in which several in one family have been 
 afflicted with the haemorrhagic diathesis * are upon record. 
 
 I have lately seen an interesting case in consultation with Dr. Swan, of 
 New York, in which the infant bled profusely from the soles of the feet, the 
 palms of the hand, the umbilicus, and the back. The complexion was very 
 sallow, and though the child when born was apparently plump, it took no 
 nourishment, and died in a few days. 
 
 Haemostatics. — The object of the surgeon is to ascertain the proper means 
 and instruments for preventing or arresting haemorrhage, occurring either 
 during or after surgical operations ; or that resulting from injury, or acci- 
 dent, or constitutional diathesis. 
 
 This is termed haemostatics, and is divided into two departments, natu- 
 ral (A.) and artificial (B.). 
 
 (A.) Natural Haemostatics. — To the student of physiology and pathology, 
 the active part that nature, even unaided, takes upon herself to repair 
 injury and preserve vitality is well known. With a wonderful and silent 
 power she keeps guard over her children in every emergency, driving out 
 the innovator ; healing broken bones ; repairing tissue ; manufacturing 
 flesh; gluing together wounds; and in haemorrhage strenuously working 
 to save her own from death. On this last point, viz., the method in 
 which natural haemostatics arrest bleeding, experimental pathology has 
 revealed much in the last few years. As long ago as 1731 Petit wrote and 
 published several treatises on this subject, giving from actual experiment 
 the manner in which " the two clots " are formed by nature to arrest haem- 
 orrhage. The inside clot he called " bouchon" the outside " couvercle." In 
 1736 Morand, besides allowing the formation of clots as proposed by Petit, 
 advanced the idea that besides this, very important changes took place in 
 the coats of the artery itself. It is rather remarkable that some years after- 
 wards Sir John Bell denied this proposition. In 1763 Kirkland made an 
 additional step by showing that besides the two clots and the arterial con- 
 tractions, syncope or swooning lessened or arrested temporarily the discharge 
 of blood, allowing time for clots to form and organize, or for mechanical 
 interference, and finally, Dr. I. F. D. Jones,f who has given us the best 
 treatise on the subject, has informed the surgical world (which it is very 
 important for us to bear in mind for the proper understanding of the ratio- 
 nale of certain methods now employed in arresting haemorrhage) that for 
 the permanent arrest of bleeding, " an effusion of coagulating lymph within 
 its (the artery's) canal, between its tunics, and in the cellular substances 
 surrounding it," is necessary, and does take place. Here are then four im- 
 portant means employed in natural haemostatics, and if we call to mind the 
 
 * Gross's Elements of Path. Anat., pp. 203, 204. Gross's Surgery, vol. i., " Hemorrhagic 
 Diathesis." Braithwaite's Eetrospect, No. 24, p. 199. Druitt's Modern Surgery, p. 305. 
 
 f A Treatise on the Process Employed by Nature in Suppressing the Haemorrhage from 
 Divided or Punctured Arteries, and on the Ligature, by I. F. D. Jones, M.D. 
 
318 
 
 A SYSTEM OF SURGERY. 
 
 method pursued by nature in repairing fractures; — the internal and external 
 callus, " the temporary " and " permanent," and the removal thereafter of 
 that which is unnecessary, a wonderful similarity in the two processes will be 
 found to exist. Let us suppose that an artery of some magnitude is cut 
 across ; almost immediately both divided ends retract within the sheath, 
 and by virtue of the elasticity of their coats, contract upon themselves, thus 
 diminishing the calibre of the vessel and necessarily diminishing the stream. 
 The sheath, however, not being nearly so elastic as the arterial tunics, re- 
 tracts but little, thus leaving a species of cylinder around the vessel to be 
 filled with coagula, which takes place from filaments of fibrin being adhe- 
 rent to its walls ; and this is increased by the increased plasticity of the 
 blood as it flows. Vide Fig. 122, which shows the plan of natural haemo- 
 statics in a cut artery ; a is the divided extremity of the arterial tube ren- 
 
 FlG. 122. 
 
 Fig. 123. 
 
 Fig. 124. 
 
 ¥ 
 
 dered conical by contraction ; b, the arterial sheath vacated by the retracted 
 artery, and occupied by coagulated blood; c, the coagulum, projecting from 
 the orifice of the sheath. The more slowly the blood 
 passes through the vessel, the more opportunity is of- 
 fered toward the formaton of the internal coagulum, 
 which forms within the vessel in a long and thin clot, 
 and if syncope have supervened, the conditions will be 
 much more favorable to the " couvercle." " In the mean 
 time, 1 ' says Jones, "the cut surface of the artery in- 
 flames; the vasa vasorum pour out lymph, which is 
 prevented from escaping by the external coagulum." 
 This lymph fills up the extremity of the artery; is situ- 
 ated between the external and internal coagula of blood ; 
 is somewhat intermingled with them, or adheres to 
 them or is firmly united all around to the internal coat 
 of the artery. Fig. 123 (after Jones) shows also the 
 plan of natural haemostatics ; a is the external coagu- 
 lum, incorporated with the coagulum of the sheath, b. 
 The internal coagulum is also seen resting upon the external and extending 
 to c, the first collateral branch. These are the processes which we find in 
 natural haemostatics, and the more we examine them, the more will the 
 
 \ 
 
HjKMOOTATICS 
 
 beauty of the process be appreciated. After haemorrhage is suppressed, the 
 artery at its extremity and sometimes up to Kb zrs: anastomosing branch, 
 becomes converted into a ligamentous cord, and the clots are removed by 
 absorption. Tig. 124 shows : 1. Plan of retracted artery after section : a. the 
 conical, contracted, and retracted arterial tube : b. the arterial sheath left 
 vacant. 2. Plan of retracted artery after laceration ; a. the retracted middle 
 and internal coats of the artery ; b. the external coat ; c. the twisted sheath. 
 B. Artificial Haemostatics." — Internal Medication. — Anions those haem- 
 orrhages belonging to surgery, besides those occurring from accidental 
 causes and the surgeon's knife, are epistaxis and bleedings from the blad- 
 der and the rectum, and even these, in the majority of instances fall 
 within the province of the physician, in the same manner as haeniopty- 
 etrorrhagia. haematemesis. and post-partum haemorrhage. I shall 
 therefore speak of internal medication, so far as it has power to arrest haenior- 
 rhage (surgically so-called ), and must confess, that it is a very difficult matter 
 to lay especial sfla 'ts ; m any medicinal means whatsoever, as in almost 
 case of haemorrhage, some local application is made simultaneously with 
 the internal treatment, or. indeed, if a medicated substance is not laid over 
 the bleeding surface, it is covered or bound up with bandages, or cloth, or 
 lint, or cotton, or some other substance, to favor the formation of the clots. 
 When vessels of any magnitude bleed. I would unhesitatingly regard it, 
 not only the height of folly, but an unpardonable dereliction of duty, to 
 rely exclusively on the internal administration of medicine, under the con- 
 viction that the bleeding will be arrested. Yet I have been told, though 
 I scarcely credit the fact, that there are physicians who. having a case of 
 arterial haemorrhage, would neither cover the wound with a bandage, nor 
 ligate a vessel, nor apply a styptic. 
 
 In passive haemorrhage there can be no doubt that medicines are capable 
 of exercising a beneficial effect. In oozings after large operations. I 
 have frequently witnessed their excellent results. I do not propose : 
 record in this place what is found in the manuals for haemorrhage, or I 
 would write that for haemorrhage in general (f) we have asa£. cocc.. copaiba, 
 iod., and crocus. Haemorrhages from u various parts," canth. and phosph. 
 Haemorrhages "from a newly opened wound," opium. Excessive haemor- 
 rhage, antinionium crud., and much of the like. My object is merely to 
 mention those remedies which, internally administered, have a beneficial 
 effect in certain forms of haemorrhage. Of these secale cornutum in half 
 drachm doses of the fluid extract repeated every hour or two is perhaps the 
 most satisfactory, and next, gallic acid in five or ten grain doses. Cinnamon, 
 iron, opium and lead are also effective. 
 
 Hamamelis will arrest a venous, haemorrhage, proceeding from varicose 
 veins, and haemorrhage^from the mouth and gums, and from haemorrhoids. 
 
 Dr. Gushing has seen it suppress haemorrhage after extracting a tooth. 
 Dr. Preston has with it cured haemorrhage from the bowels. 
 
 Veratrum viride is one of the best medicines for haemorrhage ^ ; r : ; 
 recorded of its successful use in Sriondary haemorrhage after amputation.* 
 
 Nitric acid, given internally, will arrest a secondary haemorrhage from the 
 lower part of the rectum, after the removal of haemorrhoidal turn i - 
 
 Monsel'e styptic, from 20 to 30 drops in half a glass of water, a table- 
 spoonful every half hour, will arrest an oozing from the medullary canal 
 after a resection of the humerus. I was led to its use in surgery by some 
 remarks by Dr. Malcolm McFarland. Erigeron I have administered with 
 success in haemorrhage from the bladder, after operations for vesico-vaginal 
 fistula?, rupture of the perinaeum. e: :. ¥ operations about the lower por- 
 tions of the rectum, crocus and carbo veg. are excellent medicines. S far 
 
 * Medical Record, November 1st. 1572. 
 
320 A SYSTEM OF SURGERY. 
 
 as my own knowledge goes, with the exception of arsenicum and china, in 
 those cases where there is great prostration of the vital power, and the blood 
 is thin and defibrinated, I can speak of no other internal medicines. The 
 alnus rubra, apocynum cann., erechthites hieracifolius and iris, or diadema, 
 are laid down as possessing power over haemorrhage. This is a portion of 
 the field of surgery that presents a wider scope than perhaps any other, 
 and, no doubt, will in future be more thoroughly cultivated, but as I have 
 before mentioned, the fact that many mechanical agents, from the simple 
 roller bandage to the most complicated styptic compounds, are generally 
 employed, will always embarrass the attempt to assign the proper sphere to 
 internal medication. 
 
 Styptics.— Before proceeding immediately to mention those articles which 
 may be considered the most efficient as styptics, I would have the fact borne 
 in mind that the exposure of the bleeding surface to the atmosphere will arrest 
 quite a profuse haemorrhage. Mr. Skey, years ago, taught this fact :* " A 
 surgeon who has the least fear of haemorrhage loses the least blood ; a small 
 wound may be tortured by styptics, and by compresses, and other unprofit- 
 able agents, until it becomes the fruitful source of protracted haemorrhage. 
 Masses of lint are piled up in heaps upon the wound, pressure is main- 
 tained until all the parties are exhausted, but still the haemorrhage returns 
 and continues by reason of the irritation caused by these very agents and 
 nothing more. Under these circumstances, which I have frequently borne 
 witness to, all dressings should be removed, and the wound should be opened 
 and exposed to the air by its edges being drawn widely asunder and the 
 bleeding apparently encouraged ; its surface sponged freely with cold water, 
 the coagula wiped away, and in this condition it may fearlessly be left to 
 bleed; the cessation of the haemorrhage by such means is often immediate." 
 I have known quite a number of cases where such treatment has proved 
 beneficial, and have laid down a rule, that in every operation where a band- 
 age is not absolutely necessary to support the parts, it should be done away 
 with. For the past five years, after amputation, or the removal of tumors, 
 I have not permitted the application of the dressings until all bleeding had 
 ceased, the parts being merely covered by a light cloth, and thus many 
 untoward symptoms have been prevented. A bandage often keeps up 
 venous congestion, thereby producing troublesome oozing. 
 
 Cold. — The application of cold, either by means of ice-water, or of ice 
 pounded in bladders and applied to the part, or ice-water used with a 
 syringe upon the bleeding vessel, as employed by Agnew in ruptured peri- 
 naeum, or the ether spray of Professor Richardson, or the rhigolene of Dr. 
 Bigelow, all have excellent styptic effects, and with the exception of the 
 latter are so devoid of all odor and so easily applied that they are always 
 desirable except in those cases where the haemorrhage is active. 
 
 Alum may be applied either in powder or in solution, and possesses power- 
 ful astringent properties. It is efficient in its action, and when combined 
 with tannin exercises powerful control over the bleeding surfaces. Equal 
 parts of sulphate of alumina and tannic acid I always keep ready for 
 emergency. An excellent formula for a solution combining the two is that 
 of Monsel : 
 
 R. Acidi tannici, grs. x. 
 
 Aluminse sulph., J}j. 
 
 Aquae rosae, Jiss. 
 
 M. ft. sol. 
 
 A Combination of Tannin and the Elixir of Vitriol has been known to arrest 
 a very profuse arterial haemorrhage from the tonsils. This is easily ob- 
 
 * British and Foreign Medico-Chirurgical Review, 1851, p. 290. 
 
STYPTICS. 321 
 
 tained, and though I have never applied it, yet it must be a powerful as- 
 tringent. 
 
 Rnatany. — By digesting rhatany with sulphuric acid a brown extract is ob- 
 tained, which has been highly lauded by Mr. Tessier * of Lyons, as one of 
 the best haemostatics. 
 
 Oil of Turpentine. — The properties of this substance brought it into gen- 
 eral use some seventy years ago, and it is occasionally used at present, but 
 there are so many other agents of superior efficacy, that it has fallen into 
 very general disuse. It was highly lauded and recommended by Mr. 
 Yonge. 
 
 Matico. — Dr. Jeffries, of Liverpool, is said to have introduced this sub- 
 stance as a haemostatic to the profession, in 1843. It has been given inter- 
 nally, and applied locally. A decoction is made of one-half ounce of the 
 matico to a pint of water, although Dr. Hunter Lane recommends that an 
 ounce of the substance be used to a pint of boiling water. 
 
 Sulphate of Copper. — This substance has been employed for centuries to 
 arrest bleeding ; it was formerly pounded and placed in "little linen clouts," 
 thus forming the well-known " button of vitriol," and applied. It has often 
 been mixed with tannin. 
 
 Perchloride of Iron. — The coagulable properties of the varied preparations 
 of iron render them superior in arresting haemorrhage. I have used the 
 'perchloride in very many cases with success, although of late years I have 
 preferred the persulphate. 
 
 Persulphate of Iron may be used in the form of the liquor Jerri permlphatis, 
 or in powder. It is the well-known " Monsel's styptic," and is decidedly 
 one of the most efficient we possess. I could cite many cases wherein its 
 efficacy has been proven. There is a precaution, however, which should 
 be employed in using many of these styptics, and that is, knowing their 
 liability to produce unsightly stains on whatever articles of cotton or linen 
 they touch, care should be taken to use only " old rags," as they are termed, 
 or some cheap substitute. I have known many quite valuable articles of 
 clothing, as well as bed and other linen, completely spoiled by these prepa- 
 rations carelessly applied. 
 
 Collodion, by its contractile power, and by the cold produced by evapora- 
 tion, is often efficient. I have arrested a severe and prolonged haemorrhage 
 from leech-bites, by dipping pieces of lint into collodion and placing them 
 over the bleeding surface, over this applying a piece of cardboard, and 
 then freely pouring collodion over the part. 
 
 Styptic Colloid. — This substance, which was introduced by Mr. Kichardson, 
 consists of ether saturated entirely with tannin and a collodial substance, 
 either gun-cotton or xylodine. When such is applied, the natural heat of 
 the body evaporates the ether, leaving the tannin and cotton applied to the 
 raw surface.t I can speak well of the efficacy of this agent, having used it 
 very frequently and with good results. 
 
 Chloride of Iron and Cotton. — Dr. Ehrle describes a simple preparation of 
 cotton which he has found of great service in surgical operations followed 
 by great effusion of blood. American cotton of the best quality is cleansed 
 by boiling it for an hour in a weak solution of soda (about 4 per cent.) 
 then repeatedly washed in cold water and dried. By this process it will be 
 perfectly disinfected and adapted to more ready absorption. After this, it 
 should be steeped once or twice, according to the degree of strength required, 
 in liquid chloride of iron, diluted with one-third water, pressed and thor- 
 oughly dried in the air — neither in the sun nor by the fire — then lightly pulled 
 
 * Medical Eecord, vol. ii., p. 393. 
 
 f Vide Braith wake's Ketrospect, July, 1&67, 
 
 21 
 
322 A SYSTEM OF SURGERY. 
 
 out. The cotton so prepared will be of a yellowish-brown color. It must be 
 kept very dry, as it is affected by the damp. Lint may be similarly treated, 
 but the fine texture of the cotton renders it preferable. When placed on a 
 fresh wound, it causes a moderate contraction of the tissue, and gradually 
 coagulates the blood in and beyond the injured veins, thus closing the 
 source of the effusion. 
 
 This property of the chloride of iron is increased by the dryness of the 
 cotton, and the extended surface offered for the development of its chemical 
 action. 
 
 C. Am. Ende, of New York, prepares " a styptic cotton," and also an 
 article which is called haemostatic cotton, somewhat after the formula of 
 Ehrle. This I have used with success and can highly recommend. 
 
 Benzoic Acid and Alum. — Probably the most energetic styptic known is 
 the following : 
 
 R. Benzoic acid, 1 part. 
 
 Sulphate of alumina and potash, aa 3 parts. 
 
 Ergotin of Bonjean, 3 parts. 
 
 Water, . . .24 parts. 
 
 The whole is to be boiled for half an hour in a porcelain vessel, with 
 constant stirring, replacing the evaporated with boiling water. It must 
 then be evaporated to the consistence of an extract, which is of a chocolate- 
 brown color, strongly astringent taste, and having an odor of ergotin. 
 Together with this the following formula is to be taken internally : 
 
 Benzoic acid, gr. j. 
 
 Pulv. alum, E 
 
 Ergotin, aa gr. ij. 
 
 Ft. mass, et div. in pil. no. xvi. S. One pill to be taken every two hours. 
 
 There are many other substances which are possessed of astringent prop- 
 erties. Thus the famous styptic of Broussard was composed of the agaric 
 of the oak, while, as remedies against haemorrhage, the felt of a hat, cob- 
 webs, nut galls, and the preparations of zinc and mercury have long been 
 known and applied. 
 
 Hypodermic Medication. — A very valuable agent in the arrest of haem- 
 orrhage, especially from the internal organs, is the hypodermic injection of 
 secale cornutum. I use Squibb's fluid extract, and inject ten minims under 
 the skin. In some instances I have seen most decided effects from its use. 
 Dr. Hammond has reported the cure of several pulsating tumors of small 
 size by the injection of ergot. These, however, are alluded to in another 
 portion of this volume. 
 
 The Actual Cautery. — The old surgeons applied almost universally the red- 
 hot iron to arrest bleeding after surgical operations. I have seen depicted 
 in a well-preserved copy of the Armamentarium Chirurgicum, of Scultetus, 
 published in Frankfort in 1666, the various methods of its barbarous applica- 
 tion. Melted lead, melted copper, boiling oil, and boiling oil of turpentine 
 were also used for the same purpose. The severity of this mode of arresting 
 haemorrhage, combined with its unsuccessful results (secondary bleeding gene- 
 rally following the separation of the eschar), led to its disuse, and Ambrose 
 Pare, three centuries and a quarter ago, in 1564, proposed that surgeons 
 " should cast aside all hot irons and cauteries, and apply the ligature and 
 the tourniquet."* Yet this advice was slowly followed, and Pare was 
 assailed by the surgeons of his time " for daring to introduce the ligature, 
 
 * A very interesting account of the methods employed by Pare in arresting haemorrhage can 
 be found in Simpson's work on Acupressure. 
 
FOKCED FLEXION. 323 
 
 and condemn, as they said, a method so highly commended and approved 
 by all the ancients, teaching in opposition to that, without any authority, 
 without knowledge, without experience, without good sense, some new 
 method of his own of tying arteries and veins." It took nearly two hundred 
 years to introduce into general practice the process of ligating arteries, and 
 now, having been adopted, it will take probably as long before the newer 
 methods will be looked upon as sufficiently reliable to be generally accepted. 
 So has it ever been in the history of medicine. The fact is lamentable, but 
 nevertheless true. In certain operations, however, in which there is much 
 oozing, it is necessary, even at the present day, to have recourse to the 
 heated iron. It can only be justifiable when the bleeding vessel is beyond 
 the reach of the ligature. According to Bransby Cooper, no surgeon should 
 ever undertake to remove the whole of the upper jaw without being 
 provided with a variety of actual cauteries. He recommends an iron rod, 
 working in a sheath, to prevent 
 
 the surrounding structures from fig. 125. 
 
 being injured. I have on sev- 
 
 eral occasions been obliged to ^^ c . r«*4»*-eo. 
 
 use this method of arresting -^ 
 
 bleeding, once in the removal 
 
 of the entire superior maxillary «" ■ "O 
 
 bone, and again in a resection Thomas's Cauterizing Iron. 
 
 of the inferior maxillary, in 
 
 which the dental artery bled profusely. Fig. 125 represents Thomas's 
 cautery, made by Tiemann. In its application care must be taken not to 
 have the metal too hot, a moderate red being preferable to a white heat. 
 At present the galvano-cautery and the tbermo-cautery have superseded all 
 others. For a description of Paquelin's thermo-cautery see chapter on 
 Minor Surgery. 
 
 Nitrate of Silver used formerly to be much in vogue for the suppression 01 
 bleeding, and is now occasionally applied, but the other substances which 
 have already been mentioned are so far superior to it, that only in excep- 
 tional cases can it be called for. 
 
 Over or Forced Flexion. — Malgaigne asserts, in his Anatomie Chirurgicale, 
 that the only points at which obliteration of pulsation can be obtained by 
 position alone, without the aid of external compression, are at the bend of 
 the arm and at the knee; facts which are of great import in the arrest of 
 haemorrhage. Forced flexion, as it is termed, is so simple and so easily 
 effected that it should be remembered by both physician and surgeon. 
 The method, though not by any means new, has had many advocates at the 
 present time, among whom are Nelaton, Ansiaux, Malgaigne, Klotz, Hyrtl, 
 Vidal, and others. It is well known that wounds of the palmar arch and 
 plantar surfaces, especially the former, often give rise to the most alarming 
 and uncontrollable hemorrhage, and that cases are upon record where 
 ligature of the radial, ulnar, brachial, and even axillary arteries have failed 
 to arrest the flow of blood.* 
 
 Forced flexion will, in the majority of instances, arrest the bleeding from 
 these surfaces. Thirty years since, Dr. E. Dunvell, published in .the 
 Medical Gazettef an interesting article on the subject, stating that in most 
 arterial lesions of the forearm and leg, prolonged and forcible flexion super- 
 sedes the ligation of these vessels. Mr. George Y. Heath, in an address de- 
 livered in 1870, before the British Medical Association, reported some very 
 interesting cases which occurred in his practice in 1849, in which, by forced 
 
 * For an interesting case of this kind, vide Butcher's Operative Surgery, p. 386. 
 f January, 1851. 
 
A SYSTEM OF SURGERY. 
 
 or over-flexion, haemorrhage was arrested and life saved.* His experiments 
 are both interesting and instructive, and are inserted here because they will 
 show the best methods by which over-flexion is accomplished. 
 
 (A.) Upper Extremity. — 1. Forearm bent on the arm by muscular action 
 of the individual experimented upon. In persons with considerable mus- 
 cular development, pulse at the wrist entirely stopped. 
 
 2. Forearm bent on arm — simply with the hand flat on the shoulder. Pulse 
 weak and indistinct, but rarely quite stopped. 
 
 3. Forearm bent on arm, with hand pronated ; pulse more weakened, 
 sometimes stopped. 
 
 4. Forearm bent on arm ; hand pronated and extended. Pulse usually 
 quite stopped. 
 
 5. Forearm bent on arm, hand pronated and bent at the wrist. Pulse 
 almost imperceptible, or quite stopped. 
 
 6. Forearm bent on arm, with a roll of lint or cambric pocket handker- 
 chief rolled up and laid in the bend of the elbow. Pulse almost entirely 
 stopped. 
 
 (B.) Lower Extremity. — 1. Leg flexed on thigh. Pulse in posterior tibial 
 artery much weakened. 
 
 2. Leg flexed on thigh, and thigh on abdomen. Pulse in posterior tibial 
 stopped altogether, almost invariably. 
 
 3. Leg flexed on thigh, with a roll of lint or cambric pocket handkerchief 
 laid in the bend of the knee. Pulse stopped in some cases, not always ; but 
 with flexion of thigh on abdomen also, pulse invariably stopped. 
 
 4. Thigh flexed on abdomen, the trunk bent forward. Pulse materially 
 weakened. 
 
 It will, from the above, be observed that in wounds of the palmar arch, 
 by flexing the arm on the forearm, pronating the hand, and applying an 
 ordinary compress at the bend of the elbow, severe haemorrhage can be 
 permanently arrested ; and that by applying a compress at the bend of the 
 knee, and flexing the leg on the thigh, and the thigh on the abdomen, the 
 arterial flow in the plantar arch is certainly arrested. But this method is 
 by no means a painless proceeding. It must be remembered that the suf- 
 fering resulting from maintaining the joints in an over, or forcibly flexed 
 •condition, is very intense, and in some patients cannot be borne for any 
 considerable time without danger. In such cases as these, high elevation 
 of the limb with less severe flexion may answer the purpose.f 
 
 Compression. — Although in reality " over-flexion " may be placed under 
 this division of the subject, as it is the pressure excited by muscle and bone 
 upon the artery that prevents the bleeding, yet for simplicity, it is proper to 
 treat it under a separate heading. Pressure may be either temporary or 
 permanent. " Permanent compression " may be necessary when the blood 
 flows from minute vessels, or when haemorrhage takes place from a vessel 
 imbedded in cartilaginous and bony structures, and when it is impossible 
 to apply any other means to arrest the bleeding. An excellent method of 
 making the compress is as follows : First, sponge away all the blood from 
 the wound, remove all the coagula, and place the finger and thumb firmly 
 ■over the bleeding orifice ; then prepare a dossil of lint, a piece of com- 
 pressed sponge, or prepared tow, which, if it be thought necessary, may be 
 soaked in a solution of tannin, alum, or of the liquor ferri persulphate, or 
 trolled in the powder of the persulphate of iron ; then as the fingers are re- 
 moved, place the compress so prepared, accurately over the bleeding orifice, 
 .and upon this lay another and somewhat larger one, and so on increase the 
 
 * British Medical Journal, August 13th, 1870, p. 165. 
 
 f Vide on this subject a paper read before the American Institute of Homoeopathy, at its 
 ■session in Chicago, June, 1870. 
 
COMPEESSION. 
 
 325 
 
 size of the compress "until quite a good-sized mass of the substance is used. 
 Over this carefully apply a roller bandage, and extend it upon the entire 
 part (taking special care not to make the turns too tight), which will com- 
 plete the dressing. If, however, the blood should appear through the com- 
 press, it may be taken for granted that the pressure is not properly adjusted, 
 and the whole should be removed and more accurately and carefully applied. 
 As a rule, it must be laid down that we should never be content with merely 
 using a compress over the bleeding vessel alone, but in conjunction with 
 this, the bandage applied, as already mentioned, to complete the effect. 
 The whole apparatus must be allowed to remain three or four days before 
 it is removed, and may then be again adjusted less tightly than before. 
 
 Fig. 126 shows the plan of a graduated compress : a, the artery 
 wounded ; b, b, the graduated compress, arranged so that the apex of the 
 
 Fig. 126. 
 
 Fig. 127. 
 
 cone is in immediate contact with the arterial orifice, while its base 
 occupies the general wound, and projects somewhat above the integumental 
 level. 
 
 Dr. Eiedinger* has employed catgut to arrest haemorrhage from bone. 
 Bleeding occurring after an amputation of the thigh, it became necessary 
 to stop the haemorrhage which was fruit- 
 lessly tried in the usual way; it was 
 thought that catgut cut up in several 
 ends and introduced into the bleeding 
 orifice might have the effect of stopping 
 the flow of blood, which it did, and no 
 further trouble was experienced. This 
 is an excellent method of arresting haem- 
 orrhage, first, because the irregularity 
 of the mass favors rapid clotting, and, 
 secondly, because the wound may be 
 closed over the catgut. 
 
 Indirect pressure or temporary compres- 
 sion, is generally used to restrain haem- 
 orrhage during the performance of sur- 
 gical operations, and there is no appara- 
 tus that can compare with the fingers and 
 thumbs of a competent assistant. (Fig. 
 127.) The old-fashioned tourniquet, vide 
 Fig. 128 (next page), consisting of a strap 
 to encircle the limb, a pad to place over 
 the vessel, and a screw to tighten the 
 band, is very efficient, and is used to the 
 present day in operations that take but 
 a short time for their performance. It 
 was introduced by Morrel in 1674, and 
 
 modified by Petit. Before the tourniquet is applied for amputation, it is 
 well to elevate the limb, and having it held in that position by an assistant, 
 
 Digital Compression. 
 
 * The Amer. Journ. of the Med. Sciences, April, 1878. No. CL., New Series. 
 
326 
 
 A SYSTEM OF SURGERY. 
 
 the surgeon, beginning at the extremity, with both hands encircling the 
 limb makes friction steadily and firmly towards the trunk, thus saving 
 much venous haemorrhage. 
 
 Various tourniquets have been used at different times ; those of Signorini, 
 Malan, Skey, and others. In the United States army, during the late war, 
 an ingenious tourniquet was used for temporarily suppressing arterial haem- 
 orrhage, while allowing the venous circulation to continue unrestrained. 
 
 Fig. 128. 
 
 Fig. 129. 
 
 Petit's Tourniquet. 
 
 Signorini's Tourniquet. 
 
 It consists merely of pads with flanges, the latter holding off the straps 
 which keep the compresses in their place. In some of the regiments every 
 
 Fig. 130. 
 
 Fig. 131. 
 
 Skey's Compressor. 
 
 Pancoast's Tourniquet. 
 
 soldier was supplied with one, and was taught the method of its applica- 
 tion, with what result, however, I am unable to say. 
 
 Fig. 129 represents Signorini's tourniquet. Fig. 130 shows the compres- 
 sor of Professor Skey. Fig. 131 represents Pancoast's tourniquet for the 
 compression of a single artery. 
 
 Dr. Arthur E. Spohn,* of Texas, has devised what he denominates the 
 rubber-ring tourniquet, Fig 132, which, from the remarks upon it, would seem 
 to be a very effective and an easily applied method of arresting haemorrhage. 
 
 Eichmond and Louisville Journal, November, 1876. 
 
TORSION. 
 
 327 
 
 Fig. 132. 
 
 This tourniquet is made for the arm and leg, and is applied by rolling it 
 
 up the extremity. The doctor states that he has " resected the shoulder 
 
 joint three times successfully, without the 
 
 least haemorrhage," and also amputated the 
 
 thigh " without losing any blood during the 
 
 operation." 
 
 Torsion. — The torsion or twisting of arte- 
 ries to arrest bleeding was mentioned by 
 Galen, and I believe was reintroduced by 
 Amussat, Thierry, and Velpeau, but gradually 
 fell again into disrepute, excepting in those 
 cases where the haemorrhage proceeded from 
 vessels of the fourth class. After the intro- 
 duction of the acupressure needle by Simpson 
 (over fifteen years ago), torsion again came 
 into vogue, and has met with the highest 
 favor among surgeons. The method usually 
 recommended is as follows : Seize the vessel 
 
 with the ordinary artery forceps, taking especial care that it only is embraced 
 within the jaws of the instrument. Then draw forward the artery, and 
 with a pair of forceps, with roughened and narrow blades, take hold of it 
 transversely, or at right angles with the vessel ; press down the blades of 
 
 Fig. 133. 
 
 Torsion of an Artery. 
 
 this pair of forceps firmly, in order to lacerate the internal and middle coats 
 of the vessel, and then twist the artery with the artery-forceps several times 
 around itself, and the operation is completed. Fig. 133. 
 
 In a paper read before the Clinical Society, of London, Mr. Cooper Forster 
 states that after losing two cases from haemorrhage after acupressure, he had 
 employed torsion alone in several cases of amputation, in excision of the knee, 
 elbow, and hip, and forty other operations, with complete success. He pre- 
 fers torsion to acupressure on account of the reduplication of the middle 
 and internal coats of the artery, thereby affording a mechanical impedi- 
 ment, which increases daily, while acupressure only forms pressure above 
 the pin. Dr. Bryant states that he has not employed the ligature in ampu- 
 tations since January, 1868, and has had no cases of secondary haemorrhage* 
 — of 300 cases of amputation, 110 were of thigh, and torsion practiced on 
 the femoral. This is most remarkable success, and Mr. Callender,f in a 
 lecture upon the subject, thus writes : " There is no record, where the oper- 
 ation has been properly practiced, of any sloughing of the twisted end, or 
 of any abscess along the track of the vessel ; and whilst the presence of a 
 foreign body in the wound is avoided, the patient escapes the anxiety 
 which the prospect of the removal of the ligature entails. And to add one 
 other (and this is a strong argument in favor of torsion), it is free from all 
 risk of that secondary bleeding which is sometimes associated with the 
 
 * Medical Times, October 15th, 1870, p. 22. 
 
 f Lancet, March 21st, 1874. 
 
328 
 
 A SYSTEM OF SURGERY. 
 
 separation of the ligature." It would appear also, that torsion is applicable 
 to the larger vessels, while the smaller are more secure when tied with the 
 ligature. Poland has successfully applied torsion to the femoral artery six 
 times, to the brachial twice, and to numerous smaller vessels. Durham has 
 used it for the femoral four times, to the brachial twice, and to many 
 arteries of minor calibre. Dr. Addinell Hewson devised an instrument 
 called the " torsion forceps," which does away with the necessity of using 
 two hands in the operation of torsion, and which exhibits considerable in- 
 genuity. 
 
 M. Tillaux* arrives at the following conclusions : 1. Torsion is applicable 
 to all arteries, and particularly to the larger ones. 2. A single pair of 
 forceps is sufficient, and not two pairs, as employed in England and else- 
 where. 3. The artery should be seized obliquely, and not longitudinally, 
 and in such manner that the three coats in their entire breadth should be 
 included in the grip. 4. The torsion or twisting of the artery should then 
 be practiced until the portion seized becomes detached. 5. It is unneces- 
 sary to adopt measures to limit the extent of the torsion, as practiced by 
 Amussat and the English surgeons, as the operation limits itself either to 
 the parts seized, or one or two centimeters above it. 6. Torsion is applica- 
 ble to atheromatous or inflamed arteries, as well as to arteries in a healthy 
 condition. 7. Torsion favors union by the first intention, owing to the ab- 
 sence of a foreign body, as in the case of ligatures. 8. Like the ligature, 
 torsion prevents primary haemorrhage. 9. Torsion acts more effectually 
 than the ordinary ligature in preventing secondary haemorrhage. M. Til- 
 laux asserts that ever since he began to employ torsion, in 1871, he has 
 never had a single case of primary or secondary haemorrhage, and yet he 
 has practiced it in about a hundred capital operations. 
 
 Dr. Wheeler has introduced an instrument for the torsion of arteries some- 
 what similar to that of Hewson, Fig. 134, which I have successfully employed. 
 
 Fig. 134. 
 
 Wheeler's Torsion Forceps. 
 
 Ecraseur. — In this connection it may be well to mention the ecraseur of 
 Chassaignac, which prevents haemorrhage by twisting the mouths of the 
 
 Fig. 135. 
 
 Ecraseur. 
 
 vessels, as the chain, worked slowly by the screw, passes over the part being 
 cut away (Fig. 135). From considerable experience in the use of the ecraseur 
 
 * British Medical Journal, 1872. 
 
ACUPRESSURE. 329 
 
 in very many operations, I can speak of its efficacy. In haemorrhoids, am- 
 putation of the tongue, through the pedicle of ovarian tumors, to divide the 
 stalks of uterine tumors, and in other operations, I have used it with com- 
 plete success. 
 
 The main desideratum in the application of the ecraseur is the formation 
 of a pedicle. In flat tumors this can be accomplished by passing below 
 the surface, and especially beyond the diseased mass, large needles, beneath 
 which needles a strong ligature is drawn somewhat tightly ; this makes an 
 excellent pedicle, and the chain may be passed around this and slowly 
 worked. In some instances an incision through the integument greatly 
 facilitates the operation. If there be much substance to be removed an 
 excellent method of application is as follows : A trocar, with a canula of 
 sufficient calibre to admit the passage of the chain, is passed beneath the 
 parts to be removed, and a small elastic bougie, having been tied to the end 
 of the chain, is pushed through the canula and made to emerge at the point 
 desired. In some instances it may be necessary to have two of these canula? 
 and trocars, one passing at right angles to the other. The chain and 
 
 Fig. 136. 
 
 screw should always be well oiled, and the instrument should be worked 
 slowly, especially in very vascular growths, indeed, a minute to a link is 
 allowed by some operators. This rule is a good one, and should be fol- 
 lowed by young practitioners. Instead of working with a chain, wire is 
 sometimes used. Fig. 136 represents Smith's modification of the wire 
 ecraseur. From my own experience I much prefer the chain to the wire, 
 because the latter is very liable to break. 
 
 The late Dr. Nott, of New York, devised what he termed a rectilinear 
 ecraseur, which he stated was less likely to be followed by secondary 
 haemorrhage than when the instrument of Chassaignac was used. It is not 
 claimed that it severs the tissues entirely, as does the ecraseur, but crushes 
 them to a pulp ; a ligature is placed around the pedicle, and the parts may 
 then be cut off. 
 
 The ecraseur has, of course, as have all similar instruments, the cases 
 adapted for its use, and though it will never be selected to amputate the 
 thigh, it will always be found usefulin certain vascular parts where opera- 
 tion is required. 
 
 Acupressure. — If Professor Simpson had done nothing else to immortalize 
 his name, the introduction of acupressure into the domain of surgery would 
 have been entirely sufficient. This simple and safe method of arresting haem- 
 orrhage will be more universally adopted when a more thorough trial of its 
 merits has been instituted by surgeons. On December 9th, 1859, Professor 
 Simpson read before the Royal Society of Edinburgh, a paper entitled "Acu- 
 pressure, an Excellent Method of Arresting Surgical Haemorrhage and Accel- 
 erating the Healing of Wounds;" and he subsequently published a most 
 exhaustive treatise of the same subject,* in which all the advantages claimed 
 
 * Acupressure, a New Method of Arresting Surgical Haemorrhage and of Accelerating the 
 Healing of Wounds, by J. Y. Simpson, M.D., F.B.C.S., etc. Edinburgh, Adam and Charles 
 Black, p. 571. 
 
330 A SYSTEM OF STJRGEKY. 
 
 for the method are carefully considered, and compared with other means for 
 controlling haemorrhage. It will be some time no doubt before acupressure 
 will become generally adopted. It is very difficult to overcome precon- 
 ceived opinions, and especially our actual experience. We know from facts, 
 that in operations of all magnitudes the vessels have been secured by anti- 
 septic ligatures, and that hundreds of thousands of patients have made ex- 
 cellent recoveries after hemorrhage has been restrained in this manner, 
 and therefore the apparent insecurity of acupressure has, no doubt, pre- 
 vented many from applying it. For the same reason the ancients rejected 
 the ligature of Pare. But when we contemplate the rationale of acupressure 
 we will be convinced of its efficacy. The process which takes place in the 
 artery after the introduction of acupressure needles is somewhat similar to 
 that noticed in natural haemostatics. The needle presses together the walls of 
 the artery, acting as does the external coagulum; the blood then stagnates 
 in the vessel up to the nearest anastomosing branch, forming the internal 
 coagulum. The lymph is exuded between the pin and the " couvercle," 
 and the vessel is closed. 
 
 The needles are bayonet-pointed, vary in length from two to five inches ; 
 they should have cutting edges and firm round glass heads to facilitate their 
 introduction through the tissues. The other instruments are needles of 
 various lengths, threaded with iron wire. These needles or pins may be 
 used several times. Those which I have been in the habit of using I pro- 
 cured in Edinburgh from the cutler who made them under Professor Simp- 
 son's express direction. 
 
 There are several methods of using acupressure, as described by Professor 
 Simpson, and one introduced by Joseph C. Hutchison, M.D., of Brooklyn, 
 N. Y., which he terms " The Brooklyn method." In his elaborate paper on 
 this subject Dr. Hutchison has done much to introduce the subject to the 
 American profession, and his statistics are very valuable.* Drs. Pirrie 
 and Keith have also introduced their methods, making in all eight forms 
 of acupressure, Professor Simpson at first describing but three. 
 
 1st Method. — The pin is pushed through from the cutaneous surface of 
 the flap, it is then passed sufficiently close to the artery to press together 
 its walls, and the point brought out again on the surface ; or, as Professor 
 Simpson remarks, in the same manner as we pin the stalk of a flower in the 
 lapel of a coat. 
 
 2d Method. — Take a needle, threaded with iron or silver wire, to render 
 its withdrawal easy, and having raised up the flap, catch up sufficient tissue 
 with the point to make the needle firmly hold, and then bring out the body 
 of the needle close to the vessel and imbed its point again in the tissue, in 
 the same manner as the tailors " run a thread." 
 
 3d Method. — Pass the needle behind the vessel, and having thrown a loop 
 of iron wire around its point, bring the same (the wire) in front of the artery 
 and twist it around the needle. 
 
 4th Method. — This is similar to the third, with the exception that a pin is 
 used from the cutaneous surface of the flap, rather than the needle on the 
 internal face. 
 
 5th Method. — This is known as the " Aberdeen Twist," which is performed 
 as follows : The pin or needle is inserted on one side of the bleeding vessel, 
 and its point made to emerge from the tissue a few lines from the artery. 
 The head is then made to rotate either a quarter or half a circle, and the 
 point pressed close to the artery as it is passed into the tissue beyond. 
 
 6th Method. — A loop of wire and a pin are the instruments necessary. 
 " The pin is inserted into the tissues on one side of the artery and close to 
 
 * The Merritt H. Cash Prize Essay, " A Practical Treatise on Acupressure, by Joseph C. 
 Hutchison, M.D." Transactions of New York State Medical Society, 1869, p. 86. 
 
ACUPRESSURE. 331 
 
 > 
 
 its mouth, and is carried transversely to the vessel through the tissues of 
 the opposite side ; an end of the wire is held in each hand and the loop 
 thrown over the point of the pin, and the ends, brought back on each side 
 of the artery, are crossed behind the body of the pin, and are drawn in 
 opposite directions, sufficiently tight to close the vessel ; the ends are then 
 brought up on each side, and the wire is fixed by a half twist around the 
 pin's head." 
 
 7th Method. — This is very similar to the second, with this difference ; 
 the pin is entered at the cutaneous surface of the flap, and brought out 
 again in front of the artery, thereby compressing it against the bone ; it is 
 then entered again on the cutaneous surface on the other side, and buried 
 in the tissues sufficiently to hold it securely, bringing the point out on the 
 flap. 
 
 8th Method, is that known as the Brooklyn method, and is especially ser- 
 viceable in closing arteries in their continuity. The artery is first exposed 
 by the usual dissection, then a loop of wire is laid in the wound parallel 
 with the artery. The pin is entered in the integument, and brought out be- 
 neath the vessel, the loop of wire is then passed over the point of the pin, 
 which is then pressed into the skin on the other side, and the ends of the wire 
 secured by half a turn around the pin. 
 
 The pins may be removed in a very short time, indeed, to those employ- 
 ing acupressure, it requires quite an amount of moral courage to remove 
 the pins or needles according to the directions laid down. I have with- 
 drawn a needle from the femoral in 38 hours, and from the brachial in 
 24 hours, and have removed the pins from the facial on several occasions 
 immediately after excising the lower jaw. An instance is upon record where 
 a boy removed the pin from the femoral in four hours after its application 
 without any haemorrhage. In a case of extirpation of the mamma, Coghill 
 removed the apparatus in two hours after the operation. No bleeding 
 resulted.* 
 
 In October, 1867, my friend, Dr. Comstock, applied acupressure to the 
 arteries of the leg in a secondary amputation (the primary being Chopart's, 
 and was performed by myself during my term of service), in which the 
 hemorrhage was arrested, and the pins removed in forty-eight hours. The 
 cure was perfect, and the wound healed by the first intention.f Dr. Simp- 
 son thus sums up the comparison between the ligature and acupressure. 
 
 LIGATURE. ACUPRESSURE. 
 
 1. Eequires isolation, and consequently 1. Eequires none. 
 
 some detachment of the end of the 
 vessel from its vital organic connec- 
 tion. 
 
 2. Produces direct mechanical injury, bruis- 2. Produces none. 
 
 ing and lacerating the two internal 
 coats of the artery. 
 
 3. Produces strangulation of the external 3. Produces none. 
 
 coat. 
 
 4. Leads on inevitably to ulceration or 4. Produces none. 
 
 molecular destruction of the external 
 coat of the constricted part. 
 
 5. Causes mortification of the artery at the 5. Produces none. 
 
 tied point, and usually below it. 
 
 6. Produces, consequently, as many sites of 6. Produces none. 
 
 ulceration and suppuration, and as 
 many dead decomposing sloughs in 
 each wound as there are arteries liga- 
 tured in the wound. 
 
 * Vide Simpson on Acupressure, and Hutchison, p. 87. 
 
 f Transactions of the American Institute of Homoeopathy, 1868, p. 74. 
 
332 
 
 A SYSTEM OF SURGERY. 
 
 LIGATURE. 
 
 7. If organic, as of silk or hemp, it imbibes 
 
 animal fluids, which speedily decom- 
 pose and irritate the surrounding 
 living structures. 
 
 8. Eequires to produce the three highest 
 
 stages of inflammation at each liga- 
 tured point, viz., ulceration, suppura- 
 tion, and mortification. 
 
 9. Is not removable, except by slow ulcera- 
 
 tion and sloughing of the ligatured 
 vessel, and requires a period of from 
 four or five to twenty days or more for 
 its separation. 
 
 10. Stops only the artery tied. 
 
 11. Stops only one artery. 
 
 12. Generally requires two persons for its 
 
 application. 
 
 13. Is sometimes followed by secondary haem- 
 
 orrhage, as an effect of sloughing and 
 ulceration. 
 
 14. Sometimes fails altogether, in cases of re- 
 
 curring secondary haemorrhage. 
 
 15. Sometimes cannot be applied until the 
 
 surgeon first exposes the bleeding 
 vessel by dissection with the knife, as 
 in vessels retracted in amputations, in 
 wounds of the wrist, etc. 
 
 16. Prevents, as a foreign body, adhesion of 
 
 the sides and lips of the wound by 
 first intention, in the course of its 
 track, as long as it remains. 
 
 17. Is apt, as an irritant body, to disturb and 
 
 upset the process of primary adhe- 
 sion in its vicinity. 
 
 18. Unavoidably creates within the depths 
 
 of the wound, pus, sloughs, and putrid 
 materials, which are locked up and 
 applied to the imbibing or absorbing 
 cut surfaces of the wound. 
 
 19. Places the wound, therefore, in a very 
 
 dangerous local hygienic condition. 
 
 20. Is not unfrequently followed by surgical 
 
 fever, from its leading to the formation 
 and absorption of septic matters from 
 the surface of the wound. 
 
 21. For these various reasons it makes pri- 
 
 mary union rarer, healing slower, 
 and hectic or surgical fever more fre- 
 quent. 
 
 ACUPRESSURE. 
 
 7. Requires only impervious metallic 
 
 needles or threads, which are inca- 
 pable of imbibing animal fluids. 
 
 8. Requires to produce inflammation up to 
 
 the stage of adhesion only. 
 
 Is removable in an hour or two, or in 
 one, two, or three days, at the will of 
 the operator. 
 
 10. Stops generally both artery and vein. 
 
 11. May close two or more smaller arteries 
 
 by means of a single needle. 
 
 12. Requires only one person. 
 
 13. Is seldom followed by secondary haemor- 
 
 rhage from ulceration or from slough- 
 ing, as it produces none. 
 
 14. Has succeeded under such circumstances 
 
 where the ligature has failed. 
 
 15. Does not necessarily require the exposure 
 
 of the vessel, and therefore often pre- 
 vents the necessity for antecedent dis- 
 section by the knife. 
 
 16. Is early withdrawn, and is hence far less 
 
 opposed to primary union. 
 
 17. Is early withdrawn, and has no irritant 
 
 effect. 
 
 18. Does not create nor apply any danger- 
 
 ous putrefying materials to the fresh 
 absorbing surface of the wound. 
 
 19. Places the wound locally in far healthier 
 
 hygienic conditions. 
 
 20. Is much less likely to be followed by 
 
 surgical fever, because it does not lead 
 to the formation of septic matter, and 
 closes the veins as well as the arteries. 
 For these reasons it makes complete 
 primary union more frequent, healing 
 quicker, and hectic or surgical fever 
 
 21 
 
 less common. 
 
 It will be seen that the advantages claimed for acupressure are chiefly 
 the absence of foreign substances in the wound, of inflammation and sup- 
 puration, and although since the introduction of antiseptic animal ligatures 
 the dangers of septicaemia are very much reduced, yet the presence of a 
 thoroughly carbolized pin is preferable in a wound to any variety of liga- 
 ture. I would strongly recommend this method of arresting haemorrhage. 
 
 I have found acupressure also very useful, as a means not only of arrest- 
 ing haemorrhage, but of preventing its occurrence. I do not hesitate to say 
 that the pins applied before operation will prevent haemorrhage in many 
 instances, and that the pressure temporarily excited on the veins and nerves 
 of the part give rise to slight if any inconvenience. 
 
 This method, however, has also many opposers, among whom are Dr. G. 
 M. Humphrey, surgeon to the Addenbrook's Hospital, Mr. I. Cooper Forster, 
 
ACUPRESSURE. 
 
 333 
 
 whose experiments with " torsion " we have already mentioned, Dr. Lee, 
 Dr. Callender, and others. Out of nine cases, in which Mr. Forster applied 
 acupressure, there were four deaths ; one from secondary haemorrhage and 
 pyaemia, one from the latter cause, one from the former, and one from pleuro- 
 pneumonia, following gangrene of the stump. Dr. Callender,* late assist- 
 ant surgeon at St. Bartholomew's Hospital, in speaking of Prof. Simpson's 
 success with acupressure says : " He resorted to it in the case of a breast 
 which had been removed in the Hotel Dieu. Eight needles were employed, 
 and there was no haemorrhage after their removal, but the edges of the 
 wound became erysipelatous, rigors followed, and the patient died in five 
 days after the operation." Of his own experience he says, " that he ampu- 
 tated the breast of an aged woman for scirrhus ; the bleeding was stopped 
 by means of four needles, which were removed thirty-six hours after the 
 operation, but the wound presented an erysipelatous blush, with some dusky 
 discoloration, and beginning rajDidly to distend with products of decompo- 
 sition, had to be speedily opened. Its entire surface was in a state of gan- 
 
 FlG. 137. 
 
 Fig. 138. 
 
 First method, after Pirrie. 
 Circumclusion. 
 
 Torsoclusion.— Pireie. 
 1. Introduction of pin. 2. The torsion. 
 
 grene, and the woman, sinking with symptoms of blood poison, died six 
 days after the operation." These facts are introduced here, that the impar- 
 tial may judge of the merits of this method of arresting haemorrhage, 
 although it appears to me, that most of the cases cited are scarcely fair 
 
 Fig. 139. 
 
 Retroclusion. 
 
 samples on which to test the merits of acupressure. Dr. Addinell Hewson,f 
 of the Pennsylvania Hospital, is an advocate of the method. 
 
 * A Report on the Progress of Surgery, by E. A. Clark, M.D., p. 24. 
 f Vide Pennsylvania Hospital Reports, p. 127. 
 
334 
 
 A SYSTEM OF SURGERY. 
 
 It has been proposed by Professor W. Pirrie, a great advocate of acupres- 
 sure, that three methods only should be adopted, and Sir James Simpson, 
 before his death, agreed to the proposition, and named the three methods : 
 circumclusion (Fig. 137), torsoclusion (Fig. 138), and retroclusion (Fig. 139). 
 In the first, the pin is passed behind the artery, and an elastic wire looped 
 over the point and twisted around the pin, thus, the pin is behind, the wire 
 in front. 
 
 Torsoclusion has already been described as the " Aberdeen method." 
 
 In retroclusion, the pin passes behind the artery, after its point is made 
 to describe the greater part of a semicircle.* 
 
 Several modified forms of acupressure have been adopted by surgeons, 
 but it is impossible to mention them in this chapter. A very ingenious one, 
 however, is that devised by R. Clement Lucas, Esq., late house surgeon to 
 Guy's Hospital. 
 
 Dr. Oscar H. Allisf has devised acupressure forceps of several sizes for the 
 arrest of haemorrhage, which I have used with advantage. They are readily 
 
 Fig. 140. 
 
 Fig. 141. 
 
 JFig.2 
 
 Allis's Acupressure Forceps. 
 
 applied, and answer admirably for the purpose intended. Fig. 140 repre- 
 sents the instrument open. The needle is to thrust underneath the vessels, 
 and the blunt blade closing over the bleeding surface stops the haemorrhage. 
 Fig. 141 represents the instrument straight, and shut. There are larger 
 sizes, to be used where more tissue is to be embraced between the blades. 
 
 Wyeth's haemostatic forceps is also used to take up a large quantity of 
 bleeding tissue, and by the catch at the handles is serviceable in many 
 
 Fig. 142. 
 
 Wyeth's Hemostatic Forceps. 
 
 ways. I have employed it often as a clamp before putting the ligature 
 upon tissues, or to arrest an extensive haemorrhage while an operation was 
 being completed. Fig. 142 represents the forceps. 
 
 * Braithwaite, January, 1872, p. 137. 
 
 f Medical News, Philadelphia, September 1st, 1883. 
 
ARTERY CONSTRICTOR. 
 
 335 
 
 Fig. 143. 
 
 Percutaneous Ligation. — Ledran, in 1720, was the first to mention this 
 method of securing arteries, and in 1856, Professor Middledropf, of Breslau, 
 revived it.* It is becoming quite a favorite method of 
 arresting haemorrhage, especially from the palmar arch. 
 In recent numbers of the medical periodicals I have ob- 
 served several cases of its successful application. It con- 
 sists in casting a ligature around the artery near its divi- 
 sion, or in the continuity of the vessel, by means of a 
 curved needle, threaded with silk, or silver or iron wire, 
 which is made to pierce the integument, is carried beneath 
 the vessel, including in its course more or less of the soft 
 parts, and made to emerge, in the integument, on the 
 opposite side, at a point equidistant from its point of en- 
 trance. A compress is placed between the extremities of 
 the ligature, which are then tied. The entrance of the 
 needle should be made from one-third to one and a half 
 inches from the artery. The ligature may be allowed to 
 remain from three to seven days. This is easily accom- 
 plished and is safe, no danger being apprehended from any 
 particular source. It is indeed a species of acupressure. 
 
 Other Methods. — Speir 1 s Artery Constrictor. — At a meet- 
 ing of the New York State Medical Society, held in Al- 
 bany, the Merrit H. Cash prize was awarded to S. Fleet 
 Speir, M.D., for his essay on " A New Method of Arresting 
 Surgical Haemorrhage by the Artery Constrictor," etc. 
 Having myself witnessed the application of this instru- 
 ment in several cases, with complete success, and having 
 applied it to the common carotid in its continuity, I have 
 great confidence in its power to arrest arterial haemorrhage. 
 " It consists," says Dr. Speir,| " of a flattened metal tube, 
 six inches (more or less) in length, open at both ends, 
 with a sliding steel tongue running its entire length, and 
 having a vise arrangement at its upper extremity, by 
 which it can be made to protrude from or retract within 
 the tube or sheath. The lower end of the tongue is hook- 
 shaped so as to be adapted to the artery to be constricted. 
 It is so shaped, that having grasped an artery it can be 
 made to contract upon it by means of the vise at the upper 
 end, which forces it within the sheath. The hook of the 
 tongue is so shaped and grooved as to form only a com- 
 pressing surface, by which means the artery, when acted 
 upon by the force of the vise, is compelled to assume the 
 form of the curve of the tongue, and the artery is con- 
 stricted in such a way that its internal and middle coats 
 give way, but the external coat is preserved intact. The severed internal 
 and middle coats contract, retract, and curl upon themselves, and are drawn 
 down into the artery in the form of a plug by the continued pressure of the 
 grooved tongue as it passes on into the sheath." (Fig. 143.) The experi- 
 ments made by Dr. Speir with this remarkable instrument are quite con- 
 clusive. For instance, it was applied at two points to the carotid of a horse 
 in the continuity of the vessel ; the artery was then divided between the 
 points oVappui; no haemorrhage followed. The horse was then thrown down, 
 
 Speir's Artery Con- 
 strictor. 
 
 * Keport on the Progress of Surgery, by Professor E. A. Clark, p. 33. 
 f Medical Record, April 1st, p. 49. 
 
336 A SYSTEM OF SURGERY. 
 
 but the ends of the vessel remained closed. Experiments were also made 
 upon dead arteries, upon living dogs and sheep, upon the femoral, profunda, 
 and other arteries, with remarkable success. Dr. Speir claims for his instru- 
 ment its efficiency, its safety, its ease of application ; that no internal clot is 
 necessary on account of the invagination of the middle and inner coats of 
 the vessel ; that no foreign substance is left in the wound ; that the risk of 
 pyaemia or phlebitis is very much lessened ; and that it is applicable to any 
 artery when the external coat is intact. This method of arresting haemor- 
 rhage deserves the strictest attention of the surgeon, and fair and impartial 
 trials should be made with it before it is either too highly lauded or too 
 severely condemned. I am very favorably impressed with what I have 
 seen of its action, and shall take every opportunity to give it a fair tri al. 
 
 Steams' Artery Clamp. — Dr. C. W. Stearns, of New York, has also intro- 
 duced to the profession an instrument for arresting haemorrhage, especially 
 from deep-seated arteries. It consists of a slender pair of forceps grooved 
 in the beak ; the clamp consists of perfectly annealed iron wire somewhat 
 in the shape of a horseshoe. At the other extremity of the forceps is an 
 arrangement by which the clamps may be removed. The loop of wire is 
 fitted upon the groove in the beak, thrust around the artery, and " a dead 
 pinch " made.* There is no elasticity to the wire, and it " sets " immediately 
 over the coat of the vessel. After a number of days the wire is removed, 
 as above mentioned, by a simple contrivance arranged in the handles of the 
 forceps. 
 
 Smith's Metallic Snare, and other Methods. — The late Professor Nathan R. 
 Smith, of Baltimore, devised what he termed his " Metallic Snare for 
 Arresting Haemorrhage, "f It consists of an annealed iron wire, and a silver 
 tube. The ends of the wire are slipped around the vessel, and then passed 
 through the tube, so that the flow of blood is instantaneously arrested. 
 The wire must cut its way out before it can be removed, which is rather a 
 drawback to its application. 
 
 Mr. John Dix, of Hull, and Mr. Teale, have also tried what they consider 
 a modified form of acupressure.^ The artery is to be isolated, the wire 
 passed around it, the ends being brought out through the surrounding in- 
 tegument, and fastened over a needle or probe. Dr. Sands, of New York, 
 reported to the Pathological Society, in October, 1867, a case where this 
 method was tried upon the femoral, but the patient died shortly after. Dr. 
 Aitken, of Michigan, has written a paper,§ on what he terms " Compound 
 Acupressure" in which two needles are used, the vessel being compressed 
 between them, and Dr. Van Gieson, of Greenpoint, New York, has a very 
 ingenious contrivance for arterial compression by "a sectional ligature ,"|| 
 more especially designed for the treatment of aneurism. 
 
 Ligature. — Having mentioned the numerous methods for arresting sur- 
 gical haemorrhage, which have been proposed at different periods, we come 
 last to the ligature. Its consideration has been postponed in order to 
 show that the ideas introduced by many have been entertained by others 
 in the profession in times gone by. For instance, Scarpa employed a 
 flat ligature to arrest haemorrhage, and placed between the ends of the 
 same a species of compress, because he asserted that it was not necessary 
 that inflammation should be established to obliterate the artery, all that 
 was required being an approximation of the sides of the vessel. Jones, 
 
 * American Medical Times, November 16th, 1861. 
 
 f New York Medical Gazette, vol. i., October 19th, 1867. 
 
 X Lancet, January 5th, 1867 ; Medical Gazette, December 30th, 1865. 
 
 g American Journal of the Medical Sciences, July, 1865. 
 
 || Medical and Surgical Keporter, February, 1868. 
 
LIGATURE. 337 
 
 in 1806, affirmed that Scarpa's opinion in this regard was entirely errone- 
 ous, and that it was very essential that organizable matter should be 
 thrown around and into the vessel, to permanently restrain the flow of 
 blood, and that therefore a round ligature must be applied to divide the 
 internal and middle coats of the artery. After a time, " the temporary liga- 
 ture " was introduced, which was much after the manner of what has been 
 said of percutaneous ligation. Then there was introduced "the sudden 
 obliteration," by rupturing the internal and middle coats of the artery at 
 short distances from each other, thus establishing several points where co- 
 agulable lymph would be effused, to check the flow of blood immediately, 
 and M. Travers, in his experiments upon horses, found that a ligature kept 
 upon the carotid for the space of six, two, or even one hour, generally 
 effected a permanent obliteration of the vessel. In 1817 he applied a liga- 
 ture to the brachial artery, and removed it in fifty hours without any haem- 
 orrhage, and M. Robert put a ligature upon the femoral of a sailor, left it 
 twenty-four hours, and then removed it, curing him of an aneurism in 
 twelve days. All these experiments show that the idea of closing arteries 
 by constriction was thought of by these surgeons, and it is a possible fact 
 that a ligature may be removed in a few hours after its application, and that 
 allowing it to remain longer sets up an inflammatory action, which termi- 
 nates in suppuration, and thus produces the very result the surgeon en- 
 deavors to avoid, viz., secondary haemorrhage. If the thread could be 
 removed at the proper time, viz., when there has been a sufficient effusion 
 of fibroj. enous material, would not the haemorrhage be arrested almost as 
 effectually as by the acupressure pins of Simpson ? 
 
 Dechamps invented an " artery compressor," in which a ligature behind 
 the vessel, and a metallic plate in front of it, arrested bleeding, and in Vel- 
 
 FlG 144. 
 
 peau's Surgery there is detailed, as " a new method," the same pro- 
 ceeding, with a needle threaded with wire, and a loop of the same material, 
 as already described as Simpson's third method of acupressure. 
 
 The ligatures most generally in vogue at the present day are those of 
 silk, silver, iron, and flax, with the animal 
 ligature, which we shall notice below. FlG - 145 - 
 
 To ligate a vessel, its extremity must be 
 seized with the artery forceps (Fig. 144), drawn 
 forward, and the ligature placed around it, and 
 tied by the surgeon's knot, or the ordinary 
 reef-knot (Fig. 145). It is not at all neces- 
 sary to put much strain upon the ligature ; 
 all that is required is to draw it firmly around 
 the vessel. 
 
 Sometimes, especially in small vessels, it is better to use the ordinary 
 tenaculum (vide Fig. 146;, and a portion of structure may be taken up 
 with the hook, although the artery should be as clear as possible from the 
 surrounding substance. When we are ligating an artery in its continuity, 
 after the vessel has been exposed, the ligature must be passed beneath by 
 
 22 
 
338 
 
 A SYSTEM OF SURGERY. 
 
 an aneurism-needle (vide Fig. 147), which is a blunt tenaculum, with an eye 
 near its point. 
 
 Fig. 148 represents a double tenaculum used at Bellevue Hospital ; it is 
 very useful in securing retracted vessels. For different artery forceps, 
 see page 36. 
 
 If the ligature be of silk, it must be well waxed, and that 
 article known as braided silk is preferable. Dr. Philip Syng 
 
 Fig. 146. 
 
 Fig. 148. 
 
 Fig. 147. 
 
 Physick, known as the Father of American Surgery, had the 
 strongest objection to silken threads, and much preferred those 
 of flax or bobbin, he being of opinion that the silk was much 
 more likely to slip. It was this distinguished surgeon who 
 introduced the animal ligature,* and this form of thread has 
 been largely used. He used catgut, although the fibrous tissue 
 of the deer is much preferred by some surgeons. It must be 
 dried and twisted into a firm round thread smooth and regular on 
 the surface, non-elastic, and sufficiently strong to resist the trac- 
 tion made upon it by the surgeon. The ends of this variety of 
 ligature can be cut off short, and the wound closed over them. 
 One objection, however, may be found in the fact that these 
 ligatures do not always determine the degree of inflammation 
 necessary to the obliteration of the artery. 
 
 Antiseptic Ligature. — Professor Lister, to whom the profession 
 is so largely indebted for the various methods of applying car- 
 bolic acid, speaks in terms of unqualified praise of the animal 
 ligature when it is steeped in a solution of carbolic acid. He 
 uses catgut, saturated or steeped in the following preparation : 
 
 Carbolic acid, 
 Olive oil, 
 Water, 
 
 1 part. 
 5 parts. 
 3 parts. 
 
 He says also : f " When we apply a ligature of animal tissue 
 antiseptically upon an artery, we virtually surround it with a 
 ring of horny tissue, and strengthen the vessel where we ob- 
 struct it." He also highly recommends what are termed anti- 
 septic ligatures, which are composed of silk steeped for a length 
 of time in a saturated watery solution of carbolic acid. He ex- 
 perimented with this ligature upon the carotid of a horse, dress- 
 ing the wound with a solution of carbolic acid and olive oil, one 
 part of the former to four of the latter. The wound healed by 
 the first intention, and after the death of the animal, which oc- 
 curred from causes in no way connected with the operation, the 
 
 vessel was entirely closed, and the ligature was found imbedded in a fibrous 
 
 structure, with no appearance whatever of any irritation. 
 
 * Vide Memoir of the Life of Philip Syng Physick, by Kandolph, p. 
 f London Lancet, April, 1869. 
 
 84. 
 
339 
 
 On this subject, Dr. Eben Watson reports that in all the cases of ampu- 
 tation under his charge at the Glasgow Royal Infirmary, he used ligatures 
 of Mr. Lister's prepared catgut. "I cut them," he says, "short off at the 
 knot and closed the stump over them. Never in any one case have I been 
 able to detect the ligatures in the discharge ; I mean the early sero-san- 
 guineous discharge which flows for a few hours after amputation. I may 
 say that none of the stumps suppurated, except very slightly and super- 
 ficially. I ought also to state that there was no instance of secondary haem- 
 orrhage in all these cases of amputation. I have, therefore, great pleasure 
 in recording my sense of the value of this reintroduction of organic ligatures 
 into surgery, for which we are indebted to Mr. Lister." 
 
 At present there is a good deal of discussion among surgeons regarding 
 the use of the antiseptic ligature, but the testimony of most of them is in its 
 favor. I have used it in many ways, and upon the largest vessels ; have 
 applied it to the pedicles of ovarian tumors, and in amputations, resections, 
 removal of all kinds of tumors, and have not had a single accident of any 
 kind occur. I am strongly in favor of this method of securing arteries. 
 
 There are a few rules which it is well to observe in the application of the 
 ligature : 
 
 1. Draw the vessel forward sufficiently to give a good space for the thread 
 to be passed around the artery. 
 
 2. If operating for aneurism, do not place the thread on a trunk near a 
 good-sized branch. 
 
 3. Be particular not to draw upon the thread too tightly, or the external 
 coat may be endangered. 
 
 4. Be certain that the knot does not slip, the reef-knot being the best for 
 this purpose. 
 
 5. Do not draw upon the ligature to see if it is separating, but allow it to 
 come away of itself, the period of time differing in different subjects. 
 
 According to reliable statistics, it is found that the longer period of time 
 it takes for a ligature to separate, the less danger is there of haemorrhage. 
 
 The application of wire, either of silver, iron, or platinum, was strongly 
 advocated by both Physick and Dieffenbach, although the systematic intro- 
 duction of silver sutures into the domain of surgery is claimed by Dr. Sims, 
 of New York. The varied methods of using wire have been already noted in 
 the different apparatuses employed for arresting haemorrhage — as Simp- 
 son's acupressure, Stearns' clamp, Nathan R. Smith's snare, Van Gieson's 
 sectional ligature, and others. 
 
 For further information regarding the ligature the student is referred to 
 the chapter on Minor Surgery, article " Ligature Threads" p. 38. 
 
 Esmarch's Method of Artificial Isphaemia. — If we include in the meaning 
 of the word " operation," as applied to surgery, the entire process of cut- 
 ting, ligation of vessels, and dressing of wounds, it cannot be said that Es- 
 march's method is "bloodless."* During the cutting and tying there is no 
 blood, at least a very little lost ; but after the upper band has been removed 
 there is often a plentiful supply. 
 
 Several surgeons have claimed priority for this method, more especially 
 Silvestri, of Vicenza ; Esmarch, therefore, being called the " promoter," and 
 not the discoverer of the bloodless method. Stromeyer, Langenbeck, and 
 many others, have also had similar ideas. This, however, is of little prac- 
 tical importance; the truth is that Esmarch utilized the bandage, and 
 brought it before the profession, as Morton did the ether anaesthesia, and to 
 them the profession at large are indebted. 
 
 * Vide article by K. F. Weir, M.D., Med. Rec., vol. ix., p. 60. 
 
340 
 
 A SYSTEM OF SURGERY. 
 
 As is well known, the apparatus consists of two rubber bands, one broader 
 than the other, which may be applied in the following manner : 
 
 Elevate the limb, and if there be suppurating sinuses, place over them 
 small wads of prepared oakum, and over these pads put on a roller ban- 
 dage, beginning at the toes or the fingers, as the case may be. Then take 
 the broad bandage, which was formerly made of elastic webbing, but now 
 of pure gum, and beginning at the distal extremity of the limb, put it on 
 tightly, being sure to keep the bandage on the stretch while the turns are 
 being made. A moderate amount of force is all that is required, and the 
 bandage should be slowly put on to give the blood time to recede. After a 
 point sufficiently far above the site of operation has been reached, this ban- 
 dage may be turned two or three times around the limb, and secured by 
 
 Fig. 149. 
 
 Esmarch's Bandage applied, fastened with hooks. 
 
 Fig. 150. 
 
 passing the extremity under the last turn. This being done two or three 
 times, does away with the upper band. However, if the upper band (which 
 is generally india-rubber tubing, either round or flattened) is to be applied, 
 it is put on over the upper turns of the first, and secured by the hooks and 
 chain at the end (vide Fig. 149) ; or what is better, especially if the band 
 is round, an instrument figured in the cut, which I have found very valu- 
 able in many instances, simply because 
 all slipping is prevented. 
 
 The original instrument is described 
 in Esmarch's prize essay on military 
 surgery, and was introduced to my 
 notice by Mr. Tiemann. The tubing 
 being drawn out, of course becomes thin- 
 ner, and is then pressed into the slit on 
 the top of the cylinder (Fig. 150); both 
 ends are to be put in, and then the pres- 
 sure withdrawn. The tubing coming 
 back to its original size, of course becomes 
 firmly fixed.* 
 
 After this, beginning at the distal end 
 of the extremity, or in other words at the 
 point where the bandage was started, the 
 india-rubber and the cotton roller are re- 
 moved, showing the limb blanched, pale, 
 with modified sensibility, and at a temperature lower than normal. 
 If we place the ear upon the chest when the bandage is being applied, 
 
 Clamp for Esmarch's Bandage. 
 
 * According to Dr. Eobert Weir (Medical Record, February 10th, 1878), who gives a 
 wood-cut of this instrument, Langenbeck has also devised a clamp somewhat like an ovarian 
 clamp, for similar purposes. 
 
341 
 
 there is at once perceived an increase in the action of the heart, which has 
 been supposed to arise from the diminution of the normal difference 
 between the pressure of arterial and venous blood; that is, the blood 
 being pressed up first into the veins, produces increased action of the 
 right heart. 
 
 The same result, viz., increase in the heart's action, takes place when 
 the bandage is being removed. This, no doubt, is occasioned by the reverse 
 condition, viz., the removal of arterial pressure, and the overaction of the 
 left heart. 
 
 Dr. Gamgee has made several experiments regarding the effects of this 
 pressure on the general circulation.* He found that when the blood was driven 
 from one leg, there was a short increase in the frequency of the heart-beats ; 
 when both legs were subjected to the pressure the same results followed. 
 He found also, that the blood first left the veins, then the arteries, and 
 finally the lymphatics, and was of opinion, that compressing the limbs 
 would send no more blood into the veins than into the arteries, and as the 
 lymph would have a tendency to swell, the venous pressure, the venous 
 blood, and the lymph would be greater in amount than the blood sent into 
 the arteries ; but the controlling influence of the valves of the veins would 
 prevent the general increase of pressure. 
 
 There can be no doubt of the great efficacy of this bandage in restraining 
 haemorrhage, and par excellence is it of service in all operations for bone dis- 
 ease. None but those who have cut down through the very vascular struc- 
 tures which often cover diseased bone, or those who have been groping 
 about sinuses or through incisions to find dead bone, know the comfort 
 of seeing what is being done. The general voice of the entire profession is 
 in favor of this method, although several objections have been found to it. 
 I exsected a shoulder and had paralysis of the arm follow from pressure ; 
 motion returned in three months. 1 removed a large sequestrum from the 
 femur, and had a similar result, the patient recovering in one month. These 
 two untoward circumstances are all that I have personally been cognizant 
 of, and I have used the bandage a great many times. 
 
 Dr. Weir, in the Medical Record,^ publishes a case of paralysis of the 
 hand and forearm, caused by the bandage, and refers to three cases reported 
 by LangenbeckJ where similar results followed. A similar accident is men- 
 tioned as occurring in the Roosevelt Hospital ; and Dr. Stephen Smith § re- 
 cords a case of fatal cellulitis following the use of the bandage. 
 
 A point here worthy of note is, that the elastic webbing is unsafe. When 
 new, it acts well, but after it has been used a few times, the cotton becomes 
 weak, the elastic becomes brittle, and it breaks readily . This has happened 
 to me twice. The plain rubber- is best, and has the great advantage of 
 being kept clean. The bloodstains on the webbing and other soiling, which 
 are unavoidable, soon render it unfit for use. Capillary hemorrhage, said 
 to arise from paralysis of the coats of the vessels from pressure, has also 
 been remarked. The little bleeding that I have observed, generally is soon 
 arrested by exposing the surface to air or the application of ice. 
 
 Dr. Kupper,|| of Elberfield, points out, as a serious disadvantage of Es- 
 march's bandage, the free and prolonged bleeding from many small arterial 
 branches, thus compelling the surgeon to tie two or three times the number 
 of vessels that he need have tied had not Esmarch's apparatus been used. 
 
 * American Journal of Medical Sciences, January, 1877, p. 230. f May, 1874. 
 
 X Medical Times and Gazette, January, 1874. 
 
 \ Medical Record, 1874, p. 592 ; Archives Clinical Surgery, vol. ii., p. 75. 
 || Monthly Abstract of Medical Science, Feb., 1877; London Medical Record, Dec. 15th, 
 1876 ; Deutsche Medicinische Wochenschrift, No. 43, 1876. 
 
342 A SYSTEM OF SURGERY. 
 
 This haemorrhage he attributes to a paralysis of the arterial muscular tissue 
 produced by the pressure of the bandage, and proposes as a remedy, which 
 he has successfully used, the application of a strong induced current, one pole 
 being placed in direct contact with the divided vessels and nerves, the other 
 at some distance from the seat of operation. 
 
 On the immediate capillary haemorrhage produced through Esmarch's 
 method. Dr. Xicaire* states that he is able to immediately control it, after 
 the removal of Esmarch's bandage after operations, by applying over the 
 surface of the wound a large sponge dipped in a solution of carbolic acid 
 (1 to 50), and firmly retaining it in that position until the tegumentary 
 redness disappears. Eight or ten minutes will generally suffice. 
 
 Dr. Henry B. SandsT has given a resume of 143 cases, in which this band- 
 age has been employed in Xew York city. In all these cases it was success- 
 ful, the cases of sloughing and secondary haemorrhage and paralysis being 
 attributed to the bandage being improperly applied. He suggests also that 
 this bandage would be of great service in cases of compound fractures at- 
 tended with free haemorrhage, and that it should always be in the hands of 
 the ambulance surgeon, as life might be saved thereby. 
 
 It has been suggested also that this bandage be applied in cases of ex- 
 treme prostration from haemorrhage.* It is estimated that if all the ex- 
 tremities were bandaged an addition of twenty-five per cent, of circulating 
 medium could be added to the body. 
 
 With reference to throwing back into the circulation impure or decom- 
 posing products, a good deal of diversity of opinion exists. I have never 
 seen any bad results, and Mr. Holmes considers the idea as wholly theoreti- 
 cal. Yet there are cases upon record that certainly justify prudence on the 
 part of the surgeon in this regard. It may be proper here to give a few 
 remarks of Prof. Esmarch on his experience with the bandage, and how 
 it should be applied for amputations at the hip and shoulder.§ 
 
 " I have never observed any disadvantages. Especially paralysis was 
 never witnessed as a consequence of the constriction. Where paralysis fol- 
 lowed, it might have been caused by drawing too tight the india-rubber 
 tube. I always perform bandaging and constriction myself, as assistants 
 are constantly trying to overdo the thing. Xor is every kind of india-rub- 
 ber tubing available. The heavy stiff tubes of gray vulcanized rubber are 
 not to be used, and I prefer the brown, non-vulcanized, tubes, or those pre- 
 pared from red rubber or rubber bandages. It does not need such powerful 
 constriction to prevent perfectly the afflux of arterial blood. Especially 
 the first turn need not to be made too tight, as every consequent round 
 enhances the action considerably. 
 
 " Several surgeons observed gangrene of the flaps after amputations, and 
 ascribed it to the artificial bloodlessness (Guy's Hospital) ; and as I never 
 observed it. I suppose that gangrene had more to do with the formation of 
 the flaps or with the after-treatment. 
 
 " In some cases local anaesthesia is produced in consequence of the local 
 ischaemia and the compression of the nerves, and thus the operation is less 
 painful. We therefore always apply this procedure in small operations on 
 the fingers and toes, in incisions of panaritia. in the extraction of ingrowing 
 toe-nails, exarticulation of phalanges, etc. Stokes|| relates a case where 
 
 * Monthly Abstract of Medical Science, March, 1S77 : Gaz. Medicale de Paris, No. 34, 
 1876. 
 
 t Medical Kecord, vol. x., p. 79. 
 I See Medical Record, vol. ix., 132. 
 £ Wien. Med. Wochenschrift, 1S74. 
 || Dublin Medical Press, 1874. p. 248. 
 
ESMAECH S METHOD OF ARTIFICIAL ISCHEMIA. 
 
 343 
 
 he extirpated an epithelioma on the back of the head during ischaemia, 
 where the patient did not feel the operation. Anaesthesia usually sets in 
 after the ischa?mia has lasted several minutes, but we can produce it very 
 quickly with Richardson's etherization, as the congelation occurs far more 
 rapidly when the arteries fail to carry more heat with the blood. Even 
 a rain douche of ice-water deprives quickly an ischemic finger of all 
 sensibility. 
 
 " Artificial bloodlessness renders easy a thorough examination of morbid 
 parts, especially bones and joints. I examined many a joint and bone 
 before the operation, as if it were on the dissecting-table, and only then 
 decided whether resection or amputation was indicated. I could recognize 
 the tuberculous nodules in the degenerated synovial membranes, and in 
 the scrofulous osseous granulations on the living body, and repeatedly cut 
 pieces out of tumors and examined them microscopically, in order to decide 
 on the mode of operation. 
 
 " In order to master, in operations of the shoulder joint, the afflux of 
 blood through the axillary artery, we have only to carry a rubber tube 
 
 Fig. 151. 
 
 Fig. 152. 
 
 Bloodless Method of Operating for Disarticulation at the Shoulder Joint. 
 
 under the axilla, draw it tight above the shoulder, and keep it in that ten- 
 sion by a strong hand, which supports itself on the clavicula (Fig. 151), or 
 we hold both ends tight by a clamp, for instance, like that one used for the 
 fixation of the pedicle in ovariotomy (Fig. 152.) I formerly made a spica 
 humeri with the tube, and carried it over the chest and back to the other 
 axilla, but this is not advisable, as the tension of the tube prevents respira- 
 tion too much. 
 
 " In high amputation of the thigh, the tube is carried strongly around the 
 leg once or twice close to the groin, the ends are crossed above "the inguinal 
 region, carried around the posterior surface of the pelvis, and finally closed 
 
344 
 
 A SYSTEM OF SURGERY. 
 
 with a chain on the anterior surface of the lower abdominal region (Fig. 
 153). Or a closely-rolled linen bandage may be used as a compressor to the 
 arteria iliaca externa, close above the ligamentum Pouparti, and firmly 
 pressed upon the artery by several spica-rounds of a strong rubber band- 
 
 FlG. 153. 
 
 Bloodless Method of Operating with Elastic Ligature for High Amputation of the Thigh. 
 
 age. Only in exarticulations and resections these bandages would obstruct 
 the field of operation ; hence we prefer in such cases to compress the aorta 
 in the umbilical region, using a compress or roller, made of a bandage eight 
 meters (27 feet) long and 6 centimeters (a little over two inches) broad. 
 We roll it firmly around the centre of a piece of wood, a foot long, and of 
 the thickness of a thumb, by which the compress is held in its place. This 
 compress is applied closely under the navel, and pressed firmly against the 
 vertebrae by rounds of a rubber bandage about two inches broad, carried 
 five or six times around the body (Fig. 154). Thus the arterial afflux 
 
 Fig. 154. 
 
 Compression of the Aorta with a Pad and Elastic Bandage. 
 
 through the aorta can be perfectly arrested, if we only use the precaution 
 of emptying the bowels by purgatives and injections. In other cases it 
 may be more to the point, to use a pedunculated compress, which can be 
 pressed more deeply into the abdomen. The handle' (made of steel) of my 
 compressor (palotte) is perforated with a large hole, through which the 
 rubber bandage can be easily carried. Should any surgeon be afraid of this 
 abdominal constriction, he can carry the rubber bandage around the operat- 
 ing table (Brani), or fasten it to a fenestrated splint put horizontally under 
 the back of the patient." 
 
345 
 
 Dr. Gibb* relates a most successful amputation of the hip-joint where 
 this method was practiced. Dr. Erskine Mason, of New York, reports simi- 
 lar cases.f 
 
 The use of this bandage in the treatment and the production of anaesthe- 
 sia are noted elsewhere. 
 
 Dittel's Elastic Ligature. — This method of performing operations should 
 be mentioned in this place, because it is for the most part bloodless. 
 The singular way in which Prof. Dittel was led to investigate the subject is 
 well knownj and the results which have been obtained are various. I 
 have removed a fibroid of the knee with the elastic thread, but some time 
 was required for the sloughing, and the odor was very disagreeable. In 
 fistula in ano, of the very worst varieties, I have had excellent success, 
 and have used it in over fifty cases. Of these, several did not do well — I 
 mean did not granulate rapidly, and in one instance four months elapsed 
 before the wound closed ; this, however, is often seen after the knife opera- 
 tions for this disease. 
 
 The method I used is as follows : The ligatures are of different sizes, made 
 of solid india-rubber, and they must be freshly made, or otherwise they be- 
 come very brittle, as I have found to my cost. If a fistula is to be cut 
 through, I pass the director into the fistula, and having threaded a probe 
 with the ligature (which must be done by putting it on the stretch, to make 
 its calibre smaller, and then drawing it through the eye of the probe), I 
 introduce it (the probe or needle) upon the groove of the director, and draw 
 it through the internal opening of the fistula. The director is then removed. 
 Having then at hand a small, round, leaden circlet, about the diameter of 
 a small bullet, I pass the two free ends of the ligature into the circle of 
 lead, which I then grasp in the jaws of a forceps held in my right hand ; 
 taking in my left hand the two free extremities of the ligature I put them 
 thoroughly on the stfetch, and slide the ring of lead close up to the integ- 
 ument ; then by forcibly closing the jaws of the forceps, I clamp the liga- 
 ture. This is a more secure method than tying, because in some instances 
 I have found the elasticity of the india-rubber untie the knot. If the leaden 
 rings cannot be obtained, a perforated shot will answer, or the ligature ends 
 may be secured by tying them with a piece of silk. 
 
 Prof. Dittel has gone so far as to apply the " elastic thread " not only to 
 the removal of tumors, but also for the ligation of large arteries. Sir Henry 
 Thompson has since introduced this method into England, and has removed 
 a cysto-sarcomatous tumor of the right breast by it. The tumor was pend- 
 ulous, the mamma shrivelled, and the growth the size of an orange, with 
 a fungoid ulcer on its summit. The proceeding was as follows : A large nsevus 
 needle was threaded with a tubular elastic ligature, and then passed through 
 the base of the tumor. The elastic was then divided, the needle laid aside, 
 and the ligatures tied on either side of the tumor. There was not much 
 pain, and the operation was successful. 
 
 Elastic thread is also useful for other purposes in the practice of sur- 
 gery. I have lately employed it in the withdrawal of ligatures which are 
 tardy in separating. It not unfrequently happens in a wound healing with 
 rapidity, as after removal of the breast, that granulation-tissue appears to 
 overlap the ligature, and thus causes it to remain for a length of time after 
 the vessel to which it has been applied is obliterated. Again, in wounds 
 where tendinous or nervous filaments may have been accidentally included 
 
 * Lancet, January 31st, 1874. 
 
 f Archives of Clinical Surgery, vol. i., p. 74, 1876-77. 
 
 | London Medical Record, December 3d, 1873, or Braithwaite, July, 1874, p. 108. 
 
346 A SYSTEM OF SURGERY. 
 
 within the loop, the thread is long in separating ; in such cases the elastic is 
 a success. 
 
 It may be applied as follows : Take one of the thin sections of india-rubber 
 tubing, which are now in general use, and sold by the box at the stationers. 
 Tie the free end of the " dilatory " ligature to one side of this section, slip 
 the upper end over a piece of bougie, and fix the latter, b} r means of adhe- 
 sive straps, at a point sufficiently far from the wound to put the elastic ring 
 on the stretch. The constant traction thus effected removes the ligature in 
 a short time without pain. 
 
 CHAPTER XVIII. 
 
 TRANSFUSION. 
 
 History— Uses— Apparatus— Transfusion of Blood; of Milk; of Saline and 
 
 Other Substances. 
 
 The operation of transfusion of blood from one organism to another is 
 very ancient and is shrouded in mythological conjecture. According to 
 classical writers, Medea withdrew the blood from the veins of iEson, and by 
 filling them with the juices of herbs restored to him the vigor and sprightli- 
 ness of youth. Pope Innocent the VIHth is said to have been killed by 
 the operation of transfusion. 
 
 In experiments of transmitting the blood of animals through the veins 
 of one another it was supposed that if blood was taken from an animal of 
 different species, the operation was fatal to the recipient, but if one of the 
 same species supplied the blood to another of its kind, the operation was 
 harmless. As has been since demonstrated in cases of human beings, this 
 rule does not invariably apply. The blood of sheep can be transfused in 
 cases of severe haemorrhage with beneficial results. 
 
 It is said that the circumstance that led finally to the transfusion of 
 blood, was the statement made by Sir Christopher Wren, that he could 
 construct an apparatus by which he could convey fluids into the blood 
 during life. 
 
 To Denys and Emmerett, of Paris, belong undoubtedly the credit of hav- 
 ing first performed the operation on the human being with success. 
 
 In 1666 or thereabouts, Denys operated on a maniac and relieved him ; a 
 repetition, however, in another case, resulted fatally. The operation seems 
 to have been perfected by Lower, about the year 1667, who used the method 
 of conveying the blood directly from the artery of a healthy person to the 
 vein of a patient, allowing the force of the circulation to be the propelling 
 power. 
 
 The discovery at the time was regarded by some as a new era in the art 
 of healing. The first experiments, however, unluckily resulted fatally, and 
 excited so much alarm that in France, transfusion was prohibited by an act 
 of the legislature, and soon fell into disuse. 
 
 In 1826 Dr. Blundell revived the operation and practiced both the medi- 
 ate and immediate methods, as they are called. The second was that em- 
 ployed most successfully by letting the blood pass by its own gravity from 
 the vein of one person to that of another, but finding this method unsatis- 
 factory, he used a " propella," but still used venous blood — in this differing 
 from Dr. Lower. 
 
TRANSFUSION OF BLOOD. 347 
 
 From time to time the operation has been revived, and is now coming 
 more into use. So far the results have been unsatisfactory, mainly for two 
 reasons — First, none but moribund persons have been selected for testing 
 it, and the patients are unable to overcome the symptoms of shock, which 
 are more or less constant accompaniments of the operation ; and secondly, 
 there is danger of clots being introduced into the circulation, causing embo- 
 lism, and also of the introduction of air into the veins, thus causing death 
 probably by obstruction of the capillary circulation of the lungs, and rapid 
 collapse. 
 
 The operation is especially adapted to those anaemic conditions caused by 
 constant and prolonged losses of blood,* exhausting suppuration, and varied 
 zymotic processes which take place in the system from the absorption of 
 poisons of any kind (septicaemia, pyaemia, ichorrhaemia). In diseases in 
 which there is a destruction of fibrin or degeneration of tissues, transfusion 
 also may be practiced, or in cases of starvation arising from disease. A very 
 interesting case of this kind, in which the patient was dying from actual 
 starvation from gastro-intestinal catarrh, is placed upon record by Dr. S. A. 
 Mason.f The patient was a widow, aged forty-five. She was pulseless, 
 wandering in her mind, and with five respirations a minute, when the doctor 
 first saw her. An apparatus was improvised for the occasion and from six 
 to eight ounces injected with success. 
 
 Transfusion consists in abstracting blood from a healthy individual, de- 
 fibrinating the fluid, and injecting the same into the veins of the patient. 
 This is known as " mediate " or " indirect transfusion," while " immediate " 
 and " direct transfusion " is that in which the blood flows in a continuous 
 stream from the arm of a healthy person into the circulation of the patient. 
 
 There have been many instruments devised for this purpose, but a very 
 good method, which I have employed with complete success in several 
 cases, is as follows : J 
 
 Having placed a band around the arm, just above the elbow, in order to 
 obstruct venous return, a fold of skin is then pinched up over the median 
 basilic, or median cephalic vein, and with a fine sharp-pointed bistoury 
 the integument is divided from within outward, the back of the knife being- 
 placed toward the vein; the skin is then dissected carefully from the vessel, 
 which should be exposed for about an inch and a half. Two ligatures 
 should now be placed under the vein, one at the upper end and the other 
 at the lower angle of the wound, but not tied. The next step is to see that 
 the syringe works well, and has a clean nozzle. A silver syringe, holding 
 an ounce and a half, is best. The nozzle may have an aperture about one- 
 eighth of an inch in diameter, must be movable, and fitted with a stop-cock. 
 Have then ready a basin of hot water, and a bowl, which must be placed 
 in the hot water in the basin; bring the arm of the healthy person, from 
 whom the blood is to be extracted, over the bowl, and perform ordinary 
 venesection. After having allowed several ounces to pass into the bowl, 
 the blood must be thoroughly " whipped " with an egg-beater or a bundle 
 of twigs to defibrinate it. While this latter act is being performed by an 
 assistant, the operator will tie in a single knot the ligatures, which are al- 
 ready beneath the vein, and raising up the vein, make a longitudinal in- 
 cision therein, only of sufficient length to admit the end of the nozzle of the 
 syringe, fitted with the stop-cock. Before entering the nozzle it must be 
 
 * In typhoid fever, Medical Press and Circular, November 30th, 1884. 
 f Medical Record, 1880, vol. i., p. 215. 
 
 t The first operation for transfusion of blood made by the author was on November 15th, 
 1869. Vide Western Homoeopathic Observer, vol. vii., page 152. 
 
348 A SYSTEM OF SURGERY. 
 
 warmed, and be filled even with its end with the defibrinated blood, in order 
 that no air be introduced into the vein. The nozzle now must be carefully 
 placed in the incision made in the vein, and its end insinuated gradually 
 along until it passes the upper ligature, which then must be tied over it. 
 The syringe then must be filled with blood from the basin, its end fitted 
 into the nozzle fixed in the vein, the stop-cock turned, and the piston 
 gradually pressed home. This part of the operation must be conducted 
 with care, and the piston pressed slowly down, to allow the blood gradu- 
 ally to enter the venous system ; if the blood be forced in too rapidly, the 
 patient will experience a sense of faintness, and the heart, in endeavoring 
 to accommodate itself to the additional quantity of fluid introduced into 
 the circulation, will begin to act irregularly, and serious consequences may 
 ensue. The operation of transfusion is not a very difficult one, but requires 
 careful and nice dissection and much time. The instruments should all be 
 very clean, and several assistants are required to perform the varied steps 
 of the process. The wound, after the nozzle of the syringe is withdrawn, 
 should be immediately closed with the thumb, the ligatures removed from 
 the vein, and a stitch or two taken in the integument. 
 
 Dr. Garrigues, of New York, has invented a simple and ingenious ap- 
 paratus for mediate transfusion. It is represented in Fig. 155, and the 
 following are the directions accompanying the instrument : 
 
 Draw eight or ten ounces of blood from a healthy person into a clean 
 vessel, whilst it is accumulating whip it with a silver fork, a stick of wood 
 
 or a bunch of straw, then strain it through a piece of cleanly washed linen 
 into a vessel placed within another containing warm water (about 105° F.). 
 Warm the syringe, put the suction end A into the blood, compress the bulb, 
 and when it flows through the canula, turn the stopcock C. 
 
 Having bared the patient's arm, raise a fold of skin over a vein at the bend 
 of the elbow, divide it and pass a probe or thread under the vein thus brought 
 into view. This is now held with a pair of forceps or tenaculum and an in- 
 cision made with a lancet or pair of fine-pointed scissors, carefully avoiding 
 wounding its posterior wall. Now introduce the canula D, open the stop- 
 cock and inject slowly. 
 
 The bulb contains about three fluid drachms, but by moderate compres- 
 sion about two only are expelled. In most cases it suffices to inject from 
 four to six ounces. If resistance not due to external pressure be felt, or 
 dyspnoea, or any other untoward symptom appear, the operation has to be 
 interrupted or ended. Dress the wound as after phlebotomy. 
 
 After use, the instrument must be thoroughly cleansed, which is best done 
 by separating all the parts and washing them in warm water. 
 
 For immediate or direct transfusion, the engraving will give a most 
 accurate description of the operation. It represents the apparatus of 
 Aveling. (Fig. 156.) 
 
TRANSFUSION OF BLOOD. 
 
 349 
 
 Dr. Roussel* has also invented an apparatus for the performance of 
 direct transfusion from vein to vein. 
 
 Its object, he says, is to prevent coagulation of the blood that is drawn, 
 and thus to do away with the necessity of defibrination. The instrument 
 is made of hardened pure caoutchouc, which has no effect on the blood. 
 It consists of a tube with a syringe in its course, to serve as an aspirator 
 
 Fig. 156. 
 
 Canula B is for the vein of the giver. C is placed into the vein of the patient. The tube and bulbs 
 should then be filled with warm water, or, what is preferable, a solution used by Mr. Little, composed of 60 
 grains of sodium chloride, 6 grains of potassium chloride, 3 grains soda phosphate, 20 grains soda carbo- 
 nate, and 20 ounces of water. The tubes are now adjusted to the canulse and the blood allowed to flow 
 into the apparatus. The canula being steadied by an assistant, the tube is to be nipped tightly between 
 the fingers, close to the giver's or efferent end, and then the bulb marked 1 is to be compressed, and the 
 blood of course forced on towards the receiver. While this bulb is still held compressed, the tube at the 
 giver's side is to be relaxed, and that portion of it between the bulbs is to be nipped; bulb 1 is relaxed, 
 and No. 2 compressed and held ; then the tube at the receiver's side is to be seized and held to prevent 
 regurgitation, and the whole apparatus allowed to refill. The same operation to be repeated till suffi- 
 cient blood is transfused. As suggested by Dr. Aveling. a few drops of ammonia solution may be injected 
 into the bulbs now and then, by a fine-pointed hypodermic syringe, in order to more effectually prevent 
 coagulation. It will be found that considerable force is necessary in sending blood or other fluids into 
 the veins. This we discovered while doing transfusion twice in a case after haemorrhage from gunshot 
 injury, and we have also found it in our experiments on the lower animals. It is a fact that we have 
 not seen noted in connection with transfusion, and one well worth remembering. 
 
 In order to use the apparatus as a mediate transfuser, the vessel marked A m the cut receives the 
 blood, the tube is to be applied, and the instrument used as before directed. If the blood is not defibri- 
 nated and strained, three or four drops of ammonia solution to each ounce are added, in order to avoid 
 coagulation. 
 
 of the blood from the supplying vein, and the alternate compression and ex- 
 pansion of which, allows a flow of blood to ensue ; the bulb is inwardly 
 smooth, holding ten grams, so the blood is easily measured. The appa- 
 ratus being filled with water, the vein is opened, and the contents of the cyl- 
 inder and tube pumped out, the water being expelled through the free end 
 till the blood flows from it, the stopcock is turned, and the blood (with the 
 few drops of water left in the canula now in use — that, namely, which is in- 
 serted into the vein of the patient) is injected into the patient's arm. With- 
 out drawings it is impossible to give clearly an idea of the apparatus. The 
 conditions are : 
 
 1. That the blood of the giver and receiver be of the same animal species, 
 and from the same organic source, from man to man, and vein to vein. 
 
 2. That it be pure in its chemical and physiological conditions. 
 
 3. That the ability to regulate and inject the proper quantum be present. 
 
 4. That the connection between the giving and receiving veins be by a 
 
 * Medical Times and Gazette, November 18th, 1876. 
 
350 A SYSTEM OF SURGERY. 
 
 direct channel free from air ; and that the giver's vein be opened under 
 water. 
 
 In fifty-two cases in which the operation has been performed, including 
 acute anaemia after childbirth, haemorrhage, and exhaustion after suppura- 
 tion, malignant fevers, septicaemia, etc., benefit always resulted; not a case 
 of accident or fatal result followed. 
 
 B. E. Fryer * surgeon, United States army, has modified the apparatus 
 of Aveling. 
 
 It has been noted by me in all my cases of transfusion that, as a rule, for 
 the first few hours, the patients seem to improve, and that frequently after 
 that, without apparent cause, syncope and death result. This peculiarity 
 has been noted by others, especially in cases of haemorrhage after typhoid 
 fever,f and by Dr. T. G. Morton,^ who relates this case. 
 
 The man (aged forty) had been in a comatose condition, and in order to 
 relieve the system of the poison, a large quantity of blood was drawn from 
 him before transfusing. Eight ounces of defibrinated blood were then 
 thrown into the saphena vein on the right foot. The pulse rose, the respi- 
 rations increased in number after the operation, and the patient began to 
 grow steadily better, when, five hours after the fresh blood had been in- 
 troduced, his heart suddenly ceased beating, and he died without a 
 word. 
 
 In none of my cases did I perceive the chill which is mentioned by M. 
 Roussel, but in all of them there was quickened respiration and increased 
 cardiac action, with a sensation of tightness at the praecordium. This chill 
 is said, however, to be a favorable symptom as indicating reaction of the 
 system. The quantity of blood may vary from five to ten ounces (150 to 
 300 grams). An important item also for the surgeon's consideration is 
 the qualitv of the blood injected. 
 
 Transfusion of Milk. — I have only performed this operation three times ; 
 in one instance the patient died, though it must be stated that she was in 
 extremis before the operation was performed. 
 
 As milk resembles chyle in a great degree, it was thought that by in- 
 jecting it into the circulation, the same effect would be produced as if blood 
 were employed. 
 
 Chyle is fat, suspended in its finely divided condition, and milk is also fat 
 in an emulsified form, and as chyle enters into the circulation at the sub- 
 clavian vein without bad effects, it is fair to presume that milk may be used 
 to supply nutrition in certain conditions. It certainly is very highly recom- 
 mended. Dr. Hodder, of Toronto, in 1850, I think it was, treated several 
 cases of cholera by this method, and in 1873 Dr. Howe, of this city, per- 
 formed the operation, using goat's milk — the patient died three days after 
 the second injection. Dr. Thomas repeated the operation with success 
 some years after. 
 
 The results of some experiments on dogs were reported by Dr. Howe in 
 the Medical Record, in which nine animals were bled to a condition of syn- 
 cope. Seven of them were then injected with milk and died, while two 
 were left to themselves and recovered entirely. The Doctor thinks the cause 
 of death in these cases was due to the quantity of milk that was injected ; 
 while Dr. Thomas thinks the fault was in the impurity of the substance 
 used. 
 
 A series of researches has been made by N. Wulfsberg§ on animals, with 
 
 * Medical Record, April 15th, 1874. 
 
 t Medical Press and Circular, November 30th, 1881. 
 
 % The Medical Record, March 15th, 1879, No. 436. 
 
 \ Ain. Journal of the Medical Sciences, April, 1879, No. cliv. 
 
PERITONEAL TRANSFUSION OF BLOOD. 351 
 
 regard to the effects of intravenous injection of milk, recommended by some 
 as a means of preserving life in haemorrhage and other forms of anaemia. After 
 injecting about 250 grams, and examining the blood, it was found that the 
 white corpuscles increased in number, having taken up (in fact, eaten) 
 the milk spheres. It was found impossible to maintain the life of animals 
 by subcutaneous injections of fresh milk, as they became atrophic. The 
 injection of milk caused the sounds of the heart, which previously were in- 
 audible, to become clear and distinct. 
 
 I believe that the general conviction in the minds of surgeons is, that not 
 much reliance can be placed upon the intravenous injection of milk. If, 
 however, it has to be done, it is an all-important consideration that milk 
 just drawn from the cow or goat be used, and that the fluid be kept warm. 
 In my injections at the Ward's Island Hospital, I employed a simple 
 fountain syringe with an Aveling's tube, keeping the bag in hot water and 
 using the thermometer frequently. Dr. McDonnell* reports a successful 
 intravenous injection of milk, in which ten ounces were injected. 
 
 Peritoneal Transfusion of Blood. — Strange as it may appear at first sight, 
 it has been proved by actual experiments made, notably by Ponfick, 
 Kaczorowski, Bizzozero, Golgi, and others, that defibrinated blood may be 
 allowed to flow into the abdominal cavity, not only without disastrous con- 
 sequences, but that the serous surface will absorb the haemoglobin, and thus 
 become instrumental in saving life, when threatened from anaemia, or from 
 profuse haemorrhages. The advantages claimed for the method are : first 
 the simplicity of the operation, the absence of danger, and the very suc- 
 cessful results that have thus far followed the method. The apparatus 
 for peritoneal transfusion consists of a curved trocar to be thrust into 
 the linea alba, an india-rubber tube which is to be attached to the can- 
 ula, and a funnel through which the blood — thoroughly defibrinated— is 
 poured. 
 
 In the first of the cases recorded by Professor Ponfick, the quantity of 
 blood used was 250 grams (% 8.82) ; in the second case, 350 grams (% 12.35); 
 and in the third case, 220 grams (J 7.70). The average quantity is said to 
 be, by our measure, about one pound and a third. These three patients 
 recovered without any alarming symptoms, slight fever and pain only being 
 noticed after the injection. In Kaczorowski's cases, five in number, the 
 improvement was marked immediately, and there was no unpleasant symp- 
 tom whatsoever. 
 
 After many experiments upon rabbits, the following conclusions have 
 been noted : 1st. That in less than twenty minutes after the injection, there 
 was a progressive increase in the relative quantity of red blood-corpuscles. 
 2d. The increased quantity of the haemoglobin was in the direct ratio of the 
 injected blood, but the increase never reached over fifty-seven per cent, of 
 the haemoglobin of the giver's blood. 3d. That the increased richness in 
 the blood continued for several weeks together; and 4th, that healthy 
 animals showed an increase in the blood corpuscles, as well as the 
 anaemic. 
 
 This method of transfusion I have never yet employed, but I should not 
 hesitate to put it into practice in any case in which I thought it might be 
 of service. 
 
 Transfusion of Saline Substances. — Acting upon the suggestion, that death 
 in severe cases of haemorrhage was caused less from the loss of the red 
 blood corpuscles than from the sudden emptying of the arteries — an idea 
 
 * Medical Kecord, March 29th, 1879. 
 
352 A SYSTEM OF SURGERY. 
 
 first promulgated by Goltz, — Swhartz experimented upon animals and 
 found that, when in an apparently lifeless condition from loss of blood, 
 they could be restored to life by the injection of alkaline saline solutions, 
 and declared that a similar procedure would be productive of good in 
 patients similarly reduced. 
 
 The method has been tried with success in some cases. Bischoff* gives a 
 remarkable cure. The patient was a woman who was delivered with forceps 
 of a dead child weighing 3450 grams (g 121.69). The placenta was deliv- 
 ered with the hands, and a quantity of blood, weighing 1490 grams (3 52.56), 
 was lost. Collapse followed, with pulselessness at times; at others, the 
 beats numbering 156 to the minute. The ordinary remedies appearing to 
 produce no good effect, the left radial artery was exposed, divided, and the 
 cardiac extremity tied. Into the peripheral end of the vessel a small canula 
 was inserted, and 1250 grams (3 44.09) of a saline solution were allowed to 
 pass into the circulation by means of an india-rubber tube, one end of which 
 was fixed to the canula, the other end being attached to a glass funnel, both 
 of which had been thoroughly carbolized. 
 
 The preparation was a sixteenth per cent, solution of common salt (chlo- 
 ride of sodium) mixed with a couple of drops of the liquor potassse. It 
 took exactly an hour to complete the injection. No unpleasant effect fol- 
 lowed, but, on the contrary, the patient rallied during the operation, the 
 pulse falling to 122 beats per minute, and the patient made a complete re- 
 covery. Bischoff is of opinion that the operation should not be attempted 
 in cases of acute ansemia from diseases of the spleen, and that the quantity 
 of injection should be 500 grams (3 17.64). 
 
 The hydrated oxide of sodium is said to be the preferable substance for 
 rendering the injection alkaline. 
 
 CHAPTER XIX. 
 AMPUTATIONS. 
 
 Definition — Question of Amputation — Instruments — Methods — Mortauty 
 
 After. 
 
 The term amputation in surgery signifies the "cutting off" of a portion 
 of the body ; and though it is generally restricted to the removal of either 
 the upper or lower extremities, or portions of them, it is employed also to 
 designate other operations, thus : " amputation of the breast," " of the penis," 
 "of the tongue," and other parts. By a disarticulation is to be understood 
 the removal of a limb at its articular surfaces, which operation is also desig- 
 nated "an amputation in contiguity." When amputations are made through 
 the shafts of bones, " in continuity " is the expression used. When two of the 
 extremities are removed at the same time, " double amputation" is made ; and 
 when it becomes necessary to remove a limb a second time, it is said to be 
 " re-amputated." 
 
 The question as to when an amputation is to be performed must remain 
 
 * Correspondenzblatt fner Scbweizer iErtz, December 1st, 1881. quoted by the Medical 
 Eecord, 1882, vol. i., p. 209. 
 
COMPOUND FRACTURES. 353 
 
 an open one for the consideration of the surgeon in each particular case. 
 In some instances, it would appear that the only opportunity the patient 
 may have for the preservation of life, rests in immediate amputation. In 
 severe accidents, where there is crushing, and the haemorrhage cannot 
 be arrested, such a course is the only one to be pursued. In other cases, 
 twenty-four or forty-eight hours may be allowed, to enable the patient to 
 recover from the shock, but not to postpone the operation till the occur- 
 rence of that inflammation, which the surgeon apprehends from the extent 
 of the injury will surely follow. This amputation, the " intermediate" is 
 of such danger that it should, if possible, not be practiced at all, or only 
 in extreme cases. The secondary amputations are often followed by suc- 
 cess, especially when performed after the full process of suppuration has 
 set in. 
 
 For further particulars, the reader may consult the chapters on " Gan- 
 grene," and "Wounds." 
 
 So long as the destructive effects of injuries and diseases of the extremities 
 cannot, in every instance, be prevented by the employment of other means, 
 a necessity for amputation must continue to exist, and the sacrificing of a 
 branch, as it were, thereby making use of the only rational means for main- 
 taining the integrity of the trunk, frequently becomes indispensable. 
 It is, however, the imperative duty of the surgeon never to have re- 
 course to this serious, and sometimes fatal operation, without a per- 
 fectly clear and fully substantial conviction of its necessity. It should always 
 be regarded as the last expedient to which the surgeon should resort, justi- 
 fiable only when farther attempt to save the injured or diseased part would 
 be fraught with danger to the life of the patient. With this conviction, it is 
 evident that a precise knowledge of such cases as demand amputation, as 
 also of those where it should be dispensed with, and the exact periods at 
 which its performance is most conducive to the welfare of the patient, are 
 considerations demanding marked attention. 
 
 The various conditions demanding a performance of this operation are 
 as follows : Compound fractures, extensive contused and lacerated wounds, 
 gangrene and mortification, gunshot injuries, diseases of the joints, exos- 
 tosis and necrosis, haemorrhage, etc. 
 
 Compound Fractures. — The necessity for amputation in injuries of this 
 nature does not depend entirely upon the seriousness of the accident, but 
 also, in a measure, upon other circumstances : as the condition of the 
 patient, his mode of life, the facilities for ventilation, etc. If, however, a 
 compound fracture occur in which the soft parts have been extensively in- 
 volved, and the bones have been so seriously injured that perfect quietude 
 and constant attention are unable to afford any chance of recovery, am- 
 putation should be performed. On the contrary, when the soft parts have 
 been less extensively injured, and the bones have been broken in such a 
 manner that they can readily be readjusted and maintained in their proper 
 position ; or if but one bone be involved in the injury, — amputation is 
 deemed both unnecessary and inhuman. Accompanying circumstances, 
 however, are to be considered in concluding for or against amputation.* 
 
 * The circumstances adverse to a favorable prognosis in cases of compound fracture, are 
 thus detailed by Professor Miller: " Comminution of the bone, or fracture at several points; 
 extension of the fracture into an important articulation ; an open state of the joints ; much 
 bruising and laceration of the soft parts, rendering extensive sloughing inevitable, with a 
 risk of gangrene involving the whole limb, and with a certainty of extensive and tedious sup- 
 puration following separation of the sloughs ; laceration of a large artery, as evinced either 
 by haemorrhage or by rapid formation of a large bloody swelling ; old age ; and enfeeblement 
 of the frame by disease, by privation, by intemperate habits," etc. — Principles of Surgery, 
 p. 717. 
 
 23 
 
354 A SYSTEM OF SURGERY. 
 
 In compound fractures, as Mr. Pott * pointed out, there are three distinct 
 periods when it is deemed proper to perform amputation. 
 
 The first of these is immediately, or soon as practicable after the receipt 
 of the injury. The second, when the bones remain for a great length of 
 time without manifesting any disposition to unite, and the discharge from 
 the wound has continued so long and is so excessive that the patient's 
 strength fails, together with the supervening of general symptoms foreboding 
 dissolution. And third, when mortification has so completely involved the 
 soft parts of the inferior portion of the limb, quite down to the bone, that 
 upon separation of the diseased portions, the bone or bones are left bare in 
 the interspace. The first and second of these are matters requiring serious 
 consideration. The last demands scarcely any. 
 
 A disposition to mortification is often evinced when fracture occurs in 
 the middle of a bone ; but much more frequently when any of the larger 
 joints are involved; and in many of the above-mentioned instances a de- 
 cision favorable or adverse to amputation is really a determination for or 
 against the patient's life. 
 
 If, after judicious treatment throughout every stage, by the united efforts 
 of medicine and surgery, the sore, instead of granulating kindly and con- 
 tracting daily, does not diminish in size, has a tawny, spongy surface, dis- 
 charges a large quantity of thin sanies ; the fractured ends of the bones, 
 instead of tending to exfoliate or unite, remain as perfectly loose and unu- 
 nited as at first, whilst the patient is deprived of sleep and appetite, becomes 
 greatly weakened, hectic fever, with a quick, small, hard pulse and profuse 
 sweat, contributing at the same time to bring him to the brink of the grave, 
 notwithstanding all efforts to the contrary ; under these circumstances, if 
 amputation be not performed, what else can rescue the patient from de- 
 struction ? 
 
 Extensive Contused and Lacerated Wounds. — These form the second class 
 of general cases requiring amputation; though when not in conjunction 
 with fracture, they seldom render the operation necessary. But if a limb 
 is extensively lacerated and contused, and its principal bloodvessels are 
 injured to so great an extent that a continuance of the circulation cannot 
 reasonably be expected, an immediate removal of the affected limb is recom- 
 mended, even though no bone is involved in the injury ; and as all efforts 
 of the surgeon to preserve a limb so seriously injured generally prove 
 unavailing, and such wounds are more disposed to assume a gangrenous 
 condition than any others, the sooner the operation is performed the more 
 favorable will be the prognosis. 
 
 In the preceding varieties of injuries, although amputation may not always 
 be necessary in the first instance, yet it may become so subsequently. 
 Sometimes mortification rapidly takes place, either in consequence of the 
 extreme violence of the injury, or, consecutively, from greatly excited action 
 going on in parts whose powers of resistance have been much impaired ; or 
 profuse suppuration, with its consequences and accompanying conditions, 
 ensues, which the system is unable to resist ; in these instances amputation 
 should be resorted to. 
 
 Gangrene and Mortification. — Gangrene is another cause, which, when ad- 
 vanced in a certain degree, renders amputation indispensable. At page 143 
 I have given some remarks on this subject, which is further elucidated by 
 Mr. Fergusson. 
 
 It sometimes happens that gangrene appears so extensive in either the 
 upper or lower extremities, or that mortification has committed such ravages 
 
 * Remarks on the Necessity, etc., of Amputation in Certain Cases. — Surgical Works, vol. 
 iii., London, 1808. 
 
DISEASES OF THE JOINTS. 355 
 
 as to preclude the hope of saving the limb, or even the life of the patient if 
 such a source of irritation is allowed to remain. The surgeon will seldom 
 be performing his duty if, in this instance, he leaves the case to the efforts 
 of nature so entirely as in partial slough ; for although experience proves 
 that a portion of the hand, foot, forearm, or leg, may drop off, or that either 
 member may be separated at its articulation with the trunk by the process 
 of molecular death, it is equally certain that the work is done in a tedious, 
 painful, and unsatisfactory manner, months sometimes elapsing ere the 
 parts are entirely separated ; and when at length this has been accomplished, 
 months more may pass ere cicatrization takes place. There cannot be a 
 doubt that the surgeon is justified in many of these cases, in performing 
 amputation ; and the only difficulty is to determine the proper period for 
 such a procedure.* 
 
 Practitioners have entertained very opposite opinions concerning the 
 time when the operation should be performed. Some declare that whenever 
 the disorder presents itself, especially if it be the result of external violence, 
 amputation should immediately be performed, as soon as the disease has 
 commenced, and while it is in the spreading state. Mr. Pott says that he 
 has often seen the experiment of amputating a limb in which gangrene had 
 begun to show itself tried, but never saw success follow, and it invariably 
 hastened the patient's death.f 
 
 The operation, however, may be postponed too long, and it is sometimes 
 advisable to amputate to prevent gangrene; thus when a limb has been 
 much injured by mechanical or chemical means — in the case of severe com- 
 pound fracture or burn — and it is apparent that mortification must ensue, 
 involving the whole thickness of the limb, of an acute character, tending 
 to spread, and from the first accompanied by the most formidable constitu- 
 tional symptoms, amputation is to be performed above the injured point as 
 soon as the primary shock has passed away, and the system rallied so far 
 as to afford sufficient tolerance of the operation. 
 
 In injuries of this nature, when gangrene has set in, delay, with the object 
 of waiting for the spontaneous line of separation, will be in vain. The 
 gangrene spreads upwards and upwards, with a diffused and streaky mar- 
 gin ; typhoid symptoms grow more and more intense ; the trunk is reached, 
 rendering operative interference hopeless ; or long ere this, the system has 
 sunk and the patient perished. The only hope of escape is by early ampu- 
 tation ; it is a slender chance, but it is the only one, and to it the sufferer is 
 entitled. 
 
 When gangrene is an attendant upon one particular cause, as cold ; the line 
 of disjunction is to be awaited, and as soon as it has become evident that 
 this is fairly formed, the surgeon should resort to amputation, which may 
 be performed either at the point of separation of the dead from the living 
 textures, or at a distance above, according as the circumstances of the case 
 may demand. J 
 
 Diseases of the Joints. — Scrofulous diseases of the joints involving the 
 bones, with morbid alteration of the structure of the adjacent ligaments and 
 cartilages, so extensive that resection cannot be resorted to, is another con- 
 dition in which amputation may become an absolute necessity. An un- 
 pleasant circumstance attending these affections is that the majority of 
 subjects are young children, incapable of determining for themselves. 
 All efforts at cure sometimes prove unavailing, and operation is the only 
 resort. 
 
 It is a highly important fact that amputation in these instances is attended 
 
 * Fergusson's System of Practical Surgery, p. 108. 
 
 f Surgical Works, vol. iii. 
 
 X See Question of Amputation in Gunshot Wounds. 
 
356 
 
 A SYSTEM OF SURGERY. 
 
 with a greater degree of success when the disease has considerably advanced 
 than when undertaken at an earlier period. This is particularly fortunate, 
 as it affords ample opportunity for the administration of those medicines 
 that have been mentioned, and thus, perhaps, the necessity for the opera- 
 tion may be obviated. 
 
 Bony tumors, under certain circumstances, sometimes occasion a necessity 
 for amputation ; but when they merely produce deformity without pain or 
 
 inconvenience from the pressure 
 fig. 157. which they exert on neighboring 
 
 parts, the performance of an op- 
 eration for their removal is not 
 advisable, for, as Boyer has ob- 
 served,* in a great number of in- 
 stances, the local affection is 
 much less to be dreaded than the 
 means used for its removal. 
 AYhen, however, the tumor be- 
 comes hurtful to the health, and 
 its situation permits of a ready 
 removal, this may be done with- 
 out an entire division of the part 
 on which it is situated ; but fre- 
 quently its base is so extensively 
 and deeply seated as to preclude 
 the possibility of a removal by 
 this method. If, in this case, it 
 is situated on the extremities, 
 and has become insupportable 
 on account of its weight, ampu- 
 tation should be performed in 
 preference to any operation hav- 
 ing in view the saving of the 
 limb. 
 
 Another affection of the os- 
 seous system which sometimes 
 demands the performance of am- 
 putation is necrosis— or the death 
 of the whole, or a very consider- 
 able portion of the bones of the 
 extremities. 
 
 The performance of this oper- 
 ation in these cases, however, is 
 the exception, not the rule. It 
 may happen that in acute ne- 
 " crosis in the young subject, vio- 
 lent inflammatory action is fol- 
 lowed by severe irritative fever, 
 which latter is quickly succeeded 
 by a formidable hectic that must 
 evidently be relieved at all haz- 
 ards, by a removal of its cause ; 
 or, in more chronic cases, a like 
 summary procedure may be required at a more distant date, after weeks 
 and even months have elapsed, when the separation of the sequestrum is 
 
 * Treatise on Surgical Diseases, vol. ii. 
 
AMPUTATION INSTRUMENTS. 
 
 357 
 
 far advanced, but not yet complete, after the system has long resisted the 
 exhausting burden of irritation and discharge, but when, nevertheless, it 
 has evidently become unequal to a prolongation of the contest. On the one 
 hand the surgeon must beware of sacrificing life in endeavoring to save a 
 limb, and, on the other, must be equally careful not to sacrifice a limb in 
 
 Fig. 158. 
 
 endeavoring to succor life not yet actually endangered ; and, in connection 
 with this subject, it is important to remember that necrosis is not always so 
 extensive as outward appearances would lead one to suppose. 
 
 Before an amputation is commenced, the parts should be carefully 
 washed with carbolized water, and turned towards the light, and the oper- 
 ator should so place himself that the limb to be removed falls to his right 
 side. 
 
 Instruments.— The instruments used, besides those already mentioned in 
 the chapter on minor surgery, are chiefly knives, of different lengths, sharp- 
 
 FlG. 159. 
 
 r.TIEMANNStD 
 
 
 pointed, rounded, or double-edged (catlings). Fig. 157 shows the different 
 forms of amputating knives. 
 
 Saws. — Fig. 158 shows an amputating saw ; Fig. 159, metacarpal saw ; 
 Fig. 160, Hey's saw. Bone forceps, to remove any projections of bone 
 spiculse which remain after the use of the saw, is shown by Fig. 161. 
 
 Fig. 161. 
 
 Retractors (Figs. 162 and 163), or split cloths to draw back the soft tissues 
 after they are divided with the knife, are made either with a single or double 
 split, as follows : Take a piece of muslin, a yard in length and ten inches 
 in width ; fold it upon itself, to mark its middle point, then slit one-half 
 lengthwise into two parts, or into three. The former is used in amputations 
 
358 
 
 A SYSTEM OF SURGERY. 
 
 where but a single bone is to be divided, the latter where two bones are t<3 
 be sawn through, the middle tail of the retractor passing between the 
 bones. 
 
 Fig. 163. 
 
 for two bones. 
 
 Methods. — There are two principal methods of amputation, one being 
 denominated the circular, in which the integument is divided with a circular 
 cut around the limb (Fig. 164), and then dissected and turned up like the 
 
 Fig. 164. 
 
 Circular incision. 
 
 cuff of a coat-sleeve, after which the muscular and other tissues are severed 
 to the bone, the knife being held nearly at right angles with the shaft. The 
 
METHODS OF AMPUTATION. 359 
 
 other, the "flap amputation" consists in passing the knife through the 
 integument above and below the bone (Fig. 165), and cutting outwards, 
 forming sufficient covering to make a good stump. It is not always easy 
 to determine exactly which method is best adapted to the case, especially 
 in severe accidents, when much tissue is lacerated. Often a combination 
 of both the circular and flap operation is necessary. In civil practice the 
 circular variety is generally performed at the middle of the forearm and 
 leg, while the flap is resorted to in the arm and thigh. In the lower portion 
 
 Fig. 165. 
 
 / / 
 
 Making flap by transfixion. 
 
 of the thigh, however, I have known the circular give as satisfactory, if not 
 better results than the flap, because in the former there is not nearly the 
 tendency to retraction of the flaps, which will often ensue when the ends of 
 so many powerful muscles are divided. 
 
 Amputation by a Long and Short Rectangular Flap (Teale's Amputation). — 
 The advantages claimed by Mr. Teale for this method of amputation are : 
 Avoidance of tension, a better stump for the accommodation of an artificial 
 limb, a soft and pliable covering for the ends of the bone, the non-disturb- 
 ance of the plastic process, and a favorable outlet for the discharge. 
 
 In this operation the long rectangular flap is perfectly quadrangular in 
 shape, and is of sufficient length to fall readily over the end of the bone, 
 and is made of parts devoid of important bloodvessels and nerves ; the 
 short one contains these structures, and is made about one-fourth the length 
 of the other. Mr. Teale, in his work * gives some statistics of his method, 
 which are very favorable. The directions for the operation will be found 
 in the special amputations to which it is applicable. 
 
 Carden's or the Mixed Method. — This amputation, as its name implies, is 
 partially circular and partially flap. It was devised by Young, and revived 
 and systematized by Carden. The flaps are formed from the integument 
 and fat, are oval and dissected up ; the circular portion of this operation is 
 then made by dividing the muscular tissue down to the bone. This ampu- 
 tation is a valuable one, and it is very applicable to forearm, leg, and knee. 
 
 * Amputation by a Long and Short Eectangular Flap, by Thomas P. Teale, F.L.S., 
 F.K.C.S., London. 
 
360 A SYSTEM OF STJKGERY. 
 
 In order to prevent any confusion of terms, it may be stated here, that 
 the circular method receives the name of the tegumentary, and that where the 
 skin flaps are made oval, instead of being circular, the name of oval tegu- 
 mentary is applied to the operation. The flap operation is also called the 
 musculo-tegumentary, and embraces the skin and muscular tissue. It was the 
 introduction of this method (flap) that at one time caused so much discus- 
 sion among the surgeons of England. The partisans of the flap, which num- 
 bered among its most zealous upholders Sir John Bell, were denominated 
 " flappers," while those still continuing to uphold the circular operation, fore- 
 most among whom was Sir Benjamin Bell, were called the "anti-flappers." 
 The musculo-tegumentary method was very much in vogue before the days 
 of anaesthesia, on account of the rapidity with which it could be executed by 
 skilful men. Time was of vast importance to the sufferer undergoing the 
 terrible ordeal of an amputation, and therefore for quite a long period the 
 flap method was preferred. Since the days of the safe abolition of pain in 
 surgical operations, many modifications designed for shaping the soft parts 
 covering the bone have been adopted, among which are those of Teale 
 and Carden just mentioned. A modification of the circular and flap 
 amputations I have adopted in both the arm and the thigh, which, though 
 it takes a little more time, is to my mind the most satisfactory of any of 
 the operations. 
 
 Combined Circular and Flap. — In this method the tegumentary flaps are 
 oval. The surgeon marking with his eye the point at which the bone is to 
 be sawn ; with a large scalpel or small catling makes an anterior skin flap 
 with the convexity downward, and then dissects off the skin and cellular 
 tissue for about an inch and a half, and turns up the flap. An exactly 
 similar cut is made on the posterior surface of the limb, and the posterior 
 skin flap is turned back for the same distance. Taking then a catling, he 
 enters it by transfixion, at the angle on the limb at which the tegumentary 
 flaps begin, and passes it over the anterior face of the bone, and brings out 
 the point where the two flaps on the other side begin ; then cutting outward 
 the edge of the knife is brought out at the point of the junction of the skin and 
 muscular tissue. A similar cut by transfixion is made on the posterior surface 
 of the limb. The retractor is then put on, and the periosteum is divided 
 about two inches below the point where the separation of the bone is to be 
 effected, and that membrane is to be carefully peeled off and turned back. 
 The bone- is then sawn through and the spiculse removed as in all other 
 amputations. It will be seen that by this method we have three flaps to 
 be adjusted : first, that of the periosteum, which must be carefully brought 
 over the ends of the bone ; second, the muscular flaps are to be adjusted 
 and sewn with antiseptic ligatures ; and third, the integumental coverings are 
 brought over and stitched together. At each angle of the union a decalcified 
 bone tube should be inserted. 
 
 Mortality. — To show the mortality after amputation I have arranged a 
 few statistics from the reports of the Bellevue Hospital, New York ; the 
 Pennsylvania Hospital, Philadelphia ; and St. Thomas's Hospital, London. 
 
 Table of Amputations in Bellevue Hospital, from 1864 to March, 1869, com- 
 piled by F. J. Metcalf, M.D., Acting Junior Assistant. The number of cases 
 is said to represent but about one-sixth or one-eighth of those operated 
 upon. The classification is that adopted by the Surgeon-General of the 
 United States Army.* 
 
 Total number of amputations and reamputations, fifty-five. 
 
 * Bellevue and Charity Hospital Eeports, 1870. 
 
MORTALITY AFTER AMPUTATIOX. 
 
 361 
 
 
 Cases. Cured. Died. 
 
 Amputations, 52 26 26 
 
 Reamputations, 3 1 2 
 
 Immediate or primary, .37 20 17 
 
 Intermediate, 3 3 
 
 Secondary, 12 5 7 
 
 52 25 27 
 
 Reamputations, .........3 1 2 
 
 Making a total of, 28 27 
 
 Ether was used in 43 cases, 22 being cured, and 21 died ; chloroform in 
 9 cases, of which 5 were cured, and 4 died ; nitrous oxide, 1 died ; bichl. 
 methylene, 1 died ; no anesthetic, 1 cured. 
 
 AMPUTATIONS IN CONTINUITY. 
 
 Cases. 
 
 Forearm, . .4 
 
 Arm, 11 
 
 Leg, 19 
 
 Thigh, . . . . . . . . .7 
 
 AMPUTATIONS IN CONTIGUITY. 
 
 Cases. 
 
 Wrist, 1 
 
 Elbow, 1 
 
 Knee, 8 
 
 Hip, 1 
 
 REAMPUTATIONS. 
 
 Cases. 
 
 Leg, 1 
 
 Thigh, 2 
 
 This latter is a mortality of nearly 50 per cent. 
 
 Cured. 
 
 Died. 
 
 3 
 5 
 
 10 
 3 
 
 1 
 6 
 9 
 4 
 
 Cured. 
 
 Died. 
 
 1 
 1 
 
 o 
 O 
 
 
 
 
 
 5 
 
 1 
 
 Cured. 
 
 Died. 
 
 1 
 1 
 
 
 1 
 
 AMPUTATIONS FROM JANUARY, 1872, TO JUNE, 1873. 
 
 Number of amputations, excluding those of the fingers and toes, . . 58 
 
 Recoveries, " 30 
 
 Deaths 28 
 
 Causes of death, 
 
 4 from shock. 
 
 2 
 1 
 11 
 1 
 8 
 1 
 
 secondary haemorrhage. 
 
 tetanus. 
 
 pyaemia. 
 
 hospital gangrene. 
 
 exhaustion. 
 
 osteomyelitis. 
 
 Hand, 5 amputations ; 2 recovered, 3 died. Forearm, 4 amputations ; 
 
 3 recovered, 1 died. Arm, including shoulder-joint, 11 amputations ; 6 re- 
 covered, 5 died. Thigh, 3 amputations ; 1 recovered, 2 died. Leg, includ- 
 ing knee-joint, 28 amputations ; 15 recovered, 13 died. Foot, 8 amputations ; 
 
 4 recovered, 4 died. 9 amputations for disease, 49 for injury. In one case 
 
 both forearms were amputated, 
 feet. 
 
 In two cases both legs. In two cases both 
 
362 
 
 A SYSTEM OF SURGERY. 
 
 Amputations at the Pennsylvania Hospital. — Dr. George W. Norris* gives 
 an elaborate and very carefully prepared table of the amputations per- 
 formed in that charity, from January, 1850, to January, 1860. There were 
 228 amputations made, and of these 173 were cured and 55 died. They 
 were as follows : 
 
 Thigh, 43 ; leg, 70; foot, 8; shoulder-joint, 6; arm, 38; forearm, 52; 
 wrist-joint, 8 ; elbow-joint, 1 ; hand, 2. 
 
 Cases. Cured. Died. 
 
 Primary (within 24 hours), 146 119 27 
 
 Secondary, 42 27 15 
 
 Forty were for the cure of chronic diseases, of which 27 were successful 
 and 13 died. 
 Twenty-five were done at the joints, with two deaths and 23 cures. 
 
 Cured. 
 
 Died 
 
 94 
 
 13 
 
 85 
 
 36 
 
 Upper extremity, 107 
 
 Lower extremity, 121 
 
 Dr. Norris then makes a summary of the whole number of amputations 
 performed within a period of thirty years, as follows : 
 
 There were 428 amputations performed upon 424 patients during the 
 thirty years from 1830 until 1860. 321 of these were cured, and 103 died. 
 
 Cases. 
 
 Primary, 261 
 
 Secondary, 83 
 
 For chronic diseases, 84 
 
 Upper extremity, 194 
 
 Lower extremity, 234 
 
 Joints, 46 
 
 Age — under 20 years, 
 
 between 20 and 30 years, 
 " 30 " 40 " . 
 " 40 " 50 " . 
 " 50 " 
 
 Cases. 
 
 118 
 
 133 
 
 87 
 
 62 
 
 21 
 
 Cured. 
 108 
 101 
 
 60 
 
 40 
 
 16 
 
 Died. 
 54 
 31 
 18 
 21 
 74 
 6 
 
 Died. 
 10 
 32 
 27 
 22 
 5 
 
 Amputations at St. Thomas' Hospital, from 1862-69. 
 
 Limb Amputations. 
 
 1862. 
 
 1863. 
 
 1864. 
 
 1865. 
 
 1866. 
 
 1867. 
 
 1868. 
 
 1869. 
 
 1 
 
 d 
 S 
 
 oa 
 
 o 
 
 J 
 
 d 
 S 
 
 « 
 
 m 
 O 
 
 d 
 
 s 
 
 03 
 
 02 
 83 
 
 o 
 
 -d 
 
 s 
 
 05 
 
 a> 
 to 
 
 eg 
 
 a 
 
 ■d 
 
 s 
 
 
 5 
 
 63 
 
 o 
 
 ■d 
 
 3 
 
 00 
 
 •d 
 
 S 
 
 Thigh 
 
 10 
 
 1 
 
 2 
 5 
 
 5 
 
 7 
 4 
 
 3 
 
 3 
 
 1 
 
 7 
 5 
 
 4 
 4 
 
 6 
 4 
 3 
 
 2 
 3 
 2 
 
 7 
 3 
 2 
 4 
 
 2 
 
 1 
 1 
 1 
 
 5 
 
 2 
 3 
 
 2 
 1 
 1 
 
 1 
 1 
 
 1 
 1 
 
 
 1 
 
 6 
 4 
 
 1 
 
 Leg 
 
 Arm 
 
 Forearm 
 
 
 During the eight years that the hospital has been at Surrey Gardens, 
 Music Hall, there have been 111 amputations, with a mortality of 36 ; for the 
 first four years, 57 cases and 24 deaths ; for the last four years, 54 cases and 
 
 * Pennsylvania Hospital Reports, 1868, p. 164. 
 
MOETALITY AFTER AMPUTATION. 
 
 363 
 
 12 deaths, or about half the mortality of the preceding period. The use of 
 carbolic acid, and care being taken to exclude all sufferers from foul suppu- 
 rating sores, may to a certain extent account for the improvement. 
 
 Frederick Churchill, M.D., has analyzed these cases, and separated those 
 which were primary, secondary, and for disease. The mortality will be 
 found to vary considerably. For 1861-63, and 1866-69, the amputations 
 were tabulated under these three headings, and during these seven years 
 there were 41 primary amputations with 10 deaths ; 16 secondary amputa- 
 tions and 8 deaths ; and 39 amputations for disease with 7 deaths, i.e., 
 
 Primary amputations, 1 death in 4.1 
 
 Secondary " 1 " 2. 
 
 For disease, u 1 " 5.5 
 
 The late Sir James Y. Simpson furnished statistics showing that out of 
 2089 limb amputations, " in large and metropolitan British hospitals," there 
 were 855 deaths, or a mortality of one in 2.4, and out of 2098 limb ampu- 
 tations " in patients operated on in single or isolated rooms in British 
 country practice," there was a mortality of 226, or 1 death in 9.2 cases. 
 That such a result does not tally with the experience of the surgeons at St. 
 Thomas's Hospital is evident from the table above quoted. Mr. Callender 
 published statistics of limb amputations at St. Bartholomew's Hospital, by 
 which it appears that the mortality is greatly influenced by the class of 
 cases under treatment. That whereas, the average death-rate, after all 
 amputations, at St. Bartholomew's Hospital, is 1 in 3.6, the mortality of 
 country cases in the same hospital, under similar circumstances, is one in 
 5.8, showing that other things must be taken into consideration in comparing 
 the death-rate of hospitals with that in private country practice. 
 
 The statistical tables of St. George's Hospital, London, for the year 1867- 
 1868, which were at the hospital, and examined, give the following results : 
 54 amputations, 27 recoveries; 32 for disease; 11 deaths from pyaemia; 
 most of them of the thigh, leg, and foot. The following four tables 
 are taken from Agnew's Surgery as being most complete, reliable, and 
 recent. 
 
 Table of Amputations for all Causes at all Periods; showing also the Averrage 
 Mortality for Different Amputations, and also for Amputations of all 
 kinds. 
 
 Seat. 
 
 Hand 
 
 Wrist-joint 
 
 Forearm 
 
 Elbow-joint 
 
 Arm 
 
 Shoulder 
 
 Foot 
 
 Ankle-joint." , 
 
 Leg.... 
 
 Knee-joint 
 
 Thigh.. 
 
 Hip-joint 
 
 Double 
 
 Aggregate. 
 
 No. of Cases. 
 
 62 
 
 115 
 
 1,313 
 
 30 
 
 2,867 
 298 
 159 
 150 
 
 4,337 
 215 
 
 3,947 
 
 836 
 
 37 
 
 14,366 
 
 Cured. 
 
 56 
 112 
 
 1,120 
 28 
 
 2,190 
 178 
 130 
 126 
 
 3,018 
 119 
 
 2,018 
 
 305 
 
 15 
 
 9,415 
 
 Deaths. 
 
 6 
 
 3 
 
 193 
 
 2 
 
 677 
 
 120 
 
 29 
 
 24 
 
 1,319 
 
 96 
 
 1,929 
 
 531 
 
 22 
 
 4,951 
 
 Death Rate. 
 
 9.67 
 2.60 
 14.69 
 6.66 
 23.61 
 40.13 
 18.23 
 16.00 
 30.41 
 44.65 
 48.87 
 63.51 
 59.45 
 
 34.46 
 
364 
 
 A SYSTEM OF SURGERY. 
 
 
 t^ 
 
 CO 
 
 rH 
 
 C5 
 
 tO 
 
 CO 
 
 i> 
 
 o 
 
 iO 
 
 5f 
 
 © 
 
 CC 
 
 iC 
 
 <M 
 
 Death Rate. 
 
 co 
 
 (M 
 
 o 
 
 o 
 
 t- 
 
 <M 
 
 CN 
 
 o 
 
 CN 
 
 cc 
 
 ■^ 
 
 © 
 
 Tf 
 
 «* 
 
 
 © 
 
 iH 
 
 CN 
 
 © 
 
 oc 
 
 Tt 
 
 a 
 
 © 
 
 co 
 
 C< 
 
 © 
 
 © 
 
 © 
 
 (M 
 
 
 
 
 r ~' 
 
 
 (M 
 
 "<* 
 
 ■* 
 
 CN 
 
 CO 
 
 CC 
 
 cc 
 
 ^ 
 
 iO 
 
 CO 
 
 
 © 
 
 ,_, 
 
 lO 
 
 rH 
 
 lO 
 
 t^ 
 
 00 
 
 iO 
 
 *# 
 
 <M 
 
 CO 
 
 (M 
 
 CO 
 
 r-t 
 
 Died. 
 
 
 
 CO 
 
 
 lO 
 
 CM 
 
 CN 
 
 rH 
 
 CO 
 
 CC 
 
 
 © 
 
 (M 
 
 CO 
 
 © 
 
 
 <M 
 
 © 
 
 o 
 
 _, 
 
 CO 
 
 
 00 
 
 iO 
 
 CO 
 
 CC 
 
 iC 
 
 oc 
 
 1> 
 
 © 
 
 Total. 
 
 co 
 
 t- 
 
 o 
 
 r- 
 
 oc 
 
 CO 
 
 »c 
 
 i> 
 
 a 
 
 © 
 
 oc 
 
 © 
 
 cc 
 
 iO 
 
 
 
 t^ 
 
 
 oc 
 
 
 r- 
 
 
 cc 
 
 
 oc 
 
 o 
 
 
 a> 
 
 
 
 
 
 
 
 
 
 
 -< 
 
 
 
 
 id 
 
 
 
 .00 
 
 co 
 
 CO 
 
 o 
 
 CO 
 
 I> 
 
 
 CO 
 
 © 
 
 Tf 
 
 © 
 
 
 
 Tt< 
 
 
 Death Rate. 
 
 <M 
 
 CO 
 
 CO 
 
 o 
 
 lO 
 
 o 
 
 CN 
 
 OJ 
 
 
 l> 
 
 ^* 
 
 cc 
 
 
 t^ 
 
 
 
 ^ 
 
 <M 
 
 © 
 
 o 
 
 CN 
 
 CO 
 
 © 
 
 "<* 
 
 © 
 
 iC 
 
 r^ 
 
 CC 
 
 
 CO* 
 
 6 
 
 
 rH 
 
 1—1 
 
 
 <N 
 
 rH 
 
 CN 
 
 
 
 
 CN 
 
 CN 
 
 '^ < 
 
 
 (M 
 
 Died. 
 
 rH 
 
 tH 
 
 l> 
 
 i— 1 
 
 CO 
 
 CO 
 
 CC 
 
 1> 
 
 CC 
 
 cc 
 
 cc 
 
 cr 
 
 CC 
 
 oc 
 oc 
 
 
 00 
 
 
 
 
 
 
 
 
 
 
 
 
 CC 
 
 
 
 co 
 
 03 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 s 
 
 
 © 
 
 1> 
 
 ■^ 
 
 «tf 
 
 _ 
 
 c 
 
 © 
 
 rH 
 
 iC 
 
 cc 
 
 o- 
 
 CS5 
 
 r- 
 
 to 
 
 Cured. 
 
 
 
 co 
 
 rH 
 
 
 1> 
 
 
 CO 
 
 TT 
 
 
 CN 
 
 CN 
 0C 
 
 © 
 
 I— 
 
 
 GO 
 
 ©^ 
 
 
 t^ 
 
 00 
 
 i— 1 
 
 iC 
 
 l> 
 
 cc 
 
 CC 
 
 1> 
 
 
 i(T 
 
 CN 
 
 c 
 
 r- 
 
 CO 
 
 
 For Disease. 
 
 
 
 00 
 
 
 o 
 
 T— 
 
 I> 
 
 "tf 
 
 en 
 
 CC 
 
 CC 
 
 Tf 
 
 cr 
 
 
 © 
 © 
 of 
 
 
 
 
 CO 
 
 
 "* 
 
 
 CN 
 
 CC 
 
 CC 
 
 r- 
 
 © 
 
 rf 
 
 Tt 
 
 c 
 
 © O 
 
 
 Death Rate. 
 
 CO 
 
 
 © 
 
 
 
 © 
 
 r^ 
 
 r— 
 
 cc 
 
 CC 
 
 c 
 
 c 
 
 © rH 
 
 
 
 cc 
 
 
 Tf 
 
 
 a 
 
 © 
 
 CO 
 
 1— 
 
 I— 
 
 1> 
 
 cc 
 
 c 
 
 © © 
 
 
 
 CO 
 
 
 (M 
 
 
 -* 
 
 iC 
 
 cc 
 
 r— 
 
 UZ 
 
 iC 
 
 CC 
 
 cc 
 
 iO iO 
 
 Died. 
 
 G<J 
 
 
 
 • 
 
 co 
 
 cc 
 
 ■<* 
 
 r- 
 
 oc 
 
 cc 
 
 a 
 
 lO cc 
 
 Cn 
 
 1 03 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 CO 
 
 Cured. 
 
 ^ 
 
 <M 
 
 1> 
 
 CC 
 
 
 © 
 cc 
 
 cc 
 
 a 
 
 cc 
 
 r- 
 
 cc 
 
 CC 
 
 oc 
 
 CN 
 
 CN 
 
 1 © 
 
 co 
 
 
 
 
 
 
 
 
 
 
 
 T— 
 
 
 
 
 
 CO 
 
 Secondary. 
 
 CO 
 
 <M 
 
 © 
 cc 
 
 
 cc 
 
 CO 
 
 cc 
 
 CC 
 
 a 
 
 © 
 cc 
 
 -<* 
 
 © IC 
 
 CO 
 
 -^ 
 
 1 1— ! 
 
 CO 
 
 
 
 
 
 
 
 
 
 
 
 <M 
 
 
 <M 
 
 
 
 tr^ 
 
 
 <M 
 
 
 o: 
 
 
 o 
 
 e 
 
 CR 
 
 © 
 
 © 
 
 
 iO 
 
 r- 
 
 c 
 
 i—i 
 
 
 Death Rate. 
 
 rH 
 
 
 CO 
 
 
 © 
 
 c 
 
 CC 
 
 
 
 cc 
 
 »c 
 
 CC 
 
 iC 
 
 CO 
 
 
 
 cc 
 
 
 o 
 
 
 
 c 
 
 cn 
 
 o 
 
 cc 
 
 
 to 
 
 "* 
 
 CN 
 
 iO 
 
 
 
 
 
 rH 
 
 
 <M 
 
 *C 
 
 cc 
 
 ** 
 
 rr 
 
 cc 
 
 u: 
 
 oc 
 
 CC 
 
 CO 
 
 Died. 
 
 co 
 
 
 CC 
 
 
 »© 
 
 
 1> 
 
 oc 
 
 © 
 
 iC 
 
 tc 
 
 r— 
 
 c 
 
 rH 
 
 
 
 
 "^ 
 
 ; 
 
 IC 
 
 c< 
 
 r- 
 
 
 ** 
 
 r- 
 
 oc 
 
 r- 
 
 CN 
 
 CNI 
 
 
 
 
 
 
 
 rH 
 
 
 
 
 cc 
 
 
 CN 
 
 
 
 OS 
 
 
 CO 
 
 en 
 
 Tf 
 
 io 
 
 
 
 <N 
 
 r- 
 
 cc 
 
 Tt 
 
 OC 
 
 CN 
 
 o- 
 
 1 rH 
 
 
 Cured. 
 
 TtH 
 
 CC 
 
 oc 
 
 cc 
 
 
 en 
 cc 
 
 CN 
 
 iC 
 
 r- 
 
 © 
 CC 
 
 « 
 
 OC 
 
 
 
 I© 
 
 
 © 
 
 o: 
 
 © 
 
 io 
 
 cc 
 
 CN 
 
 cr 
 
 © 
 
 CC 
 
 Oi CC 
 
 CC 
 
 CN 
 
 I ! (N 
 
 
 Primary. 
 
 "tf 
 
 cc 
 
 CO 
 
 
 
 "* 
 
 cc 
 
 r- 
 
 cc 
 
 -<* 
 
 r- 
 
 »c 
 
 T— 
 
 C 
 
 lO 
 
 of 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 a 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 to 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 <n 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 sc 
 
 w 
 
 
 c 
 
 
 c 
 
 
 
 
 C 
 
 
 e 
 
 
 
 
 to 
 
 < 
 
 
 tr 
 
 *c 
 .2 
 
 !1 
 
 1 
 
 1 
 
 < 
 
 a 
 
 1 
 
 ; i 
 
 J 
 
 a 
 
 < 
 
 ■J 
 
 # c 
 a 
 
 ! 1 
 
 4 C 
 
 *c 
 
 1 
 E 
 
 : 1 
 p 
 
 
AMPUTATION AT THE HIP- JOINT. 
 
 365 
 
 Table of Mortality of Amputations. 
 [a) Mortality of Major Amputations. 
 
 Where Performed. 
 
 Bellevue and Charity Hospital 
 
 Birmingham Hospital 
 
 Boston City Hospital 
 
 Edinburgh Royal Infirmary 
 
 Guv's Hospital 
 
 Hotel Dieu de Rouen 
 
 Leeds General Infirmary 
 
 London Hospital 
 
 London and Provincial Hospitals (thigh and leg) 
 
 Massachusetts General Hospital 
 
 Pennsylvania Hospital 
 
 Radcliffe Infirmary (Oxford) 
 
 St. Bartholomew's Hospital 
 
 St. George's Hospital 
 
 St. Thomas's Hospital, 
 
 Various places in England 
 
 Total 
 
 No. of Cases. 
 
 55 
 33 
 
 366 
 
 26 
 
 581 
 
 47 
 
 189 
 
 132 
 
 680 
 
 784 
 
 712 
 
 46 
 
 97 
 
 180 
 
 181 
 
 135 
 
 4,204 
 
 Deaths. 
 
 19 
 
 8 
 
 145 
 
 11 
 
 206 
 
 9 
 
 45 
 
 73 
 
 205 
 
 193 
 
 197 
 
 5 
 
 14 
 74 
 61 
 25 
 
 1,290 
 
 Death Rate. 
 
 34.54 
 24.24 
 39.61 
 42.30 
 35.45 
 19.15 
 23.80 
 55.31 
 32.06 
 24.61 
 27.66 
 10.86 
 14.43 
 41.11 
 33.64 
 19.25 
 
 30.68 
 
 (b) Mortality of all Amputations. 
 
 Boston City Hospital 
 
 Glasgow Royal Infirmary... 
 
 Guy's Hospital 
 
 Paris Hospitals 
 
 Pennsylvania Hospital 
 
 St. Bartholomew's Hospital 
 St. George's Hospital 
 
 Total 
 
 135 
 1,973 
 735 
 1,144 
 902 
 358 
 226 
 
 5,473 
 
 56 
 672 
 253 
 522 
 230 
 74 
 92 
 
 41.44 
 34.10 
 34.42 
 45.60 
 25.49 
 20.67 
 40.70 
 
 34.69 
 
 CHAPTER XX. 
 
 SPECIAL AMPUTATIONS. 
 
 AMPUTATION OF THE LOWER EXTREMITIES. 
 
 1. Amputation at the Hip- Joint. -—According to the report of the Surgeon- 
 General of the U. S. Army; Kerr, of Northampton, in 1774, was the first 
 surgeon who performed this formidable operation, although in 1748, La- 
 croix, of Orleans, completed the exarticulation of the limb at the coxo- 
 femoral joint, which sphacelus, from ergotism, had already almost removed. 
 Since then, the operation has been performed many times. In civil sur- 
 gery, out of forty-seven cases, there were sixteen recoveries, and in America, 
 in twenty-four examples of amputation, fifteen successful results are pub- 
 lished. The report reads thus : " Of one hundred and eleven amputations 
 
366 
 
 A SYSTEM OF SUKGERY. 
 
 at the hip-joint in civil practice here recorded, forty-six succeeded, and 
 sixty-five ended fatally." 
 
 During the late civil war there were fifty -three amputations performed at 
 the hip, thirty-four of which were done in the service of the United States, 
 and nineteen in the Confederate armies. 
 
 These cases, which have been tabulated and arranged with great care by 
 Dr. Otis, are classified into primary, of which there were nineteen ; the in- 
 termediate numbered eighteen, the secondary nine, and the reamputations 
 seven. In the first the mortality was very large, being 94.73 per cent. The 
 case of Dr. Shippen is said to be the only perfectly authentic one of 72 on 
 record, of recovery after primary amputation at the hip ; of the second 
 classification all terminated fatally ; of the third there were two recoveries ; 
 in the fourth, four were successful, making the mortality rate 42.85. 
 
 In performing the operation six assistants are necessary ; to one must be 
 given the charge of the anaesthetic, a second hands the required instruments, 
 a third and the most experienced takes charge of the limb, making the requi- 
 site movements at the proper time; a fourth controls the bleeding, with the 
 aortic compressor, and with his finger compresses the femoral artery as it 
 passes over the brim of the pelvis ; a fifth attends to the sponging, and the 
 
 sixth takes care of the sound limb, 
 fig. 166. carrying it away from the body, at 
 
 the same time holding the scrotum 
 aside with a towel, as represented 
 in Fig. 166. 
 
 The common iliac artery may be 
 compressed by carefully introduc- 
 ing a straight wooden rod with a bul- 
 bous end into the rectum for about 
 nine inches — the length of the 
 rod being about twenty-two inches. 
 Slight elevation or depression of 
 the handle, when once the instru- 
 ment is brought to bear on the 
 vessel, will be sufficient to stop or 
 to allow the flow of blood. This 
 method was successfully tried by 
 Mr. A. Pierce Gould.* Or the haem- 
 orrhage may be controlled by the 
 abdominal tourniquet of Pancoast. 
 Before the latter is applied, the en- 
 tire limb from the toes up should be 
 encased with an elastic bandage to a 
 point where it will not interfere with 
 the formation of the flaps, thus forc- 
 ing the blood out of the extremity. 
 The abdominal tourniquet is then 
 screwed down. Vide also page 344. 
 The operation which appears the most simple, is that of Mr. Bryant,f 
 who says : 
 
 " The best flaps appear to be the external and internal. The patient 
 being brought to the edge of the table, with the tuberosities of the ischium 
 in view, Lister's valuable abdominal tourniquet is to be adjusted, and, 
 when the patient is under chloroform and everything is prepared, screwed 
 up. The surgeon should then make the external skin flap by means 
 
 Anatomy of the Hip-joint, with position of the 
 knife in forming anterior flap. 
 
 * The Medical Kecord, March 8th, 1879, No. 435. 
 
 f Practice of Surgery, p. 953. 
 
AMPUTATION AT THE HIP- JOINT. 367 
 
 of a semicircular incision, starting from the tuberosity of the ischium, 
 downwards and outwards, one hand's breadth below the great trochanter, 
 then upwards and forwards to the centre of the groin on the outer side of 
 the femoral vessels, and this should then be reflected upwards above the 
 trochanter so as to expose it and allow the joint to be opened and disarticu- 
 lation to be completed, the limb being forcibly adducted by an assistant to 
 facilitate this step. In doing this no vessels of any importance are opened 
 while the most difficult part of the operation is completed. 
 
 " The inner flap now remains to be made, and this is readily done by 
 transfixing the thigh on the inner side, inserting the knife (twelve inches 
 long) in the anterior wound, passing it backwards close to the inner side of 
 the neck of the femur, and bringing it out near the tuberosity of the ischium 
 where the external incision was commenced, and then cutting out through 
 the soft parts, including all the abductors, etc. In doing this, all the pel- 
 vic muscles are separated at one clean sweep from the thigh-bone, and a 
 few touches of the knife complete the amputation. Should there be much 
 fear of loss of blood, the common femoral artery may be ligatured in the 
 wound before the second flap is made, or it may be divided and twisted. 
 The vessels are then to be secured in the way the surgeon proposes, and the 
 parts brought together, the two flaps usually forming an excellent covering 
 to the pelvic cup ; the wound is a vertical one, and therefore good for drain- 
 age, and a good scar results." 
 
 Lateral Flap Operation. — A line one inch in length should be drawn 
 downwards from the anterior superior spinous process of the ilium ; from 
 the lower extremity of this line, a second, half an inch in length, should be 
 drawn inward to mark the head of the bone. The surgeon then, standing 
 on the outer side of the limb, enters a straight single-edged amputating 
 knife, with a blade twelve to fourteen inches in length, on the inner end 
 of the last line, and passes it perpendicularly down to the head of the 
 femur. The handle of the instrument must now be slightly inclined 
 towards the pubis, and the blade pushed on the outer side of the cervix 
 femoris. The assistant in charge of the limb now raises the femur and 
 slightly abducts it. The surgeon grasps with his left hand the soft parts, 
 and brings the point out a little below the tuberosity of the ischium, about 
 an inch from the anus. The great trochanter then must be cleared as the 
 blade of the knife cuts out the flap from seven to eight inches long. 
 
 The assistant now puts the capsular ligament upon the stretch, which 
 must be divided with the point of the knife, and the head of the bone is 
 then disarticulated. Passing the knife then close to the head of the femur, 
 and behind it, an inner flap six inches in length is cut out. As the instru- 
 ment passes close to the bone, the thumb of the assistant should follow it, 
 and immediately compress the artery. 
 
 The anterior and posterior flap operation is performed as follows : 
 
 The patient having been prepared as before, and the requisite number of 
 assistants at hand, the surgeon flexes the leg slightly, rotates the thigh in- 
 ward, and introduces the point of the knife just above and posterior to the 
 trochanter major, and carries the blade across the front of the thighbone, 
 entering, if possible, the capsule of the joint in its passage, and bringing out 
 the point in the perineal fold, in front of the tuberosity of the ischium (Fig. 
 166) . The knife then is made to cut out the anterior flap, six to eight inches in 
 length. The vessels may now, if it is expedient, be secured, and without loss 
 of time the operator proceeds to the formation of the posterior flap as follows : 
 
 The femur must be drawn downwards, in order to stretch the orbicular 
 ligament of the articulation, which must be divided with the point of the 
 knife, inserted behind the head of the bone (Fig. 167), and guided by the 
 bone cuts out the posterior flap somewhat shorter than the anterior. 
 
368 A SYSTEM OF SURGERY. 
 
 Dr. Hamilton makes a somewhat different line of incision, to prevent 
 the point of the knife entering the belly or wounding the iliac artery and 
 vein,* and directs that the point be introduced " one inch in front of the 
 trochanter major, the edge of the knife being directed downwards in the 
 line of the axis of the limb. From this point the knife is made to pene- 
 
 FlG. 167. 
 
 Amputation of Hip-joint— making the posterior flap. 
 
 trate transversely, and with a slight inclination backward, so as to strike 
 the head of the femur in its upper half, and near the upper margin of the 
 acetabulum." The handle of the knife must then be carried toward the 
 head of the patient and the point, cutting the capsule, must be thrust in 
 front of the neck, and made to emerge below the tuber ischii. As the flap 
 is cut out, assistants follow with their fingers in order to arrest the bleeding. 
 The thigh must then be forcibly abducted and carried backward, and the 
 articulation opened (provided it has not been done by the manoeuvre just 
 mentioned) with a large scalpel, and the round ligament cut. The centre 
 of the blade is then passed above the head of the bone, and the knife brought 
 out at the gluteal fold. 
 
 The operation of Dr. Van Buren f consists in making the anterior flap by 
 transfixion ; the flap is drawn upward by the assistant, and " the surgeon, 
 partially kneeling, carries the knife beneath the thigh to its inner side, as in 
 a circular amputation, and placing its heel in the integument at the internal 
 angle of the wound, sweeps it lirmly across through the tissues on the back 
 part of the thigh, cutting with a slightly sawing motion down to the bone, 
 and joining the two extremities of the first incision. The long knife is then 
 immediately relinquished, and with a large straight scalpel, the femur being 
 forcibly abducted, the capsule of the joint is laid open as near as possible 
 to the acetabulum, the round ligament divided with the rotator muscles in- 
 serted into the trochanter, and the fossa at its base, the assistant regulating 
 the limb, so as to keep these parts successively on the stretch, and the 
 operation is completed." 
 
 In all the above performances the great danger is always that of haemor- 
 rhage ; since, however, the introduction of the aortic tourniquet the danger 
 has been much lessened. Compression on the abdominal aorta has been 
 ascribed to Lister, although it properly belongs to Professor Pancoast, of 
 Philadelphia. The tourniquet of Mr. Richard Davies, which is described 
 
 * The Principles and Practice of Surgery, p. 378. 
 f Trans. New York Academy of Medicine, vol. i. 
 
AMPUTATION OF THE THIGH. 369 
 
 by him as a lever, which introduced into the rectum can be made to com- 
 press the iliac artery, was introduced in 1878. 
 
 Dr. C. B. Keetley,* in a valuable article upon disarticulation at the hip- 
 joint, after detailing several methods, draws admirable conclusions. In his 
 fourth, he says, "that, if in a case of disarticulation of the hip-joint the 
 operation be divided into two parts done on separate days, so that the 
 patient has time to recover from the shock of one before the other is in- 
 flicted on him, he will be more likely to survive than if the total shock is 
 given at one operation." He advises, according to this plan, that the 
 trochanteric part of the femur with the head of the bone shall be first excised, 
 and that after the patient has recovered from the shock, say forty-eight 
 hours, the thigh should be amputated near the conjunction of the shaft with 
 the epiphysis. 
 
 In some instances the oval method of amputation may be made and the 
 bone excised afterwards ; in others the femoral artery and vein may be 
 ligated in Scarpa's space before beginning the amputation. 
 
 Amputation of the Thigh. — This operation is generally performed at the 
 lower, middle, or upper third of the thigh, and may be either the circular, 
 the flap, or the rectangular flap of Mr. Teale, or a combination of the two. 
 
 The selection of the method of forming the flaps is a subject for serious 
 consideration. The ordinary flap amputation is the most readily performed, 
 and immediately after the operation the stump appears well covered with 
 muscular tissue ; but experience has taught me, and I believe others also, 
 that this muscular covering, especially at the lower third of the thigh, 
 gradually and steadily retracts, and that after a year or more nothing re- 
 mains but a covering of skin ; and even this, in many instances, likewise 
 retracts, exposing the end of the bone, which may finally become necrosed. 
 The arguments in behalf of the flap amputation are : that its rapidity of 
 execution renders it much less painful and prolonged ; that soft parts can 
 be readily furnished to form an excellent muscular covering for the stump, 
 and that, the different textures being allowed to remain in connection with- 
 out dissection, there is much more likelihood of rapid union. But these 
 reasons in its favor are counterbalanced by others, among which are : shock 
 from the rapidity of the operation ; that there is a greater extent of surface 
 exposed, and that the contraction of muscles, even after the most carefully 
 conducted operation, often leaves what is called a conical stump. There- 
 fore, the numerous powerful muscles of the thigh, which are divided at 
 their extremities in the ordinary flap operation, at the lower third, would 
 tend to the formation of the undesirable conical stump. These reasons 
 seem to be sufficiently forcible to determine in favor of the circular opera- 
 tion at the lower third of the thigh. Moreover, the nearer we operate to the 
 neck of the femur, the more likelihood will there be of a good stump by the 
 flap procedure. 
 
 When the lower or middle third is selected, a tourniquet must be applied 
 high up in Scarpa's space, but when the operation has to be performed at 
 the upper third, an assistant must compress the artery where it passes over 
 the brim of the pelvis. This is readily done by grasping the greater tro- 
 chanter with the fingers, and pressing the thumb firmly upon the artery ; 
 upon this the thumb of the other hand may be firmly pressed and the 
 artery kept under complete control, Esmarch's bandage may also be used. 
 
 Sometimes the condition of the limb will admit of no choice, and the place 
 for operating will then be where flaps can most readily be secured. A 
 double circular operation may be practiced at any part of the thigh with 
 success. The military surgeon frequently finds the tissues entirely destroyed 
 
 * Annals of Surgery, vol. ii., 1886, p. 473. 
 24 
 
370 A SYSTEM OF SURGERY. 
 
 upon one side ; under such circumstances the covering of the bone must be 
 obtained from the opposite side. 
 
 Lateral Flaps. — The thigh may be removed by a lateral flap operation in 
 the following manner, which is especially applicable to the lower third : 
 The exterior or outer flap is first made by entering the point of the knife 
 at the middle of the thigh, about three inches above the patella, carrying 
 it close around the bone and bringing it out through the centre of the ham, 
 and cutting downwards and outwards. The point of the knife is again 
 entered at the upper angle of the incision, and carried around the bone on 
 its inner side, and made to cut out a flap of similar dimensions to that 
 first formed. 
 
 By keeping the knife close to the bone the danger of splitting or prick- 
 ing the femoral artery is avoided. The bone then must be well cleared and 
 sawn off at about four and a half inches above its articular surface. At 
 the middle and upper third of the thigh, if flaps are determined upon, the 
 anterior and posterior flap are preferable. 
 
 Anterior and Posterior Flaps. — In the majority of cases the anterior is the 
 flap first made. The surgeon, standing on the outside of the limb, raises 
 with his left hand all the structures from the bone, and enters the point of 
 the knife about the site where the division of the bone is contemplated (Fig. 
 168). This flap must be cut out and held back by an assistant, or as is 
 
 Fig. 168. 
 
 preferred by some surgeons, the flap may be made from without inwards. 
 The soft parts are then drawn down on the posterior side, and the knife 
 entered at about the same point at which it passed to make the anterior 
 flap. Then the knife is allowed to cut itself out, making the posterior flap. 
 The two-tailed retractor is then placed around the bone, which is evenly 
 divided with the saw. The spiculse of bone are then carefully removed 
 with the bone pliers, the vessels secured either by acupressure or ligature, 
 and the wound closed with silver sutures and the collodion and gauze dress- 
 ing. If, however, the patient is much emaciated it is very difficult to pro- 
 cure a good cushion from the anterior flap ; in such instances it is better to 
 follow another course and make the posterior flap first by transfixion, and 
 the other by cutting from without inwards. When the muscular tissue is 
 much mutilated an excellent stump can be made by a long square anterior 
 flap, and then with one stroke of the knife cutting through the soft parts 
 on the back of the thigh, obliquely from below upw T ard ; thus the anterior 
 flap, when laid down, will form the cushion at the end of the stump. 
 
 Dr. Child, of Mobile, Alabama, suggests a single oblique flap opera- 
 tion, the division of the soft parts being made by cutting from without in- 
 
AMPUTATION THROUGH THE CONDYLES. 371 
 
 ward on the anterior face of the femur, and after having transfixed the 
 tissues on the posterior surface of the bone, cutting downward and backward. 
 
 Combination Method. — The method that I prefer in amputating any por- 
 tion of the shaft of the femur from below the trochanter to the base of the 
 condyles is the mixed method, which is fully described in the preceding 
 chapter under the head of " Methods." No one after performing this opera- 
 tion several times would, I think, provided there were integument sufficient 
 to form the flaps, resort to any other. 
 
 The Rectangular Flap of Mr. Teale. — In his work " On Amputation, by a 
 Long and Short Rectangular Flap," Mr. Teale speaks of the imperfections of 
 many stumps after the usual methods of amputation, and remarks that in 
 the stumps formed after the circular and transfixion methods, it is ex- 
 tremely rare to find a soft movable mass of tissue over the ends of the bone ; 
 secondly, that with very few exceptions, the cicatrix is adherent to the ends 
 of the bone, and that, in addition to this, such stumps are generally unable 
 to bear pressure on their extremities. To remedy all this he proposes the 
 operation named above, and which will be described below. It has been 
 regarded with a good deal of favor by some distinguished surgeons, and 
 makes a most excellent stump for the application of a patent limb. 
 
 In this operation the long flap folds over the ends (Fig. 169) of the bone, 
 and is, in the majority of instances, devoid of important bloodvessels and 
 nerves, while both are found in the 
 
 short flap. Mr. Teale says : " The size FlG - m 
 
 of the long flap is determined by the 
 circumference of the limb at the place 
 of amputation, its length and its breadth 
 being each equal to half its circumfer- 
 ence. The long flap is, therefore, a 
 perfect square, and is long enough to 
 fall easily over the end of the bone. 
 The short flap, containing the chief 
 vessels and nerves, is in length, one- 
 fourth of the other." 
 
 In the thigh amputation, the circum- 
 ference must be measured at the point Stump after Teale's Amputation. 
 
 where the bone is to be sawn ; if this 
 
 be eighteen inches, then the long flap must be nine inches long, and nine 
 inches broad, and it is recommended that these measurements be accurately 
 made, and the lines traced with ink, or other substance, upon the limb. The 
 length of the short flap will be one-quarter of nine, or two and one-quarter 
 inches in length and breadth. 
 
 In the commencement of the operation, the lateral incisions are to be 
 made through the integument only. The transverse incision joining these 
 two cuts is to be made down to the femur. The flap must then be made, 
 by cutting the fleshy structures from below upwards, close to the bone. 
 
 The posterior flap must be made with one sweep of the knife down to the 
 bone ; the soft structures being afterward carefully separated from the perios- 
 teum. The vessels may then be secured, and the flaps united. 
 
 Amputation through the Condyles known as Stokes'.— This method of am- 
 putation is now receiving much attention from surgeons, and has many 
 points of interest. When the femur is sawn through at the condyles, the 
 medullary canal — the largest in the body — is not opened ; there is not a 
 compact structure of bone to be removed, and the soft or cancellated struc- 
 ture opened is more rapidly reproduced than the hard ivory texture of the 
 shaft. Professor Fergusson has recorded several interesting cases of this 
 successful amputation. Mr. Jessup, of Leeds, and others, also speak highly 
 
372 A SYSTEM OF SURGERY. 
 
 of it. In this operation, the incision is commenced about two inches above 
 one condyle, and carried around the knee in a semicircular incision, with 
 its convexity downward, about an inch below the tubercle of the tibia, and 
 extended upward to a point on the opposite condyle, to correspond with 
 the commencement of the incision. The lig amentum patellae is then cut off, 
 the flap turned up, and a thin slice of the patella sawed off. The posterior 
 integumental flap, one-third the length of the anterior, is then made. The 
 joint is then opened and the condyles sawn through. The sliced patella in 
 the anterior flap is then brought in apposition to the sawn femur and the 
 wound dressed. 
 
 The special advantages of this amputation are described as being the fol- 
 lowing : 1. The resulting stump is more useful, as pressure can be borne 
 on its extremity. 2. There is a diminished liability to tubular sequestra. 3. 
 The operation is less hazardous to the patient than amputation of the thigh, 
 its situation being more distant from the trunk. 4. It is accompanied by 
 less shock. 5. There is less tendency to the occurrence of suppuration. 
 6. In the posterior surface of the anterior flap, which is lined with a natural 
 synovial membrane, no vessels or nerves are included. 7. The preserved 
 portion of the patella acts as an osseous curtain, covering the cut surface of 
 the femur, and has not yet been known to slough away. 8. The attach- 
 ment of the tendon of the quadriceps extensor muscle to the patella gives 
 an increased power of extending the thigh in progression, and renders the 
 formation of a conical stump impossible. 9. The vessels are divided at 
 right angles to their continuity, and not obliquely, as in all flap operations, 
 thus being less exposed to inflammatory action from the extent of the 
 wounds. 
 
 The operation known as Gritti's is similar to the one just detailed, but in 
 reality is not a very new amputation, it having been performed in this 
 country many years ago. 
 
 Circular Method. — In performing this operation a medium-sized, or rather 
 a small amputating knife, with a sharp point, should be used. The sur- 
 geon stands on the outside of the limb, which having been raised, he places 
 his arm underneath the thigh and touches the heel of the knife at a point 
 on the anterior aspect of the limb, and with a single sweep around the thigh 
 divides the integument and superficial fascia ; the parts are then to be drawn 
 backward by an assistant, or a free dissection of the skin from the muscles 
 may be necessary for two or three inches ; then with the arm and hand 
 placed in the same position as that when the first incision was made, he di- 
 vides all the parts down to the bone ; a retractor, or the hands of an expert 
 assistant, may be used to retract and hold the flap, while the bone is sawn 
 through. The arteries are secured and the flaps adjusted according to gen- 
 eral principles. 
 
 Amputation at the Knee-joint. — The advantages claimed for this somewhat 
 popular operation, are thus stated by Dr. Markoe, of New York, who has 
 arrived at his conclusions from careful observation of fourteen cases : 
 
 " 1. The grand advantage of this operation is the useful character of the 
 stump that results, strongly contrasting with the uselessness of the stump 
 left after amputation of the thigh, and enabling the patient to wear an arti- 
 ficial limb with comfort and advantage. 2. The seat of operation is farther 
 removed from the trunk, and the constitutional shock is probably, there- 
 fore, less. 3. The section at the knee-joint is less extensive than that of 
 amputation higher up, no parts being divided but the integuments, and, 
 although a large surface is exposed, a great portion of it, the femoral carti- 
 lage, is a healthy, not a wounded surface. 4. No muscular interspaces are 
 exposed by the knife excepting those of the heads of the gastrocnemius, 
 which are of small extent and depth. There is, therefore, less chance of any 
 
AMPUTATION AT THE KNEE-JOINT. 
 
 373 
 
 inflammation that may attack the stump travelling upwards and forming 
 burrowing abscesses, amidst the soft areolar tissue filling such interspaces. 
 The section of tendons that takes place in this operation is rarely followed 
 by any other than reparative inflammation. 5. Fewer ligatures are re- 
 quired, and the orifices of the divided arteries lie close together in the centre 
 of the popliteal space. By following Blandin's procedure, therefore, of 
 making a small opening through the integument, of which alone the poste- 
 rior flap consists, we are enabled to bring all the threads out of the stump 
 by a short and direct route, in the most depending position, and thus the 
 space between the flaps and condyles, where we are most anxious to pro- 
 cure adhesive inflammation, is not fretted into suppuration by the presence 
 of the ligatures crossing it, to be brought out between the lips of the wound. 
 6. The muscular attachments concerned in the movements of the limb are 
 not divided. Those which are severed are merely for the movements of the 
 leg, all the muscles proper to the thigh being left untouched. The result is 
 that the patient is able to move the stump with astonishing freedom and 
 facility. 7. Another advantage directly resulting from this is that there is 
 no muscular retraction after the healing of the wound. Dr. S. Smith has 
 made a comparison of this operation, and that of amputation at the thigh, 
 and finds that in European practice, of 28 cases of amputation at the knee, 
 12 died and 16 recovered. There have been 18 American cases, with 13 
 recoveries and 5 deaths ; making in all 46 cases and 17 deaths. The pro- 
 portion of deaths in European practice has been, therefore, 43, in America 
 28, and together 37 per cent. Of 987 cases of amputation at the thigh, col- 
 lected by Phillips, 435 died ; and in 68 American cases, collected by Dr. 
 Markoe, there were 29 deaths, being an average mortality of about 43? per 
 cent, and making a difference of 6? per cent, in favor of amputation at the 
 knee-joint." 
 
 Fig. 171. 
 
 Fig. 170. 
 
 In amputation at the knee it must be remembered that it requires more 
 integument to cover the broad surface of the condyles than to protect merely 
 the shaft of the femur, and therefore, it is well to make the anterior flap 
 long, and the posterior flap short (Fig. 170 shows lines of incision), although 
 
374 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 172. 
 
 circumstances may demand that the posterior be the long, and the anterior 
 the short flap. If we desire to make the former operation it must be done 
 as follows : the leg should be bent at a right angle with the thigh, the sur- 
 geon takes a large and strong scalpel, and, beginning at the posterior surface 
 of either condyle, makes a semicircular incision, extending about an inch 
 and a half or two inches below the tubercle of the tibia ; the flap is then 
 raised and the joint opened ; the ligaments of the articulation are divided, 
 and the knife, kept close to the posterior surface of the tibia, is made to cut 
 itself out with a short flap (Fig. 171). When it is necessary to make the 
 posterior flap the long one, the leg is placed in a horizontal rather than the 
 flexed position ; the incision is made as before, with the difference that in- 
 stead of extending some distance below the tubercle of the tibia, it passes 
 just above that prominence; the ligamentum patellae is then cut through, 
 and the leg flexed as for resection of this joint, then an amputating knife is 
 thrust behind the bones, and a flap of six to eight inches is cut awa} r from 
 the posterior surface of the limb. 
 
 Carden's, or the Mixed Amputation at the Knee. — " The operation consists 
 in reflecting a rounded or semi-oval flap of skin and fat from the front of 
 the joint (knee), dividing everything else straight down to the bone, and 
 sawing the bone slightly above the plane of the muscles, thus forming a 
 flat-faced stump with a bonnet of integument to fall over it. The operation 
 is simple. The operator, standing on the right side of the limb, seizes it be- 
 tween his left forefinger and thumb at the spot selected for the base of the 
 flap, and enters the point of the knife close to his finger, bringing it round 
 through skin and fat below the patella to the spot pressed by his thumb ; 
 then turning the edge downwards at a right angle with the line of the limb, 
 
 he passes it through to the spot where it first 
 entered, cutting outwards through everything 
 behind the bone. The flap is then reflected, 
 and the remainder of the soft parts divided 
 straight down to the bone ; the muscles are then 
 slightly cleared upwards and the saw is ap- 
 plied. Or the limb being held as before, the 
 hand and knife may be brought round under 
 the limb, as in the circular operation, and the 
 blade entered near the thumb and drawn round 
 to the opposite side, when the ham may be cut 
 across by turning the edge of the knife upwards, 
 and the operation completed as before. In am- 
 putating through the condyles, the patella is 
 drawn down by flexing the knee to a right 
 angle before dividing the soft parts in front of 
 the bone ; or, if that be inconvenient, the patella 
 may be reflected downwards." 
 
 Circular Method. — In the performance of this 
 operation, the leg must be fully extended, and 
 a circular incision made around the upper por- 
 tion of the leg about three inches or a little more 
 below the patella. This cuff of integument must 
 be dissected up, to facilitate which, the flap 
 may be divided at each side by a small longitu- 
 dinal cut. The joint is then to be flexed and the 
 ligament cut off just below the knee-cap, and 
 the anterior part of the capsule, together with 
 the lateral ligaments, divided as closely as possible to the condyles of the 
 femur, thus leaving the semilunar cartilage as much as possible undis- 
 
 Disarticulation at the Knee (Cir 
 cular Method). 
 
AMPUTATION OF THE LEG — FLAP OPERATION. 375 
 
 turbed. The joint then must be more flexed, and the crucial ligaments 
 divided also close to the femur. The leg must now be brought into almost 
 a straight position, and the soft parts divided with one sweep of the knife 
 (Fig. 172). The patella may be now removed if necessary, and the edges 
 of the wound approximated according to directions already given. 
 
 The removal of the patella, in my opinion, is rarely called for. I have 
 never as yet had reason to remove it excepting on one occasion, and then I 
 found that not only was its careful cutting out a matter of some time, a 
 nicety of dissection, but the flap sloughed afterward. If the upper flap 
 should show any tendency to retraction, an extension with a weight of four 
 to six pounds may be applied to the stump, until the cicatrix is firmly 
 formed. 
 
 Amputation of the Leg. — Flap Operation. — This is a very favorite operation 
 with many surgeons, although I am, from the satisfactory results obtained 
 in my own cases, very partial to the circular, especially in the lower third. 
 The operator, standing on the outer side of the right leg, or the inner side of 
 the left, introduces a knife behind both bones, cutting downward and for- 
 ward, making a flap four or five inches in length, from the posterior muscles 
 of the leg. He may then relinquish the catling, and with a strong scalpel 
 join the points where the posterior flap begins with a similar incision, hav- 
 ing its convexity downwards. ' This integumental anterior flap is then dis- 
 sected up and the bone sawn through, dividing the fibula first and removing 
 the spine of the tibia to prevent its afterward cutting through the flap. 
 
 Mr. Fergusson's method, which is illustrated in Fig. 173, is described as 
 follows : 
 
 He first places the heel of the knife on the side of the leg farthest from 
 him, and draws it across the front of the limb, cutting a semilunar flap of 
 skin ; when its point has arrived at the opposite side, it is at once made to 
 transfix the limb — this stage of the operation is represented in the figure — 
 and then the flap is cut as above directed. When transfixing the right 
 limb, the surgeon must take great care not to get his knife between the 
 two bones. When the operation is performed high up, the popliteal artery 
 will be divided, instead of the two tibials. The tibia, however, should never 
 
 Fig. 173. 
 
 be sawn higher than its tuberosity, or the joint will be laid open. The am- 
 putation may be performed near the ankle in the same manner. If low 
 down, the tendo Achillas will require to be shortened after the flap is made. 
 The flap is to be brought forwards and confined by a stitch or two, the line 
 of junction being, of course, horizontal. 
 
376 
 
 A SYSTEM OF SURGERY. 
 
 Circular Method. — The patient having been brought to the edge of the 
 table, an assistant supports the ankle, while a second draws back the in- 
 tegument and steadies the knee ; the surgeon (on the inner side if the right 
 leg is to be removed, and vice versa) places his arm beneath the leg and 
 brings the heel of the amputating knife in contact with the integument near 
 the spine of the tibia ; with a circular motion he divides the skin and fascia 
 around the leg. This can be conveniently done with the small catling, the 
 use of which renders a change of instruments unnecessary in the after stages 
 of the operation. The integument is then dissected up and turned back, 
 and the tissues divided down to the bones. The catling is then passed be- 
 tween the bones to divide the interosseous ligaments and muscles. When 
 this is thoroughly done, the three-tailed retractor is to be used, the middle 
 " tail " being passed between the bones, and the flesh well drawn back. 
 The knife is now laid aside, the saw applied, and the bones sawn through. 
 If any spiculse remain, they must be removed with the bone-pliers, and 
 the flaps are then adjusted with silver wire sutures. The integuments, when 
 put together, should make a, perpendicular line of junction. 
 
 Teale's Amputation. — In removal of the leg by this method, the point 
 selected should be at the junction of the lower and middle third of the leg. 
 The measurements are made according to the same rule as for amputation 
 of the thigh. Two lateral incisions, through the skin only, are to be made, 
 the transverse one being carried through all the structures down to the 
 bone. The long flap is then dissected up, keeping close to the periosteum. 
 The short flap, by a direct cut through all the structures down to the bones, 
 is made and dissected upwards, the bones are sawn, and the flaps placed in 
 apposition as before mentioned. 
 
 In the mixed method the skin flaps should be lateral, and should be made 
 of sufficient length to fall readily over the ends of the bones. The circular 
 incision should be made about an inch below the point of union of the 
 skin and muscular tissue, making thus a better stump. 
 
 Amputation at the Ankle-joint. — Syme's Operation. — This operation is by 
 no means new. Sedellier is said to have first performed it, and by referring 
 
 Fig. 174. 
 
 Fig. 175. 
 
 Fig. 176. 
 
 to Velpeau it will be seen that it was held in repute by many French sur- 
 geons. Mr. Syme, of Edinburgh, systematized the operation, and it has 
 
AMPUTATION AT THE ANKJ.E-JOINT. 
 
 377 
 
 since gone by his name, and to him is due the credit of removing the ob- 
 jections : first, of scantiness of flap, which he has practically demonstrated 
 can be taken from the heel ; and secondly, the exposure of larger articulat- 
 ing surfaces, which are lessened by the removal of the malleoli and the 
 cartilages. The latter plan was first practiced by M. Baudens. The results 
 of this operation are not always satisfactory. 
 
 The operation is performed as follows : The patient is subjected to the 
 influence of an anaesthetic, and the arteries compressed by assistants, or 
 Esmarch's bandage applied. The foot then being held at a right angle, the 
 point of the knife should be introduced directly below and a little posterior 
 to the external malleolus (Fig. 174 a), and then cutting down to the bone, 
 is to be carried under the sole of the foot (Fig. 175 b-c) to a point on the 
 inner side, directly opposite its place of entrance. The incision is then con- 
 tinued to the front of the ankle-joint till it reaches the incision already made. 
 (Fig. 176 a-d.) The lower flap must then be detached, which requires an 
 accurate dissection, and is somewhat tedious, the knife being kept close to 
 the bone. After the os calcis is completely denuded, the tendo Achillis must 
 
 Fig. 177. 
 
 Fig. 178. 
 
 
 Fig. 177.— The bone sawn through after Symes's operation. 
 Fig. 178.— Heel-flap seen from the interior. 
 
 be severed. The next movement is to open the joint in front, which is done 
 by applying the knife to each side of the astragalus, dividing the lateral liga- 
 ments and liberating the joint, during which procedure it is advantageous 
 to depress the foot The malleoli are then to be exposed by careful dissec- 
 tion, and their articular projections sawn off, taking care to remove the 
 cartilages with them. (Fig. 177.) The anterior tibial, the external and 
 internal plantar arteries, and smaller twigs require ligation. Fig. 178 
 shows the appearance of the flap after the removal of the bone. The flaps 
 arethen brought together and secured by metallic sutures. The objections 
 which are urged against this operation are that, in some cases, the large 
 
378 
 
 A SYSTEM OF SURGERY. 
 
 band of muscular fibres acting upon the tendo Achillis, no longer antago- 
 nized by the anterior and plantar muscles, would draw the stump upwards 
 and backwards, and destroy or remove the line of cicatrix, which would 
 point to the ground. Mr. Syme met these objections by expressing his 
 belief that the cut extremities on the forepart of the foot would speedily 
 acquire new attachments and act as extensors. Experience shows such to 
 be the fact. 
 
 In this operation there is also a tendency to sloughing of the lower flap, and, 
 therefore, a flap may be made of more than sufficient length to come into 
 close apposition. This has been proved to be of great advantage. 
 
 Amputation at the Ankle-joint by a Lateral Plantar Flap. — This operation 
 is performed as follows : Having extended the leg, mark a point on the 
 dorsum of the foot equidistant from each malleolus. With a small sharp- 
 pointed amputating knife pierce the tissues down to the bone at the site 
 above mentioned, and cutting steadily carry the knife outside of the joint, 
 a very little below the malleolus of the fibula, and finish the incision at the 
 insertion of the tendo Achillis. Enter the knife again at this point, namely, 
 at the extreme projection of the heel, and, making an acute angle, bring it 
 downwards and forwards to the sole, and then mounting over the dorsum 
 of the foot, it divides the tendon of the tibialis anticus, and reaches the 
 point where the first incision commenced. The foot must now be strongly 
 everted and the joint being opened, the inferior flap is dissected off the heel. 
 The tendons of the calf muscles must now be divided, and the foot turned 
 out of its socket. By a careful dissection the internal adherent flap is dis- 
 sected off and the foot removed. The after treatment is the same as before 
 stated. 
 
 Pirogoff's Operation (Osteo-Plastic). — This amputation thus differs from 
 that of Mr. Syme : in that of Pirogoff the posterior portion of the calca- 
 
 Fig. 179. 
 
 Fig. 180. 
 
 Pirogoff's amputation (sawing 
 the os calcis). 
 
 After the division of the bones 
 in Pirogoff's operation. 
 
 neum is allowed to remain in the heel-flap, and its advantages are a longer 
 limb and a more perfect stump. 
 
 The incisions are made in the same manner as those directed for a Syme's 
 amputation, but the heel-flap is not dissected up. The lateral ligaments 
 are divided, and the foot disarticulated in front ; the os calcis can then be 
 
CHOPART S AMPUTATION THROUGH THE TARSUS. 
 
 379 
 
 seen behind the astragalus (Fig. 179), when the former is to be sawn through 
 in the line of the heel; the foot is then removed, and the ends of the tibia 
 and fibula are sawn off. Fig. 180 shows the lines of the division of the 
 bones in PirogofT's operation. Watson and Pirrie performed the latter por- 
 tion of the operation without previous disarticulation. 
 
 PirogorT's operation, as modified and amply tested by Professor Hayfelder, 
 of Prussia, in the Prusso-Austrian war of 1866, seems to be highly merito- 
 rious. The modification is performed as follows:* "Make a curved in- 
 cision, which, commencing above the posterior edge of the internal malle- 
 olus, passes along the dorsal surface of the foot and terminates at the 
 outer malleolus. After this incision (which divides only the skin), and the 
 preliminary separation of the incised parts, the subjacent tissues are com- 
 pletely cut through down to the bone, and the epiphyses of the two bones 
 of the leg are removed by the saw. The soft parts covering the os calcis 
 are next divided, and the bone sawn in the same direction. The sawn sur- 
 faces of the bones of the leg and of the os calcis are easily brought in contact, 
 which is impossible by the unmodified procedure even after section of the 
 tendo Achillis." 
 
 Chopart's Amputation through the Tarsus is as follows : The foot must be 
 held, as for the operation just described, and the position of the articulation 
 
 Fig. 181. 
 
 Fig. 182. 
 
 ascertained by the same guiding marks. The thumb of the left hand should 
 rest upon the external extremity of the joint, and the index finger on the 
 tuberosity of the scaphoid. A semilunar incision is then made, with its 
 convexity downward around the dorsum of the foot, about half an inch 
 beyond the line of the articulation. (Fig. 181, a-b.) The flap may then be 
 raised about an inch, and the tendons divided down to the bone. The 
 fibrous bands connecting the astragalus and the scaphoid bones are then 
 to be carefully and completely divided in order to facilitate the opening of 
 
 * Half- Yearly Abstract of the Medical Sciences, January, 1869. 
 
380 A SYSTEM OF SURGERY. 
 
 the joint, which is effected by entering the point of the knife from above, 
 recollecting that the edge of the scaphoid overlaps the astragalus. The 
 articulation being opened, pass the flat of the blade behind the bones, and 
 cut the flap from the sole of the foot as seen in Fig. 182. Fig. 183 represents 
 the disarticulated bones. 
 
 Subastragaloid Amputation. — This operation removes all that Chopart's 
 amputation effects, and with it the os calcis also. Malgaigne described the 
 operation in 1846. The dorsal flap is made in the same manner as directed 
 
 Fig. 183. 
 
 Disarticulation through the tarsus (Chopart). 
 
 above in the performance of Chopart's ; the heel-flap after the manner of 
 Syme. The knife is then entered between the scaphoid and astragalus, 
 the joint opened, and the foot removed by disarticulating the os calcis from 
 the astragalus. Hancock has made a modification of this operation, by 
 removing only the forepart of the heel-bone, leaving its tuberosity to be 
 turned up in the flap. The under surface of the astragalus is " freshened " 
 by the removal of a slice of bone, thus making an osteo-plastic operation. 
 This operation is rarely called for. 
 
 Amputation through the Tarso-metatarsal Articulation (Lisfranc's). — In the 
 removal of the forward portion of the foot, no matter which operation be 
 selected, a knowledge of the anatomy is absolutely essential. The tarso- 
 metatarsal joint is formed posteriorly by four bones, viz., the internal, 
 middle, and external cuneiform, and the cuboid bone ; anteriorly by the 
 articular surfaces of the metatarsal bones. The outline of this joint is very 
 irregular, but the following directions will assist the operator : Grasp the 
 dorsum of the foot with the palm of the left hand and extend it. With 
 the finger of the right hand on the inner side of the foot, trace the inner 
 border of the first metatarsal bone backward until a prominence is detected. 
 One or two lines anterior to this point is the commencement of the articula- 
 tion internally. On the outer side follow the border (external) of the fifth 
 metatarsal bone, until its proximal extremity is recognized by the protu- 
 berance at the end of the bone. The outside of the articulation lies im- 
 mediately behind it. 
 
 The operation is performed as follows. Find the outer and inner margins 
 of the joint as directed, and, holding the foot as seen in Fig. 184, make a 
 semilunar incision, with its convexity downward across the dorsum of 
 the foot, about half an inch anterior to the line of the articulation. 
 (Fig. 184 a-b.) This incision must extend to the bones, and the flap raised 
 with the point of the knife. The dorsal ligaments are divided on a line 
 with the joint, and the articulation of the head of the second metatarsal 
 bone opened by carrying the point of the knife between the internal cunei- 
 form and the head of the first metatarsal bone (vide Fig. 185). When this 
 has been accomplished, pressure downward with the left hand will separate 
 the articular surfaces and the metatarsus ; the remaining attachments must 
 
AMPUTATIOX OF THE TOES. 
 
 381 
 
 be divided, and the knife is then passed beneath the heads of these benes, 
 and a flap cut out from the sole of the foot. 
 
 Fig. 184. 
 
 Fig. 185. 
 
 Amputation of the Toes. — Amputation of the great toe is performed as follows : 
 The surgeon, having satisfactorily ascertained the point of articulation be- 
 tween the metatarsal and phalangeal bones, enters the knife on the dorsum 
 of the foot, about an inch behind the articulation, and carries it around the 
 inside of the toe to the centre of the space between the toes. A second 
 
 Fig. 186. 
 
 Fig. 187. 
 
 Fig. 188. 
 
 incision is then made, beginning at the point of entrance of the first, and 
 is brought around the other side of the toe to meet the extremity of the first 
 cut (vide Fig. 186). The soft parts are then dissected up, and the bone 
 disarticulated, or the head of the metatarsal bone is exposed and sawn off, 
 which latter is preferable, as the removal of this large protrusion will yield 
 a much better stump, and allow the patient to wear a boot without much 
 inconvenience. In some cases the toes, especially the second and third, 
 may have to be removed at the second joint, which I have found to be 
 necessary in consequence of contraction of the flexor tendons, causing great 
 inconvenience in walking or dancing. Should their removal be demanded, 
 an anterior and posterior flap can be made, and the bones divided with the 
 
382 A SYSTEM OF SURGERY. 
 
 pliers, just behind the articular surface of the phalanges, as also may be 
 seen in Fig. 186. Two or more toes may have to be removed together, the 
 character of the stump being represented in Fig. 187. In general, however, 
 in disarticulation of a single toe, it is the better practice to remove it at the 
 metatarsal joint, as the small size of the phalanges, and their comparative 
 unimportance, render the preservation of parts of far less moment than 
 those of the hand. 
 
 Disarticulation of all the Toes. — The surgeon, seated before the patient, takes 
 in his left hand all the toes, and with a strong scalpel makes a semicircular 
 incision in front of the metatarso -phalangeal articulation, from the border 
 of the fifth to that of the first metatarsal bone. The point of the knife, 
 
 Fig. 189. 
 
 Amputation of tne metatarsus (sawing). 
 
 which should be narrow-bladed and sharp, is introduced into the joints of 
 each toe successively, and the ligaments divided; the knife is then carried 
 behind the phalanges, and the flap cut out on the plantar surfaces (Fig. 
 188), or the saw may be applied as seen in Fig. 189, and the heads of all 
 the bones removed. 
 
 AMPUTATION OF THE UPPER EXTREMITIES. 
 
 Amputation at the Shoulder-joint. — There are many methods proposed for 
 removal of the shoulder. An excellent one consists in making the flaps 
 from the outer and inner aspect of the joint. The position of the patient, 
 the application of the Esmarch, and the lines of the flap are well shown 
 (Fig. 190). The operation is thus performed : Supposing the left arm is 
 about to be disarticulated, the head of the humerus must be depressed as 
 far as possible, by raising the arm at right angles with the body, and the 
 knife entered at the posterior border of the deltoid, and in front of the ten- 
 dons of the lattisimus dorsi and teres major muscles, and brought out below 
 and in front of the clavicle, and made to cut its way outward around the 
 head of the humerus. This flap will be mostly composed of the deltoid 
 muscle, which must be held aside, and the head of the bone can then readily 
 be detached from the glenoid cavity. The bone must then be turned upon 
 its longitudinal axis, and thrust outwardly and upwardly (Fig. 191). 
 The operator then carries the knife behind it, and grazing the humerus 
 cuts out the internal flap, by carrying the instrument downward and for- 
 ward (see Fig. 191). 
 
 If the right shoulder requires removal, the first incision should be 
 made by entering the knife at the infra-clavicular triangle, and bringing it 
 
AMPUTATION AT THE SHOULDER-JOINT. 
 
 383 
 
 out at the posterior margin of the deltoid, thus reversing the method as 
 described for the left shoulder. 
 
 As the inferior flap is cut, compression is made by the assistants on the 
 great vessels contained in it. 
 
 The method of Larrey, or that known as the oval shoulder-joint amputa- 
 tion, is done as follows : The surgeon first enters the knife at the edge of 
 
 the acromion process, and makes a vertical incision to a point about an 
 inch below the head of the arm-bone. Two long oval incisions are then 
 made, one on the anterior and another on the posterior surface of the 
 shoulder, extending from the centre of the short vertical cut already men- 
 tioned, through the tissues composing the anterior and posterior walls of 
 
384 
 
 A SYSTEM OF SURGERY. 
 
 the axillary space. The next step is to draw downward the humerus, to 
 stretch the ligament and open the joint from the top, and disarticulate the 
 head of the bone from the glenoid cavity, and finish then, by joining the 
 
 extremities of the oval cuts already 
 made, by division of the soft parts in 
 the axilla. The last incision severs the 
 artery, which must be immediately 
 secured. A somewhat similar opera- 
 tion may be performed by making 
 the flaps by transfixion, and not from 
 without inwards. 
 
 Amputation of the Arm. — In ampu- 
 tation of the arm, the patient having 
 been placed under anaesthetic influ- 
 ence, a tourniquet, or Esmarch's band- 
 age, applied, and the arm placed at 
 right angles from the body and held 
 by an assistant, the operator then, if 
 the flap operation is selected, grasps the 
 skin and all the tissues, and, raising 
 them from the bone, enters the knife 
 in the middle of the arm, grazes the 
 posterior face of the humerus with its 
 point and brings it out on the inner 
 side. He then cuts a flap of several inches, according to the circumstances 
 of the case. The anterior flap is then made in the same manner, the 
 
 Fig. 192. 
 
 Amputation by Muscular Flaps. Langenbeck's Method. 
 
 retractor applied, and the bone sawn through ; or the flaps may be made 
 according to Langenbeck's method, from without inward (Fig. 192). 
 
 If the circular method be preferred, the arm is drawn from the body at 
 right angles, and the surgeon, standing on either side of the limb, passes 
 his arm underneath the arm of the patient, enters the heel of the ampu- 
 tating knife on the upper surface, and draws it steadily around the arm, divid- 
 ing only integument and fascia. The flap is then dissected and turned up, 
 and the muscular tissue divided down to the bone (Fig. 193) ; the two- 
 
AMPUTATION OF THE FOREARM. 
 
 385 
 
 tailed retractor is then applied, and the bone sawn through. Teale's or Car- 
 den's operation may also be performed if the operator prefer. 
 
 Fig. 193. 
 
 Fig. 194. 
 
 Division of the Muscle at the Edge of the Turned-up Cuff. 
 
 Amputation of the Forearm. — When it is necessary to remove the forearm, 
 the arm should be held securely by two assistants, one of whom steadies 
 the elbow, the other grasps the wrist. The circular or flap method may be 
 selected according to the circumstances of the case, although cxteris paribus 
 I prefer the circular. If the right 
 forearm requires removal, the surgeon 
 stands on the outer side of the limb ; 
 if the left, he places himself on the 
 inner side. The integ anient and fas- 
 cia should be divided with a "single 
 sweep of the knife, taking care to 
 commence the incision with the heel 
 of the instrument (Fig. 194). The 
 integument must then be dissected 
 and turned back ; the soft parts are 
 then divided down to the bone, and 
 with a narrow knife the interosseous 
 muscles also cleared from the bone; 
 a " three-tailed" retractor is then ap- 
 plied, the centre piece, or tongue, being- 
 drawn through between the bones. 
 The saw is now applied carefully, and 
 in this instance both bones should be 
 divided at the same time. The ves- 
 sels, sometimes two, more frequently 
 three, are to be secured, the flap 
 turned down, and properly adjusted. 
 
 The flap operation is performed in the following manner. An assistant 
 compresses the brachial artery, or applies Esmarch's bandage, and ex- 
 tends the limb in a position between supination and pronation. The sur- 
 geon then may transfix the flaps with a small amputating knife, or may cut 
 
 25 
 
 Position of Knife in Circular Amputation of 
 Forearm. 
 
386 
 
 A SYSTEM OF SURGERY. 
 
 from without inward, forming an anterior or posterior flap. The interos- 
 seous muscles are separated, and the bones sawn through as before. 
 
 Teale's Method. — In the forearm the long flap must be taken from the 
 dorsal aspect, and, as in all like amputations, it is recommended that the 
 lines of incision be traced on the limb. In this amputation, in marking 
 out the long flap, a longitudinal line is drawn over the radius so as to leave 
 the radial vessels in the short flap. At a distance equal to half the cir- 
 cumference of the limb, another line, parallel with the former, is drawn 
 along the ulna. These are then joined at their lower ends by a transverse 
 line equal in length to half the circumference of the forearm. The short 
 flap is marked by a transverse line on the palmar aspect, one-fourth the 
 length of the long one. The operator, in forming the long flap, makes the 
 two longitudinal incisions merely through the integuments, but the- trans- 
 verse one is carried directly down to the bones. The short flap is made by 
 a transverse incision down to the bones, care being taken to separate the 
 parts upwards close to the periosteum. 
 
 Fig. 195. 
 
 Fig. 196. 
 
 Making Anterior Flap — Amputation at 
 Elbow. 
 
 Amputation at Wrist. Opening Joint from 
 Dorsal Surface. 
 
 According to Mr. Bryant, amputation of the forearm should always be a 
 " mixed " one ; he says : u two well-cut and fairly long skin-flaps, and a clean 
 circular section of the muscles are far preferable to the flap operation, and 
 yield a good stump." 
 
 Amputation at the Elbow-joint. — This operation is usually performed by a 
 long anterior and short posterior flap. The forearm should be slighly 
 flexed upon the arm, and the knife entered in front of the joint close to the 
 bone, and brought out by cutting upwards and forwards in order to make a 
 sufficient flap of the muscular tissue. The operator stands on the inner 
 side of the right arm and the outer side of the left. A transverse incision is 
 then made behind the joint, the extremities of which cut should meet the 
 beginning of the first cut, or at the base of the flap. The external lateral 
 ligament must then be divided, and the joint opened between the external 
 condyle of the humerus and the head of the radius ; the internal lateral lig- 
 
AMPUTATION AT THE WRIST- JOINT. 
 
 387 
 
 ament must then be severed, and the olecranon process of the ulna sawn 
 through below the point of insertion of the triceps, a portion of the process 
 being left in the stump, which is to be treated on general principles. It is 
 sometimes thought advisable to make the posterior flap first, which may be 
 done by an incision carried around the posterior aspect of the joint, its line 
 being a little below the head of the radius, which can be detected by pronat- 
 ing and supinating the hand ; this flap is to be dissected up as high as the 
 upper border of the olecranon process, as seen in the figure. The forearm 
 must then be flexed, and the joint entered above the olecranon, and carried 
 through the joint and made to cut itself out on the anterior face of the limb. 
 In Fig. 195 the position of the parts and knife are represented. 
 
 An anterior and posterior flap of skin and fat may also be made and the 
 bone disarticulated ; then with a circular sweep of the knife the remaining 
 muscles are to be divided. 
 
 Amputation at the Wrist-joint. — The circular method of amputating at the 
 radio-carpal articulation is as follows : An assistant should draw back the 
 integument, and hold the arm firmly with both his hands, making pressure 
 with his thumbs on the brachial artery. The surgeon then makes a circular 
 incision, from an inch to an inch and a half below the styloid process of 
 the radius, through the skin and superficial fascia, down to the tendons ; 
 the flap must then be carefully dissected up to a point above the line of 
 
 Fig. 197. 
 
 Metacarpophalangeal Amputation of all the Fingers. 
 
 articulation, which flap must be reflected. A second circular incision must 
 then be carried through the tendons, and the joint opened from its dorsal 
 to its palmar aspect. 
 
 There are several important points to be considered in performing this 
 amputation. First, that the two styloid processes are marks by which to 
 distinguish the line of articulation, and that the styloid process of the 
 radius 'projects lower than that of the ulna, consequently the joint is more 
 accessible at that point; second, that the first fold of the skin on the pal- 
 mar surface of the wrist, reckoning from the arm toward the palm, almost 
 covers the joint. Recollecting these important bearings, and entering the 
 joint from the dorsal surface, and on the ulnar side, the facility of opening 
 the articulation will be increased, and the operator be much less likely to 
 enter the knife between the rows of carpal bones, a mistake which might 
 otherwise easily occur. 
 
 Fig. 196 represents amputation at the radio-carpal articulation; the joint 
 
388 
 
 A SYSTEM OF SURGERY. 
 
 is opened upon the back of the hand, and the skin and cellular tissue re- 
 flected back. 
 
 Amputation of the Fingers. — There are different methods proposed for the 
 removal of the fingers, but the size and direction of the flaps must be in 
 accordance (adhering to the general rule for all amputations) with the 
 amount of integument left to cover the bone. 
 
 Metacarpophalangeal Amputation of the Fingers. — All the fingers may 
 have to be removed at once, in consequence of mill, railroad, or machinery 
 casualties; or from gangrene, frostbite, or embolism. The best method for 
 these operations is for the surgeon to take the fingers to be removed, 
 prone, in his own hand, and have a good assistant steady the wrist and 
 draw aside the thumb. A semilunar incision is then made with a strong 
 scalpel, extending from the outside to the inside of the hand, a little in ad- 
 vance of the joints: the fascia and integument must then be dissected up, 
 and the extensor tendons be divided. The fingers, still held firmly, are 
 then flexed at a right angle, the lateral and other ligaments divided, and 
 each joint fully and carefully opened ; a small-sized narrow-bladed cat- 
 ling, its flat being 'placed close to the phalanges, is made to cut itself out on the 
 palm of the hand, forming a sufficient flap. (Fig. 197.) 
 
 Disarticulation of the Last Four Metacarpal Bones Preserving the Thumb. — 
 The incision in this amputation is peculiar and must be made with care. 
 The surgeon begins his cutting on the palm of the hand at the web of 
 
 Fig. 198. 
 
 Fig. 200. 
 
 Palmar incision. Dorsal incision. 
 
 Disarticulation of the Last Four Metacarpal Bones. 
 
 Line of union. 
 
 the thumb and carries it with a convexity forward to the base of the fifth 
 metatarsal bone (Fig. 198). The dorsal incision also must begin at the 
 web of the thumb, is carried upward toward the wrist as far as the upper 
 third of the second metacarpal bone and then is carried over the hand, as 
 seen in Fig. 199, to meet the line of the palmar cut. These flaps must then 
 be carefully dissected back beyond the carpo-metacarpal joints, which are 
 to be opened with great care, keeping the knife close to the bone, especial 
 watchfulness being maintained when opening the finger-joint at the trape- 
 zium, otherwise its connection with the thumb may be opened. The pos- 
 session of the thumb is of the greatest possible advantage to the patient. 
 Fig. 200 shows the line of cicatrix after the operation. 
 
AMPUTATION OF THE INDEX FINGER. 
 
 389 
 
 Fig. 201. 
 
 Amputation through the Metacarpus. — If it be necessary to amputate through 
 the metacarpus, a double flap is made, one on the anterior, the other on the 
 posterior face of the joint, and the bones exposed. Then a five-tailed re- 
 tractor is placed between the fingers to protect the tendons, and the saw may 
 be evenly applied to the whole. As a general rule, when a single finger is 
 to be amputated, it is not necessary to ligate the arteries ; the surgeon may 
 remove clots, wait awhile, making slight lateral pressure, and then dress 
 the parts with cold dilute calendula. 
 
 Amputation of a Finger. — To remove a finger is a very simple perform- 
 ance. A flap anteriorly and posteriorly (vide Fig. 201) is made, the flaps 
 held aside with the finger and thumb of the left 
 hand, and the bone forceps applied just behind 
 the protuberant extremities of the phalanges or 
 metacarpal bones. If it is deemed advisable to 
 disarticulate, after the superior flap is made, the 
 finger may be flexed, the joint entered, and after 
 having divided the tendons the inferior flap is 
 made. 
 
 Amputation of the Index Finger. — The important 
 office subserved by the index and ring fingers, has 
 given rise to the question among surgeons, whether it is more advisable to 
 save as much of the palmar phalanx as possible to give the patient a more 
 useful stump, or to remove the entire phalanx and a portion of the meta- 
 carpal bone, thereby making a much more seemly stump. It is better, as a 
 rule, in all the fingers except the index, that the extremity or head of the 
 metacarpal bone should be taken away, otherwise it leaves a projection 
 which is oftentimes much in the way, and is liable to be struck or injured. 
 This is accomplished by making a V-shaped incision, the apex looking 
 toward the wrist, and having reached the bone, with a pair of strong bone 
 pliers, held at right angles with the hand, the metacarpal bone is divided 
 close behind the head. 
 
 In removal of the index finger much depends upon the judgment of the 
 surgeon. He must determine as to " usefulness " or " appearance." If the 
 applicant is a laborer, depending upon manual exertion for support, as much 
 
 Amputation of a Finger. 
 
 Fig. 202. 
 
 as possible of the finger should be saved, but if it be a person in the upper 
 ranks of life, who might be horrified at an unseemly finger, then operate in 
 a manner to leave the least possible deformity. As a general rule, a better 
 stump is made by removing the bone in its continuity than at the joint, on 
 account of the rounded and protuberant extremity of the articulation pre- 
 senting a knobby appearance after the parts have healed. When the little 
 finger is to be removed, in conjunction with the metacarpal bone (an opera- 
 tion which, as yet, I have never been called upon to perform), a somewhat 
 oval incision is necessary. Enter the knife at the junction of the metacarpal 
 bones with the wrist, bring the incision upward around the back of the 
 hand, and terminate it on the palmar surface. This ma}* be continued 
 
390 A SYSTEM OF SURGERY. 
 
 around the finger, down its outside, to the point of beginning. The tendons 
 are carefully divided and disarticulation effected as in other cases. 
 
 Amputation at Carpo-metacarpal Articulation of the Thumb. — The same 
 rule is followed with the thumb {vide Fig. 202), beginning at about half an 
 inch in front of the styloid process of the radius, carry the incision around 
 the thumb, and back again to the point of entrance. Divide the extensor 
 tendons from behind, and by flexing the thumb the disarticulation is easy. 
 In this operation two or three small arteries may require torsion. 
 
 Treatment After Amputation. — The management of the stump is of great 
 import, and differs materially at the present from that practiced a few years 
 ago. It was the custom, after having secured the flaps, to strap the stump 
 closely, then to apply a wad of charpie or lint ; over this the " Maltese 
 cross," and then to envelop the limb with a roller bandage, thus doing 
 everything to cause retention of the effete fluids, and keep the parts hot 
 and feverish. It has been my custom, in all the varieties of amputation, 
 to dispense with this pernicious treatment. In every amputation, after 
 the bleeding has been arrested, the entire surface of the stump should be 
 
 Fig. 203. 
 
 Dressing of an Amputation Stump with Carbolized Strips of Gauze and Bandages. 
 
 thoroughly irrigated with a hot solution of calendula, one to six, and all 
 the clots carefully picked out. Antiseptic (decalcified bone if possible) drain- 
 age tubes should be inserted down to the bone on each side of the wound, 
 and to prevent the drainage tubes from slipping back as they are being ab- 
 sorbed, I am in the habit of piercing them with a moderate sized safety 
 pin. The surgeon should then call for hot water containing calendula 
 one to four, corrosive sublimate aVoa , or carbolic acid y^-, and thoroughly 
 inject the parts through the drainage tubes, pressing out the solution, and 
 continuing to use the injection until the water runs clear. Then the dry 
 dressings are applied as follows : Along the whole line of the incision a 
 narrow strip of protective made of gossamer india-rubber cloth, clean and 
 disinfected, is to be laid. Then strips of salicylated india-rubber plaster 
 A, A, in Fig. 203, are applied as seen in the engraving. Over this an anti- 
 septic bandage is (not too tightly) wound, and upon this several layers of 
 antiseptic cotton (that prepared in sheets and enclosed in antiseptic gauze 
 
NEURALGIA OF THE STUMP. 391 
 
 — as manufactured by C. Am Ende — is best) are placed. Finally, a bit of 
 antiseptic oiled silk, held in position with an antiseptic bandage — loosely 
 applied — and kept in position with safety pins will complete the dressing. 
 This method, if conducted with the requisite care and cleanliness, need not 
 be removed for several weeks. If, however, the dressing become soiled, or 
 there is odor detected from the wound, the outside layers should be care- 
 fully removed and the soiled portions taken away, or if necessary the entire 
 toilette be gone over. 
 
 Lister's and other methods, especially the " open " (so much practiced by 
 Dr. James R. Wood) and the " dry," are so fully described in Chapters 
 XV. and XVI., that space forbids any repetition in this place. 
 
 Neuralgia of the Stump. — This is a most distressing affection, and often 
 is very intractable. It may arise from a bulbous affection of the nerves, or 
 their adherence to the cicatrix, which subjects them to constant and con- 
 tinued pressure ; this latter cause, however, is not always present, the pain 
 arising from irritation of the spinal cord. The symptoms generally appear 
 in paroxysms, are almost unendurable during the night, with spasm and 
 twitching of the stump, which not unfrequently terminate in muscular 
 contraction, causing the bone to protrude. The sensations vary in different 
 individuals, and at different times in the same individual. A successful 
 treatment depends upon an exact correspondence between the symptoms 
 of the medicine and the sensations experienced. Such similarity may be 
 found in the Materia Medica, which contains remedies wherewith to miti- 
 gate or entirely subdue the sufferings of the patient. 
 
 To this storehouse the surgeon must resort, and with patience and pre- 
 cision select his weapon. 
 
 Perhaps among the primary influential impulses which homoeopathy 
 received was the successful treatment by Hahnemann of the distinguished 
 cavalry chief at the battle of Waterloo, the Marquis of Anglesey, who 
 underwent amputation of the leg in consequence of a wound inflicted by 
 a cannon-shot. Neuralgia of a torturing kind followed, and the fruitless 
 efforts of many physicians induced this renowned nobleman to solicit the 
 advice of Hahnemann, then practicing in Paris. The private physician of 
 the marquis (Dr. Dunsford) became a convert to the homoeopathic doctrine 
 after having witnessed the salutary effects of the medicines which Hahne- 
 mann administered. The medicines I have found most serviceable are 
 aeon., bell., ignatia, cuprum, veratrum, hellebor., and spigelia, according to 
 the presenting symptoms, which must be looked for in the Codex. But I 
 desire here to invite attention to a medicine which was brought to my notice 
 by Dr. Shelton, of Jersey City, and accidentally came to his knowledge after 
 the following manner : He had amputated the thigh of a man, and the 
 wound had almost entirely healed by the first intention, when most intense 
 neuralgia of the stump followed. 'The doctor prescribed all the medicines 
 that appeared indicated, with little or no relief. I saw the patient in con- 
 sultation with him, but nothing we tried was of permanent service. After 
 both high and low potencies had been given without benefit, the patient 
 became desperate. Extract of hyos., zinc, valer., codeia, chloroform, and 
 chloral were administered. An ointment of bell, and opium was rubbed 
 into the stump. The muriate of ammonia, in half-drachm doses, produced 
 for a time decided effect ; a repetition of the same medicine was of no avail 
 whatever. Hypericum and cannabis in tincture, and the higher potencies, 
 were equally unavailing. The following is the record for September 5th : 
 
 " The patient picked up a scrap of printed paper with which to light a 
 cigar. Before doing so, he whiled away a few moments in looking it over. 
 It was in French, and, rather strange to say, his eye met a little paragraph 
 on raw onion in neuralgia. He resolved to try it. He ate a whole one at 
 
392 A SYSTEM OF SURGERY. 
 
 bedtime. All pain immediately ceased, and he slept quietly that night. 
 He continued to do so nightly until the 23d, with entire relief, when the 
 onion was omitted for two nights, to see what the result would be. The 
 pain returned. 
 
 " Sept. 25th. — Allium cepa 200 was given for two days, without any effect. 
 Ten-drop doses of the tincture were taken for two days, when all pain ceased 
 from that date to the present — 8th of November." 
 
 Retraction of Flaps. — Perhaps this accident occurs to the young surgeon 
 more frequently than any other, at least it did so in my own practice. The 
 axiom to spare the skin and never the bone, is a good one — as a rule too 
 much bone cannot be taken off. The retractors should draw the soft 
 parts well up on the bone, and the surgeon with his hands should push 
 upward the muscular tissue around the bone as far as he can get it before 
 he applies the saw. In the flap operation, retraction of the flaps is more 
 likely to occur than in the circular or mixed methods, on account of the 
 large amount of muscular tissue, which forms the greater portion of the 
 flaps. Sometimes, notwithstanding the utmost care, this untoward accident 
 occurs. If, therefore, the surgeon, on the second or third day, feels that the 
 bone is nearing the line of the incision, he should immediately apply ex- 
 tension to the stump— a large strap of adhesive plaster extending along 
 each side of the stump for nine inches, with " a traverse " at its distal end 
 for fastening the cord, should be put on, and kept securely in position by a 
 roller bandage. The cord should be made to play over a pulley at the foot 
 of the bed, and a weight of four or five pounds be attached. This will 
 greatly overcome the retraction, and prevent the formation of a conical 
 stump. 
 
 Conical Stump. — This disagreeable complication is caused by the retraction 
 of, or insufficient flaps, or from sloughing, either of which allows a portion 
 of the end of the bone to show itself; after a time however this end becomes 
 covered with granulation tissue, and, finally, partially cicatrizes, leaving a 
 conical shaped stump of low vitality, often disposed to ulcerate from slight 
 irritation, and always of great annoyance to the patient. There is no remedy 
 for such a condition but re-amputation, which must be a complete division 
 of the skin, muscle, and bone, together with the excision of all cicatricial 
 tissue; this is often more difficult to accomplish than the primary amputa- 
 tion. 
 
 CHAPTER XXI. 
 PLASTIC SURGERY. 
 
 Antiquity of— General Considerations — Varied Methods of 
 Transplanting Flaps. 
 
 There is no branch of surgical science that demands more inquiry, and 
 that is so often both satisfactory and unsatisfactory in its results, as that 
 of plastic surgery. Autoplastic and other varieties of plastic surgery signify 
 methods of reconstruction of parts that are deficient. These may be either 
 congenital defects or the products of accident or disease. Sir Spencer 
 Wells gives this definition of plastic surgery : " It is," he says, " that de- 
 partment of operative surgery, which has for its end the reparation or 
 restoration of some lost, defective, mutilated, or deformed part of the 
 body." 
 
PLASTIC SURGERY. 393 
 
 It is said that Celsus and Galen were acquainted with this method of 
 restoration of parts ; but it is generally conceded that the father of " plastics," 
 was Gasparo Tagliacozzi or Taliacotius, who lived in the sixteenth century, 
 was professor of surgery and anatomy at Bologna, and who was supposed 
 to be a necromancer, on account of his being able to restore parts which 
 were lost ; to fit on a nose if it were gone, to put on a prepuce if it had been 
 destroj^ed by a chancre, etc. 
 
 In the olden times plastic surgery was mostly limited to the integu- 
 mentary surfaces, but recent operations, termed the osteoplastic, have given 
 such favorable results, that they will necessarily come under the head of 
 " plastics " in surgery. The skin-grafting of ulcers, transplantation of flesh 
 and tissue, either with or without pedicles, the operations for hare-lip, 
 cleft palate, lacerated cervix and perinseum, operations upon the eyelids 
 and urethra, all belong to this interesting field. 
 
 The osteoplastic operations on the maxillary bones, Pirogoff 's amputation, 
 amputation through the condyles of the femur, with attachment of patella, 
 and the recent operative measures for removing tumors of the antrum and 
 naso-pharyngeal polypi, as well as various operations for deformities of the 
 lower extremities, render the domain of plastics a wide one indeed. 
 
 The great points to be remembered in performing such operations are : 
 
 1st. The general condition of the patient. 
 
 2d. To completely arrest the haemorrhage before closure of the wound. 
 
 3d. To obtain union by the first intention. 
 
 All patients about to be subjected to plastic operations, should be allowed 
 to remain in bed for several days. Abernethy remarks, that he found that 
 patients who had been confined in bed for a length of time, underwent 
 operations better than those who had not been so rested, and I am disposed 
 to agree with him. A bath should be given daily, and all food prohibited 
 which would tend to cause dyspeptic symptoms. Cheerful apartments, 
 attentive nurses, good ventilation, and proper diet are essential in all opera- 
 tions, and especially in the more delicate ones of which we treat. During 
 this period the iodide of potassium should be given twice a day, about 
 three grains at a dose in six tablespoonfuls of water. 
 
 A peculiar fact which I have noticed, especially in the treatment of ulcers, 
 is, that the grafts do better, and are not so likely to abort, when the patient 
 has been using silex for a week or two previous to the operation. In syph- 
 ilitic patients silicea has no effect, but I am positive the iodide of potash has, 
 particularly when administered in tangible quantities as above. 
 
 The best method of arresting hemorrhage in the operation, if it be pos- 
 sible, is by torsion. Speir's artery constrictor will often serve the purpose, 
 as will the acupressure pin, well applied. After the bleeding has stopped, 
 every clot should be washed away, and oozing allowed to cease. The sutures 
 to be used are those of silver wire, carbolized catgut or whole tendon, or 
 the iron-dyed silk. ( Vide page 38.) 
 
 In closing the wound, such sutures must be used as will in the least 
 degree obstruct the circulation of the flaps. These, perhaps, are the bar 
 sutures with the perforated shot, or the ordinary quilled sutures. The 
 needles should be round, slightly curved at the point, and without cutting 
 edge. In making the flaps, much time and discrimination must be used, 
 and many patient measurements taken, especially if the flap is to be twisted 
 or bent upon a pedicle. It has been recommended by some surgeons that 
 the dimensions of the flap should be taken on card-paper, or gutta-percha; 
 but I can recommend a better article in parchment which has been wetted. 
 It is very pliable, and will twist upon itself as easily as the integument ; 
 it is semitransparent, and being laid over the part to be closed, the boun- 
 daries can be clearly defined and traced. It is especially serviceable in the 
 
394 A SYSTEM OF SURGERY. 
 
 many manipulations which are often necessary, because it does not tear. 
 I have used this substance for a number of years, and have reason to speak 
 well of it, for the purposes mentioned. 
 
 In repairing parts of the body wanting, either from arrest of development, 
 or from the ravages of disease or accident, the surgeon should bear in mind 
 the fact that he cannot expect to have a result equal to nature, and he, be 
 it patient or surgeon, who anticipates such a result, will certainly be disap- 
 pointed. " Nature ever triumphs over art, and here is the boundary between 
 what is God-like and what is human." 
 
 Another item to be remembered, is the shrinkage of the flap, which almost 
 invariably occurs, and which should be in a measure anticipated by always 
 dissecting off a flap which will be somewhat larger than the exact size of 
 the wound. 
 
 Gangrene which may result from a defective supply of blood, either from 
 too much constriction of the pedicle, or the pressure of the sutures, together 
 with the presence of the so-called nodular tissue, which must be cut away 
 entirely if we expect a good union — are often the causes of failure. The 
 simplest plastic operation is skin-grafting in ulcers. It is a method which, 
 according to Jobert, was known long ago in India. The grafts were taken 
 from the nates, having been previously slightly bruised to increase vascu- 
 larity. This method, however, failed frequently, probably from the bruising 
 process to which the parts were subjected. 
 
 There is no doubting the fact, that portions of the body have been entirely 
 cut off, and, having been speedily replaced, have united themselves per- 
 fectly. 
 
 Dr. Prince* mentions the case of a man, who, having cut off two of his 
 fingers, replaced them, and then consulted a surgeon ; he, for the sake of 
 greater security, applied additional dressings to them. The fingers united 
 firmly, but their ends became gangrenous, in consequence of the tight 
 strapping which had been employed. 
 
 Professor Evef cites the case of a woman who had the whole of the soft 
 parts of her nose bitten off in a fight with a man. Three hours after she 
 was seen by the surgeon, who insisted upon searching for the lost olfactory. 
 After a considerable time the missing member was found, " contracted and 
 covered with filth." It was thoroughly cleansed, adjusted, and reapplied. 
 In thirty-seven days it was firmly united, but had assumed a bluish hue. 
 A solution of nitrate of silver was applied to the tip, and in five days it 
 had resumed its natural color. 
 
 Brown-Sequard, in 1850, grafted the tail of a cat on a cock's comb with 
 success. 
 
 On one occasion I replaced the end of a finger which had been severed 
 by an accident, and held it in situ by straps and bandages. Not the slightest 
 attempt at union resulted. In a second case my efforts were followed by 
 success. I do not propose to occupy any space with the simple methods of 
 the skin-grafting process, which can be found at page 136. It is generally 
 attributed to M. Reverdin, who, in 1870, published a paper on " Epidermic 
 Grafting." In Holmes's System of Surgery the following paragraph occurs, 
 written by Holmes while surgeon to St. Bartholomew's. 
 
 Speaking of the "transplantation of skin," he says: "the ingenuity and 
 merit of the invention, which is due to M. Reverdin, of Paris, the readiness 
 of adoption, which is due to Mr. Pollock, and the great success which has 
 followed the numerous trials now made in every direction, warrant the 
 conclusion that the proceeding is one of the most striking and successful in 
 
 * Plastic Surgery. 
 
 f Remarkable Cases in Surgery. 
 
PLASTIC SURGERY. 395 
 
 modern surgery." I can claim for this country priority for this operation, 
 as I can for excision of the jaw, by Deaderick, of Tennessee, and of ovari- 
 otomy by McDowell, of Kentucky. In a report of the Dispensary of the 
 Geneva Medical College, 1847, can be found the record of the case of a boy 
 whose leg had been stripped of integument eight years before, and the 
 wound not having healed, Dr. F. H. Hamilton proposed the transplanting 
 of a piece of sound integument, in the centre of the ulcer, to which, how- 
 ever, the patient did not consent. On January the 21st, 1854, Professor 
 Hamilton made his first operation in the case of one Horace Driscoll, at 
 the Buffalo Hospital of the Sisters of Charity. The ulcer was large, and 
 the healthy integument was taken from the opposite leg. In ninety days 
 cicatrization was complete. On the 24th of June, 1854, Dr. Hamilton read 
 a paper before the Buffalo Medical Association, on " Old Ulcers Treated by 
 Anaplasty," which gives tohim the priority of claim in this department. 
 His views and some interesting remarks on skin-grafting are detailed by him 
 in his work.* 
 
 The classification of the different methods of performing plastic opera- 
 tions is — first, when the flaps are taken from the same person. This is known 
 as autoplasty. When the term heteroplasty is used, it is understood that the 
 supply comes from another; and when other substances, sponge, etc., are 
 used, the term prothesis is used. 
 
 The varied methods of performing plastic operations are as follows : 
 
 I. Sliding in a direct line. 
 
 II. Sliding in a curved line. 
 
 III. Jumping. (Indian method.) 
 
 IV. Inversion or eversion. 
 
 V. Taliacotian. (The part obtained from a distance.) 
 VI. Grafting. (Already considered.) 
 
 As I have already remarked, no rules can be laid down for plastic opera- 
 tions. Every case is so different that each requires a careful consideration, 
 as to the number and character of the operations to be performed. Some- 
 times the result is so satisfactory that the surgeon is more than gratified 
 with it ; while at others so unsatisfactory, that both the surgeon and the 
 patient become discouraged from frequent disappointments. 
 
 As a rule, however, it may be said that the sliding method, having pre- 
 viously cut under the edges of the flaps, and the torsion method, are the two 
 which are the most practical and give the best results. In the proper places, 
 hare-lip, rhinoplasty, cheiloplasty, osteoplasty, and other plastic operations 
 are fully described, to detail which in this place would be merely repetition. 
 
 * Principles and Practice of Surgery, by F. H. Hamilton, A.M., M.D., LL.D., p. 42. 
 
PAET III. 
 
 SURGERY OF SPECIAL REGIONS AND TISSUES. 
 
 CHAPTER XXII. 
 
 DISEASES AND INJURIES OF THE SKIN AND CELLULAR 
 
 TISSUE. 
 
 Erysipelas — Poisoning with Rhus — Furuncle, Boil — Anthrax, Carbuncle — 
 Effects of Cold, Pernio — Burns and Scalds— Cicatrices— Paronychia, Whit- 
 low — Lupus — Elephantiasis Arabum — Malignant Pustule — Internal Malig- 
 nant Pustule — Verruc^e, Warts — Bed-Sores — Ingrowing Toe Nail — Onychia 
 — Subungual Exostosis — Perforating Ulcer of the Foot. 
 
 Erysipelas. — In a work upon general surgery, only a description of those 
 diseases of the skin which fall within the province of the surgeon can be 
 mentioned ; the varied and multiform affections, with their classification and 
 treatment, which belong to Dermatology, must be sought for in works upon 
 that specialty, — a department indeed of medicine which, within the last 
 few years, has assumed vast importance. 
 
 Erysipelas is an inflammatory affection, accompanied with fever, which, 
 together with drowsiness, is generally present a few days before the attack, 
 the latter symptom disappearing when the disease is fully established. 
 
 The inflammation is generally confined to the epidermis, which becomes 
 hot, red, and swollen, and sometimes covered with blisters (erysipelas bullo- 
 sum), or vesicular erysipelas, but in very violent cases the deeper-seated 
 tissues are affected, and the disease is termed phlegmonous erysipelas, or 
 the cellulo-cutaneous. Every part of the body is liable to be attacked, 
 although the face, legs, and feet are most frequently affected. 
 
 Erysipelas does not often attack persons before the age of puberty ; it is 
 a disease of advanced life, and is more frequently encountered among fe- 
 males than males, particularly those of a sanguine, irritable temperament. 
 
 In some individuals there appears to exist a predisposition to the disease. 
 In other instances it returns periodically, attacking the patient once or 
 twice a year, and sometimes oftener, thereby greatly exhausting strength. 
 
 Erysipelas is occasioned by the several causes that are liable to excite in- 
 flammation, such as injuries of all kinds, the external application of acrid 
 substances to the skin, exposure to cold, obstructed perspirations, suppressed 
 evacuations, etc., etc. The disease also appears to be, under certain circum- 
 stances, epidemic, caused by a peculiar state of the atmosphere, and this is 
 frequently the case in crowded ships or in hospitals. 
 
 In slight cases, when the extremities are attacked, this disease makes its 
 appearance with roughness, pain, heat, and redness of the skin, which be- 
 comes pale when the finger is pressed upon it, but immediately returns to 
 its former color when the pressure is removed. There also prevails a slight 
 febrile disposition, and the patient is rather hot and thirsty. If the attack 
 be mild, these symptoms will continue for a day or two, when the surface of 
 
Heat-line in Erysipelas. 
 
 ERYSIPELAS. 397 
 
 the affected part assumes a yellowish tinge ; the cuticle may separate in 
 small scales, and the patient experience no further inconvenience ; but if 
 the attack be severe, and the symptoms of high inflammation be present, 
 there will be intense throbbing pain in the head, pain in the back, great 
 heat, thirst, and restlessness ; the affected parts will swell, the pulse become 
 frequent, and either hard and tense, or it may be small and rebounding; 
 the temperature often rises abruptly, as is seen in the accompanying cut, 
 Fig. 204. About the fourth day a num- 
 ber of small vesicles make their appear- FlG - 204 - 
 ance, containing a limpid, or in some 
 cases a yellowish fluid. In unfavorable 
 cases these blisters have sometimes de- 
 generated into obstinate ulcers, which 
 assume a gangrenous character. This, 
 however, does not happen frequently, 
 for though the surface of the skin and 
 the bullae may assume a bluish, or even 
 a blackish tinge, yet such appearances 
 generally disappear, together with the 
 other symptoms of the complaint. 
 
 The appearance of these vesicles is not 
 always present in an attack of erysipe- 
 las, and when they do show themselves, the period of their eruption is very 
 uncertain. 
 
 The trunk is also attacked with erysipelas, but less frequently than the 
 extremities ; but infants in a few days after birth may be affected in this 
 manner, the genital organs being generally involved. 
 
 When erysipelas attacks the face, the premonitory manifestations are 
 chilliness, succeeded by heat, thirst, restlessness, glistening eyes, coated 
 tongue, redness of the cheeks and other febrile symptoms, with a tempera- 
 ture of 104° to 105° ; there is drowsiness, or a tendency to coma and 
 delirium, and the pulse is very frequent and full. At the end of two or 
 three days, a scarlet redness appears on some parts of the face, which 
 may extend to the scalp, and then gradually down the neck, leaving 
 tumefaction in every part occupied by the redness. When the swelling 
 and redness have continued for a time, blisters, varying in size and contain- 
 ing a thin, colorless, and sometimes acrid liquor, appear on the face, which 
 becomes turgid and swollen, and the eyelids are sometimes swelled to such 
 a degree that the patient for a time is deprived of sight. The fever some- 
 times becomes less when the inflammation is established, but in the major- 
 ity of cases it increases as the latter extends, and, unless checked by the 
 appropriate means, may continue for the space of eight or ten days. If 
 such is the case, the coma and delirium increase greatly, and the patient 
 may be destroyed between the seventh and eleventh day. If the attack be 
 mild, the inflammatory symptoms subside gradually, and the disease ter- 
 minates in a few days. 
 
 In ordinary practice, erysipelas cannot be said to be contagious ; but in 
 hospitals, or where many persons are crowded together in a small space, with 
 poor ventilation, the character of the disease assumes a far different type. 
 It sometimes causes the surgeon great apprehension, especially for the wel- 
 fare of other patients suffering from wounds. I well recollect my conster- 
 nation when, after having performed a resection of the elbow-joint at the 
 hospital, on going through the wards I found a case of erysipelas in a little 
 girl in one of the lower rooms. Although every precaution was used, on 
 the next day symptoms of the disease developed themselves in a boy from 
 whom I had removed half of the inferior maxillary bone about ten days 
 
398 A SYSTEM OF SURGERY. 
 
 previous. The patient from whom the elbow-joint had been exsected died 
 about the twelfth day. In the case of the little girl I administered bella- 
 donna every two hours, and in a few days she was able to undergo the oper- 
 ation of removal of the limb. 
 
 With reference to ki hospital erysipelas," Mr. T. Holmes,* in his admir- 
 able work on surgery, thus writes : 
 
 " I cannot but protest against the assumption involved in the terms 
 ' hospital erysipelas ' and ' hospital diseases ' as descriptive of the complica- 
 tions of wounds. Such complications are met with, it is true, most com- 
 monly in hospitals, for the simple reason that wounds are also met with 
 most commonly there ; but they occur very frequently in private practice, 
 even under the most favorable circumstances, and they have never really 
 been proved to be relatively more frequent in good hospitals than in private 
 practice, in similar cases. There is much need for us all to do our best to 
 improve in every way the air, the treatment, the dressing, and all the other 
 circumstances of the wounded in our hospitals, and thereby, doubtless, the 
 prevalence of these complications will be lessened ; but it is a sad error to 
 impair the reputation and thus diminish the usefulness of our hospitals by 
 reckless aspersions on their salubrity." 
 
 Erysipelas of the face is more dangerous than when other portions of the 
 body are attacked, because there is a tendency of the inflammation to 
 attack the brain. The prognosis is unfavorable if the fever assumes a 
 malignant type, or when there is threatened metastasis to internal noble 
 organs. These are generally indicated by a persistently high temperature. 
 
 Treatment.- — The medicines that are most serviceable in erysipelas are 
 aeon., apis mel., bell., bry., euphorb., puis., rhus t., sulph., canth. 
 
 Rhus tox is the principal medicine for vesicular erysipelas ; it is also in- 
 dicated in erysipelas where there is excessive oedema, or where there is a 
 tendency to metastasis of the disease to the brain ; rhus radicans has been 
 very highly extolled for facial erysipelas, as have been also graphites and 
 hepar, but of course there must be corresponding symptoms to indicate 
 their use. 
 
 According to Reissig, nux vom. is well adapted to this disease when it 
 attacks the knees or feet, when there is intense pain and bright-red swelling. 
 
 If there be a tendency to metastasis to the brain, cuprum acet. is an ex- 
 tremely valuable medicine, as the author has had opportunity of witness- 
 ing. Dr. Schmid, of Vienna, also corroborates this statement. 
 
 Belladonna and rhus tox. are adapted to many forms of this disease, even 
 to that found in hospitals, in which it partakes of the phlegmonous charac- 
 ter, and therefore the former remedy would perhaps be preferable. If the 
 disease assume a gangrenous form, the vesicles become dark and blackish, 
 with prostration, dry skin, frequent but easily quencbiable thirst, arsen. 
 should be administered, or perhaps carbo veg. msiy also be indicated in 
 erysipelas gangrenosum, particularly if there be night and morning sweats, 
 excessive prostration, and disposition to typhoid symptoms. 
 
 Rhus should also be remembered, and administered if suitable for such 
 a condition. If there be a disposition to ulceration, sulph., hepar, graph., 
 silic, are important medicines.f 
 
 I have never witnessed satisfactory results from the use of local applica- 
 tions in the treatment of erysipelas. It is very fashionable (and fashiona- 
 ble folly too), to apply poultices or mercurial ointment, or the acetate of 
 
 * A Treatise on Surgery, its Principles and Practice, 1876, p. 70. 
 
 f There have been many interesting cases of erysipelas reported in the homoeopathic peri- 
 odicals. One of the best can be found in the British Journal of Homoeopathy, vol. vi., 
 p. 532. 
 
BOIL, FURUXCULUS. . 399 
 
 lead in solution, or to pencil the parts with tincture of iodine and nitrate 
 of silver. These are worse than useless. The medicines are so marked in 
 their action in the disease, and so extremely efficacious, that all outside 
 applications positively retard recovery. If there be much itching towards 
 the close of the affection, rye flour dusted over the part is quite sufficient 
 to allay it, and even this symptom is often quickly relieved by hepar sulph., 
 or sulphur. 
 
 Poisoning with Rhus tox. — It is well known that certain individuals are 
 very susceptible to the poisoning of rhus toxicodendron, and other varieties 
 of the poison oak. What causes this peculiar idiosyncrasy, it is difficult to 
 say ; certain, however, it is, that while some persons (even members of one 
 family) may handle the plant with impunity, others are so easily affected 
 by it, that simply passing in a neighborhood where the poison oak is grow- 
 ing, produces a peculiar inflammatory action upon the skin, resembling 
 very closely the vesicular variety of erysipelas, and causing much incon- 
 venience and pain. The affection thus produced is called by some rhus 
 dermatitis. The period of incubation varies from a few hours to a couple of 
 days, but in the cases that have come under my observation — which 
 have not been few — four or five hours generally is a sufficient period to 
 develop the eruption. The hands and face are most frequently affected, 
 although if other portions of the body have been exposed, as is the case in 
 persons about to swim or bathe, the arms and genital organs may suffer. 
 At this present writing I have a lady under my care whose left ear and 
 side of the face are covered with the vesicles peculiar to the poisoning. 
 
 The symptoms begin with a slight efflorescence and considerable itching, 
 which in a short time are accompanied by oedema, which is often great, es- 
 pecially about the face. Small vesicles then appear, which are filled with 
 serum. If the inflammation has covered a large extent of surface, there 
 maybe some febrile exacerbations, but, as a rule, fever is absent. The vesi- 
 cles either rupture themselves, or gradually shrink and dry away, leaving, 
 as in erysipelas, a slight dry scale. 
 
 Treatment. — According to the old law "isdem, iisdem, curantur" which law 
 is in some parts of the country mistaken for the homoeopathic formula, 
 rhus toxicodendron, in small doses, is the remedy for this disorder ; and I 
 have found this medicine, in the second and third dilutions, administered 
 internally, a very reliable method of treating the affection. Sometimes I 
 have given sulphur, and at other times bella., and on one or two occasions, 
 the rhus radicans was of the most marked service. Either of these medi- 
 cines, selected according to the judgment of the practitioner, will be found 
 efficacious in arresting the disease. I do not think much of the fashiona- 
 ble carbolic acid lotions, but prefer the juice of the sanguinaria canadensis, 
 or if this cannot be obtained, the tincture, diluted one-half with water (or in 
 some cases pure) painted over the parts. The fluid extract of the grindelia 
 robusta, two drachms to a pint of water, makes an excellent application. 
 Sometimes I have also used the ordinary saleratus, and again borax: one 
 drachm to half a pint of water, — as an application to the inflamed surfaces. 
 Cloths wrung out in either of the solutions may be used, as the judgment of 
 the practitioner may direct. 
 
 Boil, Furnnculns. — A boil is a prominent, hard, red, and circumscribed 
 tumor, very often extremely painful, and though terminating in suppura- 
 tion, the process by which the pus is formed is frequently of long duration. 
 
 The inflammation is of the sthenic type, affecting the skin and areolar 
 tissue; the latter becoming disorganized, constitutes what is termed the 
 core of the boil. 
 
 A common furuncle differs from a carbuncle, because the latter is as- 
 thenic, not only constitutionally, but locally, the life of the patient being 
 
400 A SYSTEM OF SURGERY. 
 
 often endangered by the disease ; while a boil is sthenic in itself, is gener- 
 ally developed in robust and plethoric temperaments, and is in most in- 
 stances free from fever or any constitutional disturbance. The cases in 
 which fever may be expected, are those in which the tumor is large, and 
 situated on a sensitive part, or when a number of these swellings appear at 
 the same time in different places. A carbuncle contains no single core, 
 but has several openings for the exit of sloughs. 
 
 As suppuration progresses in a boil, the apex of the cone becomes 
 yellowish, and surrounding this, the hardness of the swelling disappears, 
 though still the base is firm and unyielding. The pus is superficial, the 
 slough or core being at the base. 
 
 According to Richerand, the origin of boils depends upon a disordered 
 state of the gastric organs ; this is frequently the predisposing, Avhile the 
 exciting cause may be a prick, a scratch, or some other slight irritation. 
 Constitutional irregularity, however, is, in very many instances, sufficient 
 in itself to produce this variety of inflammation. 
 
 Boils may appear in any part of the cellular tissue, and are mostly found 
 among young plethoric individuals, or in those persons who are given to 
 high living and suffer from dyspepsia. Some individuals appear to be par- 
 ticularly liable to the formation of furuncle, and the hips and buttocks are 
 frequently the seat of the disease ; it is in this locality that they are ex- 
 tremely vexatious, as the afflicted mortal can neither sit with comfort nor 
 walk without pain, which is occasioned when the muscles are rendered tense, 
 and, moreover, the individual is constantly kept in a ferment of anxiety 
 and suffering, consequent upon the frequent blows that are invariably, unac- 
 countably and inadvertently inflicted upon the tender and painful tumor. 
 
 A boil, after suppuration is complete, bursts at its apex, and the purulent 
 secretion is discharged, after which the pain, heat, and swelling subside ; 
 but unless the slough is also extracted, the part may remain in a subacute 
 inflammatory condition, the disorganized tissue acting as any other me- 
 chanical irritant. At certain periods of evolution of the system, a number 
 of boils are apt to make their appearance in the same individual. 
 
 Treatment. — At the climacteric, during teething, or about pubescence, the 
 surgeon is often called to treat a succession of these disagreeable visitors. 
 A systematic constitutional treatment must then be adopted; the medi- 
 cines being chiefly hepar, kali hydriodicum, and sulphur. The homoe- 
 opathic treatment of boils is very efficacious ; indeed, the careful practi- 
 tioner can frequently administer prophylactic medicines to those in whom 
 there is a tendency to this variety of inflammation, thereby saving the 
 patient from great inconvenience and a considerable amount of pain. 
 
 In the treatment of furuncle a poultice is very often necessary. The 
 heat and moisture of an unmedicated fomentation produces often great 
 relief. Such means, however, I have not always found essential. There is 
 naturally existing in the minds of the older portion of the community, 
 whether physicians or laymen, a favorable predisposition in regard to the 
 application of a poultice. Those who have been born, bred, and habituated 
 to the application of such means for almost every variety of local inflam- 
 mation, cannot, without some hesitation, resign the adjuvants ; but experi- 
 ence teaches that patients can be cured as speedily, and in some instances 
 more radically, of such inflammation, by homoeopathic medicines, than by 
 purging the patient with drastics, " touching the liver " by means of mer- 
 cury, and enveloping the tumor with a poultice of mush, oatmeal, flaxseed, 
 or slippery elm. 
 
 The medicines that are most applicable in the treatment of boils are : am., 
 bell., calc, hep., lye, phos., sulph., or alum., antim. c, led., mere, mur. ac, 
 nit. ac, nux vom., sep., thuj. 
 
401 
 
 To eradicate the disposition to boils, the medicines are : calc, lye, nux 
 vom., phos., and sulph. 
 
 If suppuration progress slowly, mere, will hasten the formation of pus. 
 
 When there are stinging pains in the boil, the medicine is nux vom. 
 
 When there is troublesome itching, carb. veg. or thuja, the latter particu- 
 larly when the redness extends to some distance around. 
 
 If the pain is lancinating, calc. carb. If the pain is stinging when the 
 boil is touched, lye. If this be present during motion, mur. ac. 
 
 If burning, colocynth. 
 
 If there is burning pain, extending to some distance around, antim. crud. 
 
 Dr. Gallupe, of Bangor, has seen good results follow the exhibition of 
 crotalus horridus in furuncle. 
 
 There are also many other remedies mentioned for boils appearing on 
 different parts of the body, but it is probable that if the above symptoms 
 are present, the medicines will relieve without regard to locality. However, 
 the student is referred to the Symptomen Codex, to ascertain the particular 
 situation of th$ boil, if the treatment above recommended has been unsuc- 
 cessful. 
 
 Berberis vulgaris is an excellent medicine to hasten suppuration in boils, 
 and by its proper administration has removed the predisposition to them. 
 
 In the British Journal of Homoeopathy, for July 1st, 1861, p. 499, is de- 
 scribed the lotion (so highly lauded by Rademacher) of the solution of cal- 
 carea muriatica. This I have used topically for bpils, but think it better 
 adapted to anthrax. 
 
 Dr. Dudgeon has witnessed the beneficial effects of the solution. The 
 prescription is as follows : 
 
 R. Calc. mur., ziij. 
 
 Aquae purse, 3iij. 
 
 M. 
 
 Dr. Kallenbach, Sr., of Utrecht, has given an excellent paper on the 
 subject. 
 
 In Hale's New Remedies, asclepias, erigeron, gnaph., nymph., phyto., and 
 sanguin., have all been proved to be beneficial; and hamamelis, iris ver., 
 and stillingia would, by provings, seem to be indicated as efficient reme- 
 dies. 
 
 Anthrax, Carbuncle. — A carbuncle is, in some respects, analogous to a 
 furuncle, though the former is much more dangerous, the inflammation 
 being more extensive and gangrenous in character. 
 
 This inflammatory swelling must not, however, be confounded with the 
 charbon, or malignant pustule, of which something will be said further on. 
 
 The tumor is deep-seated, hard,' and circumscribed, and rapidly advances, 
 becoming livid, and attended with severe burning or lancinating pain. The 
 inflammation, as has been before stated, is of the asthenic type, and attacks 
 the skin and subjacent areolar tissue. 
 
 As the inflammatory process progresses, the tumor becomes soft, of a 
 purple hue, and spongy ; suppuration, ulceration, and sloughing of the cel- 
 lular tissue supervene, and numerous small apertures form in the skin, 
 through which a thin sanious pus is discharged, together with the disinte- 
 grated areolar tissue. This condition is one of the most important diag- 
 nostic signs between anthrax and common boil, for in the latter, however 
 large, there is but a single opening. 
 
 The usual situation of carbuncle is the back, from the nape of the neck 
 to the pelvis, though any portion of the body may be attacked. The size 
 varies from that of a chestnut to that of the palm of the hand, the con- 
 
 26 
 
402 A SYSTEM OF SURGERY. 
 
 stitutional symptoms, when the tumor is large, being dangerous in the 
 extreme. 
 
 The fever, primarily, is simple, or may be bilious in its character ; but as 
 the disease progresses, typhoid symptoms make their appearance and in- 
 crease, and as the occult gangrene extends, prostration becomes more 
 extreme, and hiccough, delirium, coma, and even death may ensue. 
 
 The swelling is generally flat, bluish, and spongy, only slightly elevated 
 above the surrounding skin, and in most instances circular, and circum- 
 scribed by a distinct line of demarcation, which, as in other sloughs, indi- 
 cates the separation of the dead from the living tissues. 
 
 Carbuncles are most common in advanced life, although they may be seen 
 in young persons, especially among those who have been accustomed to 
 hardships or severe privations. They are also encountered in adults who 
 indulge in the excesses of the table, or who have debilitated their consti- 
 tutions by a life of debauchery. 
 
 Treatment. — The medicines for carbuncle are : arsen., bell., chin., hyos., 
 acid mur., acid nit., rhus., tarantula cub., secal. cor., silic. 9 
 
 Dr. Pardo * and Dr. Victor de Iturralde f mention several cases of car- 
 buncle that were cured by homoeopathic treatment; the medicines em- 
 ployed were ars., bell., and silic. The latter-named gentleman used chiefly 
 bell., and after relating his success, he remarks : u The irritability under the 
 usual treatment was great; by homoeopathic treatment, however, nine- 
 tenths less." 
 
 It is usually laid down in the text-books, that free incisions into the in- 
 flamed surface is the proper and appropriate treatment. For some years, 
 however, indeed ever since I have had mental fortitude enough to lay 
 aside the routine practice of the schools and think for myself, I have had 
 my doubts with reference to these free incisions, and when I carefully 
 review the cases I have seen treated by others, as well as those that have 
 come under my own observation, I have as yet to discover that decided 
 benefit accrued from the "free incisions" to prevent spreading. I am, 
 therefore, glad to observe that the celebrated Mr. Paget, of St. Bartholo- 
 mew's, is also averse to this method of treatment. In the Practitioner, he 
 says : 
 
 " I have seen carbuncles spread in as large a proportion of cases after in- 
 cisions as in cases that have never been incised at all. I have in my mind 
 a striking case that occurred to me early in practice, when I followed the 
 routine, and a friend of mine divided the carbuncle most freely. I cut it 
 after the most approved fashion in depth, and length, and width, and then 
 it spread. After two or three days more, all the newly-formed part was cut 
 as freely as the first, and then it spread again, and again it was cut as freely. 
 Then it spread again, and was not cut. Then in a natural time it ceased to 
 
 spread, and all went on well On a very strong, general impression, 
 
 however, I say that carbuncles will spread after cutting in as large a pro- 
 portion of cases as they will spread without cutting." In reference to the 
 supposed relief of pain by incision, and the alleged acceleration of the heal- 
 ing powers by this operation, Mr. Paget expresses grave doubts ; indeed, in 
 regard to the latter, he distinctly states that the " healing without incisions 
 is very cleanly, and certainly a great deal the quicker." 
 
 In every particular I believe Mr. Paget is correct, and to homoeopathists 
 who know there are medicines for the constitutional treatment of the dis- 
 ease, I would say, avoid the use of incisions, unless there be a large slough 
 
 * Bulletin Official de la Soc. Hahnemann, vol. ii., No. 12, 1848. 
 f Loc. cit., vol. ii., No. 1, 1847. 
 
TREATMENT OF CARBUNCLES. 403 
 
 to be removed. Dress the sore with a hot solution of calendula, several 
 times daily, covering the compress with a piece of oiled silk, and rely on 
 internal rather than external medication, and the cases will proceed with 
 much greater celerity to a successful termination than if the cutting and 
 slashing practice be resorted to, with all manner of poultices, cataplasms, 
 and ointments. Remove the sloughs as they are formed with delicate for- 
 ceps and keep the parts clean, bathing them frequently with tepid water. 
 Allow the patient a good but unstimulating diet, and the results will be 
 satisfactory. 
 
 Of late, however, I have adopted a treatment which has been so successful 
 that I have been surprised at the results. It is simple, cleanly, and devoid 
 of trouble ; no poultices or incisions are necessary, and the cases have pro- 
 ceeded to a rapid and favorable termination. It consists in applying over 
 the parts four thicknesses of patent lint, saturated with a solution of calen- 
 dula, one part to six of water. Over this apply a piece of oiled silk, and upon 
 this a square of spongio-piline, of sufficient size to cover all the other 
 dressings. The lint must be removed every two hours, wrung out in tepid 
 water, and re-saturated with the calendula solution, and carefully reap- 
 plied. During the night the dressing ought to be used as regularly as during 
 the day, and the patient given a powder of five grains of the 3d decimal 
 trituration of arsenicum alb., every time the dressing is changed. I have 
 recently treated in this manner a gentleman who some years before had 
 suffered from a carbuncle, and had gone through the routine of poultices 
 and incisions, and who could scarcely believe that he was afflicted with a 
 true carbuncle, so free from pain was he during the entire course of the 
 treatment. 
 
 Dr. M. O. Terry, of Utica, N. Y., says in reference to the causation of boils 
 and carbuncles : 
 
 " I am thoroughly convinced that a large majority of boils and carbun- 
 cles are due primarily to the butyric acid in butter, and secondly, by the ab- 
 sorption of the pus when once formed, being taken up by the lymphatics. 
 Youmans says : " Butyric acid, C 4 H 8 2 , is prepared by allowing a mixture 
 of sugar, chalk, and cheese to ferment. It is found in small quantity in 
 butter, in perspiration, in some plants, and in the juice of human flesh. It 
 resembles acetic acid in appearance, has a peculiar rancid odor, and is sol- 
 uble in water.' 
 
 " Now, inasmuch as all sw>eet butter contains butyric acid — unless you order 
 it made from sweet cream — in all of the butter eaten there is the germ cause 
 for boils and carbuncles. Lactic acid is the first change of fermentation in 
 cream, and butyric acid is the second stage of the process. It is this acid 
 which gives the disagreeable odor to rancid butter. The reason why it is 
 found in the 'perspiration' and in the 'juice of human flesh,' is that the 
 bacteria forming this acid are non-assimilable. They irritate and set up an 
 inflammation in the sebaceous follicles by their septic qualities. 
 
 " The theory above given of the causation of boils and carbuncles has been 
 conclusively proven to be true in the following way : 1. By injecting the 
 carbuncles with an antiseptic solution. Furuncles in the external meatus, 
 which often last for months, are cured in a few days by cautiously injecting 
 them with a few drops of such a solution. 2. Small boils will often* disap- 
 pear by discontinuing butter. If they do not disappear it is because pus has 
 formed, and such being the case, the injection will be necessary, not only 
 for a speedy cure, but to prevent pus deposit in other regions." 
 
 Dr. Terry further remarks* in reference to the treatment of carbuncles : 
 
 " First, apply several coatings of collodion over the carbuncle, extending 
 
 * Transactions of the N. Y. State Homoeopathic Med. Soc, 1885. 
 
404 A SYSTEM OF SURGERY. 
 
 beyond the periphery of inflammation, but omitting at the centre of the car- 
 buncle an area of one-fourth of an inch. Second. Make a small crucial 
 opening. Third. With a solution of carbolic acid, glycerine, and water, 
 according to the following formula : 
 
 R. Crystal, sol. acid carbolic, gtt. xx. 
 
 Glycerinise, 
 
 Aquse, aa gij. 
 
 Inject, with a hypodermic syringe, to which is attached a lachrymal 
 canula, a few drops in several directions, pushing the canula well toward 
 the periphery. Repeat every day if necessary. It is generally unnecessary 
 to make more than five treatments, and your patient will not need your 
 attention after one week. Any simple cerate, as vaseline and calendula or 
 iodoform, applied with absorbent cotton, will make a good dressing." 
 
 Dr. Vincent,* of Troy, relates a most remarkable case of anthrax of the 
 face, which he treated successfully with calendula, followed by pix liquida 
 and beer as an application. 
 
 Carbolic acid, or permanganate of potash, or Labarraque's solution, must 
 be employed to allay fetor. 
 
 Effects of Cold. — If a portion of the body is exposed for a period to intense 
 cold, gangrene results, although it must be borne in mind that parts may be 
 frozen for a short period and yet regain their natural color and warmth with- 
 out any untoward circumstances. This is daily exemplified in the practice 
 of local anaesthesia. If, however, the cold be continuously applied, the 
 parts first become shrunken and hardened, and are redder than natural, 
 from the diminution of the arterial supply; if the exposure be continued, 
 the shrinkage increases, but the redness changes to a pallor, and sensibility 
 is lost. This may continue until death of the frozen parts results. 
 
 A still more serious effect of intense cold, when applied universally to the 
 body, is that of coma. The first sensations are those of pain and numbness, 
 sometimes accompanied with a feeling of sickness at the stomach ; after this 
 there gradually steals over the patient an irresistible drowsiness, an uncon- 
 querable desire to sleep. The patient generally is aware of his condition, 
 and endeavors to rally himself by exercise or motion of some kind. He is 
 often conscious of the fact that if he yields to the drowsiness, death will be 
 the inevitable result. 
 
 From this, it will be seen that there are several effects which are pro- 
 duced by exposure to cold, the milder form being a simple chilblain, the 
 next actual frostbite occasioning gangrene, and finally the constitutional 
 effects resulting in coma and death. It is a most remarkable fact, that 
 persons who are habitually used to taking alcoholic beverages, or those 
 who ply themselves with stimulants before exposure, are those in whom the 
 dangerous constitutional effects of cold are most manifest. The history of 
 many Arctic expeditions, and the personal experience of those who have 
 been obliged to face intense cold, prove this fact beyond a doubt. Cold 
 water, or what is better, cold tea, taken before exposure, offers better 
 chances for endurance than any other kinds of hot or cold stimulating 
 drinks.. 
 
 Treatment. — When a part is frozen, care must be taken not to expose it 
 too suddenly to a heated atmosphere. The parts should be briskly rubbed 
 with snow or ice-water, until a slight degree of warmth is obtained. After 
 this, water of ordinary temperature may be employed, and the part elevated 
 and often actually suspended, the friction being always made from the peri- 
 phery toward the centre of the circulation. So soon as the circulation is 
 
 * Transactions of the N. Y. State Homoeopathic Med. Soc, 1874. 
 
PERNIO. 405 
 
 restored the room may be made gradually warm, and the parts enveloped in 
 flannel cloths. 
 
 At this time, the pain from the reaction may be intense, and fever may 
 appear. This is allayed by the internal administration of aconite, and the 
 application of the same tincture, diluted one-half with water, over the part, 
 or the local application of tincture of iodine may be used, or what is better, 
 the following preparation, which was employed most successfully in the 
 Austrian Polar expedition : 
 
 R. Iodinii, . 4 parts, by weight. 
 
 Etheris sulphurici, 30 " " 
 
 Collodii, . 100 " 
 
 Apply with a brush. 
 
 If a person has become comatose from the general effects of cold, the 
 same principles must apply that have been already recommended. The 
 patient must be taken into a cold room, and while Sylvester's method of 
 artificial respiration is resorted to by some of the persons present, others 
 must rub briskly the whole body. This must be done for a few moments 
 with great vigor. Perseverance and regularity of all the movements are 
 essential. After this, when signs of returning vitality begin to be manifest, 
 the room may be gradually warmed ; the frictions and artificial respiration 
 may be less frequent, and finally may cease. The patient at this time gene- 
 rally will have sighing respiration and some slight movement; a partial 
 return of color to the lips and a more healthy appearance of the skin in- 
 dicate that the circulation is being established. At this stage, drop doses of 
 spirits of camphor, at first every quarter of an hour, and at longer intervals 
 as the reactionary symptoms progress, should be given. This medicine, 
 however, must give way, in the course of a few hours, to aconite and bella- 
 donna, which should be given in alternation every hour if violent inflam- 
 matory symptoms supervene. 
 
 If the exposed parts are dead beyond resolution, then an emollient poul- 
 tice must be applied, disinfectants used, and the surgeon wait for nature to 
 draw the line between the living and dead tissues. Other medicines of course 
 must be given according to the presenting symptom, in the varied condi- 
 tions mentioned. 
 
 Pernio is an inflammatory affection, usually the secondary effect of cold, 
 caused by heat and circulation being prematurely restored. It is com- 
 monly met with in the extreme parts of the body, as the fingers, toes, 
 heels, ears, and nose, as these are not only habitually exposed to cold, 
 but also are of comparatively weak circulation, and consequently of low 
 power. 
 
 The skin is at first pale, and presents a somewhat shrivelled appearance, 
 but this is in a short time succeeded by tumefaction and dark redness, with 
 a sensation of heat and intense itching. The swelling also sometimes cracks 
 and bleeds, and there is a tendency to ulceration. 
 
 These are usually the presenting symptoms in ordinary chilblain ; how- 
 ever, if the disease advance, the skin assumes a purplish cast, the tingling, 
 burning, and itching become intolerable, and vesicles form, which contain a 
 serous fluid ; these do not desquamate in the ordinary manner, but burst 
 and disclose beneath a painful and ill-conditioned sore, that discharges a 
 thin, watery fluid; this ulcer is often slow to heal, and may assume the 
 character of an irritable or indolent sore, which is generally superficial, but 
 may become gangrenous, or may penetrate to a considerable depth, involv- 
 ing tendons or bone. 
 
 The milder form of the complaint — that unattended with ulceration — is 
 of frequent occurrence in this climate during the winter season. It par- 
 
406 A SYSTEM OF SURGERY. 
 
 ticularly appears on the feet of those who have been compelled to stand or 
 labor in the snow, which, melting, penetrates through the leather of the shoes 
 or boots, thus wetting the feet, which are often imprudently held near a warm 
 fire and allowed to dry ; this premature restoration of heat engenders the 
 affection. 
 
 Chilblains often disappear spontaneously in the summer, but return 
 again in the winter, generally attacking those parts that have previously 
 suffered. 
 
 This affection is also very liable to occur in those individuals afflicted 
 with dyspepsia or other diseases which render extreme circulation imper- 
 fect. 
 
 The medicines for chilblains are : agar., arn., ars., bry., bell., carbo a., 
 kali c.j lye, nit. ac, nux vom., petr., phosph., puis., sulph., zinc. met. 
 
 For " chilblains on the feet, with pain and redness during the summer 
 season," antim. crud. 
 
 The feet should be bathed night and morning in cool water, and rubbed 
 thoroughly with a coarse towel, hair mitten, or flesh brush. Persons 
 subject to pernio should wear cotton stockings or socks. If any external 
 application is needed, vaseline or cosmoline, which is pure petroleum, 
 is preferable. In the country coal oil is used, and I have seen much benefit 
 from it. 
 
 Burns and Scalds. — The practitioner is frequently called upon to treat in- 
 juries that have resulted from the application of heated solids or fluids to 
 the skin. Sometimes the danger to the system is slight, but at others, when 
 the heated matter has come in contact with a large surface, the prognosis is 
 very unfavorable. By the term scald is understood the effect of heated 
 fluids when applied to any portion of the body, while the consequences of 
 hot solids or ignited combustibles are termed burns. The latter class is, in 
 the generality of instances, the most serious, although the former, though not 
 injuring the skin deeply, gives rise to very alarming symptoms when a large 
 extent of surface is involved. 
 
 Dr. Magill* has recorded one of the most interesting cases of instant 
 rigidity, from the effects of heat, in the annals of surgery. The reader is 
 referred to it, as it indicates the rapid coagulation of the muscle fibrin of the 
 entire body by intense heat. 
 
 A slight degree of heat is only productive of a sharp hot pain, with red- 
 ness of the surface, and these may both subside without any other unpleasant 
 symptoms, but in very many instances effusion of serum immediately takes 
 place beneath the cuticle. In other cases the cutis may be destroyed by the 
 intensity of the heat. Parts also that at first do not present appearances of 
 any very serious injury may afterwards be involved, perish, and be cast off 
 as a slough. The surrounding textures also have their vitality diminished, 
 and when they come to be the seat of the inflammatory process, are unable 
 to sustain the increased action, and from the want of corresponding power 
 sloughing very often ensues. 
 
 In this era of steam, coal oil, and beer-making, accidents are very fre- 
 quent, occurring chiefly among the lower classes. Brewers, engineers, soap- 
 boilers, manufacturers and refiners of sugar are most liable to scalds, which 
 implies the application of heat, together with a certain degree of moisture ; 
 while iron-workers, machine makers, foundrymen, who work among metals, 
 are the most frequent subjects of burns. 
 
 Certain .substances, having a greater capacity for caloric than others, 
 necessarily produce, under similar circumstances, more severe burns than 
 others. Thus, molten lead causes a more severe burn than boiling oil, and 
 
 * British and Foreign Medico-Chirurgical Eeview, January, 1877. 
 
BURNS AND SCALDS. • 407 
 
 boiling oil more severe effects than boiling water ; copper, when heated, is 
 said to act more severely than iron at the same temperature. 
 
 Burns on the trunk and genital organs are very serious and productive of 
 the most disastrous results, and extensive injuries of this kind, no matter in 
 what portion of the body, are much to be dreaded. The constitutional 
 symptoms are often well marked ; they are, great sinking of the vital powers 
 (which generally is present immediately after the reception of the injury), 
 shivering, weakness, cold extremities, anxiety, vomiting. And these may 
 be readily accounted for, when it is remembered what an important office is 
 fulfilled by the texture that is in almost every instance the first to be impli- 
 cated. 
 
 Authors differ in their classification of burns. One makes three divisions : 
 1. Redness ; 2. Vesication ; 3 Mortification. Another, of equal celebrity, 
 divides these accidents into four varieties, according to the intensity of the 
 heat applied. Dr. Thompson * arranged them : 
 
 1st. Into such as produce an inflammation of the cutaneous texture ; but 
 an inflammation which, if it be not improperly treated, almost always mani- 
 fests a tendency to resolution. 
 
 2d. Into burns which injure the vital powers of the cutis, occasion the 
 separation of the cuticle, and produce suppuration on the surface of the 
 cutaneous texture. 
 
 3d. Into burns in which the vitality and organization of a greater or less 
 portion of the cutis is either immediately or subsequently destroyed, and a 
 soft slough or hard eschar produced. 
 
 Pearson also names three varieties, and his arrangement is approved and 
 followed by Dr. Gibson, viz. : 
 
 1st. Superficial ; 2d. Ulcerated ; 3d. Carbunculous. 
 
 The best classification, however, is that of Dupuytren, which is recom- 
 mended by Dr. Henriques.f He divides burns into six degrees. 
 
 The first occurs when a small quantity of caloric has been applied for a 
 short space of time, which determines simply a greater or less degree of inflam- 
 mation of the skin, and much resembles simple erysipelas. 
 
 In the second degree, there is not only cutaneous irritation or augmented 
 organic action, but there is also vesication or the formation of bladders, more or 
 less considerable, which resemble strikingly the blisters of very acute vesicular ery- 
 sipelas. 
 
 The third degree is characterized by disorganization of the dermoid tissue, 
 and its conversion into a hard, black, and dry slough. 
 
 In the fourth degree, both the dermoid and subcutaneous tissues are com- 
 pletely disorganized. 
 
 The fifth degree comprises those only in which there is disorganization of 
 the skin and all the subjacent tissues, except the osseous ; and in the sixth, 
 there is carbonization of the osseous tissue, as well as of the surrounding 
 soft parts. 
 
 From the fact, says Dr. Henriques, " that caloric does not act with the 
 same degree of intensity upon the whole burnt surface, it will readily be 
 understood that only the first degree can occur alone, and that two or more 
 degrees will be found in all other cases of burns. This is admirably illus- 
 trated in the application of the moxa, where it will be found, at the part 
 where the heat is immediately applied, the skin diseased and gangrenous, 
 whilst simple inflammation will be present around the edges of the slough, 
 which gradually diminishes, the inflammation assuming the figures of con- 
 centric circles." 
 
 * Lectures on Inflammation. 
 
 f British Journal of Homoeopathy, vol. xi., p. 97. 
 
408 A SYSTEM OF SURGERY. 
 
 A burn covering a large extent of surface is a fearful disaster. Imme- 
 diately after its occurrence the surgeon may be compelled to cut away the 
 charred and blackened clothing. The sufferer has to encounter shock, then 
 pass through the periods of reaction, suppuration, ulceration, and sloughing, 
 and, after all, death probably may be the result. This series of trials will 
 require untiring vigilance and call forth all the knowledge and skill of the 
 surgeon. 
 
 Widespread injuries from heat are often accompanied with diarrhoea, 
 and when the surface of the abdomen is extensively involved a fatal 
 haemorrhage sometimes follows. In a case that I attended of a servant girl, 
 whose clothes were ignited, before the flames were extinguished the entire 
 surface of her back and abdomen were covered with large bullae ; diarrhoea 
 set in with the reaction and continued until her death, which happened 
 on the fourth day. 
 
 In children perforation of the duodenum is known frequently to take place, 
 the symptoms being those of rapid collapse. 
 
 There are four periods of danger during the progress of a case of severe 
 burn : 
 
 1st. Immediately after the injury, the patient may die of shock. 
 
 2d. After the third or fourth day, sympathetic fever or sympathetic affec- 
 tions of the brain or bowels may produce an unfavorable result. 
 
 3d. During the period of suppuration, hectic or pyaemia may appear. 
 
 4th. From the prolonged irritation the patient may perish from hectic 
 fever or pulmonary consumption. The degree of danger is measured, first, 
 by the extent of the burned surface; second, by the depth of the burn. 
 
 A burn or scald covering a large surface is always dangerous, although 
 only the integument be involved. It has been stated that when two-thirds 
 of the surface of the body is implicated the patients never recover. 
 
 A burn, though dangerous from its extreme depth, is not so likely to be 
 followed by as great prostration and collapse as in the former case, where 
 so many of the peripheral nerves are implicated. 
 
 Treatment. — The treatment of burns varies according to the period of 
 time at which the practitioner is called. If shortly after the accident and 
 the patient is suffering from shock, opium, camphor, arsenicum, or veratrum 
 may be indicated. During this period, when the patient is partially insen- 
 sible, a favorable opportunity is offered for the removal of the charred and 
 burnt clothing, which must be carefully cut away, raising it gently from the 
 burned surfaces, to prevent tearing off the elevated epidermis. The parts 
 are then to be washed with a solution of cantharides, spirits of turpentine, 
 or urtica urens, a drachm of either to four ounces of warm water, and the 
 parts gently though well covered with the solution. 
 
 Dr. Henriques applies a solution composed of ten drops of either arnica, 
 cantharides, or urtica urens to half a pint of pale brandy.* If no symptoms 
 of reaction should have supervened, a small quantity of opium in water 
 will assist the efforts of nature if given internally. 
 
 An excellent lotion at this period of burn is the creasote water of the 
 U. S. Pharmacopoeia : 
 
 R. Creasote, fl^j. 
 
 Water, O. 
 
 M. 
 
 Shake the bottle until the creasote is dissolved, and apply carefully. 
 The next thing to be done is the application of such dressings as will 
 absolutely exclude the external air. Before, however, applying these, the 
 
 * Vide B. J. H., vol. xi., p. 100. 
 
TREATMENT OF BURNS AND SCALDS. 409 
 
 vesicles must be pricked with a needle and their contents evacuated. Many 
 substances are commended to protect the parts; cotton, in thick layers, is 
 especially recommended. The value of this application was discovered 
 accidentally by a lady living in Harford County, Maryland, whose child 
 was scalded by boiling water over nearly its whole body. The mother was 
 carding cotton in an adjoining room at the time of the accident, and having 
 no medical assistance within reach, undressed the child as quickly as pos- 
 sible, and covered the whole burnt surface with masses of cotton. The 
 effect was wonderful, for the child soon became perfectly quiet, fell asleep, 
 and upon removing the cotton a few hours afterwards, no inflammation 
 whatever could be perceived.* 
 
 Dr. Morris, of Baltimore, is averse to the old-fashioned carron oil treat- 
 ment, and recommends that the patient be entirely covered with loose bran. 
 This strikes me as an excellent method, for the soiled or lumpy particles 
 can be replaced with fresh material without disturbing the patient.f 
 
 Many surgeons apply a thick coating of soap or the emplastrum saponis ; 
 others prefer a solution of glue or a mucilage of gum. Dr. W. F. Jackson,! 
 of Roxbury, Mass., commends very highly the whites of eggs and olive oil, 
 in equal quantities, beaten together and applied with a soft brush. 
 
 The application of cotton upon which has been poured a mixture of one 
 part of carbolic acid with six parts of olive oil, then covered with tin foil 
 and a bandage, is well spoken of. 
 
 Cosmoline, a substance prepared by Mr. Houghton, of Philadelphia, from 
 crude petroleum, is likewise used with favorable result. I can testify to its 
 efficacy from experience. 
 
 Carbolic acid, dissolved in glycerin and afterwards in olive oil, is reputed 
 as having been successful in a severe case. 
 
 Dr. Gross recommends highly the carbonate of lead, mixed with linseed 
 oil to the consistence of cream. 
 Collodion has also been used. 
 Carbolated cotton is another excellent dressing. 
 And, finally, dry earth has its especial advocates. 
 
 In domestic practice molasses and honey are also used. The once popular 
 application of linseed oil and lime-water has not been mentioned, indeed it 
 may be considered obsolete, as numerous better applications have super- 
 seded it. Most of those just mentioned I have employed in the treatment 
 of burns. Of these the carded cotton is the simplest, and often proved 
 satisfactory. The carbonate of lead, recommended by Gross, I have used 
 in severe cases, and found it very efficacious, especially when over the 
 painted surface carded cotton was applied. I have not known any un- 
 pleasant symptoms follow. Dry earth I have used with success during the 
 profuse suppuration, but have ascertained that it must be carefully watched. 
 It destroys fetor immediately, but as soon as the pus soaks through the 
 dressings, the odor is extremely disgusting. As soon as suppuration begins 
 to be profuse and reaction commences, I place upon the parts carded cotton, 
 and keep it wet with calendula ; administer calendula likewise internally, 
 unless other medicines are indicated, in the third decimal preparation. The 
 effect of this plan of treatment often is surprising. The dressing is cleanly 
 and easily applied. 
 
 If the pain be severe, the following will, as a rule, not disappoint the 
 practitioner : 
 
 * Gibson's Institutes and Practice of Surgery, vol. i., p. 72. 
 
 f Napheys' Surgical Therapeutics, p. 174. 
 
 J Publication of Mass. Horn. Med. Society, vol. ii., p. 417. 
 
410 A SYSTEM OF SURGERY. 
 
 R. Iodoformi, ^ij. 
 
 Ung. cetacei, ^j. 
 
 Ext. conii, ^iss. 
 
 Acidi carbolici, gtt. x. 
 
 M. Applied over the inflamed surface, which must be 
 covered with oiled silk. 
 
 A retired foundryman claims the following as a cure for burns :* 
 
 Powdered charcoal — from pine wood is the best — he says, thickly sprinkled 
 over the burned or scalded surface, and renewed as soon as it falls off, is a 
 never-failing, grateful, and speedy remedy. He further states, that it relieves 
 pain, and heals as if by magic. 
 
 In order to remedy constitutional disturbances, which always occur with 
 more or less intensity and gravity, the best remedies are, in the first in- 
 stances, opium, arnica, coffea, carbo veg. 
 
 Opium is indicated principally in children, who frequently show a dispo- 
 sition to convulsions and other spasmodic affections, generally the result of 
 fright, which this accident produces in the extreme nervous susceptibility 
 natural to this age. 
 
 Arnica is useful in all cases and ages to allay the extreme sensibility of 
 the whole body, the general restlessness, and intense pain in the seat of 
 injury. 
 
 Coffea is necessary to promote sleep and allay nervous excitement. 
 
 Camphor in drop doses, frequently repeated, is peculiarly adapted to 
 those extreme cases formerly alluded to, in which the shock is so severe as 
 to threaten the complete extinction of life. 
 
 When excessive reaction takes place, and there is dry burning heat of 
 the skin, with thirst, head hot and painful, face red, pulse hard, frequent, 
 and contracted, aconite is the medicine indicated. Should suppuration 
 take place, and the discharge be so great as to impair the constitution, it 
 will be necessary to administer hepar sulphuris and china to combat its 
 morbid effects. Causticum and calcarea carbonica may sometimes be indi- 
 cated in such cases. 
 
 To favor the sloughing of eschars, and to promote healthy granulation 
 and cicatrization in the most severe cases of burns, either arsenicum, nit. 
 ac, lachesis, calcium sulphide, or mercury may be required, according to 
 the totality of symptoms present in any given case. 
 
 If diarrhoea should supervene, arsenicum, carbo veg., phosphorus, or 
 veratrum may be used, and for haemorrhage, nitric acid, ferrum, hamamelis, 
 erigeron, crocus, or diadema should be remembered. 
 
 Cicatrices. — The last result of which it is necessary to speak relates to 
 the formation of cicatricial tissue which follows extensive burns; this 
 is a most important point in the treatment of these injuries, because 
 this not only results in deformity, but also impedes the free motion of parts 
 where it occurs, and sometimes prevents the exercise of an important 
 function. 
 
 In some instances, no matter how judicious the treatment, this most dis- 
 agreeable and unfortunate result cannot be prevented. It is a natural con- 
 sequence of the contractive force of the modular or cicatrizing tissue. In 
 order to avoid it, however, the process of cicatrization must be carefully 
 and constantly watched, and so regulated that the cicatrix may have the same 
 extent of surface as the original skin that has been destroyed, and to prevent 
 it from being formed by drawing together of the edges of the surrounding 
 skin ; this may be effected, first, by the administration of appropriate medi- 
 
 * The Medical Kecord, March 15th, 1879, No. 436. 
 
PARONYCHIA WHITLOW. 411 
 
 cines, when the granulations are unhealthy ; second, by the proper position 
 of the injured part; third, by the method of dressing the wound ; fourth, 
 by the use of fitting mechanical apparatus, which must vary according to 
 presenting circumstances. Notwithstanding all these means, should we fail 
 in preventing deformity, there is still a resource in operative surgery which 
 may relieve the patient. 
 
 These operations consist, first, in freely dissecting the cicatrices, and re- 
 storing, as nearly as possible, the parts to their original position. In most 
 instances the entire cicatrix may be cut out, leaving the wound to heal by 
 granulation, taking care to maintain the parts in proper position while the 
 process of repair is going on; or dermoplasty may be resorted to, which 
 consists in taking away the hard inodular tissue, forming a proper flap from 
 sound integument, and fixing it over the wound. The success attendant 
 upon these processes is variable, but there is in all of them a great tendency 
 to the return, at all events in a degree, of the inodular tissue and deformity. 
 
 When the process of cicatrization is accompanied by excessive inflam- 
 matory action of the surrounding edges, either ars., hepar, mere, nit. ac, 
 phosph., ruta, or silicea will be found useful, according to the particular 
 indicatioDS of the special case. When the granulations appear luxuriant 
 or excessive, alum., sep., thuja, are indicated. When cicatrization is inter- 
 rupted by excessive suppuration, the most appropriate remedies are asaf., 
 hepar, mere, puis., rhus, silic, or sepia. When the ulcerated surface 
 bleeds, the remedies most indicated are: am., ars., creas., crocus, phos. ac, 
 or secale cor. 
 
 Paronychia — Whitlow. — A whitlow is an inflammation very much dis- 
 posed to suppurate and generally productive of severe pain, commencing 
 in the extremities of the fingers, though the toes are sometimes the seat of 
 the disease. 
 
 By some this disease is supposed to be a variety of carbunculous inflam- 
 mation depending upon constitutional derangement, while others consider 
 it to be entirely of local origin. It is rare to find a whitlow or felon, as it 
 is generally called, in children, and women are supposed to be more liable 
 to it than men, although, from my own observation, I have not found that 
 the one sex is more predisposed than the other. 
 
 Writers generally divide whitlows into four varieties : In the first and 
 least severe, the disease commences under the cuticle near the root or side 
 of the nail, the pus not being deep-seated and soon evacuated ; sometimes, 
 how T ever, the abscess takes place under the nail, in which case the pain is 
 severe, and not unfrequently shoots up as far as the external condyle. The 
 second variety is situated chiefly in the cellular tissue under the skin, and 
 generally occurs at the very ends of the fingers. In such cases the inflam- 
 matory symptoms, especially the pain, are far more violent than in other 
 common inflammations of not greater extent. However, though the pain 
 be severe, it does not generally extend far from the affected part. The in- 
 tensity of the sufferings and the severity of the inflammatory process are 
 owing to the hard unyielding nature of the integument covering the hands ; 
 consequently, when the laboring classes are affected by the disease, the pain 
 is much more pungent and deep-seated than when those in the higher walks 
 of life are attacked ; for the same reason there is often great difficulty in 
 perceiving any fluctuation after the formation of pus. 
 
 The third kind of whitlow is distinguished from the others, by the follow- 
 ing circumstances. The pain is excruciating, there is very little swelling 
 in the affected finger, but very much in the hand, particularly about the 
 wrist, and sometimes even extending throughout the entire forearm ; the 
 pain is experienced along the hand and wrist to the elbow, and in the most 
 severe cases to the shoulder ; suppuration proceeds slowly, and after the 
 
412 A SYSTEM OF SURGERY. 
 
 formation of pus, fluctuation can only be perceived in the hand, the affected 
 finger appearing swollen and tense. The patient is deprived of all rest, 
 and suffers for nights and days together; considerable fever also being 
 present, and sometimes delirium. 
 
 The disease in this variety is situated in the tendons and their sheaths, 
 consequently the power of moving the finger, and often the hand, is entirely 
 lost. 
 
 In the fourth variety, the inflammation appears to attack the periosteum. 
 The peculiarity of this form of paronychia appears to be, that, however 
 violent the pain, it seldom extends along the forearm, nor is there any ex- 
 ternal swelling of the affected finger. Suppuration is soon established, and 
 unless the disease be checked and the matter evacuated caries or necrosis of 
 the subjacent bones may be the result. 
 
 Whitlow generally arises from local causes, such as splinters, pricks with 
 needles, or other sharp instruments, bruises, warmth suddenly applied to 
 parts cold from exposure, etc. Those individuals whose occupation requires 
 frequent immersion of the hands in warm water and other fluids are par- 
 ticularly liable to the disease ; however, there are some cases in which it is 
 impossible to assign any cause. 
 
 Treatment. — In the first variety of whitlow, when the disease is superficial, 
 hepar must be used ; it is also suitable for the swelling, allays the stiffness 
 and numbness of the fingers, hastens the formation of pus, and mitigates 
 the pain, itching, and throbbing ; indeed, in the Materia Medica this medi- 
 cine is spoken of as being " a specific against panaritia." 
 
 Mercurius should be administered when the pains are intolerable at night, 
 with intense aching and burning under the finger-nail, when there is hard- 
 ness of the surrounding skin and the suppurative process is slow. 
 
 Arsenicum is a valuable medicine, when the part assumes a bluish-red 
 appearance, with intense burning pain, with stiffness and rigidity of the 
 joints. 
 
 The pus in the first variety soon accumulates, and will evacuate itself 
 without the aid of the knife ; it is well, however, if the skin be hard and 
 unyielding, to wrap around the affected part four or five layers of lint, and 
 keep it constantly moist with tepid water. After the pus evacuates itself, 
 silic. or sulph. will generally facilitate the cure. 
 
 In the second variety, the inflammation being more deeply seated, when 
 there is tearing and burning in the affected part, and if the surrounding 
 skin have an unhealthy appearance, with brittle and discolored nails, silic. 
 is to be administered ; or if after the evacuation of the matter, unhealthy 
 fungous granulations appear, this medicine is of the utmost importance. 
 
 If the affection arise from wounds, a lotion of calendula should be ap- 
 plied to the part. Carbo veg. or arsen. must be given, if there appear a 
 black angry-looking sore, with burnings and tearings, and throbbing pain, 
 and strong disposition to ulceration. There is no doubt that in many cases 
 free incision with the bistoury should be made, as soon as the surgeon is 
 fully convinced that pus is present, as the non-elasticity of the parts, the 
 slow suppurative process that takes place, together with the imperfect for- 
 mation of matter, all tend to increase the sufferings of the patient, and 
 cause an extension of the disease, until more important parts are involved. 
 If the inflammation arises from a puncture, and the patient complains of 
 coldness and alternations of heat, ledum is recommended by M. Teste. Of 
 course in treating any case of panaritium, if there be any extraneous mat- 
 ter present, giving rise to the inflammatory process, it should be removed 
 immediately. 
 
 In the third variety of whitlow, when there is violent burning-aching 
 under the finger-nails, with sensation of ulceration when touching anything, 
 
TKEATMENT OF WHITLOW. 413 
 
 or if the panaris causes a digging-burning pain, with tingling, and if there 
 be proud flesh, causticum is the medicine. If there be numbness or tearing, 
 rhus tox. may be indicated. Sepia will be beneficial if there be tearing under 
 the nail, with contraction of the finger, with violent beating and stinging. 
 These medicines allay the pains, but often it may be useful to alternate with 
 them either hepar, mere, silic, or sulph. 
 
 It is necessary also in this variety of whitlow to have recourse to the 
 knife; the surgeon must not be content merely to plunge a lancet into the 
 sore, but should lay open with a bistoury the whole sheath, taking care, 
 however, not to sever the tendon ; after which, by applying a solution of 
 calendula to the part, and inclosing the fingers in lint, the disease may be 
 in a short period cured ; if there be unhealthy granulations (proud flesh), 
 and the cut surface shows little disposition to unite, sepia, silic. or calendula 
 may be administered, and sometimes the unhealthy granulations will have 
 to be slightly sprinkled with alum ust. 
 
 In the fourth variety, mere, mez., phosph. ac, silic, are chiefly to be re- 
 lied on. Mez. may be given when there is intense pain. But the matter, 
 as has been before remarked, often forms quickly ; here also the knife must 
 be called into requisition. It is useless for homoeopathic physicians to de- 
 cry the knife in all cases, and in every variety of whitlow ; in the first, and 
 sometimes in the second form of the disease, the proper selection a*nd ad- 
 ministration of medicine may produce the desired result, but in the third 
 and fourth, when the pus has formed within the sheaths of tendons, or be- 
 neath the periosteum, incision is imperative, and he who neglects it should 
 be held to a certain degree responsible for the future pain, and perhaps the 
 loss of the finger to which the patient may have to submit. 
 
 In the ordinary progress of abscess, the majority of the surrounding tex- 
 tures are pushed aside, and the pus approaches the surface, where a point 
 is destroyed by ulceration, and the matter evacuated. But if nature be 
 balked in her endeavors by resisting textures, as the sheaths of tendons 
 and periosteum, the pressure is increased to a dangerous degree at various 
 points, areolar tissue is broken up, muscles are detached, bone ulcerates 
 and dies, bloodvessels perforate, joints stiffen, and are rendered useless ; 
 therefore, although medicine may relieve pain, hasten suppuration, and, 
 after the evacuation of matter, exert a controlling influence over the process 
 of granulation and cicatrization, still the knife must be employed ; it must 
 penetrate the periosteum down to the bone, and must be used early. 
 
 The toughness of the integuments, and the high grade of inflammation 
 that are present in panaritia, render the incisions very painful. It is, there- 
 fore, better before dividing the integuments, thoroughly to freeze the parts 
 with ether or rhigolene spray, and then operate quickly with a very keen- 
 edged knife. The surgeon must do his work thoroughly. 
 
 A whitlow may be prevented 'if, as soon as pain and the inflammation are 
 perceived, the skin of an egg which has been boiled be wrapped around the 
 affected part. At first the patient will experience aggravation of the symp- 
 toms, but if the application be allowed to remain, or perhaps applied at in- 
 tervals, the affection will often be arrested. Electricity is also said to prevent 
 and cure the disease. 
 
 Another preventive treatment, which is very efficacious, is to envelop the 
 parts as soon as they commence to swell, with a compress saturated with 
 the tincture of lobelia, and renew the application every two hours. I have 
 employed the nitric acid treatment, first recommended by Dr. Hirsch, of 
 Prague,* but have been disappointed with it. 
 
 There is another point to which I would call attention in the treatment, 
 
 * British Journal of Homoeopathy, vol. xxi., p. 218. 
 
414 A SYSTEM OF SURGERY. 
 
 viz. : the importance of cutting away with the scissors the indurated and 
 horny epidermis which has been loosened by the violence of the inflamma- 
 tory action. This much relieves the patient. 
 
 Lupus. — Dermatologists have made several classifications of lupus, some 
 of which are mentioned in this chapter, but the most simple division for all 
 practical purposes is into lupus exedens, in which the ulceration involves 
 both the integument and the subjacent structures, and the non exedens, where 
 there are extensive changes in the structure of the skin, without much con- 
 secutive ulceration ; the former, no doubt, is a variety of the cancroid ; the 
 latter is known by the older authorities as the serpiginous ulcer ; it has also 
 received the name rodent ulcer; while the former variety is called noli-me- 
 tangere, or the corroding xdcer of Clark. 
 
 Lupus Exedens first appears in the form of a tubercle (by some derma- 
 tologists it is classified with the tuberculous diseases) on the alaof the nose ; 
 it is hard and dusky red, quite sore, the soreness sometimes extending into 
 the nostril. After a time ulceration commences, and a scab forms. It then 
 begins to spread with alarming rapidity, and assumes that especial type of 
 the disease known as vorax. 
 
 There are several important diagnostic marks, which it is necessary to 
 observe, and in which this disease differs from cancer. 
 
 A peculiarity of the affection is, that it may continue for years, making 
 the most horrible inroads upon the structures which it attacks, and yet the 
 constitution suffer but slightly, thereby differing greatly from cancer, in 
 which there generally is that terrible nervous irritation which often, breaks 
 down the system. 
 
 If we examine the parts attacked, they are covered by a dark-brown or 
 blackish scab, and the surrounding integument adjoining the ulceration is 
 apparently healthy. There are two other diagnostic marks. In cancer, the 
 surrounding parts are infiltrated and red, and are filled with cancer cells. 
 In lupus there is no great redness around the chasm, and scarcely any odor 
 from the ulceration, which is cleanly cut. All these appearances are very 
 different in cancer, and in syphilitic affections, or in Greek elephantiasis, 
 for which the disorder may sometimes be mistaken. The chief character- 
 istics are : 
 
 1st. The lack of constitutional irritation. 
 
 2d. The dark-brown or blackish crust. 
 
 3d. The healthiness of the integument up to the very margin of the sore. 
 
 4th. The absence of swelling and redness. 
 
 5th. Absence of fetor. (Comparative.) 
 
 6th. The location of the disease. 
 
 Lupus non exedens may appear on the face and chest, and spreads in a 
 serpiginous manner, or extends to one portion of the integument while that 
 portion first attacked is healing. 
 
 According to Professor Volkmann, of Halle, a distinguished teacher, lupus 
 may be associated with a scrofulous taint ; in other words, with enlarge- 
 ment of the glands, and he has " had to deplore the loss of patients by 
 tuberculosis," although it cannot be said to be a malignant scrofulosis, as 
 classed by Bazin. 
 
 Virchow points out the relation of white swelling of the joints (tumor 
 albus articulorum) with certain forms of lupus, although, as yet, perhaps 
 sufficient demonstrations of the fact have not been collected. Lupus is sep- 
 arate and distinct from syphilis, and can never be classed in the same cate- 
 gory- 
 
 Hypertrophic lupus is a variety of the disease, in which parts may be 
 covered with bluish, knobby, and warty swellings. These may ulcerate, 
 
lupus. 415 
 
 and are frequently covered with the black crust which is so often a mark of 
 the disease. 
 
 It is a disputed point, whether such a form of lupus may not become 
 cancroid or develop into cancer, and some authorities have supposed that 
 they could trace distinctly the transformation of lupus to carcinoma, and 
 have thereby endeavored to establish the epithelial nature of the affection. 
 This can, at present, scarcely be allowed; and the fact that lupus, even after 
 existing for a quarter of a century, may cure itself spontaneously, is an 
 argument against its cancerous admixture. 
 
 Microscopic Appearances of Lupoid Tissue. — As usual the microscopists are 
 at variance regarding the pathology of lupus ; some declaring that it is 
 essentially tuberculous in its nature, others as strenuously maintaining that 
 it is not. The former announce that, as the tubercle bacillus of Koch is 
 found in lupus, therefore the true nature of the affection is declared. The 
 latter deny that such discovery has been made, and, therefore, persist in clas- 
 sifying lupus as a non-tubercular disease. The question is, at present, far 
 from settled. Dr. Morrison, in an excellent paper on this subject,* after de- 
 tailing his own and the experiments of others in the inoculation of the lupus 
 virus in animals, says : " In these there need be no question of a bacillus, as 
 
 Pig. 205. 
 
 The Author's case of Lupus exedens 
 
 the cause of the disease. The material inoculated may contain any un- 
 known virus, but should, whatever this may be, produce the specific disease. 
 This, lupus does not do with sufficient promptness to warrant us classing 
 it as tuberculous, and, although Cornil suggests, that it may be a kind of 
 attenuated tuberculosis, yet the clinical fact, that those affected with lupus 
 are not necessarily exempt from tuberculosis, makes one skeptical, a priori, 
 as to the success of the proposed experiments." 
 
 Lupus, therefore, may be considered in all its relations as an inflamma- 
 tory process, which emanates from the connective tissue, and is found to 
 
 American Journal of the Medical Sciences, April, 1884. 
 
416 A SYSTEM OF SURGERY. 
 
 consist in a large amount of granulating cells, which, from pressure and 
 infiltration of the parts, destroy the elements of the cutis. 
 
 There are other varieties mentioned by authors, all partaking more or 
 less of the same characteristics. Thus, we find that Cazenave mentions the 
 lupus erythematodes, which, like other forms of the disease, appears upon the 
 face, as small, scarlet and slightly swollen spots, which may or may not 
 become confluent. These points are covered by scales, which are thin, dark- 
 colored, and very closely adherent to the parts beneath them, and consist 
 mostly of secretion from the sebaceous glands, which, from constant irrita- 
 tion, pour out a much-increased discharge, which becomes commingled with 
 the epidermic scales. If these layers, so formed, be removed or scooged 
 out, the skin beneath is red, and its papillae appear elevated, resembling 
 warty excrescences. 
 
 Dr. Piffard* thus writes : " If we remove portions of lupus tissue, and 
 harden, slice, and stain them with carmine, we shall find, on microscopical 
 examination of the stained slices, very notable deviations from the appear- 
 ances presented by the normal tissues. The prevailing feature in all cases 
 is an infiltration of small round cells, resembling the colorless corpuscles 
 of the blood. This infiltration may be simply diffuse, or diffuse with the 
 addition of certain other cells of peculiar appearance. These are many 
 times larger than the small round cells, are polynucleated, and on account 
 of their size have received the name of giant-cells. Lastly, the small round 
 cells, instead of being diffusely infiltrated, are collected into certain little 
 clumps or heaps. These three principal histological types found in lupus 
 correspond to three pretty distinctly marked clinical varieties, which differ 
 widely in their appearance, course, and prognosis. 
 
 " In comparing the microscopical appearances with the cases from which 
 the specimens are derived, we find : First, that the diffuse infiltration cor- 
 responds to the superficial forms of lupus, in which ulceration never occurs ; 
 second, that the infiltration associated with giant-cells occurs in the deeper 
 forms, with ulceration and destruction of the entire thickness of the skin ; 
 and thirdly, that the ' cell-heaps ' are met with in cases tnat also invade the 
 deeper tissues beneath the skin. The diffuse, small, round-cell infiltration 
 met with in superficial lupus cannot be distinguished microscopically from 
 small-cell infiltration in other affections, for we may find identical appear- 
 ances in syphilis, and even in simple inflammation. In the deeper cuta- 
 neous lupus, characterized by the diffuse infiltration plus giant-cells, we 
 again find nothing peculiar, as giant-cells are met with in many scrofulous 
 hyperplasias, in syphilis, and even in normal infantile bone-marrow. The 
 cell-heaps, however, that we find in the deeply ulcerating form are peculiar 
 to lupus, not having been found elsewhere, so far as I am aware. From 
 this we see that there is but a single histological appearance that can with 
 propriety be regarded as peculiar, and this is met with in but a small min- 
 ority of cases." 
 
 The illustration on preceding page (Fig. 205) represents a man who Was 
 under my treatment for a length of time in the Good Samaritan Hospital. 
 The patient was sixty-two years of age, and the disease had existed for over 
 a dozen years. The entire right half of his face had been devoured by the 
 lupus. Bone, muscles, arteries, veins, and nerves disappeared under the 
 action of the disease. The superior maxillary and turbinated bones, the 
 lower rim of the orbit and floor of the same, the septum and ala of the nose 
 were eaten through, leaving a distinct view of the superior maxillary and 
 palate bones of the left side. Yet even under this terrible deformity, at 
 
 * Certain Points Relating to the Nature and Treatment of Lupus, by Henry G. Piffard, 
 A.M., M.D., Albany, 1877. 
 
lupus. 417 
 
 times the patient was comparatively comfortable. He rode with me a con- 
 siderable distance to have his photograph taken ; appeared before the classes 
 at the hospital, and gave a detailed account of his disease, its duration, and 
 its ravages. 
 
 The medicines that have been recommended for lupus are not many, and 
 those that have been used have not, so far as I can learn, been productive 
 of very good effect. It may be that lupus exedens especially, is not a 
 constitutional disease, or that the constitution only becomes implicated 
 after the long duration of the local disorder. If this be so, then as we treat 
 the chancroid, so we should deal with lupus ; indeed, from the success which 
 has attended upon this method of treatment in the hands of Volkmann 
 and Dr. Piffard, such a supposition may be correct. At all events, it is cer- 
 tainly worth a trial. 
 
 In the case to which I have just alluded, I gave with apparent benefit for 
 the time, a weak solution of the chloride of zinc. The patient stated that 
 he thought the medicine benefited him, and really for a time the ravages, 
 if they did not cease, were not nearly so rapid or successive. 
 
 I then tried acetic acid, pure, five drops in a teaspoonful of water, to be 
 taken three times each day, and dressed the cavity with a solution of car- 
 bolic acid and glycerin. 
 
 In another case which came under my observation, I tried lycopodium, 
 the thirtieth trituration, and from the report of Dr. West, under whose care 
 the patient came, I learned that beneficial action was produced for the time. 
 
 Dr. Von Meyer reports a case of lupus non exedens cured by apis. 
 
 Dr. Andouit* details a pase of lupus exedens of the nose treated with hydro- 
 cotyle. The patient commenced taking it February 14th, and on the 23d 
 of July was cured. 
 
 The local treatment of lupus is of as much import as internal medica- 
 tion, because, like the chancroid, in many instances it does not affect the 
 constitution, and the treatment must be not only to destroy the nodules, 
 which in reality belong to the disease, but to restore those tissues which 
 may have been but slightly infiltrated, and great watchfulness and patience 
 must be maintained by both surgeon and patient, to procure a successful 
 result. Relapses, which are frequent, must be guarded against, and the 
 disease again immediately attacked when it begins to manifest itself. The 
 caustics which are in most common use are caustic potash, the nitrate 
 of silver, and chloride of zinc. Before, however, these can be applied with 
 any benefit, the crusts must be soaked off from the sores by olive or cod- 
 liver oil, and then the caustic (if it be potash or nitrate of silver, the solid 
 stick may be used ; if the chloride of zinc, equal parts of that and of flour) 
 should be thoroughly applied ; a very important consideration in the appli- 
 cation of the zinc or potash is not to allow them to act too long, or the 
 healthy tissues which lie beneath the disease may be eaten away also. 
 
 The lupous tissue gives way beneath the action of the caustic, and exudes, 
 and must be wiped away, and when this action ceases, then for the present 
 the application of the caustic must be dispensed with. 
 
 Manet's paste, which, containing arsenic, is dreadfully severe, is not 
 much in vogue at present, that of Hebra taking its place. The formula is : 
 Arsenicum alb., one part; cinnabar, three parts; unguentum picis liquidse, 
 twenty-five parts. 
 
 This may he used for three or four days after the true lupus has been 
 mostly removed, or in the type known as the non-exedens ; the tissues, 
 which, though not ulcerated, are infiltrated, and of a bluish-red color, must 
 be carefully washed with a solution of nitrate of silver. 
 
 * British Journal of Homoeopathy, 1858, pp. 585, 586. 
 27 
 
418 A SYSTEM OF SURGERY. 
 
 Dr. Piffard's treatment consists in thoroughly scraping out as much as 
 possible of the diseased parts, and cauterizing the entire surface and mar- 
 gins of the sore with the actual cautery at a white heat. 
 
 The treatment above recommended has been found useful in certain cases 
 of lupus, but Professor Volkmann has introduced another method, which, 
 according to his testimony, is superior to all others. The operations are 
 very painful, and ether should be used ; then the soft lupus degenerations 
 should be scraped away with a sharp-edged knife, and the infiltrated, and 
 hard and bluish, though non-ulcerated nodules, must be attacked with 
 "multiple-pointed scarification." This is performed with a very sharp- 
 pointed small-bladed knife; hundreds or thousands of points are made 
 closely together, about two lines deep, or deeper in the diseased part of 
 the skin, which frequently looks discolored after the pricking, or like 
 chopped meat, or perfectly white, but he never saw gangrene result. The 
 pricked places are then covered with lint, which is closely pressed in to 
 stop the bleeding, and left to its spontaneous falling off. These punctures 
 are repeated at intervals of from two to four weeks, five or even eight 
 times. At first the knife enters easily the luxuriant tissues, interwoven 
 by cellular granulations ; after a while, it finds more and more resistance, 
 the skin becomes tougher, and loses its abnormal swelling and redness. 
 
 Fig. 206. 
 
 Dr. Neumann's Apparatus for Galvano-Puncture. 
 
 Professor Volkmann states that no lupus has resisted this method, and 
 the cure, in most cases, was very rapidly accomplished, and that many 
 have been cured in less than eight weeks, after resisting for years all other treat- 
 ment. 
 
 Dr. Neumann has invented an instrument by which the galva no-punc- 
 ture is very readily applied. Fig. 206 represents the apparatus and the 
 method of its application. 
 
 I have tried both the treatment of Dr. Piffard and that of Volkmann, and 
 in some cases have repeated the operation several times, but must say that 
 though the progress of the disease was arrested for a time, yet in no in- 
 stance was a cure effected. 
 
 In this connection I desire to invite attention to the Hydrocotyle Asiatica , 
 a plant long known as an Indian remedy, and which acquired great repu- 
 tation in the hands of Dr. Boileau, resident in Mauritius. A plant in 
 
ELEPHANTIASIS ARABUM. 
 
 419 
 
 his own garden, which he named Bevilaqua, was ascertained to be the Hy- 
 drocotyle Asiatica, known in America by the name of Chinchunchilly. 
 The doctor treated with it fifty-seven persons suffering from lupus. In all, 
 without exception, the disease was arrested, and in a very short time. 
 
 Dr. Popeau, the successor of Dr. Boileau, treated successfully a case of 
 Arabian elephantiasis, of three years' duration, with the same medicine.* 
 
 Veielf highly recommends scraping away the tissue and applying chlor- 
 acetic acid. He states that for small superficial patches a single application 
 suffices. 
 
 " Larger and deeper places are best treated by boring the acid into them 
 with a glass rod, and treating the wound after the crust falls by mild cau- 
 terization with chloride of zinc. In this way he succeeded in perfectly heal- 
 ing a lupus superficialis, which covered a large part of the upper arm. The 
 
 acid is of great service also in de- 
 
 FlG. 207. 
 
 
 stroying the projecting cicatricial 
 cords which sometimes follow the 
 cure of lupus, employing between 
 the cauterization the emplastrum 
 cinereum. 
 
 " In lupus erythematosus good 
 results were obtained in some cases 
 by the repeated use of an ointment 
 of biniodide of mercury, one part to 
 five. Scarification with subsequent 
 cauterization with chloride of zinc 
 also produced a cure." 
 
 Elephantiasis Arabum. — Hyper- 
 trophy of the skin and cellular tis- 
 sue is a variety of hypertrophic 
 tumor rarely seen in this country or 
 in Europe, but is quite prevalent in 
 tropical regions. It is described by 
 Paget as a " fibro-cellular cutaneous 
 outgrowth." Some authors regard 
 it as a variety of fibrous tumor. 
 
 In this disease the skin and cel- 
 lular tissue become enormously 
 thickened (vide Fig. 207) ; the mus- 
 cles waste and pass into a state of 
 fatty degeneration, and the blood- 
 vessels and nerves are generally en- 
 larged. It attacks by preference the 
 
 lower extremities, but is also found in other parts of the body. Elephanti- 
 asis of the scrotum, the " pendulous sarcoma " of some authors, is quite 
 common in the East Indies ; and Gross cites a case in which this scrotal 
 hypertrophy attained the weight of 102 pounds. The accompanying 
 figure, taken from a photograph, represents the enormous size to which 
 the scrotum may attain. It is the well-known case of Isaac Newton. The 
 tumor, when the patient is standing, measures in its long diameter, from 
 the symphysis pubis to the preputial orifice, in a direct line, twenty-eight 
 inches; when sitting, the tumor resting on the floor or bed, twenty-six 
 inches. In the sitting posture the transverse diameter is twenty -two inches, 
 
 * British Journal of Homoeopathy, vol. xvi., p. 463. 
 f Boston Med. and Surgical Journal, Dec. 7th, 1876. 
 
420 A SYSTEM OF SURGERY. 
 
 and the anteroposterior seven inches ; the circumference fifty -two inches, 
 and the weight sixty pounds. 
 
 Dr. Andouit, in his proving of the Hydrocotyle Asiatica, with clinical 
 remarks thereon, relates a case of elephantiasis of the Greeks (Lepra tuber cu- 
 leuse d'Alibert). After an unsatisfactory use of graphites, petrol., phosph., 
 and arsen., he resorted to hydrocotyle 6 , 25 centigrams in 125 grams of water, a 
 teaspoonful every morning. Its administration was commenced on the 28th 
 of January, 1856, and the patient was perfectly cured by the 31st of March. 
 
 During the winter of 1873, a patient was brought by Dr. Moses to my 
 clinic at the college, who had suffered for a considerable period with ele- 
 phantiasis of the leg. The measurement around the calf was somewhat 
 over twenty-eight inches, and a mole on the inner side of the leg, which was 
 formerly about a quarter of an inch in diameter, had enormously enlarged, 
 presenting an appearance resembling somewhat in color an encephaloid. 
 At my suggestion she was placed under hydrocotyle, and after having used 
 the medicine for a time, complained of burning and shooting sensations 
 through the affected part. After a continuation of the treatment for a 
 longer period, the limb diminished two inches in circumference. She con- 
 tinued under treatment for several months, with gradual diminution of the 
 parts, but ultimately removed from the city. 
 
 Dr. J. M. Carnochan, of New York, reports three cases of elephantiasis of 
 the leg, which were treated by ligating the femoral artery. In one of these* 
 the ligature came away from the femoral on the eleventh day, with second- 
 ary haemorrhage, for the arrest of which the external iliac was ligated by 
 Dr. A. E. Hossack. 
 
 In 1857, Dr. Campbell, of Philadelphia, performed a similar operation 
 but without satisfactory result. It is a question, however, whether such sur- 
 gical interference can, as a general rule, be justified. 
 
 Dr. Dayf gives us the results of a post-mortem examination of a fatal 
 case of lymphatic elephantiasis arabum as follows : There was no evidence 
 of any obstruction of the femoral vein, and, apparently, no enlargement of 
 the arterial or venous trunks ; though it seemed probable that some disturb- 
 ance took place owing to the heat of the limb, pain, and swelling, and those 
 changes which ensued after the fatal seizure. The affected limb grew in 
 length, in which this case differed from others, although a somewhat similar 
 one is said to have been reported by Dujardin in 1854. The above results 
 are negative, on account of our limited knowledge of the pathology of the 
 lymphatic system. 
 
 By Keloid is understood a fibro-plastic growth of the integument, which 
 is characterized by elevations varying in size from that of a pea to that of 
 a bean, which are grouped together in grotesque forms. Sometimes this 
 grouping is imagined to resemble a crab, hence the name keloid. This 
 disease may appear on any or all parts of the body. The elevations are at 
 times the color of the surrounding skin, or they are either darker or lighter. 
 They are quite firm, somewhat elastic, and in the majority of instances 
 ovoid. Their number and extent of surface are often remarkable, and 
 though they at times are very large, there appears no tendency to malignant 
 degeneration. Most writers recognize two varieties of the affection, which 
 they denominate the true and the spurious, the latter arising from a cicatrix 
 from a wound or burn ; the former appearing without any previous lesion 
 or injury. Dr. Hamilton^ has known the growth to appear after excision 
 of fatty tumors and injuries. Dr. Gross, however, declares such a division 
 
 * New York Journal of Medicine, 1852. 
 
 f The Medical Record, Jan. 25th, 1879, No. 429. 
 
 % The Principles and Practice of Surgery, 1872, p. 501. 
 
MALIGNANT PUSTULE. 421 
 
 to be arbitrary, " the structure in both of the so-called varieties being per- 
 fectly identical."* The symptoms are chiefly itching and burning. 
 
 The treatment, both medical and surgical, is unsatisfactory. Excision 
 has, in some instances, been attempted with relief, but generally the disease 
 returns in a short time after operation. An aggravated case of multiple 
 keloids, which were removed at the Cook County Hospital, Chicago, by Dr. 
 Henry Sherry ,f will repay perusal. Several operations are sometimes nec- 
 essary, and may be performed with the ecraseur. 
 
 Malignant Pustule. — This affection, termed also by the French, charbon, 
 is a septic disease of the subcutaneous cellular tissue, in which a rapid 
 tendency to gangrene is prominent. It is a disease of ancient origin, and 
 was confounded by older writers with carbuncle. It is generated in men 
 from an animal poison, sui generis, developed in cattle suffering with mur- 
 rain, those persons being most frequently attacked who labor in tanyards, 
 or are employed in removing offal. It is also frequently found in steve- 
 dores who are employed in handling hides and the horns of cattle imported 
 from localities where cattle diseases have prevailed. 
 
 Upon subjecting the discharges to the microscope, the bacillus anthracis 
 is easily seen ; it consists of a rod or a filament, which varies in length 
 from y^-g-Q to -g-rro" °f an inch, and in breadth is about y-j-Juir 0I> an inch. In 
 the one specimen which I had an opportunity of examining, these fila- 
 ments were curved, and, in some instances, looped upon themselves. This 
 bacillus was discovered in 1849 by Pollender. Davaine gave the germ the 
 name of bacteridium, but to Cohn is attributed the honor of classifying 
 and arranging the anthrax bacillus. 
 
 The parts of the body most liable to be affected are the face, hands, arms, 
 and neck, where it first appears as a swelling, painful and hard, which, after 
 a few days, shows a purple spot in its centre. A blister soon forms, accom- 
 panied with itching, which, in about thirty-six hours, disappears, and the 
 part becomes dry and livid. Around this purple spot there soon forms an 
 inflamed areola, which is covered with vesicles in size varying from a millet- 
 seed to a grain of wheat. The surrounding structures are hard and painful 
 to the touch, and become very much swollen, which receives the name of 
 the anthrax oedema, cedema matin, or anthrax erj^sipelas ; while on the other 
 hand, the pain may be so slight as to give rise to no inconvenience. This 
 symptom, viz., the absence of severe pain in the disease, which is so different 
 from other violent inflammations, may be regarded as diagnostic. There 
 is likewise considerable oedema of the parts, especially the face, which is 
 distorted by the swelling. During this time the constitution shows the 
 usual signs of septicaemia ; the pulse is irritable ; the patient complains of 
 a feeling of weariness and exhaustion ; there is anorexia with sleeplessness. 
 As the disease progresses, the symptoms of gangrene become more and more 
 apparent, and the sphacelus spreads from the centre to the circumference of 
 the tumor ; the discharge is thin, fetid, and acrid ; fainting, sweats, pinched 
 features, and parched skin, plainly evince rapid exhaustion of the vital 
 powers, and the patient dies in from five to eight days from the commence- 
 ment of the attack. If, however, instead of gangrenous symptoms being 
 immediate, there is a tendency to suppuration, the prognosis may be con- 
 sidered more favorable. In such instances the pulse becomes less irritable, 
 there is moderate perspiration, a softer skin, a cleaner tongue, and the separa- 
 tion and casting off of the dead portions. In such cases the patients recover. 
 
 General or Internal Malignant Pustule. — The bacillus anthracis maybe in- 
 troduced within the system as well as being developed locally, or, indeed, 
 
 * Gross's System of Surgery, vol. i., p. 731. 
 f The Medical Current, July 15th, 1886. 
 
422 A SYSTEM OF SURGERY. 
 
 the poison may produce most severe constitutional symptoms, without any 
 of the local manifestations being developed. These symptoms constitute the 
 affection known as fievre charbonneuse, anihracsemia, or mycosis intestinalis. The 
 disease is also named according to the vocation of the persons who are 
 affected — thus, " wool-sorters' disease," " tanners' disease," etc. There are 
 no especial lesions noticed in this affection ; the main features at the outset 
 being those of coldness, shivering, and general malaise, followed by the most 
 intense prostration, often accompanied by vomiting, and sometimes by 
 delirium and subsultus tendinum. If the pulmonary organs suffer, the 
 symptoms resemble those of pneumonia ; and if the intestines are affected, 
 the manifestations are of the worse forms of enteritis. The prostration 
 is a well-marked symptom, and is often accompanied with haemorrhages 
 from nose and mouth, and profuse diarrhoea ; cyanosis and collapse occur 
 often in a few hours, and death takes place in from two to five days. 
 
 Treatment. — As soon as a person is supposed to have been inoculated 
 with the poison, immediate destruction of the part should be the aim of 
 the surgeon. It may be either freely removed by the knife, or by the appli- 
 cation of the actual cautery. The sore occasioned thereby should be thor- 
 oughly cleansed by carbolic acid spray from an appropriate atomizer, and 
 then covered with marine lint. This should be repeated every three or 
 four hours. In the meantime a large quantity of stimulus, in the form of 
 porter or ale, should be given, even as often as every hour or two, and the 
 medicine most specific, lachesis, should be given in frequent doses. Arseni- 
 cum is also indicated when there is excessive restlessness. 
 
 Dr. Dunham speaks very highly of lachesis in the disease,* and has 
 related to me a successful case in which this medicine was used with great 
 advantage, together with stimulants. He says, in a note to me upon the 
 subject, " I have pushed food and stimulants with the greatest zeal, prefer- 
 ring Dublin porter to every other form of stimulant, finding that beverage 
 more preferred by patients. I have used in some cases, and did in the case 
 I narrated to you, urge and compel the patient to drink at least a bottle of 
 Dublin porter every two hours, until the pulse revived, and the restlessness 
 subsided." 
 
 Arum triphyllum has also been suggested in the disease. I have never had 
 a marked, case under my care, and can say nothing regarding the treatment 
 from individual experience, but should suppose from the general character 
 of the symptoms, that besides pushing stimulants to their fullest extent, 
 the patient should be given arsenic, sulpho-carbolate of soda, or the hypo- 
 sulphite of soda in large doses. 
 
 Morbid Growths upon the Skin. — Many growths are developed in the skin 
 and cellular tissue, some of which are innocent, others of a malignant 
 character. Among the former are: 
 
 Verrucse, Warts. — These are elevations caused by a hypertrophic condi- 
 tion of the papillae, and sometimes of the subcutaneous cellular tissue. 
 The seat of such growths is commonly the hand, less often the face, lips, 
 and other portions of the body. They are not confined to any period of 
 life, but are most frequent during childhood and youth. Marc relates the 
 case of a woman whose fingers were covered with warts after an apoplectic 
 attack. Cruveilhier informs us that M. Brunei showed him a warty band 
 on the dorsum of the hand, assuring him that it had sprung up on the 
 line of the stream of blood which followed the removal of one of these 
 excrescences. 
 
 Sometimes warts appear to be contagious, at others no such origin can be 
 assigned. It is, however, certain that some persons have a predisposition 
 
 * Vide Am. Horn. Review, vol. iv., p. 110. 
 
BED-SORES. 423 
 
 to warts, and to their reappearance after excision or removal by caustic. 
 The growths very frequently disappear spontaneously, and many persons 
 bear testimony of remarkable cures having been effected by ''charms," 
 " amulets," and other extraordinary means. 
 
 Treatment. — In the first place it may be emphatically declared that it 
 is never necessary to apply either nitric acid or lunar caustic, the routine 
 practice formerly pursued. Internal medication is the most certain means 
 for the eradication of warts. To accomplish this end the medicines are 
 calcarea, causticum, dulcamara, natrum mur., nit. acid, rhus tox., sepia, 
 thuja, and sulphur. 
 
 I have often succeeded in the removal of warts by giving calcarea, 3d 
 trituration, 2 grains every night for a week, and following it with thuja, 3d 
 dilution, 2 drops night and morning, and applying thuja in tincture to the 
 wart at night. Should other symptoms call for other medicines they may 
 have to be employed, and those most likely to be adapted will be rhus, 
 causticum, or sepia. 
 
 It may truthfully be asserted that cures seldom fail to follow the admin- 
 istration of one or other of these medicines. If the warts be pedunculated, 
 thuja is the specific, and sometimes exercises a marvellous power. 
 
 Bed-sores. — This most troublesome and often disgusting concomitant of 
 long confinement to bed in one position, is always difficult to manage and re- 
 quires watchfulness and perseverance on the part of both the surgeon and 
 the nurse. Like the perforating ulcer of the foot, this affection has been 
 proved by Charcot to be a neurosis, produced by pressure on the peripheral 
 extremities of the sensitive nerves. The vaso-motor system is partially 
 paralyzed in its action, the parts are gradually deprived of their nutrition, 
 the inflammatory process is set up, which is speedily followed by sloughing 
 and gangrene. The first evidence of a bed-sore is a redness of the integu- 
 ment covering a protuberance of bone, or on a spot where there has been 
 much pressure. This redness receives the name paratrimma. Bed-sores are 
 generally met with about the sacrum and along the spinal column. At their 
 commencement, itching, burning, and pricking sensations are experienced. 
 Sloughs of a blackish hue and fetid odor sooner or later are discharged. In 
 some instances the bony structure becomes implicated. 
 
 Treatment. — The first consideration is to lessen the amount of pressure. 
 This end is best attained by the use of circular air-cushions. The parts 
 are to be carefully washed with a weak solution of arnica. Some prefer 
 them to be sprayed with Richardson's 100th of carbolic acid. Occasionally 
 a poultice may be applied, to hasten the separation of the slough, which 
 being removed, the very best application is the carbolated calendula. For 
 the bed-sore, internal medication can seldom be resorted to, the patients 
 being already under treatment for the diseases which confine them to their 
 beds. 
 
 Dr. Brown-Sequard's treatment of bed-sores is both successful and simple. 
 It consists in applying sponges, alternately wetted with hot and cold water, 
 to the sores. Each sponge should be allowed to remain upon the part for 
 about one minute, and the entire time occupied should be about ten minutes 
 or a quarter of an hour. 
 
 Crussel, of St. Petersburg, recommended galvanism; and in 1859, Mr. 
 Spencer Wells also advocated it. Of it Dr. Hammond writes : " During 
 the last six years I have employed it to a great extent in the treatment of 
 bed-sores, caused by diseases of the spinal cord, and with scarcely a failure, 
 indeed, I may say without any failure, except in two cases, where deep 
 sinuses had formed which could not be reached by the apparatus. A thin 
 silver plate, no thicker than a sheet of paper, is cut to the exact size and 
 shape of the bed-sore, a zinc plate of about the same size is connected with 
 
424 A SYSTEM OF SURGERY. 
 
 the silver plate by a fine silver or copper wire six or eight inches in length ; 
 the silver plate is then placed in immediate contact with the bed-sore, and 
 the zinc plate on some part of the skin above, a piece of chamois skin soaked 
 in vinegar intervening : this must be kept moist, or there is little or no action 
 of the battery. Within a few hours the effect is perceptible, and in a day 
 or two the cure is complete in a great majority of cases. In a few instances 
 a longer time is required. I have frequently seen bed-sores three or four 
 inches in diameter, and half an inch deep, heal entirely over in forty-eight 
 hours. Mr. Spencer Wells states that he has often witnessed large ulcers 
 covered with granulations within twenty -four hours, and completely filled up 
 and cicatrization begun in forty-eight hours. During his recent visit to this 
 country, I informed him of my experience, and he reiterated his opinion, 
 that it was the best of all methods for treating ulcers of indolent character 
 and bed-sores." 
 
 Ingrowing Toe-nail. — It is scarcely necessary to describe this affection, 
 it is so well known. Those who are in the habit of wearing tight boots 
 or pointed shoes are liable, from the pressure, preventing the nail growing 
 in a proper direction, to suffer from the complaint. Or the cause may be 
 that the soft parts are pressed up over the sides of the nail, thus giving rise 
 to the affection. Sometimes the cuticle may collect under the edge of 
 the nail and cause inflammatory action. This terminates in ulceration, 
 the matrix becomes affected, the cells lose their vitality, and the solution of 
 continuity is constantly kept up, a process of repair also being at the same 
 time carried on. The toe becomes excessively sensitive, and often swollen ; 
 there is a constant but scanty discharge, and the patient suffers continu- 
 ously. 
 
 Treatment. — In the earlier stages, scrape away in a line from the matrix 
 to the extremity of the nail the external layer of cells, which are never 
 nucleated. When we reach the middle layer, in which are nuclei, there 
 will be sensitiveness. So soon as this is noticed, desist, and cut a deep 
 notch at the extremity of the nail. Then partially raise the ingrowing 
 parts with the probe, and insert under them small bits of tinfoil. Direct 
 the patient to cut a hole in the end of the boot to prevent further pressure ; 
 continue the scraping and notching for several weeks, and success will gene- 
 rally be the result. If, however, the stage of ulceration has been reached, 
 and the complaint has lasted for some time, a plan which I have found 
 very efficacious is to shave off the cuticle on each side of the nail, and raise 
 the ingrowing ends. Dress the wound with calendula and remove pressure. 
 Dr. McDonald informs me that he has found much success in splitting the 
 nail, withdrawing it, and then with a pair of fine scissors, curved on the 
 flat, dissecting carefully away the entire matrix. This makes a perfect 
 cure, and there is no likelihood of a recurrence of the trouble, as the nail is 
 not reproduced, although a horny growth appears in its place. Dr. Talbot,* 
 of Boston, prepares a small plate of silver, " about a quarter of an inch wide 
 and an inch in length. The edges should be made very smooth, and 
 slightly rounded. About one-sixteenth of an inch from one end should be 
 turned over upon itself, making a kind of hook. This hook should be 
 passed down the edge of the nail until it reaches the lower corner ; then, 
 by simply bending the silver plate over the fungus and outer side to the 
 under part of the toe and fastening it in place by a little adhesive plaster, 
 it will have accomplished three purposes : 1. The covering of the edge of 
 the nail so as to protect the inflamed part. 2. The raising of the nail to its 
 proper position ; and 3. By pressing down the granulations, the concealed 
 ulcer becomes open, and the discharge therefrom is not prevented." 
 
 * New England Medical Gazette, January, 1877, p. 10. 
 
ONYCHIA. 425 
 
 Dr. J. O'Neal* proposes, speaking from personal experience, to first pour 
 a few drops of liquor potassse on the ulceration. This renders the nail more 
 flexible and reduces the unhealthy granulations, although at first a good 
 deal of pain is experienced by its application. Then gently raise the im- 
 bedded nail and insert under it a piece of thin velvet cork. It is this sub- 
 stance, elastic and not absorbent, which is said to constitute the superiority 
 of the treatment. 
 
 My friend, Dr. Terry, of Utica, has been very successful in the treatment, 
 which I give in his own words from a letter written me on the subject : 
 
 " The substance of the treatment which I have found comparatively pain- 
 less is this: R. Liquor potassa 1 part, to water 4 parts. With the flat end 
 of a director, or any thin narrow blade without edge, insert absorbent cotton 
 under, over, and above the edge of the nail, allowing it to spread over the 
 ulcerated hypertrophied tissue should there be any. If the cotton be prop- 
 erly applied the cutting edge of the nail is slightly elevated and perfectly 
 separated from the swollen tissue at the side and above the nail. Next 
 apply with a camel's hair brush collodion over the cotton and inflamed 
 hypertrophied surface. Use it freely, as by so doing it presses the blood 
 from the part, causes the swollen tissue to draw away from the nail, and 
 effects a speedy obliteration of the granulation. Lastly, with a long narrow 
 strip of surgical isinglass plaster attach an end as close to the nail on the 
 swollen part as possible, and bring it around the toe two or three times, 
 drawing the hypertrophy away as best you can. If the case is a very bad 
 one, it will require from three to five dressings, which should not be changed 
 under fort}^-eight hours. The nail should never be cut in such manner that 
 the corner can push into the toe. Allow the nail to grow above the soft 
 tissue." 
 
 Cocaine should not be forgotten as a substance by which the ingrowing 
 toe-nail may be removed without pain. A few drops of a 4 per cent, solu- 
 tion of the hydrochlorate should be slowly injected into the furrow on 
 either side of the nail, and a cloth wet with a solution wrapped around the 
 toe and allowed to remain fifteen minutes. Dr. Porcher reports a successful 
 operation by this method. 
 
 Onychia. — This is a peculiar disorder, and one which is rare. It is said, 
 according to Mr. T. Smith, that it is chiefly found among children under 
 ten years of age, for among seven thousand surgical patients, only nine cases 
 of the disease were noted, and these occurred between the ages of one year 
 and seven. At one of my recent clinics I had a patient, a boy about fifteen, 
 suffering from the disease. It has generally been considered as an incurable 
 affection, and certainly is most intractable. In the opinion of some, it is 
 connected with hereditary syphilis, but Mr. MacCormack, who has given 
 some attention to the subject, could not find any such connection. The 
 ulcer is situated beneath the nail, is gray, ashy-looking, jagged, and irregu- 
 lar. The smell from comparatively so small a surface is intense. There 
 are often red unhealthy granulations scattered over the surface of the sore, 
 and the black uneven and jagged edge of the nail projects around it (Fig. 
 208). The entire last phalanx of the affected part is often blue and puffed, 
 and the pain is most intense and continuous, and is generally of a gnawing- 
 boring character, worse at night, preventing sleep and wearing away the 
 patient's strength. The disease continues for years, and I believe evulsion 
 of the nail, so often, practiced, rather aggravates than ameliorates the 
 suffering. 
 
 Treatment. — The entire matrix of the nail must be cut carefully away ? 
 simple evulsion will not do, and the ulcer must be rubbed with iodoform. 
 
 * Medical Record, vol. xii., p. 557. 
 
426 A SYSTEM OF SURGERY. 
 
 There is another treatment, which I think ought to be tried before re- 
 sorting to this painful procedure, and which in the hands of Professor 
 Vanzetti, of the University of Padua, has been followed with most remark- 
 able success. 
 
 He relates twelve cases cured by the application of the nitrate of lead. 
 The ulcer is sprinkled thoroughly with the nitrate, and after a day or two 
 
 Fig. 208. * Fig. 209. 
 
 Acute Onychia. Subungual Exostosis. 
 
 the crust that forms is removed ; the sore then assumes a more healthy ap- 
 pearance, the pain ceases shortly, the fetor diminishes, and within a week 
 sometimes, the cure is complete. 
 
 Subungual Exostosis.— Either from pressure of a boot or injury to the 
 last phalanx of the great toe, disease attacks the periosteum and bone, the 
 latter enlarges, presses up the under surface of the nail, giving rise to in- 
 tense suffering. The greater the pressure from below, the more sensitive 
 becomes the matrix, and in some instances the pain is excruciating. Ex- 
 cision of the diseased part is sometimes beneficial, but unless the entire 
 bone be removed at its articulation there is great probability that the 
 disease will return. Fk 209 gives a good representation of the affection. 
 
 Perforating Ulcer of the Foot. — Although this peculiar solution of conti- 
 nuity should scarcely be placed under diseases of the skin and cellular 
 tissue, yet for the sake of convenience I introduce a brief mention of it in 
 this place. 
 
 In this ulcer the ball of the foot is generally attacked, and no tissue 
 is spared by the abnormal process. Bones become carious, tendons are laid 
 bare, joints are opened, and the entire foot, after a time, is perforated, hence 
 the name of the disease. The ulcer, in the beginning of its invasion, is oval 
 in shape, with a singularly clean-cut margin and ragged base. There is not 
 much discharge, and although what there is, often is of disagreeable odor, it 
 is not particularly offensive. It has been stated by many writers that, like 
 bed-sores, these ulcers are occasioned by a degenerative lesion of the nerves 
 of the region on which they appear. On this subject, Dr. Michaux,* who 
 has given the subject some study, states that all perforating ulcers cannot 
 be assimilated with the ulcers found in muscular atrophy or locomotor- 
 ataxy, and that they should be divided into two categories : 
 
 1. Those ulcers which are symptomatic of diseases of the spinal cord, and 
 are accompanied by grave symptoms of constitutional disturbance, as numb- 
 ness and "paralysis. 
 
 2. The perforating ulcer of Nelaton, which is unaccompanied by any 
 such grave complications, but is merely a peripheric sclerosis of the pa- 
 pilla?. 
 
 * Monthly Abstract Med. Sciences, November, 1876. 
 
CONTUSIONS AND WOUNDS — THECITIS. 427 
 
 Treatment. — The best treatment locally for perforating ulcer is the thorough 
 application of the galvano-cautery, and after the slough has separated, to 
 treat the sore with electro-galvanism, after the manner already described in 
 the management of bed-sores. The best internal medicine is arsenicum, 
 and a drop (at least) of the tincture in a teaspoonful of water should be given 
 three times a week. Cod-liver oil and whiskey, taken in fair doses, will be 
 also of service. The treatment, however, is generally rather unsatisfactory. 
 
 CHAPTER XXIII. 
 
 INJURIES AND DISEASES OF THE MUSCLES, TENDONS, AND 
 
 BURS.E. 
 
 Contusions— Thecitis— Dislocations of Muscles and Tendons — Rupture of Mus- 
 cles and Tendons — Muscular Atrophy — Reflex Muscular Atrophy — Acute 
 and Chronic Bursitis — Ganglion— Sprains — Dupuytren's Contraction. 
 
 The muscles, with their attachments and bursse, are all liable to injuries 
 and diseases of more or less import, some trivial, others very severe. 
 
 Contusions and Wounds are very common, and are considered fully in the 
 chapters upon Contused and Lacerated Wounds. Inflammation often 
 attacks the sheaths of tendons and gives rise to a serious disease known as 
 Thecitis, a painful affection generally located about the hands and feet, and 
 is sometimes occasioned by a severe sprain, or by the spread of inflamma- 
 tory action of surrounding parts. There is no disease which occasions more 
 intense suffering and more serious constitutional disturbance, especially 
 when many tendons are involved. Pain and tenderness are first noticed 
 along the course of the affected tendons ; this suffering is aggravated during 
 the" night, and, as the disease progresses, becomes agonizing ; the pains are 
 burning, throbbing, and boring — the most gentle touch to the part, the 
 slightest movement, or, indeed, attempts to flex the fingers or toes, increasing 
 the suffering. The pain extends the entire length of the limb, which be- 
 comes stiff, the axillary and inguinal glands being involved. 
 
 Severe constitutional disturbance follows, and I have known delirium, 
 and even trismus, result. During the progress of the disease, the patient is 
 deprived of sleep, the appetite fails, and the extremity becomes attenuated, 
 stiff, and immovable. In a very severe case under my care, the disease was 
 brought on from the prick of a spicula of glass. This patient, it may be 
 remarked, was predisposed to the affection from long and constant practice 
 upon the piano. She experienced the most relief by placing the hand in 
 cold water, and allowing it to remain in it night and day. Neither poultices 
 nor other warm applications could be tolerated ; incisions afforded no relief, 
 and administration of anodynes was the only means that appeared to be in- 
 strumental in the preservation of her life. 
 
 Treatment. — In thecitis of an ordinary character, the medicines affording 
 the greatest prospect of relief are aconite, belladonna, bryonia, rhus tox., 
 ruta graveolens and gelseminum. The first, especially in the earlier stages, 
 will be serviceable. If, however, the disease does not yield, a selection must 
 be made from among the medicines just mentioned, to the choice of which 
 the symptoms in the Materia Medica will be the guide. In some instances, 
 as in the case above related, where the excruciating pain causes delirium, 
 and symptoms of tetanus are present, the Calabar bean is much extolled, 
 
428 A SYSTEM OF SURGERY. 
 
 especially when hypodermically administered. Other medicines for tetanus 
 may be found in the chapter on that subject. 
 
 Dislocation of Muscles and Tendons. — Dislocation of the long head of the 
 biceps has occurred occasionally, and was first mentioned by William Cowper 
 in 1724. This first case was that of a woman, who was supposed to have 
 dislocated her shoulder while wringing out some linen clothes. The rather 
 celebrated case of Mr. John Sodon was communicated to the Royal Medical 
 Clinical Society of London, in 1841. In this case, the patient placed his 
 arm behind him while falling backwards, and the pain was so severe that 
 a fracture was supposed to exist ; afterwards a severe sprain was diagnosed. 
 The arm was entirely powerless, and any exercise caused great pain. The 
 post-mortem examination was supposed to verify the diagnosis, but some 
 doubts have since been expressed regarding the case. Dr. James Green 
 has noted a somewhat similar instance, and Dr. Callender has treated one 
 in which the symptoms clearly pointed to a dislocation of the long head of 
 the biceps, by the absence of the tendon from the groove, and the detection 
 of the groove itself. I have had under my care two cases, which I believe 
 to have been dislocation of this tendon. One was that of a banker, who, 
 during an excursion into the country, endeavored, for a wager, to throw a 
 heavy ball in a perpendicular line to a considerable height; as the ball left 
 his hand a snap was felt, the arm was powerless, and when I saw him there 
 was some slight rotation inward of the humerus. The second case was that 
 of a boy, who fell whilst going down the stairway of the Elevated Rail- 
 road. His arm was thrown behind him, and as he rolled from the top to 
 the bottom of the flight, he felt something distinctly give way in his 
 shoulder. I saw him only after the swelling was very great, and at first 
 could not make the diagnosis. I did not see him for nearly a week, and 
 when I did so, I supposed the long head of the biceps to have been re- 
 moved from the groove. However, of this I am not certain. Decidedly 
 the most interesting case on record, and the best paper I know on the sub- 
 ject, is written by J. William White, M.D.,* who draws the following diag- 
 nostic marks from a careful stud} T of his case, which is remarkable. They 
 will serve to give the true symptomatology of the accident. 
 
 (1.) The recognition of the bicipital groove empty. 
 
 (2.) Recognition of the tendon itself. 
 
 (3.) Inward rotation of the arm. 
 
 (4.) A slight depression under the tip of the acromion ; a prominence of 
 the shoulder in front, and flattening behind. 
 
 (5.) Diminution in the vertical circumference of the shoulder. 
 
 (6.) Shortening of the arm as measured from the tip of the acromion to 
 the external condyle. 
 
 (7.) Elevation of shoulder, tilting up of acromion, and elongation and 
 narrowing of axilla when the arm is carried upwards. 
 
 (8.) A peculiar depression situated over the bicipital groove. 
 
 (9.) A line of ecchymosis following and strictly limited to the course of 
 the biceps muscle. 
 
 (10.) A creak or "squeak" heard distinctly on carrying the elbow away 
 from the side. 
 
 (11.) Flexion of the forearm on the arm is painful, the pain being sharp, 
 lancinating, and felt at the front of the shoulder ; flexion during supination 
 is much more painful than flexion during pronation. 
 
 (12.) When extension of the forearm is attempted, a tense line along the 
 edge of the biceps can be felt and seen. 
 
 (13.) The pain felt over the joint is also felt along the line of the biceps 
 
 * American Journal of the Medical Sciences, January, 1884. 
 
RUPTURE OF MUSCLES AND TENDONS. 
 
 429 
 
 m severe 
 
 as far as its insertion, and the patient often has a " drawing " sensation over 
 that region. 
 
 (14.) The arm is preternaturally mobile for some time after the accident. 
 
 Callender* gives an interesting case, in which a gentleman dislocated his 
 pronator, radii teres while playing lawn tennis. In making a back-stroke 
 the forearm was thrown into extreme pronation. The condition was recog- 
 nized from the seat of pain and the distress when the hand was moved in 
 pronation. 
 
 The following rules are laid down by Mr. Callender for reducing the dis- 
 location of a muscle, and are so concise and to the point, that I give them 
 here : 
 
 First. Decide as to the muscle or digitation of a muscle which, probably, 
 is the seat of trouble — guided by the pain. 
 
 Secondly. Relax the muscle as far as you can. 
 
 Thirdly. By firm manipulation endeavor to replace it. 
 
 Fourthly. This failing, press over the part, whilst bringing the muscle into 
 action ; put it on the stretch, and this is almost certain to bring it into 
 position. 
 
 Rupture of Muscles and Tendons. — Laceration of muscular fibres often 
 occurs from violent muscular action, as is sometimes noticed 
 tetanic spasms, the rectus abdominis generally 
 being affected in such cases. According to the 
 researches of Sedillot, out of twenty-eight cases 
 of ruptured muscle, thirteen took place at the 
 junction of the tendon with the muscular fibre. 
 There may be a simple tear involving a portion 
 of the muscle, or it may be torn through en- 
 tirely, or there may be a compound laceration. 
 In such cases, more or less ecchymosis may be 
 expected. When a tendon is torn across, it is 
 characterized by immediate lameness. The 
 patient falls, and is unable to resume the erect 
 position ; much pain is experienced at the seat 
 of injury. There is generally consciousness of 
 something having given way, accompanied with 
 a sensation of .a blow upon the part, accom- 
 panied often with an audible snapping noise, 
 and the gap between the ends can be detected 
 by the touch. The tendo Achillis is more fre- 
 quently ruptured than any other, the biceps 
 also sometimes suffering. 
 
 During one of my terms of service at the 
 hospital at Ward's Island, there was a man 
 who had ruptured the tendon of the biceps. 
 The muscular fibre had contracted at the upper 
 third of the humerus, forming a soft fleshy 
 tumor. A similar case is also reported by Dr. 
 
 Bryant. During the past winter, 1886, I* treated a bad case of rupture of 
 the tendo Achillis. 
 
 Treatment. — A great portion of the management of these cases consists 
 in position and rest. Arnica may be applied in some instances, particu- 
 larly when muscular fibres have been torn. Rhus and ruta are preferable 
 when the tendons are involved. Aconite and belladonna may also be used, 
 if the constitutional symptoms call for their administration. If the seat 
 
 The Medical Record, August 31st, 1878, No. 408. 
 
430 A SYSTEM OF SURGERY. 
 
 of the injury be the gastrocnemius muscle, or the tehdo Achillis, a slipper 
 should be placed upon the foot; a belt or band secured around the lower 
 part of the thigh, and to the heel of the slipper a stout cord or tape should 
 be attached ; the leg is then to be flexed on the thigh, the foot is extended, 
 and the tape made fast to the belt around the thigh. (Fig. 210.) This posi- 
 tion must be maintained until the divided parts unite, which, as a rule, 
 will take longer than the repair of fractured bones. When the patient com- 
 mences to walk, he should use a stick or crutch, and wear a high-heeled shoe. 
 
 Muscular Atrophy. — The muscles are very likely to become atrophied 
 from want of use, or from compression with bandages, or from paralytic 
 affections, especially in children. In rare cases acute muscular atrophy 
 (which is said to arise from a diseased condition of certain cells called 
 " trophic," situated in the anterior horns of the cord) is found in the adult. 
 A most remarkable case of this kind has been reported by Professor H. C. 
 Wood, Jr., of Philadelphia.* During the past winter two cases of paralysis 
 following measles were brought to the clinic of the college, and in each the 
 arm was the seat of the disorder, the muscles being shrunken and emaci- 
 ated. I have seen the same result follow from accidental division of nerves 
 in tenotomy. Typhoid fever and diphtheria are also factors in the produc- 
 tion of the disorder. There is another disease, however, which is particu- 
 larly noted by Mr. Lockhart Clarke,f who says : " There is another form of 
 this malady, which is known by the name of progressive muscular atrophy 
 (Cruveilhier), atrophie musculaire graisseuse progressive (Duchenne), and wast- 
 ing palsy. This curious disease differs in several respects from the other 
 atrophies. It is always chronic, but of uncertain duration ; is frequently 
 hereditary, is capricious or irregular in its invasion, prone to spread from 
 one part to another, or become general, and thus go on to a fatal termination. 
 The affected muscles suffer different degrees of wasting, and assume a 
 variety of aspects. Even in the same muscle, bundles in different stages of 
 atrophy and degeneration may be found by the side of others that have 
 retained their normal state. When the wasting is extreme in all the bun- 
 dles, a long muscle may be reduced to a mere fibrous and cylindrical cord, 
 or to a kind of tendon, and a flat muscle may be reduced in the same 
 manner to a species of membrane. In some instances the atrophy may be 
 simple, that is, the muscular tissue may be wasted to a considerable degree 
 without any granular or fatty degeneration ; but generally one or both of 
 these alterations of structure is found to exist to a greater or less extent. 
 The muscle also changes and varies in color, according to the nature and 
 degree of the atrophy. It is paler than natural ; occasionally it is quite 
 colorless, like the flesh of fish, or it may have a faint yellow or ochreous 
 tint. Its consistence for the most part is increased in consequence of the 
 increase in the interfibrillar connective tissue. W^hen examined under the 
 microscope the affected muscles may be seen to have lost, to a variable 
 extent and degree, or even entirely, the appearance of transverse and longi- 
 tudinal striation, while in a corresponding proportion the sarcous or mus- 
 cular element is transformed into granules, which in some instances are too 
 fine to be distinguished as separate particles. The granules are soluble in 
 acetic acid. In this odd affection the granular, fatty, and waxy degenera- 
 tions are found side by side." 
 
 In the treatment of muscular atrophy of course the local cause, if there 
 be any, must be removed. The requisite attention must be given to diet 
 and fresh air, and massage must be practiced regularly and persevered in 
 steadily for a considerable time. In conjunction with this, faradization 
 
 * Medical Kecord, December 22d, 1877. 
 f Holmes's System of Surgery, vol. Hi., 629. 
 
REFLEX MUSCULAR ATROPHY — BURSITIS. 
 
 431 
 
 Ftg. 211. 
 
 must be used, and the internal administration of such medicines as may 
 be indicated under the homoeopathic law prescribed. Among these will be 
 found arsenicum, belladonna, calcarea carb., plumbum, phosphorus, nux 
 vomica, rhus tox., and sulphur. 
 
 Dr. J. M. Kershaw has recorded a most interesting case of this affection.* 
 
 Reflex Muscular Atrophy. — There is besides the forms already noted an 
 atrophy arising from joint diseases and certain forms of osteitis, which is 
 called reflex muscular atrophy. 
 
 The fact that nerve irritation is capable of and indeed has alone the 
 power of producing rapid muscular atrophy, was, according to Dr. Shaffer,f 
 first demonstrated by Brown-Sequard. It is very important to bear in 
 mind this fact in the treatment of such conditions, otherwise in endeavoring 
 to overcome the secondary affection, we may really aggravate the primary 
 cause of the disease. The cause then of such a condition must be care- 
 ful] v sought after and relieved, if we desire a permanent cure. 
 
 Bursitis. — The bursas are lined by a membrane, resembling the synovial 
 in function, appearance, and disease ; they are frequently the seat of in- 
 flammatory action, which, in the generality of instances, is of short dura- 
 tion, and terminates in an increased accumulation of the secreted fluid. 
 The abnormal action may be either acute or chronic, and may take place in 
 those bursa? situated over the patella, olecranon, inner side of the head of 
 the tibia, the angle of the scapula, or about the carpal articulations. 
 
 When the inflammation is acute the pain is severe, and there is much 
 swelling and fever. The affection may be distinguished from inflammation 
 of the synovial membrane, by the superficial nature and 
 regularity of the tumefaction. Occasionally the action 
 terminates in suppuration, pus being effused to a greater 
 or less amount within the cavity. The affection is fre- 
 quently encountered among servants ; and inflammation 
 of the bursa? of the knee-joints is found particularly among 
 females, who, from resting upon their knees while per- 
 forming household duties, irritate the bursa? ; hence the 
 term, housemaid's knee. However, those in the higher 
 walks of life are not exempt from the disease. In some 
 cases chronic bursitis consists in nothing more than an 
 enlargement of the sac ; but if the disease be not arrested 
 more extensive organic changes follow. An alteration may 
 take place in the lining membrane of the sac ; it may 
 thicken and be interspersed with fibrous bands which 
 pass in different directions, and finally the original sac 
 formation is almost entirely lost and a solid tumor re- 
 sults. 
 
 Chronic enlargement of the bursa on the metatarsal 
 joint of the great toe is also frequently met with, especially 
 in those advanced in years, causing some deformity, and 
 at times considerable pain; to this affection the term 
 bunion is applied. 
 
 When at the elbow, it receives the name " miner's elbow" and when on the 
 tuberosity of the ischium, "weaver's bottom." 
 
 The surgeon, however, must remember that bursa? are found in many 
 other portions of the body, which may inflame and give rise to considerable 
 swelling and pain, which have often been mistaken for rheumatism. 
 
 Enlarged bursa, with 
 structural changes. 
 
 * Progressive Muscular Atrophy, by J. M. Kershaw, of St. Louis, Chicago, 1878. 
 
 f Reflex Muscular Contraction and Atrophy in Joint Disease, by N. M. Shaffer, M.D. 
 
 Archives Clinical Surgery, vol. ii., p. 83. 
 
432 A SYSTEM OF SURGERY. 
 
 There is a bursa situated on the upper and posterior part of the os calcis, 
 another beneath the tendons of the psoas, and also beneath the deltoid and 
 extensor muscles of the thigh. These are all deep bursas, and may, under 
 peculiar circumstances, especially if undue straining is put upon the part, 
 inflame and give rise to both local and constitutional symptoms. 
 
 Treatment. — The medicines for inflamed bursa? are aeon., bell., graph., 
 hepar, iocl., led., mere, rhus, sulph. 
 
 In my experience the iodide of potash is more effectual in the treatment 
 of chronic bursitis than any other medicine which I have employed. 
 
 The bursse may be punctured, and the effused fluid pressed out. The in- 
 strument should be finely pointed, of good material, and should contain a 
 groove, the side of which should have cutting edges. Sometimes consider- 
 able pressure is required to force the instrument through the walls of the 
 bursse ; and to prevent the instrument from snapping, steady pressure should 
 be used. 
 
 The passage of a seton through the sac has in my hands often proved 
 satisfactory. An injection of iodine, though attended with risk, is effectual. 
 A better method (surgically) is to make a longitudinal incision into the 
 bursse, and paint the interior of the sac with tincture of iodine. In aggra- 
 vated cases, in which the tumor is solid, the excision of the entire mass 
 should be resorted to. There is but slight risk in the operation, and it is 
 very effectual. A chief aim should be to obviate pressure upon the swelling, 
 directly upon which should be placed a small-sized soft pad, having a hole 
 in the centre. It is also sometimes necessary, when the bursa of the great 
 toe is affected, to divide subcutaneously the external lateral ligament of the 
 metatarso-phalangeal articulation, as well as the tendon of the adductor 
 pollicis, in order to restore the position of the toe, after which the foot 
 should be kept for a time upon a palmar splint. 
 
 Ganglion. — By the term ganglion is understood an adventitious bursa 
 along the course of a tendon. Ganglia are rounded in shape, and are most 
 frequently situated about the wrist, but Gross records a case in which " two 
 tumors of the kind, each the size of a small bird's egg, were situated upon 
 the dorsal surface of the foot." They are sometimes formed on the scapula, 
 tibia, or patella. These generally produce swellings, but little pain, espe- 
 cially when located about the back of the wrist. A sensation of weakness, 
 however, and stiffness may be experienced. They contain a fluid of various 
 consistency. It sometimes resembles the vitreous humor; at others, it is 
 straw-colored and thin. Fig. 211 represents a ganglion, formed by the syno- 
 vial sheath of the flexor tendon of a finger. 
 
 There is another variety of ganglion besides the localized one which has 
 just been described, which is difficult to treat, and is often followed by 
 serious results, viz., the diffuse ganglion. In this disease one or more of the 
 tendons are implicated, generally the flexors ; the swelling is diffuse and 
 irregular, the pain intense, and the rigidity constant when the ganglion is 
 opened. There is sometimes a peculiar discharge consisting of numerous 
 " melon seeds," as they are called, with serous and synovial fluid. 
 
 Treatment. — Operative measures are the only certain ones for the destruc- 
 tion of ganglia. The simplest and oldest is either to rupture the cyst by 
 forcible pressure of the thumbs, or with a smart blow with a book or some 
 hard substance, the patient's hand being extended ; or else to thrust a small 
 tenotomy knife or cataract-needle into the sac, and move it freely about, in 
 order thoroughly to divide it, or to make many incisions into the walls of 
 the ganglion, and thereby excite sufficient inflammation to cause the parts 
 to adhere. Moderate pressure must then be applied, and the part allowed 
 to remain quiet for a length of time. 
 
 There are other modes of treating ganglion. Some surgeons, as Sir Henry 
 
SPRAINS. 433 
 
 Thompson, prefer first to apply tinct. of iodine, and continue it for six 
 weeks ; if this fails he introduces a seton, squeezing out the contents of the 
 sac through the needle-holes. Mr. Heath punctures with a grooved needle, 
 and afterwards applies iodine paint. Mr. Smith, of King's College, passes 
 a single ligature of silk through the centre of the tumor, allows it to remain 
 until suppuration takes place, when it is withdrawn.* 
 
 In the diffuse variety it is necessary to make an incision above and below 
 the annular ligament down to the theca and apply a poultice. The hand 
 should be placed in a splint, and after a day or two passive motion 
 employed. Sometimes in this very distressing affection permanent de- 
 formity results, and, indeed, in aggravated cases arising from neglect, ampu- 
 tation may have to be resorted to. The young surgeon should be careful 
 in watching such cases, as deformities of hands and feet are often exhibited 
 to the everlasting obloquy of the surgeon, whether, indeed, he deserve it or 
 not. 
 
 Sprains. — These injuries are sometimes very painful. They arise often 
 from momentary displacement of bones, which strain or partially tear the 
 apparatus of the joints. They are accompanied frequently with some con- 
 stitutional disturbance ; the affected part swells, and the synovial membrane 
 may be involved. 
 
 A severe sprain, if neglected, is by no means a trifling matter, particu- 
 larly if located about the ankle, hip, or knee, on which there is constantly 
 more or less pressure. Often caries, especially of the ankle-joint, may re- 
 sult in consequence of a badly managed sprain. 
 
 Treatment of such injuries consists in restoring the bones to their normal 
 position by extension and direct pressure, and applying a solution of 
 arnica to the part, which must be also bandaged to support the limb, and 
 prevent recurrence of the accident, and a few doses of the same medicine 
 of the 2d dilution administered internally. 
 
 When an individual muscle has been injured by the effect of a violent 
 strain, Dr. Goullon remarks that rhus will more readily restore its tone and 
 remove the pain than any other medicine. This is a truthful observation, 
 as most practitioners of our school can testify. Rhus is particularly adapted 
 to sprains occurring in tendinous parts with swelling and great pain. It 
 may be used both externally and internally ; the solution that is used as a 
 lotion should be adapted to the sensitiveness of the skin of the patient. 
 There are some individuals who are particularly susceptible to the action 
 of the poison oak ; and the surgeon should therefore exercise caution and 
 discretion when prescribing this medicine; it possesses considerable power 
 over the tendons of the lower extremities and the inferior maxillary bone ; 
 it is also recommended for the bad consequences of strains, and prevents 
 liability to such accidents. This medicine has been alternated with arnica 
 in some cases, but the indications for its use are generally sufficiently well 
 marked to render entirely unnecessary any such alternation. 
 
 If the patient should have injured himself by lifting heavy weights rhus 
 is also an important medicine, particularly when the dorsal and cervical 
 muscles and the vertebral column are affected, and there is headache accom- 
 panied with general bruised sensation of the whole body, pains in the 
 back or gastric ailments. Bryonia should be exhibited if the pains are 
 occasioned by the same cause, but are aggravated by motion, and the mus- 
 cular system is chiefly involved. 
 
 If pain is experienced immediately after raising a heavy weight calc. will 
 prove serviceable, and may also remove the existing predisposition to such 
 
 * Vide a paper on " The Treatment of Ganglion at the London Hospitals," Braithwaite, 
 January, 1872, p. 168. 
 
 28 
 
434 
 
 A SYSTEM OF SURGERY. 
 
 accident; it should also be remembered when, after the injury, there is con- 
 gestion of blood to the head, or there are pains, as from bruises, in the 
 joints and small of the back, the parts being sensitive to touch. 
 
 Amm. carb. has been mentioned by some authors as useful in the variety 
 of injury under consideration, but there have been no particular indica- 
 tions given. In its pathogenesis we find : sensation as if bruised in the 
 whole body, with fatigue and weakness of the limbs ; pains, as if sprained, 
 in the joints ; drawing and tension in the joints, as though the tendons were 
 too short. 
 
 Lycop., petrol., or ruta may be applicable in some cases. Sepia is recom- 
 mended for many troublesome constitutional symptoms that may supervene 
 from a sprain. 
 
 If an inguinal hernia should have been caused by lifting or straining the 
 part, or if an old protrusion become painful, nux vom., sulph. ac, cocc, or 
 sulph. should be administered. If a prolapsus of the uterus have been occa- 
 sioned by such causes, nux has proved almost a specific medicine ; after its 
 exhibition, bell, or sepia may be required. 
 
 If the accident occasion nausea and vomiting, veratrum or sulph. may be 
 required, either of which may be used in alternation with arnica. 
 
 For the ill effects of making a misstep, or pressing the foot to the floor 
 with too much violence, arn. and bry. are often sufficient ; sometimes, how- 
 ever, con., puis., and rhus may be indicated. 
 
 Rest certainty is the most important part of the treatment, and this must 
 be absolute, to prevent any action of the tendons implicated, or any friction 
 between the surfaces of bones. In sprains about the ankle-joint, Dr. Lewis 
 A. Sayre has invented an apparatus which I have found very advantageous.* 
 It consists " of a firm steel or hard rubber plate made to fit the sole of 
 the foot; at the heel is a hinge-joint, and attached to it a rod, slightly 
 curved at the bottom, and extending up the back of the leg to near the 
 knee. Over the instep is an arch, like the top of a stirrup, with a hinge- 
 joint at its summit, from which springs another rod, which runs in front 
 of the leg, of equal length with the one behind." These rods are made 
 with a male and female screw, or ratchet and cog, for extension, and con- 
 nected at the top by a firm band of sheet iron, on one side of which is a 
 hinge, and a lock on the other, like a dog collar (Fig. 212). The instru- 
 
 FlG. 212. 
 
 FIG. 213. 
 
 Fig. 214. 
 
 ment is applied with firm adhesive plaster, cut in strips about one inch 
 in width, and long enough to reach from the ankle to two or three inches 
 above the tubercle of the tibia, and placed all around the limb (Fig. 213). 
 " The plaster is secured in position to within two or three inches of the 
 
 Bellevue and Charity Hospital Eeports, p. 111. 
 
CONTE ACTION OF THE PALMAR FASCIA. 435 
 
 upper extremity by a well-adjusted roller." The instrument is fixed and 
 secured by a number of strips of adhesive plaster. A roller should be care- 
 fully applied over this to prevent its slipping, and the ends of the plaster 
 at the top of the instrument turned over the collar, which has been previously 
 locked, just tight enough to be comfortable, and secured by a turn or two 
 of the bandage (Fig. 214). 
 
 Dr. W. 0. Terry, of Utica, N. Y., in an article, published in the Transac- 
 tions of that State for 1884, formulates the following systematic treatment : 
 
 '" The first step in the treatment of a sprain of recent origin is to relieve 
 pain. This can invariably be done speedily by hot fomentations or by immer- 
 sion, which must be continued, increasing the temperature as the patient 
 gets accustomed to the heat, until pain has ceased. 
 
 " The second step is the application of the rubber bandage, which is to be 
 put on immediately after the discontinuance of the hot water and worn 
 constantly. Should there have been considerable laceration of the liga- 
 ments, or should the parts have been bruised, the rubber bandage had bet- 
 ter be placed over a wet compress for twenty-four hours. In the treatment 
 of knee injuries, however, it will be necessary in many cases to use the com- 
 press for several days. It should be put on hot and changed every few hours. 
 Should this treatment be pursued in any case, it will be well to omit the 
 compress, as one would a poultice, so soon as the skin thickens or becomes 
 white, as it will rot under constant moisture. The rubber bandage must 
 be worn constantly, however, and the compress reapplied should pain suc- 
 ceed its discontinuance." 
 
 " Conclusions : It is evident — inasmuch as one author says, ' rest in the 
 horizontal state;' another, 'walk it off;' one uses cold, another hot; 
 again the ' immovable apparatus ' is recommended by one and condemned 
 by authority equally good — that a treatment which will relieve pain imme- 
 diately, prevent swelling and effusion, and restore speedily without stiffness 
 a joint to its natural condition, will not be considered ill-timed." 
 
 Contraction of the Balmar Fascia — "Dupuytren's Contraction." — This 
 peculiar disease consists in flexion of the fingers from contraction of the 
 palmar fascia, generally of the first phalanx. All the fingers and the thumb 
 may be so flexed, or one or two may be affected. There is generally a local 
 cause for the disease, but besides this, there is also a constitutional predis- 
 position which is rheumatic in its character. A similar affection is some- 
 times noted in the soles of the feet. The contraction is painless, but sensibility 
 and motion are always greatly impaired, if not entirely lost. Operative 
 measures are the best, and the subcutaneous ones are always to be preferred. 
 It was formerly the custom to make large crucial incisions through the 
 fascia, or to dissect out the contractile tissue, but the success attendant on 
 such procedure was not equal to the severity of the operation, and the 
 simpler and subcutaneous ones now are mostly relied on. 
 
 Dr. A. C. Post* regards " Dupuytren's contraction " as not invariably due 
 to the contraction of the palmar fascia alone, but considers that the sheaths 
 of the flexor tendons are sometimes involved. He removes the forced 
 flexion by subcutaneous section of the fascia by as many punctures as 
 needed, employs a proper splint to produce extension, and looks upon pas- 
 sive motion as an essential to the success of the treatment. In each of the 
 six hands in which he has removed the deformity, he found that the power 
 of flexing, not only the affected fingers, but those previously normal, was 
 very much diminished. The power of flexion is very slowly regained, and 
 sometimes never to its full extent. 
 
 Mr. William Adamsf operates for Dupuytren's contraction of the palmar 
 
 * Archives of Clinical Surgery, August, 1876. f Lancet, June 9th, 1877. 
 
436 A SYSTEM OF SURGERY. 
 
 fascia, 1st, by subcutaneous division of all the contracted bands by the 
 smallest tenotomy knife passed in many punctures under the skin, and 
 cutting from above downwards ; 2d, immediate extension of the contracted 
 fingers upon an appropriate splint ; 3d, removal of the bandages on the 
 fourth day, " when the punctures will be found to be healed ; " 4th, constant 
 wearing of the extension splint for two or three weeks, and at night for three 
 or four weeks longer. Passive motion must be employed every day. By 
 this method of treatment, Mr. Adams believes that relapse will be pre- 
 vented. He condemns severely the treatment by open wound. 
 
 Vulpian's ointment is said to have produced excellent results in this dis- 
 ease. It is thus prepared : 
 
 Zinc, iodinii, £ss 
 
 Potass, iodidi, . .^ijss 
 
 Vaselini, ^v. 
 
 M. ft. ung. 
 
 This is to be liberally used and for a long period over the palm, being 
 applied once a day. After the use of this salve cotton batting should be 
 placed upon the hand and secured by a roller bandage. Internal use of 
 medicines together with massage assists materially in the treatment. 
 
 CHAPTER XXIV. 
 
 INJURIES AND DISEASES OF THE ARTERIES. 
 
 Arteritis, Adhesive and Diffuse — Atheroma — Embolism — Aneurtsm: Varieties, 
 General Treatment, Medical Treatment — Compression— Manipulation — 
 Rapid Method for External Aneurism, Injection, Ligature — Special 
 Aneurisms. 
 
 Arteritis. — The arteries, like all other textures of the human body, are 
 liable to inflammation, suppuration, and ulceration. The internal coat of 
 the vessels is more obnoxious to the process than either of the others, as is 
 evinced by the effusion of lymph, which is poured out in large quantity on 
 its inner surface, in consequence of inflammation of contiguous parts, from 
 the application of ligatures, wounds, and from the presence of tumors. 
 
 Two stages of the inflammatory process are particularly noticed ; in the 
 one there is adhesion, and the arteritis is limited ; in the other it is diffuse. 
 In the former, not only the coats of the vessel itself, but the contained blood, 
 are altered, and an effusion of plastic matter takes place around them, the 
 vessel loses its resiliency and becomes fragile, and a plug or clot of decolor- 
 ized fibrin is formed that blocks up the vessel, causing one variety of occlu- 
 sion (embolism). In the diffuse variety of arteritis, as has already been 
 noted, the inflammatory action is more extended, but without an}^ plastic 
 exudation. 
 
 Dr. Moxon* has described a peculiar disease confined to the outer coats 
 of the vessel, which he calls periangioma. It consists in a new growth form- 
 ing a tumor on the scalp, in which ramify enlarged vascular structures, in 
 which the outer coat is almost exclusively affected. 
 
 Treatment. — For acute adhesive arteritis the medicines are, aconite, bella- 
 donna, gelseminum, or veratrum viride. The first is to be prescribed in the 
 
 * Referred to in Holmes's System of Surgery, vol. iii., p. 393. 
 
ATHEKOMA — EMBOLISM. 437 
 
 early stages of the affection, when there is some constitutional disturbance ; 
 but when the face is hot and flushed, belladonna or gelseminum is indi- 
 cated : the differential indications being the congestion of the head, indi- 
 cating the former ; congestion of the biliary apparatus and head, the latter. 
 If there is a rheumatic tendency, bryonia would be the appropriate medi- 
 cine, or in some cases actea racemosa. The green hellebore I have never 
 used, but from the marked action it possesses over the circulatory apparatus, 
 I should be strongly inclined to try it. Digitalis, which has been highly 
 lauded, has not in my hands proved efficacious ; in fact, it is a medicine 
 which has often disappointed expectations in cases in which it has been 
 apparently indicated. 
 
 For more chronic and diffuse arteritis, belladonna is, according to my 
 experience, a very reliable medicine, but its use must be persisted in for a 
 considerable time. Arsenicum, carbo veg., lycopodium, pulsatilla, and sepia 
 may also be selected. 
 
 Atheroma. — By the term atheroma is understood the degeneration of 
 the coats of an artery, and the formation of a soft, foreign, pappy deposit 
 within the coats of the vessel. These deposits assume different shapes and 
 somewhat different appearances, according to their age, and generally begin 
 near the mouth of the larger vessels. In the earliest stages, thin whitish 
 opaque streaks line the internal membrane of the tube, making a new lin- 
 ing of it, and presenting a smooth and shining appearance. After a time a 
 second layer of plastic material is deposited on the prior one, which becomes 
 consolidated with the true coating of the artery, which, by adhesion with 
 the new substance, first becomes indurated, then loses its natural color, and 
 finally softens. Sometimes the atheromatous deposit, from being of a yel- 
 lowish color, becomes a grayish tough membrane, called by Hodgson the 
 steatomatosis deposit. These deposits also soften, as those already mentioned, 
 and are converted into a cheesy mass, which is sometimes so fluid and of 
 such peculiar color that it resembles true pus. 
 
 Atheromatous masses are often found imbedded in sacs along the course 
 of a vessel, and may be partly or entirely washed away by the current of 
 circulating blood. Around the point of the vessel, in which this degenera- 
 tion takes place, the internal and middle coats may become closely adherent 
 and thus prevent a further extension of the disease, while a conservative 
 process goes on in the external coating, rendering it thicker and more dense 
 by a deposit of plastic material. Finally, a deposit of calcareous matter may 
 take place in the coats of the vessel, and calcification or ossification ensue, 
 which renders the tube brittle, and gives rise to severe and sometimes fatal 
 haemorrhage after surgical operations. 
 
 It must be remembered, however, that though this latter process has re- 
 ceived the name of ossification, yet no true bone-cells have been discovered in 
 the calcareous mass, which consists, according to Lassaigne, of two parts of 
 the carbonate and forty-eight parts of the phosphate of lime, to fifty parts 
 of animal matter. 
 
 With reference to cell formation, Dr. Moxon thus writes : " I might give 
 practically any number of cases and drawings, showing the active cell forma- 
 tion in cases of atheroma. This cell formation is found in the deep layer of 
 the inner coat especially, and causes the production of little nests of cells, 
 in which fat and lime soon accumulate. In severer cases the middle and 
 outer coats and the deep layer of the inner coat are seen to be charged with 
 lymph-cells, in enormous numbers, crowded together, and separating the 
 proper elastic and the muscular fibres into little patches and shreds, while 
 both elastic and muscular fibres fall into a state of fatty degeneration." 
 
 Embolism. — By this term is understood the obstruction of an artery by 
 some foreign substance. It may be an atheromatous patch washed into the 
 
438 A SYSTEM OF SURGERY. 
 
 circulation, and having lodged in a vessel near a bifurcation, a plastic deposit 
 is formed around it, and the circulation thereby is obstructed ; or after arter- 
 itis a conical plug of plastic deposit may obstruct the circulation, or a fibrous 
 clot may pass from the heart, and, having circulated through the larger 
 vessels, be arrested by the smaller calibre of other arteries ; or a foreign 
 body, as a needle, for example, may lodge in a vessel, affording a nucleus for 
 a clot* In the varied forms of heart disease, these clots are most likely to 
 form, and in endocarditis and among puerperal women sudden deaths from 
 this cause are related. Embolism may also occur after fractures, as in a 
 case lately under my supervision. 
 
 As a rule this form of obstruction arises from fat, and the term "fat em- 
 bolism " is applied to it. The causes of the affection are involved in obscurity, 
 but the obstruction is generally produced by small particles of adipose 
 accumulating in the smaller vessels and capillaries. 
 
 The symptoms of obstruction or occlusion of an artery are, first, a 
 severe pain at the point of obstruction. The part becomes blue, swollen, 
 and insensible, and gangrene ensues ; or if the collateral circulation be es- 
 tablished a slow returning vitality may prevent mortification. In two cases, 
 which have lately come under my observation, one occurred in a lady of 
 sixty, who had long been suffering from valvular disease, and who was re- 
 covering from double pneumonia ; the obstructed artery was the radial, 
 and complete mortification ensued in three or four days. An amputation 
 was about to be performed, but an attack of hemiplegia, on the very day 
 appointed for the operation, soon terminated her existence. The second 
 was in a man, aged forty, suffering from abscess of the knee-joint and 
 rheumatism. He was improving, and about to sit up, when, suddenly, a 
 pain in the region of the heart, with difficult respiration, terminated his 
 existence in a few hours. Embolism of the pulmonary artery was found in 
 this case. 
 
 In gangrene, resulting from embolism, many patients die before the line of 
 demarcation is formed, and some do not survive the process of separation. 
 
 Treatment. — In the degeneration of arteries the medicines which are espe- 
 cially indicated are lycopodium, calcarea, phosphorus, graphites, silicea, and 
 sulphur ; perhaps, also, the iodide of potash. From the action of sulphuric 
 acid upon ossific deposits it might be serviceable. The practitioner, how- 
 ever, should regard with particular attention the predisposing and exciting 
 causes, whether they be constitutional or local, should note the symptoms 
 carefully, and with the aid of the Repertory and Materia Medica, select the 
 medicines best adapted to each presenting case. 
 
 In embolism, amputation is the only resort, and then is generally hazard- 
 ous, as in a majority of cases, heart disease already is present. Before the 
 operation, it is necessary that the site of the embolus be clearly ascertained, 
 and the point of selection made some distance from the obstructed part. If 
 a line of demarcation is formed, the surgeon should be governed by the rules 
 laid down in the chapter upon Gangrene. 
 
 Aneurism. — Aneurism, with its varied locality, its manner of formation, 
 its many and extreme dangers, and the varied methods of its cure, has ever 
 been a subject of great interest to the surgeon. 
 
 Sir Charles Bell defines aneurism as a pulsating tumor, formed of arterial 
 blood ; but Mr. Miller, with his usual preciseness, writes that by the term 
 aneurism is understood : " a pulsating tumor, composed of a cyst, which is 
 filled with blood, partly fluid and partly coagulated, and whose cavity com- 
 municates with the arterial canal." 
 
 Aneurisms have been variously divided, viz.: External, internal, spon- 
 
 * Sach a case is reported in Holmes's System of Surgery, vol. iii., p. 403. 
 
ANEURISM. 
 
 439 
 
 taneous, traumatic, true, false, circumscribed, diffuse, dissecting, aneurismal 
 varix, and aneurism by anastomosis. 
 
 External Aneurism. — This disease presents itself as a small tumor, pulsat- 
 ing very strongly, containing only fluid blood, of which it can be readily 
 emptied if pressure be made near the distended artery on the cardiac side. 
 Little pain is experienced at this time, excepting cramps, which may occur 
 in the limb below the situation of the aneurism. In a more advanced stage, 
 the tumor is larger, more solid, and cannot be completely emptied as in the 
 former case, the blood being partly coagulated in the interior of the sac, 
 which is much thickened. The circulation in the surrounding parts is 
 retarded, and pain is experienced when pressure is made upon the tumor; 
 the pulsation is distinct, but not so well marked as in the first period of the 
 affection. In the third stage, the tumor is larger and more solid, pulsation 
 is indistinct, and the sac is filled with layers of fibrinous matter, and con- 
 tains but little fluid blood. There is pain and inconvenience when moving 
 the limb, which becomes cedematous and deprived of sensation from pressure 
 upon the nerves. 
 
 Internal Aneurism occupies the cavity of the abdomen, chest, or cranium, 
 and the diagnosis is frequently difficult. 
 
 True Aneurism (Fig. 215) is that wherein the sac is composed of all the 
 arterial coats, dilated at one point in the course of the vessel. 
 
 False Aneurism. — When the two internal coats have ruptured, and the 
 tumor is formed merely of the external coat, the aneurism is said to be false 
 
 False Aneurism. Sac formed by 
 outer coat. 
 
 True Aneurism. 
 
 Hernial Aneurism. 
 
 (Fig. 216). It may be said here that true aneurisms generally become false 
 as they increase, and that the latter are those most frequently seen. 
 
 A Hernial Aneurism is one in which the sac is formed by the inner coat 
 only (Fig. 217). 
 
440 
 
 A SYSTEM OF SURGERY. 
 
 Aneurism by dilatation is most frequent in the aorta. The coats of the 
 vessel do not give way, but are gradually and evenly distended; the in- 
 tegrity and the continuity of the tunics remaining entire, which can be dis- 
 tinctly traced, particularly after maceration. 
 
 The dilatation may be cylindroid, fusiform, or sacciform. 
 
 In the first instance the expansion is abrupt and uniform ; in the second 
 — as the derivation of the word would lead us to suppose — the enlargement 
 is spindle-shaped ; and in the third the dilatation is partial, and arises from 
 
 Fig. 218. 
 
 Dissecting Aneurism. 
 
 the side of the vessel. These may all be divided into the true and the false; 
 in the former there is a partial dilatation of all the coats of the vessel ; in 
 the latter, the expansion of the one and the rupture of the other. 
 
 Dilatation and rupture of the arterial tunics do not occur at the same 
 time. In the first instance the abnormal cavity is formed by dilatation, and 
 after a time the internal and middle coats are ruptured, either by muscular 
 exertion or ulceration. The external coat expands, and receives strength 
 from organized fibrinous deposits, afforded by effused blood. 
 
 Aneurism by rupture generally arises 
 fig. 219. from sudden muscular exertion ; the in- 
 
 ternal and middle coats give way by 
 laceration, and aneurismal formation 
 speedily follows. 
 
 When blood passes between the tunics 
 of an artery, separating or dissecting the 
 one from the other, the aneurism is 
 termed dissecting". In such cases, the 
 inner coat of the arterj^, either from 
 atheroma or calcification, may split, and 
 the blood force for itself a passage be- 
 tween the tunics ; or as more frequently 
 happens, the blood may find its way 
 between the layers of the middle coat ; 
 it may then pass some distance along 
 the course of the vessel, dissecting up the 
 coats, and may rupture externally, i. e., 
 through the outer coat, causing death ; 
 or may find a passage back into the ves- 
 sel. This happens in the aorta, and 
 no doubt gave rise to what was for- 
 merly known as the double aorta (Fig. 
 218). 
 
 An aneurism is said to be pedunculated when the sac is connected with 
 the artery by means of a narrow neck. A limited aneurism is one in which 
 it is bound within the limits of a proper cyst ; and diffuse aneurism is formed 
 by the blood escaping from a wound in an artery into the surrounding cel- 
 
 Diffuse Aneurism. Cellular Tissue.— Holmes. 
 
SYMPTOMS OF ANEURISM. 441 
 
 hilar tissue. In this the cyst is not composed of any of the arterial coats, 
 but consists entirely of tissues exterior or adjoining the vessel (Fig. 219). It 
 may result from wounds, lacerations, or ulceration external to the vessel. 
 Diffuse aneurism usually follows injuries at the bend of the arm, in which 
 instance the vein may be stretched over the forepart of the sac ; the cicatrix 
 from the previous wound is found stretched and thin over the surface of the 
 tumor. 
 
 Cirsoid Aneurism is one in which the coats of a single artery become 
 enlarged and elongated. It is often very difficult to diagnose from ordinary 
 aneurism by anastomosis, wherein there is a pulsating tumor composed of 
 enlarged and tortuous capillary bloodvessels. 
 
 Aneurismal Varix. — This affection is the consequence of a wound which 
 has primarily implicated both an artery and a vein, leaving a communica- 
 tion between the vessels. It will readily be understood that at each throb- 
 bing impulse of the arterial tube, a jet of blood is thrown into the vein, 
 which after a time is so weakened from the repeated shocks, that the valves 
 become obliterated, and the neighboring venous trunks enlarge. In this 
 peculiar disorder there are two currents of blood opposing each other, one 
 being the direct flow of the venous blood upward toward the centre of the 
 circulation ; the other the jet of arterial blood thrown into the vein from the 
 artery. The sound made by these opposing currents is peculiar. It is a 
 " thrilling," a u whistling," or " humming," resembling that of machinery at 
 a distance. 
 
 After the disease has existed for a time, both artery and vein lose their 
 natural structures, their coats expand and weaken, and become more atten- 
 uated than natural ; the veins become tortuous, and often pulsate. 
 
 Treatment. — The most approved method of treatment is palliative. There 
 is no danger, because there is no absolute obstruction of the circulation ; the 
 veins, it is true, may undergo enlargement, but they will not rupture, and 
 therefore a properly fitting elastic stocking is the appliance. 
 
 Arterio-venous Ajieurism, as the name implies, is one in which the sac 
 communicates with both the artery and the vein. In these cases, a varicose 
 condition of the surrounding veins is a consequence, with pulsation of the 
 venous trunks. The bruit is remarkable for its " whirr " or its " hum," 
 which is more distinctly heard on the cardiac side of the tumor. In vari- 
 cose aneurism, the blood passes from the artery to the sac, and from the 
 sac into the vein. This condition is usually caused by wounds, in which 
 imperfect compression is made. Its most frequent site, when venesec- 
 tion was the fashion, was at the bend of the elbow. This variety differs 
 from the ordinary false aneurism in its free communication with the vein. 
 The growth of the swelling is slow, and it rarely attains the size of a hen's 
 egg, because, there being but little pressure on the walls of the sac, the 
 blood is forced into the surrounding trunks, thereby breaking the violence 
 of the impulse. 
 
 Treatment. — Pressure, direct and prolonged, must be used in varicose 
 aneurism, for if the disease be not checked, oedema and hemorrhage will 
 result. If pressure fail, resort must be had to the ligature ; and the most 
 judicious plan is to ligate the vessel above and below the tumor, and allow 
 the sac to remain unopened. 
 
 Symptoms of Aneurism. — These are, first, those belonging to the disease 
 itself; and, second, those manifestations caused by the actual pressure of 
 the tumor upon the surrounding parts. 
 
 In internal aneurism, the stethoscope assists the diagnosis by the convey- 
 ance of sounds to the ear, while the symptoms which are attributable to pres- 
 sure on internal organs are distinctly recognized. 
 
442 A SYSTEM OF SURGERY. 
 
 Shape. — The shape of an aneurismal tumor is generally ovoid ; sometimes 
 it is round, and, in most instances, circumscribed. 
 
 Location. — We generally are much assisted in the diagnosis when the 
 swelling can be located in the immediate vicinity of a large arterial trunk. 
 
 Pulsation. — This is one of the most conclusive evidences of aneurism, and 
 though, in some instances, an abscess situated directly over the course of a 
 large vessel may pulsate, yet even in such cases the throbbing tells that 
 certainly an artery is somewhere in the vicinity, and places the practitioner 
 upon his guard. When there exists a pulsating tumor, the motion of which 
 can be materially lessened or made absolutely to cease by pressure above 
 it; and when the pulsation can be made to increase and the tumor to enlarge 
 by pressure below it, the evidence of aneurismal formation is sufficient for 
 a correct diagnosis. But it must also be remembered that an aneurism 
 may exist with but slight pulsation, and in some instances no " beating " 
 can be recognized. The absence of this important symptom may be occa- 
 sioned by the sac being completely filled with laminated fibrin. In such 
 cases, however, by taking the tumor between the hands, and exerting for a 
 time a gradual and uniform pressure, there will take place a diminution of 
 its size ; but the pressure being withdrawn, the blood will rush again into 
 the cavity, and the swelling regain its former outline. 
 
 The pulsation in aneurism is from within, outward. 
 
 Sounds. — The sounds revealed by auscultation vary much. In some cases 
 there is a distinct and heavy " thud," in others a rasping, and in others a 
 grating sound, which is especially found in true or " tubular aneurism." The 
 sounds also vary according to the position of the patient, being most dis- 
 tinct when the sac is moderately distended with blood. On the other hand 
 when the sac is overdistended and supplied by vessels with small mouths, 
 the bruit may be ver}^ indistinct or wanting altogether. 
 
 These are "the signs and symptoms which belong to the tumor proper, viz., 
 shape, location, pulsation, and sound. The pressure symptoms are pain 
 which is often of a sharp, lancinating, neuralgic character, darting along a 
 compressed nerve, or the patients suffer most intensely from prolonged 
 aching, burning, or tearing. These sufferings are very persistent and often 
 embitter life. 
 
 Swelling'. — (Edema is one of the most common symptoms of pressure from 
 either an aneurismal or other tumor, from obstructed venous return; if 
 severe and prolonged, gangrene and mortification may result, and absorp- 
 tion of bone may also take place. 
 
 Functional Disturbance.— Hoarseness, difficult breathing, cough, faintness, 
 spasm of the glottis, vomiting, constipation, and spasm, may also be noted 
 as secondary symptoms of true aneurism. 
 
 Deformity may also result from the presence of aneurism. The internal 
 organs may be very much displaced. In several cases that came under my 
 own observation, the sternum, ribs, and vertebrae were very much misplaced 
 from the great enlargement of the sac. 
 
 The symptoms of diffuse are somewhat different from those presented by 
 true aneurism. In this case, when the sac ruptures and the blood escapes 
 into the surrounding cellular tissues, the symptoms of shock are often 
 apparent ; the coldness, faintness, sickness which result are characteristic. 
 The parts become numb, heavy, and cold ; the limb swells, and the pain is 
 often agonizing ; the tumor upon examination is larger, but not circumscribed; 
 it is more flabby, and the pulsation very indistinct. After a time this tumor 
 may become harder from the coagulation of blood around the cellular 
 structure, and the aneurism may again become limited, or this very coagu- 
 lation may so obstruct the circulation of the part that symptoms of gan- 
 grene result. As soon as the boundary line is established the tumor again 
 
SPONTANEOUS CURE OF ANEURISM. 443 
 
 enlarges and its pulsation increases, the system becomes somewhat accus- 
 tomed to the pressure of the new formation, and a collateral circulation is 
 established. 
 
 Sometimes suppuration and sloughing result; pain, heat, swelling, and 
 redness supervene, the wall ruptures ; broken and disintegrated tissue and 
 imperfect coagula are forced out, and finally copious and fatal haemorrhages 
 ensue. 
 
 The arteries which are most liable to aneurism are the aorta and the 
 popliteal ; next to these, the subclavian, external iliac, and innominata. 
 
 When an aneurismal sac is opened, it is found to consist of several layers 
 of various colors and different degrees of density. The internal formation 
 consists of a dark-red substance, partly clotted and partly fluid, the coats 
 of the vessel being materially altered in structure. In false aneurism but 
 little deposit is found within the walls of the sac, while the external coat is 
 very much thickened by the constant accumulation of plastic matter which 
 has been deposited along the sides of the vessel from the continual " swash- 
 ing " within it. The strata or lamina sometimes are numerous and thick, 
 and bear no resemblance whatever to the coagula found in the interior of 
 the sac, which is nothing more nor less than simple coagulation. The 
 thicker the walls of an aneurismal tumor, the less perceptible is the sound. 
 
 Causes. — Of the causes of aneurism very little is known. The arterial coats, 
 from some conditions, appear to undergo degeneration ; there is a greater or 
 less deposit of fat-globules in their coats, the elasticity and strength of which 
 necessarily suffer ; their contractile power is lost ; they cannot sustain the 
 frequent shocks from the heart's pulsation ; they gradually enlarge and one 
 form or another of aneurism results. Again, there is a distinct deposit of 
 atheroma, which softens the lining membrane, and the inner and middle 
 coats become eroded. Any disease or predisposition which has a tendency 
 to produce these changes in the arterial tissues will, of course, favor the 
 formation of aneurism. Arthritis, syphilis, and the abuse or prolonged 
 use of mercurials, especially the latter, materially predispose to the dis- 
 ease. It is said that pulmonary consumption favors aneurism. By far the 
 most frequent cause of aneurism, however, is mechanical injury. Strains 
 and wounds are, in a majority of instances, the causes, and upon closely 
 questioning a patient it will be ascertained that the first symptoms will be 
 traced either to some violent muscular exertion, wound or injury. 
 
 Climate also possesses a remarkable influence, aneurism more frequently 
 occurring in cold than in warm latitudes. 
 
 , Spontaneous Cure. — There is no doubt that nature always endeavors to 
 cure an aneurism, both by the deposit of fibrinous layers in the coats of the 
 artery and the formation of a coagulum within the sac ; she is sometimes, 
 however, unsuccessful, but there are instances in which her efforts have 
 availed. The occlusion is brought about in several ways ; first, by inflam- 
 mation and necessary obliteration of the tumor ; from the presence of firm 
 coagula in the mouth of the vessel supplying the sac ; by an entire obliter- 
 ation of the artery below the sac, and by closure of the vessel by pressure, 
 either from the mass itself or other morbid growth. 
 
 The form of aneurism which is most favorable to spontaneous cure is the 
 true sacculated; the tubular variety or true aneurism does not admit so 
 readily of spontaneous cure. It is the deposit of the stratified fibrin 
 that, forming in concentric layers, gradually fills the sac and thus oblit- 
 erates it. 
 
 When nature, however, is unable to accomplish the result, and medical 
 or surgical advice has been either disregarded or proved insufficient, a fatal 
 termination may certainly be expected. The sac will burst externally, or 
 perhaps beneath the integument, thus forming a diffuse aneurism, which 
 
444 A SYSTEM OF SURGERY. 
 
 may result in gangrene and death; syncope may immediately ensue; or 
 inflammation may attack the wall of the tumor ; it may open gradually or 
 suddenly, discharging large quantities of blood; or, in other instances, pa- 
 tients may lose a great deal of blood from time to time after the rupture of 
 an aneurism, and die from pressure of the tumor. This happened to the 
 celebrated Mr. Liston, who died, not from haemorrhage, although the sac of 
 the aneurism was ruptured and a large coagulum was found projecting into 
 the trachea, yet death was occasioned by the irritation and exhaustion which 
 pressure upon the inferior laryngeal nerve produced. 
 
 Diagnosis. — From what has already been said regarding the symptoms of 
 aneurism, it will be seen that there are many cases in which the diagnosis 
 is readily made, whilst in other instances there is great difficulty. The fact 
 that every pulsating tumor is not an aneurism is perplexing. Sometimes 
 Hie diastolic impulse can be felt on all sides of the tumor, and even a dimi- 
 nution in its size take place from pressure on the cardiac side and no aneu- 
 rism exist. Very distinguished surgeons have thus been misled. Dupuy- 
 tren found a certain diastolic impulse on all sides of a malignant tumor of 
 the foot, and Nelaton stopped the pulsation of a tumor over the femur, 
 which proved to be a disease of the bone. Mr. Teale describes a case of 
 large serous cyst of the neck, extending below the clavicle in the vicinity of 
 all the large vessels, in which the pulsation was so great that both himself 
 and several other surgeons regarded the case as one of aneurism. 
 
 Dr. Stephen Smith, of New York, mentions two cases, one in which an 
 aneurism in the popliteal space was mistaken for a simple sarcoma, and 
 was operated upon, the patient dying in a short time, after a most profuse 
 loss of blood; and a second casein which a fatty tumor was diagnosed as an 
 aneurism. 
 
 The bruit, the location, the course of great vessels in the vicinity of a tumor, 
 materially assist in making a diagnosis. The character of the pain in aneu- 
 rism has been, at times, mistaken for neuralgia or rheumatism. The dis- 
 tinction is that aneurism pain is lancinating and intermittent, with a 
 continuous aching ; at times a burning sensation. When such have long 
 continued, and have defied the means employed for their relief, the surgeon 
 should bestow especial attention to the bloodvessels of the vicinity. 
 
 General Treatment of Aneurism. — There are two modes of treatment, the 
 medical and the surgical ; the first embracing not only those means em- 
 ployed to repair the constitution, but to prevent, if possible, undue action 
 of the bloodvessels, and even to diminish the power of the heart's action. 
 Valsalva's method, which is well spoken of by Hodgson, Pelletan, and Erich-, 
 sen, and which is certainly anomalistic, consists, first by starvation and de- 
 pletion to reduce the power of the heart, and then by an abundant supply 
 of food to promote the formation of fibrin. In addition, small bleedings 
 were sometimes resorted to as part of the treatment, the whole of which I 
 think should be ignored. 
 
 Rest. — Mr. Joliffe Tufhell* recommends most highly perfect, complete, and 
 prolonged rest. There must be no rising up, and as little movement as pos- 
 sible, for weeks and months together. During this time the diet must be as 
 follows : For breakfast, three fluid ounces of cocoa or milk and two ounces of 
 bread and butter. For dinner : three ounces of meat, either boiled or broiled, 
 three ounces of potatoes, and four fluid ounces of light wine or water. For 
 supper : bread and butter, nine ounces; milk or tea, two fluid ounces in a 
 day. 
 
 The patient may be quieted with five grains of lactucarium at night, and 
 pain subdued whenever it appears. He reports ten cases of cure. 
 
 * Successful Treatment of Internal Aneurism. London, 1875. 
 
TREATMENT OF ANEURISM. 445 
 
 Dr. Head* thus gives his experience in treating a case of aneurism of the 
 innominate artery by Tufnell's method : 
 
 A patient had a spot about the size of a five-shilling piece on the chest 
 below the right collar-bone. He had suffered much from neuralgia in the 
 back and shoulder and was at once subjected to Tufnell's method of treat- 
 ment, which consists in the horizontal posture, absolute rest, solid food, and 
 little liquid. No medicine was given, except occasional doses of aconite, 
 when palpitation occurred. After the recumbent posture for over three 
 months, he was permitted to get up, when he fell into a state of mental de- 
 pression, and ended his life by throwing himself into the river. 
 
 The medical treatment of aneurism is of great importance, as there are 
 medicines which have a specific power over the heart's action and the great 
 vessels, and others which have a decided influence over the plasticity of the 
 blood. Of these, veratrum viride must always be remembered. I have wit- 
 nessed its beneficial effects in haemorrhage. In a case of severe gunshot 
 wound of the ear, in which profuse and almost uncontrollable haemorrhage 
 took place, veratrum viride was given, five drops every three hours until 
 the pulse went down to fifty-five or sixty beats in the minute, and so was 
 kept for some days. The haemorrhage ceased. The same amount of com- 
 pression was used before the use of the medicine as after, but the bleeding 
 would invariably recur. Belladonna, aconite, digitalis, and gelseminum are 
 all medicines which should be given regularly for a time, and then one of 
 the following, viz. : calcarea, lycopodium or sulphur ; the phosphate of lime 
 or the sulphate of soda may be required, perfect rest being enjoined. 
 
 A great deal lately has been written on the treatment of aneurism with 
 large doses of iodide of potash, and remarkable results have followed its 
 administration, Dr. Da Costa, of Philadelphia, believing it, together with 
 secale, to be the only two medicines for the disease. Drs. Clutterbutty, of 
 Calcutta, and Balfour, of Edinburgh, are advocates of this method of treat- 
 ment. The doses given were from fifteen to thirty grains of the substance. 
 Dr. Roberts also speaks favorably of the drug.f The actea racemosa has 
 been used by Dr. Von Gottschalk, and lycopodium by Dr. A. S. Ball. I 
 have now a case of thoracic aneurism, in which the iodide of potash is 
 being administered ; as yet there is no perceptible improvement. In another 
 very aggravated case it entirely failed. 
 
 I must, from some personal experience in the treatment of internal 
 aneurism, state my convictions that gallic acid in half-drachm doses is the 
 most effective medicine in the cure of aneurism. In one instance a patient 
 was brought to me from San Francisco, with an immense aneurism of the 
 arch of the aorta, The following are my notes of the case. 
 
 Mr. P., a resident of China, was first taken with intermittent fever at a 
 town on the Yang-Tse-Kiang River, and had it for nearly a month ; he 
 suffered a great deal of pain through his chest, and was ordered a change 
 of climate. His disease was called "rheumatism of the heart." He then 
 went to Shanghai, and was attended by a French physician, and improved, 
 but the trouble began again to develop. He had great pulsation in the 
 neck from the slightest cause, also severe neuralgia in the head, particularly 
 on the left side. Motion became almost impossible, on account of the 
 violence of the pulsation, which any attempt to move was sure to produce. 
 He went four hundred miles further south, but the trouble still continued. 
 There he was treated by an English physician, who called the disease 
 aneurism of the heart. He was so weak that the doctor thought he would 
 die before he could get to Japan. He then visited San Francisco, and 
 
 * The Medical Record, March loth, 1879.— No. 436. 
 f British Journal of Homoeopathy, vol. xxi., p. 494. 
 
446 A SYSTEM OF SURGERY. 
 
 nearly died while there. The doctor gave him medicine, which relieved 
 him for a time ; he thought that he was improving, and returned home. 
 He arrived there in June, and had to leave in September. Then he came 
 to New York, and was brought to me by Dr. White, of Harlem, and went 
 into the hospital on the 15th of October. When I saw him he had no 
 radial pulse ; he had an enlargement on the upper side of the chest, with 
 a pulsation or bruit, which was very well marked, and of tremendous 
 power. He was sleepless and restless, and suffered a great deal from 
 neuralgia, but never lost his appetite. His digestion was good from the 
 first. He felt' so miserable that, as he expressed it, " he did not care whether 
 he lived or died." I gave him one-half drachm of gallic acid three times 
 a day in cinnamon water, and kept him in a recumbent position, though 
 not continuously, for four months. His many symptoms were quieted from 
 time to time, but the peculiar nervous phenomena were remarkable. For 
 instance, he would lose all control of certain muscles or nerves. He would 
 have a piece of beef on his fork, and endeavor to put it to his mouth, but 
 suddenly would lose control of his arm, and the meat would go over his 
 head. He did not appear to have any control over the nerves or the volun- 
 tary muscles. Before taking the acid, his hands were constantly numb, and 
 for a number of days after he spit blood, accompanied with a great deal of 
 phlegm, which nauseated him. 
 
 After four months' treatment all his symptoms subsided ; he was able to 
 go about his usual business. He died about fourteen months after, from 
 lobular pneumonia, in intense agony, owing to the pressure of the consoli- 
 dated aneurism on the inflamed parenchyma of the lung. Before his depar- 
 ture from the hospital he had promised me that a post-mortem should be 
 made, and bequeathed to me the specimen. I have it now in my collection, 
 a perfectly consolidated sac, measuring 3J inches in diameter and 14* inches 
 in circumference. Through the centre is a channel about half the size of a 
 healthy aorta ; adhesions had taken place to the column and to the sur- 
 rounding structures. 
 
 In one other case I have had a somewhat similar, though not so marked 
 a result, while again in another there was no permanent benefit. 
 
 I was led to this treatment by perusing a paper by S. Fleet Spier,* of 
 Brooklyn, who alternated the gallic acid with five minims of the liq. ferri 
 subsulph. 
 
 Compression. — This method of treating aneurism is at present much in 
 vogue, and from its safety and the success which has attended it in many 
 instances, much may be expected of it. By referring to the chapter on the 
 " Means and Instruments for Arresting Haemorrhage," several tourniquets 
 and compresses for this purpose are mentioned, but the best kind of com- 
 pression is that made by the fingers, and should always be selected, provided 
 the requisite number of assistants can be obtained. It must also be recol- 
 lected that the object in applying compression is not entirely and at once 
 to obliterate the vessel, but to cause the passage of the current more slowly, 
 and thereby favor the formation of laminated fibrin. For this reason, 
 especially, medical means may be combined with the local, and the heart's 
 action be materially lessened, especially by the use of veratrum viride. An 
 objection to more forcible compression than that with the fingers is the 
 danger of impairing the vitality of the structures. To avoid this risk also 
 the pressure should be made in two places; if for popliteal aneurism, for 
 instance, it should be applied alternately, first at Poupart's ligament, and 
 secondly at the apex of Scarpa's space ; if the aneurism be in the forearm, 
 pressure should be made first on the radial and then on the ulnar side, thus 
 
 * Medical and Surgical Reporter and Medical Record. 
 
TKEATMENT OF ANEUEISM. 447 
 
 relieving the patient of the severe pain which is occasioned by the continued 
 compression. If it be possible to combine forced flexion with the pressure, 
 an additional advantage will be gained. For the methods of applying flexion 
 to arrest the circulation, the reader will refer to the chapter on Arresting 
 Haemorrhage. 
 
 The treatment of aneurism by pressure or by compression, is not of recent 
 date, and although medical historians are not exactly agreed as to the pre- 
 cise time when this method was inaugurated, it is said that Jean de Vigo, 
 a physician of Geneva in the sixteenth century, conceived the idea, and 
 that Tulpius, a professor of Amsterdam, in 1641, recorded a successful case 
 treated in this manner, the aneurism being situated between the thumb and 
 forefinger. 
 
 The first instrument devised for the pressure treatment was that of the 
 Abbe Bourdelot, and was called & ponton; it consisted of a pad of peculiar 
 shape, with a channel or groove on its under surface which was supposed 
 to allow a portion of the blood to pass beneath it, and from which circum- 
 stance, the term "ponton" or bridge, was applied to it. In those days the 
 majority of external aneurisms were situated at the bend of the elbow in 
 the course of the brachial artery, occasioned by accidentally wounding the 
 vessel in venesection. This indeed was the cause of the tumor in the case 
 of Bourdelot, and it was for his own case that the instrument was invented, 
 and which he wore continuously for a year before the cure was effected. 
 
 After that period many compresses were invented and modified by'Vallant, 
 Serefno, Armaud, Heister, Fourbert, Petit, Dupuytren, Scarpa, Tenooni, 
 and others, and to this day, those interested in the subject can find records 
 of tourniquets, pads, weights, and rings adapted for the compression of 
 external aneurism. 
 
 The varied points at which pressure has been applied is also a matter of 
 interest. Bellingham tell us that by some it was directed immediately upon 
 the aneurismal sac ; by others, the sac and the entire limb were at the same 
 time compressed, which is a somewhat similar method to that about to be 
 more fully considered. Then again, the point believed to be the best was 
 upon the artery between the aneurism and the heart, which was modified 
 again by additional pressure on the sac. After these had been employed 
 with more or less success for a considerable time, the idea of exerting com- 
 pression on the distal side of the tumor (probably arising from the success 
 of Bradsor's and Wardrop's ligature) was carried out and was effective in 
 the hands of several surgeons, while others declared that the sac should be 
 laid open (after the method of Antyllus) and pressure made upon the rup- 
 tured vessel. A combination of dissection and pressure has been • also 
 recommended, the main vessel being exposed by dissection and upon it the 
 weight directly applied. 
 
 The duration of treatment by compression varies much, as does also the 
 immediate effect produced upon the tumor; sometimes this is immediate, 
 the swelling becoming more solid, the bruit less marked, the pain less severe, 
 and the pulsation ceasing rapidly. 
 
 Generally, however, the changes are more gradual. In twenty-six cases 
 of popliteal aneurism in the London hospitals treated by compression, Mr. 
 Hutchinson records the average time as nineteen days. Dr. Agnew, of 
 Philadelphia, reported a very interesting case of double popliteal aneu- 
 rism, in which the left one, being the largest, was treated first by tour- 
 niquets and digital compression, and the right side by digital alone, 
 conducted by trustworthy assistants, each keeping his position for about 
 thirty minutes. For the first twenty-four hours there was considerable but 
 bearable pain, occasioned by the establishment of the collateral circulation. 
 In thirty -six hours great restlessness came on, and in forty-eight hours the 
 
448 A SYSTEM OF SURGERY. 
 
 suffering was so great that the instruments were abandoned and digital 
 compression alone continued for seventeen additional hours, when all pul- 
 sation ceased. The patient was then allowed three days' rest, and the right 
 leg was then subjected to digital compression. In seven and a half hours 
 all pulsation ceased in the tumor, and in twenty-four hours the compression 
 was relaxed.* 
 
 In two cases of my own f the compression was kept up seventy-two and 
 eighty hours respectively by relays of medical students. There were six 
 classes, each composed of five students ; each class was relieved every six 
 hours, each student making pressure at some point in Scarpa's space for 
 twelve minutes. Thus it will be seen that each gentleman made direct pres- 
 sure on the femoral three times during his period of service. Pulsation 
 ceased in twenty-four hours, but for the sake of security pressure was 
 made in the same manner from 9 o'clock in the morning until 9 o'clock 
 at night, for three days. At that time there was no bruit or pulsation, 
 the collateral circulation was fully established, the tumor was diminished 
 to one-half its size, being perfectly firm and circumscribed. 
 
 It is very important during this treatment that the whole limb be evenly 
 and uniformly bandaged and closely watched, lest appearance of gangrene 
 should supervene. The statistics presented thus far favor compression rather 
 than the ligature ; thus in the thirty-fourth volume of the Medical and Sur- 
 gical Transactions, Dr. Bellingham, a strong advocate for this method, gives 
 thirty-two cases treated by it, of which twenty -six were cured; one failed, 
 and recourse was had to the ligature; in two, amputation was performed; 
 two died, and one failed, the pressure being discontinued. Of one hun- 
 dred and eighty-eight cases, recorded in Dr. George Norris's tables upon 
 the ligation of arteries, one hundred and forty-two were cured, forty-six 
 died, six were amputated ; in twelve suppuration and gangrene followed ; 
 showing a proportion of deaths of one to four, and accidents one to three, 
 while the compression exhibits a proportion of failures 1 to 5.3, and of 
 deaths 1 to 16. 
 
 Mr. T. Holmes reports two cases of traumatic aneurism successfully treated 
 by direct pressure. One, a subclavian aneurism, was compressed by means 
 of a rubber ball bandaged on to the tumor, and subsequently replaced by a 
 pad, gradual consolidation taking place. The other, a femoral aneurism, 
 was made to consolidate by means of digital pressure upon the femoral 
 artery at the brim of the pelvis by relays of students. This compression 
 was kept up for twenty-six consecutive hours, the bruit at that time having 
 entirely disappeared, and but slight pulsation remaining, which disappeared 
 after a few days, upon a short renewal of the pressure.^ 
 
 Manipulation. — This treatment of aneurism, introduced by Sir William 
 Fergusson, imitates nature in the endeavor to form new clots within the 
 eac. By manipulation, a certain amount of force being used, the clots are 
 broken, and carried from the external wall of the aneurism and pushed 
 into the current of the circulation, thus forming so many new centres of 
 coagulation. Fergusson has published cases of cure by this method, and 
 Dr. Van Buren § thinks that most of the spontaneous cures of aneurism 
 which have been reported have taken place in this manner ; care, how- 
 ever, must be taken lest rupture of the sac or embolism of adjoining vessels 
 result. 
 
 * Vide Medical and Surgical Reporter, Philadelphia, August 12th, 1871 ; also New York 
 Medical Record, New York, August, 1872. 
 
 f Transactions of the Horn. Med. Society of the State of New York, 1873-74, p. 141. 
 
 t Month. Abs. of Med. Science, April, 1876; Lancet, February 12th, 1876. 
 
 | Treatment of Aneurism. Transactions of the International Medical Congress at Phila- 
 delphia, 1876, p. 565. 
 
THE RAPID METHOD OF TREATING EXTERNAL ANEURISM. 449 
 
 The Old Operation. — The so-called old operation, which dates back to the 
 times of Antyllus, but which was revived by Syme, consists in arresting the 
 blood by compression above the vessel, then opening the sac, turning out 
 the clots, and applying a ligature above and below it. This operation has 
 always been considered daring, dangerous, and difficult ; but Mr. Syme, 
 with that boldness which characterized his surgical achievements, performed 
 the same successfully in cases of popliteal, axillary, gluteal, iliac, and carotid 
 aneurisms. Esmarch's bandage carefully applied would be a valuable ad- 
 junct in the performance of such an operation. 
 
 The Rapid Method of Treating External Aneurism. — If blood be drawn from 
 the body and allowed to remain at perfect rest, a true blood clot is formed, 
 consisting of fibrin, white and red corpuscles and serum ; if, however, this 
 blood be defibrinated by whipping, as is done previous to transfusion, 
 the fibrin adheres in strings and shreds to the instrument used, the 
 corpuscles and serum remaining in a semi-liquid state. This is merely a 
 physical effect, and is true without the body as well as within it, as shown 
 in the character of the clot which is found above the ligature after an artery 
 has been tied, and also by the bits of fibrin that tip the valves of the heart 
 in certain organic forms of cardiac disease. Therefore, in the one case we 
 have a true blood clot, which can become either organized (as we see in the 
 occluded artery — the leucocytes rapidly adhering to the coats of the vessels, 
 and proceeding without delay to the formation of tissue) or disintegrated 
 or destroyed, as we may observe in certain cases of venous thrombi, while 
 in the other case we have merely laminated fibrin that remains laminated 
 fibrin forever, no matter how old the case may be; or a soft clot without the 
 power of even forming a single lamina. From these deductions the rule 
 has been laid down that " laminated fibrin is only separated from blood in 
 motion ; when once formed it is very stable, not prone to disintegration or 
 to organization. A true blood clot is only formed when the blood is at ab- 
 solute rest; and when formed the clot is unstable, readily being organized, 
 disintegrated, absorbed or converted into a dry, friable material, " — which 
 formula will explain both the rationale of cure and of failure by the so-called 
 rapid method. 
 
 The object, as has already been explained, is to form a true blood clot, 
 which can only be accomplished by keeping the blood quiet in the sac. To 
 this end, therefore, the patient being recumbent, beginning at the distal ex- 
 tremity of the limb (let us say at the toes for a popliteal aneurism), the 
 "Esmarch " is wound tightly around the limb until the aneurism is reached, 
 over which a few light turns are made, merely as a means of support to the 
 walls of the tumor, and so soon as the aneurism is passed, the india-rubber 
 must again be tightly applied up to the centre of the thigh, and there made 
 fast, either by a few extra turns or by the elastic tubing. Some surgeons 
 prefer to leave the aneurism entirely uncovered, applying the elastic above 
 and below it ; others (as I understand from a case lately treated by Dr. R. 
 F. Weir, in the New York Hospital) put on the " Esmarch " up to the site 
 of the aneurism, while the patient is recumbent, then he is placed erect and 
 the adjustment of the elastic above the tumor completed. This is done, 
 first, to fill the sac, and second, to shut off all communication with it, both 
 above and below. Others have applied the tubing above at the cardiac side 
 of the tumor. It may be interesting in this place to state that Dr. Walter 
 Reid, of the English Navy, is the author of the method of treatment we are 
 now considering, and that he was led to the idea by perceiving how well 
 the elastic tourniquet was borne for over an hour in a case of necrosis of the 
 femur upon which he was operating. Having at that time a case of popliteal 
 aneurism under his care, on September 11th, 1875, at 10.20 o'clock a.m., he 
 applied the elastic roller, as I have already mentioned, and removed it in 
 
 29 
 
450 A SYSTEM OF SURGERY. 
 
 fifty minutes, on account of the severe pain it occasioned. There was still 
 some pulsation in the tumor and a Cait's compressor was lightly applied till 
 the next evening, when the patient was cured. This case is recorded in full 
 and will repay perusal.* 
 
 This treatment is certainly a variety of the compression method, which 
 has already been alluded to, but differs very materially from that either 
 by the ordinary tourniquet, by digital compression, or by the ligature. 
 
 So soon as the circulation is arrested, either by digital compression or by 
 a pad, or by a ligature to the artery on the cardiac side of the tumor, 
 the bloodvessels in the vicinity of the obstructed artery at once begin 
 to expand, and in a short period the collateral circulation is established, 
 and a few drops of blood force themselves into the aneurismal sac and 
 a small stream finally trickles through the centre of the tumor, thus dis- 
 turbing the stability of the clot, interfering with its proper organization, 
 and necessarily protracting the time occupied for the cure from several days 
 to several weeks. In a case of popliteal aneurism which came under my 
 care, I was obliged to continue digital compression at Scarpa's space for 
 seventy-five hours, night and day, without interruption, and after an inter- 
 val of some hours, to re-apply it, before the cure was effected ; and this 
 was considered a short period when compared with the time occupied in 
 the treatment of other cases. 
 
 Esmarch's bandage, as now employed, acts in a very different man- 
 ner; the entire circulation is arrested above and below the aneurismal 
 tumor and the formation of a true clot thus materially favored. This clot 
 then becoming firm, there is an additional plug formed in the artery itself, 
 which, if the blood be in a good condition, proceeds rapidly to organiza- 
 tion and the aneurism is cured, or becomes disintegrated, and the effort is 
 a failure. 
 
 Dr. A. Pearce Gould has tabulated seventy -two cases treated by this method, 
 of which there were thirty-five cured. In two the result was doubtful ; five 
 died, and in thirty the aneurisms were not cured ; showing a success of 
 about fifty per cent. Of those cured, one was of the anterior tibial, one 
 iliac, five femoral, and twenty-eight popliteal. Of the failures, there were 
 twenty-four cases of popliteal, three of the femoral, two brachial, one axil- 
 lary and one of the internal circumflex. Some of these cases were subjected 
 to a preparatory treatment by medicine and rest, and some were not. Of 
 the twenty-eight cases of popliteal aneurism, the bandage was applied once 
 in eighteen cases, twice in five cases, and more than twice in four cases, and 
 in one case the record is not clear. 
 
 In twenty-nine successful cases the length of time the bandage was allowed 
 to remain on the limb is also given. In five cases the time was under an 
 hour ; in eighteen cases, over an hour and under two ; in two cases, more 
 than two and less than three hours ; and in four cases the bandage was not 
 removed for over three hours. In many instances — indeed, in Dr. Reed's 
 first case — the combined treatment of bandage with instrumental compres- 
 sion has been employed. Thus, Mr. Wagstaff applied the bandage fifty 
 minutes, followed by two tourniquets for six and a half hours ; loosely, 
 for eleven and a half hours, and more loosely for eleven hours more. 
 
 Heathf records a case, in which the bandage was employed for an hour, 
 Signorini's tourniquet for five hours, and loosety for two days longer. In 
 T. Smith's case the bandage remained on the limb for an hour, and Signorini's 
 tourniquet for two hours more. Mr. Tyrrel used the bandage for fifty 
 minutes, digital compression for two hours, and a compressor at the groin 
 
 * London Lancet, 1875, vol. iii., p. 448. 
 t Loc. cit, vol. ii., 1876. 
 
THE RAPID METHOD OF TREATING EXTERNAL ANEURISM. 451 
 
 for a time after. In fact, in many of the recorded cases a combined treat- 
 ment seems to have been necessary. 
 
 While upon this subject it is important to bear in mind that the rapid 
 method is not devoid of danger, and that Mr. Gould, in his tables, records 
 deaths during or shortly after the treatment ; one occurring in the practice 
 of Dr. Weir,* of New York, in which the autopsy showed fatty degeneration 
 of the heart. The second was under the care of Mr. F. A. Heath ; the post- 
 mortem revealing a ruptured aneurism of the aorta. The third was under 
 the charge of Mr. Rivington, and was peculiar, in that a small aneurysmal 
 tumor below the right knee had been opened and a diffuse aneurism created. 
 The Esmarch was applied and gangrene resulted. The examination after 
 death revealed a rupture of the anterior tibial artery. In a fourth instance, 
 after the aneurism had consolidated, gangrene, also, made its appearance, 
 and amputation was resorted to, but the patient perished. It has been 
 argued that in all these cases the demise was not caused by the treatment, 
 but it appears to me that strong evidence may be adduced to the contrary. 
 It must be remembered that by accurate calculation, it has been found that 
 in applying the Esmarch bandage from the toes to the middle of the thigh 
 in a man of 168 or 170 pounds weight, about one pound of blood is forced 
 back into the circulation. Those who are familiar with transfusion will 
 remember that often an ounce or two of blood thrown into the vascular cur- 
 rent produces severe palpitations and cardiac commotions ; it may, there- 
 fore, readily be seen that such an amount of sudden tension as would 
 necessarily follow the introduction of so large a quantity of blood into the 
 body, might so overtax a weak heart as to cause it to readily break down ; 
 or, if an aneurism existed (as was the case in that under the care of Mr. 
 Heath) a rupture of an internal aneurism might result from sudden arterial 
 tension, or an atheromatous artery give way, cutting off all blood supply, 
 and gangrene be readily produced. 
 
 The question now remaining to be considered is how the cure is wrought 
 by this method of treatment. 
 
 In all the cases of death recorded by Mr. Gould, examinations, post mor- 
 tem, of the aneurism showed the following appearaces : The clot found in the 
 aneurismal sac was of the mixed variety, soft and not fully organized in the 
 centre; whereas, that which occluded the artery had become a perfectly or- 
 ganized substance — a true fibro-cellular tissue. This difference, however, 
 in structural formation is readily explained. An Esmarch is applied in the 
 manner I have already described. Of course, before any treatment has 
 been adopted, the cavity of the aneurism will contain the external lami- 
 nated fibrinous clot caused by the whirling of the blood through its cavity. 
 As soon as the circulation is entirely cut off, a true blood clot forms, a clot 
 which, if the blood be in a healthy condition, and surrounded by normal 
 structures, is capable of becoming transformed into fully organized sub- 
 stance. But this clot, viz., that within the tumor, is not surrounded by 
 healthy tissue ; it is in contact for most of its circumference with simple, 
 unproductive fibrinous deposit, containing neither bloodvessels nor nerves, 
 which is again overlaid by the distended, and very often diseased, arterial 
 walls ; therefore, there are no favoring circumstances for further complete 
 organization ; yet the clot is of sufficient plasticity to obstruct the passage 
 of blood into the tumor when the pressure is removed from its cardiac side. 
 
 Let us see now what happens : The pressure is "let up;" the blood flows 
 speedily down along the vessel to the aneurism, and there is arrested by the 
 clot within the tumor. No sooner does this stoppage in the circulation 
 take place, than a clot immediately forms in the vessel, and is at rest at its 
 
 * Medical Archives, April, 1880. 
 
452 A SYSTEM OF SURGERY. 
 
 aneurismal side; still the blood flows on, the clot extends upward in the 
 tube, there is an additional amount of leucocytes and red blood corpuscles 
 packed together, which generally continues up to the first anastomotic 
 branch, where the division of the blood stream causes the further forma- 
 tion of a true blood clot impossible. The walls of the artery are in a healthy 
 condition, well nourished by arteries, veins, and nerves ; by their amoeboid 
 motion the leucocytes begin rapidly to adhere to the internal wall of the 
 vessel, and, as is well known, cell development and stable corpuscles are 
 formed, until finally a consolidated and completely organized plug fills up 
 the artery, and thus the aneurism is cured. 
 
 If, on the other hand, from a poor condition of the blood, or increased 
 disease of the arterial wall, a very unstable clot is formed within the aneu- 
 rism, then upon relinquishing the pressure on its cardiac side, the clot is 
 not able to stand against the vis a tergo of the blood stream, and is disinte- 
 grated and washed out, and the result is a failure. 
 
 Therefore, the process of cure depends first, upon a blood clot within the 
 sac, of sufficient stability to obstruct the arterial flow ; second, and more 
 especially, upon the obliteration of the vessel by the formation of a fibro- 
 cellular plug within the tube. 
 
 Injection into the Sac. — The treatment of aneurism by injections of the per- 
 chloride of iron has caused much interest among surgeons. Dr. Pravaz first 
 introduced the practice, and it has been since used by many surgeons with 
 varied success. Its failure in some instances has been attributed to the fact, 
 that either too much or too little of the perchloride was injected ; the quan- 
 tity of fluid to be used not having been specified. The effect is generally 
 the immediate formation of a clot in the sac — arrest of pulsation and finally 
 obliteration of the trunk of the vessel. 
 
 The dangers attendant upon this practice should receive serious consider- 
 ation. Fever results, and formation of pus in the artery has taken place. 
 
 Excessive injection excites acute inflammation of the sac, followed by 
 ulceration and expulsion of the clot ; the essential part of the operation 
 consists in so managing that there should be slow absorption of the foreign 
 matter introduced within the tumor. 
 
 Pravaz remarked that in the case of an aneurism the size of a pigeon's 
 egg, he would not inject more than four or five drops of the perchloride, and 
 that he would repeat the operation should the pulsations in the tumor not 
 cease after a certain time. 
 
 The persulphate of iron has also been used successfully, as likewise the 
 ergot of rye (secale cornutum), as already mentioned, page 155. 
 
 The following interesting case is recorded to show what value may be 
 placed in some instances upon hypodermic medication : 
 
 Prof. Von Langenbeck reported a case to the Medical Society of Berlin, 
 on the 17th of February. The patient, a man forty -five years of age, with 
 strong constitution and previously healthy, was attacked in the spring of 
 1864 with pain in the right arm, which radiated from shoulder or side of the 
 neck ; was treated for rheumatism with sulphur baths. Pain increased, de- 
 priving him of sleep ; the arm grew weaker, and in September a pulsatory 
 swelling on right side of the neck was observed. In October the doctor traced 
 the same to the right fossa supraclavicularis and found an aneurism the 
 size of a pigeon's egg. A moxa of neutral chrom. potass, was applied to sac, 
 from the beginning of October until December four times, at intervals of 
 three or four weeks. Under this treatment the symptoms improved ; pain 
 almost vanished ; now and then, however, the patient observed a slight 
 twitching of the arm, and in the beginning of January he returned to his 
 home. From January, 1865, to the summer of 1868, he was apparent^ well 
 and pursued his former occupation. The aneurism had become smaller 
 

 TREATMENT OF ANEURISM BY LIGATURE. 453 
 
 and caused no trouble, although it still plainly pulsated. During the sum- 
 mer of 1868 the patient visited Misdroy for sea-bathing, after which his con- 
 dition became rapidly worse. The swelling increased, the pulsations were 
 stronger, and the pain reappeared ; the arm became weaker and sleep again 
 deserted him, and so continued until January 1st, 1869, when the doctor 
 made the first hypodermic injection of 0.03 gram of ext. sec. cornut. aq. From 
 January 6th to February 17th (and generally at intervals of three days) 
 there was injected altogether two grams of ergotin in doses of 0.03 to 0.18, 
 since which the improvement steadily went on, the pulsation being per- 
 ceptibly weaker, the circumference materially decreased, the jugular more 
 superficial, and the fossa triangularis between the sterno-mastoidei almost 
 restored. No constitutional effects were observed from the ergot. On the occa- 
 sion of the injection of 0.18 gram the patient complained of glittering before 
 the eyes and giddiness, but the doctor thought it might have arisen from some 
 other cause. The injections were made in the morning between eleven and 
 twelve o'clock, and always under the skin covering the aneurism. Dr. Lan- 
 genbeck has thus far used the watery extract of Bonjean. R. Ex. secale 
 corn, aq., hrxI; Spir. vin. rectif., Glycerin, aa 3ij* 
 
 Dr. Eckel reports a case of a married woman, aged forty-six years, in 
 which a tumor, on April 23d, 1870, was as large as an English walnut, with 
 pains and other symptoms much the same as the foregoing, when an ice 
 compress was ordered to be renewed every hour. Aeon, and bry. that night 
 were given. " On the 24th, no change ; tried lachesis. On the 25th, patient 
 same; injected three drops of secale corn. (English preparation; it is said 
 one drop is as strong as one grain of the powder) under the skin over the 
 centre of the tumor ; cold water continued, sleep obtained, and pain relieved. 
 Injections repeated on April 27th and 29th, May 1st and oth, when slight 
 erysipelas set in and injection omitted for four days, but on the 10th, the 
 erysipelas having entirely disappeared, the sixth injection was made. Swell- 
 ing now much less, and great general improvement. On June 1st, made the 
 twelfth injection, and, for the present, the last. At the last four injections 
 ten drops were used; in all, seventy -six drops of ergot, followed by no bad 
 result. On June 6th, patient ordered outdoors ; she had good appetite, 
 slept well, no pain, pulsations very faint." Dr. Eckel asks why caulo- 
 phyllin could not be used in such cases, no good resulting from aeon., bry., 
 sulph., lach., or digitalis. 
 
 " On June the 14th the patient ceased complaining, and could dress her 
 own hair. The aneurism was reduced one-half. "f 
 
 Galvano-puncture.— In 1832 Phillips introduced the following method of 
 treating aneurism. It consists in the introduction of galvanic needles into 
 the sac, applying the battery, and thereby causing coagulation. According 
 to Drs. Beard and Rockwell, the treatment requires a battery of from five to 
 twenty cells. Insulated needles, two or three in number, and connected 
 with the negative pole of the battery, must be thrust into the tumor, while 
 an electrode of sponge is laid near by. Dr. A. McL. Hamilton has collected 
 ninety cases in which the galvano-puncture was used, and gives forty- eight 
 cures. For further information the reader is referred to the section on 
 Electrolysis, page 58. 
 
 Ligature. — The various methods of applying the ligature and the best 
 materials employed will be found in the chapter on Haemorrhage, as well 
 as explicit directions for tying the knot. At this place ligatures will be 
 noticed only in connection with aneurism. 
 
 There are several places at which the ligature may be applied. First, 
 
 * U. S. Med. and Surg. Journ., Chicago, Julv, 1870, p 458. 
 f U. S. Med. and Sarg. Journ., July, 1870, p. 490. 
 
454 A SYSTEM OF SURGERY. 
 
 above or on the cardiac side and close to the tumor, as was used by Anel, 
 who placed a ligature on the brachial artery above the tumor, on the 30th 
 of January, 1710. Since then the operation has gone by his name. In the 
 Hunterian method the application of a ligature is made to the cardiac side, 
 but farther away from the sac, thereby avoiding all diseased structures, and 
 constricting the artery at a point where all the coats are healthy ; this idea, 
 however, has been objected to very emphatically, and especially by Mr. 
 Syme, who argued that the size of the tumor does not depend upon the 
 state of the vessel, and therefore forms no criterion of the extent of the ab- 
 normal condition, while the formation of the clot, so far from being inju- 
 rious, would rather contribute to strengthen and support it by consolidating 
 the textures in the neighborhood. Hunter's operation was performed in 
 December, 1785. 
 
 Brasdor's method consists in tying the vessel at the distal side of the aneu- 
 rism. This process was at first ridiculed, and like many other remarkable 
 advances in surgery was nearly abandoned in consequence of the unsuc- 
 cessful terminations of the first cases. Deschamp first tied the femoral, and 
 the patient died, the pulsation rapidly increasing after the ligature was 
 applied. Allan Burns and others denounced the method as perfectly ab- 
 surd. Astley Cooper, however, in 1818, convinced of the feasibility of the 
 process, successfully applied a ligature to the distal side of a tumor of the 
 groin. In 1825 Mr. Wardrop placed a ligature on the common carotid, and 
 in 1826 another, which brought the operation conspicuously before the pro- 
 fession. This operation bears the name of Wardrop as well as that of 
 Brasdor. 
 
 Thus there are three points d'appui in aneurism : 
 
 1st. Anel's method, cardiac side, close to tumor. 
 
 2d. Hunter's method, cardiac side, remote from tumor. 
 
 3d. Brasdor's or Wardrop's method, on distal side. 
 
 The old method was to ligate the trunk of the vessel above and below the 
 aneurismal tumor, as already mentioned. 
 
 The Carbolized Catgut Ligature. — By this method the danger of secondary 
 haemorrhage is certainly lessened, although it is claimed by some that the 
 animal tissue becomes soft in too short a period of time, and that secondary 
 bleeding will result. Mr. Flemming,* who has made many experiments with 
 this form of ligature, says, " that a gradual softening of the ligature takes 
 place from without, inwards, the catgut breaking down and becoming infil- 
 trated with cells, probably leucocytes. This process takes from five days to 
 about twenty, varying with the specimen of catgut, the tissues among which 
 it is situated, and the age and vitality of the animal. Last, the pultaceous 
 mass into which it has been converted begins to metamorphose and is soon 
 permeated with blood-channels, and ultimately may be described as a cat- 
 gut, in a kind of granulation-tissue, freely supplied with bloodvessels, which 
 in many of my sections are very fully injected. If, then, we admit these 
 conclusions, we can easily account for the different results obtained by the 
 use of catgut in different hands." That is to say, that if there is sufficient 
 obstruction lasting long enough to procure the formation and hardening 
 of the clot the result will be favorable ; if not, secondary haemorrhage will 
 result. In other words, the u sample of catgut " and the " vitality of the 
 patient " regulate the success of the ligation. 
 
 In all these operations the ligature must not be drawn too tight ; the object 
 being to cause a deposit of lamellated fibrin wherewith to obstruct the vessel. 
 
 Of percutaneous ligation, acupressure, Spier's constrictor, and other 
 methods, descriptions are contained in the Chapter upon Haemorrhage. 
 
 * Lancet, May 27th, 1876. 
 
TREATMENT OF ANEURISM BY LIGATURE. 455 
 
 The After-effects of the Ligature.— The symptoms following the applica- 
 tion of the ligature are either immediate or remote, and are very important. 
 They are: 1st. Coldness or heat of the part; 2d. Inflammation and sup- 
 puration; 3d. Gangrene; 4th. Shock; 5th. Shrinkage; 6th. Arrest or return 
 of pulsation. 
 
 In the majority of instances, shortly after the ligature is applied, the parts 
 become cold from arrest of the circulation, to counteract which the limb 
 should be wrapped in carded cotton immediately after the operation ; but 
 instead of coldness, very often an intense degree of heat follows, which is 
 the concomitant of inflammation. For this untoward symptom, the limb 
 should be lightly bandaged, and a few drops of the tincture of aconite be 
 mixed with four ounces of water, of which a tablespoonful should be taken 
 every hour. The part should also be elevated. If, in connection with the 
 intense heat, the swelling should increase in size, become reddish and dis- 
 colored, the wall of the sac become thinner, and finally give way, there will 
 be liberated pus, coagulated blood, and often a fetid fluid, commingled with 
 soft broken-down clots. This haemorrhage may in a short time prove fatal 
 from the amount of blood, or it may continue to discharge in small quantities 
 for a longer period of time. If, however, suppuration and sloughing of the 
 sac take place a considerable time after the application of the ligature, the 
 secondary haemorrhage does not invariably follow, the mouth of the artery 
 having been doubtless effectually closed by a coagulum. 
 
 In treating such cases, the better plan is, when the evidences of suppura- 
 tion are unmistakable, to open the sac, turn out the contents, and, if haemor- 
 rhage take place, arrest it either by compression, ligating the vessel in the 
 wound, or tying it in a healthy part above the sac. In severe cases, when 
 there is no time to be lost, the actual cautery should be immediately and 
 freely employed. If these means fail, there remains amputation, which, 
 though a desperate alternative, may prove effectual. 
 
 Sphacelus. — If gangrene commence, intense pain is experienced along the 
 entire course of the limb, which assumes a mottled appearance, the color 
 being rather of a livid and greenish hue than the ordinary purple, with its 
 surface covered with phlyctaenae. 
 
 In such cases the condition of the patient may be regarded as almost 
 hopeless, and nothing remains but to amputate. This, however, should not 
 be done without due deliberation ; time should be allowed to ascertain 
 whether the disease becomes circumscribed ; should such prove to be the 
 case, the ordinary treatment for gangrene must be pursued. 
 
 Shock. — In some cases, after the ligature is applied, the system suffers 
 very severely, and alarming symptoms supervene ; the pulse becoming weak 
 and irregular, the skin cold, the surface bluish, and delirium, together with 
 convulsive movements occur, and this may be followed by intense fever, 
 with tendency to congestions in other parts of the body. 
 
 Shrinkage and Pulsation. — In most instances, as might be expected, the 
 tumor lessens after the application of the ligature, and the pulsation ceases. 
 These changes, however, may not continue, and a recurrent beating may take 
 place, caused by the supply of blood being directed into the sac through 
 anastomosing branches and smaller collateral channels, and this may occur 
 at different times. If within the first thirty-six or forty-eight hours an in- 
 distinct pulsation is manifested, which continues for a short period and then 
 gradually becomes less, the surgeon need feel no apprehension concerning 
 the case, as it shows a good condition of the collateral circulation. If, how- 
 ever, after a month has elapsed, the pulsation, having ceased, should grad- 
 ually return, the prognosis will be unfavorable. This recurrent pulsation 
 is best treated by moderate pressure upon the sac. 
 
456 A SYSTEM OF SURGERY. 
 
 The Introduction of Foreign Material into the Sac. — Mr. Moore was the first 
 to introduce this method of treating aneurism. Iron wire was gradually 
 introduced into the sac. Dr. Levis, of Philadelphia, substituted horsehair, 
 which he passes through a hypodermic needle. He inserted twenty-four 
 feet nine inches of horsehair into the sac of a subclavian aneurism ; the 
 pulsation ceased, the tumor became hard, and no pulse could be detected 
 in the radial at the wrist. The man died, but it was found that there had 
 been a rupture of the vessel previous to the operation. Mr. Bryant also 
 has used the same method. 
 
 Conclusions. — Of all these methods, Dr. Van Buren, in his paper read 
 before the International Medical Congress at Philadelphia, thus speaks : 
 
 1. Tufnell's treatment of aneurism, by rest, position, and restricted diet, 
 offers a valuable resource in thoracic and abdominal aneurisms. 
 
 2. It should always be tried in innominate, subclavian, subclavio-axillary, 
 and iliac aneurisms, before resorting to measures attended by risk of life. 
 
 3. For aneurisms of the subclavian and iliac arteries, the Hunterian 
 operation, with our present means of preventing secondary haemorrhage, is 
 not justifiable. 
 
 4. For reasons formally set forth by Holmes and Henry Lee, the " old 
 operation " cannot properly be substituted for the Hunterian operation in 
 these cases, but should be held in reserve for special ones. 
 
 5. It is the most safe and surgical resource in gluteal aneurism, if the 
 circulation can be commanded by the hand in situ. 
 
 6. The mode of cure by embolism, aimed at in the method of manipulation, 
 is a not unfrequent explanation of what is called spontaneous cure of 
 aneurism. 
 
 7. The value of Esmarch's bandage in the treatment of aneurism is prob- 
 ably not fully estimated. 
 
 8. In view of the promising features presented by the case of Levis and 
 Bryant, in which horsehair was introduced into aneurismal tumors, the- 
 repetition of this operation, or the substitution for horsehair of Lister's 
 prepared catgut or other animal substances, may be properly tried. 
 
 Special Aneurisms. — Aneurism of the aorta occurs either in the arch of the 
 vessel as it passes through the thorax or in the abdominal portion. In 
 many instances it is most difficult to diagnose, especially if the enlargement 
 is small. In other cases the symptoms are sufficiently pronounced to obtain 
 a more certain diagnosis. Persons whose occupations require severe bodily 
 exertion are most obnoxious to this morbid arterial condition ; atheroma 
 and mechanical injuries are also causes. It is asserted that coach-drivers 
 are more liable to the formation of aneurism of the aorta, owing to their 
 position and exertions in driving. It is rarely found among the young, 
 most frequently affecting those in the prime of life. The shape of the 
 swelling varies somewhat, being either round, cylindrical, or spindle-shaped, 
 giving rise, from its pressure on important organs, to a great variety of 
 symptoms. 
 
 Symptoms. — An early manifestation of aneurism of the aorta, is a dull and 
 circumscribed sound, yielded by percussing either the anterior or posterior 
 walls of the thorax. If the anterior wall of the vessel be affected, the 
 sound will be recognized on the left sternal border ; if the posterior wall, it 
 will be heard on the left side of the vertebral column. When the swelling 
 has attained considerable bulk, the eye may detect the enlargement, and 
 the systolic concussions are well marked. As the disease progresses, the 
 pain, which in the beginning was not severe, increases ; organs are pushed 
 from their natural positions, the body assumes a bent attitude and inclines 
 to one side or the other ; dyspnoea takes place from stasis pulmonum ; 
 cyanosis, vertigo, headache, swelling of the neck and head, and a varicose 
 
ANEURISM OF THE ARTERIA INNOMINATA. 457 
 
 condition of the veins are all accompaniments of the morbid changes which 
 are taking place. If the aneurism occupy the upper part of the vessel, there 
 is a retardation of the pulse at the wrist ; if the abdominal aorta be affected, 
 a similar condition is noted in the femoral artery. Upon auscultation two 
 murmurs will be heard, — the systolic and the diastolic — the former often 
 accompanied by that peculiar blowing noise called the " bellows murmur." 
 The second sound is occasioned, in most instances, not from any peculiarity 
 in the aneurism, but by the closing of the semilunar valves. Intercostal 
 neuralgia is frequently present. 
 
 The most distressing symptom of the affection is dyspnoea, the effect 
 probably of pressure upon the trachea, or nerves, and which is materially 
 increased by motion, causing a more powerful action of the heart. Very 
 often an early symptom is difficulty of deglutition. If the swelling is in 
 the vicinity of the left bronchus, lying on that side greatly increases the 
 difficulty of breathing, a change of position relieving the patient. 
 
 Aneurism of the thoracic aorta is at times accompanied with severe or- 
 ganic affection of the heart, giving rise to dropsical swellings in different 
 parts of the body. If the aneurism is situated at the arch of the vessel, 
 it is more noticeable on the right than on the left side, and either pushes 
 forward the sternum and ribs and rises high in the chest, or occasions 
 severe pressure-symptoms from encroachment upon the recurrent laryngeal 
 nerve, trachea, or bronchi. From these circumstances there is a remark- 
 able retardation of the wrist pulse. In the aorta descendens, if the seat 
 of the disorder is in the anterior wall of the thoracic portion, there is a 
 pulsating tumor in front 'of the thorax to the left of the sternum ; in the 
 posterior wall of the descending vessel the pulsation is found to the left of 
 the spinal column. It occasions pain and stiffness on motion, sometimes 
 accompanied with inflammation of the muscles and caries of the bone. In 
 the abdomen the location of aneurism of the aorta is generally in the vicinity 
 of the cceliac axis ; it is either above or below the umbilicus ; it does not 
 convey a double murmur, as in the arch, but only imparts a systolic sound. 
 The crural pulse is slower than the beats of the heart or the pulsations of 
 the radial artery at the wrist. 
 
 The pathological appearances are those belonging to aneurisms generally ; 
 these have already been adverted to, viz., an altered condition of the coats 
 of the vessel, they being laminated and fibrinous, and within the sac a 
 bloody coagulum. 
 
 The pressure-indications are often very remarkable. The parietes of the 
 enlargement may be closely adherent to the surrounding tissues ; there may 
 be degeneration of the bony structures in the vicinity, as atrophy of the 
 ribs and sternum, caries of the vertebrae, which may have been occasioned 
 from extension of the inflammatory process and pressure on the spine. 
 Partial paralysis may also occur. 
 
 Treatment. — The prognosis of aneurism of the aorta is always unfavor- 
 able, but sometimes much may be done to alleviate the sufferings of the 
 patient. Exertion must be avoided; the diet allowed be of the most nour- 
 ishing and easily digested kind ; and if the tumor is in a position where 
 moderate pressure can be used it should be employed. I have seen cases 
 in which a large and slightly concave shield fitted over the pulsating tumor 
 gave great ease and support. The aorta has been ligated four times. In 
 Sir Astley Cooper's case, the first, in 1817, the patient lived forty hours. 
 The longest time that a patient has survived the operation is ten days. 
 
 Aneurism of the Arteria Innominata, from its position, must always be 
 associated with serious and dangerous symptoms. Before the disease is 
 fully developed the patients often complain of pains, apparently of a neu- 
 ralgic or rheumatic character, in the neck, face, arm, and shoulder. These 
 
458 A SYSTEM OF SURGERY. 
 
 generally are the pressure-symptoms, induced by irritation of the brachial 
 plexus, and take the course of the cervical nerves, either upward or down- 
 ward. The right arm becomes numb and cold, and motion and sensation 
 are more or less impaired. After an indefinite period a slight globular 
 swelling or enlargement may be perceived at the junction of the clavicle 
 with the sternum, which may be painful, together with swelling of the side 
 of the face and neck. This increases for a time, filling up more or less 
 completely the bow in the front of the neck, displacing the sterno-mastoid 
 forward, and extending outward to the shoulder. While these changes are 
 taking place there are symptoms of cough, dyspnoea, and difficult degluti- 
 tion. In some instances, where no special enlargement is observed in the 
 neck, the sternum is pushed forward. The tumor, when visible, as just 
 mentioned, is soft and fluctuating, has pulsation and bruit of more or less 
 distinctness. 
 
 The cough and dyspnoea are often very distressing, and depend either 
 upon direct pressure upon the larynx and bronchi, or upon compression 
 of the recurrent nerve. The prognosis is unfavorable and the treatment 
 surgical. [The surgical anatomy and methods of applying the ligature are 
 mentioned elsewhere.] Valentine Mott, of New York, was the first to pro- 
 pose and perform the operation of ligating this vessel, in a man twenty- 
 seven years of age, May 11th, 1818. Death did not occur until the twenty- 
 sixth day* In 1822 Graefe repeated the operation ; the patient lived sixty- 
 eight days, and died from haemorrhage occasioned by overexertion. In the 
 case of Bland, secondary haemorrhage took place on the eighteenth day, 
 and in that of Hall on the eighth. Lizars performed the operation on the 
 31st day of May, 1837, and the patient died on the 21st of June. In Kuhl's 
 case the patient died on the third day. It was reserved for America to 
 achieve the feat of ligating successfully the innominata, which operation 
 was performed by Dr. J. W. Smyth, of New Orleans, in 1864. It must be 
 remembered, however, that the common carotid was also tied at the same 
 time, and that after several haemorrhages, on the fifty-fourth day the right 
 vertebral was ligated. The recovery was complete. 
 
 The distal operation for aneurism of the innominata can be performed at 
 several points ; either at the subclavian or the carotid, or the ligature may 
 be placed upon both these vessels. 
 
 Mr. Richard Barwellf relates an interesting case, in which the aorta, 
 innominata, subclavian, and carotid were involved in one aneurism, for 
 which he successfully ligated the carotid and subclavian at their distal ex- 
 tremities. In his paper he states that six such cases have been treated with 
 the distal ligature ; of these, two proved fatal on the sixth day, one on the 
 fifty-sixth day, and one on the sixty-fifth day, and two received no benefit, 
 but lived some weeks. 
 
 In a case of my own, in which the aneurism involved both the subcla- 
 vian and carotid, I tied the subclavian at its distal extremity. Pulsation 
 was arrested, but the patient perished from haemorrhage from the bursting 
 of the sac. 
 
 Aneurism of the Carotid Artery is sometimes difficult to diagnose. For 
 instance, if the artery pass through glandular tumors, giving pulsation but 
 no diminution in the size of the tumor from pressure, or if in large ab- 
 scesses a distinct pulsation be felt, the diagnosis becomes complicated. 
 
 Various swellings occupying the triangles of the neck have been mis- 
 taken for aneurisms ; indeed, I am very well aware that hygroma are very 
 
 * For an account of this and other interesting cases, see Mott on Aneurism. Velpeau's 
 Operative Surgery, vol. vii.. p. 255. 
 
 f American Journal of the Medical Sciences, January, 1878, p. 275. 
 
ANEURISM OF THE SUBCLAVIAN. 459 
 
 similar in feel and pulsation to aneurism al tumors. Aneurismal varix of 
 the carotid artery and jugular vein, being soft and evenly compressible, are 
 accom pained with pulsation, and consequently very liable to lead to mis- 
 takes in diagnosis. If the swelling be glandular, it may be lifted from the 
 vessel, and then it will be found to lack the pulsation of aneurism. Again, 
 glandular swellings are more hard and nodulated than aneurismal tumors. 
 In abscess the general symptoms, such as the pointing and fluctuating, will 
 aid in resolving the doubt, or a hypodermic syringe in this as in hygroma 
 will determine the difficulty. In none of these cases, however, do the swell 
 and increase of pulsation, which belong to true aneurism, occur. A well- 
 defined tumor, soft, compressible, and pulsating, diminishing on pressure, 
 situated on the side of the neck, in the neighborhood of the angle of the 
 inferior maxillary bone, accompanied with shooting pain in the head, buzzing 
 in the ears, spots before the eyes, difficulty of swallowing, and sometimes 
 of breathing, presents all the evidences of an aneurism of the carotid artery. 
 
 These are the obvious signs and symptoms, and must be well weighed 
 before a positive opinion can be entertained. In a table of thirty-nine 
 cases, in which the vessel was ligated for aneurism, or rather for what was 
 mistaken for aneurism, in eight cases there were no traces of the disease, 
 and in the others, solid tumors or cysts occupied the spaces. After liga- 
 ture of the carotid, sometimes suppuration of the sac takes place, and sec- 
 ondary haemorrhage follows, but the most frequent untoward occurrence is 
 cerebral disease, occasioned by the sudden withdrawal of a large amount 
 of arterial supply to the brain. Symptoms of this deficiency are faintness, 
 giddiness, and even syncope, which are immediate, followed by the graver 
 manifestations of brain diseases, terminating in paralysis, convulsions, and 
 death. The thoracic organs likewise frequently sympathize, congestion of 
 the lungs following the tightening of the ligature. To this peculiar affection 
 attention has been directed by Prof. Miller. Sir Astley Cooper ligated the 
 common carotid in 1805. 
 
 Aneurism of the Subclavian. — Aneurism of this important vessel is, in the 
 majority of instances, occasioned by mechanical violence or muscular exer- 
 tion ; it occurs on the right side in the proportion of three to one, and is 
 much more frequent in males than in females ; indeed, it is asserted that to its 
 occurring once in women it is found sixteen times in men. From a careful 
 study of the anatomy of the three subdivisions of this vessel it will be seen 
 that on the left side, where it is well covered by the scaleni muscles, the 
 aneurismal tumor cannot make its appearance until it has passed these 
 muscles ; while on the right side it is most usually found at the upper part 
 of the chest. The tumor is generally ovoid in shape, and often appears 
 above the clavicle in the posterior triangle of the neck (vide surgical ana- 
 tomy of the neck). When the shoulder is elevated, if the swelling has not 
 attained great bulk, it will disappear ; if larger, a part only of it will be hid- 
 den below the clavicle. Together with the tumor there are present the 
 usual pressure-symptoms, such as pain, numbness, and weakness, with 
 swelling of the arm and hand, and a varicose condition of the veins of the 
 neck with oedema. A peculiar and distressing symptom is often referred to 
 the epigastric region, which is more or less persistent, accompanied with a 
 contractile sensation about that region, owing to the irritation of the phrenic 
 nerve and spasmodic diaphragmatic action. 
 
 Notwithstanding, however, all the morbid exhibitions, there is always 
 difficulty in diagnosing the existence of aneurism in the lower portion of 
 the neck and around the clavicles, simply for the reason that the swelling 
 of an aneurism may be remote from the place where it is really situated. 
 Dr. Mott asserts that he has seen an aneurism of the arch of the aorta pre- 
 sent a tumefaction above the clavicles, in the situation where we would natu- 
 
460 A SYSTEM OF SURGERY. 
 
 rally expect to find aneurism of the subclavians. In relation to this subject 
 he offered the following candid and practical opinion. He says : " All sur- 
 geons whose opinions are of any value will readily excuse mistakes that 
 are made even by those who have had the greatest experience, because, not- 
 withstanding all the light afforded by pathological investigations and stethoscopic 
 examinations, it will, we think, be generally admitted by the profession, that 
 no subject is more difficult and obscure than that of substernal and thoracic 
 aneurism." 
 
 In the remarks on his case, Prof. Mott writes : " Several very important 
 facts are established b}^ this operation — facts which no surgical operation has 
 ever before confirmed. It proves very conclusively that the heart, the 
 brain, and the right arm were not in the least inj ured by it, or in any of 
 their functions. In no instance did I ever view the countenance of a man 
 with more fluctuations of hope and fear than in drawing the ligature upon 
 this artery. To intercept suddenly one-fourth of the quantity of blood, so 
 near to the heart, without producing some unpleasant effect, no surgeon, a 
 priori, would have believed possible. I therefore drew the ligature gradu- 
 ally, and with my eyes fixed upon his face. I determined to remove it in- 
 stantly, if any alarming symptoms appeared. But instead of this, when 
 he showed no change of feature or agitation of body, my gratification was 
 of the highest kind." 
 
 This statement is of great interest in showing by what circuitous routes 
 the collateral circulation may be accomplished, and the idea that a suffi- 
 cient supply of blood could still be afforded if further obstruction to the 
 circulation should be offered was so forcibly impressed upon the mind of 
 Dr. Mott, that he says : " Yet, if ever a case should present itself again, / 
 should tie the primitive carotid at the same time that I tied the innominata." 
 
 Aneurism of the Axillary Artery. — One of the first symptoms experienced 
 by a person suffering from axillary aneurism is a sense of weight and un- 
 easiness in the affected part, occasioned by pressure upon the brachial plexus. 
 This uneasiness soon amounts to pain, which, as the tumor enlarges, shoots 
 upward into the neck, downward along the arm, and into the chest, and is 
 aggravated by movement, sneezing, or coughing. Together with these suf- 
 ferings there always is experienced a sense of prickling and numbness, which 
 at times amounts to paralysis of the hand and fingers, and is often accom- 
 panied by oedema and coldness. Slight pressure even with the tips of the 
 fingers aggravates the pain, sometimes rendering it very intense. The tumor, 
 in the early stages of the disease, is somewhat soft, fluctuating and dis- 
 tinctly pulsating ; it may appear below the clavicle, or it may enlarge the 
 anterior margin of the axillary space. There is a distinct bruit, and the 
 pulsation can be controlled by direct pressure upon the subclavian. The 
 tumor is apt to increase more rapidly in this location than in other varieties 
 of aneurism, the loose cellular structure of the armpit offering less resist- 
 ance to its growth. In rare cases, and when it is situated high up, the clav- 
 icle may be pushed forward and upward, giving rise to considerable 
 deformity. In operating for this aneurism, the point usually selected is 
 that which lies on the first rib beyond the scalenus anticus muscle. Should 
 it become necessary to ligate the axillary the operation may be performed 
 according to the directions given elsewhere. 
 
 Aneurism of the Arm, Forearm, or Hand. — Aneurisms of the arm or fore- 
 arm are generally traumatic, the spontaneous variety being very rarely met 
 with. Gross has never witnessed a case, and is not acquainted with a 
 record of any in this country. Mr. Todd relates a case treated in Univer- 
 sity College Hospital in 1849, in which a tumor presenting all the aneurismal 
 characteristics was discovered at the upper third of the right ulnar artery. 
 The symptoms of traumatic or false aneurism have already been detailed 
 
ABDOMINAL ANEURISM — FEMORAL ANEURISM. 461 
 
 in the general considerations of aneurism. The symptoms are easily recog- 
 nized, and demand no further notice. Pressure may be tried before 
 resort is had to operative measures, which, however, are chiefly to be relied 
 upon. 
 
 Abdominal Aneurism. — In the consideration of aortic aneurism, mention 
 was made of the enlargement of the abdominal aorta ; but the iliac vessels 
 may be the seat of the affection. There are no varieties of aneurism which 
 require more attention in the endeavor to reach a correct diagnosis, and in 
 the search of which there is so great -liability to be misled. In the iliac 
 region there may be pulsating enlargements, the true nature of which may 
 not only perplex, but positively deceive the most experienced in the profes- 
 sion. An interesting case of the kind may be found on page 382 of Holmes's 
 System of Surgery, in which Mr. Moore ligated the common iliac artery for a 
 'pulsating tumor, which proved to be a " cancer deposited in a mass of 
 glands, situated at the bifurcation of the common iliac, between the exter- 
 nal and internal iliac arteries." This, together with other observations, has 
 proved that many pulsating tumors of the belly may be of malignant for- 
 mation, and not aneurism. A bony pulsating tumor may also strongly 
 simulate aneurism. 
 
 Treatment. — For iliac aneurism, the pressure treatment may be used, es- 
 pecially if the patient be thin. It is to be applied in the manner already 
 directed, a compressor generally being required. For the additional treat- 
 ment, see Ligation of the Internal Iliac Artery. 
 
 An Inguinal Aneurism may arise either from the femoral or from the ex- 
 ternal iliac artery ; when from the latter it passes upward toward the in- 
 guinal region, and often into the abdomen. There is but slight suffering, 
 the tumor at first is small, but increases rapidly, and has a distinct bruit 
 and pulsation. From its weight and pressure there are oedema of the limb, 
 pain in the leg and thigh, and a varicose condition of the leg from obstructed 
 return into the saphena vein. The pain in this variety of aneurism is gen- 
 erally experienced in the lumbar region, and extends along the crest of the 
 ilium down to the testicle and scrotum, being caused by pressure on the 
 branches of the ilio-lumbar nerve. If these symptoms are manifest the 
 diagnosis generally is readily made out. If, however, the aneurism be old, 
 and there be a deposit of plastic material within the sac, imparting a feel- 
 ing of solidity to it, and likewise an absence of pulsation, then it cannot be 
 distinguished from an encephaloid or bony tumor. No less celebrated sur- 
 geons than Mr. Stanley and Mr. Syme have entirely confounded these two 
 diseases. From abscess it is known by the history of the case, the preced- 
 ing inflammation, the constitutional manifestations appertaining to the 
 formation of pus, and general symptoms. This diagnosis is also difficult. 
 From hernia it may be known by the absence of cough impulse, by the 
 history of the case, the appearance and progress of the rupture, and the 
 ability of the patient, in many cases, to return the protruded bowel. In 
 this variety of aneurism the iliacs must be tied (see Chapter on Ligation of 
 Arteries) after pressure, either digital or instrumental, has been faithfully 
 applied. 
 
 A Femoral Aneurism is of infrequent occurrence, but may arise in any por- 
 tion of the vessel from its entrance at the thigh to its termination in the 
 popliteal artery. 
 
 These aneurisms may be either spontaneous or traumatic. When the 
 former, the site is the apex of Scarpa's space, and the pain felt at the inner 
 portion of the knee owing to pressure on the saphenous and obturator nerves. 
 There are pulsation and bruit in the tumor, which, however, it is to be re- 
 membered, sometimes are met with in other growths. I recently removed 
 from the thigh of a man a pendulous fatty tumor weighing five and a half 
 
462 A SYSTEM OF SURGERY. 
 
 pounds, in which there was distinct pulsation. In such a case, if it be pos- 
 sible, the growth should be lifted from the artery to ascertain if with its al- 
 tered position, pulsation ceases. Abscesses also may have many symptoms 
 in common with femoral aneurism, and, therefore, careful and critical in- 
 quiry into the history of the case must be instituted, to aid in the formation 
 of a correct opinion of the nature of the disease. If compression over the 
 femoral as it emerges from the pelvis arrest immediately the pulsation in 
 the tumor, and the bruit be no longer heard, the case may be diagnosed as 
 femoral aneurism. Again, if steady and prolonged pressure empty the sac, 
 another important diagnostic sign is revealed. 
 
 A femoral aneurism may extend so high up in Scarpa's triangle as to pass 
 underneath Poupart's ligament and thus simulate an inguinal aneurism ; or, 
 if the lower portion of the vessel be implicated, the swelling may extend 
 around the lower portion of the thigh and simulate an enlargement of the 
 popliteal artery. 
 
 Together with the symptoms which have been noted, there is oedema of 
 the limb, with sensation of stiffness and soreness, with coldness, heaviness, 
 and insensibility ; and finally, if relief is not experienced, gangrene or haem- 
 orrhage terminates the life of the patient. In some exceptional cases a 
 spontaneous cure has been known to result. 
 
 Traumatic Femoral Aneurism is generally produced by a wound of that 
 vessel, or, in some instances, by an injury to both artery and vein. The 
 tumor at first is small, but gradually enlarges, with thrill and pulsation, 
 causing pain, tenderness, and soreness of the parts. 
 
 Treatment. — In the treatment of femoral aneurism compression should 
 always be diligently and persistently tried before operative means are re- 
 sorted to, the best method of accomplishing which is by the fingers of assist- 
 ants. It is important that the pressure be steady and that relays of assistants 
 should be constantly in attendance ; that the pressure be not relaxed from 
 weariness and numbness of the hands, which always take place after a short 
 period of exertion. Cases are recorded in which solidification of the tumor 
 took place in about forty-six hours from continued pressure. If digital com- 
 pression is not attainable, the requisite pressure may be made by one of the 
 several artery compressors which are mentioned in the Chapter on Haemor- 
 rhage, or by Esmarclvs bandage. 
 
 If these means prove unsuccessful, the artery may be ligated in Scarpa's 
 triangle, for aneurism in the course of the vessel, or if the tumor has 
 passed upward, filling that space, it may be necessary to place the ligature 
 upon the external iliac. For the methods of performing either of these 
 operations, the reader is referred to the chapter on the " Ligation of 
 Arteries." 
 
 Popliteal Aneurism. — The popliteal artery is more subject to aneurism than 
 any other vessel of the body. In 551 cases of aneurism in the tables of Crisp, 
 137 were popliteal. Sometimes both vessels are affected at the same time, 
 as has been adverted to in Dr. Agnew's case. 
 
 A popliteal aneurism is generally situated in the lower half of the vessel, 
 and is first noticed by the patient " as of something giving way." It is 
 very probable that, from the many and sudden genuflections constantly 
 made, the coats of this vessel become weakened and are liable to rupture or 
 expansion. 
 
 At first there is a feeling of slight stiffness and lameness, with aching ; 
 which symptoms, however, are not persistent. Or in other cases, after the 
 u snap," the patient is aware that the mobility of the joint is impaired, and, 
 in a few instances, the surgeon is the first to recognize the true nature of 
 the disease, the patient himself supposing he is suffering from a subacute 
 rheumatic attack. With these symptoms there is a sensation of numbness 
 
LIGATION OF ARTERIES. 463 
 
 along the posterior portion of the leg, with coldness of the foot. The swell- 
 ing is first small, so much so, indeed, that it escapes notice ; gradually, how- 
 ever, it enlarges, pulsates, and can be emptied by firm pressure made with 
 the finger and thumb. When the compression is relaxed the tumor imme- 
 diately reappears. As the swelling increases, the leg is bent at an obtuse 
 angle with the thigh, and the soft parts in the vicinity of the popliteal space 
 are pushed outward. After a time, however, from the deposit on the outside 
 of the sac, the tumor becomes more dense, and finally quite hard, and, in 
 such instances, the diagnosis is more obscure, as solid growths, such as en- 
 chondroma and fibroids, sometimes appear in the ham ; in these cases the 
 general history of the case, the slowness of growth, the absence of pulsation 
 and bruit will be the guiding symptoms. 
 
 A fusiform aneurism in the popliteal space is occasionally met with, and 
 such a case is recorded by Mr. Spence, from whose admirable lectures I 
 quote. He writes : " In such cases the patient feels pain and uneasiness in 
 the site of the aneurism, and some coldness of the limb with numbness, and 
 a pricking sensation, from the irregular circulation, but not from pressure on 
 the nerves, for in the early stage this kind of aneurism is just like a dilated 
 artery. We feel the artery pulsating more distinctly than we do in the 
 healthy limb. There is, in fact, simply a dilatation at one point of the vessel, 
 which gradually narrows on either side of the dilatation, giving the aneurism 
 a peculiar spindle-like shape."* 
 
 Treatment. — In the management of popliteal aneurism, pressure has, in 
 the majority of cases, superseded the use of the knife. 
 
 Forced flexion, also, as directed in the Chapter on Haemorrhage, may be 
 tried. If pressure be attempted it should be applied directly over the 
 course of the femoral vessel in Scarpa's space. For instructions how con- 
 tinued digital compression may be applied, the student can refer to general 
 treatment of aneurism, on a preceding page. 
 
 If compression fail, the femoral artery must be tied. 
 
 Aneurisms of the Leg and Foot. — Sometimes false aneurisms of the leg 
 occur, in which the haemorrhage may prove very troublesome. A case of 
 the kind gave me a great deal of trouble, and was finally cured by deliga- 
 tion of the posterior tibial artery. If the wound be in the sole of the foot, 
 forced flexion may be tried ; but if this fail, the plantar arteries may be 
 ligated. 
 
 CHAPTER XXV. 
 
 LIGATION OF ARTERIES. 
 
 Surgical Anatomy of the Vessels and Methods of Operating. 
 
 Before perusing the following chapter the student will find it to his 
 advantage to study the accompanying cut (Fig. 220), as by a thorough 
 understanding thereof the remarks upon the vessels of the head and neck 
 will be better understood. The cut, indeed all the illustrations in this 
 chapter, are taken from the admirable atlas of Von Pitha and Billroth. 
 
 The side of the neck presents, with the boundaries we propose to specify, 
 a quadrilateral space, which is bounded in front by a line from the chin to 
 the centre of the manubrium of the sternum ; behind by the anterior bor- 
 
 * Spence, Lectures on Surgery, London, vol. i., p. 586. 
 
464 
 
 A SYSTEM OF SURGERY 
 
 der of the trapezius muscle, above by the lower margin of the body of the 
 inferior maxillary, and a line extending from the angle of the jaw to the 
 mastoid process, and below by the upper border of the clavicle. 
 
 Fig. 220. 
 
 A. Pericranium. B. Zygomatic arch. C. Clavicle. D. Socia parotidea. E. Steno's duct. F. Auricle. 
 G. Submaxillary gland. H. Larynx. J. Cervical glands. Muscles : a. Orbicularis oculi (external), a'. 
 Orbicularis oculi (internal), b. Orbicularis oris. c. Levator anguli oris. d. Depressor labii inferioris. e. 
 Buccinator, f. Temporal, g. Masseter. h. Sterno-cleido mastoid, h'. Sternal extremity of sterno-mastoid. 
 h". Clavicular extremity of sterno-mastoid. j. Digastric, k. Mylo-hyoid. 1. Sterno-hyoid. m.Omo-hyoid. 
 n. Sterno-thyroid. o. Levator anguli scapulae, p. Splenius capitis, q. Trapezius, r" Scalenus anticus. s. 
 Scalenamedius. Vessels and Nerves : 1. Common carotid artery. 2. Internal carotid artery. 3. External 
 carotid artery. 4. Dorsalis scapulae, or transversus colli. 5. Superior thyroid artery. 6. Facial, or ex- 
 ternal maxillary artery. 7. Inferior coronary artery. 8. Superior coronary artery. 9. External nasal 
 artery. 10. Frontal artery. 11. Temporal arte'ry. 12* Transverse facial artery. 13. Occipital artery. 14. 
 External jugular vein. 15. Internal jugular vein. 16. Superior thyroid vein. 17. Anterior facial vein. 
 18. Nasal vein. 19. Frontal vein. 20. Temporal vein. 21. Occipital vein. 22. Supraorbital nerve. 23. 
 Infraorbital nerve. 24. Branch of facial nerve. 25. Hypoglossal nerve. 26. Branch of hypoglossal nerve. 
 27. Auricular nerve and branches. 28. Cervical nerve. 29. Phrenic nerve. 30. Brachial plexus. 
 
 The sterno-cleido mastoid muscle extends diagonally across this quad- 
 rangle, dividing it into two triangles, which are called anterior and pos- 
 

 
 LIGATURE OF THE COMMON CAROTID ABOVE THE OMO-HYOID. 465 
 
 terior; the base of the former is at the jaw, its apex at the sternum, while 
 the base of the posterior is at the clavicle and its apex at the mastoid pro- 
 cess of the temporal bone. 
 
 The anterior triangular space is divided into three other triangular spaces 
 by the omo-hyoid (m m) and digastric muscles. These triangles are called, 
 ascending from below upwards, the inferior carotid triangle, the superior carotid 
 triangle, and the submaxillary triangle. 
 
 The inferior carotid triangle is bounded above by the anterior belly of the 
 omo-hyoid (m), below by the anterior margin of the sterno-mastoid (A), 
 and in front by the mesian line of the neck (I). Within this space the 
 sterno-hyoid and sterno-thyroid muscles, together with the anterior border 
 of the sterno-mastoid, conceal the lower part of the common carotid artery. 
 
 It must be remembered that the pneumogastric nerve lies within the 
 sheath of the vessel, and that the vein on the right side of the neck lies on 
 the outside of the artery, while in the left side it overlaps it. It is in the 
 upper part of this space that ligation of the common carotid below the 
 omo-hyoid muscle is practiced. 
 
 The superior carotid triangle has its apex at that point near the body of 
 the hyoid bone, to which the aponeurotic attachment of the digastric is 
 attached; the posterior boundary is the anterior margin of the sterno- 
 mastoid, its superior, the posterior belly of the digastric, and its inferior, 
 the anterior portion of the omo-hyoid. In this space we have the upper 
 portion of the common carotid, and at the point opposite the superior mar- 
 gin of the thyroid cartilage the bifurcation of the vessel into the external 
 and internal carotids. Of these vessels, which are overlapped by the margin 
 of .the sterno-mastoid, the external lies more to the front. In this space the 
 main arteries are the facial, ascending over the body of the lower jaw ; the 
 lingual, passing forward to supply the tongue ; the superior thyroid, taking 
 its direction forward and downwards; the occipital backward, and the 
 ascending pharyngeal upward. 
 
 The submaxillary triangle is bounded above by the margin of the lower 
 jaw and a line drawn from its angle directly backward. The stylo-hyoid 
 and digastric form its posterior limits, and in front it is bounded by the 
 mesian line of the neck. In this space are located the facial artery and 
 the submaxillary gland, which occupy its anterior portion, while behind the 
 sterno-maxillary ligament the external carotid is imbedded in the parotid 
 gland ; and still deeper is the seat of the internal jugular vein, internal 
 carotid and pneumogastric nerve. 
 
 The posterior triangular space has its apex at the occiput, its base at the 
 clavicle, its anterior border being the posterior margin of the sterno-mas- 
 toid, and its posterior border the anterior margin of the trapezius. This 
 triangle is subdivided into a larger and smaller triangle by the passage of 
 the omo-hyoid ; the superior space* receiving the name of the " occipital," 
 the lower being designated the "subclavian." The latter forms almost a 
 right-angled triangle ; its anterior margin being the lower part of the posterior 
 edge of the sterno-mastoid ; its inferior, the upper portion of the clavicle, and 
 its posterior, the anterior margin of the posterior belly of the digastric. 
 The space varies much, or with the elevation or depression of the shoulder. 
 The third portion of the subclavian artery curves outward and downward 
 from the scalenus anticus muscle, passing across the upper rib to the axilla. 
 The brachial plexus is also found in this space, and the external jugular 
 vein passes in a vertical direction to reach the subclavian. 
 
 Ligature of the Common Carotid above the Omo-hyoid. — Anatomy. — Fig. 221 
 shows the direction of incision along the border of the sterno-cleido-mastoid 
 muscle. The artery is distinctly visible in the centre of the wound with the 
 ligature beneath it ; at the upper angle is seen a plexus of veins belonging to the 
 
 30 
 
466 
 
 A SYSTEM OF SURGERY. 
 
 external jugular, which often has to be held aside ; immediately, and in 
 contact with the artery on the right, is the pneumogastric nerve, and still to 
 the right the internal jugular vein — the nervous filament lying between the 
 two. At the lower angle of the wound are seen the fibres of the omo-hyoid, 
 above which a portion of the thyroid gland is visible. 
 
 The figure (221) also shows the plan of incision for the facial, or, as it is 
 sometimes called, the external maxillary, G. Also the occipital artery, 
 
 Fig. 221. 
 
 with the margins of the splenius capitis and sterno-mastoid muscle. The 
 direction of the artery is well shown, C. 
 
 Instructions for Operating. — The patient must be placed as below directed 
 for ligature of the carotid, the same instruments, and a like number of 
 assistants being required ; the incision should commence at a point on a 
 level with the cricoid cartilage, be three inches in length, and on the border 
 of the sterno-mastoid muscle. The integument must be held asunder by 
 assistants using blunt hooks, and if the middle thyroid vein should be ex- 
 posed it also must be thrust entirely aside. The deep fascia must now be 
 divided upon a director below the omo-hyoid, and the sheath of the vessel 
 found, which can be detected by the pulsation. The operator must then 
 draw forward the sheath and open it carefully upon a director, and expose 
 the vessel. The aneurism-needle is then to be passed round the vessel, the 
 ligature placed in its eye by an assistant, and the needle carefully with- 
 drawn. Before tying, be very careful not to include the descendens noni in 
 the thread. 
 
 As the needle must be passed from without inwards, care must be taken 
 to avoid the inferior thyroid artery. 
 
 Ligature of the Common Carotid below the Omo-hyoid. — The instruments 
 ready for use should be, besides the inhaler or handkerchief for anaesthetics, 
 a probe-pointed bistoury and a scalpel, two grooved directors, blunt hooks 
 set in handles, scissors, a helix aneurism-needle, two pairs of forceps of dif- 
 ferent sizes, besides ligatures, bandage, strapping, and sponges set in handles. 
 The patient should be placed upon the back, with the chest raised and the 
 head thrown somewhat back, the face turned to the opposite side, and the 
 angle of the jaw facing the light. 
 
 Operation. — An assistant stands at the head of the patient and administers 
 the anaesthetic; when the patient is perfectly unconscious, the operator 
 makes an incision about three inches in length along the prominent border 
 
LIGATURE OF THE LIXGUAL ARTERY. 467 
 
 of the sterno-mastoid muscle, beginning a little above the sternum. This 
 incision includes the integument and the platysma myoides muscle. Here 
 a little dissection is required to separate the flaps which must now be held 
 aside by an assistant with blunt hooks. The cervical fascia must then be 
 raised and nicked with the scalpel, a director introduced, and upon it the 
 layers divided. Any plexus of veins, or the descendens noni, must also be 
 held out of the way by the assistant. It must also be remembered that the 
 pneumogastric nerve lies in the sulcus between and posterior to the vein 
 and artery. 
 
 The operator must then cautiously feel with his finger for that point 
 where the pulsation of the artery is distinct, and when he is certain that he 
 has found it, he raises the sheath and divides it upon a director. The aneu- 
 rism-needle, without the ligature, is then gently insinuated beneath the 
 vessel from without inwards, taking especial care not to include the par 
 vagum. When the point of the needle emerges from behind the vessel, an 
 assistant passes an antiseptic ligature into its eye, avoiding other structures; 
 the aneurism-needle is then carefully withdrawn and the knot firmly tied 
 upon the vessel ; the ends are cut close to the knot. The assistants then 
 unite the wound with silver sutures and straps, and the patient is made 
 to lie with his head in such a position that the sterno-mastoid is relaxed. 
 
 Ligature of the External Carotid. — It may be necessary in some instances 
 to tie the external carotid, and one of two points may be selected for this 
 purpose: 1st. Between the parotid gland and the digastric muscle; 2d. 
 Near the origin of the vessel where it is crossed by the digastric. If the 
 former be decided upon, an incision should be made from below the ear to 
 the great cornu of the hyoid bone ; the integument and fascia are held aside 
 by an assistant, and by separating the stylo-hyoid and digastric muscles 
 from the parotid, the vessel is brought in sight and the ligature applied. 
 If the point chosen be lower in the neck, the incision should extend from 
 the angle of the jaw to the cricoid cartilage, and the other steps of the 
 operation conducted in the manner already described in ligating the com- 
 mon carotid. 
 
 Ligature of the Facial or External Maxillary Artery. — Anatomy.— In Fig. 
 221 (G) will be seen the point at which the facial artery winds around 
 the body of the inferior maxillary bone, and is the point at which pres- 
 sure is made to arrest haemorrhage. Pressure, however, in the majority 
 of instances, does not arrest the haemorrhage from this vessel because of its 
 free inosculation with its fellow of the opposite side through the coronary 
 arteries. The point alluded to is an excellent one for performing acupres- 
 sure or percutaneous ligation. It must be borne in mind that the facial may 
 arise with the Ungual from a common trunk. It passes over the maxillary bone 
 at the anterior margin of the masseter muscle. The facial vein lies close on 
 its temporal side, and is covered, though sparsely, with branches of the 
 facial nerve. 
 
 Operation. — Make the incision three-quarters of an inch in length in the 
 direction represented in the figure, and having carefully dissected the integu- 
 ment, the vessel is easily found by its pulsation and its superficial course. 
 The needle must be passed from without inward to exclude the vein. 
 
 If it should be necessary to apply a ligature to the occipital it must be 
 remembered that it is covered by the fibres of several muscles. It is not, 
 however, often difficult to secure. 
 
 Ligature of the Lingual Artery. — Anatomy. — This vessel is a branch of 
 the external carotid, and is given off from that trunk just above the cornu 
 of the thyroid cartilage ; it then passes above the os hyoides and enters 
 the root of the tongue between the genio-hyo-glossus and hyo-glossus mus- 
 cles. The vessel is deeply seated and sometimes difficult to find. 
 
468 A SYSTEM OF SURGERY. 
 
 Operation. — Having elevated the shoulders and thrown back the head of 
 the patient, an incision should be made two inches long, just above the 
 cornu of the os hyoides, vide line of incisions, Fig. 221 ; the submaxillary 
 gland is then brought to view and held to one side. The digastric muscle 
 must then be hooked and drawn upward, beneath which the hypoglossal 
 nerve will be seen. The finger now introduced into the wound will detect the 
 pulsation of the artery at a point a little below the nerve, through the fibres of 
 the hyo-glossus muscle, which overlaps it. The fibres of this muscle should 
 be divided with great care, when the artery can be found and secured as usual. 
 Ligature of the Subclavian. — Anatomy. — This vessel passes from the thorax 
 between the scalenus medius and the scalenus anticus muscle, and takes 
 its course underneath the middle third of the clavicle. The last-named 
 muscle and the tubercle of the first rib mark its internal boundary ; the 
 brachial plexus of nerves and the scalenus medius muscle bound it ex- 
 ternally, the nearest nerve, which is about the size of the artery, lying about 
 a quarter of an inch to its outer side. The nerve must not be mistaken for 
 the vessel itself. The subclavian vein lies below and anterior to the artery, 
 and at the outer edge of the scalenus anticus muscle and in contact with, 
 the artery, the suprascapular and external jugular vein. Sometimes the 
 posterior cervical artery arises from the subclavian ; and, taking its course 
 to the trapezius, crosses the root of the neck on the outer side of the scaleni 
 muscles, and may be directly in the course of the incision during the opera- 
 tion. It must also be remembered that there is sometimes considerable 
 variation in the origin and course of the subclavian vessels on the different 
 sides of the body, the right sometimes coming off from the innominata 
 above the articulation of the sternum and the clavicle, but in the majority 
 of cases, below that joint and within the thoracic cavity. 
 
 Sometimes a separate trunk is given off from the aortic arch. The left 
 subclavian also is sometimes joined at its origin with the left carotid. 
 
 Anatomy of the Subclavian outside the Scaleni. — Fig. 222 represents surgical 
 anatomy of the subclavian without the scaleni. The artery is seen with the 
 
 ligature beneath it; to the right, 
 _ _™ 'J^' the brachial plexus ; to the left, the 
 
 margin of the scalenus anticus. 
 The integument, cellular tissue, and 
 superficial fascia of the neck are 
 seen around the incision. The 
 deep cervical fascia passes over the 
 '" ^^^^^^^^S artery and the brachial plexus and 
 
 ^^^^^^^^^;" 4 dips under the omo-hyoid, which, on 
 
 ■'-.. IIJIf the right of the cut, passes upward. 
 The subclavian vein lies along 
 the lower margin of the wound 
 with the transverse scapular vein passing into it. Below this is the supra- 
 scapular artery. 
 
 The operation for tying the subclavian outside the scaleni muscles, which is 
 the spot, if practical, always preferred {vide figure), is performed as follows : 
 The patient is placed upon a table, and fully brought under anaesthetic 
 influence. The shoulder should be depressed as much as possible, to 
 lower the clavicle ; the integument then should be drawn down tightly 
 over that bone, and an incision made from the anterior border of the tra- 
 pezius to the posterior border of the sterno-cleido-mastoid ; the different 
 layers of muscular fibre (platysma myoides) and cervical fascia should be 
 raised with the forceps, snipped, a director passed beneath them, and di- 
 vided with a curved or straight probe-pointed bistoury. If this incision is 
 not long enough the sterno-mastoid may be cut through, and, if more room 
 
LIGATURE OF THE SUBCLAVIAN. 469 
 
 be required, the trapezius also. The external jugular vein is now at the inner 
 side of the wound, which must be held aside, or, if divided, the ends must 
 be secured. The suprascapular artery must also be avoided, and the aneu- 
 rism needle passed from before backward to exclude the brachial plexus. 
 Sometimes the tumor may be so extensive that it is impossible to pass the 
 ligature in this situation, in which case the artery can be sought for behind 
 the scalenus and above the first rib. 
 
 In some instances the artery is tied at the second portion of its course, 
 but the operation is liable to many objections, — the close proximity of the 
 phrenic nerve and internal juguiar vein, the pleura and large vessels (a 
 wound of either of which might be productive of most dangerous conse- 
 quences), are all most serious difficulties to be encountered, which are 
 heightened by the occasional passage of the vessel in front of the scalenus, 
 or sometimes both artery and vein course behind that muscle. 
 
 In rare cases it may be deemed necessary to tie the subclavian in the first 
 part of its course. 
 
 Anatomy of First Part of Subclavian. — In the figure (223) the vessel is 
 seen with the ligature beneath it, giving off the internal mammary below 
 and the vertebral artery above. In the centre, crossing the vessel at right 
 angles, is the phrenic nerve, next to this the scalenus anticus muscle, and 
 still outside, the broad fasciculi of the brachial plexus. The omo-hyoid is 
 seen held up by the upper retractor, and between the curve of the vessel 
 and the margin of the brachial plexus is the transversalis colli or dorsalis 
 scapulae; the internal jugular vein is seen crossing the artery and being 
 held aside with the hook at the lower and internal angle. On the left side 
 the operation is almost impracticahle, on account of the great depth of the 
 vessel, the arteries which arise 
 
 both above and below it, the in- FlG - 223 - 
 
 timate relations of the pleura, and 
 the passage of so many important 
 nerves. 
 
 The same instruments are re- 
 quired as those for ligating other 
 vessels, and the patient placed in 
 a similar position. The neck 
 should be put upon the stretch 
 and an incision made three inches 
 in length along the inner border 
 of the stern o-mastoid muscle, ter- 
 minating at the inner part of the clavicle. A second incision, at right 
 angles with the first and running along the inner margin of the collar-bone, 
 should now be completed, and the sternal tendon of the sterno-mastoid cut 
 and turned aside. The smaller vessels which may appear should be 
 avoided and held aside with blunt hooks, and the sterno-thyroid and the 
 sterno-hyoid muscles divided upon a director. The deep fascia is ex- 
 posed, which must be carefully separated and torn through with the nail 
 or handle of the scalpel, when the internal jugular will come into view 
 passing over the vessel. This must be carefully held aside, and the artery 
 secured by passing the needle from below, upward. 
 
 This artery was cut down upon, but not ligated, by Porter, Post, Ashton, 
 Key, and Hoffman. 
 
 The vessel was first tied in 1809 by Ramsden, although Sir Astley Cooper 
 " tried in vein to seize this vascular trunk," but tied a nerve in its stead ; the 
 patient perished of haemorrhage. The first successful case was performed 
 by Dr. Wright Post, of New York. Many of our distinguished surgeons 
 have since performed the difficult operation with varied success. 
 
470 
 
 A SYSTEM OF SURGERY. 
 
 Ligature of the Axillary Artery. — Fig. 224 represents the Incisions and Surgical 
 Anatomy of the Axillary Artery. The wound is held apart by directors ; the 
 
 artery, partly deprived of its 
 sheath, is seen with the ligature 
 beneath it ; to the inner side is 
 the median nerve ; still more in- 
 ternally is the coraco-brachialis 
 and short head of the biceps. 
 The median cutaneous nerve 
 passes in proximity to the vessel 
 and lies alongside thereof, ex- 
 tending from the upper angle of 
 the wound. Next to this, on the 
 outside, is the large axillary vein, 
 giving off on the internal side 
 and crossing the artery, the ex- 
 ternal thoracic vein, and exter- 
 nally the subscapular vein. 
 
 The lymphatic axillary glands 
 are seen in the lower margin of 
 the wound. 
 
 The axillary artery may be 
 tied just below the clavicle or in the armpit. In the first of these situations 
 difficulty is always to be apprehended from the depth and surroundings of 
 the vessel. 
 
 Operation. — The patient is placed in a horizontal position, and the arm 
 separated from the side with the hand abducted ; an incision is made along 
 the inferior border of the clavicle from the sternum nearly to the deltoid 
 muscle. The next incision divides the fibres of the pectoralis major. Then 
 the costo-coracoid membrane must be carefully separated from the parts, 
 and the artery will be seen at the bottom of the wound. The vein lies in 
 front of it and the brachial plexus behind. The anterior thoracic artery is 
 also in close proximity to the vessel. It will therefore be apparent that 
 there are many difficulties connected with the operation ; a thick muscle is 
 to be divided, the cephalic and axillary veins surround it, and it is in the 
 bottom of a deep wound. If the case permit, it would be more advisable 
 to apply the ligature to the third part of the subclavian. 
 
 In the axilla the operation is performed as follows : The patient is placed 
 upon the bed and the arm drawn aside from the body ; the surgeon then 
 moves the humerus upward and downward to render himself perfectly con- 
 versant with the situation of the head of the bone. An incision is made 
 nearer the posterior than to the anterior border of the axilla, over the head 
 of the humerus. A careful but not very difficult dissection brings into view 
 the areolar tissue, fascia, the median nerve, and axillary vein {vide Fig. 224). 
 The elbow must now be flexed to relax the parts, and the nerve held to the 
 outer and the vein to the inner margin of the cut. The ligature is passed 
 around the vessel from the ulnar to the radial side. 
 
 Ligature of the Arteria Innominata.— Fig. 225 represents the anatomy 
 of the arteria innominata. The artery, large in size, is seen at the in- 
 ner angle of the wound with the ligature beneath it. The inferior thyroid 
 vein passes across it ; passing upward in the centre of the cut is the margin 
 of the scalenus anticus, with the phrenic nerve lying on its outside border. 
 Next to this is plainly marked the fascia in which the incision has been 
 made to expose the parts already mentioned ; over this, at the upper and 
 outer end of the wound, is the border of the omo-hyoid muscle, and next to 
 this the superficial fascia. 
 
LIGATURE OF THE SUPERIOR THYROID. 
 
 471 
 
 Fig. 225. 
 
 Dr. Mott, of New York, was the first to tie this vessel, on the 11th of May, 
 1818. The patient lived twenty-six days. The operation has been repeated 
 by several surgeons, with un- 
 favorable results. It was suc- 
 cessfully tied by Dr. Smyth, of 
 New Orleans. 
 
 The dangers of the operation 
 are inflammation of the pleura 
 and lung, and repeated profuse 
 and secondary haemorrhages. 
 The operation should be per- 
 formed with great care, and the 
 surgeon attempting it should 
 have a thorough knowledge of 
 the parts to be divided. 
 
 The patient is to be placed 
 supine, with the shoulders ele- 
 vated, and the head drawn back. 
 An incision is to be made about 
 three inches in length along the 
 upper margin of the clavicle, be- 
 ginning at the attachment of the 
 
 sterno-mastoid and extending outward. A second cut is made along the 
 anterior border of the sterno-mastoid muscle, of about the same length 
 and terminating where the first incision began. Dissecting up this flap 
 brings into view the platysma myoides, which must be divided upon a 
 director, and the same process followed with the greater part of the attach- 
 ment of the sterno-mastoid close to its clavicular portion. After the division 
 of this muscle there may be exposed a considerable amount of cellular 
 tissue, which must be carefully removed or held aside with the retractors. 
 The sterno-thyroid and sterno-hyoid muscles will then be exposed and 
 must be divided. The thyroid plexus is to be drawn aside. This 
 brings into view the subclavian vein, and the right internal jugular, which 
 also must be held aside. The carotid is now exposed, and should be care- 
 fully traced down until the innominata is reached. The director is to be 
 curved somewhat, and the left vena innominata depressed. The pneumo- 
 gastric nerve and internal jugular are drawn to the right side, and the liga- 
 ture passed around the vessel as high up as possible to permit the formation 
 of a clot between it and the aorta. The aneurism-needle must be passed 
 from below upwards, the cardiac nerve, the trachea, and the pleural sac 
 being avoided. 
 
 Ligature of the Superior Thyroid — Anatomy.— Fig. 225 shows in the upper 
 portion of the neck the relations of the superior thyroid. The vessel is seen 
 in the middle of the incision with the ligature beneath it. Just above it is 
 the thyroid branch of the hypoglossal nerve lying alongside of the greater 
 cornu of the os hyoides, above which, at the upper angle of the wound, is 
 the margin of the belly of the digastric. The large vessel passing directly 
 upward is the superior thyroid vein, and to the outer side of the incision 
 the superior thyroid artery. 
 
 Operation. — This vessel is secured by making an incision about three inches 
 in length along the inner margin of the sterno-mastoid muscle. This must 
 be pushed aside from the larynx, and after having divided the fibro-cellular 
 lamella, the carotid, jugular vein and omo-hyoid space are brought to view. 
 The vessel is seen curving downward to the thyroid gland, and is secured in 
 the usual manner. 
 
472 
 
 A SYSTEM OF SURGERY. 
 
 Ligature of the Brachial.— Anatomy.— Fig. 226 represents the regional 
 anatomy of the brachial artery, which is seen passing directly down through 
 the centre of the incision with the ligature beneath it. In contact with 
 and on the outer side of the vessel is the median nerve; still passing out- 
 ward, in proximity with the nerve, is the margin of the biceps. On the 
 inner side of the artery is the brachial vein ; still more internal is the 
 ulnar nerve, the margin of the cut surfaces showing the integument and 
 superficial fascia. A line drawn from the hollow of the axilla to the middle 
 of the anterior face of the elbow-joint, follows directly the course of the 
 artery. 
 
 Operation. — The operation, for the most part, is not difficult of perform- 
 ance, as the artery lies comparatively near the surface, its pulsations being 
 readily felt. It can be secured at its upper, lower, or middle third, the most 
 favorable points being either above or below the insertion of the coraco- 
 brachialis. 
 
 In the lower part of the arm the vessel bears close relations with the median 
 basilic and the median cephalic veins, the latter running parallel with the 
 
 artery, being separated from the bicipital fascia. 
 The incision should be made along the inner 
 border of the biceps, and the fascia exposed 
 and divided upon a. director, the median basilic 
 vein having been drawn aside, and the aneu- 
 rism-needle passed from without inwards. 
 
 In the middle part of the arm, an incision 
 should be made along the inner margin of the 
 biceps. The fascia should then be raised and 
 divided upon a director. By slightly flexing 
 the forearm upon the arm, the median nerve 
 will be seen lying across or underneath the 
 vessel. This must be pushed inwards while the 
 two-headed muscle is drawn outwards. The 
 veins must then be separated and the vessels 
 secured. Sometimes the inferior profunda has 
 been mistaken for the trunk of the vessel. It 
 must be recollected that the main trunk lies 
 nearer to the biceps. 
 
 In its upper portion the incision is made on 
 the ulnar side of the coraco-brachialis. This 
 incision must be cautiously made and the dis- 
 section carefully carried on, the fascia being di- 
 vided upon a director to protect the basilic vein, 
 which, in some cases, passes over this part of 
 the artery. The internal cutaneous and the 
 ulnar nerve are on the inner side, while the 
 median nerve lies to the outside of the vessel. 
 These are drawn away with the retractors, and 
 the ligature passed from the ulnar to the radial 
 side of the artery. 
 
 Sometimes two vessels are present ; in such 
 cases the one which is found either giving forth 
 blood or supplying the aneurism must be tied, 
 or both, if necessary, be included within the ligature. 
 
 Ligature of the Radial Artery. — Anatomy. — Same plate (Fig. 226) shows 
 the radial artery, with the radial vein on its outer side; the supinator longus 
 is seen at the lower end of the incision outside the artery, while the pronator 
 radii teres lies on the inner side. The musculo-cutaneous nerve lies on the 
 
LIGATURE OF THE ULNAR ARTERY. 
 
 473 
 
 outside of the artery, and is seen traversing almost the entire length of the 
 wound. 
 
 Operation. — The vessel may be tied in any portion of its course. In the 
 loicer third, an incision should be made at the margin of the flexor carpi 
 radialis muscle, the fascia dissected up, and the vessel is found passing 
 between the muscle mentioned and the supinator longus. 
 
 In the middle third the incision should be made along the inner margin of 
 the supinator longus, and the fascia divided. In this dissection in some 
 cases, there may be a number of veins which require to be held aside, and 
 it must be remembered that the radial nerve lies close to the outer side of 
 the artery, and must, therefore, be avoided. 
 
 At the upper third of the forearm, the ligation of the radial is with more 
 difficulty effected, because it is overlapped by the pronator radii teres and 
 the supinator longus muscles. The incision in this case should be three and 
 a half to four inches in length, extending on the radial side of the forearm 
 obliquely downwards and outwards from the bend of the elbow. The fascia 
 must then be divided, the vense comites held aside, and the thread passed 
 from the radial to the ulnar side. 
 
 Ligature cf the Ulnar Artery. — Anatomy. — Fig. 227 represents the surgical 
 anatomy of the ulnar artery, which is seen in the lower half of the incision 
 
 Fig. 227 
 
 Fig. 228. 
 
 with the ligature beneath it. The large mass of muscular fibres filling the 
 upper angle of the wound are those of the superior flexors of the fingers 
 (nexores digitorum sublimis) ; on the inside of the artery is the ulnar nerve, 
 and still internal to the nerve is the flexor carpi ulnaris. 
 
 Operation. — This vessel at its upper third, being covered by the entire 
 thickness of the superficial flexor muscles, is not selected for the applica- 
 tion of the ligature unless the wound be in that locality. In the middle 
 and lower two-thirds it rests upon the flexor digitorum profundus, between 
 the flexor carpi ulnaris and the digitorum sublimis. The incision must be 
 made along the inner border of the carpi ulnaris and the fascia divided. 
 The flexor carpi ulnaris and the flexor sublimis must be separated from 
 
474 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 229. 
 
 each other ; the ulnar nerve lies on the inner side of the vessel and the vein 
 on the outer side. The ligature must be passed from the ulnar to the radial 
 side. 
 
 Ligature of the Superficial Palmar Arch. — Anatomy. — Fig. 228 represents 
 the arcus superficialis volaris in the palm, with the curve of incision neces- 
 sary. The artery is seen with the ligature underneath it. The median 
 nerve passes just by the vessel, where it terminates in the common digital 
 artery running outward toward the fingers. The palmar fascia is also well 
 illustrated. 
 
 It is the continuation of the ulnar artery in the hand, which is denomi- 
 nated the superficial palmar arch, and a ligature is required in cases of 
 wounds or of aneurism. The incision must be made in the palm of the 
 hand, and the fascia carefully raised ; the palmar fascia must now be snipped 
 and divided upon a director ; the fibres of the palmaris brevis are then 
 seen, and must be caught and held aside with retractors ; the arch now 
 appears, the convexity directed toward the fingers, the concavity toward the 
 muscles of the thumb. The median nerve must be avoided as the ligature 
 is passed. 
 
 Ligature of the Common Iliac. — Anatomy.— The vessel (Fig. 229) passes 
 diagonally across the centre of the wound with the ligature surrounding 
 it just above its bifurcation. Externally is seen a large portion of the 
 
 iliacus internus muscle with the anterior 
 cutaneous nerve passing over it. Above 
 is the peritoneum, covered successively 
 from within outwards by the trans ver- 
 salis, the internal oblique and the exter- 
 nal abdominal muscles ; and these by the 
 fascia. 
 
 Internally is seen the external iliac or 
 crural vein, and external spermatic 
 nerve. 
 
 In an article on the Ligation of the 
 Common Iliac Artery, which appeared 
 in the Medical News, April 5th, 1884, the 
 editor gives the result of seventy-nine 
 cases, which he divides into the following 
 four classes, dependent upon the condi- 
 tions under which the vessel had been 
 tied : First, for haemorrhage, whether pri- 
 msijry or consecutive to the ligation of 
 other trunks, or during performance of other operations. Secondly, for the 
 cure of aneurism. Thirdly, for pulsating tumors, simulating aneurism. 
 Fourthly, as a preliminary step to prevent haemorrhage during the removal 
 of a tumor or amputation at the hip-joint. 
 
 Of the first class there were twenty-eight cases, four recoveries and twenty- 
 four deaths. Of the second class, forty-three cases, fifteen recoveries and 
 twenty-eight deaths. Of the third class, five cases, one recovery and four 
 deaths. Of the fourth class there were three cases, all fatal. 
 
 Operation. — There are several incisions recommended for the application 
 of a ligature to the common iliac artery, the choice depending upon the 
 nature of the case, or the enlargement of the abdomen. If a line be drawn 
 across the abdomen from the highest point of the crests of the ilia, a point a 
 little to the left of the umbilicus would mark the commencement of the 
 common iliac artery ; and a line drawn from this point to the centre of Pou- 
 part's ligament would mark almost the direct course of the vessel itself. 
 If the surgeon have reason to select the iliac region as the place of operation, 
 
LIGATURE OF THE EXTERNAL ILIAC. 475 
 
 a curved incision should be made, beginning at the left of the umbilicus, 
 sloping outward toward the anterior superior spinous process of the ilium, 
 and extending along the upper border of Poupart's ligament to its middle. 
 This cut should be made at least six inches in length. The abdominal mus- 
 cles must then be divided in succession — external oblique, internal oblique, 
 and transversalis ; the transversalis fascia must then be raised upon the 
 director and divided ; the peritoneum now comes into view, which together 
 with the ureter, must be held aside, and search made for the sacro-iliac sym- 
 physis, for at this articulation the vessel can be felt and seen pulsating, 
 accompanied by its vein. On the right side of the body the inferior vena 
 cava, as well as the iliac veins, are in proximity to the vessel, and of course 
 must be avoided. The aneurism needle is passed in the usual manner. 
 
 If the judgment of the surgeon lead him to select the side of the abdom- 
 inal wall as the site of his incision, a cut may be made five or six inches in 
 length, about two inches above and to the left of the umbilicus, curving out- 
 ward toward the lumbar region, and terminating below the anterior superior 
 spine of the ilium. 
 
 Ligature of the Internal Iliac Artery. — The internal iliac is about an inch 
 and a half long, is directed downward and inwards to the sarco-sciatic notch, 
 and divides into numerous branches. 
 
 Operation. — The patient having been placed in a horizontal position, the 
 incision is made in the iliac region, as seen in the figure, and of about the 
 same extent as required for the common iliac ; the abdominal muscles hav- 
 ing been divided and held aside, the transversalis fascia is carefully divided 
 as before directed. The peritoneum must now be pushed inward toward 
 the pelvis, and at the bottom of the wound the pulsation of the external 
 iliac vessel will be discovered ; tracing this upward, the internal iliac is 
 found opposite the junction of the sacrum and the ilium. The vein lies to 
 the right and the ureter and peritoneum in front of the vessel, both of which 
 must carefully be avoided when introducing the ligature. 
 
 Ligature of "the External Iliac. — Anatomy. — The external iliac extends from 
 the division of the common iliac to the crural arch. Its course would be 
 indicated by a line drawn' from the left side of the umbilicus to the centre 
 of Poupart's ligament. It has in front the peritoneum, intestines, and fascia 
 iliaca, the spermatic vessels and lymphatic glands, the genito-crural nerve, 
 and circumflex ilii vein. Behind it is found the external iliac vein ; on the 
 outside is the psoas magnus and fascia iliaca, and to the inner side the vas 
 deferens and external iliac vein. 
 
 The vessel is seen toward the lower part of the wound (Fig. 230) raised 
 upon the aneurism-needle, which is threaded. A blunt hook on the right, 
 holding asunder the flaps, touches the point of the superficial epigastric 
 vein, between which and the aneurism-needle is seen the external iliac vein, 
 which is crossed obliquely at its lower part by the superficial epigastric. 
 The circumflex ilii vein passes downward and forward to the external iliac 
 vein, and the circumflex ilii artery passes upward from the vessel about to 
 be ligated. 
 
 The operation is performed in the following manner : The patient having 
 been placed upon his back and the foot rotated outwards, the knife is entered 
 at a point an inch above and to the inner side of the anterior spine of the 
 ilium, and carried downward and outward to the outer end of Poupart's lig- 
 ament, and continued parallel with it along half its course. The abdominal 
 muscles must be divided, and the transversalis fascia also, the peritoneum 
 separated from the iliac fascia as mentioned in describing the ligation of the 
 internal iliac, and at the bottom of the wound along the inner border of the 
 psoas muscle, the artery is found, with the iliac vein on its inner side, at 
 which point the aneurism-needle should be introduced. 
 
476 
 
 A SYSTEM OF SUEGERY. 
 
 Ligature of the Femoral. — Anatomy. — Fig. 231 represents the line of in- 
 cision and surgical anatomy of the femoral artery after it has passed beneath 
 the crural arch. The vessel takes nearly a straight course downward, and 
 is seen^n the middle of the cut, with the ligature beneath it. External to 
 
 Fig. 230. 
 
 Fig. 231. 
 
 ™^^\\V^S**SS$S^ 
 
 it is the great crural nerve, which is represented as touching the portion of 
 the instrument which holds aside the fascia lata. Internal to the artery we 
 find the femoral vein, and internal to it the lymphatic glands. 
 
 The same illustration shows the plan of incision and regional anatomy of 
 the femoral at the lower part of its course. 
 
 The femoral artery, with ligature beneath it, passes through the centre of 
 the wound ; externally is the saphenous nerve (cutaneus femoris internus 
 magnus), internally the femoral vein. 
 
 Operation. — In the upper third of its course the vessel is quite superficial, 
 and passes through Scarpa's space or triangle, which is bounded as follows : 
 The floor is formed by the adductor longus, pectineus, psoas, and iliacus 
 muscles. Its base, Poupart's ligament, its apex downward ; its external 
 boundary, the sartorius; its internal, the adductor longus. The artery 
 passes through the centre, and gives off the profunda and superficial 
 vessels. 
 
 The incision is commenced about an inch below Poupart's ligament, 
 passing a little outward, and carried to the extent of four inches ; the fascia 
 is then dissected up, and the sheath of the vessel raised and divided care- 
 fully upon a director. The vessel now is distinctly seen, with the crural 
 nerve external, and the femoral vein internal to it. These must be sepa- 
 rated with the handle of a scalpel, or with the finger, and the needle passed 
 from without inwards. 
 
 To ligate the femoral in the lower part of its course : the limb having been 
 slightly flexed and everted, an incision is made on the inner side of the 
 sartorius muscle, about three inches in length, extending half into the 
 middle and half into the lower third of the thigh. The fascia is divided, 
 
LIGATURE OF THE ANTERIOR TIBIAL ARTERY. 477 
 
 and the edge of the sartorius muscle found and drawn to the outer side ; 
 underneath the muscle, and in a groove separating the vastus externus from 
 the adductor, will be found the sheath, which is divided, exposing the ar- 
 terv, with the saphenous nerve externally and the femoral vein internally. 
 
 ligature of the Popliteal Artery. — Anatomy. — Fig. 232 represents the 
 course of the popliteal and posterior tibial arteries and their surgical relations. 
 
 The artery is shown, being very deep, as being drawn forward by the 
 aneurism-needle threaded ; to the left the popliteal vein. External to the 
 last-named vessel is the tibial nerve, and on each side, at the lower angle of 
 the wound, the fibres represent the heads of the gastrocnemius. The depth 
 of adipose and circular tissue is seen in the wound. 
 
 Operation. — The patient should be placed upon his face, and the limb 
 extended. The surgeon stands on the outer side, and makes an incision in 
 the centre of the ham, from three to four inches in length, dividing the in- 
 tegument and fascia; the limb is now slightly flexed and held in that posi- 
 tion, while the heads of the gastrocnemius are felt for and the cellular tissue 
 separated carefully with the finger or handle of the scalpel. This will take 
 some time, as the vessel is deep and there is always a considerable amount of 
 adipose tissue surrounding the parts. The veins must be carefully separated 
 and the needle passed. If it be necessary to secure the artery above the 
 condyles the incision should be extended a little higher up and made nearer 
 to the internal border of the popliteal space, the direction of the cut being 
 toward the intercondyloid notch. In this situation the artery also is a little 
 deeper seated. 
 
 Ligature of the Posterior Tibial. — Anatomy. — Fig. 232 shows the course 
 and position of the posterior tibial at the lower third of the leg. The vessel 
 is drawn forward with a pin. External to it is the tibial nerve ; internal, 
 the posterior tibial vein. 
 
 In the same cut the posterior tibial artery, as it winds around the internal 
 malleolus, is shown with the ligature beneath it. The posterior tibial vein 
 lies external to the artery, and the tibial nerve posterior to this. 
 
 Operation. — For facility the leg should be flexed and laid upon its external 
 side. The incision must be made from a point about an inch above and a 
 few lines behind the malleolus, and curving forward, extend about an inch 
 below this protuberance, thus making the convexity backward. This cut 
 must be made with caution, as in some cases the vessel is so superficial that 
 there is risk of its being wounded. The fascia is raised upon a director, 
 and the vessel is found with the posterior tibial nerve external to the artery. 
 
 Below the Calf. — A straight incision three inches in length, equidistant 
 from the inner border of the tibia and the tendo Achillis is made. The 
 aponeurosis is raised and divided upon a director. The deep fascia is then 
 sought for, and the posterior tibial vein and the tibial nerve must be care- 
 fully avoided. This aponeurosis is divided upon a director and the artery 
 secured. 
 
 In some unusual instances it may be necessary to cut down upon the 
 artery through the calf, but in such cases a ligature placed upon the popli- 
 teal would be preferable. 
 
 ligature of the Anterior Tibial Artery. — Anatomy. — Fig. 233 shows direction 
 of the tibialis anticus at the upper and outer part of the leg. The mass of 
 muscular fibres at the outside of the incision belong to the extensor digitorum 
 sublimis. At the upper part are seen the fascia and fibres of the tibialis 
 anticus. The artery passes downward through the centre of the incision 
 with the anterior tibial vein to its inner side. 
 
 Same plate shows relations of the anterior tibial vessel in the lower and ante- 
 rior portion of the leg. The fibres of the extensor longus pollicis are 
 represented as being drawn aside by the hook to expose the artery beneath 
 
478 
 
 A SYSTEM OF SURGERY. 
 
 it, which is seen with the ligature around it. The anterior, tibial vein passes 
 down with and directly internal to the vessel. Internal to the last named is 
 the anterior tibial nerve. 
 
 Fig. 232. 
 
 Fig. 233. 
 
 Operation. — The patient is placed upon the bed with the limb semiflexed 
 and the foot somewhat extended, and an incision, made from a point mid- 
 way between the head of the fibula and the spine of the tibia, should extend 
 
INJURIES AND DISEASES OF THE VEINS. 479 
 
 three inches downward on a line which, if continued, would reach the 
 middle of the instep ; the aponeurosis and fascia should be dissected up 
 as already mentioned ; then, with the finger or handle of the scalpel, sepa- 
 rate the extensor muscles from the tibialis anticus; the artery then 
 comes in view with the anterior tibial vein on its inner side, and can be 
 secured. 
 
 In the lower part of the leg the operation for ligation may be performed 
 at several points. This incision is made along the course of the artery as 
 indicated by the line which has already been mentioned. The integument, 
 fascia, and aponeurosis are divided, and the fibres of the extensor longus 
 pollicis are exposed. This muscle must be separated from the surrounding 
 tissues and drawn with retractors to the side ; when the artery is found 
 beneath it. On the internal side of the vessel is the anterior tibial vein. 
 The ligature should be passed from the inside toward the outer side. 
 
 Ligature of the Dorsalis Pedis. — Anatomy. — Same plate (Fig. 233) repre- 
 sents the dorsalis pedis emerging from the leg to the ankle. The artery, 
 with the ligature underneath, is distinctly seen ; internal to which is the 
 tendon of the extensor longus pollicis ; externally, the tibialis anticus nerve 
 is found ; external to which are the fibres of the extensor brevis digitorum pedis. 
 
 Operation. — An incision should be made two inches in length, in a line 
 carried from the middle of the instep to the first interosseous space. The 
 integument is dissected up for a little distance ; then the incision is carried 
 down in succession between the tendons of the first two toes and until the 
 deep fascia is reached ; this is divided upon a director, and the artery is 
 exposed at its internal side, having the tendon of the extensor longus 
 pollicis internally, and externally the anterior tibial nerve. 
 
 CHAPTER XXVI. 
 
 INJURIES AND DISEASES OF THE VEINS. 
 
 Thrombosis— Thromballosis — Coagulation in Veins — Thrombus— Phlebitis — 
 Varix— Entrance of Air — Wounds — Phlebolithes. 
 
 By these terms are understood those manifestations and changes which 
 occur from coagulation of the blood within the veins, and by some within 
 the arteries also. Virchow* proposes to drop entirely the old terms phlebitis 
 and arteritis, and substitute the word thrombosis, " inasmuch," he says, " as 
 the affection essentially consists in a real coagulation of blood, at a certain 
 fixed point." There has been a good deal of confusion of terms in both 
 diseases of arteries and veins, and to prevent future misunderstanding in 
 this volume, thrombosis will signify the coagulation of blood in veins, and 
 embolism the formation of clots in arteries. 
 
 Thrombosis occurs, in some instances, from the spontaneous coagulation 
 of blood fibrin, or by the formation of clots after injuries, while the method 
 of repair is being carried on, or from slow and imperfect circulation, occa- 
 sioned either by unwholesome food, pressure of tumors, or defective nutri- 
 tion. The dots may increase either in the direction of the current of the 
 blood or against it, and when they commence forming, a true phlebitis may 
 also set in, thereby assisting the clot deposit. After the coagulum has ex- 
 isted for a time, it slowly contracts upon itself, and is retained in its posi- 
 
 * Cellular Pathology, p. 233. 
 
480 A SYSTEM OF SURGERY. 
 
 tion by the firm fibrinous processes which attach themselves to the vein- 
 wall ; it may be more closely fastened to one side than the other, and the 
 blood may thus regain a passage by flowing between the clot and the wall 
 of the vein. 
 
 When the thrombus is so large as to entirely arrest the circulation and 
 terminates in obliteration of the vein, there of course follows great oedema, 
 which is of remarkable paleness, and is called "the white leg." To this 
 there is often a state of inflammation superadded, softening and disinte- 
 gration of the fibrin, and a puriform substance is generated. This sub- 
 stance was formerly supposed to be pure pus, whereas later investigators 
 prove it to be puriform. 
 
 When thrombosis affects a limb, the constitutional disturbance at first is 
 not very severe ; the face feels hot and dry, with considerable stiffness ; the 
 surface veins are found hard and corded, and when the inflammation is 
 established its usual symptoms appear. If with these symptoms there is an 
 injury or bruise, the diagnosis will be sufficiently clear. 
 
 The prognosis of thrombosis depends upon the size of the vessel affected 
 and the magnitude of the clot ; when both are large, nutrition is much in- 
 terfered with, and if portions of the clot separate and are carried into the 
 circulation, symptoms of pyaemia may supervene. 
 
 Treatment. — In the first stages of this disease, aconite is the appropriate 
 medicine, and must be given often and in fair doses to produce a percepti- 
 ble effect. When the symptoms are further advanced and evidences of 
 suppuration appear, then hepar sulph., mercurius, cham., lycop., and sulph., 
 are appropriate medicines. When the oedema begins, an elastic bandage 
 or stocking must be employed and perfect rest enjoined. In the treatment 
 of this affection there is yet much uncertainty, its true pathology having 
 been so recently recognized, which, together with the rarity of its occur- 
 rence, has permitted but little therapeutical experience. I should select 
 rhus radicans, lachesis, or hepar sulph. in addition to those medicines 
 mentioned above. 
 
 Phlebitis. — Inflammation of the Veins. — Phlebitis may be either acute or 
 chronic ; the former may terminate fatally if not arrested ; the latter is not 
 dangerous, and generally affects varicose veins of the lower extremities. 
 In acute phlebitis the countenance of the patient expresses anxiety and de- 
 pression of spirits, there are repeated rigors, dry, brown, or blackish tongue, 
 cadaverous skin, great prostration, pulse rapid and weak, muttering deli- 
 rium, and vomiting of bile. 
 
 Consecutive abscess is said to be a characteristic termination of acute phle- 
 bitis; excessive pain may be experienced in any of the joints, which is 
 rapidly succeeded by a copious formation of pus ; purulent formations may, 
 after this, collect in other parts of the body, especially in the lungs and 
 liver. 
 
 Many of the symptoms formerly attributed to phlebitis are now known 
 to originate from thrombosis ; in fact the ordinary suppurative phlebitis, 
 says Mr. Holmes, " is nothing more than a diffused phlegmonous inflammation, 
 and should be reclassed with disorders of that character."* 
 
 Treatment. — The treatment of acute phlebitis is somewhat difficult, which, 
 in many instances, is owing to the disjointed character of the homoeopathic 
 Materia Medica. However, for the presenting symptoms, particularly in 
 the first stages of the affection, when the fever is high, with a quick, full 
 pulse, dry, furred tongue, etc., aconite should be employed. 
 
 If after a time the brain appears to participate in the disease, belladonna 
 
 * Holmes, System of Surgery, vol. iii., p. 302. 
 
VARIX — TREATMENT. 481 
 
 is indicated ; but the medicine that is best adapte'd to inflammation of the 
 veins is pulsatilla, which may be employed after aconite or belladonna, in 
 the first stages of the inflammatory process ; but when the tongue becomes 
 dry, brown, and cracked, when the patient is much prostrated, with burn- 
 ing thirst, and hot, dry skin, arsenicum is distinctly required. Carbo veg. 
 may be prescribed for a somewhat similar group of symptoms, and perhaps 
 would be a preferable medicine, when the action of the arterial system has 
 been almost entirely overpowered, and venous congestion is indicated by a 
 blue tinge of the skin over the whole surface of the body, attended with 
 anguish about the heart, and icy coldness of the surface. 
 
 If suppuration threaten, or if it have actually occurred, and the amount 
 of purulent secretion is considerable, silicea should be administered, or the 
 case may strongly call for hepar, mere, sol., or sulphur. 
 
 For chronic phlebitis, besides the medicines just mentioned, arn., cham., 
 lye, nux vom., spig., or zincum, may be demanded. 
 
 Hamamelis is one of the most suitable medicines for the chronic form of 
 phlebitis, which together with pulsatilla and lachesis, are more to be relied 
 upon than any other medicines. The last named was efficient in the hands 
 of Mr. Ayerst. 
 
 Lachesis.* — Dr. Dunham relates the following : " I have three times been 
 called to cases of chronic ulcer of the lower extremities, probably of syph- 
 ilitic origin, in which the discharge had ceased, the extremities became 
 ©edematous, and a hard slightly red swelling, extending up along the course 
 of the principal veins, together with great and sudden prostration of strength, 
 low muttering delirium, and typhoid symptoms, gave good reason for sup- 
 posing that general phlebitis had occurred. In these cases a careful study 
 of the symptoms induced me to give lachesis ; the effect was all that could 
 be desired, the patients rallying promptly, and all the symptoms of phlebitis 
 speedily disappearing." 
 
 Varix. — The term varix designates an hypertrophied condition of the 
 veins, in which they are divided into irregular pouches, in consequence of 
 not being able to sustain the reflex column of blood. In other cases the 
 walls of the veins become thinner than usual, or may be unequal to their 
 dilatation. Deepseated as well as superficial veins are frequently rendered 
 varicose by undue muscular action, by interruption of the circulation from 
 ligatures, by the pressure of tumors, and by the gravid uterus. The veins 
 of the upper extremities are rarely affected with hypertrophy, while those 
 of the lower, especially the saphenas and their branches, are very liable to 
 the disease. In the commencement, numerous small circumscribed swell- 
 ings are observed, but after a time the venous trunks and branches appear 
 enlarged throughout their whole extent ; sometimes they are knotted or 
 doubled upon each other, and these gyrations are particularly conspicuous 
 in the neighborhood of the valves. 
 
 An enlargement of the veins may continue for a considerable period 
 without giving much inconvenience to the patient ; but in the generality 
 of cases, after the veins have attained any magnitude, a sense of soreness, 
 weight, fulness, and fatigue of the limb are experienced. The feet are cold 
 and the veins become more prominent, corded, and swollen, particularly 
 after exercise, or when standing. Sometimes the thin walls give way and 
 profuse haemorrhage results. After these varicose enlargements have con- 
 tinued for a time, the parts are deprived of their vitality, there is an 
 obstruction of the absorbents, and the varicose ulcer is produced (vide 
 page 133). 
 
 Treatment. — The opinion was long entertained that any attempt to 
 
 * American Homoeopathic Eeview, vol. iv. 
 31 
 
482 A SYSTEM OF SURGERY. 
 
 operate upon veins was" a rash procedure and fraught with extreme 
 peril. Experience, however, has shown that in many cases this appre- 
 hension is unfounded, and I am satisfied, from my own experience in 
 operations for varicose veins in different portions of the body, that, with a 
 moderate amount of care, untoward symptoms will not occur. There are 
 different methods of obliterating varix. Those which I have found most 
 simple and successful are with the caustic paste and by the subcutaneous 
 method. 
 
 The first is effected as follows : Prepare equal parts of caustic potash and 
 quick-lime. Mix them together with sufficient alcohol to make a paste, 
 and then, with a glass rod, apply the mixture to the vein. After having 
 allowed it to remain for a few minutes, wash off the eschar with vinegar, 
 and wait for the separation of the slough. If sufficient caustic has not 
 been used, a second or third application may be necessary. Sometimes 
 as the dead portions separate, quite a haemorrhage follows, which, how- 
 ever, is readily checked. This process I have repeatedly resorted to with 
 success, as I have also the following : Place beneath the vein, about three 
 inches apart, two hare-lip pins, twist over each of them a piece of silver 
 wire, then introduce a narrow tenotome flatwise beneath the vessel, turn 
 the sharp edge outward and divide the vein, taking care not to bring the 
 edge through the integument. After a few days the pins are to be re- 
 moved. 
 
 Sir Benjamin Brodie thus writes: "For this operation I have generally 
 employed a narrow, sharp-pointed bistoury, slightly curved, with its cutting 
 edge on the convex side. Having then ascertained the precise situation of 
 the veins or cluster of veins from which the distress of the patient appears 
 principally to arise, I introduce the point of the bistoury through the skin 
 on one side of the varix, and pass it on between the skin and the vein with 
 one of the flat surfaces turned forwards, and the other backwards, until it 
 reaches the opposite side. I then turn the cutting edge of the bistoury 
 backwards, and, in withdrawing the instrument, the division of the varix 
 is effected. The patient experiences pain, which is occasionally severe, 
 but which subsides in the course of a short time. There is always haemor- 
 rhage, which will be often profuse if neglected, but which is readily stopped 
 by moderate pressure, made by means of a compress and bandage correctly 
 applied." 
 
 Mr. Cart-wright and also Mr. Mayo apply over the course of the distended 
 vessel potassa cum calce, which causes sufficient inflammation to produce 
 coagulation of the blood and occlusion of the vein. 
 
 Velpeau advocates the twisted suture alone. 
 
 Davit passed needles through the veins at right angles with transverse 
 needles previously introduced beneath the vessels. 
 
 Others apply the galvano-puncture, and others again the injection of the 
 perchloride of iron. 
 
 An excellent method may be found in having a pin constructed after the 
 fashion of an ordinary diaper pin used in dressing infants ; pass the sharp 
 point behind the vein and bring down and catch upon its point the clasp, 
 having laid a piece of linen over the integument to prevent too much abra- 
 sion. 
 
 In the treatment of superficial varices, Cazin, referring to these cases and 
 the avoidance of phlebitis or pyaemia, recommends the following procedure : 
 An incision, three centimetres long, is made parallel to the vein, and at a 
 distance of one centimetre from it. At the two extremities of this incision 
 two others are made transversely towards the vein, and reaching to it. This 
 flap is dissected up and the vein is isolated by a blunt instrument. The 
 flap is next passed beneath the vein and replaced in its original position 
 
EXCISION OF THE VEINS — ENTKANCE OF AIR. 483 
 
 and fastened, the vein remaining thoroughly isolated without any ligature 
 having been used. 
 
 Great advantage may be derived from allowing the patient to encase the 
 limb in an elastic stocking, which is constructed especially for the treat- 
 ment of varicose veins ; this should be constantly worn, and at the same 
 time medicines should be internally administered, which are chiefly agaric, 
 ars., particularly when the veins are of a livid color, and attended with 
 severe burning pains; bell., when erysipelatous inflammation surrounds 
 the varices; carbo veg., graph., lye, puis.; the latter is perhaps the most 
 efficacious medicine when there is considerable inflammation, excessive 
 pain and swelling, and when the limb assumes a livid hue ; arnica is a 
 valuable medicine in the treatment of this affection ; it is particularly use- 
 ful when the patient is obliged to maintain an erect posture for a length of 
 time, or when the veins have become diseased in consequence of wounds or 
 blows ; very beneficial results have been obtained by the exhibition of arnica 
 and pulsatilla in alternation, a dose every night. Hamamelis virginiana 
 has been highly recommended by Dr. Okie, of Providence, in the treatment 
 of this affection. It has been used with beneficial effect both as an external 
 application and as an internal medicine, and has done me good service in 
 several cases. 
 
 Excision of the Veins. — Excision of the vein in varix may be performed 
 in many ways. Dr. Fry * has formulated his method in the following 
 w r ords : 
 
 " 1. Excise through several small incisions not more than two inches in 
 length, leaving one large piece, as by so doing the vein is included at seve- 
 ral points. 
 
 " 2. Mark the site of the intended incisions before applying the bandage, 
 as the position of the varix becomes identified with the limb when it is 
 rendered bloodless. 
 
 " 3. Apply the Esmarch bandage carefully to thoroughly empty the 
 bloodvessels, or the wound becoming full of blood, there will be considerable 
 difficulty in dissecting out the vein and very troublesome haemorrhage may 
 occur. 
 
 " 4. Ligate the vein at its upper end and dissect it out from above down- 
 wards. 
 
 " 5. Remove as little as possible of the tissues surrounding the vein, but 
 if it is unavoidable take away the deeper tissues which are well supplied 
 with blood. 
 
 " 6. Apply the dressing and bandage to the limb before removing the 
 tourniquet ; by this means haemorrhage is avoided, and primary union en- 
 couraged. 
 
 " 7. Above all be careful to employ antiseptic measures during the opera- 
 tion and in subsequent dressings." 
 
 Entrance of Air. — The entrance of air into veins is an untoward acci- 
 dent, and has occurred many times in the practice of distinguished sur- 
 geons. The accident is so immediately followed by alarming, if not fatal 
 consequences, that it must always be regarded as a serious complica- 
 tion. The symptoms which indicate the presence of air in the veins 
 are the sudden and peculiar gurgling noise, similar to that heard when 
 pouring a fluid from a bottle, with sudden prostration, rapid collapse, 
 and death. The air probably passes into the lungs, and there arrests the 
 circulation of both systems, and complete stoppage of respiration takes 
 place. 
 
 Prof. Hamilton details an interesting case of this kind (in which, however, 
 
 * British Medical Journal, September 5th, 1885. 
 
484 A SYSTEM OF SURGERY. 
 
 his patient was saved) in his chapter on Enlarged Lymphatic Glands of 
 the Neck. The following are supposed to be the conditions which predis- 
 pose to the entrance of air into the veins : " Incision of a large vein in the 
 vicinity of the heart, and especially in the lower anterior portion of the 
 neck, where these vessels experience a reflex pulsation. Canalization of 
 a vein, in consequence of a thickening of its coats from morbid deposits, or 
 in consequence of fibrinous infiltrations into the adjacent tissues, or owing 
 to its being more or less imbedded in a solid tumor, either of which circum- 
 stances converts the vessel into a rigid incollapsing attachment of the outer 
 wall of the vein to the base of the tumor, so that in lifting the latter the 
 two walls of the vein become drawn asunder and collapse is prevented, when 
 the blood escapes. Traction made upon the outer wall of the vein by the 
 forceps, or by tension of the overlying structures, or a deep inspiration 
 made at the moment of dividing the vessel may accomplish the same re- 
 sult."* 
 
 It is only necessary carefully to read the above causes of this serious 
 accident to prevent its occurrence, and if it should transpire, arrest of haem- 
 orrhage by immediate compression and rapid artificial respiration are all 
 that can be done. 
 
 Wounds of the Veins. — The veins are frequently wounded during the per- 
 formance of operations, but the haemorrhage can generally be arrested by 
 properly applied pressure; in some instances, however (though the pro- 
 ceeding, if possible, should be avoided), ligatures become absolutely neces- 
 sary. 
 
 In such instances, the threads may be applied at both ends, and as a gen- 
 eral rule, without danger. If possible, however, the ordinary acupressure 
 pins, if introduced beneath the vein, and allowed to remain for a few hours, 
 will prove efficacious and safe. 
 
 Phlebolithes. — Loose calculi are sometimes found in veins, to which the 
 term phlebolithes is given ; these peculiar formations are found growing to 
 the inner coats of the vein, are oval in shape, and attached by a narrow 
 pedicle. There are many conjectures concerning their formation, the most 
 plausible being that they are the transformations of inspissated coagula. 
 They appear to move from place to place in the circulation, the pedicle 
 having broken from its attachment to the inner coat by the force of the 
 stream of blood. They are composed almost entirely of protein material 
 and phosphate of lime. ( Vide Thrombosis.) 
 
 CHAPTER XXVII. 
 
 DISEASES OF THE CAPILLARIES. 
 
 Erectile Tumors — N^vi — Telangiectasis. 
 
 The erectile tumor of arteries occurs most frequently in the submucous 
 and subcutaneous cellular tissue about the head, face, and neck ; but may 
 also exist in nearly every part of the body, and has even been found in 
 bones. It is soft, compressible, of a slightly higher temperature than sur- 
 rounding parts, pulsates synchronously with the beats of the heart, and has 
 a peculiar bruit, which is sometimes loud and harsh, at other times soft 
 and cooing. This peculiar bruit, the distance of the tumor from any large 
 
 * Hamilton's Principles and Practice of Surgery, p. 189. 
 
TKEATMEXT OF N^VTJS. 485 
 
 artery, and its less forcible pulsation, will serve to distinguish it from aneu- 
 rism. It varies in color according to situation ; when deeply imbedded in 
 subcellular tissue, the tumor presents a bluish appearance, but when situ- 
 ated on the surface it is generally of a vivid scarlet. 
 
 Capillary nsevi are flat, slightly elevated, and of a red or purplish hue ; 
 they are usually small, and occur most frequently on the head, face, neck, 
 and. arms. The contained blood may be arterial or venous, or a mixture 
 of the two. 
 
 As a general rule, these growths do not attain a size much larger than 
 an egg. Fig. 234, taken from a photograph, represents a case of my own, 
 in which the growth had attained the size of 
 half an ordinary melon, and for which I fig. 234. 
 
 ligated the common carotid below the omo- 
 hyoid, after failure by other means. At first 
 the tumor diminished one-half, remained sta- 
 tionary for a time, and then disappeared. In 
 an interesting paper by Dr. George H. Hub- 
 bard, entitled " The Big Nsevus,"* the growth 
 measured twelve inches in its long diameter and 
 eight in its transverse, "and extended from the 
 second dorsal vertebra nearly to the crest of the 
 ilium." 
 
 The tumor was ligated in mass with needles w ^ SftSJTASKa E 
 a foot in length, armed with whip-cord ; during gated below the omohyoid, 
 the sloughing period it was constantly soaked 
 
 with a solution of the sulphate of iron. In six weeks the man went to 
 his work. In three months more there only remained an unhealed surface 
 the size of half a dollar, but shortly after, an abscess formed beneath the latis- 
 simus dorsi, which never healed, and finally caused the death of the patient. 
 
 Treatment. — It may be laid down as a general rule, that the treatment of 
 these cases must be purely surgical. 
 
 When the nsevus consists of a simple red spot, it may be cured by vacci- 
 nation, or by application of collodion with pressure. When situated over 
 a bone, the tumor may be treated by compression with pads of ivory or 
 other hard substances. External application of nitric acid, setons, and the 
 passage of one or more silk threads soaked in some caustic solution, have 
 also been recommended. Some surgeons prefer nitrate of silver or the 
 actual cautery. Injections of persulphate or perchloride of iron, sulphate 
 of zinc, lactate of iron, matico, tannin and other astringents, may prove 
 useful. 
 
 Dr. John Pattison treats nsevi by injection of persulphate of iron, fol- 
 lowed by enucleation in the manner described under cystic tumors. Gross 
 speaks highly of the topical application of " Vienna paste." Sometimes 
 small nsevi may be cured by breaking up their substance subcutaneously 
 with a cataract-needle or tenotome and applying pressure. Puncture with 
 red-hot needles or acupressure pins has been advised bv Dr. Valentine 
 Mott. 
 
 Dr. Hamilton has succeeded in removing superficial nsevi in the neighbor- 
 hood of the eyelids, where eversion of the lid must have followed removal 
 of the integument, by dissecting up the skin covering the naevus, cutting 
 away the subcutaneous areolar tissue, and then replacing the flap. 
 
 Perhaps the best method of treating naevi is by electrolysis or galvano- 
 puncture. Many successful cases are upon record treated by these methods. 
 
 * Transactions of the Medical Society of the State of New York, 1870. 
 
486 
 
 A SYSTEM OF SURGERY. 
 
 The student may refer to page 58 for a full description of the method of 
 performing electrolysis. 
 
 Division of the soft parts around the tumor is recommended by Mr. 
 Lawrence. Fergusson treats small naevi by passing a pin beneath them, 
 and then compressing the tumors between the pin and a loop of wire, as in 
 the third method of acupressure. 
 
 For tumors composed of dilated veins, subcutaneous incision and con- 
 tinued bandaging is excellent. 
 
 Naevi may also be treated by the following methods of ligature : 
 
 1. Pass two pins or needles beneath the naevus, at right angles with each 
 other ; then throw a ligature behind them, and tie it tightly. The pins 
 should be introduced and brought out at least one-eighth of an inch from 
 the margins of the tumor. 
 
 2. Dr. Barton's method is similar to the above, with the exception that 
 the ligature is first passed behind the pins, and then carried over the top of 
 the tumor. 
 
 3. Pass beneath the tumor a needle threaded with a double ligature, and 
 tie the ends so as to strangle each half of the naevus separately. 
 
 4. Liston's method : Pass two needles threaded with double ligatures, cut 
 each noose and tie the contiguous ends of the ligatures. By drawing the 
 last knot very firmly, all the other nooses are tightened and the knots 
 dragged toward the centre. When the tumor is entirely subcutaneous, 
 and the surgeon desires to avoid an unseemly scar, the skin may be di- 
 vided by a crucial incision and the flaps turned down before passing the 
 needles. 
 
 5. Erichsen's method: Take a strong whipcord three feet in length, 
 stained one-half black, the other half white ; thread a long needle upon the 
 
 Fig. 235. 
 
 Fig. 236. 
 
 Fig. 235.— Ligature for strangulating a large naevus. The white loops are divided on one side, and the 
 black on the other, and the corresponding ends (a a', b b') tied together. The terminal strings c c may- 
 be either tied or withdrawn, as the surgeon thinks best. 
 
 Fig. 236.— Subcutaneous ligature of naevus. The upper figure shows a single ligature carried round 
 the tumor. The lower (in which no tumor is depicted) shows a double string carried below the centre 
 of the base, then divided into two, aa'b b', and each of the two carried subcutaneously round half of 
 the naevus, and then tied. 
 
 middle of this cord. Then commencing at about one-quarter of an inch 
 from the end of the tumor, pass the needle several times beneath the naevus. 
 The loops should be three-quarters of an inch apart, and the last one 
 brought out through the healthy tissue beyond the tumor. (Fig. 235.) 
 " Thus we have double loops — one white and one black — on each side. Cut 
 the white loops on one side and the black on the other ; then tie firmly the 
 
TREATMENT OF N^VUS. 487 
 
 white threads on one side and the black on the other,"* and the nsevus is 
 effectually strangulated. 
 
 6. Fergusson's method : " A double thread is thrust transversely beneath 
 the centre of the tumor and divided in the middle. Next, one end of the 
 thread is passed through the eye of a long needle (the eye near the point), 
 and having been brought one-fourth around the circumference of the tumor, 
 is thrust transversely through its base. Then it is to be disengaged from 
 the eye of the needle, and the other thread to be put into the eye and to be 
 carried back with it. Lastly, the adjoining ends of the two threads are to 
 be tied tightly, so that each of the two threads shall include an 8-shaped 
 portion of the tumor ; after two or three days the ligatures should be tight- 
 ened or fresh ones applied, "f 
 
 7. Mr. Curling proposed subcutaneous ligation, which may be performed 
 in the following manner: A needle threaded with a stout ligature is 
 passed beneath the middle of the tumor, then the needle is withdrawn 
 and the ligature divided into two threads. u One end, being passed through 
 the eye of the needle, is thrust into the second wound, and carried semi- 
 circularly round under the skin and brought out at the first wound, where 
 it is seized and held firmly whilst the needle is withdrawn. One end of 
 the other thread, being in like manner put into the needle, is thrust in, and 
 carried round under the skin, on the right side, and brought out as the 
 first. The operation is completed by tying the ends very tightly, so as to 
 strangle the half of the base of the tumor, encircled by each respectively. 
 The ends are to be left and fastened with plaster, so that they may be 
 tightened if requisite and drawn out, as the base of the tumor perishes by 
 ulceration."! 
 
 8. Mr. Startin proposes to pass the ligatures subcutaneously, attach them 
 to rubber rings, and make traction upon the tumor by means of tapes tied 
 to the rings. 
 
 When the nsevus is not situated in the vicinity of any large artery, it 
 may be excised by carefully dissecting it from the cellular tissue. Great 
 care must be observed not to puncture the tumor during the operation, for 
 this accident is always followed by profuse and obstinate haemorrhage. 
 
 For large vascular nsevi Dr. William Gibson, of Philadelphia, has recom- 
 mended partial incision, which is performed in the following manner : One- 
 half of the tumor is dissected up, the bleeding vessels secured, and lint 
 interposed between the raw edges to prevent union ; then, after a few days' 
 interval, the operation is repeated, and the tumor completely excised. Very 
 large nsevi may require three or four operations. 
 
 When the tumor is inaccessible to knife or ligature it has been proposed 
 to ligate the nutrient arteries. This is often successful when the tumor is 
 situated in a non-vascular part, but ligation of the carotid for nsevi of the 
 head and face often fails on account of extensive collateral circulation. 
 Amputation even is sometimes necessary in naevi of the limbs. 
 
 * Gross's Surgery, vol. i., p. 787. 
 f Druitt's Surgery, p. 315. 
 £ Druitt's Surgery, p» 116. 
 
488 A SYSTEM OF SURGERY. 
 
 CHAPTER XXVIII. 
 
 THE NERVOUS SYSTEM AFTER INJURIES AND OPERATIONS. 
 
 Symptoms of Shock — Temperature During— Secondary Shock — Treatment — 
 Tetanus — Wounds of the Nerves — Nerve Stretching — Nerve Suture — 
 Neuralgia. 
 
 After surgical operations of magnitude, when there has been a large 
 amount of tissue removed, or excessive haemorrhage ; when the patient has 
 been a long time under anaesthetic influence ; when a large quantity of 
 fluid, either serum or pus, has escaped, or where closed cavities have been 
 opened, there is always a greater or less degree of nervous prostration, which 
 is denominated " shock" The nervous system has a powerful influence over 
 the action of the heart and vessels, and death has been known to result 
 without any assignable cause, excepting that which can be attributed to 
 the nervous system. I recollect an instance of this kind. I was present at 
 the post-mortem examination of a young lady, who had been unwell for a 
 few days, but who on the evening before her death had been enjoying the 
 society of her friends, and accompanied them to the street-door of her resi- 
 dence at their departure. On retiring for the night she took, by the direc- 
 tion of her physician, a dose of the 200th potency of rhus. In the morning 
 she was discovered dead in her bed. The coroner was called to investigate 
 the matter. A most thorough post-morten examination was made, every 
 organ in the body carefully and minutely inspected, the fluid from the ven- 
 tricles of the brain, the stomach, and bladder examined by professional 
 chemists, but no cause whatever could be discovered for her demise. Many 
 other similar cases are upon record. Dr. H. C. Cameron relates two inter- 
 esting cases. He says :* u Some years ago I had occasion to make an incision 
 in the leg of an old soldier, and as he was very bronchitic I persuaded him 
 to dispense with chloroform. The moment the incision was made, he 
 screamed, gave vent to a volley of oaths, and almost immediately expired. 
 A post-mortem revealed nothing beyond evidences of old bronchitis, and of 
 advanced granular disease of the kidneys. I was asked to see an elderly 
 lady with a small tumor in the groin, which was causing her no uneasiness 
 but great anxiety. She was said to be the subject of fatty heart, prone to 
 attacks of syncope, and with a weak and often irregular pulse. The tumor 
 was evidently a small femoral hernia, and on trying to move it a little from 
 side to side, it slipped with a gurgle from between my finger and thumb 
 and passed up. I said to her, ' Did I cause you any pain ?' She replied, 
 ' Not in the least.' I then asked her to feel the tumor now. On discovering 
 that it had gone, she was evidently greatly startled and surprised, no doubt 
 pleasantly so, for it had been much in her thoughts. Almost immediately 
 she complained of feeling faint and asked for some cold water. This was 
 supplied, but her syncope deepened and in about ten minutes life was ex- 
 tinct. These are examples of shock following respectively upon sudden 
 pain and sudden mental emotion." With a knowledge of these facts, it is 
 evident that sudden and severe impressions upon the nervous system some- 
 times produce such a decided action upon the circulatory apparatus that 
 
 * Glasgow Medical Journal, March, 1884. 
 
shock. 489 
 
 symptoms of the gravest character, nay, death itself, may be the conse- 
 quence. The symptoms of shock or collapse, once having been witnessed, 
 can never be misapprehended. The lips are blanched, a deadly pallor 
 overspreads the face, the skin is cold and clammy, drops of cold perspiration 
 appear upon the forehead, a dull leaden hue overspreads the face, the ex- 
 tremities are cold, the nose is pinched, sometimes the nostrils are dilated, 
 the eye partially glazed and slightly turned in the socket, with a drooping 
 lid. The pulse is fluttering and tremulous, and the heart is feeble, with 
 temperature of 96° or 97°. In fact, the symptoms resemble those often seen 
 in cholera, as the patient sinks into collapse, or in cases where fatal haemor- 
 rhage is stealing away vitality. As reaction takes place the pulse loses its 
 " whirring " beat, the motion of the heart, though feeble, becomes much 
 more regular and a little " rounder," and as the blood begins to flow into 
 the larger capillaries an increased temperature and decreased pallor result, 
 the eye becomes more natural in expression, and warmth gradually diffuses 
 itself over the surface. With these symptoms of returning life there are 
 generally long-drawn respirations, and the patient becomes rather restless. 
 These symptoms may continue until the unmistakable presence of increased 
 action shows that fever has commenced, a condition which must be as care- 
 fully watched ; for if the action is excessive, and flushed face, intense thirst, 
 delirium, jactitation of muscles, insomnia, and other well-marked indica- 
 tions of a high degree of nervous irritability succeed, the prognosis is unfa- 
 vorable, and hiccough, convulsions, coma, and death may ensue. 
 
 It is well, also, to bear in mind that these symptoms often vary very 
 much in intensity and duration, and require the utmost care and watchful- 
 ness of the surgeon. Some patients may never fully recover from the effects 
 of a severe shock, though they may be able to perform imperfectly the 
 usual duties of life. 
 
 In an interesting essay on this subject by W. W. Wagstaffe, F. R. C. S. E., 
 published in St. Thomas's Hospital Reports, are several tables which show 
 the fall of temperature in the fatal and non-fatal cases. In eighteen cases 
 of operations, embracing ovariotomy, hip-joint operation, herniotomy, and 
 the removal of tumors, the difference in the fall of temperature in the fatal 
 and non-fatal cases was as follows : Non-fatal, mean fall, 0.3° ; in the fatal, 
 3.70°. From this it is inferred that if there be no especial cause for shock 
 before an operation, the thermometer should not fall more than 1° ; and if 
 it is more than this, an unfavorable prognosis may be anticipated in pro- 
 portion to the downward tendency. 
 
 The following table, taken from the article in question, shows the fall of 
 temperature in certain forms of surgical injury : 
 
 XOT FATAL. FATAL. 
 
 A mean fall. 
 
 A. Burns and scalds, . . * 0.1° 3.5° 
 
 Severe fractures, 1.6° 2.1° 
 
 Operations (without undue haemorrhage), . . 0.3° 3.0° 
 
 B. Concussion of brain, 1.2° 6.1° 
 
 Injury to spinal cord, 5.6° 
 
 C. Visceral injury (extravasation into peritoneum), . 3.3° 3.8° 
 
 D. Haemorrhage, 2.2° 
 
 The employment of the thermometer is, therefore, found to be a useful 
 adjunct in forming a prognosis, both before and after surgical operations 
 and injuries. 
 
 In some constitutions there is another condition produced by accidents 
 and operations, which is not nearly of so acute a character as that already 
 described, and which is termed by some surgical writers Secondary Shock. 
 In these cases the patient appears to rally, and reaction to be somewhat 
 
490 A SYSTEM OF SURGERY. 
 
 established. There are no particular symptoms excepting, perhaps, occa- 
 sional weakness ; the pulse is moderately good and the mind active ; yet 
 the countenance becomes dejected, the skin sallow, the functions of different 
 organs impaired, and although nature makes strenuous efforts to react, the 
 shock has been too great for the system to withstand, and the patient ulti- 
 mately succumbs. 
 
 Different temperaments suffer in different degrees from the effects of 
 shock ; this is especially noticeable in gunshot wounds and railway acci- 
 dents, where many individuals are affected with different degrees of col- 
 lapse. No doubt in these cases, the suddenness of the injury, combined 
 with a certain degree of mental excitement, assist in producing the collapse. 
 Mental emotions, weak constitutions, debauchery, and excess of eny kind, 
 or advanced years, are all predisposing causes of shock, and must be taken 
 carefully into the consideration of each particular case. 
 
 Prof. Von Nussbaum remarks, that many deaths after injuries and opera- 
 tions, attributed to shock, are really the result of other causes. He believes 
 that, in cases of rapid absorption of septic peritoneal contents, death is 
 caused by septicaemic collapse. Then there is the sudden death of old 
 people after a day or two's satisfactory progress, death resulting from the 
 haemorrhage caused by the operation, although its effects are not apparent 
 until the final collapse takes place. The sudden fatality, after severe rail- 
 way accidents and their consequent amputations, he attributes to " fat-em- 
 bolism," showing itself in dyspnoea, oedema of the lung, and death. Death 
 also results from sudden and extensive cooling of the abdominal viscera, 
 the abstraction of heat having been found by Wegner " to be a competent 
 fatal agent." To sum up, the conditions apt to be confounded with shock 
 are, " septicaemia, senile anaemia, fat-embolism, in crushing of bones, and 
 abdominal cooling."* 
 
 Treatment. — The first object of attention in the treatment of shock is to 
 ascertain the condition of the heart, and whether its action is altogether 
 suspended. If it be, and there is reason to suppose the organ has for some 
 time ceased performing its function, little can be done ; but even in such 
 cases it is well that electricity be applied, together with frictions to the ex- 
 tremities. Artificial respiration should also be resorted to. For ordinary 
 cases of severe shock there are homoeopathic medicines which are of 
 great service. Of these, camphor, veratrum, arsenicum, and china are, 
 as far as my experience goes, the best, and the surgeon will scarcely be 
 called upon to use any others. Camphor, when demanded, should be 
 given in one or two drop doses every ten or fifteen minutes when the 
 body is cold and clammy, and when the shock is sudden. With the 
 internal administration of this medicine, frictions to the extremities and 
 warm applications are to be perseveringly tried, and if improvement does 
 not supervene, then veratrum is the medicine par excellence. The patho- 
 genesis of this extraordinary medicine, its great value in diseases which are 
 liable to terminate in collapse, and its great reliability and uniformity 
 of action, render it of signal service in these affections. It is especially 
 called for when, in connection with other symptoms, there is nausea and 
 vomiting. 
 
 Prof. John C. Morganf adds the following medicines to the list : Capsi- 
 cum, calamus (especially after profuse haemorrhage), cuprum, nux mos- 
 
 * London Medical Eecord, May 15, 1877 ; Monthly Abstract of Medical Science, July, 
 1877. 
 
 f Franklin's Science and Art of Surgery, vol. i., p. 618 ; and Transactions of American 
 Institute of Homoeopathy for 1869, p. 112. 
 
TETANUS. 491 
 
 chata, aconite, arnica, strontiana, chloroform, digitalis, nux vomica, ammo- 
 nium-causticum, carbo vegetabilis, mercurius, natrum muriaticum and 
 phosphorus. 
 
 Stimulants. — The question arises, and it is an important one, as to 
 the propriety of administering stimulants in the condition of which I 
 am speaking. I have employed them often and with benefit, and again 
 have observed that no satisfactory result followed their administration. I 
 am, however, convinced that the habit of pouring down brandy or whiskey, 
 ad libitum, cannot be too emphatically denounced. I am disposed to be- 
 lieve, that, in the majority of cases, if reliance is placed in the medicines, 
 the patients will do as well, probably better, without stimulants. If 
 the surgeon considers it expedient to use them, brandy is the best, because 
 more prompt. It should be given in tablespoonful doses, of a mixture of 
 equal parts of the best cognac and water. The effects of each dose must be 
 carefully watched, and only repeated when the effects of the preceding one 
 are subsiding. 
 
 The late Dr. John T. Hogden, of St. Louis, recommended very highly 
 the hypodermic use of -^th to -g^th of a grain of atropia in collapse. His 
 first experiments were made in 1866 and 1867, during the cholera epidemic.* 
 He states that within a period of twelve years he employed it in many 
 cases of collapse ; among them, in that arising from strangulation of the 
 intestines. Dr. Weber has recommended belladonna for the same pur- 
 poses.f This medicine demands a thorough trial in cases of genuine shock 
 as well as in those of collapse. 
 
 Tetanus. — This disease is well known and is frequently the result of in- 
 juries, and so intractable is the affection under any method of treatment, 
 that its occurrence is always regarded by the practitioner as unfortunate 
 in the extreme; and although the influence that homoeopathy possesses 
 over this, as well as over many dangerous surgical diseases, modifies in some 
 degree the danger of the affection, still, until the light of further investiga- 
 tion be brought to bear upon it, the surgeon cannot otherwise than entertain 
 for it a doubtful prognosis. 
 
 Tetanus is characterized by a permanent spasm of the muscles of a portion, 
 or nearly the whole of the body, rendering it stiff and straight. When the 
 spasm presents itself in the muscles of the neck, throat, and jaws, the term 
 trismus or lockjaw designates such a condition. When the muscles of the 
 back are affected, the word opisthotonos expresses the affection, while empros- 
 thotonos denotes an exactly opposite condition ; the body being bent for- 
 wards. Pleurosthotonos is the term used when the muscles of the side of the 
 body are affected with tetanic spasm. 
 
 The disease may be either traumatic or idiopathic; the latter often arises 
 without any assignable cause, and is usually chronic ; the former, being 
 acute, follows upon a wound, or other injury, is much more dangerous and 
 of more frequent occurrence. The spinal system is the seat of the disease ; 
 there is an " excitable state of the spinal cord and medulla oblongata, not 
 involving the ganglia of special sense. This may be the result of causes 
 altogether internal, as in the idiopathic form of the disease, in which the 
 condition exactly resembles that which may be artificially induced by the 
 administration of strychnine, or by its application to the cord. Or it may 
 be first occasioned by some local irritation, as that of a lacerated wound ; 
 the irritation of the injured nerve being propagated to the nervous centres, 
 and establishing the excitable state in them. When the complaint has 
 
 * St. Louis Medical and Surgical Journal, November, 1866. 
 f Philadelphia Medical Times, February 2d, 1878. 
 
492 A SYSTEM OF SURGERY. 
 
 once manifested itself, the removal of the original cause of irritation (as by 
 the amputation of the injured limb) is seldom of service, since the 
 slighest impressions upon almost any part of the body are sufficient to ex- 
 cite the tetanic spasm." 
 
 The brain only becomes affected in the last stage of the disease, when 
 the delirium and stupor supervene that are present before death. 
 
 Dr. Cullen wrote : " In this disease the head is seldom affected with de- 
 lirium or even confusion of thought, till the last stage of it, when by the 
 repeated shocks of a violent distemper, every function of the system is 
 greatly disordered." 
 
 The spasm, in the generality of instances, approaches in the most insidi- 
 ous manner ; if trismus is about to commence there is slight difficulty in 
 swallowing, and the patient cannot open his mouth to the usual width, 
 there is also hardness of the muscles about the neck and throat ; the spasm 
 increases, the mouth becomes distorted, the pulse quick and irregular, the 
 teeth clenched, and the temporal and masseter muscles become hard and 
 bulging ; the face is distorted by the spasmodic action ; the corrugatores 
 supercilii act upon the eyebrows and draw them into angles ; the forehead 
 is wrinkled, the nostrils dilate, and the angles of the mouth are drawn back- 
 ward. The orbicularis oris binds the lips firmly on the teeth, which, how- 
 ever, are now always more or less seen, and sometimes wholly disclosed. 
 The expression is indicative of much suffering, and is quite peculiar to the 
 disease ; it may, indeed, be said, to be pathognomonic. 
 
 Hitherto the only muscles that have been affected are the voluntary, but 
 at this stage of the disease the involuntary also become attacked ; the first 
 affected is the diaphragm, and consequently breathing is performed with 
 difficulty; the other muscles of the system soon participate, until the whole 
 body becomes fixed and rigid. The arms are the last attacked, but the 
 fingers may retain their motive power to the last. The bowels are consti- 
 pated, and there is difficulty in passing urine, occasioned by the spasm of 
 the muscles of the perinseum and neck of the bladder. 
 
 The disease is more common in hot than in temperate climates, and 
 children and adults are more liable to be attacked than youth or aged indi- 
 viduals. At certain seasons portions of Long Island appear especially ob- 
 noxious to the development of the disease. It arises most frequently from 
 wounds, etc., inflicted in tendinous parts that are well supplied with 
 nerves, but it has been occasioned by mere bruises or blows. It also 
 has followed an injury done to the nerves, as when torn in wounds or 
 ligated together with an artery. 
 
 The size of the wound is of no consequence, in regard to its influence upon 
 tetanus, as severe incised, lacerated, or contused wounds may heal without 
 its accession, while the disease may appear from a slight puncture or mere 
 scratch. 
 
 The duration of time between the infliction of a wound and the accession 
 of tetanus varies. The case which illustrates the shortest period on record, 
 between infliction and invasion, is that related by Prof. Robison, of Edin- 
 burgh, in which a negro expired in fifteen minutes after having torn his 
 thumb with a broken china plate.* 
 
 If three weeks elapse, the patient may generally be considered safe. 
 
 Treatment. — The remedies that are adapted, and those that have been 
 most successfully used in tetanus, are aeon., ang., arn., ars., bella., camph., 
 cham., cic. vir., cupr. met, hyos., ipecac, ignat., lauro., nux vom., opium, 
 rhus tox., secal. cor., stram., verat. 
 
 * Kees's Cyclopsedia, article Tetanus. 
 
TREATMENT OF TETANUS. 493 
 
 With reference to other treatment of this distressing malady I may remark 
 that, throughout the medical periodicals, numerous cases are recorded as 
 cured by the exhibition of chloral hydrate. 
 
 From experience of my own, I am disposed to regard it as a valuable 
 medicine. The case was one in which I had resected the head and 
 upper portion of the humerus for caries, resulting from a gunshot wound 
 of the axilla, of sixteen years' duration. The operation was difficult, pro- 
 longed, and bloody, on account of extensive bony adhesions to the body of 
 the scapula. For ten days after the operation everything progressed well. 
 On the eleventh day, a slight stiffness in the nape of the neck, with some 
 rigidity of the temporo-maxillary articulation, indicated what was to come. 
 Severe tetanus followed ; trismus and opisthotonos, with profuse sweating 
 resulted. The spasms were most violent in character, a draft of air, the 
 contact of the spoon to the lips, or movement about the room, producing 
 them. Almost all the medicines recorded above were tried without avail. 
 Chloral hydrate, in ten-grain doses, was given, and immediate relief was 
 experienced. This medicine, with opium, first decimal, finally cured the 
 patient. The recovery was slow ; at one time, during convalescence, the 
 patient was covered with herpes circinatus ; this disappearing, strangury 
 resulted, and for a long time flushes, with sudden perspiration, depression 
 of mind, and bed-sores, complicated the case, which was under continued 
 supervision for over three months. Upon referring to current medical liter- 
 ature, more cases are reported as successfully treated by chloral than by any 
 other one medicine. A proving of this substance is now being made, from 
 which more reliable data may be afforded. It may be used hypodermically 
 in o-grain doses. 
 
 Dr. Chapard,* in These de Paris, from a review of eighty cases of tetanus, 
 concludes that chloral administered by enema or draught, offers the best 
 hope of saving the patient's life. Enemata are made by adding the solution 
 of chloral to milk into which the yolk of an egg has been stirred. 
 
 In a case that came under my observation the calabar bean was used 
 hypodermically with amelioration of the symptoms, especially the spasms 
 of the muscles of deglutition. The formula was : 
 
 R. Alcoholic extract Calabar bean (English), grs. vij. 
 
 Alcohol dilute, ^j. 
 
 M. 
 
 Of this eight drops were injected every three hours. 
 
 Atropia in ^ grain doses, hypoderraically, is also much commended. 
 
 M. Demarquay has reported two cases of traumatic tetanus treated by 
 intramuscular injections of morphine. The hypodermic syringe was intro- 
 duced first into the masseters, and afterwards into any of the muscles most 
 affected. 
 
 Dr. Kella recommends curare (the arrrow-poison of the Indians, which 
 antidotes strychnine and removes spasms) as a remedy of great service in 
 tetanus.f 
 
 E. Brown-Sequard has written an interesting paper on the action of 
 extract of nux vomica compared with that of the curare.J 
 
 A very remarkable cure of trismus is worthy of record :§ A soldier having 
 lockjaw from a wound in the foot, was given over to die. An officer cut a 
 
 * Monthly Abstract of Medical Science, May, 1877. London Med. Kecord, March loth, 
 1877. 
 
 f United States Journal of Homoeopathy, vol. ii., p. 547. 
 
 X Journal de la Physiologie ; condensed in the United States Journal of Homoeopathy, 
 vol. i., p. 10. 
 
494 A SYSTEM OF SURGERY. 
 
 piece of tobacco, about three inches square, put it in a pan of boiling water, 
 and, having thus softened it, flattened it out and placed it over the. epigas- 
 trium. In five minutes deadly pallor ensued with twitchings, and the jaws 
 completely relaxed. 
 
 Dr. Bompart* attributes the cure of a case of tetanus to four grams daily 
 of jaborandi (powdered leaves in infusion), given from January 23d to 
 March 3d. At the same time, clysters of eggs, broth, wine, black coffee, 
 and the elixir alimentaire de Ducro, were administered. The jaborandi pro- 
 duced very abundant salivation. 
 
 Dr. George W. Le Cato reports a cure of traumatic tetanus, in which the 
 symptoms developed two weeks after the accident ; these lasted a little over 
 two weeks, during which the patient, besides large doses of chloral, took 
 " more than half a pound of bromide of potassium and nearly two ounces 
 of calabar bean."f 
 
 Kalmia latifolia is also reported to have cured tetanus. 
 
 Nerve stretching. — This method will be alluded to further on in this 
 chapter.J 
 
 Amputation of the affected part has been employed in some cases with 
 varying results. 
 
 Wounds of the Nerves. — The nerves are frequently wounded by cuts, stabs, 
 and in the performance of surgical operations : but they, after a time, are 
 repaired by intervening tissue, through which the nerve-power appears to 
 be conducted. If a nerve is merely pricked, the symptoms for a moment 
 are quite severe ; the sensation is sharp and darting, with tingling and 
 numbness below the part injured. With rest, however, these symptoms 
 generally pass away. If a nerve be entirely divided, there is loss of motion 
 and of sensation in the part which it supplies, with coldness and paleness 
 of the surface, and if the nerve-force is not restored, permanent paralysis 
 results. 
 
 In the subcutaneous division of tendons a nerve is sometimes divided, as 
 happened to me lately while operating for anchylosis of the knee. In divid- 
 ing the tendon of the biceps the peroneal nerve, which lies in close prox- 
 imity, was cut through. This was followed by immediate paralysis of the 
 abductors and extensors of the foot, which continued for two months, after 
 which motion was entirely regained. Sometimes after a division of nerve- 
 substance, especially if the gap be wide between the severed ends, the parts 
 connect by an enlarged or button-like formation of the extremities ; these 
 are excessively painful and occasion great suffering ; in such cases a redi- 
 vision has been necessary, and indeed a reamputation may be the only 
 means of relief. 
 
 Prof. Willard Parker, of New York, has described a condition of the ner- 
 vous system which he calls concussion of the nerves* The first symptoms after 
 the injury are paralysis, then reaction, followed by inflammation, and the 
 patient is left weak or miserable for a considerable time. 
 
 Treatment. — For an injured nerve rest is essential ; the part should be 
 elevated and enveloped in cotton-wool or batting. Twice during the day, 
 frictions made with towels, dipped in a mixture of salt and whiskey, should 
 be used ; and if symptoms of reaction do not appear, a current of electricity 
 
 * Monthly Abstract of Medical Science, June, 1876 ; London Medical Record, April 
 15th, 1876. 
 
 t Medical News, November 25th, 1882. 
 
 X Dr. Paul Vogt (Monthly Abstract of Medical Science, March, 1877), in a case of trau- 
 matic tetanus supervening upon an injury to the right hand, and in which there was tender- 
 ness of the brachial plexus, completely and immediately cured the patient, although he had 
 opisthotonos and clonic spasms, by exposing the plexus at the anterior border of the trape- 
 zius, vigorously pulling the nerves centripetally and centrifugally, and freely dividing nerve- 
 sheaths, which were red. 
 
NERVE fTEETCHING. 495 
 
 should be passed through the part. If this treatment does not relieve, in 
 ordinary cases, a few doses of aconite will be serviceable. If after puncture 
 of a nerve there should be swelling, together with sprained sensation of the 
 joints, accompanied with excruciating pains, hypericum is very useful. 
 Other medicines are : moschus, ignatia, camphor, veratrum alb., strychnia, 
 calabar bean, tabacum, hyoscyamus, secale, and zinc. 
 
 Nerve Stretching. — The first experiments in nerve stretching were made 
 by Harless and Haber, in 1858, and in 1864 Valentin arrived at the follow- 
 ing conclusions, which were more recently verified by Paul Vogt : That 
 nerve stretching, in a moderate degree, lengthens the primitive fasciculi of 
 the nerve trunks, and by decreasing their calibre, frees them in a greater or 
 less degree from the pressure exerted upon them by their sheaths, and that 
 the microscope, even after quite extensive stretching, does not discover 
 anything abnormal, excepting that, at certain points, the nerve substance 
 appears to be separated from the neurilemma. 
 
 According to further experiments, the fact is apparently proven that " the 
 excitability of a nerve trunk, and the reflex excitability of the parts supplied 
 with it, are lowered by prolonged stretching." Various experiments were 
 made to answer the following postulates ; 
 
 First. Does the forcible extension of a nerve trunk act especially on the 
 central ganglion or organ ? 
 
 Second. Does the stretching, instead of affecting the origin of the nerve, 
 produce changes in the organ supplied by its terminal (peripheral) extremi- 
 ties? 
 
 Third. Is the power of a nerve, thus treated, altered as a conductor of 
 sensibility ? 
 
 With regard to the first point, it has been found that the central organ is 
 not materially affected by stretching ; to prove this, the sciatic nerve of a goat 
 was laid bare at its junction with the spinal cord, and also between the 
 tuber ischii and the great trochanter ; at the latter point, the trunk was 
 stretched to such a degree, that the nerve ruptured, but no change could be 
 noted to take place at its spinal connection. The reverse of this, however, 
 took place when the direction of the force was altered. Two openings were 
 made on the arm, one just above the wrist, three centimetres square, on the 
 flexor surface of the forearm, and the median nerve exposed. A second 
 opening was made at the brachial plexus, and the nerve also exposed at 
 that point ; traction was then made upon it in the latter locality, and at 
 once the nerve at the wrist opening could be seen to move considerably 
 from its position. In other words, the centripetal stretching produces a mate- 
 rial effect on the peripheral termination of the trunk. 
 
 With reference to the last point, as to whether the power of the nerve as 
 a conductor of sensibility is altered .by stretching ; after various experiments 
 the following conclusions were noted, viz., that the nerve is only elastic and 
 stretchable within certain limits, that the limits of normal elasticity corre- 
 spond with the physiological limits of the motion of the human body, and 
 that any attempts to stretch the nerve beyond these limits are followed by 
 a rupture in its continuity. In the second of my reported cases,* it will be 
 noted that the lady was always better when the sciatic nerve was put fully 
 upon the stretch, almost to its extreme physiological limits, viz., when she 
 was on horseback, with her knee over the pommel of the saddle, in a state 
 of flexion and abduction ; the leg, also, in this position being flexed on the 
 thigh, and muscular power exerted to hold the body firmly in the saddle 
 during the movements of the horse. From these facts, it would appear that 
 nerve stretching carried beyond the ordinary elasticity of the nerve, to a 
 
 * Pamphlet on Nerve Stretching. 
 
496 A SYSTEM OF SURGERY. 
 
 degree sufficient to separate the continuity of the primitive fasciculi, is at 
 least one point in the rationale of the cure, or at all events in the relief of 
 the pain. 
 
 With reference to the amount of stretching required, the following were the 
 results of interesting experiments reported by Vogt : * 
 
 1. That slight stretching (once) of the trunk of the sciatica in decapitated 
 frogs increased the reflex irritability of the respective extremity. 
 
 2. That a second stretching, following shortly upon the first, reduces the 
 irritability. 
 
 3. That a third stretching, following the second, reduces the irritability 
 far below the normal standard, though mechanical stimuli may still act. 
 
 4. That the centripetal fibres of the sciatic cannot be exposed to prolonged 
 and forcible stretching without losing, partially or fully, their function. 
 
 From these, he lays down the axiom that " every severe stretching of a 
 nerve trunk reduces its irritability and its reflex power, in the region sup- 
 plied by it; or, in other words, the mechanical irritation of stretching 
 changes the mechanism of nervous activity." 
 
 The following is the list of published cases in which the operation of 
 nerve stretching has been performed, as given by Dr. Paul Vogt,t in his 
 work on the subject : 
 
 1. Billroth (operation performed in 1869, published in 1872) : Laying 
 bare the sciatic nerve and examining it with the finger. Nothing abnormal 
 was detected. The spasm of the leg, for which the operation had been 
 undertaken, completely ceased within three months after the operation. 
 
 2. Von Nussbaum (operation 1872) : Laying bare and stretching the 
 brachial plexus, on account of an intense neuralgia, with spasmodic con- 
 tractions, and loss of sensation of the muscles of the arm. This operation 
 was completely successful. 
 
 3. Gartner (1872) : Laying bare and stretching the brachial plexus, for a 
 paralysis of thirty-four years' standing. The arm was greatly wasted and 
 the fingers contracted. 
 
 4. Patruban (1872) : Laying bare and stretching of the sciatic nerve for 
 sciatica. Great amelioration. 
 
 5. Vogt (1874) : Laying bare and stretching of the ulnar nerve for paral- 
 ysis, in consequence of adhesions of the nerve. Cured. 
 
 6. Von Nussbaum (1875) : Laying bare and stretching of the tibial and 
 peroneal nerves in a case of reflex epilepsy. Complete cure. 
 
 7. Callender (1875) : Laying bare and stretching of the median nerve in 
 the stump of a forearm, on account of neuralgia. Cured. 
 
 8. Von Nussbaum (1876) : Laying bare and stretching the sciatic and 
 crural nerves of both sides, for central disease. Paralysis of lower extremi- 
 ties with clonic spasms, following on a fall eleven years ago. Spasm en- 
 tirely cured. 
 
 9. Vogt (1876) : Laying bare and stretching the brachial plexus in traumatic 
 tetanus following extensive injury to the hand. Cured. 
 
 10. Kocher (1876) : Laying bare and stretching of the tibial nerve for 
 traumatic tetanus. 
 
 11. Petersen (1876) : Laying bare and stretching of the tibial nerve for 
 neuralgia. 
 
 12. Vogt (1876) : Laying bare and stretching of the inferior dental for 
 neuralgia. Cured. 
 
 * Die Nerven-Dehnung, als operation in der chirurgischen praxis. Leipzig, Vogel., 1877. 
 f An abstract of the work can be found in the Monthly Abstract of Medical Science, 
 November, 1877. 
 
NERVE STRETCHING. 497 
 
 Besides these, Dr. Vogt gives three other operations of his own, each per- 
 formed for tetanus, and in two of the three cases the patients recovered. 
 The following may be cited to show the philosophy of the operation. 
 The case was one of traumatic tetanus, following injury to the hand. 
 The patient was a man sixty-three years old, in whom tetanus had devel- 
 oped about two weeks after his receiving a severe lacerated wound of 
 the right hand. In spite of local treatment and large doses of opiates, 
 violent opisthotonos set in, with tonic rigidity of the back and lower 
 extremities, with intercurrent clonic spasms. The wound had not thor- 
 oughly healed, but neither this nor any part of the arm or forearm was 
 abnormally sensitive, while pressure over the region of the brachial plexus 
 caused pain and a return of the tonic contractions of the muscles of the 
 neck. Other treatment having been of no avail, and the cicatrix of the 
 wound being in the vicinity of the median and radial nerves, it was decided 
 to divide the cicatrix, detach the edges of the wound, excise these two 
 nerves, and also stretch the brachial plexus. After the operation at the seat 
 of the wound had been performed, the brachial plexus was exposed through 
 a longitudinal cut at the anterior border of the trapezius, about two inches 
 above the clavicle. The loops of the plexus were then raised upon the 
 finger, drawn out, and thoroughly stretched in both directions. In the 
 operation, the nerve sheaths, which were found to be quite red, were freely 
 divided. The wound was dressed with salicylicated jute, a drainage-tube 
 having been used to provide for free discharge. A short and violent attack 
 of vomiting took place on the next day, but the recovery from the tetanic 
 condition was immediate and complete. There was free use of the jaws, 
 tongue, and throat, and neither the mobility nor the sensibility of the arm 
 appeared to be appreciably affected. In about two weeks the patient went 
 out completely cured. 
 
 In addition to the foregoing cases, I have found the following ones. Mr. 
 John Chiene* records two cases of stretching the sciatic which are somewhat 
 remarkable, in that the patients, immediately after the procedure, retained 
 complete motor power. The first operation was performed on the 19th of 
 April ; the next day the pain had entirely disappeared. The patient was 
 discharged on May 11th, 1877. In the second case, the nerve was stretched 
 on the 23d of April ; the nerve substance appeared fatty, and its course was 
 covered by a plexus of large and tortuous veins. In attempting to raise 
 the limb from the table, it stretched to such a degree that the operator sup- 
 posed he had torn it. On the following day both sensation and motion 
 were not affected, and the patient, as in the first case, expressed himself as 
 not having been so comfortable for months. By the 10th of May he was 
 cured. In my cases of sciatic stretching, motion was at first much impaired 
 and only gradually restored ; the pains were often intense, but not of the 
 neuralgic character, and lasted for several days. 
 
 In the Lancet^ another case of sciatica is reported, which was treated by 
 Dr. Macfarlane, of Kilmarnock, with success, by stretching the nerve. In 
 this case the nerve was thoroughly extended, although the leg was not raised 
 from the table. After eight months, there had been no return of the pain. 
 
 DuplayJ reported two cases of nerve stretching, in one of which the 
 nerves thus treated were the median and the radial, the disease being 
 paralysis ; a cure rapidly followed. 
 
 The second case — a man aged twenty-six, who had been wounded at 
 the wrist, where a small tumor appeared, which was excessively painful. 
 
 * Practitioner, June, 1877. f Medical Eecord, December, 1878. 
 
 % London Medical Kecord, January loth, 1879. 
 
 32 
 
498 A SYSTEM OF SURGERY. 
 
 The nerve was fully stretched, the tumor soon disappeared, the muscles 
 regained their contractility, and the pain ceased. 
 
 Dr. William C. Cox* reports the two cases alluded to as operated upon 
 by Thomas G. Morton, M.D., of Philadelphia. The first case was one of 
 neuralgia of the shoulder and arm, arising from an accidental wound, made 
 by the sharp points of a pair of scissors entering the outer side of the right 
 wrist. The patient was just convalescing from an attack of typhoid fever, 
 and, although the wound had healed within two weeks, the pain in the 
 forearm extended to the elbow and shoulder, and resisted all means used to 
 procure relief. The accident occurred on February 11th, 1877, and on May 
 7th the operation was performed. The stretching was done by the fore- 
 finger, and the wound closed with silver sutures. The record, to which I 
 desire to call special attention, because the symptoms are those which I 
 have noted in three cases now reported, and which it is important to know, 
 with reference to prognosis, thus continues : " The pain in the arm, after 
 the effects of the ether had passed off, was intense, notwithstanding large 
 doses of morphia, used hypodermically. A few days later an abscess formed 
 in the upper part of the wound, which discharged through the opening 
 near the wrist. For several weeks a feeling of numbness continued in the little 
 and ring fingers and upon the outside of the hand, but gradually these 
 
 symptoms disappeared In a month the pain had ceased ; sewing and 
 
 writing still produced an ache, which was participated in by the whole arm and 
 shoulder.^ This gradually diminished ; but as the patient was of a rheu- 
 matic temperament, it may have been aggravated by that condition." 
 
 In the second case, the most intense neuralgia afflicted the leg and foot, 
 arising from a fall upon the buttocks from a scaffold twenty-five feet from 
 the ground, the patient striking upon a stone pavement. After ten days of 
 insensibility he partially recovered, with difficulty in articulation. From 
 this he gradually convalesced, but paralysis of both legs followed. After five 
 months the patient was able to get about on crutches, but without motion 
 or sensation in the left leg. Shortly after, he had an attack of acute 
 articular rheumatism, which was followed by excruciating pain on the 
 outside of the foot. For this, Dr. Casselberry, of Hazelton, excised a portion 
 of the plantar nerves, which gave relief for seven years. In 1874 the pains 
 returned, and on June 12th, 1877, Dr. Morton stretched the sciatic, in the 
 middle of the posterior surface of the thigh. The limb was lifted twice 
 from the bed by the nerve. The patient returned home on the second day 
 after the operation, but was not relieved. The pains continued so severe that 
 neurectomy was performed on the external popliteal nerve, which gave relief. 
 
 I have detailed these earlier cases of nerve-stretching that the student 
 may have an idea of the first history of the operation, which now has become 
 so popular that the record of the cases would occupy more space than could 
 be allotted to the subject. In the third volume of Agnew^s Surgery the most 
 complete table can be found. 
 
 From these cases we learn : that immediately after severe stretching, there 
 may be not only loss of power and sensitiveness, but also excruciating pain 
 and twitchings ; that after twenty-four to thirty-six hours, we may reason- 
 ably hope the severity of the suffering will be materially diminished, and 
 that it generally will disappear; that tingling burning pain, and often 
 swelling, remain for some time, and are especially noticed during motion, 
 and that these symptoms pass gradually away ; that when we have reason 
 to believe that the neuralgic pains are returning, from the peculiar character 
 of the sufferings, which are easily recognized by the patient and often 
 
 * American Journal of the Medical Sciences, vol. lxxv., page 150. 
 
 f These italics are made use of here to note that time is often required to complete the 
 cure after these operations. 
 
NERVE SUTURE. 499 
 
 described as " the old pain," a thorough manipulation of the parts (if prac- 
 ticable) in all directions, putting the nerve to the utmost stretch of its 
 physiological limits, may assist the cure, in preventing the formation of new 
 adhesions. 
 
 I have performed nerve stretching many times and on different nerves 
 with varied success. Some of my cases have been published elsewhere,* 
 and others have not been recorded. The reader may refer to the published 
 cases, if he desire further information on the subject. 
 
 The methods of performing nerve stretching must vary, of course, according 
 to the position of the nerve to be stretched. As a rule, those incisions made 
 for the ligation of arteries, and described in the chapter upon that subject, 
 will be the same as those necessary for finding the great nerves. When the 
 diseased nerve is found, a blunt hook must be insinuated gently beneath it, 
 until the little finger or, in the sciatic, one or even two fingers be gotten 
 under it, then it is gently drawn out until quite a loop is made. The 
 stretching is discontinued and the wound closed. The whole operation 
 must be done antiseptically. For more explicit directions regarding the 
 finding the nerve, the student may refer to Vogt's pamphletf or to Agnew's 
 article.'! 
 
 It must be remembered that nerve stretching is not without its dangers, 
 and that death has been known to result from the operation. Socin, Langen- 
 beck, Billroth, Berger, and Benedict have been unfortunate in this re- 
 spect, and the cause of death in all the cases has been attributed to shock 
 conveyed to the medulla oblongata from too violent stretching. Vomiting, 
 singultus, cyanosis, emesis, and paralysis of the bowels were the symptoms 
 that preceded death. § 
 
 Nerve Suture. — The sewing together of divided nerves has been, like many 
 other so-called recent operations, considered and even practiced by the 
 older surgeons. Guy de Chauliac and Lanfranc are said, if not to have 
 done it, to have advised it, and Dupuytren is said to have performed it. 
 
 The question arising in the surgeon's mind is in the selection of the cases 
 suitable for the operation. When we remember how beautifully nature, 
 after a part has been seriously wounded, restores it to its usefulness, both 
 in motion and sensibility, there can be no doubt that in by far the majority 
 of cases of wounds, the parts after having been carefully adjusted should be 
 left to themselves. 
 
 The symptoms, however, that indicate the non-union of nervous trunks 
 and filaments are generally soon made manifest, and are pain, anaesthesia 
 of the part, and trophic changes materially affecting nutrition ; these often 
 are noticed before the wound is completely cicatrized. The first symptom, 
 in by far the greater number of instances, is neuralgia, the pain radiating 
 in directions corresponding with the course of the nervous filaments. It is 
 said by some authors that the suffering is more acute when the nerve is 
 contused than when it is completely divided. Accompanying the pain 
 there is a burning, sticking sensation, often also associated with redness and 
 sometimes with itching. The anaesthesia which, of course, begins upon the 
 complete severance of a trunk, is at first confined to a spot surrounding the 
 point of division, but soon the insensibility extends to a considerable dis- 
 tance, and by reflex action may even be noted in remote parts ; this is as- 
 
 * Nerve Stretching, with a Short History of the Operation, with Illustrated Cases. Boston, 
 1879. Otis Clapp and Sons. Also New England Medical Gazette, 1879. Also The American 
 Journal of Electrology and Neurology, July, 1879. 
 
 t Die Nerven Dehnung als Operation in der Chirurgischen Praxis, von Paul Vogt. 
 Leipzig, 1877. Also Traite des Sections Nerveuses par M. Leitrevant. Paris, 1873. 
 
 X Agnew's Surgery, vol. iii., p. 727. 
 
 \ British Medical Journal, January 7th, 1882. 
 
500 A SYSTEM OF SURGERY. 
 
 sociated with motor paralysis, and in bad cases, by spasmodic action of the 
 parts supplied by the nerves. 
 
 The trophic changes also soon become apparent in the defective nutrition 
 and are made manifest in a variety of ways. These metamorphoses are 
 frequently, and indeed generally, shown in the dermatous tissues. The 
 skin assumes a slight redness, becomes glossy, somewhat hard, and resem- 
 bles that seen in pernio. Often vesicles appear, sometimes bullae, the nails, 
 according to Mitchell, become " turtle shelled," the sweat glands are inter- 
 fered with in their function, and finally the body wastes and the mind 
 suffers. 
 
 In such cases as these, it is certainly necessary that the nerve be su- 
 tured. 
 
 If a nerve be united when the first dressing is made to a wound, the 
 term primary suture is used ; when some time has elapsed, either with or 
 without complete cicatrization of the wound, the nerve is united by secondary 
 suture. 
 
 Dr. T. Gluck* referring to his experiences on animals regarding the path- 
 ology of divided nerves, is of opinion that when a nerve is divided the first 
 evident change is that the sheath retracts, and the myelin spreads over the 
 cut surface, while blood is effused into the ends of the nerve and wound. 
 The nerves and muscles degenerate, the limb wastes, and the animals die 
 about the fifth month — this has been found in experiments on the sciatic in 
 the fowl, as the result of division. When a piece of nerve is excised, and 
 the ends brought together by sutures, the process is less simple and less 
 rapid in its course ; microscopically, the two ends are hardly to be distin- 
 guished ; each presents thrombosis in the minute vessels, and a somewhat 
 wavy appearance of the nerve-tubes. In the young granulation-tissue be- 
 tween the ends of the nerves, about the fifth day, peculiar fusiform cells 
 appear, dark, granular, and looking like the ganglion-cells of the nerve- 
 centres. What becomes of the catgut ligature during this process ? It is 
 apparently absorbed — in eighty hours the section shows deep excavations 
 in the thread, which increase in size the next few days, and in about a week 
 all traces of the catgut have disappeared. 
 
 An early restoration to function in divided nerves has been doubted by 
 pathologists, and the theory of a collateral path has seemed a more probable 
 explanation, than that of a restoration of function through the injured part; 
 it is difficult, indeed, to exclude the possibility of such an explanation in 
 the experiments on animals if the recovery of power in the muscles at first 
 paralyzed is taken as the indication of the recovery of functional power in 
 the divided nerve. 
 
 How the function of a part is restored, after section, or even when united 
 by nature, has been a matter of discussion ever since the time of Sir Charles 
 Bell, and as yet pathologists have arrived at no very definite conclusion in 
 the matter. However, it is now a pretty well established fact, that primary 
 suture of nerve trunks should always be done ; indeed, Mr. H. E. Clark 
 says : f "It should be as much a rule of practice to bring together the cut 
 ends of a divided nerve, as to stitch the wound in the muscles and skin." 
 Experiments of Vulpian and Brown-Sequard have tended much to the 
 arrival of this conclusion. 
 
 Secondary Nerve Suture was considered as a very doubtful procedure until 
 recently, but the satisfactory results obtained by those surgeons, who had 
 the temerity to perform the operation, has in a great measure changed the 
 tide of public opinion. In some cases complete restoration of function has 
 
 * The Monthly Abstract of Medical Sc ; ence, July, 1878, vol. v., No. 7. 
 f Glasgow Medical Journal, October, 1883. 
 

 NEURALGIA. 501 
 
 been effected after an absence of many months, indeed Tillaux reports one 
 after eighteen years. The average time, however, for the establishment of 
 sensibility is from t six months to one year; that for the reproduction of 
 motion being a longer time, on account of the paralysis of the muscles 
 which is always more or less present. The operation itself is not difficult, 
 but delicate ; it requires a thorough knowledge of the anatomy of the part. 
 The young surgeon before he essays it should, if possible, make a careful 
 dissection upon the cadaver, and must bear in mind that in looking for the 
 divided or injured nerve in the living, he may find it altered somewhat in 
 character, thickened and bulbous, therefore the incision should be made 
 three or four inches long and the trunk of the nerve be exposed above and below 
 the site of injury ; it should then be carefully raised from its bed and traction 
 made upon it, until the two extremities are nearly approximated and the 
 suture (always of gut) should be passed through the neurilemma and the nerve 
 substance and then secured with a knot ; two stitches or even three (if the 
 nerve be large) will generally be sufficient. If there be a considerable sepa- 
 ration between the divided extremities of the nerve, it may with gradual 
 traction be drawn together, even to the distance of an inch. 
 
 In no case has tetanus been known to result from this somewhat serious 
 interference with nerve trunks, and of thirty-three cases collected by Weis- 
 senstein, sixty per cent, were completely cured — of the balance, there were 
 imperfect accounts given of three ; in six, there was little or no change ; 
 and sensibility alone returned to four. This makes an excellent showing, 
 and demands a trial of the operation whenever the symptoms already noted 
 are present from injuries to the nerves. 
 
 Neuralgia is a Greek term, compounded of Nzupov, a nerve, and alyaq, pain ; 
 a generic term for a number of certain diseases, distinguished by very acute 
 pain, following the course of a nerve through its trunk and ramifications. 
 The principal neuralgias are known as : 1. Ischias nervosa digitalis ; in 
 this variety the pain extends from where the nerve passes under the inner 
 condyle, to the back of the hand and to its cubital edge. 2. Neuralgia den- 
 talis, odontalgia nervosa. 3. Neuralgia facial, neuralgia faciei, trismus 
 dolorificus, tic douloureux, dolor faciei, prosopalgia, dolor faciei Fother- 
 gilli. 4. Neuralgia femoro-poplitaBa, sciatica, coxalgia, neuralgia ischiadica, 
 ischias nervosa ; this latter is characterized by pain following the great sci- 
 atic nerve, from the ischiatic notch to the ham, and along the posterior sur- 
 face of the leg to the sole of the foot. 5. Ischias nervosa antica ; the pain 
 in this variety commences in the groin, extends along the forepart of the 
 thigh, and passes down on the inner side of the leg to the inner ankle and 
 back of the foot. 
 
 Neuralgia also attacks the liver, uterus, vagina, spleen, the plantar nerves, 
 the heart, and other parts of the body. These affections are obstinate in 
 character and are the most painful of all diseases. 
 
 Some nerves are more disposed to the disease than others, especially the 
 three grand divisions of the fifth, and the facial portion of the seventh pair, 
 although this has been denied upon the supposed discoveries of Sir Charles 
 Bell and Shaw. 
 
 The pains vary in character, though alwa}*s violent in the extreme, oc- 
 curring either suddenly or gradually, with numbness, itching, heat, or 
 preceded by numbness or coldness. Neuralgic pains at times resemble 
 electric sparks passing through the nerves. When the neuralgic attack 
 is at its acme, the part feels as though burning needles were thrust into 
 it ; after a while the intensity of the pain diminishes and is followed by 
 numbness, or great sensibility of the part to touch, or sometimes a feeling 
 as though it had. received a blow. When the affected part feels cold, no 
 actual diminution of temperature is ascertained, nor is there any evidence 
 
502 A SYSTEM OF SURGERY. 
 
 of inflammation or congestion ; muscles to which the affected nerves pass 
 are sometimes agitated with slight contractions, not reaching to that degree, 
 however, to which the term of spasm could be applied. These contractions, 
 continuing, produce involuntary twitchings, called by the French tics, whence 
 the term tic douloureux. When the nerves affected supply glandular or- 
 gans, morbid and increased secretions take place. The severity of the pain 
 may irritate the vascular system to increased action, which does not, how- 
 ever, indicate inflammation. Affected organs decrease in bulk, and are ob- 
 served to become paler. In long-continued cases of great severity, the 
 system severely suffers. 
 
 A neuralgic affection may continue from days to years. When pains in 
 a nerve are produced by pressure upon it, as for instance by a tumor, with 
 the removal of which the neuralgia disappears, such neuralgias are termed 
 false. 
 
 Prosopalgia, or tic douloureux, is most apt to attack females, one attack 
 predisposing to others. Neuralgias attack neither very young nor old per- 
 sons ; the period of life most obnoxious to the disease is between the thir- 
 tieth and the sixtieth years. Exciting causes are moist, cold winds, the 
 slightest exposure to either being sufficient to bring on a very severe attack. 
 The causes, however, are generally obscure; mechanical injuries are included 
 among the number. When the predisposition to the disease is strong, the 
 attacks are induced by the slightest corporeal or mental disturbance. Ma- 
 laria has been assigned as a cause, the periodical character of the affection 
 strengthening such an opinion. Sometimes great regularity is observed in 
 the returns of the paroxysms, the type being quotidian ; this periodicity 
 generally takes place in recent cases ; when the affection becomes chronic, 
 the intervals between the attacks are of very different duration. The 
 superficial or subcutaneous nerves are those frequently attacked, and this 
 is explained by the fact of their greater exposure. The shades and varie- 
 ties of pain experienced in this disease, it would be impossible to enu- 
 merate. Among them, however, of a prominent kind, are tearing, tugging, 
 darting, piercing, plunging, dragging, jerking, sharp, sudden, pricking, lan- 
 cinating, burning, cutting, lacerating, stabbing ; sometimes radiating through 
 the entire ramifications of a nerve, at others passing along a few of its 
 branches only. The pains also extend in different directions ; outwards, 
 inwards, backwards, upwards, or downwards. The pains are, at times, also 
 gnawing, pressing, heavy, dull, obtuse, boring, like the pressure of a dull 
 instrument. 
 
 Sometimes, as has already been noticed, the attacks come on suddenly ; 
 at others, they are preceded by rigors, heat, perspiration, and an abundant 
 secretion of clear, pale urine. During the paroxysms the surrounding parts 
 are very sensitive to touch, and a characteristic circumstance in many cases 
 is that the slightest touch will produce agony, while firmer pressure not 
 only occasions less pain, but will sometimes afford much relief; at times 
 much soreness is left after the paroxysm, and in general the bloodvessels 
 in the vicinity of the affected part are swollen. 
 
 Sometimes the paroxysm is composed of a series of transitory shocks of 
 darting pain, with short intervals of respite from suffering. In general, 
 much pain is felt during the entire paroxysm, with frequent darting pains, 
 so severe as to produce loss of consciousness or delirium. A paroxysm may 
 continue a few minutes, or may last for days, weeks, or even months, with 
 only at times a few seconds' relief from pain. The intervals between the 
 attacks may be of hours, weeks, or months' continuance. In recent cases 
 there is a complete intermission of pain; in chronic cases the patient always 
 feels some uneasiness. 
 
 Dissection affords no assistance in the elucidation of the pathology. In- 
 
DISEASES OF THE LYMPHATICS. 503 
 
 flamed conditions of the nervous tissues, either of the nerve itself, or a 
 thickening of the neurilemma, the fine transparent membrane which en- 
 velops the nerves, when found, are only effects of the disease. Its cause 
 has been supposed to be an inflammation of the periosteum of the bones, 
 over which the affected nerves are distributed. Morbid alterations will not 
 explain the periodical nature of the affection. The short, quick paroxysms, 
 the absence of all signs of inflammation or swelling ; the pain following the 
 course of the nerves ; the periodicity of the affection ; its diminishing rather 
 than increasing from firm pressure, are diagnostic signs of sufficient pre- 
 cision to prevent its being confounded with other affections. 
 
 The disease seldom terminates fatally ; it has been alleged that apoplexy 
 and insanity have followed it, but such results are certainly very unusual, 
 and Dr. Quinn suggests them as the effects of the treatment rather 
 than of the disease. Neuralgias, when acute, although more violent, are 
 more easily cured than when chronic. Neuralgias have been noticed when 
 epidemic fevers prevail, and also as attacking more individuals at cer- 
 tain seasons. The disease most frequently attacks the face — prosopalgia, 
 tic douloureux, neuralgia facialis, dolor faciei — the pains following the 
 course of the different branches of nerves of one side of the face ; for both 
 sides of the face to be attacked at the same time is a very unusual occur- 
 rence, if indeed it ever takes place ; the pains, however, after subsiding in 
 one side may attack the other, and this often happens. If the supraorbital 
 branch be affected, the pains are felt in the supraorbital foramen, from 
 which they shoot to the eyebrows and eyelids. 
 
 Treatment. — A great variety of medicines have been employed in the 
 treatment of the varied forms of neuralgia. Among these are : aconite, bel- 
 ladonna, china, arsenic, calc. carb., veratrum, colocynthis, spigelia, meze- 
 reum, stannum, lycopodium, phosphorus, staphisagria, platina, rhus t., 
 bryonia, conium, digitalis, aurum, verbascum, sepia, cannabis, ignatia, nux 
 vomica, pulsatilla, chamomilla, and many others. The names of these 
 medicines are given that their proper pathogeneses may be studied. 
 
 Neurotomy and Neurectomy. — When remedial measures have failed neu- 
 rotomy is to be remembered ; it consists in making a subcutaneous punc- 
 ture, or a small incision transversly across the immediate track of the 
 nerve, down to the bone ; or neurectomy may be preferred in which the 
 surgeon by a careful and minute dissection exposes the trunk of the 
 nerve and cuts away a portion of it, from half to an inch in length. Dr. 
 Carnochan, of New York, had made some remarkable dissections and 
 removal of nerves for this disease. 
 
 CHAPTER XXIX. 
 
 DISEASES OF THE LYMPHATICS. 
 
 Lymphangitis— Angeioleucitis — Adenitis — Neoplasms — Lymphadenoma — 
 
 Lymphoma. 
 
 The various diseases of the lymphatic system are not as a rule idiopathic, 
 being rather secondary to some other disorder. The pathology also of these 
 affections is not well understood, although it is an established fact that in- 
 flammation, suppuration, calcification, and finally obliteration of the coats 
 of the vessels, and even of the thoracic duct, occasionally occur. 
 
504 A SYSTEM OF SURGERY. 
 
 Lymphangitis is generally occasioned by poisonous substances, — which 
 may have their points of origin either on the surface or within the body, — 
 being taken up and circulating through the lymphatic vessels. It frequently 
 follows certain varieties of punctured wounds, as in such, septic matters are 
 not so liable to be washed away by the blood, the discharges and the dress- 
 ings, as in the more open varieties of wounds. The disease also may arise 
 from the presence of cold abscesses, from diseases of the connective tissue 
 about the uterus, especially in puerperal women. 
 
 The symptoms belonging to this disease have in part been mentioned in 
 the Chapter upon Poisoned Wounds. The first manifestation usually 
 noticed is a severe rigor, followed by fever, thirst, and restlessness, then the 
 appearance of faint red lines, following the course of the vessels which either 
 take a direct course, or appear fo anastomose with each other. At the focus 
 of the disease there is much swelling, on account of the accumulation of 
 lymph, which cannot be removed by the enlarged vessels. The pain varies 
 in severity, according to the number of the vessels involved and their depth ; 
 the deeper the duct from the surface the more severe the pain. Some of the 
 diagnostic marks between lymphangitis and inflammation of the veins con- 
 sist in the facts that the red lines alluded to are much larger and more tender 
 in phlebitis ; that they run in the direction of the tymphatics and not of the 
 veins in lymphangitis, and that the area of tenderness is much less in the 
 latter. 
 
 Another diagnostic point is that, as Mr. Holmes* says : " The inflammation 
 ceases at the nearest gland. This is a fact abundantly exemplified both in the 
 simple and in the specific inflammation of the absorbents. The known situa- 
 tions of the superficial glands are those toward which inflamed absorbents 
 may be traced, and at which their inflammation culminates to the highest 
 degree of severity, and is almost invariably extinguished. The gland appears 
 to arrest the free progress of the acrid lymph, itself becoming inflamed." 
 
 During this time there is continuous fever, the pulse beating 130, and a 
 temperature sometimes as high as 104°, but rarely higher. I have mostly 
 found it range from 102° to 103°, and keep pretty much at these figures 
 through the extent of the disease. The corresponding glands are always 
 more or less affected (adenitis); they become hard, painful, and enlarged, 
 and finally, as already noted, may suppurate. The inflammatory process 
 often extends into the surrounding connective tissue, which may also sup- 
 purate, or this process may take place in the vessels themselves. 
 
 If this latter result is to be favorable, the diseased lymphatics are but 
 partially obliterated, and the glands gradually resume their normal condi- 
 tion, though it is not by any means uncommon for them to remain cedema- 
 tous for a long period of time after the original disease has passed away. 
 
 If, however, the suppuration continues, the symptoms of a more dangerous 
 disease are developed. From the obstructed lymph return, the parts be- 
 come permanently oedematous, and sclerosis and hypertrophy of the con- 
 nective tissue results, and here and there are found indurated tumors of 
 transformed tissue. It is considered by some that elephantiasis is the result 
 of lymphangitis. When the ducts are completely plugged by diseased 
 lymph, occasioned by the inflammatory process, we have a thrombosis of 
 the lymphatics. This form of the disease is often met with in the uterus, and 
 is due in the majority of instances to some injury to the inner surface of 
 the organ; the lymphatics are found filled with viscid, purulent, or dark- 
 colored matter. When the thoracic duct is the seat of the inflammation, 
 which fortunately is a rare occurrence, especially in the idiopathic form, the 
 most grave complications are to be expected. It appears that this duct is 
 
 * System of Surgery, vol. iii., p. 331. 
 
LYMPH ADENOMA. 505 
 
 not prone either to thrombosis or stenosis, for in three hundred post-mor- 
 tem examinations, made by Andral, the duct was found perfectly normal in 
 two hundred and ninety-five. The symptoms, as observed by Worms, ap- 
 pear to be : rigors, very high fever, rapid rise in temperature, swelling of the 
 left arm, with intense agony extending down to the fingers, pyaemia, jaun- 
 dice, and death. 
 
 Neoplasms. — In cancer and tuberculosis, the glands and lymphatics be- 
 come sooner or later involved ; degenerate cells, cancer-juice, and other 
 debris are soon taken up by the vessels and are carried on in the lymph- 
 ducts, until they either adhere to the coats of the tubes themselves or are 
 stopped short at a gland, whereat indeed many such accumulations may be 
 present. Here the seeds are sown that soon take root and develop neo- 
 plasms of different formations. Neoplasms also, may originate in the lym- 
 phatic system, at least such is the assertion of Klebs, Rindfleisch, and 
 others. One thing, however, is certain, that the glands themselves often 
 become chronically indurated, and the disease known as lymphoma or 
 lymphadenoma, is a variety of adenitis accompanied with lymphangitis. 
 
 Lymphadenoma, Lymphoma, Lympho-sarcoma, are terms used to designate 
 a peculiar hypertrophy of the lymphatic glands, which has been so accu- 
 rately described by Dr. Hodgkin, in the Medico- Chirurgical Transactions, for 
 1832, that it is now named " Hodgkin's Disease." Wilks calls the disease 
 lymphatic ansemia, Cassy, general hypertrophy of the lymphatic glands, and 
 Wunclerlich, multiple lymph adenoma. The cervical glands are those most 
 generally affected, but the axillary are also not unfrequently attacked, as 
 may be other of the glandular tissues. The disease does not depend on 
 zymotic influences, and bears in many respects a resemblance to phthisis. 
 In some cases it may be caused by traumatism. The glands gradually en- 
 large, with their connective tissue, and these appearances may result from 
 a bruise or a strain, or may appear without any appreciable cause. A small 
 swelling may be the first indication of the disease. Acute pain, neuralgic 
 in character, accompanies the growth, or may appear in the locality before 
 the tumor is noticed. The tumor at first appears movable, but grows rapidty 
 without seriously inconveniencing the patient. A peculiar and frequent 
 accompaniment of the disease is leucocytha?mia, the white blood-corpuscles 
 being always in excess, and often in enormous quantities. There is also 
 the usual bruit de souffle which accompanies the condition. A single gland 
 may be thus affected, or, as is more frequently the case, several become seats 
 of the disorder, and finally tumors in the lungs, liver, and cellular tissue 
 are developed. Lymphadenoma is not always accompanied by leucocythse- 
 mia, as is noted by Mr. Haward, and offers a better opportunity for treat- 
 ment when uncomplicated. M. Jaccoud concludes, that this disease is 
 occasioned by a twofold condition of the blood. In the one the red globules 
 are much reduced ; in the other, this condition coexists with a vast increase 
 in the leucocytes. According to this view the anatomical constitution is 
 different in each variety. He is of opinion that in the latter cases, viz., where 
 there is a great increase in the amount of the white blood-corpuscles, the 
 new growth is altogether expended in the cellular elements, but when both 
 conditions noted above are combined, the capsule of the glands and the 
 connective tissue are much thickened. At present, operative interference 
 is scarcely considered justifiable, as most of the cases reported have proved 
 fatal* 
 
 Mr. Warrington Hawardf presented at the Clinical Society of London 
 the following interesting case of lymphadenoma. "The patient, a child of 
 
 * Vide Medical Times and Gazette, January 27th, 1877. 
 
 f Medical Times and Gazette, December 25th, 1875. Keported also in the Monthly Abstract 
 of Medical Science. 
 
506 A SYSTEM OF SURGERY. 
 
 four years, had on the left side of the neck an immense mass of enlarged 
 glands, extending from the ear above to the clavicle below, and from the 
 spine behind to the trachea in front. The glands were elastic, and mode- 
 rately firm and not adherent to the skin. There was no evidence of dis- 
 ease in any other part of the body, and the number of the white globules 
 in the blood was not increased. There was a family history of phthisis on 
 the mother's side. The child was pale and rather thin ; the growth was of 
 a year's duration, and commenced soon after an attack of small-pox. As 
 the disease of the glands appeared to be confined to those visible in the 
 neck, it was determined to remove these, in the hope that the general in- 
 fection might thus be prevented or delayed. As the removal of the disease 
 involved the dissection of the whole of one side of the neck, it was effected 
 in two operations. At the first, the affected glands were removed from the 
 anterior triangle of the neck ; at the second, from the posterior triangle. 
 The child recovered well from the operation, and soon gained flesh and 
 color to a remarkable extent. Subsequently, however, the disease returned 
 in the upper part of the left anterior triangle of the neck, and tumors after- 
 wards appeared in the axilla and groin. The child died, pale and emaci- 
 ated, and post-mortem adenoid growths were found in the abdominal vis- 
 cera in addition to the enlargement of the glands. No recurrence occurred 
 in the posterior triangle of the neck, and it was thought that possibly some 
 diseased glands might have been left in the upper part of the anterior tri- 
 angle, where the growth first reappeared." 
 
 M. Trelat (in the Lancet, April 14th, 1877)* mentions two cases of removal 
 of lymphadenomata, attended in each case with similar growths in other 
 parts of the body. In both these cases there was a recurrence of the growth 
 and a fatal issue, and lymphomatous growths were found in the vertebrae, 
 sternum, spleen, and liver. It is held that there are forms of lymphade- 
 noma which are malignant, and others which are not, but the definite his- 
 tological criteria for determining between the two varieties is not pointed 
 out. The conclusion drawn from these eases is that the removal of these 
 tumors is not advisable when there is any suspicion of visceral implication. 
 
 Lymphatic Fistula. — In some cases of lymphangitis, a fistula forms and 
 opens upon some portion of the body, from which the secretion is poured 
 out. Such may also result from a wound, or it may arise from a varicose 
 condition of the lymphatic vessels. It is said that elephantiasis of the ex- 
 tremities is a frequent accompaniment of these fistula?, and that their most 
 frequent site is the groin and the scrotum. 
 
 Treatment. — In the treatment of lymphangitis, the first indication, if. the 
 disorder is of local origin, is to remove, if possible, the exciting cause. 
 The application of the cautery, chloride of zinc, or lunar caustic to the 
 wound, the constant application of poultices, in the admixture of which 
 antiseptics have been freely used, and withal, great attention to cleanliness 
 and fresh air, are important items. The system must then be nourished 
 with appropriate diet and judicious stimulation. I say judicious, because 
 it is much the custom in such cases to pour into the stomach all kinds of 
 drinks, at all kinds of unreasonable hours, without regard to the condition 
 of the patient, or the digestive apparatus. There are some individuals who 
 bear with favorable results an incredible amount of stimulants, and there 
 are others with whom even small quantities will disagree. These cases 
 must be duly discriminated. Internally, either the second decimal dilution 
 of nitric acid, or the first decimal dilution of carbolic acid, prepared with 
 glycerin, or arsenicum in the third trituration, will be found the appropri- 
 ate medicine. China, lachesis, or carbo vegetabilis may be indicated. 
 
 * American Journal of the Medical Sciences, July, 1877, page 256. 
 
INJURIES AND DISEASES OF THE BONES. 507 
 
 In the idiopathic variety (by which I mean those cases occurring without 
 appreciable local causes), aconite and belladonna in the earlier stages, and 
 mercurius iodatus or soluble mercury may be of service. When there is 
 chronic enlargement of the glands, calc. carb., conium, baryta carb., or sulph., 
 should be remembered. When the tendency to oedema is great, the two 
 medicines which in the majority of cases will produce the best results are 
 arsenic and apis mel. I believe that these remedial agents will often shorten 
 the duration of the disease. 
 
 Latterly I have used, with a great deal of success, arsenic in doses of ^ G 
 of a grain three times a day, or the liquor potas. arsen., three drops after 
 meals, in conjunction with kali hydriod., and the application of mineral 
 earth made into a paste and worn night and day. 
 
 Professor Busch* of Bonn, has treated, with great success, certain cases 
 of lympho-sarcomata, by what are known as Kern's cataplasmata. 
 
 After speaking of the unsuccessful treatment of these growths by the or- 
 dinary surgical procedures he was induced to use the cataplasmata which 
 are composed of one part of mustard flour and five parts of black soap, the 
 whole being applied in a gauze bag over the tumor four or five hours. Very 
 often a severe irritation of the skin is produced almost amounting to an 
 erysipelas. 
 
 Phosphorus, the carbonates and phosphates of lime, with ferrum iod. 
 or ferrum met., with the occasional use, as symptoms may indicate, of lyco- 
 podium and silicea, may prove successful. Dr. Lilienthal has suggested to 
 me the use of hecla lava in this disease, especially where there is cervical 
 adenitis. 
 
 For lymphatic fistula little can be done : care with reference to position, 
 the judicious application of straps, the careful application of an astringent 
 or caustic lotion to the parts, with internal medication as the symptoms 
 may present, is all that can be done in such cases. 
 
 CHAPTER XXX. 
 
 INJURIES AND DISEASES OF THE BONES. 
 
 Periostitis — Osteitis, Suppuration and Sclerosis — Osteo-Myelitis — Caries — 
 Scrofula and Syphilis in Bone — Necrosis— Mollities Ossium and Rachitis — 
 Fragilitas Ossium — Atrophy of -Bone — Tumors, Innocent and Malignant. 
 
 Inflammatory action effects changes in the osseous as well as in other 
 parts of animal structure. 
 
 The bones pass through the different stages of inflammation, suppuration, 
 ulceration, and death; and are subject to peculiar deviations from healthy 
 formation, owing to their chemical composition. 
 
 To effect a cure of diseases of the bones, the causes upon which such 
 affections depend must be removed ; a want of such knowledge often in- 
 duces the most distinguished surgeons to employ severe methods of treat- 
 ment, which rather aggravate these affections than produce a beneficial 
 effect. By the administration of proper medicines the constitution of the 
 patient can be improved, and the disease more successfully treated. The 
 
 * Medical Record, September 15th, 1883. 
 
508 A SYSTEM OF SURGERY. 
 
 dilution of the medicine and the repetition of the dose are of paramount 
 importance. Experience teaches that the exhibition of dynamization, to 
 the 6th, is more speedily followed by beneficial effects than when the crude 
 drugs are employed ; the system by the latter being excited to a reac- 
 tion prejudicial to favorable results, whilst the too frequent repetition 
 of medicines often disturbs their curative action, and thereby retards re- 
 covery. 
 
 I have for years used with surprising efficacy medicines triturated to the 
 30th potency, by Dr. Henry M. Smith, of this city, and have been much 
 gratified by their action, especially in bone diseases. 
 
 " We are often at a loss to determine," writes Dr. Jeanes * "which of the 
 remedies that are indicated by the morbid condition, or its particular de- 
 velopment, as caries, hyperostosis, etc., is the appropriate remedy for the 
 individual case. The circumstances which can guide in the choice of the 
 remedy, are the temperament, the disposition, the character of antecedent 
 diseases, and the treatment to which they have been subjected, and the 
 nature of the exciting cause of the existing disease of the bone. The symp- 
 toms which indicate the remedies are those of the disease of the bone, viz., 
 the appearances, the pains, and other manifestations which accompany it, 
 and the symptoms which affect the whole system, or particular parts of it, 
 other than those immediately implicated by the disease of the bone. But 
 most of the latter, which may be termed the general symptoms, namely, 
 hectic, loss of appetite, emaciation, debility, etc., are often merely the result 
 of the local irritation." 
 
 It is also of some importance for the practitioner to become acquainted 
 with the manner in which any antecedent disease may have been treated, 
 as all such circumstances tend to aid in the selection of appropriate reme- 
 dial agents. 
 
 Periostitis. — Periosteum is the name given to the strong white fibrous 
 membrane that closely envelops bones, excepting such of them as are 
 covered with cartilage. This membrane is connected externally to adjacent 
 cellular substance, and therefore indirectly with muscular tissue ; the inner 
 surface adheres closely to the bone by means of short strong fibres, which 
 enter the numberless foramina on the surface of the ossific structure. 
 
 Although fibrous tissues are not as liable to be attacked by inflammation 
 as other textures of the body, still, when such abnormal action is found, 
 the sufferings of the patient are often exceedingly severe ; and if the inflam- 
 matory process be considerable or acute, it is seldom limited to the tissue 
 originally affected, but extends to all the surrounding parts. 
 
 Great pain is the usual attendant upon this disease, whether acute or 
 chronic, and when in the former variety, if the inflammation has extended 
 to the bone, the sufferings of the patient are excruciating. This increase 
 of suffering may be readily accounted for, if we remember that the inflam- 
 matory process progresses with greater rapidity in tissues which are secon- 
 darily involved, consequently there is an increased amount of exudation, 
 which, being confined by the external membrane, tends greatly to aggravate 
 the pain. 
 
 The swelling in periostitis is small compared to the violence of the in- 
 flammatory action ; this may also be explained in the same manner alluded 
 to when speaking of the unusual degree of pain that is present in the dis- 
 ease, viz., the confinement of the exudation. All the symptoms are aggra- 
 vated at night. 
 
 The constitutional symptoms are well marked in periostitis. If the dis- 
 ease be acute there is a high degree of inflammatory fever ; if chronic, the 
 
 * Homoeopathic Practice of Medicine. 
 
PERIOSTITIS. 509 
 
 system is gradually undermined by the continued loss of sleep, caused by 
 the severe nocturnal sufferings. Emaciation, loss of appetite and spirits, 
 and hectic, often supervene, rendering the patient extremely miserable. 
 
 In the acute form of the affection the membrane is softer and loosened 
 from its connection with the subjacent bone ; in the chronic variety it be- 
 comes more dense, and adheres with unnatural firmness. 
 
 When inflammation does not become fully established, or, in other words, 
 if active congestion be only present, fibrin is exuded, and the swelling is 
 termed a node, which, when arising from syphilis, is denominated the 
 'venereal, when complicated with the results of large doses of mercury, the 
 mercurial, or the two causes may be combined, giving rise to the mercurio- 
 syphilitic node. 
 
 If inflammation proceed a step further, and the bone becomes involved, 
 a purulent formation (abscess in the bone) is the result, which, not being 
 able to approach the surface, from the strength and non-ulcerative property 
 of the periosteum, extends laterally, denuding the bone of its membrane. 
 
 The same process may be present in ossific structure, as has been here- 
 tofore related concerning inflammation occurring in other textures ; the 
 inflammatory process having established suppuration, gradual molecular 
 disintegration (ulceration) of the bone may ensue, and if this be not re- 
 strained, necrosis may take place. 
 
 Sometimes, in the acute form of the disease, these terminations may be- 
 come apparent in a short time after inflammation has developed itself; if 
 chronic, weeks and months may elapse before caries or necrosis is estab- 
 lished, but the patient will exhibit unmistakable signs of severe constitu- 
 tional irritation. 
 
 There is a variety of periostitis, known as secondary, in which the mem- 
 brane has not been primarily affected, but has become so from contagious 
 sympathy, the bone, or spinal marrow, being primarily the seat of the 
 inflammatory action. In this disease the symptoms are even more severe 
 than in the ordinary variety, and the constitution is more profoundly 
 affected. 
 
 Some of the differential marks of diagnosis between periostitis and endo- 
 stitis (ostitis) are thus clearly pointed out by Mr. Bryant :* 
 
 " In periostitis, when suppuration is about to take place, external evidence 
 will appear in the form of increased swelling, tenderness, and redness of the 
 skin ; oedema of the tissues covering in the node and fluctuation will be 
 present. In endostitis terminating in abscess there will be a great aggrava- 
 tion of all local pain, with constitutional disturbance, and often rigors ; 
 oedema of the soft parts over the bone and external evidence of inflamma- 
 tion will rarely appear, and then only when the abscess is making its way 
 through the periosteum externally (vide Abscess in Bone). 
 
 " When periostitis ends in necrosis it is only of the shell of bone beneath 
 the inflamed node (peripheral necrosis). When endostitis ends in necrosis 
 it is usually of a greater or less mass occupying the centre of the bone (cen- 
 tral necrosis) ; sometimes the whole shaft or articular extremity dies. 
 
 " In periosteal necrosis the dead bone rests exposed, and when covered in 
 it is by soft parts alone, no new bone surrounding it. 
 
 " In endosteal necrosis the dead bone or sequestrum is more or less com- 
 pletely surrounded by new bone — a new periosteal formation. W T hen this is 
 incomplete, it is a fair proof that the periosteum has been involved. 
 
 " In necrosis of a long bone the result of periostitis, and endostitis by ex- 
 tension, the hope of a new bone being formed is a forlorn one ; whilst in the 
 necrosis of endostitis there is every hope of a complete restoration of the 
 
 * Practice of Surgery, 806. 
 
510 A SYSTEM OF SURGERY. 
 
 bone taking place, through its periosteal covering, on the removal of the dead 
 portion or sequestrum. 
 
 " In the necrosis of the skull which is always periosteal, no new bone is 
 formed, the bone-forming membrane, the periosteum, having been destroyed. 
 When following an injury to the skull it is preceded by ' puffy tumor of 
 Pott.' In syphilis it follows a suppurating node." 
 
 Treatment. — The medicines that are of service in periostitis are aur., calc, 
 carb. an., caust, kali c, lye, mere, mez., nit. ac, ruta, rhododen., staphis., 
 and sulph., or croc, fluor. ac, magnes. c, natr. mur., petrol., pulsat, silic 
 
 Staphisagria and sulph. have also symptoms that may be present in peri- 
 ostitis, but for the precise indications of these, as well as the other medicines 
 before mentioned, the student must refer to the repertory and symptomen 
 codex. 
 
 By the administration of some of these medicines the disease may be 
 arrested before the inflammatory process has reached the suppurative stage ; 
 at all events, many of the most distressing symptoms of the patient certainly 
 will be alleviated, thus rendering him comparatively comfortable. 
 
 But when pus has formed and collected beneath the periosteum, the 
 matter must be evacuated, and that as speedily as possible, or caries and 
 necrosis may be the result of delay. If the operation of dividing the peri- 
 osteum be performed, as soon as the surgeon has satisfactory reason to be- 
 lieve that matter is present, simple ulceration only may have taken place, 
 and as soon as the pressure occasioned by the pus is removed, the repro- 
 ductive process will in all probability complete the cure in a short time. 
 But although this practice is eminently beneficial in acute abscess of the 
 bone, it must never be employed unless the signs of suppuration are suffi- 
 ciently obvious to render it certain that pus is accumulating rapidly and 
 in quantity between bone and periosteum. Cod-liver oil (o/. jec. ase.) has 
 been employed by many practitioners with excellent results, when there 
 exists a scrofulous taint. 
 
 M. Duplay,* in a discourse on the Treatment of Diffuse Phlegmonous 
 Periostitis, offers the following interesting case : 
 
 A boy, aged 16 years, had suffered from abscess in one of the phalangeal 
 joints of the middle finger. Subsequently periostitis exposed nearly the 
 whole shaft of the tibia. 
 
 It was determined to resect the shaft of this bone superiosteally, instead 
 of amputating. A free incision was made, the periosteum where it was ad- 
 herent was easily detached, a chain saw was passed around the bone at the 
 upper limit of the disease (as was believed) and the bone sawn through op- 
 posite the tubercle of the tibia ; the diseased shaft was then extracted with 
 but little blood lost. But the portion of the shaft which had been left, kept 
 up suppuration, and it became necessary to remove it also, the two together 
 measuring nearly nine inches. The patient recovered perfectly and with a 
 thoroughly useful leg. 
 
 M. Duplay dwells chiefly in his remarks on this case, to the advantages 
 of resection as contrasted with amputation ; and in this he seems to meet 
 with no. opposition. This interesting case shows conclusively the success 
 that may attend the attempt to save the patient's life without amputation in 
 such instances. 
 
 About a year since, a boy, aged 14, was brought to me with his right 
 arm in a sling and entirely useless. From the elbow to the wrist the 
 tumefaction was very great, and several large openings with everted edges 
 proclaimed serious bone disease beneath. I determined to amputate the arm, 
 and it was only after the urgent appeal of the father that I consented to 
 
 * London Medical Record, February 15th, 1876. 
 
INFLAMMATION OF BONE — OSTITIS. 511 
 
 make the endeavor to save it. Upon cutting down upon the bone, I found 
 it so much diseased that I determined to resect the whole of it. I therefore 
 removed the entire ulna embracing the olecranon at the elbow and the styloid 
 at the wrist, saving the periosteum. It was beautiful to see the new spicule 
 of bone projecting from the interior of the periosteum, as it was lifted away, 
 and to observe how rapidly the boy gained in health after the removal of 
 the bone. I also found it necessary to take away the head of the radius and 
 the external condyle of the humerus. 
 
 Inflammation of Bone — Ostitis. — In the early stages of inflammation of 
 bone, it is difficult to diagnose whether the abnormal action is affecting the 
 periosteum, the bone, or the medulla ; after a time, however, the uniformity 
 of the swelling will indicate that the bone-substance is diseased, thus dif- 
 fering from the enlargement which has just been described under the head 
 of periostitis. Dr. Markoe * classifies the different varieties of the inflam- 
 matory process as affecting the osseous system, first, as those attended 
 with organization of exuded products ; second, those in which the exuda- 
 tion ends in suppuration; third, ulceration or caries; and fourth, necrosis. 
 It has been maintained by some authors that the true bone-cells are never 
 primarily affected, the first accession of the disease being in the marrow. 
 There are not, however, sufficient grounds for this belief, for although the 
 bones, especially in their compact structure, are not very largely supplied 
 with bloodvessels, yet there is certainly sufficient blood to carry on nutri- 
 tion, and in some, the nutrient arteries are of considerable size. From these 
 facts there is no reason why inflammation should not attack the bones, 
 although, perhaps, not as frequently as other structures of the body. The 
 cancellated structure is of course more obnoxious to inflammation than the 
 compact. Ostitis may be acute or chronic, and the disease may begin in 
 the marrow and extend to the bone, or vice versa. The acute variety is not so 
 frequently met with as the chronic, and, in the majority of instances, I think 
 we find that ostitis partakes more of the subacute variety of the inflamma- 
 tory process. 
 
 The symptoms of the disease resemble much those of periostitis ; the 
 pains are severe, sometimes excruciating, and are, in the majority of in- 
 stances, worse at night, They are boring, throbbing, and burning. The 
 patient will complain of the peculiar " deepseated " nature of his suffer- 
 ings. Movement aggravates the pain, and atmospheric changes are pecu- 
 liarly noted. In fair, bright weather the sufferings are less, but the patient 
 can predict a change to dampness and rain, by a peculiar increase of suffer- 
 ing, before any evidences of an approaching storm are apparent. It will 
 be readily understood that a short season of such severe pain may induce 
 constitutional symptoms. Fever, especially at night, is present; exhaustion, 
 loss of appetite, fretfulness, emaciation, and hectic often supervene, espe- 
 cially when the sufferings have" been prolonged. Important structural 
 changes also take place in the bones affected with inflammation. The 
 Haversian canals enlarge in the same manner as the bloodvessels in other 
 tissues ; there is an increase in the density of the bone, and often also of the 
 periosteum ; thus having a close resemblance to the hardness and increased 
 size of the soft parts in the earlier stages of inflammatory action. As the dis- 
 ease progresses the density gives place to a more softened structure, although 
 the parts still are enlarged and laminated. The bony structure, in part, 
 may disappear, leaving pores throughout the surface, and the bone-cells are 
 filled with a sero-sanguinolent fluid. Thus the enlargement which takes 
 place in ostitis may be occasioned first by an increase of density, and 
 second, by softening from metamorphosis of the structural elements of the 
 bone. 
 
 * A Treatise on Diseases of the Bones, by Thomas D. Markoe, New York, 1872, p. 19. 
 
512 
 
 A SYSTEM OF SURGERY. 
 
 Many constitutional causes give rise to inflammation of bone, as syph- 
 ilis, scrofula, scurvy, rheumatism, gout, or mercurial poisoning, as well 
 as those injuries which are known to produce the disease. Exposures to 
 damp weather or to cold are very often exciting causes of the affection. 
 
 Resolution may occur in ostitis as well as in other tissues affected by in- 
 flammation; and when such result obtains, the bone generally remains en- 
 larged, if not permanently, certainly for a considerable time. 
 
 Treatment. — The medicines which have been found most serviceable in 
 this disease are asaf., bell., calc, calc. phosph., mere, mez., nit. acid, phosph. 
 acid, staphis., sulph., kali hydriod., Symphytum. 
 
 Suppuration and Sclerosis in Bone.— If the inflammatory process has not 
 been arrested, the next step is the gradual softening of structure and the 
 formation of pus. In speaking of abscess (page 115) the acute or circum- 
 scribed, and the diffuse variety as occurring in the soft parts, are men- 
 tioned. The formations of pus are similar in the osseous system ; a true 
 abscess often forms in bone, as well as purulent infiltration. According to Dr. 
 Markoe, the abscess (properly so called, not including purulent formations 
 of caries and necrosis) may occur in three situations: "1. In the cancellous 
 structure. 2. In the medulla. 3. Between the periosteum and the bone." 
 Wherever the abscess forms, the pains are those of inflammation united 
 w r ith the constitutional manifestations indicative of the formation of pus in 
 other parts of the body. The pains are agonizing, worse at night, and 
 sometimes of an intermittent character, the patient being at times compara- 
 tively free from suffering. The integument covering the diseased bone is 
 very sensitive to the touch, is oedematous, and pits upon pressure. The 
 constitutional symptoms are severe, and hectic fever is not an uncommon 
 occurrence. 
 
 In many instances it is difficult to diagnose true abscess in bone from 
 other inflammations, but the deepseated character of the pain, the chronic 
 nature of the suffering, the aggravation of the symptoms at night, and the 
 previous history of the case, must be the guides in these cases. 
 
 In some instances, however, after the pus has been imperfectly evacuated, 
 the inflammation continues, though not so acute, and the pus burrows here 
 and there, forming sinuses, which are difficult to 
 heal, and are often followed by disastrous conse- 
 quences to the bony structure in the vicinity. This 
 disease is termed the chronic sinuous abscess ; or, when 
 the patient is of better constitution, the inflam- 
 matory products within the bone become partially 
 organized, and the bone expands, developing the 
 disease known as sclerosis in bone. 
 
 Treatment. — The medicines which have been 
 mentioned in the preceding section must be em- 
 ployed for the inflammation, and hepar, mere, sili- 
 cea, and sulphur be used according to symptoms. 
 But when the pus is formed, the sooner it is evacu- 
 ated the better. This may be done as follows : A 
 semicircular flap is raised over the swelling, and the 
 periosteum carefully raised with an instrument 
 made for the purpose. A trephine (Fig. 237) is 
 then applied, the pin pushed dowm, and the bone 
 sawn through. If the matter is reached, it will 
 generally exude ; if not, the surgeon must try 
 again. In some instances several openings may be 
 necessary. If there is but a small collection of pus, an instrument devised 
 by the late Dr. Charles A. Pope, of St. Louis, and shown in Fig. 238, may be 
 
 Fig. 237. 
 
OSTEO- MYELITIS. 
 
 513 
 
 used. In other cases again there may be such an amount of deposit, and 
 that so hard and firm, that a trephine with an auger-handle, but with a small 
 cutting crown, will be the most serviceable instrument. 
 
 Fig. 238. 
 
 T/EMANN=CO 
 
 Osteo-myelitis. — There is a peculiar inflammation of the cancellated or 
 medullary structure of bone almost exclusively of traumatic origin, and 
 occurring in crowded hospitals, or in ill-ventilated apartments, which has 
 received the name of " osteo-myelitis." It must not, however, be under- 
 
 Fig. 239. 
 
 FIG. 240. 
 
 Fig. 241. 
 
 Fig. 239.— Osteo-myelitis of the femur.— From a drawing in the Museum of St. George's Hospital. 
 
 Fig. 240.— Inflammation of the femoral vein from the same case. 
 
 Fig. 241.— Upper portion of humerus amputated for necrosis after osteo-myelitis. The necrosis does not 
 extend into the tuberosities, neck, or head of the bone, which, however, are expanded by inflammation 
 (osteo-porosis).— After Longmore, in Med.-Chir. Trans., vol. xlviii.— (Holmes.) 
 
 stood that the marrow and medullary canal are alone affected ; the abnormal 
 action also extends to the compact structure and the periosteal surface of 
 the bone. Dr. Lidell, who has given considerable attention to this pecu- 
 liar variety of ostitis, especially in connection with military surgery, makes 
 several divisions of the disease : first, carnification ; second, suppuration ; 
 
 33 
 
514 A SYSTEM OF SURGERY. 
 
 third, mortification of the medullary matter. The disease also may be acute 
 or chronic, diffused or circumscribed. 
 
 When a patient is about to be attacked with the disease, a chill is gener- 
 ally the precursor, which is followed by fever and most severe and agoniz- 
 ing pains, much aggravated at night, especially by the warmth of the bed. 
 The pain is very peculiar ; the patient knows that it is in the bone ; it is 
 deepseated, and so violent that the sensation is that of the bones being 
 broken off. Together with these symptoms, oedema of the parts, with sen- 
 sitiveness, ensue ; the swelling at first is circumscribed, which latter fact is of 
 especial import in the diagnosis of the affection. The fever, after a few 
 days, assumes a typhoid type ; the system appears to be profoundly affected ; 
 delirium supervenes, of a low muttering character ; there is great prostra- 
 tion and profuse nightsweats. While the constitution is showing such 
 marked signs of disturbance, the wound also changes its appearance, the 
 discharges become unhealthy, are either ichorous, sanious, or flocculent. 
 In some cases there may be a great diminution in the quantity, granula- 
 tions which had been healthy become bluish or fungoid, the process of 
 granulation is arrested, and there • appears to be a tendency to sloughing 
 and gangrene. Suppuration then follows ; the whole bone-tissue becomes 
 involved. Figs. 239, 240, and 241 show the extent to which the bones and 
 even the bloodvessels become affected. Very often symptoms of severe septi- 
 caemia are present. During the latter process the marrow becomes softened, 
 oozes from the bone, mixed with a thin ill-looking pus, and accompanied 
 with severe constitutional symptoms. 
 
 According to Prof. Busch, the changes which take place in the medulla 
 present all degrees of variation, from simple hyperemia of the fatty marrow 
 to complete transformation of the same into red (lymphoid) marrow. The 
 changes are not, however, equally intense in all the bones, being most 
 marked in the humerus and femur ; the tibia, radius, and ulna present more 
 resistance to the morbid process. In the portions of bone removed for ex- 
 amination, no bloodvessels are found, though nucleated red blood-corpuscles 
 can be seen in small numbers. In one case some of the nuclei of white cells 
 were distinctly colored by hematine. The microscopical appearances were 
 similar to those in cases of leucocythaemia. 
 
 Idiopathic Symmetrical Osteo-myelitis. — There are certain cases of osteo- 
 myelitis which are very acute in their character, and present no traumatism 
 or other local assignable cause in their history. The epiphyses or the ex- 
 tremities of the bones are likely to be affected, and from thence the entire 
 shaft may become involved. The disease, being " symmetrical," and affect- 
 ing several joints at once with oedema, sensitiveness, and redness, and being 
 accompanied by fever, is likely to be mistaken for acute rheumatism. A 
 case of this variety of osteo-myelitis is recorded by Dr. Charles Carey .* 
 
 Treatment. — In the outset of the treatment of this malady arnica is a 
 medicine which, internally administered, will often produce excellent re- 
 sults. The medicines are chiefly phosphoric acid, staphis., lachesis, arsen., 
 mere. corr. sub., kali iod., aurum, nit. acid. 
 
 Arsenicum should be given when the symptoms are of a very low grade ; 
 when there is much restlessness, thirst, and delirium ; when symptoms of 
 pyaemia or ichorrhaemia present, and the pus is sanious and offensive, with 
 biueness of surface, coldness of skin, and thirst. 
 
 Nit. acid may be employed in cases in which mercury has been previously 
 administered in large doses, and when the osseous system appears to suffer 
 
 * Med. Kecord, vol. xiii., p. 109. 
 
CAKIES ULCERATION OF BONE. 515 
 
 much from a thorough impregnation of this drug ; also when there is present 
 a syphilitic dyscrasia. 
 
 Merc. corr. sub. — The bichloride of mercury acts better in this form of 
 bone disease than any other mercurial with which I am acquainted. It is 
 especially indicated for bone-pains with swelling and tenseness of the parts, 
 when the disease runs a very rapid course, and when there exists no pre- 
 vious mercurial taint in the system. Other medicines are calc, sulph., 
 silic, graph., iod., lycop., kali bich., phosph., baryta carb., and mang. 
 With regard to local treatment, which is sometimes necessary to allay 
 severe sufferings, cold applications are very efficacious. When pus has 
 formed it must be evacuated by the trephine, and free incisions into the 
 surrounding structures are often necessary to relieve tension and evacuate 
 fluids. As a last resort amputation may have to be performed, and even 
 this affords no guarantee that the existing state of the system will not pre- 
 dispose to an outbreak of the disorder in the stump. 
 
 Caries — Ulceration of Bone. — The term caries is used to denote a peculiar 
 ulceration of bone in which reparation is rarely effected by nature, and is 
 with difficulty obtained by the most skilfully applied artificial means ; or, 
 according to Mr. Miller* a breach of continuity of bone of altogether a pe- 
 culiar kind ; of itself very difficult to cure, yet not in any degree partaking 
 of truly malignant action. 
 
 On this subject Dr. Markoe writes : " Without attempting, therefore, to 
 define caries, I will content myself with describing it as a disease of the 
 cancellous structure of bone, characterized by a chronic or subacute inflam- 
 mation terminating in suppuration, which is partly infiltrated and partly 
 collected into abscesses, the cavities of which abscesses, after they have dis- 
 charged their contents, have a tendency to ulceration, whereby sometimes 
 extensive destruction of bone-tissue results."f 
 
 Every portion of the osseous system is liable to be attacked with caries ; 
 but it has been observed that those bones that partake most of the cancel- 
 lated structure are more frequently the seat of the disease than those of a 
 more firm and compact conformation ; thus the vertebrae, the bones of the 
 carpus and tarsus, the sternum, and the extremities of the long bones, are 
 the most frequent sites of this disease. For similar reasons the ossific struc- 
 ture in young persons is more subject to it than those of advanced years. 
 
 Surgeons of the olden time confounded caries with necrosis, the latter 
 being termed by them dry caries ; others have considered it the same as 
 necrosis. These suppositions appear the more strange when we consider 
 that caries was described by Galen as being somewhat analogous to ulcer- 
 ation of the soft parts.;}; 
 
 It has been previously remarked that ossific matter, when attacked by in- 
 flammation, becomes acutely sensitive, hence, in the commencement of this 
 disease, in which the inflammator}' process is always present, the patient 
 suffers considerable pain; so great, in the generality of instances, as to 
 prevent the enjoyment of repose' for weeks and months together. The 
 affected part is considerably swollen, but the enlargement is seldom so gen- 
 eral or so great as is present in the diseased condition of the ligaments and 
 other apparatus of the joints, although affections of the bursse, ligaments, or 
 synovial membrane, may in time extend to the adjacent bones, and breach 
 of continuity be the consequence. 
 
 In caries, the affected portion appears neither to possess vital action 
 
 * Principles of Surgery, p. 435. 
 
 f A Treatise on Diseases of the Bones, by Thomas M. Markoe, M.D., New York, 
 p. 94. 
 
 X See Cooper's Surgical Dictionary, vol. i., p. 820. . 
 
516 
 
 A SYSTEM OF SURGERY. 
 
 enough to enable it to repair the solution of continuity, nor is the diseased 
 mass sufficiently deprived of vitality to be thrown off by the surrounding 
 tissues. When the affected parts have remained a considerable time in this 
 inactive state, the surrounding vessels become somewhat excited, and the 
 surface of the bone in the vicinity is studded with small points of new 
 osseous formation; these new deposits, however, are not limited to the 
 affected bone, but may be traced to those with which it is articulated. The 
 soft parts surrounding the diseased mass are commonly more or less 
 thickened and rendered exceedingly dense by effusion of lymph into the 
 cellular tissue, which sometimes becomes of a cartilaginous hardness. As 
 the ulceration proceeds, a cavity forms in the bone, with soft, spongy mar- 
 gins, with an unequal bottom, deep at one portion and completely shallow 
 in another (vide Fig. 242) ; the substance of the bone may crumble easily, 
 or the part may be covered with pale and unhealthy granulations ; often' a 
 loose, fungous growth sprouts from the interstices formed on the surface of 
 the diseased bone, bleeding readily at the slightest touch ; from the decaying 
 structure also a thin, fetid, and corrosive ichor is discharged, in many in- 
 
 FlG. 242. 
 
 -A 
 
 Caries of the lower extremity of Humerus after resection. Author's collection. A, showing 
 commencement of ulceration. 
 
 stances through a sinus which has been formed in the soft parts ; these 
 symptoms, however, as well as the tendency in the accompanying ulcer or 
 sinus to produce large fungous granulations, are more constantly met with 
 in necrosis than caries, for the latter disease has been known to exist for a 
 considerable length of time unattended with any outward sore, abscess, or 
 sinus. 
 
 A superficial caries may be ascertained without much difficulty, and when 
 the affected bone is deepseated it may be discovered by the use of the 
 probe ; for if the disease exist, the surgeon can often readily detect the in- 
 equalities of surface, and, owing to the spongy character of the diseased 
 part, the instrument can readily be made to penetrate the substance of the 
 bone; in some instances, however, when there exist the unhealthy granu- 
 
SYPHILIS IN BONE. 517 
 
 lations already mentioned, a moderate degree of force is required ; the 
 latter fact, if remembered, may prevent in some instances an incorrect 
 diagnosis. 
 
 There are some bones which may be diseased, and which from their situ- 
 ation, do not admit of the use of a probe ; in such cases the diagnosis may 
 be more difficult ; however, if a fistula, from which a fetid, corrosive, and 
 dark-colored matter is discharged, be found leading directly from the sur- 
 face of a bone, and if the surrounding part be at the same time turgid and 
 indurated, there is every reason to suppose the existence of caries. 
 
 " If a person," wrote Boyer,* " affected with certain constitutional dis- 
 ease, feels deepseated or acute pains in any of his bones, and if the pained 
 part swell and become the seat of an abscess, from which a purulent matter 
 of a bad quality flows, there is reason to believe that the bone affected with 
 pain is carious. Inert abscesses are attended with nearly the same symp- 
 toms, with this difference, that they are not preceded by pain. Caries oc- 
 casioned by syphilis affects most commonly the tibia, os frontis, ossa nasi, 
 ossa palati, and sternum. Whenever, therefore, any of these bones become 
 carious, whilst the person labors under syphilis, there is just ground for 
 concluding that the caries is a symptom of the venereal affection." 
 
 Caries may be divided into three varieties, simple, scrofulous, and tubercu- 
 lar. The simple form is such as has been described, the scrofulous variety 
 is dependent on a constitution affected with scrofula, and in tubercular, 
 the disease is accompanied by deposit of tubercle in the loose texture of the 
 bone. 
 
 The causes of caries are various. It may arise from disease of the soft 
 parts — ulcers, etc. — having extended to the bone, or constitutional taint 
 may be the remote, and recent injury the proximate cause, but probably 
 the disease most frequently arises from scrofula, syphilis, or abuse of mercury. 
 
 Scrofula in Bone — Scrofulous Ulceration of Bones.— As will be imagined, 
 this condition is characterized by the deposition of tubercular matter, or 
 01 a very low grade of inflammatory action. In the earlier stages the bone 
 becomes soft, and an oily material is found deposited in its substance. At 
 a later period a soft worm-eaten and foully-smelling ulceration is discovered. 
 After a period the entire periosteum is destroyed or thickened. The can- 
 celli and the lacunas are filled with an exudation. Dr. Blackf finds that 
 there is in tuberculous bone always fatty degeneration ; that the lime salts 
 are diminished and the soluble salts are increased. The peculiar appear- 
 ance of a whitish, cedematous, indolent swelling, characteristic of scrofula, 
 is found around the ulcer. There is not much pain nor much swelling. 
 When the bone is examined, pits or round holes, with sharp edges, and filled 
 with a cheesy deposit, are found. These peculiar pits are regarded as char- 
 acteristic. 
 
 Syphilis in Bone. — When the bones are affected with the tertiary forms of 
 syphilis, the appearances presented at first are those of a node which has 
 already been described. If the disease is not arrested in this stage, the 
 ulceration attacks the bones in one of the two varieties of syphilitic ulcera- 
 tion, viz., the annular ulcer or the tubercular ulcer. In the former there is a 
 round depression, generally found in the cranium, with a groove around 
 the margins like a trench, which marks the outset of the ulcerating process, 
 while in the latter form, a syphilitic tubercle first appears, which finally 
 ulcerates, and penetrates deeply into the bone ; indeed, in some instances, 
 the entire thickness of the bone may be eaten through. 
 
 * See the Lectures of Boyer upon Diseases of the Bones, arranged by Eicherand, trans- 
 lated by Farrell, and edited by Joseph Hartshorne, M.D., p. 167. 
 f Pathology of Tuberculous Bone, p. 32. 
 
518 A SYSTEM OF SUKGERY. 
 
 Treatment. — Much vigilance should be exercised with a view to prevent 
 the occurrence of this morbid condition ; therefore, if there be ulcers and 
 abscesses in the soft parts which appear to have a tendency to involve the 
 bones, they must be carefully watched and judiciously treated.* If simple 
 suppuration occur as a consequence of diseased periosteum, the medicines 
 before mentioned for periostitis should be administered in accordance with 
 the presenting symptoms. 
 
 By careful watching, the formation of matter may be averted ; but to 
 accomplish such desirable result, the treatment must be commenced early. 
 When there is merely an inflammation of the bone with slight swelling, red- 
 ness of the integument, and extreme sensibility to touch, bryonia and Pul- 
 satilla are recommended ; the latter being more adapted to the disease when 
 it occurs in persons of a phlegmatic temperament, with mild disposition, 
 apathy, etc. ; the former deserving preference if the patient be of a dry, 
 meagre habit, with bilious or nervous temperament. Mercurius is an im- 
 portant medicine for ostitis as well as periostitis, and by its administration 
 the inflammatory action occurring in the bone may be checked before other 
 untoward symptoms present themselves. The indications for the admin- 
 istration of this medicine, as well as others, have been mentioned in the 
 previous chapters. If inflammation of the bone is chronic, the following 
 medicines may be resorted to, according to the correspondence of symp- 
 toms in each individual case : asaf., calc, phosph., phosph. ac, silic, sta- 
 phis., and sulph. When the affection has arisen from the abuse of mercury, 
 and the disease is accompanied with mercurial or mercurio-syphilitic symp- 
 toms, aurum, hepar, or nitric acid may be used. If from a blow or bruise, 
 ostitis threaten, am., calen., ruta, or Symphytum may be employed ; but 
 when there is considerable erysipelatous redness around the wounded part, 
 bella. may be used and in some cases in alternation with arnica. 
 
 My friend Dr. Holcomb says of asafcetida in this connection : " I have 
 twice verified the value of this remedy in scrofulous caries of the bones. I 
 used the 12th dilution. It is singular that a remedy whose principal appli- 
 cations are for the most fugitive and sympathetic disturbances of the ner- 
 vous system, should extend its curative power to the most deeply seated 
 and chronic organic lesions. My opinion is that we know almost nothing 
 about this ' devil's dung,' as the Persians call it, and that it is well worth a 
 thorough study." 
 
 Other medicines that have been serviceable in the treatment of caries are 
 baryta, carb. veg., dulc, fluor. ac, lye, mang., mez., staphis. 
 
 If a patient affected with caries apply for relief, the first duty of the 
 physician must be, if possible, to remove the causes which have either 
 proximately, remotely, or both, given rise to the disease. 
 
 The paucity of symptoms recorded in the Materia Medica belonging to 
 caries, makes it difficult to select appropriate medicines for each case. The 
 medicines mentioned, however, have proved beneficial, ex usu morbis, in the 
 treatment of this disease. 
 
 Mr. Pollock has recently used sulphuric acid topically, with marked suc- 
 cess, to hasten the separation of dying or diseased bone. In his essay upon 
 the subject he has made some important observations. He says : 
 
 " I am not aware that the application of sulphuric acid in the treatment 
 of carious bone has been previously adopted in preference to the use of the 
 gouge, actual cautery, or caustic potash. I find no special reference made 
 to its effects, nor any allusion to its extreme applicability or efficacy in the 
 treatment of caries, in any of the modern treatises on bone. In the number 
 
 * See Abscess, p. 113 ; Ulcers, p. 131. 
 
NECROSIS — DEATH OF BONE. 519 
 
 of cases which have come under my notice both in St. George's Hospital and 
 in private practice, in no one instance have evil consequences been known 
 to follow the application of sulphuric acid to diseased bone in any part of 
 the body, nor has the treatment been found a painful one when the acid has 
 been used in a diluted form." 
 
 He then directs that if there be a cavity it may be packed with lint, 
 saturated with dilute acid; or a syringe may be used charged with a 
 solution. A very peculiar fact connected with the process is, that the dilute 
 acid will not act on healthy bone, but limits its operation to the diseased 
 structure. 
 
 Mr. Henry Noad, clinical clerk to Mr. Pollock, conducted the following 
 experiments in view of the fact stated above. 
 
 Ten grains each of (1) diseased, (2) dead, (3 and 4) healthy bone, both 
 of middle age and of old age, were subjected for three days to the action 
 of a mixture of sulphuric acid and water, one part in four, at the tempera- 
 ture of 100°. The following were the results : 1. From the dead bone, 2 
 grains of phosphate of lime and 3.3 of carbonate of lime were dissolved in 
 the acid. 2. From the diseased bone, 2 grains of phosphate of lime and 
 1.3 of carbonate of lime were dissolved. 3 and 4. In both specimens of 
 healthy bone no action took place. In several cases this treatment has, in my 
 hands, been successful. 
 
 Necrosis — Death of Bone. — The term necrosis, which literally means 
 destruction, is by surgeons applied to bone deprived of its vitality. It was 
 first used in this particular sense by M. Louis, who restricted this appella- 
 tion, however, to cases in which the whole thickness of a bone was destroyed. 
 The ancients termed the disease " dry caries." 
 
 Between caries and necrosis, says Wiedmann, there is all that difference 
 which exists between ulcers and gangrene, or sphacelus of the soft parts. 
 In caries, the nutrition of the bone is impaired, and an irregular action 
 disunites the elements of bony structure, which consequently sustains a 
 loss of substance. In necrosis, on the contrary, the vitality and nutritive 
 function cease altogether in certain portions of the bone, the separation of 
 which then becomes indispensable. 
 
 Bones are not as extensively supplied with bloodvessels as other textures 
 of the body, and their natural powers are inferior to those of the softer 
 parts ; and this circumstance may serve to explain the frequent occurrence 
 of the disease under consideration. 
 
 Necrosis may appear at various periods of life, but is most commonly 
 met with in young subjects, in whom the inflammatory action is allowed to 
 make some progress before it is noticed or attended to. It may affect the 
 external or internal structure of a bone, or nearly its whole thickness. An 
 entire bone seldom dies in consequence of diseased action ; and it is in rare 
 instances that the whole thickness of any portion of it is found necrosed, 
 although a larger proportion may be involved, 
 
 Mr. Miller divides the process, of necrosis into several stages : 1st. The 
 bone or portion of bone inflames. 2d. The bone dies. 3d. The dead por- 
 tion is separated from the living. 4th. Separation of the dead portion is 
 complete. 5th. The dead portion is extruded. 
 
 " When a portion of bone is to die," writes Holmes,* in an admirable 
 article, " the first phenomenon is the cessation of circulation in it. This 
 leaves it hard, white, and sonorous when struck. It does not bleed when 
 exposed or cut into, and is insensible. Occasionally, when the dead bone 
 is exposed to the air, and acted on by the presence of putrid pus, its color 
 
 * System of Surgery, vol. iii., p. 760. 
 
520 A SYSTEM OF SURGERY. 
 
 becomes nearly or quite black ; large surfaces of hard, black, necrosed bone 
 are sometimes left exposed by the sloughing of the skin over the tibia. 
 The dead bone at first retains its connection to the bone around, as well as 
 to the periosteum or whatever part of the nutrient membrane may belong 
 to it ; but the presence of a dead part is never long tolerated by the living 
 tissues, and accordingly the processes which are to eliminate it soon become 
 perceptible in both these structures. The periosteum or medullary mem- 
 brane, as the case may be, separates from the dead bone and becomes in- 
 flamed, a quantity of ossific deposit (more or less, according to circum- 
 stances) is poured out between it and the dead bone, and this deposit soon 
 becomes converted into new bone, forming a sheath over the dead portion, 
 by which the latter is inclosed or invaginated, as the technical term is. The 
 dead part is now called a sequestrum, a name only properly applied to it 
 when loose and invaginated, though often incorrectly used of any piece of 
 the dead bone. While this sheath is being formed from the membrane 
 coating the dead bone, changes are going on in the living bone to which it 
 was attached. When the latter has been previously diseased, i. e., when 
 the necrosis has been of inflammatory origin, the inflammatory deposit 
 which surrounds the sequestrum softens, pus is formed, and a groove of 
 ulceration is produced at the expense of the circle of inflamed bone which 
 forms the margin of the sequestrum. If the surrounding bone has been 
 previously healthy, the sequestrum acts as an irritant upon it, setting up 
 first inflammation and thickening to a variable distance, and then ulcera- 
 tion. Thus a groove is traced round the sequestrum, and the formation of 
 the groove is accompanied by suppuration, ' the pus containing much 
 earthy matter from the disintegrated tissue, B. B. Cooper stating 1\ per cent, 
 of phosphate of lime.' " 
 
 When the disease has not far advanced, there is a copious discharge of 
 purulent matter* and the external openings, through which the pus finds 
 exit, are found to lead to cloacae, or apertures in the new bone (the involu- 
 crum), which encases the old ; through these, the dead portions can be dis- 
 covered by the probe. Sequestra are also sometimes cast off, the hue of 
 which resembles that of ossific matter which has been for some time buried 
 in the earth. When a sequestrum is discharged, the disease may be con- 
 sidered at its height ; for Nature is throwing off the dead structure, which 
 can no longer be of any service to the economy. Often at this period, by 
 introducing a probe, several pieces of detached bone may be readily felt. 
 These symptoms of necrosis, thus evident in affections of those bones that 
 are covered with thick muscular fibre, are still more so in cases of flat 
 superficial bones, as those of the skull ; in diseases of the latter, the skin 
 at first becomes thick, hard, and reddish ; but soon ulcerates, and discharges 
 matter of the character before mentioned. 
 
 The prognosis varies according to the situation of the bone affected, and 
 the circumstances with which the disease may be complicated. If necrosis 
 occurs, and is confined to a small surface of a bone, it is not very difficult 
 to cure ; but when large portions of the osseous system are involved, and if 
 the introduction of instruments be required to separate the exfoliated por- 
 tions (sequestra), the prognosis is extremely unfavorable. 
 
 In cases of necrosis, in which the dead bone is entirely inclosed in that 
 newly formed, the prognosis may vary, according to the state of the sur- 
 rounding soft parts, the age and strength of the patient, and the form of the 
 
 * " Formation of matter is occasionally the cause of necrosis. I have seen several instances 
 in which it occurred from neglected erysipelas of the leg." — Liston's Elements, p. 76. 
 
DEATH OF BONE — TREATMENT. 521 
 
 new osseous substance. There is in some cases a peculiar variety of intra- 
 osseous necrosis without suppuration. 
 
 W. M. Baker* mentions a case of intraosseous necrosis of the femur, 
 without suppuration, for which amputation at the hip-joint was per- 
 formed. The case presented all the characteristics of malignant tumor of 
 the femur, even to undergoing spontaneous fracture, and the amputation 
 was resorted to on that diagnosis. The patient recovered. On dissecting 
 the amputated limb it was found that nearly the whole of the femur had 
 perished, and in some parts, the dead bone was beginning to separate, but 
 not a drop of pus was anywhere to be detected. New bone had been pro- 
 duced, both by the periosteum and by the medullary membrane, and the 
 dead bone was so locked in by it as to render futile an attempt to remove 
 the disease by any other method than by amputation. This form of 
 necrosis is held to be the last of a series of changes, of which the earlier 
 consist of chronic ostitis with hypertrophy and sclerosis. 
 
 The tumefaction of the limb may be excessive ; the fistula? numerous ; 
 the suppuration abundant ; and the patient reduced by colliquative diar- 
 rhoea and hectic ; under such circumstances the danger is much greater than 
 if the suppuration were trifling, the patient young and healthy. A favor- 
 able termination of the disease may be anticipated, if, together with these 
 latter conditions, the newly-formed bone is perforated by nature, that the 
 dead portion may be readily withdrawn. 
 
 The causes of necrosis may be divided into internal and external : among 
 the latter may be classed — contusion, excessive pressure, imprudent appli- 
 cation of caustic,f etc. ; and of the former, syphilis, scrofula, or mercury, 
 or the inhalation of the vapor from phosphorus. In persons thus constitu- 
 tionally affected, a blow, or other external accident, may prove an exciting 
 cause of the disease. 
 
 Concerning the death of bone, and the reproduction of new ossiflc matter, 
 Dr. Gibson writes :■ J "So far as opportunities have been afforded me of 
 ascertaining this point, I have no hesitation to express the belief, that the 
 periosteum is the chief agent in both processes. If from any cause the 
 periosteum inflame, and matter is poured out between it and the bone, so 
 as to separate one from the other, all vascular intercourse must cease — or, 
 at least, the bone then depends exclusively for its support upon the internal 
 periosteum and marrow ; but these being inadequate to furnish the requi- 
 site supply, a part or the whole of the bone will necessarily perish." 
 
 Violent inflammatory fever attends the excited action of the bone and 
 periosteum, which precedes necrosis. But, after the matter has accumulated 
 and been discharged, most of the painful symptoms subside. 
 
 Frequently fresh collections of pus are generated, as each portion of the 
 dead bone approaches the surface. When the formation of new ossific 
 material has extended to a neighboring joint, its motion maybe very much 
 impeded, and if the limb is kept at perfect rest anchylosis may occur. 
 
 Treatment. — In the treatment .of this disease,§ as in caries, the great ob- 
 ject is prevention, to be accomplished by the successful treatment of ostitis, 
 periostitis, caries, and of the constitutional affection (if any be present), 
 upon which death of the bone may follow as a consequence. 
 
 * American Journal of the Medical Sciences, July, 1877, p. 267. 
 
 f As happened in a case of a woman, who had caustic potash applied to an exostosis on 
 the internal side of the tibia. 
 
 X Institutes and Practice of Surgery, vol. ii., p. 55. 
 
 | For an interesting paper on this subject, see Quarterly Homoeopathic Journal, vol. i., 
 p. 86 ; an article entitled " Case of Necrosis of the Posterior Portion of the Superior Maxil- 
 lary Bone, and Gangrene of the Gums and Cheeks," by J. Lloyd Martin, M.D. 
 
522 A SYSTEM OF SURGERY. 
 
 One of the principal indications is the evacuation of purulent formation, 
 which frequently bathes the inflamed bone and detaches it from the perios- 
 teum. 
 
 Separation of the sequestrum may be hastened by the administration of 
 medicines, which, acting beneficially upon the surrounding osseous struc- 
 ture, tend to increase the action by which exfoliations are cast off. The 
 affected part must be allowed to remain at rest, and all stimulating appli- 
 cations avoided. In the first stage of the disease, if there should be severe 
 or extensive inflammation of the soft parts, aeon., bell., bry., hepar, mere, 
 or sulph., are indicated. 
 
 Asaf., calc, phos., silic, sulph., and, according to some authorities, Sym- 
 phytum, when properly prescribed, materially lessen the tendency of parts 
 to renewed inflammatory action, and also exert a specific action upon the 
 osseous system; either of these may be administered, according to the 
 presenting symptoms, to hasten the separation of the dead from the living 
 bone. After this is accomplished, it is the duty of the surgeon to interfere, 
 and, by the requisite incisions and proper mode of extraction, liberate the 
 necrosed portions of bone, which, if allowed to remain, acting as extraneous 
 matter, irritate the parts and give rise to increased inflammation and pro- 
 fuse suppuration. But the surgeon must ascertain that the sequestrum is 
 entirely detached before attempting its removal. On this point Mr. Miller 
 writes : " A common error, in practical surgery, is interference with the 
 sequestrum before it has become loose. To lay hold of it and use violence, 
 after exposure by incision, is certainly to induce a combination of evils. 
 The evulsive effort often fails, and consequently the patient has been put to 
 a grave amount of pain, unnecessarily and fruitlessly. By the violence, in- 
 flammatory reaccession is certainly induced in and around the part origi- 
 nally implicated. In other words, a fresh ostitis — probably both acute 
 and extensive — is induced, and aggravation of the necrosis is most likely to 
 follow. Also the loss of blood which attends on such attempts, whether 
 successful or not, is invariably considerable ; coming from a wound of soft 
 parts, which are not only unusually vascular, but besides unfavorable to ' 
 natural haemostatics. And the patient's state of system is generally such, 
 in the advanced stage of necrosis, as to be altogether intolerant of a repe- 
 tition of such haemorrhages. Therefore, on this ground alone, it is plain 
 that the operation for removal of a sequestrum should never be undertaken, 
 unless the surgeon be tolerably certain that his efforts will then prove suc- 
 cessful." 
 
 In probing, the simultaneous use of two instruments is sometimes advan- 
 tageous. One probe resting on the end of the sequestrum, a second is in- 
 troduced through another cloaca; and by pressing with each other alternately, 
 looseness of the sequestrum may be made plain in circumstances otherwise 
 extremely doubtful. 
 
 If the disease arise from syphilis, or scrofula, or if from scorbutic 
 symptoms complications appear, the medicines must be selected with the 
 view of meeting, if possible, both the constitutional vice and the local 
 affection ; although in many cases, by removing the former, the latter will 
 also be remedied. If the disease originate from injury, the application of 
 arnica externally and internally will be beneficial. 
 
 A man, set. 28, fell from a tree, and seriously injured his arm by striking 
 it against a stump; for the space of four months all motion was pre- 
 vented ; after which, though mobility in a degree returned, the limb was 
 somewhat painful, and at times quite rigid. Two years subsequently, seve- 
 ral fistulous openings were formed, through which fragments of bone fre- 
 quently were discharged. Arnica relieved the pain. Silic, calc, and sulph. 
 
OPERATIVE MEASURES. 
 
 523 
 
 effected a cure. A remaining stiffness of the joints was removed by colo- 
 cynth.* 
 
 Operative Measures. — When it becomes necessary to remove a sequestrum, 
 
 Fig. 243. 
 
 E 
 
 G. T1EMANN &. CO 
 Bone Chisel. 
 
 especially if it be firmly covered by the involucrum, a free incision should 
 be made down to the bone with a strong scalpel, through the tissues, the 
 
 Fig. 244. 
 
 Bone Hammer. 
 
 point selected being out of the way of bloodvessels and nerves. It may be 
 necessary now to enlarge the cloacae by means of the chisel (Fig. 243) and 
 
 Fig. 245. 
 
 Bone Forceps for Deep Cavities. 
 
 hammer (Fig. 244), and then to remove the sequestra with forceps, repre- 
 sentations of which will be found in the Chapter upon " Resection of Bones 
 
 Fig. 246. 
 
 G.T/EMANN Si CO 
 Bone Gouge. 
 
 and Joints." A forceps curved at the beak, in a manner seen in the cut 
 (Fig. 245), is very useful in deep cavities. 
 
 Fig. 247. 
 
 Bone Graining Forceps. 
 
 Dr. Markoe also has a gouge for operations in necrosis (Fig. 246), which, 
 * See Jeanes's Homoeopathic Practice, pp. 55-57. 
 
524 A SYSTEM OF SURGERY. 
 
 he says, gives him " a very delicate corner to work with — delicacy is re- 
 quired, and a powerful instrument where heavy cutting is to be done." 
 
 Forceps for biting or graining away bone are often serviceable, as seen in 
 Fig. 247, and gouges, rasps, and elevators, which are contained in the ordi- 
 nary resection cases. 
 
 From a case of necrosis of the femur which he relates, M. Sedillot thinks 
 he ought to draw the following conclusions in regard to the treatment of the 
 periosteum during these operations :* 
 
 " 1st. Superiority of operations saving the relations of the periosteum with 
 the subjacent osseous layers. 
 
 " 2d. Condemnation of the methods in which the periosteum is dissected 
 and isolated from the osseous surfaces in contact. 
 
 " 3d. Failure of the attempts at regeneration of bone from the periosteum 
 detached from the splinters in the seat of fractures. 
 
 " 4th. Absence of osseous reproduction from the fringe of periosteum pre- 
 served around amputated bones. 
 
 " 5th. Absence of osseous regeneration in cases of pseudarthrosis treated 
 by resection with preservation of a periostic sheath." 
 
 Mollities Ossium or Malacosteon and Rachitis. — Both of these affections are 
 occasioned by a deficiency of the requisite proportion of earthy material in 
 the bony structure, and differ only in this, that in the latter the cretaceous 
 matter is not deposited originally, while in the former, it is absorbed after 
 having been deposited. 
 
 The difference between mollities ossium and rickets appears to be simply 
 this : rickets is an affection of childhood, and bears a close resemblance to 
 scrofula in the factors which produce it ; it is curable, and patients are gene- 
 rally improved by constitutional treatment. Mollities is found chiefly in 
 adult life, and there is no scrofulous cachexia. In its obstinacy it bears a 
 strong relationship to cancer, to which class of diseases it has been assigned 
 by some nosologists. 
 
 Softening of the bones is met with at all ages and in different degrees. It 
 often follows dentition, measles, whooping-cough, or other infantile diseases 
 which induce general debility ; and in females it appears to be produced 
 by the weakening effects of leucorrhcea, miscarrriages, etc. Mercury ad- 
 ministered in inordinate quantities, also produces the disease ; but by far 
 the greater portion of cases are said to depend on scrofulosis. As in all other 
 chronic dyscrasise, the development of the affection is gradual ; the first 
 symptoms that are noticed being generally those of derangement of the di- 
 gestive functions, alteration of secretion, etc. ; by degrees a material change 
 in the solids of the body takes place, particularly in the osseous system, and 
 the alterations of composition in the latter give birth to many functional 
 derangements. 
 
 The gastric symptoms that are noticed, as precursors of the disease, espe- 
 cially when children are affected, are : flatulency, acidity of the stomach, 
 distension of the abdomen, sour eructations, and vomiting. The appetite is 
 impaired, the patient usually desiring those articles of food which are par- 
 ticularly indigestible ; the countenance is pale and cadaverous, the urine 
 becomes turbid and cloudy, and if subjected to chemical analysis, is found 
 to contain a superabundance of phosphate of lime, and probably benzoic 
 and oxalic acids. 
 
 In children (rachitis) there is much emaciation ; the skin and muscles 
 become flaccid, the face is wrinkled, distorted, and resembles that of the 
 aged. The growth of the child is arrested, walking is difficult, and in the 
 
 * See a paper prepared by Dr. Deslande, American Medical Times, November, 1861. 
 
MOLLITIES OSSIUM — TEEATMENT. 525 
 
 more advanced stages altogether impracticable ; the teeth become yellow, 
 brown, or streaked transversely, are at length attacked by caries, and soon 
 fall out. 
 
 During the progress of the disease the bones flatten and bend, are soft, 
 cellular, and of a brown color, contain a dark fluid, and are very deficient 
 in earthy matter. In many instances, this latter component of ossiflc 
 structure is almost entirely removed, the bones consisting of an extremely 
 thin external osseous shell, covered by thickened periosteum, and contain- 
 ing a pulpy substance resembling fatty matter. Although this disease has 
 been said to attack individuals of all ages, by far the greater proportion of 
 those affected are young children. Certain rare cases, however, have been 
 recorded, in which all the bones of the adult were softened to a very great 
 degree. 
 
 The vertebral column is particularly liable to be affected with rachitis, 
 and the disease may be in certain instances confined to it alone. When 
 the cervical vertebrae are attacked, the anterior part of the neck projects, 
 the head falls backwards, and appears sunken between the shoulders. 
 When the affection is general, the vertebral column becomes shorter, and 
 is curved in various directions ; the breast is deformed, not only in con- 
 sequence of the curvature of the spine, but by the depression of the ribs 
 and projection of the sternum ; the bones of the pelvis fall inwards, and 
 generally the pubis approaches the sacrum.* 
 
 According to the observation of Mr. Stanley, when the tibia and fibula 
 become affected they acquire increased breadth in the direction of the curve, 
 losing a proportional degree of thickness in the opposite direction.! 
 
 The proximate cause of softening of the bones is involved in much 
 obscurity ; various authors have endeavored to explain the origin of the 
 affection in accordance with their own peculiar views. These conflicting 
 suppositions, although possessed of much interest to the curious, are of 
 no practical value, and therefore need no comment in this place. 
 
 Treatment. — In this disease great advantage is to be derived from the 
 general treatment ; the patient, if residing in the city, should, if possible, be 
 removed to the country, where an elevated and dry situation should be 
 chosen, nourishing diet, with a moderate quantity of wine, may be allowed, 
 and the strictest cleanliness, with regularity of habits, should be observed. 
 But as the poor, among whom the disease is most frequently observed, are 
 not able to procure change of residence, the patient should be placed in 
 a room that is well ventilated and clean, and in temperate weather be 
 allowed to walk or sit in the sunlight. A straw or wheaten chaff mattress 
 should be used, as it is dry and does not yield to the weight of the body ; 
 the clothing should be sufficient to prevent uncomfortableness from ex- 
 tremes of heat and cold, and should be changed to suit the variations of 
 temperature. In the first stages of the disease, when gastric derangements 
 predominate, ipecac, bry., nux and verat. are indicated, and their adminis- 
 tration is frequently followed by beneficial results.. 
 
 In addition to this, appropriate splints and bandages should be applied, 
 which will, in certain cases, if used in the earlier stages of the disease, be 
 productive of much good. If these mechanical means be not sufficient, the 
 child should be thoroughly etherized, and forcible means employed to re- 
 store the parts to their natural position. If this also is not sufficient, the 
 surgeon must resort to subcutaneous osteotomy, for which directions are given 
 at the end of this chapter. 
 
 * Boyer on the Bones, p. 190. 
 
 f Med.-Chir. Trans., vol. vii., p. 402. 
 
526 A SYSTEM OF SURGERY. 
 
 In children, when the abdomen is hard and distended, the gait unsteady 
 and staggering, and the complexion pale, with occasional flushes of heat, 
 bell, is particularly indicated. 
 
 Sulph., calc, hepar, and silic. are also powerful agents in the treatment 
 of rachitis; by their exhibition the general health improves, and the dis- 
 ease has been known to be arrested in a short period of time. The attenua- 
 tion of these medicines, however, is an important consideration ; the practi- 
 tioner will fail in his endeavors if recourse be had to the crude, inasmuch 
 as the most beneficial results are more certainly attained by the adminis- 
 tration of the third dilution. 
 
 Hartmann writes :* " I have employed with great success brucea anti- 
 dysenterica, particularly when the feet were turned outwards and the chil- 
 dren walked on the inner ankles." 
 
 In another work,f he further says : " According to my experience, it is in 
 the preliminary stage that cod-liver oil will do the most good and actually 
 effect a cure, and remove the danger of relapse, providing a proper dietetic 
 and hygienic regimen is observed. The oil may be used internally, and at 
 the same time rubbed on the abdomen. If no improvement should set in 
 after using the oil a fortnight, or if the child should evince an insurmount- 
 able repugnance to taking the medicine, as a matter of course some other 
 remedy will have to be used." 
 
 Acid, phosph., ruta, staphis., mez., lyco., calc, and asaf. may be indicated 
 in the treatment of this disease. 
 
 According to Dr. Patzack, pinus sylvestris is often of great benefit in the 
 treatment of rickets. It may be used both externally and internally. 
 
 In the Medical Record, I find an article headed " Artificial Production of 
 Pickets and Osteomalacia," which is well worthy of mention here. It 
 appears that Heitzman has lately been making some experiments with 
 lactic acid, and that selecting a number of dogs and cats, he fed them every 
 day with a small quantity of the drug, at the same time injecting it subcu- 
 taneously. After two weeks the epiphyses of the long bones, and the ribs 
 at the attachment of the costal cartilages, began to enlarge, and at the same 
 time there was diarrhoea and emaciation. These symptoms increased, and 
 finally there was bending in the bones in a marked degree. The micro- 
 scope revealed the same appearances as seen in the bones of persons suffering 
 from rickets. To make the experiment still more certain, some of the 
 animals were allowed to recover, and were treated in the same manner a 
 second time with precisely the same results. By persevering in the use of 
 lactic acid for four months, every appearance of osteomalacia was presented, 
 the medullary substance possessing a great degree of vascularity, and the 
 compact structure being much thinned. 
 
 In those animals living almost exclusively on vegetable diet, there was 
 a somewhat different result, death ensuing in from three to five months. 
 The conclusions arrived at are : " That carnivorous animals, fed on lactic 
 acid, first develop rickets and then osteomalacia. Herbiverous animals, on 
 the other hand, develop osteomalacia without previously having rickets. 
 Finally, osteomalacia and rickets seem to be due to the same general cause, 
 viz., an excess of lactic acid in the system." 
 
 Subcutaneous Osteotomy. — Considerable attention is now being given to 
 this method of relieving the deformities occasioned by rachitis. Some sur- 
 geons, as Langenbeck, perform the operation with a small auger and a 
 straight saw. Mr. Bradley + uses a tenotome to divide the integument, and 
 
 * Chronic Diseases, vol. i., p. 63. 
 f Diseases of Children, p. 401. 
 % Lancet, July 21st, 1877, p. 78. 
 
FRAGILITAS 068IUM. 527 
 
 then a very fine saw to cut through the bone ; the extremities are then 
 placed in appropriate splints, and the wound covered with collodion. The 
 cases which require the performance of this operation are those which have 
 resisted the treatment by splints and bandages; as also those in which forcible 
 manipulation has been tried while the patient is under anaesthetic influence. 
 He says in conclusion : 
 
 *■ From time to time surgeons have advocated the use of instruments, in 
 appearance worthy of an old torture-room, to break the crooked rickety 
 bones when they resisted the pressure of the hands ; but by most, these 
 appliances are relegated to the limbo of forgotten rubbish, and, as it seems 
 to me, wisely, since we have in subcutaneous osteotomy an operation at 
 once so safe and so satisfactory. And one final word on this subject. When 
 subcutaneous osteotomy is performed for the cure of rickety legs, we need 
 be under no apprehension about the filling up of the V-shaped interval 
 which is necessarily left when the bones are straightened, for, as a matter 
 of experience, this gap always does fill up with fresh bone, and thus we 
 secure not only a strong and straight leg, but a limb not shortened, as it 
 would of course be if we were compelled to excise a wedge-shaped piece 
 of bone instead of simply sawing across the concavity." 
 
 M. J. Bceckel,* who has operated nine times for rachitic deformities, 
 always with success, gives his method of treatment, as follows : 
 
 " First, he tries manual reduction : if this fail, he endeavors to break 
 them by the ordinary methods of osteoclasty ; if this also fail, he cuts clown 
 to the periosteum, peels it off the bone ; the bone is divided by the chisel 
 and hammer, the saw is never used. The wound dressed after Lister's 
 method, reduction performed when it is cicatrized. The operations were 
 performed on patients whose ages varied from fifteen months to eight years.'' 
 The varied operations of subcutaneous osteotomy are detailed in the 
 chapters upon deformities of joints, etc; to them the student must refer for 
 more specific directions. 
 
 Fragilitas Ossium is a term which ought to become obsolete, as it is merely 
 a symptom of other diseases. This condition occurs chiefly in old people 
 whose osseous system contains an undue quantity of earthy material. Boy erf 
 states that a certain degree of fragilitas ossium necessarily occurs in old 
 age, because the proportion of lime in the bones increases with age, while 
 the organic matter decreases in the same ratio ; but Mr. WilsonJ observes 
 that they are never found so friable and fragile as to crumble like calcined 
 bone, but, on the contrary, contain a large quantity of oil. The latter fact 
 is also noticed by Mr. Liston,§ who gives as a definition of the disease that 
 the bones become brittle on account of an undue proportion of earthy 
 matter, are endowed with little vascularity, and are full of an oleaginous 
 fluid. 
 
 In persons who have been long afflicted with cancerous disease, the bones 
 are said to become as brittle as if they had been calcined. In inveterate 
 syphilis, deprivation of organic 'material in the osseous system has been 
 noticed, and in those individuals who have been frequently afflicted with 
 severe attacks of scurvy, the bones become so brittle that they are fractured 
 from the slightest causes. Dr. Markoe, Mr. Stanley, and others have re- 
 corded remarkable cases of this kind. 
 
 The following interesting case was communicated to me by Dr. Charles A. 
 
 * Journal de Med. et de Chir., March, 1876. Abstract Med. Science, vol. iii., Xo. yii. 
 
 f On Diseases of the Rones, p. 197. 
 
 X On the Skeleton and Diseases of the Bones, p. 258. 
 
 § Elements of Surgery, p. 80. 
 
528 A SYSTEM OF SURGERY. 
 
 Church, of New York. I saw the patient with him in the Children's 
 Hospital of the Five Points House of Industry in that city : 
 
 Willie S., aged twelve, while playing with the children, sustained a trans- 
 verse fracture of the femur at the middle third, by being pushed, and, at 
 the same time, struck upon the thigh by the knee of one of the other chil- 
 dren. In December, 1869, he had a fracture of the tibia, caused by falling 
 down. His family history I got from his mother, as follows : His only 
 sister had her leg fractured at two different times ; his oldest brother had 
 one thigh fractured three times, the other twice; also one leg, one arm, one 
 clavicle, and three ribs ; his mother has had fractures of one leg, scapula, 
 and three ribs ; his mother's brother had fracture of one thigh three times, 
 both legs, both arms, and one clavicle; and yet he served through the 
 whole war in the Southern army without receiving an injury. His child 
 has had fractures of both legs, one thigh, one arm, and one clavicle. The 
 mother's sister had fractures of one arm and one clavicle ; her father had 
 fracture of one thigh three times and one clavicle ; and all his brothers and 
 sisters had more or less of broken bones, — how many I cannot ascertain. 
 The patient has a younger brother that has not yet had a fracture, but he 
 has an unenviable prospect before him. The general health of the whole 
 family, aside from this tendency to fracture, has always been remarkably 
 good. 
 
 Treatment. — This disease, particularly when occurring in the aged, is very 
 difficult to cure. The patient should be allowed a generous diet, and pro- 
 hibited from much muscular exertion ; indeed, all circumstances likely to 
 produce sudden action of any particular combination of muscles should be 
 studiously avoided. 
 
 The medicines that are best adapted to this affection are ruta, phosph. ac, 
 nit. ac. ; and from the effects that have been produced by Symphytum, this 
 medicinal agent should exercise much influence in this peculiar disorder. 
 If the fragility of bone depend upon constitutional affections, syphilis, 
 scrofula, etc., great advantage may be derived from the internal treatment 
 of these diseases. 
 
 The internal and persistent use of the phosphate of lime in the second 
 trituration — five grains twice a day — has produced most excellent results. 
 Churchill's hypophosphites of lime and soda I always order taken with the 
 food, and Dr. McCready's lacto-phosphates are also very highly spoken of. 
 
 Atrophy of Bone. — This is a peculiar affection, which, as a rule, is not 
 marked with any characteristic symptoms. It may be caused by fatty de- 
 generation, the result of the inflammatory process. The disease just men- 
 tioned as brittleness of bone, is, no doubt, especially in the aged, a variety 
 of atrophy. The most frequent cause, however, of the affection, is fracture 
 occurring near or at the point of entrance of the nutrient vessels. A pecu- 
 liar variety of this disease is the arrest of development of the epiphyses of 
 the long bones. In such cases there generally has been some injury in- 
 flicted upon the epiphysial cartilages. 
 
 In the treatment of this disease calc. carb., Symphytum, silicea, and sulph. 
 are the very best medicines. They must be persevered in for a long time, 
 and every attention paid to hygienic measures. 
 
 Tnmors in Bone. — Tumors in bone are divided into the malignant and 
 the non-malignant, and partake very much of the character of tumors in 
 other portions of the body. There is, however, great trouble often in making 
 a correct diagnosis, and I think I may say that in some cases it is wholly 
 impossible. 
 
 Innocent Tumors — Exostosis. — Any bone in the body is liable to enlarge- 
 ment, and in such cases we merely have an ordinary hypertrophy of bone. 
 
CANCELLATED EXOSTOSIS. 529 
 
 which can scarcely be classed as a tumor. A circumscribed exostosis is a bony- 
 tumor, which has a well defined margin and is generally formed of compact 
 structure. 
 
 The formation of exostosis is similar to that of new bone ; a plasma is 
 exuded and becomes organized ; this passes into transitional cartilage, and 
 thence the osseous structure is gradually completed. At one time the term 
 was made to include all growths,— fleshy, osseous, and cartilaginous, — but 
 with propriety it is now limited to growth of bone from bone. 
 
 Sir Astley Cooper wrote : " Exostosis has two different seats ; it is either 
 periosteal or medullary. By the periosteal exostosis I mean a deposition seated 
 between the external surface of the bone and the internal surface of the 
 periosteum, adhering with firmness to both surfaces ; and by the medullary, 
 is to be understood a formation of a similar kind, originating in the medul- 
 lary membrane and cancellated structure of bone." This description is 
 true at the present day ; the "periosteal" being the eburnous, or dense, ivory- 
 like exostosis, and the other the common cancellated exostosis. The first is 
 smooth, shining, and presents a polished appearance resembling ivory or 
 pearl, is solid throughout, and appears almost destitute of those vessels by 
 which an internal circulation is carried on. It usually appears on the flat 
 bones, especially on the cranium, but the most frequent site of this form of 
 the disease is the superciliary ridges.* The growth of this tumor is slow, 
 and it is often unattended with pain. 
 
 Cancellated Exostosis appears to be mere enlargement of processes of the 
 parent bone, the cancellated tissue extending itself and forming the interior 
 of the new bony formation, while the exterior resembles a proportionate 
 extension of the outer lamina.f This kind of exostosis seldom occurs ex- 
 cept in the long bones of the extremities, and is most frequent in the femur 
 at its lower part. The cancellated texture usually predominates, the external 
 laminae being thin and delicate. 
 
 Exostosis, according to BoyerJ rarely proceeds from an external cause, 
 such as contusion. In most cases it is produced by an internal disease, and 
 principally by lues venerea or scrofula. 
 
 The effects of exostosis may be divided into general and special ; thus the 
 swelling is accompanied by a sense of weight, pain is produced by the mor- 
 bid action, and the affected part is necessarily deformed. Its particular or 
 special effects arise from its situation; thus if an exostosis form in the 
 orbit, the eye is expelled from its cavity, and the patient is deprived of sight. 
 If a tumor of this nature arise from the clavicle or sternum internally, death 
 may result by compression of the principal bloodvessels. 
 
 The prognosis differs according to the nature of the primary disease from 
 which the exostosis originates, and according to the particular change in 
 the texture of the bone. The ivory exostosis, if so situated that it does not 
 impede the action of any organ, is said to be the least dangerous of all. 
 
 Treatment. — The medicines that are best adapted to exostosis are : arm, 
 asaf., calc. c, dulc, led., lye, mere, mez., phosph., rhus., sep., silic, sulph. 
 The primary ostitis must be treated as before recommended, and if the dis- 
 ease still progress, any of the above-mentioned medicines may be selected 
 in accordance with the presenting symptoms. For exostosis syphilitica, 
 aur., bell., nit. ac, and phosph. are recommended. 
 
 I may here mention that I have given the Hecla lava, as recommended 
 by Dr. Holcomb, whose attention was directed to it by J. J. Garth Wil- 
 kinson,§ in man}' cases of exostosis and of caries, with the following 
 
 * See McClellan's Principles and Practice of Surgery, p. 343. 
 f Liston's Elements, p. 114. 
 X See Boyer on the Bones, p. 177. 
 
 1 Transactions of the American Institute of Homoeopathy, 1870, p. 249. 
 
 34 
 
530 A SYSTEM OF SURGERY. 
 
 results : Exostosis of the wrist, of two years' standing, in a gentleman who 
 suffered most intensely. The medicine was taken in the sixth potency, and 
 was continued for two months ; great improvement, but not a cure, followed. 
 
 In a second case, a boy with circumscribed exostosis of the ulna, was 
 also benefited, but I lost sight of the patient. In a third case of cartilaginous 
 tumor, approaching exostosis, no good result was obtained. In a fourth 
 case the tibia was affected seriously, and the suffering was much relieved, 
 and the tumor, though it did not diminish, ceased growing. In a case of 
 caries I think I did not give the medicine a fair trial, though the patient 
 ultimately completely recovered. Other cases gave similar results. 
 
 If the bony tumor is large, and medicines do not appear to produce any 
 beneficial effect, the surgeon may think proper to remove it by mechanical 
 means. This may conveniently be done by the knife, Hey's saw, and tre- 
 phine. Sometimes a spring-saw will be found to answer a better purpose 
 than any other instrument. 
 
 Rarefying Ostitis — Osteo-Cystoma. — By these terms are understood an ex- 
 pansion of bone from a collection of matter, which is not purulent but 
 serous, glairy or gelatinous. The cyst has not a pyogenic membrane, but 
 is composed of a structure resembling that which is found in some en- 
 cysted tumors. Its growth is slow, but the bulk acquired may be enormous. 
 The disease may be produced by external injury exciting inflammation, and 
 consequently suppuration in the cancellated tissue ; or the inflammatory 
 action may be of a less acute kind, particularly in weakened and unhealthy 
 constitutions. As the disease progresses, the fluid accumulates, the cancelii 
 are broken down, and the much-attenuated parietes of the bone are pressed 
 outward. Occasionally the inflammatory action may be excited on the ex- 
 ternal surface, from the pressure of the contained fluid ; and, when this is 
 the case, minute nodules of osseous matter are formed, as if nature en- 
 deavored to strengthen the parietes, which from diseased action daily be- 
 come thinner and more incapable of affording support. Sir Astley Cooper 
 describes this disease as a species of exostosis;* Boy erf mentions it under 
 osteosarcoma ; but the difference between the latter and the affection now 
 under consideration appears to be, that in spina ventosa the discharge 
 is uniformly fluid and of a serous character, though sometimes mixed with 
 a cheesy matter, there is no fungus protruding after a portion of the attenu- 
 ated bone has given way, and the tumor is not of a malignant character. 
 
 There is considerable pain while suppuration is being established ; but 
 after the formation of matter the more acute suffering subsides, and in some 
 instances there is but slight inconvenience and the tumor remains stationary. 
 In other cases the enlargement is enormous, and the constitution of the pa- 
 tient is very materially affected. X 
 
 Treatment. — Previous to the development of the disease, if the patient 
 complain of weariness, heaviness, and aching in the limbs, arnica or phosph. 
 acid may be prescribed. These medicines are also suitable, if, upon careful 
 examination, slight swelling of the bone be detected, which is sensitive to 
 pressure. By the exhibition of these medicines, together with mezereum, 
 the disease may be arrested in its incipient stage, 
 
 Asaf., phosph., sulph., and silic, have also been recommended for this 
 disease. 
 
 Other medicines are calc, phosp., staphis., hepar, and sepia. 
 
 Together with this treatment, a moderate degree of long-continued pres- 
 
 * See Gibson's Institutes and Practice of Surgery, vol. ii., p. 62. 
 
 f On the Bones, p. 182. 
 
 j For an interesting case of osteo-cystoma of the cranium, which was skilfully and 
 effectually removed by the late Dr. George McClellan, see McClellan's Principles and Prac- 
 tice of Surgery, pp. 348-352. 
 
OSTEOSARCOMA — CANCER IN BONE. 531 
 
 sure upon the part may also be resorted to. This method alone is said to 
 have effected the cure of the disease. The best treatment is to freely open 
 the cyst and pack the cavity with lint saturated with balsam of Peru. 
 
 Should any of the large cylindrical bones be the seat of osteo-cystoma, 
 and after a thorough trial of remedial agents, the disease appears to be 
 steadily advancing, amputation or resection may be performed. 
 
 Osteo-sarcoma. — This term, though rather vague, is applied to that variety 
 of tumor in which there exists an outside bony lamella with an internal 
 fleshy or fibro-plastic substance, partaking of the nature of one or other of the 
 varieties of sarcoma. 
 
 In the commencement of this disease the bone is slightly enlarged, per- 
 haps somewhat thickened in its outer laminae ; and if a section of it be made, 
 it is found to contain a brown fleshy substance instead of the usual cancel- 
 lated structure. If this be placed under the microscope the cells are found 
 to be either myeloid, spindle-shaped, or round. The osseous portions of the 
 tumor are in the form of spiculse, radiating outward, leaving interstices 
 w T hich are occupied by the sarcomatous tissue. Most frequently it is com- 
 posed of sarcomatous substance, containing portions of cartilage. If the 
 structures are composed of cysts, these are lined by a secreting membrane, 
 and it is thought by some that on the perverted action of this formation, 
 the increase as well as the peculiar structure of the disease depends. By 
 the pressure of the new formation, the parietes of bone are forced outwards ; 
 in some cases attenuated, in others thickened by deposition of new osseous 
 matter. To this the name " ossifying sarcoma " is given by Butlin. If the 
 disease begin in the interior of the bone the term " central sarcoma " is given 
 to it. As the disease advances, the bone becomes more attenuated, and in 
 some places extremely thin, diaphanous, and somewhat flexible and elastic. 
 From the latter condition it w r ould appear that the part of the osseous 
 system affected had lost its proportion of earthy matter, and was filled 
 with one of the varieties of sarcomatous cells. 
 
 To a tumor composed chiefly of cartilage, with an admixture of bony 
 lamella, the name osteo-chondroma, or enchondroma is given. For a full de- 
 scription of this variety of tumor, as well as of myeloid tumors of bone, 
 the student is referred to the Chapter on Tumors. 
 
 For the usual forms of osteo-sarcoma there is nothing, in my opinion, to 
 be done but amputation, or removal of the tumor, and too often when this 
 is practiced, the disease is found to be of a malignant or recurrent character, 
 and again makes its appearance. 
 
 Cancer in Bone. — Sir James Paget lays dow r n the following important rules 
 for diagnosis, between innocent and malignant bony tumors : 
 
 " 1. The tumor is probably cancerous if its growth commenced before 
 puberty, or after middle age, unless it be a cartilaginous or bony tumor on 
 a finger or toe or near an articulation. 
 
 " 2. If a tumor has existed, on or in a bone, for two or more years, and is 
 still of doubtful nature, it is probably not cancerous or recurrent, and this 
 probability increases with the increasing duration of the tumor. 
 
 " 3. If a tumor, on or in a bone, has doubled, or more than doubled its 
 size in six months, and is not inflamed, it is probably cancerous, or recur- 
 rent ; and this probability is increased if, among the usual coincidences of 
 rapid growth, the veins over the tumor have much enlarged, or the tumor 
 has protruded far through ulcerated openings and bleeds, and profusely dis- 
 charges ichor. 
 
 " 4. If with any such tumor, not being inflamed, the lymph-glands near 
 it are enlarged, it is probably cancerous, and still more probably if the pa- 
 tient have lost weight and strength to amounts more than proportionate to 
 the damage of health by pain or fever or other accident of the tumor. 
 
532 A SYSTEM OF SURGERY. 
 
 " 5. A tumor on the shaft of any bone but a phalanx is rarely innocent, 
 and so are any but cartilaginous outgrowths on the pelvis, or any but the 
 hard bony tumors on the bones of the skull." 
 
 Of all the malignant diseases, the encephaloid is the most frequent, and 
 presents itself as periosteal or interstitial. The periosteal is chiefly confined 
 to the long bones, while the flat ones are generally affected with the inter- 
 stitial form of the disease. 
 
 The following are the symptoms in the periosteal variety : 
 
 The pains experienced by the patient are at first dull and deepseated, 
 but in a short time they become more intense, the volume of the bone in- 
 creases, though the soft parts appear yet in their natural state. The latter, 
 however, soon become red and inflamed ; the pain becomes severe, and is 
 lancinating in character ; the system is deranged, the tumor softens, often 
 presents a sense of distinct fluctuation, and on being freely handled, is 
 found to crepitate in consequence of loose spiculas of bone being pressed 
 against each other. Ultimately the integument becomes livid, or dark red, 
 ulcerates, and allows a portion of the softened tumor to protrude in the form 
 of a fungus. There is profuse discharge, thin and sometimes bloody ; and, 
 as may be supposed, much constitutional irritation and exhaustion. Not 
 unfrequently during the progress of the disease, especially if it be situate 
 in the cylindrical bones, fractures occur either from muscular contraction 
 or external injury. This accident gives rise to serious complication, as the 
 process of reproduction in the diseased bone is very slow, if, indeed, it is 
 not altogether suspended, consequently the fracture does not unite, suppu- 
 ration is increased, and the disease is, therefore, much hastened. 
 
 Although after the protrusion of the fungus, the soft parts are not readily 
 involved, the tumor may properly be pronounced malignant. At an earlier 
 stage of progress it is confined to the tissue in which it originated by laminae 
 of bone, but after this barrier has given way, it projects further through the 
 aperture, and contaminates all the surrounding structures until again held 
 in check by bony formation. 
 
 Treatment. — In the commencement of this affection, several medicines may 
 be indicated in accordance with symptoms which present themselves, among 
 which are ars., bell., mere, mez., phosph., phosph. ac, nit. ac, sulph. 
 
 If the constitution of the patient suffers severely from the exhausting 
 suppuration, china or hepar should be administered. If the disease has been 
 occasioned by a blow, arnica, ruta, rhus or Symphytum may be called for. 
 
 From the action of thuja upon fungous formations, this medicine must be 
 remembered, and should be prescribed if the sarcomatous formations are red 
 and fleshy, pouring out blood profusely at the slightest touch ; if the patient 
 is debilitated both in body and mind, and the symptoms are all aggravated 
 towards evening or at night. 
 
 The mercurial preparations are often used. Some have highly recom- 
 mended the oxymuriate of mercury, which, according to other authors, 
 has proved quite efficacious. The latter treatment is noticed in this place 
 with the hope that some may be incited to experiment with the mercurial 
 preparation just mentioned. 
 
 If medical treatment fail, which it generally does, surgeons of the present 
 day have recourse to amputation or extirpation ; the result, however, is sel- 
 dom favorable, the disease returning with renewed vigor either in the stump 
 or in some other portion of the body. 
 
 When the cancer is interstitial it arises generally in the cancellous struc- 
 ture, the pain being very intense, because the affection progresses rapidly, 
 and the bone is mechanically forced open, from the continued and increas- 
 ing pressure of the diseased mass in its interior. 
 
 The characteristics which distinguish malignant from non-malignant 
 
PULSATING TUMORS IN BONE. 533 
 
 tumors in bone, are also present, and the disease has a tendency to involve 
 the subjacent textures. 
 
 The chief indication in the treatment of these tumors is to commence 
 early the medical treatment. Frequently, if the primary affection can be 
 subdued, or the constitutional symptoms successfully combated, the disease 
 may be arrested ; these ends may be accomplished by the treatment that 
 has previously been mentioned for diseases of the periosteum and bones. 
 The medicines that are best adapted to the medullary sarcoma are asaf., 
 bell., calc, mez., mere, phosph., phosph. ac, silic, or sulph. 
 
 For a description of myeloid tumors as affecting the bones, the reader is 
 referred to page 168, in which case the entire superior maxillary, malar, 
 and turbinated bones were converted into the peculiar suet-like mass of 
 myeloid formation. 
 
 Pulsating Tumors in Bone.— To this variety of bony tumor especial atten- 
 tion should be directed, because although the diagnosis in certain cases is 
 comparatively easy, in others it is almost impossible. Nelaton collected 
 six cases of this disease, and named it " true aneurism of bone." Volkmann 
 collected four cases, Cappelletti and Landi each recording one. It is inter- 
 esting to note, that of these twelve cases, in nine the head of the tibia was 
 affected, the lower end of the femur in two, and the head of the humerus 
 in one. 
 
 In all these, pulsation was distinct, except one, in which there was a per- 
 ceptible blowing murmur. In Dr. Carnochan's case, there was a bruit, the 
 only one in the twelve where such a symptom was noticed. In two of the 
 cases an aneurism of the anterior tibial artery was diagnosed.* The chief 
 difficulty in diagnosis is to distinguish these tumors from aneurism by 
 anastomosis, and this must be especially the case when the tumor appears 
 in localities where such aneurisms are found, especially in the scalp. The 
 chief points to be looked after are first, whether there be any unmistakable 
 signs of a cancerous cachexia ; second, whether the pulsation seems to be 
 defined, or compressed by the periosteum, which offers some resistance to 
 the throbbing. These certainly are but meagre signs upon which to base 
 an opinion, and it is from these very facts that the diagnosis is so difficult. 
 When the tumor lies upon a superficial bone, and is out of the track of a 
 large artery, the diagnosis may be more readily made out. These tumors 
 grow rapidly and the skin covering them shows enlarged superficial veins. 
 
 Treatment. — If the tumor is small, it may be removed by cutting down 
 upon it, and applying the galvano-cautery or the thermo-cautery, but as a 
 rule the part if possible should be amputated. According to Professor 
 Landi, who has analyzed the twelve cases already mentioned, two were 
 cured by ligature of the main artery of the part, two ceased to pulsate, but 
 were not removed ; in three cases the ligature failed but amputation was 
 successful ; primary amputation was successful in three, and fatal in two 
 cases. 
 
 A most interesting case of pulsating bone tumor, which was mistaken 
 for popliteal aneurism, is recorded by Dr. Erskine Mason.f Every symptom 
 of the latter disease was present, especially the " distinct eccentric " pulsa- 
 tion and loud and distinct bruit. The femoral was ligated in Scarpa's space, 
 which effectually stopped all pulsation. The post-mortem revealed a sar- 
 comatous tumor involving five inches of the femur. 
 
 * London Medical Record, November 15th, 1877. 
 
 f American Journal of the Medical Sciences, January, 1877, p 85. 
 
534 A SYSTEM OF SURGERY. 
 
 CHAPTER XXXI. 
 
 Fractures: General Considerations in the Treatment of — Divisions — Causes — 
 Symptoms — Examination of Patient — Mode of Repair — General Treatment. 
 Flexion or Bending of the Bones — Pseudo-arthrosis — Cracked Bones — 
 Special Fractures in the Various Regions of the Body. 
 
 Professor Gross, speaking of fractures, indicates the importance of a 
 thorough understanding of the subject in the following words : " If I were 
 called upon to testify, under oath, what branch of surgery I regarded as the 
 most trying and the most difficult to practice successfully and creditably, I 
 should unhesitatingly assert that it was that which relates to the present 
 subject, and I am quite sure that every enlightened practitioner would 
 concur with me in the justice of this opinion." 
 
 From the moment the young practitioner begins his professional life, he 
 is liable to be called upon to treat this variety of injury, and as the first 
 case may be one of those difficult and trying ones which baffle the skill of 
 experienced surgeons, it is of the utmost importance that a thorough knowl- 
 edge of the subject be imparted to the student. 
 
 Let it be borne in mind by the young surgeon that there is generally 
 deformity after fracture ; it may be so slight as to be almost unnoticeable, 
 or it may be so great as to cause deformity the most unsightly ; but certain 
 it is that the best authorities of the present day are cautious in expressing 
 their opinion in regard to 'perfect apposition of the fragments of broken 
 bones. 
 
 On this subject, Dr. Hamilton writes : " I am frank to confess, that until 
 I commenced these investigations, I had not any just notion of the frequency 
 of deformities after fractures. Students will continue to go out from our 
 hospitals with a belief that perfect union of the broken bones is the rule, 
 and that the exceptions imply unskilful management ; and if, when here- 
 after they have themselves occasion to treat a fractured femur, the result 
 falls short of their standard of perfect success, they, taught also by the 
 same instinct of self-preservation which actuated their teacher, will conceal 
 the truth from others, or even from themselves, if possible." I introduce 
 these remarks, for the sake of encouragement to those beginning their sur- 
 gical career, and will produce such cases, as we proceed with the subject, as 
 will show that we must not expect too much in the treatment of fractures, 
 especially if they be in the vicinity of joints, or complicated with much 
 laceration of the soft parts. 
 
 By the term fracture is understood a solution of continuity of the osseous 
 system, or, in other words, a separation or breakage of the bones, by various 
 causes, both direct and indirect. Various divisions are recognized by sur- 
 geons. Thus : 
 
 Simple Fracture. — The bone being broken at one point. 
 
 Compound Fracture. — The bone being broken, and there being a wound in 
 the soft parts communicating with the bone. 
 
 Comminuted Fracture. — The bone being broken or crushed in many 
 places. 
 
 By the term compound comminuted fracture is understood the breakage of a 
 bone into several fragments, with accompanying wounds of the soft parts. 
 
 An impacted fracture is that in which one extremity or portion of the bone 
 is wedged or driven into the other; a complete fracture is one in which there 
 is an entire separation of the bone; an incomplete fracture signifies but a 
 partial division of the osseous material. 
 
 Again, terms are used to designate the directions in which the separation 
 
FRACTURES — CAUSES — SYMPTOMS. 535 
 
 may occur; thus we have the transverse, longitudinal, oblique, or serrated. Of 
 these the second variety is most rare, and is generally occasioned by gunshot 
 injuries. 
 
 Causes. — These are many, and are divided as usual into predisposing and 
 exciting. Among the former we may enumerate : 1. Sex ; men seeming to 
 be more liable, although the difference in the avocations of the sexes may 
 account for the more frequent occurrence in men than in women. 2. The 
 season of the year ; more fractures being treated in the winter than in the 
 summer. 3. Age; old persons, from the preternatural brittleness of the 
 bones, are especially liable to suffer from fracture, while the bones of younger 
 persons, being supplied with more cartilaginous material, have much greater 
 power of resistance. On the other hand, however, it must not be forgotten 
 that in the former case, there is generally greater risk encountered from 
 greater activity and exposure to accident. 4. The situation of the bones ; 
 the long bones of the extremities, being used naturally for locomotion and 
 protection, are the most liable to be broken, while the small and irregular 
 ones rarely suffer. 5. The position of the bones ; the fibula is external, and 
 is thin and slender, and is more frequently the seat of fracture than the 
 tibia. The radius, being attached to the hand, more often suffers than the 
 ulna, and the clavicle, from its articulations and position, is rendered very 
 obnoxious to accident. 6. Disease: there are several diseases which render 
 the osseous system liable to fracture : some of these are to be classed as 
 regular diseases of the bone, which are of a constitutional character. Among 
 the former we have rickets, mollities. and fragilitas ossium. and among the 
 latter syphilis, scurvy, gout, mercurialization. cancer, scrofula, etc. It is 
 in these latter diseases that the proper exhibition of medicine may, by re- 
 storing the healthy equilibrium and nutrition of the parts, render the patient 
 less liable to fracture. 
 
 The exciting or the efficient causes of fracture are generally external vio- 
 lence and muscular contraction. Of these, the first is the more frequent, 
 and can take place in either a direct or indirect manner. A man receives 
 a blow on the leg or the arm, and the bone separates immediately at the spot 
 where the force has been applied ; another man falls upon the pavement, 
 stretches out his arm to save himself, and though the force may be applied 
 to the hand, the radius breaks above the wrist. Sometimes two forces may 
 operate, one at each extremity of a bone, and it may separate in the centre, 
 as is observed in the clavicles. 
 
 Muscular contraction may cause a solution of osseous continuity, espe- 
 cially in persons advanced in life, and also in young persons in whom 
 the muscular system is well developed, while the bones may be small in 
 size. 
 
 The late Dr. Hodgen * of St. Louis, recorded a remarkable case of 
 fracture of the sternum, and also fracture of the spinous processes of the 
 vertebra? by muscular action. 
 
 Symptoms. — Crepitus. — By the 'term crepitus is understood not only the 
 sound which is emitted when the fractured extremities of a bone are rubbed 
 together, but the peculiar sensation that may be felt by the surgeon during 
 a careful examination. When this is really' present it is always pathogno- 
 monic, but it must never be forgotten that there are sometimes present in 
 fractures what might not inaptly be termed false crepitus, by which I mean 
 that peculiar rubbing noise that may be distinctly heard in the irritated 
 sheaths of tendons and joints, or from the accumulation of air in the 
 tissues. 
 
 I have now in mind a case of injury of the knee-joint, caused by the fall 
 
 * Medical Kecord, Dec. 22d, 1877. 
 
536 A SYSTEM OF SURGERY. 
 
 of a horse upon the limb of a young and athletic man, in which at first I 
 was led to suppose that a partial fracture of the patella must certainly exist, 
 from the crepitus both felt and heard upon attempting to move the knee- 
 cap. Sometimes the sound is very obscure, and the over-anxious surgeon 
 may fancy that he can detect it when such is not in reality present ; in such 
 cases the application of the stethoscope may facilitate the diagnosis. We 
 must also bear an important fact in mind, that a fracture may exist with- 
 out crepitus. Thus, in the so-called impacted fractures, or in those where 
 strong muscular contraction draws asunder the fragments, there may not be 
 a trace of the sound, and I would have this point strongly impressed upon 
 the mind. 
 
 Preternatural Mobility. — This symptom is generally present in fractures, 
 although in the bones of the leg and forearm, when one bone only is the 
 seat of injury, the increased motion may be very slight, as may also be 
 noticed in the impacted variety ; but by grasping the fractured bone above 
 the site of contusion and holding it firmly, and moving the lower portion of 
 it in a lateral direction, an unnatural motion may be generally observed. 
 This preternatural mobility may also be difficult to recognize, especially 
 when the bony lesion takes place in the vicinity of a joint, and there is 
 much contusion of the soft parts, which are torn or lacerated. 
 
 Deformity. — We find deformity noticed in a great number of fractures ; 
 sometimes it is in itself sufficient to render the diagnosis perfect. In some 
 fractures we find — as in those of the olecranon and patella — there is a con- 
 cavity existing between the broken extremities, in others an angularity may 
 be observed ; again, a prominence indicates the injury. In the long bones 
 it may be asserted that the more nearly the lesion approaches the trans- 
 verse variety, the less deformity may be expected, while the more oblique 
 the direction of the fracture, the more will deformity exist. The pain 
 and swelling belonging to these injuries, as a general rule, will have but 
 little weight in establishing a diagnosis, for the reason that severe symptoms 
 of this character, together with ecchymosis, are found in ordinary bruises 
 and sprains. 
 
 It is well for the young practitioner to remember in this connection 
 an important fact, viz.: that because a patient may have considerable 
 motion of a part, there is no reason that a fracture may not exist ; a man 
 with an impacted fracture of the femur has been known to walk unassisted 
 for a considerable distance, and Velpeau has pointed out that even with a 
 lesion of the collar bone, the arm of the affected side may be raised to the 
 head. 
 
 Taking into consideration what has already been mentioned, that 
 crepitus, preternatural mobility, and deformity are the general symptoms 
 upon which to depend, and in many cases these may one or all be 
 difficult to detect; that in muscular subjects, and where the contusion 
 or laceration of tissue is great, these symptoms may be, if present, 
 hard to find, and that the usual presence of pain adds doubt to the 
 appreciation of the injury, it will readily be understood what difficulties 
 the surgeon may have to encounter. When to these we add the de- 
 formity that frequently happens after the most judiciously managed 
 cases, and the odium which is cast upon the surgeon by the ignorant or 
 the malicious, or those whose cupidity for gain has smothered their feel- 
 ings of honesty — is it remarkable that so distinguished an authority as 
 Dr. Gross has written the words which are inserted at the beginning of this 
 chapter ? 
 
 Examination of the Patient. — When oalled to examine a patient in whom 
 a fracture is apprehended, if there is the slightest doubt as to the diag- 
 nosis, the best method is to place him immediately and completely under 
 
FRACTURES — MODE OF REPAIR. 
 
 537 
 
 Fig. 248. 
 
 anaesthetic influence, and then conduct the manipulations thoroughly 
 and as gently as possible. The sooner the examination is made the better, 
 before much tumefaction has appeared, and before the excessive soreness, 
 which soon is manifested. Never be in a hurry ; if many demands upon 
 your time are engaging your attention, either postpone some of them, or, if 
 that cannot be done, the patient must be turned over to another surgeon. 
 Another remark may also be inserted : do not be discouraged if the diag- 
 nosis is not made clear upon the first, second, or even the third visit. There 
 are some cases of obscure nature that the surgeon may never entirely diag- 
 nose ; and if he were candid enough to admit the fact, many are the cases 
 that have made a fair recovery which were not entirely understood during 
 a prolonged treatment. 
 
 Mode of Repair. — The method which nature observes in repairing lesions 
 of the osseous structure is beautiful, and when carefully noted may be 
 divided into several stages ; thus we have, first — 
 
 A. The period of rest, which may again be divided into — 
 
 1. The period of exudation, when inflammatory lymph is thrown out 
 around the site of injury, which may occupy two or three days. The tis- 
 sues during this stage are soft and somewhat succulent, and 
 infiltrated with a fluid containing leucocytes. 
 
 2. The period of true rest, so far as the ends of the bone are 
 concerned, which remain in a quiet condition, while nature 
 removes the debris, clears away extravasated blood, takes 
 away the swelling, and prepares for the second period. 
 
 B. The period of uniting the fragments together. This is 
 accomplished by the deposition of a fibrinous, gelatinous sub- 
 stance (granulation tissue), which surrounds the extremi- 
 ties as it were with a pad, holding them together. This 
 substance may also be poured out, though in a lesser degree, 
 in the medullary canal ; thus giving support both externally 
 and internally to the fractured ends of the bone. This sub- 
 stance gradually and in different ways is transformed into 
 the so-called provisional or intermediate callus. (Fig. 248.) 
 This last process I shall not here minutely describe, suppos- 
 ing that all are in a measure acquainted with osteogeny, or 
 the origin and growth of bone in the foetus. 
 
 According to Mr. Paget, it may be accomplished through 
 fibrous tissue, or by either nucleated cells or nucleated blastema, 
 or by cartilage. Perhaps the best description of the manner in which broken 
 bones may unite, may be found in Prof. Hamilton's excellent Treatise on 
 Fractures. He states that fractures of the adult human bone, " whether 
 placed end to end or overlapped, unite most naturally and most promptly 
 either immediately or mediately, and in the same manner as the soft tis- 
 sues unite, that is to say, without the interposition of any reparative mate- 
 rial, or through the medium of'any intermediate permanent callus; and 
 that all deviations from these simple methods are accidental, or the result 
 of disturbing influences." 
 
 In whatever manner, however, ossification of callus takes place, so soon 
 as the broken ends of the bone are surrounded and held in position by the 
 provisional callus, then the uniting of the fractured extremities takes place 
 through the permanent callus, which is followed by 
 
 C. or that period when the provisional callus is removed by the absorbent 
 system, by which the bone is restored to its original shape. 
 
 From these remarks, we learn that the fractured ends of a bone, being 
 brought into direct and perfect apposition, which, by the way, is very rarely 
 
 Method of Re- 
 pair in Frac- 
 
538 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 249. 
 
 ' 
 
 the case, will unite without the formation of the provisional callus, or more 
 after the fashion of union by the first intention in the soft parts, but that in 
 the majority of instances we have first a period of rest, divided 
 into that of exudation and clearance, followed by the forma- 
 tion of provisional or intermediate callus, both exterior and 
 interior to the bone ; after which we have the deposition of the 
 permanent callus, and, finally, the removal of the extraneous 
 bony deposit, which is no longer of service. These processes 
 are more or less varied in accordance with the extent or direc- 
 tion of the fracture, or the position of the bone. When 
 bones are not brought into apposition, the callus is thrown 
 around the opposing ends, or, indeed, in some instances, a com- 
 plete bridge of bone may extend from one fragment to the 
 other. (Fig. 249.) 
 
 General Treatment. — The indications in the treatment of 
 fractures are : 1st. To set the bones ; or, in other words, to 
 restore the fragments as nearly as possible to their natural 
 position. 2d. To maintain them in that position. 3d. To 
 prevent or allay constitutional or local disturbances. 
 
 According to the old-fashioned method of treatment, a frac- 
 ture bed, especially when bones of the lower extremities were 
 the seat of injury, was considered an almost indispensable re- 
 quisite. These were often very ingenious contrivances, with 
 pulleys and joints and hinges, by means of which the patient 
 could be raised or moved slightly without materially affecting the broken 
 bones ; but of late, with the new methods of treating fractures of the lower 
 extremities, all that is required is a good* moss or hair mattress, covered 
 with a sufficiency of blankets or " comfortables " to render it soft to the 
 patient. It is really curious to look over the cumbersome contrivances called 
 " fracture-beds," which were used by our ancestors. The fracture-bed of 
 Jenks, at least the plate thereof, reminds one of the curious representations 
 in the Armamentarium Chirurgicum of Scultetus, or some of the instru- 
 ments of torture in the Tower of London. 
 
 Let the bed be made comfortable to the patient, and let sufficient care be 
 taken to insure this condition. Let the bones be set as soon as possi- 
 ble after the injury ; this is the rule, and if it cannot be accomplished en- 
 tirely, bring the parts as nearty in apposition as the swelling will allow, and 
 apply the splint, and a pad, and a roller to maintain them in such position. 
 Callus does not form until the eighth or tenth day, and therefore, say some 
 surgeons, there is no particular hurry in readjusting the fragments. The 
 longer any portion of the body, or any organ or part of an organ, muscle, 
 tendon, or bone, is allowed to remain in an abnormal position, the greater 
 will be the irritation, both local and constitutional, and the more difficult 
 and painful will be the manipulations. 
 
 Treatment. — The apparatuses for treatment of fractures are bandages, 
 splints, adhesive strips, and cushions or pads. 
 
 In regard to fractures especially, it is absolutely required that a precise 
 knowledge be had of the indications to be fulfilled for a satisfactory use of 
 the means. Without the possession of such knowledge, there would be but 
 little practical profit from an acquaintance with all the very numerous kinds 
 of bandages and other contrivances, however ingenious or highly recom- 
 mended, which from time to time have been introduced to the notice of the 
 profession. By such as are curious in these matters, the older surgical 
 writers may be examined. In the present work it is designed to invite at- 
 tention to means now in use, selecting those only which by the most talented 
 
SPLINTS. 539 
 
 and experienced in the profession are considered best adapted to accomplish 
 the ends desired. 
 
 Splints. — A great variety of splints have been introduced at various times 
 to the notice of the profession, some possessing advantages over others. The 
 essential points necessary for a good splint are lightness, firmness, facility 
 of application, and adaptation to the parts to which they are applied. A 
 great many substances have been used, some of which are capable of being 
 moulded to the part, as those constructed of felt, sole-leather, binders' 
 board, or gutta-percha. Others are constructed of iron, iron and brass 
 wire, or of tin, and of zinc. The most serviceable materials, and perhaps 
 the best for the upper extremities, are wood, metal, or felt ; and for the 
 lower, those made of iron wire and narrow board, as we will show as we 
 proceed with the subject. 
 
 Those splints which are constructed of gutta-percha, sole-leather, etc., 
 and prevent the proper exhalation from the part, become offensive; and 
 if the fracture be of the compound variety, and there has been much 
 suppuration, and the pus makes its way beneath the splints, maggots 
 may be bred, and the patient rendered miserable from the odor and the 
 filth. 
 
 Excellent splints for fractures of the upper extremities are those made 
 of thin poplar boards which are glued upon sheep-skin, and then cut 
 through lengthwise. These are greatly in vogue, and are so easily made, 
 and are so handy of application, that the surgeon should always have them 
 in readiness. 
 
 A variety of splints is constructed of perforated hard rubber, which, 
 when heated, can be moulded to the part affected. Dr. Bushrod W. 
 
 Fig. 250. 
 
 James, of Philadelphia, has devised a good splint for fractures of the 
 forearm. 
 
 New and very good splints have lately been introduced under the name 
 of " Ahl's Adaptable Porous Felt Splints." They can be obtained in sets 
 of fifty pieces, and are adapted to every fracture in the human body. They 
 are constructed of porous material, arid both hot and cold water dressings 
 can be applied through them. They are moulded to the limb, will remain 
 pliable but firm, and are in many ways most desirable. 
 
 Johnstone has also introduced a porous felt splint of utility and conven- 
 
540 
 
 A SYSTEM OF SURGERY. 
 
 ience. Figs. 250, 251, 252 show how admirably adapted these splints are 
 to both the superior and inferior extremities. 
 
 Carved splints sometimes answer a good purpose, although to make 
 them fit accurately they should be prepared for each individual case. 
 
 Fig. 251. 
 
 Fig. 252. 
 
 Dr. R. J. Levis, of Philadelphia, has devised a set of metallic splints 
 which possess excellent qualities. They are made of copper, less than one- 
 eightieth of an inch in thickness, are perforated for free ventilation and 
 the exit of discharges. They do not become offensive, and can be adapted 
 to the inequalities of surface without trouble. These splints are arranged 
 in sets, and are made by the cutler William Snowden, of Philadelphia. 
 
 Plaster of Paris Splints. — In some instances the application of plaster 
 of Paris, or immovable dressing, is of great benefit in the treatment of frac- 
 tures, especially in the bones of the leg. It seems that the use of this sub- 
 stance was known in remote times, and was employed by the Arabians 
 a century since. In 1814, Hendricks introduced it into the hospital of 
 Groningen, and Kyle and Dieffenbach subsequently made use of it. Prof. 
 Pirogoff, during the Crimean campaign, used the plaster of Paris in a dif- 
 ferent and highly satisfactory manner, and in 1854 published a monograph 
 on " A new method of bandaging fractured limbs with linen soaked in a 
 solution of plaster of Paris." 
 
 The formation and use of the plaster of Paris splint were devised by 
 the late Dr. James L. Little, of this city (New York). He introduced 
 it into the New York Hospital in 1861, and published the method in the 
 American Medical Times of that year, from which the description below is 
 taken. 
 
PLASTER OF PARIS SPLINTS. 541 
 
 In 1867, Dr. Little called the attention of the American Medical Associa- 
 tion to his method, which since that time has been almost universally 
 adopted in certain fractures, especially those of the leg. It can, however, 
 be applied anywhere, as it moulds and adapts itself to any part. The 
 student must be careful not to confound the plaster of Paris bandage, now 
 so much in vogue in the treatment of spinal deformities, and employed by 
 some in the treatment of fractures, with the plaster of Paris splint. The 
 former is open to the following objections : 
 
 The parts shrink away from it and it becomes loose, thus losing all 
 its supporting power. The limb cannot be properly inspected, and the 
 bandage has to be renewed, or else pieces cut out of it to make it adapt 
 itself to the surface, in either case a troublesome proceeding. Dr. Little 
 has also published his method * to which the reader is referred for accu- 
 rate details for the application of the splint to both the upper and lower 
 extremities. 
 
 The mode of application to the leg is as follows : "The limb is first 
 shaven *or slightly oiled ; a piece of old coarse washed muslin is next se- 
 lected, of a size that when folded about four thicknesses it is wide enough 
 to envelop more than half of the circumference of the limb, and long 
 enough to extend from a little below the under surface of the knee to about 
 five inches below the heel. The solution of plaster is then to be prepared. 
 Fine, well-dried, white plaster had better be selected, and before using, a 
 small portion should be mixed with water in a spoon and allowed ' to set,' 
 with a view of ascertaining the length of time requisite for that process. If 
 it is over five minutes, a small quantity of common salt had better be dis- 
 solved in the water before adding the plaster. The more salt added the 
 sooner will the plaster ' set.' If delay be necessary, the addition of a few 
 drops of carpenter's glue or mucilage will subserve that end. Equal parts 
 of water and plaster are the best proportions. The plaster is sprinkled in 
 the water and gradually mixed with it. The cloth, unfolded, is immersed 
 in the solution and well saturated ; it is then to be quickly folded as before 
 arranged and laid on a flat surface, such as a board or a table, and smoothed 
 once or twice with the hand in order to remove any irregularities of its sur- 
 face, and then, with the help of an assistant, applied to the posterior sur- 
 face of the limb. The portion extending below the heel is turned up on 
 the sole of the foot, and the sides folded over the dorsum and a fold made 
 at the ankle on either side, and a roller bandage applied pretty firmly over 
 all. The limb is then to be held in a proper position (extension being 
 made if necessary by the surgeon), until the plaster becomes hard. The 
 time required in preparing the cloth, mixing the plaster, and applying the 
 casing to the limb, need not take more than fifteen minutes. After the 
 plaster is firm and the bandage removed, we will have a solid plaster of 
 Paris case, partially enveloping the limb, leaving a portion of its anterior 
 surface exposed to view. If any swelling occur, arnica lotion can be ap- 
 plied to the exposed surface, and we can always easily determine the rela- 
 tion of the fractured ends. If necessary, an anterior splint, made of the 
 same material, can be applied, and then both bound together with adhesive 
 plaster, and, if desirable, a roller bandage over all. If the anterior splint 
 is not used, two or three strips of adhesive plaster, one inch wide, or bands 
 of any kind, may be applied around the casing, and will serve to hold them 
 in position." 
 
 The advantage of plaster of Paris over the starch bandage is, that it "sets " 
 while the surgeon moulds it to the part, whereas the starch apparatus may 
 take several days to thoroughly dry. 
 
 * Medical Record, 1873, p. 530. 
 
542 A SYSTEM OF SURGERY. 
 
 The use of metallic strips as an application to the plaster of Paris splints, 
 is highly spoken of.* I have found that they not only give additional 
 strength to the splint, but do away with the necessity of keeping up manual 
 extension until the splint has set. 
 
 Dr. Harris, of New York city, states that by preparing it in the following 
 manner, the weight of the dressing may be considerably diminished, thus : 
 water, by weight, 100 parts; gypsum, 75 parts; boiled starch, clarified, 2 
 parts. 
 
 In the appendix to the Army Medical Report, for 1869, a plaster dressing 
 is described by Staff-Assistant Surgeon Moffit, who states that it is used by 
 the Bavarian Ambulance Corps. Two pieces of flannel, suited to the length 
 of the limb, are cut sufficiently wide to overlap slightly in front. When so 
 prepared they resemble the leg of a stocking cut vertically. One is now 
 laid over the other, and they are stitched together from top to bottom, down 
 the mesial line, like two sheets of note-paper stitched at the fold. They 
 must now be spread out under the injured limb, so that the line of stitching 
 corresponds to the back of the calf. The two inner leaves, so to speak, are 
 now brought together over the shin, and fastened by long pins, the heads 
 of which are bent. The leg being held firmly, an assistant mixes the 
 plaster with about an equal bulk of water, and rapidly applies it, partly 
 with a spoon and partly pouring over the outer surface of the flannel cover- 
 ing the limb. The two portions of the second layer are then quickly 
 brought over, so as to meet, and the inequalities in the distribution of the 
 plaster are removed before it hardens, by smoothing with the hand. In 
 about three minutes the gypsum sets, and the limb is encased in a strong 
 rigid covering, which gives uniform pressure and support to every part. 
 The edges of the flannel in front can now be trimmed, and the pins with- 
 drawn from the inner layer, by seizing their bent heads. A couple of straps, 
 or a few turns of a roller, make all secure. In order to take the apparatus 
 off, it is only necessary to remove the straps and separate the edges of the 
 flannel, when the two sides will fall asunder, the line of stitching behind 
 acting as a hinge. 
 
 The application takes less than ten minutes, the removal about two. 
 Thus, from day to day if necessary, the limb can be inspected, and the splints 
 (for they are no less) reapplied. In cases of compound fracture, an open- 
 ing suitable to the wound may easily be made. In most cases it is desirable 
 to make a number of perforations with a gimlet, to prevent unnecessary 
 heat. 
 
 Starch Bandage, or the Movo-amobile Apparatus of Suetin. — To apply the 
 starch bandage, which was introduced by Suetin, of Brussels, in 1834, the 
 following precautions are necessary, which taken, it may be used in cases of 
 recent fracture with great benefit. It has the advantage of being much more 
 cleanly than the plaster of Paris splint, although it takes much longer to 
 harden. There can be no doubt that this variety of permanent dressing 
 may be properly applied in recent fractures, when there is no shortening of 
 the limb to be overcome, and no painful spasms of the muscles have been 
 excited by the irritation of the fractured bones. Having prepared some of 
 the best starch, and having boiled and strained it either through a piece 
 of cambric or a wire sieve, envelop the part in carded cotton, in order to 
 cover all inequalities of surface, and over the cotton apply, not too tightly, 
 a wet bandage. After, the limb has been thus encircled, with the hands, 
 and not with a brush, apply the starch all over the bandage, taking care to 
 cover it thoroughly ; having done this carefully, again retrace the course of 
 the bandage, and again apply the starch, and after performing the manipu- 
 
 * Medical Record, May 1st, 1874. 
 
MEDICAL MANAGEMENT. 
 
 543 
 
 lation for the third time, allow the dressing to set for half an hour, and over 
 the whole apply a dry. bandage. 
 
 It will take nearly thirty hours for this bandage to dry, but whtn it has 
 become hard, it will be found to be very immovable and permanent. If it 
 is necessary or deemed expedient that the starch apparatus be dried sooner, 
 by placing heated plates alongside the dressing, the process will be facilitated. 
 It is necessary on the third or fourth day to open the bandage and to ex- 
 amine the limb, and for the division of the apparatus, Suetin devised a pair 
 of pliers or shears which are serviceable. After the splint has been divided, 
 it must be kept in apposition by an additional bandage. It will be seen 
 that this apparatus is both immovable and movable, and in fact is called by 
 Suetin himself, movo-amobile. 
 
 Velpeau uses dextrin in the preparation of such a bandage, and Hamil- 
 ton says : " For myself, I am quite as much in the habit of using wheat 
 flour paste as either starch or dextrin, and if properly made, it dries about 
 as quickly as starch, and is equally as firm." 
 
 To remove this bandage a pair of Suetin's pliers may be used, or the in- 
 strument devised by Dr. Henry for the purpose (Fig. 253). The flat blade 
 
 Fig. 253. 
 
 being introduced under the bandage prevents any irritation of the skin, and 
 gives support to the instrument in the act of dividing the bandage. 
 
 Fracture-cushions are made of different shapes and sizes, to correspond 
 with the inequalities which are to be filled. They are made of unbleached 
 muslin stuffed with horse-hair, moss, or excelsior. A form of fracture- 
 cushion very much in vogue is made of oblong bags filled about two-thirds 
 with bran or sawdust. These are serviceable to place alongside fractured 
 bones, as they prevent displacement. 
 
 Compresses are made of muslin or linen, and must be adapted to the 
 parts to which they are to be applied. 
 
 Adhesive straps are now employed by many distinguished surgeons, not 
 only for fixing dressings and appliances, but for exerting extension and 
 counter-extension. In 1830, Prof. Samuel D. Gross called attention to their 
 use, and since that period they have been almost constantly employed. 
 
 Medical Management. — So soon as a person with a fracture is brought in, 
 it is well, as before mentioned, if possible to set the bones, and having ap- 
 plied a loose dressing, merely sufficient to maintain the parts in apposition, 
 to cover the whole limb with a large towel which is wetted with a strong 
 solution of arnica, in proportion of an ounce of the tincture to one pint of 
 water. If the swelling be very great, it is well to use the irrigator, or to 
 
544 A SYSTEM OF SUEGERY. 
 
 allow a stream of cold water to fall gently upon the surrounding parts as 
 well as upon the direct seat of injury. A dose of arnica 3d should then be 
 given, a*d at the proper time, that is as soon as the swelling subsides, the 
 permanent bandages should be applied. The medicines which are best 
 adapted to the treatment of fractures, to hasten the formation of tardy cal- 
 lus, are the phosphate and carbonate of lime. These are to be given in the 
 3d trituration, about 3 grains three times daily ; the symptoms, or rather 
 general conditions which lead to their use, are these : In children, when 
 there is a tendency to marasmus and deficient nutrition, when the nutritive 
 nervous system is especially disarranged, and in adults who have dyspepsia, 
 sour stomach, and frequent gastric disturbance, or in females when the 
 menstrual function is irregular, and there is a low grade of vitality, then the 
 carbonate of lime is the more appropriate. The phosphate must be given 
 when there is tendency to thoracic disease, bronchial disorders, cough, etc. 
 I have known phthisis pulmonalis result in these cases by giving, after in- 
 jury, the carbonate of lime in oft-repeated doses. 
 
 Another excellent method of introducing lime into the system, and one 
 which I have seen do good service, is by the use of that preparation known 
 as Churchill's hypophosphites of lime and soda. A teaspoonful of this 
 preparation may be mixed with a glassful of water, and taken during meals. 
 An indication to either lessen the quantity administered, or to discontinue 
 its use, is a peculiar taste of lime which remains long in the mouth, or may 
 come on suddenly, and, after continuing for a time, disappear. I have never 
 found either sulphur, silicea, or hepar serviceable in the treatment of frac- 
 tures, that is, so far as assisting the formative process is concerned. I have 
 also used Symphytum after the direction of Croserio, but am not sure that 
 good results have followed. Ruta has also been employed by Dr. Hen- 
 riques, and I have seen excellent effects from its use. 
 
 Very frequently after a severe fracture, there is a tendency to spasmodic 
 muscular action, which is sometimes so great that there is danger of the 
 fragments being drawn out of place. In such cases ignatia and cuprum 
 have always proved sufficient in my hands ; my friend, Dr. Willard, has 
 seen similar good results from the exhibition of ignatia, and on one or two 
 occasions hyoscyamus has produced quiet and sleep, when the jactitation 
 w#s sufficient to give the patient great annoyance. Chamomilla is useful 
 when the patient faints frequently, with uneasiness about the heart, with 
 twitching of the limbs and oppression of the chest. Other symptoms which 
 are sometimes present, may be combated with the appropriate medicines, 
 which may be found in the chapters on Erysipelas, Wounds, Suppuration, 
 etc. If there are excessive pains in the bones and periosteum, mez. will be 
 the best medicine, or phosph. acid or rhododendron may be called for. 
 
 Flexion, or Bending of the Bones. — In children, or in those whose osseous 
 systems are deficient in lime, bending of the bones is sometimes found. In 
 the early periods of life, when there is a preponderance of cartilaginous ma- 
 terial, the bones, especially the cranial, are soft, and can readily, without 
 any noticeable fracture, be flexed to a considerable degree. We find this 
 exemplified in those Indian tribes whose craniums are subjected to pressure 
 to alter the conformation of the skull. When, however, the patients are 
 more advanced in life, there is a partial fracture of the ossific substance 
 which allows the bone to bend. This fracture has received the name of 
 " green-stick fracture," as represented in Fig. 254. 
 
 Dr. Willard* reports a case in which there was bending of both radius 
 and ulna, and after the removal of the splints, callosities appeared, showing 
 that in this case the bending had been accompanied with a partial fracture. 
 
 * Western Homoeopathic Observer, vol. vi., p. 350. 
 
NON-UNION OF BROKEN BONES, OR FALSE JOINT. 
 
 545 
 
 Fig. 254. 
 
 Some authors treat these alike, classing them as bending of the bones, 
 cracked bones, or incomplete fracture. The symptoms are generally easily 
 recognized. The first diagnostic symptom upon which the greatest stress is 
 laid in fractures, viz., crepitation, is wanting, but there is curvature, pain, 
 immobility. The treatment consists in gradually and gently 
 restoring the bones to their situation, and keeping them in 
 position with appropriate splints and bandages, and admin- 
 istering to the patient the third trituration of the phosphate 
 of lime. 
 
 Non-union of Broken Bones, or False Joint — Pseudo-arthro- 
 sis. — The humerus and the femur are the bones that are 
 said to be the most likely to be affected with false joint after 
 fractures, although ununited fractures are discovered in other 
 bones. Considering the number and variety of fractures 
 which occur, this untoward accident is not frequent, and 
 when such a result happens, it is generally occasioned 
 by some disease of the osseous system, or dyscrasia, or 
 from premature use of the limb after fracture, or perhaps 
 from want of the proper management on the part of the 
 surgeon. Very frequently, in advanced life, the progress of 
 ossification is tardy, indeed it is often delayed a length of 
 time in fractures occurring in persons of intemperate habits ; 
 if these cases are not thoroughly appreciated, and are 
 treated as ordinary fractures, that is, the bandages and splints 
 removed at the ordinary time, then a false joint will be the result ; but 
 such an unfortunate result may be prevented by the surgeon insisting 
 that the apparatus be kept constantly on the fracture, and the appropriate 
 medicine be perseveringly administered; ruta, calc. carb., calc. phosph., or 
 Symphytum being appropriate. But when from whatever circumstances 
 the fractured extremities of bones do not unite, we then have pseudo- 
 arthrosis, or false joint. In all the long bones 
 nutrient foramina are found, and it is re- 
 markable to observe the obliquity with which 
 they enter the substance of the bone. From 
 these facts, Gueretin was led to investigate 
 whether the peculiar course of the arteries 
 had any influence upon the time occupied 
 in the consolidation of fracture ; from his 
 experiments it was discovered that if the 
 fracture occurred below the entrance of a nu- 
 trient artery which took its course upward, 
 a false joint was most likely there to form, 
 and vice versa. 
 
 Dr. Norris, of Philadelphia, has classified 
 false joints into four varieties : First, when 
 the fractured ends are completely covered by 
 cartilage, making the bone movable. Second, 
 when there has been no attempt at union and 
 the limb is wasted and shrunken. Third, in 
 which the ends of the bone become wounded, 
 and are covered with a cartilaginous forma- 
 tion, the medullary canal being obliterated 
 and the ends working the one upon the 
 other (Fig. 255). Fourth, when a capsular 
 ligament has formed over the broken ends of the bone, making very 
 nearly a true diarthrodial articulation ; this last is quite rare, while the 
 
 35 
 
 Fig. 255. 
 
 False Joint. 
 
546 A SYSTEM OF SURGERY. 
 
 third variety is that most commonly found. In a later work Dr. Norris 
 finds : 
 
 "1st. That non-union after fracture is most common in the thigh and arm. 
 2d. That the mortality after operations for its cure follows the same law as 
 after amputations and other great operations on the extremities, viz. : That 
 the danger increases with the size of the limb operated on, and the nearness 
 of the operation to the trunk ; the mortality after them being greater in the 
 thigh and humerus than in the leg and forearm. 3d. That the failures after 
 operations for their relief are most frequent in the humerus. 4th. Failures 
 are not more frequent in middle-aged and elderly than in young subjects. 
 5th. That the seton and. its modifications are safer, speedier, and more 
 successful than resection and caustic. 6th. That incising the soft parts 
 previous to passing the seton augments the danger of the method, though 
 fewer failures occur after it. 7th. That the cure by seton is not more certain 
 by allowing it to remain for a very long period, while it exposes to 
 accidents. 8th. That it is least successful on the femur and humerus." 
 
 I have taken the liberty of quoting these deductions in full, because they 
 are replete with instruction. 
 
 Treatment. — There can generally be little done medically after pseudo-ar- 
 throsis has taken place, although proper medicinal agents administered and 
 judicious pressure being brought to bear on the uniting fragments, may, in 
 many instances, prevent it. The pressure is made by compresses, wetted 
 in a solution of Symphytum, one part to four of water, and constantly ap- 
 plied over the seat of accident. 
 
 This unfortunate termination of fracture may in some instances be pre- 
 vented by the internal administration of calcarea carb., or perhaps the 
 phosphate of lime ; the latter has been recommended for such conditions, 
 but there are no indications in the meagre proving of this medicine which 
 would lead the practitioner to have recourse to it. The former, however, 
 is a well-known medicine, and in numerous instances has been of essen- 
 tial service in the treatment of fractures and other injuries occurring in 
 individuals of a weak, sickly constitution, and scrofulous diathesis. This 
 medicine improves the tone of all the organs in the body, by giving addi- 
 tional power to the functions of assimilation and sanguification, therefore it 
 is a valuable assistant in the treatment of those cases of fractures in which 
 the reproductive process appears to proceed tardily from a deficient ac- 
 tivity. 
 
 Ruta has been employed by homoeopathic surgeons to hasten the forma- 
 tion of ossific matter. Dr. Henriques,* in recording the treatment of a case 
 of oblique fracture of the superior third of the femur below the capsule, 
 which occurred spontaneously in an aged patient, of enfeebled and vitiated 
 constitution, who had been liable to periodical attacks of diarrhoea and cere- 
 bral congestion, dysuria and cough, remarks concerning the action of ruta, 
 that it " appears to possess a decided elective affinity for the periosteum, as 
 well as the osseous system in general ; and it was the desire to avail myself 
 of the known specific property of ruta, that led me to employ it as a means 
 of promoting the process of ossification. I have no doubt in my own mind 
 that it had the desired effect ; for if the unfavorable prognosis of the case 
 be compared with the ultimate happy and prompt result obtained, I do not 
 think it possible to deny that the action of this medicine contributed in some 
 degree to the final consolidation of the fracture." 
 
 Symphytum has also been recommended for the purpose of inducing ossific 
 deposit. 
 
 The general health of the patient should receive attention ; if the consti- 
 
 * British Journal of Homoeopathy, vol. x., p. 448, a paper entitled Fractures, and their 
 Homoeopathic Treatment. 
 
NON-UNION OF BKOKEN BONES TREATMENT. 547 
 
 tution is worn out by disease, or debilitated either from hereditary taint or 
 more proximate causes, the general tone of the system should be strengthened 
 by the administration of the appropriate medicine ; by such means the 
 patient may be restored to perfect health, and the performance of painful 
 operations avoided. However, if after the patient administration of medi- 
 cines, the formation of false joint does occur, it may then be advisable to 
 have recourse to friction of the broken surfaces ; this in some instances has 
 produced the desired effect. 
 
 Before proceeding to the more heroic measures about to be detailed, it 
 would be expedient to try the injection of a weak solution of carbolic acid 
 into the joint, as recommended by Dr. Becker.* It must be performed once 
 or twice during the clay, the strength of the solution being increased or 
 diminished in accordance with the symptoms. 
 
 Dr. Physick's method of treatment has been successful in many instances ; 
 it consists in passing a seton between the fractured surfaces. A seton needle 
 is armed with a skein of silk or other material ; the limb is extended to 
 separate the fragments, and the seton is passed between them, care being 
 taken to avoid all large vessels and nerves. Violent inflammation follows 
 the application of the seton in all cases, and bony union may take place. 
 
 The late Prof. Mutter performed the following operation, first introduced 
 by Dieffenbach, to remedy pseudo-arthrosis : The fractured extremities of 
 the bones are exposed by incision, and, by means of gimlets, perforations 
 made on each side of the false joint; into these openings ivory pegs should 
 be driven, and the wound dressed antiseptically. Union very frequently 
 follows, and absorption soon removes the extraneous matter forced into the 
 bones. 
 
 There are many other methods of uniting the false joint. Dr. Brainerd, 
 of Chicago, succeeded by perforating the extremities of the bone in vari- 
 ous directions, by an instrument which bears the name of Brainerd 's Per- 
 forator. He uses it as follows : " In case of an oblique fracture, or of one 
 with overlapping, the skin is perforated with the instrument at such a 
 point as to enable it to be carried through the ends of the fragments, to 
 
 Fig. 256. 
 
 Si 
 
 ^^-O** 
 
 Brainerd's Perforator. 
 
 wound their surfaces and to transfix whatever tissue may be placed between 
 them. After having transfixed them in one direction it is withdrawn from 
 the bone but not from the skin, its direction changed and another perfo- 
 ration made, and this operation is repeated as often as may be required." 
 Dr. Brainerd has several drills, fitting into a single handle (Fig. 256). 
 
 * Medical Times and Gazette, November 18th, 1876. 
 
548 
 
 A SYSTEM OF SURGERY. 
 
 Recently success has been obtained by " pounding " the extremities of the 
 bone with a small hammer with a head of gutta-percha. 
 
 Dr. Geo. F. Shrady * of New York, has introduced an instrument com- 
 bining saw, knife, and rasp, which he devised for operating upon the ex- 
 tremities of the fragments in ununited fractures. The instrument is for 
 subcutaneous work and can be used in many operations. 
 
 As will be seen in Fig. 257, the instrument consists of a trocar, fenestrated 
 canula (Fig. 1), and a staff (Fig. 2), with handle and blunt extremity. A 
 portion of this staff at a short distance from the extremity is flattened, one 
 edge (B) being made into a knife-blade, and the other edge (C) being pro- 
 vided with saw-teeth. This staff (Fig. 2) is intended to replace the trocar 
 in the canula after the latter is introduced. When in position (Fig. 3), 
 either the saw (C) or the knife (2?) edge of the shaft, according to the way 
 the latter is turned, corresponds with the opening in the canula. The saw 
 or knife can then be worked to and fro within the canula, by a piston-like 
 movement, the canula being steadied by grasping the flange (D) at its 
 base. 
 
 Another excellent mode of proceeding, and one which in the majority of 
 instances is successful, is, after having removed the soft substance from the 
 extremities, to pierce the ends with a common gimlet, then, after having 
 made considerable friction between the surfaces, pass into the holes a suture 
 of strong iron or silver wire, and draw the pieces of bone into apposition. 
 After a number of weeks the wire is withdrawn, and reunion is found to 
 have taken place. 
 
 Dr. Smith, t of Philadelphia, objects to all the modes of treating this 
 accident, as founded on a wrong principle. He objects particularly to the 
 opinion that absolute rest is necessary to the cure, and that this idea is 
 one very fruitful source of failure. His plan is to fix the limb in an iron 
 framework, constructed with joints to allow movement of the limbs, and 
 by straps and pads to steady the extremities of the broken bones in a 
 proper position. Fixed in this apparatus, he allows the patient to use the 
 injured limb, and he asserts that union is effected with much less consti- 
 tutional and local disturbance than by means of the various plans of treat- 
 ment used by practitioners, viz., violent friction, the seton, resection, Dieffen- 
 bach's plan, and others, while at the same time the patient is less exposed 
 to phlebitis and other i*isks, he escapes the disagreeable monotony of a long 
 confinement.! This method appears to have many advantages over some 
 
 * Medical Kecord, January 4th, 1879. 
 
 f American Quarterly Journal of Medical Sciences, January, 1855. 
 
 X See Banking's Abstract, vol. xi., July, 1855. 
 
FRACTURE OF THE NASAL BONES. 549 
 
 others, but more statistics will be necessary before its actual value can be 
 ascertained. If internal treatment be adopted with the use of the apparatus 
 of Dr. Smith, the results doubtless would be more speedily accomplished 
 than when the apparatus alone is used.* 
 
 Resection has also been practiced, but generally it is a last resource, for 
 it should be remembered that cutting down to the extremities of the bone 
 and scraping or removing portions of them, at once converts the simple to a 
 compound fracture. 
 
 Cracked Bones or Incomplete Fracture. — It sometimes happens that a bone 
 is cracked when the force applied has not been sufficient to produce an 
 entire separation, but only adequate to break the continuity of some of its 
 fibres, whilst others remain entire. This injury is generally found where 
 there are two bones, as in the leg or forearm, when the uninjured one sup- 
 ports that which is partially broken. It is probable that it occurs occa- 
 sionally in both bones, although the accident is rare. 
 
 Diagnosis. — Diagnosis is more difficult when the bone is merely cracked 
 than when the solution of continuity is complete ; still, with care, it may be 
 recognized. 
 
 The patient is unable to use the limb without considerable pain; he 
 has a sense of pricking about the seat of injury, and when the bone is 
 closely examined, there may be a slight deviation from the direct line of 
 its axis, but there is no crepitus ; yet when the above signs follow a severe 
 blow or fall upon the part, and the pain and inability to use the limb freely 
 exist after the effects of the contusion have subsided, it is probable there is 
 a solution of continuity in some of the fibres of the bone. In other words, 
 the bone is cracked but not entirely broken. 
 
 Treatment for the repair of this injury is the same as if the bone were 
 broken into two fragments. It is not necessary, however, to keep the appa- 
 ratus quite as long applied as in complete fracture. The medical manage- 
 ment has already been given. 
 
 SPECIAL FRACTURES OF THE HEAD AND FACE. 
 
 Fracture of the Nasal Bones. — Fracture of the nasal bones is generally the 
 result of direct violence, as falls and blows. The swelling, which usually 
 is great and follows immediately after the accident, often prevents a cor- 
 rect diagnosis. Of the site of the fracture, Prof. Hamilton thus speaks: 
 " When the ossa nasi are struck with considerable force from before and 
 from above, a transverse fracture occurs, usually within three to six lines 
 of their lower and free margins, and the fragments are simply displaced 
 backward ; or if the blow is received partially upon one side, they are dis- 
 placed more or less laterally. This is what will happen in the great 
 majority of cases, as I have proven by the examination of the noses of 
 those persons who have been the subjects of this accident, and by repeated 
 experiments upon the recent subject. " These bones heal with great rapidity. 
 
 Treatment. — If the surgeon be timely called, manipulation with the fingers 
 outside and the introduction of a female silver catheter within the nares 
 
 * Dr. Smith's plan has been tried 
 
 in several 
 
 cases with these resu 
 
 Its 
 
 
 
 
 Cases. 
 
 Cured, 
 
 Relieved. 
 
 
 Failed, but able to walk. 
 
 False joints in the femur, . 
 " " leg bones, 
 " " humerus, 
 
 • 
 
 4 
 
 8 
 2 
 
 3 
 
 7 
 
 
 
 
 
 2 
 
 
 1 
 1 
 
 
 Total, 
 
 . 
 
 14 
 
 10 
 
 2 
 
 
 2 
 
550 A SYSTEM OF SURGERY. 
 
 will in a measure restore the bones to something near position, the nostrils 
 may then be filled, though not too tightly, with lint ; or if there be a 
 tendency to epistaxis, with prepared oakum, and narrow strips of plaster 
 placed across the nose in such manner as to make the parts secure. The 
 septum of the nose being flexible may be turned to one side or the other, and 
 thus complicate the case. Under such circumstances the plugs may be in- 
 troduced from the posterior nares and thereby assist in restoring the sep- 
 tum and give support to the ossa nasi. In a case of this kind, I found 
 great contusion about the face, and profuse haemorrhage from the nose, 
 which was almost flattened upon the cheek. The epistaxis had continued 
 for an hour, and the patient was much exhausted. Upon examination, the 
 lower portion of the nasal bones (properly so called) were found broken, 
 and by introducing a female catheter along the floor of the inferior meatus, 
 the inferior cartilage could be felt turned to one side, and the loose frag- 
 ments of the inferior turbinated bone on the other. It struck me at once 
 that the haemorrhage might be arrested, the broken bones replaced and 
 held to a certain extent in situ, by plugging the posterior nares. I had not 
 a Bellocque's canula, and therefore substituted a well-curved male catheter, 
 and, by the ordinary method of procedure for arresting nasal haemorrhage, 
 plugged up the nares. By introducing at the external meatus conical 
 plugs of lint, and keeping them well up to the septum, I had the satis- 
 faction of seeing the nose almost restored to its normal position. It may 
 be remarked, that erysipelas of the face set in on the second day, which 
 was successfully combated by the usual remedies. 
 
 One of the best and most recent methods of treating fracture of the nasal 
 bones, especially when the breakage extends to the nasal process of the 
 superior maxillary, is that introduced by Mason. The deformity is to be 
 remedied as before noted with the catheter or sound, and by gentle manipu- 
 lation, the bones are to be replaced. A good-sized needle is then to be 
 passed transversely across the nose, through the line of fracture. A strong 
 and broad piece of tape, or an india-rubber bandage, is laid over the nose 
 and attached to the ends of the needle, which necessarily projects on either 
 side of the nose. 
 
 Fracture of the Superior Maxillary Bones. — Fractures of the upper jaw, 
 like breakage of the nasal bones, are caused by direct violence. The bones 
 are broken in many directions. The displacement also is varied. The 
 bone may be pressed downward and backward, or downward and forward, 
 or directly downward ; or be separated from its surrounding connections, or 
 it may be complicated with fracture of the nasal and malar bones. 
 
 The accident is often accompanied with symptoms of concussion, and 
 sometimes followed by severe inflammation and facial erysipelas. 
 
 Treatment. — The indications for treatment are to endeavor to mould the 
 parts into nearly a natural state as possible by using the fingers, and allow 
 the parts to remain quiet. If the alveolar margins are broken away, the 
 ends may be retained in their position by wire, although this, in many in- 
 stances, is difficult to accomplish ; or a gutta-percha splint may be moulded 
 to the bone. In the efforts to replace the fragments, the parts should be 
 approached both within and without the mouth. The symptoms of inflam- 
 mation and erysipelas must be combated with the usual medicines. 
 
 Fracture of the Malar Bones. — This fracture is produced by direct violence, 
 as falls, blows, or other injuries. There may be a depression of one of the 
 fragments or there may, in rare cases, be outward displacement. In the 
 generality of instances there is considerable injury done to the face, and the 
 accident is followed by much swelling, which for a time maj render the 
 diagnosis very obscure. By passing the finger along the zygomatic arch, by 
 attempted movement of the jaws, and in some cases by the projection of one 
 
FRACTURE OF THE INFERIOR MAXILLARY BONE. 551 
 
 of the fragments into the tendon of the temporal muscle, the diagnosis may- 
 be made. 
 
 Treatment. — If there is not much displacement a simple bandage is all 
 that will be required. If, however, there is evident depression, and the 
 movements of the temporal muscle are impaired, the effort should be 
 made to restore the fragments by manipulation within and without the 
 mouth. If the fracture be compound, and there is an opportunity of 
 applying an elevator to the depressed fragments, the facility of coapta- 
 tion will be very much increased. Some authors recommend that in a 
 simple fracture with depression, it is justifiable to make an incision, and 
 apply the elevator. It appears to me, that in each case the practitioner 
 should use his own judgment, and if material injury is threatened to the 
 temporal muscle, or, more properly, its tendon, it would be justifiable to 
 make an incision and use the instrument. If, on the other hand, the func- 
 tions of the mouth and jaws are not much impaired, nature may prove 
 sufficient for the necessary restoration. 
 
 Fracture of the Hyoid Bone. — This bone, from its peculiar situation, 
 being protected by the chin, and possessing a certain degree of mobility, 
 is not often broken. When the accident does occur, it is usually from a 
 blow upon the neck, either by falling against some unyielding body, or 
 from a sudden grasp of the hand or clinch of the fingers, or from the 
 tightening of a bandage around the neck. The patient is generally made 
 aware of the accident by a sudden sensation about the throat as though 
 something had given way ; severe pain is experienced in talking, degluti- 
 tion, in fact all movements bringing into motion the muscles connected 
 with the hyoid bone aggravate the suffering. Salivation and tumefaction 
 are likewise present, and sometimes haemorrhage from the pharynx, cough, 
 dyspnoea, and expectoration. 
 
 When passing the finger along the body of the hyoid, an inequality is 
 perceived, although in some instances the tumefaction is so great that this 
 may not be at once distinguished ; after a time, however, the mobility of 
 the parts can be more easily detected. 
 
 Fracture of this bone or of its cornu is often accompanied with severe 
 complications ; abscesses, oedema of the glottis, necrosis, and severe lacera- 
 tions of the soft parts. Puncture of the adjoining tubes and other unto- 
 ward accidents may lead to an unfavorable termination ; the complications 
 being, as a rule, of more import than the fracture. 
 
 Treatment. — In ordinary cases, excepting when the complications above 
 alluded to are present, for complete reunion of a fracture of the hyoid, from 
 six to nine weeks are required. Reduction of the fragments should be at- 
 tempted as soon as possible, by introducing the finger into the pharynx, 
 and moulding the parts, bringing them as nearly as possible into their natu- 
 ral position. There appears to be no especial rule as to the position of the 
 head, whether it be thrown backward, forward, or sidewise. The position, 
 according to circumstances, will vary in different cases, that one being 
 preferable which brings the fragments most nearly in apposition. After 
 the fragments are put in position, perfect rest must be enjoined, and the 
 head placed in the most comfortable manner and supported. Talking or 
 any movement of the jaws must be forbidden, and light nourishment 
 allowed, of a liquid kind and at long intervals. If the patient should 
 apparently suffer from want of sufficient nutrition, injections of beef tea 
 may be given per rectum. Compresses wet with a solution of arnica and 
 water should be constantly applied to the throat. 
 
 Fracture of the Inferior Maxillary Bone.— In most instances fractures of 
 the lower jaw occur in the body of the bone (Fig. 258), although the rami 
 may be the seat of the injury, as may the condyles ; though the latter is 
 
552 A SYSTEM OF SURGERY. 
 
 infrequent, The coronoid process, owing to its muscular covering, rarely 
 suffers. Some surgeons deny the existence of fracture in the direct line of 
 the symphysis, while others assert that separation of the bone does occur 
 in a direct line in that part. It is, however, difficult to decide precisely 
 
 the course of fracture. The causes are 
 FlG - 2 s8 - generally direct violence, as a blow, fall, 
 
 kick, etc., although a crushing force, as 
 the passage of a wagon or car over the 
 side of the face, will produce a fracture 
 of the body of the bone. The symptoms, 
 in the majority of instances, are easily 
 recognized. The line of the inferior 
 maxillary is broken, there is crepitation 
 when moving the part, and often severe 
 pain is experienced. When the bone is 
 fractured near the middle, there is a 
 tendency of the angles of the jaw to 
 spread outward. The points of the teeth have lost their regularity, and 
 when the bone is broken at both angles, the action of the throat muscles tends 
 to draw the central fragment downward. If the ramus be fractured, any 
 motion of the part is exquisitely painful, and the suffering is sometimes 
 attributed to the ear. In this variety of fracture the displacement is not so 
 well marked as in other parts of the bone, on account of the thick, strong, 
 and double layer of the masseter fibres, which cover this entire portion of 
 the bone. 
 
 An occurrence may also take place in fractures of the lower jaw which 
 may give rise to some perplexity, and perhaps may alarm the young 
 surgeon. I refer to haemorrhage from laceration of the inferior dental 
 artery. It may happen that the fragments become impacted, or driven 
 one behind the other. Dr. Buck gives an instance in which he was 
 obliged to dissect up the lip and use the saw before he could adjust the 
 fracture. Sometimes, from laceration of the nerves, the soft parts become 
 numb and insensible ; and in the majority of instances there is necessarily 
 difficulty of mastication and articulation, together with salivation and con- 
 tusion. The prognosis in simple fracture is favorable; if the bone is broken 
 in several places the treatment is often very unsatisfactory on account of 
 the difficulty of keeping all the parts in proper position. Dr. Stephen 
 Smith, of New York, reports a case in which, after careful treatment for 
 one hundred and thirty-seven days, the bone had not united ; and instances 
 are on record where years elapsed without bony union having taken 
 place. 
 
 Treatment. — When called to treat a fracture of the lower jaw, the first 
 thing to be done is to remove those teeth which the force has entirely sepa- 
 rated from the alveoli, while those that are partially loosened should be 
 carefully replaced in their sockets, and this must be attended to before dress- 
 ings are applied. A great number of apparatuses, some of them extremely 
 complicated, consisting of jack-screws, plates, wires, moulds of gutta- 
 percha, bandages, slings, etc., have been devised for the treatment of frac- 
 ture of the lower jaw. Many of these I shall not notice, but merely invite 
 attention to those which are simple in construction and best suited to the 
 object in view. 
 
 Velpeau,* on this subject, writes : "Unless there are very great displace- 
 ments, and difficulty in maintaining them reduced, I abstain from applying 
 any ' bandage.' The pain of the injury is amply sufficient to prevent the 
 
 * Velpeau's Lessons, p. 15. 
 
TREATMENT OF FRACTURE OF THE LOWER JAW. 
 
 553 
 
 Fig. 259. 
 
 Fig. 260. 
 
 patient from making any injurious movements, and the consolidation is 
 effected regularly without the patient being condemned to an immobility 
 which is a real hardship." 
 
 The simplest contrivance is the four-tailed bandage, and many satisfac- 
 tory cures have been made with it ; and this, with the application of the 
 pasteboard splint (Fig. 259), is frequently used by sur- 
 geons, especially by those residing in the country. To 
 make the four-tailed bandage, take a piece of muslin one 
 yard and a quarter long, and tear it longitudinally at 
 each end, to within four inches of its centre. To apply 
 it, lay a piece of pasteboard, which has been moulded to 
 the part, or the splint of Barton, on the jaw, and then, 
 having placed the middle of the bandage upon the chin, 
 the two upper ends are carried backward and tied on 
 the nape of the neck, and the two lower ones carried up 
 over the sides of the face and tied at the occiput. Sometimes a slit is made 
 in the centre piece, through which the chin is allowed to protrude. 
 
 Silver wire has also been used to keep the fragments in apposition, 
 and Dr. T. B. Gunning, of New York, has used vulcanized india-rubber. 
 
 Dr. Gibson's bandage (Fig. 260) is made by a 
 roller an inch and a half wide, which is passed in 
 circular turns under the jaw up the face, and over 
 the head several times ; it is then pinned at the 
 temple and turned at right angles, encircling the 
 back of the head and forehead by several turns ; 
 it is pinned again at the temple, and carried down 
 the side of the face and pinned on a line with the 
 chin ; carried then at right angles, several hori- 
 zontal turns are made, embracing the chin and 
 back of the neck. A strip of roller is then carried 
 over the top of the head and pinned to the 
 several turns, to secure the bandage from slip- 
 ping. 
 
 Dr. Rhea Barton's bandage, with the use of a pasteboard splint, is one 
 of the simplest and best that has been recommended. It consists in a 
 narrow roller, the initial end of which is to be placed under the occipital 
 protuberance ; the bandage is carried over the right parietal bone, obliquely 
 across the coronal suture to the left temple, down the left side-face, under 
 the jaw, up the right side-face, and obliquely over the coronal suture to the 
 left ear (above it), being carried around the occipital protuberance to the 
 right side, then passing under the ear, is carried around the chin, embracing 
 the neck and chin by a circular turn ; it is then carried on under the occi- 
 pital protuberance, over the right parietal bone, and again obliquely over 
 the coronal suture to the left temple, and continued in these turns until ex- 
 pended. 
 
 With each of these bandages it is necessary to have the compress or wet 
 pasteboard well adapted to the jaw. The patient must be nourished by 
 liquids, the teeth always leaving sufficient space for this purpose. When 
 the position of the fracture makes it practicable, it is a good plan to 
 bind the teeth together at the seat of fracture by passing a silk ligature or 
 silver wire around them. This plan is quite old and sometimes may be 
 successful. 
 
 Dr. E. A. Clark, of St. Louis, invented an interdental splint of gutta-percha, 
 which is held together with springs, and applied as follows. (Fig. 261.) The 
 directions are in Dr. Clark's words : 
 
 In order to adjust the splints properly, the springs should be compressed 
 
554 
 
 A SYSTEM OF SURGERY. 
 
 by grasping the plates between the thumbs and fingers so as to insert them 
 between the jaws, and place them in proper position upon the crowns of 
 the teeth, then force the fragments into their proper position, when the in- 
 ferior plate will be found to fit the jaw accurately, which it will not do until 
 the bone is properly adjusted. After the plates and fracture are once in 
 position, the mouth will be forced wide open by the action of the interden- 
 tal springs. This is counteracted by a sling bandage passing beneath the 
 jaw and over the top of the head, forcing the jaws in such proximity as to 
 leave a sufficient space between them in front to enable the patient to 
 take food and drink, and at the same time allow him to talk so as to be 
 understood distinctly, while he is also enabled to expectorate without diffi- 
 culty. The amount of space that will exist between the plates in front, 
 will depend upon the amount of force necessary to be used by the sling 
 bandage, and which should be just sufficient to place the fragments in their 
 proper axis. If the force required for this purpose should be greater than 
 the resistance of the springs in any given case, and force the plates in con- 
 tact with each other, the springs should be removed and replaced by 
 stronger ones. Another difficulty existing in the apparatus of Gibson and 
 Barton is obviated in this appliance, i.e., instead of drawing the anterior 
 fragment backwards, in which direction it is already displaced to some ex- 
 tent in fractures of the body of the bone, the interdental springs, when 
 compressed by the sling bandage, have a tendency to push the anterior arch 
 forwards, while, by keeping the inferior maxilla depressed by the force of 
 the springs, the submental muscles are in a measure relaxed, and the ten- 
 dency to displacement downwards and backwards of the anterior fragment 
 
 Fig. 261. 
 
 Fig. 262. 
 
 Clark"s Interdental Splint. 
 
 Hamilton's Apparatus for fracture of the lower jaw. 
 
 is diminished. Indeed, the principle involved in the apparatus is to sub- 
 stitute these two plates for the jaws, the former of which being entirely 
 under our control by means of the interdental springs, so that just as we 
 control the splints so do we control the jaw, while, at the same time, the 
 force exerted is operating upon the entire surface of both maxillse at the 
 same time, thus adapting the apparatus to fractures occurring at any point 
 of the jaw that can be reached by the material necessary to secure a cast of 
 the fragments, regardless of the absence or irregularities of the teeth, or the 
 character of displacement of the fracture. 
 
FRACTURE OF THE VERTEBRA. 555 
 
 Prof. Hamilton's sling is also often very serviceable, and is composed of 
 a maxillary strap made of leather, which passes under the chin perpendicu- 
 larly upward, and buckles upon the top of the head. A counter-strap is 
 then passed around the occiput and forehead, which, above the ears (Fig. 
 262), is looped upon the first-mentioned strap. A second counter-strap, 
 called "the vertical,'' passes over the top of the head to the maxillary strap, 
 which prevents the latter from dropping over the forehead. Beneath the 
 symphysis the maxillary strap is narrow, becomes wider at the sides of the 
 jaw. and to this, across the front of the chin, a strong piece of linen or 
 webbing is stitched. 
 
 An excellent interdental splint has been devised by Dr. Thomas Bryan 
 Gunning, of Xew York. Dr. Goodwillie likewise has invented a useful splint 
 for fracture of the lower jaw.* The most recent, however, is that of Levis. 
 
 Fig. 263. 
 
 SNOWDEN. ,v-.-,,- 
 
 Dr. Levis's Metallic Splint for fracture of lower jaw. 
 
 This splint forms a complete cap or covering for the entire chin and lower max- 
 illary bones, and keeps the fractured parts in the correct position. (Fig. 263.) 
 
 FRACTURES OF THE TRUXK. 
 
 Fracture of the Vertebrae. — When we consider the peculiar manner in 
 which the vertebrae are joined together, and how closely they are fitted by 
 numerous joints to each other, the shortness of their processes, the round- 
 ness of their bodies, the double curve of the entire column when the body 
 is erect, and the amount of tendon and muscular fibre with which they are 
 closely connected, a fracture would appear almost impossible. Neverthe- 
 less^ from great violence applied directly to the spinal column, or from 
 the indirect force of a fall from " a great height, these bones are at times 
 broken. The symptoms of fracture of the vertebra? differ materially ac- 
 cording to the portion of the column injured. Generally the most promi- 
 nent symptom is paralysis. If the lumbar vertebras are broken, the lower 
 extremities suffer, and there is in most cases complete or partial paralysis 
 of the legs, with involuntary passage of faeces and urine. Cases are recorded, 
 however, where fracture has occurred below the second lumbar vertebra, 
 without the power of motion being lost. 
 
 * For a full description of these splints the reader is referred to Xos. xviii. and xix. of 
 the Xew York Medical Journal; to a Report on the Progress of Surgery, by E. A. Clark; 
 and to a pamphlet on Resection of the Maxillary Bones, by Dr. Goodwillie. 
 
556 A SYSTEM OF SURGERY. 
 
 If the dorsal vertebrse are broken below the origin of the brachial plexus, 
 the superior extremities are not paralyzed, nor are the lower, but there are 
 abdominal and thoracic symptoms, torpid bowels, distended abdomen, and 
 retention of urine. If the upper dorsal or lower cervical bones are injured, 
 there is either partial or total paralysis of the upper extremities, together 
 with the general symptoms of paralysis exhibiting themselves upon the in- 
 testines and bladder. If the second or third cervical vertebra be injured 
 the phrenic nerves are involved and death soon takes place. There may be 
 crepitus, but in most cases it is absent, and displacement is often difficult to 
 recognize. 
 
 With the foregoing symptoms, and with a knowledge of the fact, that 
 paralysis may occur from extravasation and concussion, it will readily be 
 supposed that very often the diagnosis is difficult, and the prognosis bad. 
 In this connection, however, one point must be borne in mind, that the 
 spinous processes may be broken off without any material injury to other 
 parts of the column. 
 
 Treatment. — Vertebral fracture is generally fatal; little can be done 
 toward restoring displaced fragments, removing extravasations, or remedy- 
 ing the paralytic symptoms, the latter being caused by mechanical pressure. 
 Professor Hamilton, the best authority on the subject, says :* 
 
 " The first and most important requisite of successful treatment in a ma- 
 jority of these cases, is a water bed, since, without this, bedsores are almost 
 inevitable, if life is prolonged a few weeks. I have, in a few cases of late, 
 when the fracture was below the middle of the dorsal region, employed with 
 advantage moderate extension by means of a pulley and weight, the exten- 
 sion being applied to the lower extremities, in the same manner as in frac- 
 tures of the femur. In case this plan is adopted, the bandages employed to 
 make fast the adhesive plasters must not be applied very tight, lest they 
 should cause oedema and excoriations of the limbs, and the weight must be 
 light, not exceeding eight or ten pounds for an adult. In two examples also 
 of fracture of the cervical vertebrse, my patients have experienced great relief 
 from extension in the opposite direction, by means of straps fastened under 
 the chin and occiput." 
 
 Internal medication may be of considerable service in mitigating the suf- 
 ferings of the patient. If inflammatory symptoms supervene, aconite, bella- 
 donna, nux vomica, strychnia, veratrum viride, phosphorus, cuprum, ignatia, 
 cocculus, zincum, and that class of medicines, selected according to present- 
 ing symptoms, may be prescribed. 
 
 If there be violent fever, with inability to pass urine, aeon, may be ad- 
 ministered, at the same time compresses moistened with arnica solution may 
 be applied to the seat of fracture. If there be much urinary tenesmus, canth. 
 alone, or in alternation with arnica, will probably relieve the patient, if not, 
 bell., camph., hepar, puis., or sulph., may produce the desired effect. If 
 these means fail, the catheter should be used. 
 
 If there be a tendency of the spinal cord to take on inflammatory action 
 aeon, should be used ; it is one of the highly recommended medicines in 
 the treatment of myelitis. 
 
 When the inflammation is seated in the lumbar and sacral regions, when 
 the adjoining abdominal organs are affected, and the alvine evacuations dif- 
 ficult, bry. should be administered. 
 
 Ars., bella., cocc, dulc, dig., ignat, nux vom., puis., and veratrum may 
 be employed. 
 
 Effusion of blood and suppuration sometimes occur in the course of the 
 
 * The Principles and Practice of Surgery, New York, 1886. 
 
FRACTURE OF THE STERNUM. 557 
 
 spinal marrow, and in its sheath, which give rise to very dangerous symp- 
 toms. 
 
 The patient must be kept at perfect rest, in the horizontal posture, and 
 great care taken to prevent gangrene of the nates. This may be effected 
 by arranging pillows or air-cushions in such manner that the parts are equally 
 supported. If the skin assume a bluish appearance, or, from the constant 
 irritation of the parts, bedsores are present, a solution of arnica relieves the 
 sufferings of the patient. 
 
 Fracture of the Ribs. — This fracture results from being run over by heavily 
 laden wagons, or by being crushed between cars, or being thrust forcibly 
 against a wall. A powerful force is required to fracture a rib, especially in 
 children, in consequence of the mobility of these bones, and their attach- 
 ment anteriorly to elastic cartilages. The ribs which are most frequently 
 fractured are those which give roundness to the chest ; they are mainly the 
 fifth, sixth, and seventh. The accident is generally produced by indirect 
 violence. The bones are apt to yield about one-third, either from their 
 posterior or anterior termination, and the fracture generally is slightly 
 oblique. A single rib may be broken, or several may participate at the same 
 time. In the case of an old gentleman who was caught between two cars, 
 both in motion, at a railway station, four ribs gave way, the fourth, fifth, 
 sixth, and seventh, the patient hearing distinctly the snap of each fracture ; 
 the clavicle also was broken. 
 
 In these cases there is acute pain of a sticking character at the place of 
 injury, painful respiration, crepitus often, especially in lean subjects, and in 
 a majority of cases, emphysema. The patient often is conscious of the crep- 
 itus, detecting it when he attempts to take a full inspiration. These frac- 
 tures are not dangerous in themselves, but may become so from the irritation 
 produced from constant friction of the fragments, which are often spiculated, 
 against the pleura and lungs. 
 
 Treatment. — The most approved treatment of fractured ribs is to envelop 
 the body with a belt, or encircle the thorax with adhesive straps, bringing 
 the bones as nearly as possible into apposition. To accomplish this, two 
 pieces of antiseptic plaster should be used ; the initial end of one should 
 be placed on the anterior face of the thorax, and the initial end of the 
 other on the posterior surface of the chest. Having these well secured, 
 traction should be made on the free ends, which are to cross each other 
 as they are laid over the chest. For this purpose, gauze and collodion 
 will answer every requisite, and will " hold " even better than the adhesive 
 strips, possessing the advantage of allowing any application to be made 
 to the contused surfaces. If the fragments should press into the lung- 
 structure and so endanger the patient's life, the propriety of resection, or at 
 least elevation of the offending piece of bone should be considered. 
 
 If the lungs have been wounded, or any of the internal structures impli- 
 cated, arnica or calendula lotions should be kept applied to the part, and 
 either administered internally, according to the character of the wound and 
 the symptoms manifested. If inflammation of the pleura supervene, arnica 
 is an excellent internal medicine ; its characteristic indications are, stinging 
 pain in the affected part, dyspnoea, short, dry cough, general internal heat 
 with coldness of the hands and feet. Other medicines are, sulph., scill., bry., 
 nux vom., or ant. tart. 
 
 The costal cartilages may be fractured; the repair in such cases being 
 by bone, not cartilage. The force required to break these elastic communi- 
 cations of ribs and sternum is very great, and fatal results often accompany 
 the accident from severe injury done to other organs. The treatment is the 
 same as that for fractured ribs. 
 
 Fracture of the Sternum. — When a fracture of the breast-bone takes place 
 
558 
 
 A SYSTEM OF SURGERY. 
 
 it is usually at its articulation with the ribs. The bone originally is devel- 
 oped from six points of ossification, and is not fully solidified until adult age. 
 This fracture is usually transverse and is occasioned by direct violence. 
 The lower fragment rides slightly upon the upper, and by placing the pa- 
 tient in an upright position and forcibly drawing back the shoulders and 
 raising the arms, crepitus and mobility are detected. The accident, like 
 fracture of the ribs, is often complicated with severe injury of the thoracic 
 organs, and often is followed by suppuration and hectic. 
 
 Treatment. — The patient must be placed in the upright position, the 
 shoulders drawn back, and pressure made upon the over-riding fragment. 
 When this is adjusted, or nearly so, a compress should be placed over the 
 site of fracture, and adhesive straps applied around the chest above and 
 below, as well as over the fracture. A figure-of-eight bandage around the 
 shoulders, crossing over the back, will assist in maintaining the bones in 
 position. 
 
 Compresses, moistened with a solution of the tincture of arnica, should 
 be applied to the fractured part, and a dose or two of the medicine admin- 
 istered internally. 
 
 If the fever be synochal ; the pulse hard, quick, and full ; the face red ; 
 excessive chilliness or heat; the pains in the chest violent, and the respira- 
 tion oppressed and accompanied with anxiety, aconite should be given in 
 repeated doses. 
 
 If the pain in the chest is not exceedingly severe, but there are evident 
 signs of inflammation of the lungs, if a loose cough be present, the op- 
 pression not excessive,* with constant desire to inspire, bryonia should be 
 exhibited. 
 
 When there are evident symptoms of violent pneumonia, with sticking 
 pains in the chest excited by coughing or breathing (also pleuro-pneumonia) ; 
 when the pains are violent and extend over a large surface; when a consid- 
 erable portion of the lung is inflamed, with dyspnoea; when the cough is 
 dry and the sputa rust-colored, phosphorus is indicated, and will probably 
 relieve the patient in eight or twelve hours. This medicine may be given 
 in alternation with aconite or bella., agreeably to the presenting symptoms. 
 
 For further treatment of pneumonia the 
 student is referred to works on the Prac- 
 tice of Medicine. 
 
 Carious portions of the bone can be re- 
 moved by Hey's saw, bone-nippers, and 
 forceps ; but aid in this way should not be 
 rendered too officiously. 
 ~"\ JJJi - ''MS* The trephine has been successfully ap- 
 
 =^ '^S3!!|gpj|g|y plied in evacuating collections of pus in 
 
 **3 ^i^^f^^ JiMi anterior mediastinum. 
 
 ' E V^ Utf"" ^ai Fracture of the Clavicle. — A fracture of 
 
 the collar-bone may be caused either by 
 direct or indirect violence, although more 
 frequently by the latter. The exposed 
 situation of the bone, it being the imme- 
 diate support of the shoulder, renders it 
 very liable to be broken by a counter- 
 stroke, as a fall upon the hand, or the 
 stretching out the arm for protection when falling. If the bone were 
 straight it would even be more obnoxious to fracture, but nature, for its 
 safety, gives it the shape of the italic letter /, which, being a double arch, 
 adds materially to its strength. 
 
 The clavicle may be broken at its outer, its middle (Fig. 264), or its 
 
 Fig. 264. 
 
 Oblique Fracture near the middle third of 
 the Clavicle. 
 
FRACTURE OF THE CLAVICLE — TREATMENT. 
 
 559 
 
 inner third. Often the diagnosis is easy, but sometimes extremely diffi- 
 cult When the fracture takes place at the middle third, the deformity is 
 well marked ; the outer fragment is displaced inward and downward, occa- 
 sioned partly by the dropping of the arm and partly from the action of 
 the muscles which pass from the trunk to the shoulder, drawing upward 
 the inner fragment, The shoulder is flattened ; the patient supports the 
 injured side with the hand of the sound side applied to the elbow. The 
 integument is stretched tightly over the protruding end of the bone ; crepitus 
 can be produced by raising and rotating the shoulder ; indeed, the whole 
 appearance of the patient proclaims " fracture of the clavicle." It has been 
 stated that the shortening and deformity which exist, even after the best 
 managed cases of this fracture, are greater than those of any other bone, 
 excepting, perhaps, the femur. 
 
 Fracture of the Acromial Extremity of the Clavicle. — If the bone be broken 
 between the coraco-clavicular ligaments, there is seldom any displacement, 
 only a slight alteration in the direction of the bone, its convexity being in- 
 creased. 
 
 Treatment. — Numerous appliances have been introduced from time to 
 time for the treatment of this injury, some of which are cumbrous and 
 difficult of application, while others have the advantage of simplicity and 
 effectiveness. Dessault's apparatus, with its three rollers and anterior and 
 posterior triangles, has fallen entirely into disuse. Most of the more recent 
 appliances partake, more or less, of the principles of Fox's apparatus. 
 
 Fig. 266. 
 
 G.TIEMANN &VO> 
 
 Fox's Apparatus. 
 
 Levis's Apparatus for Broken Clavicle. 
 
 This latter contrivance is in use in the Pennsylvania Hospital, and proves 
 extremely satisfactory. It consisfs of a padded ring, with buckles attached, 
 which fits over the sound shoulder; and of a wedge-shaped pad, which fits 
 into the axilla of the injured side. From the top of this pad pieces of web- 
 bing are fastened, one of which is to be passed anteriorly over the chest and 
 buckled to the ring over the sound arm ; the other to be passed over the 
 posterior wall of the thorax and fitted to the posterior portion of the ring; 
 a sling made of stout linen or other material, in length about two-thirds of 
 the forearm, and in depth sufficient to cover it completely , is then applied to 
 the elbow and secured tightly to the ring (Fig. 265). The hand must be 
 supported by a bandage as seen in the cuts. 
 
 The following is the very ingenious apparatus of Dr. Levis. It consists 
 of a pad for the axilla, a shoulder strap, and a sling, and is adjusted in the 
 
560 A SYSTEM OF SURGERY. 
 
 following manner : The arm is passed through the opening above the pad, 
 the wide band is thrown across the opposite shoulder, the elbow placed in 
 the sling, and the long strap attached to the back of the sling and brought 
 round in front. The extra buckle noticed in the figure at the front of the 
 wide band comes into use when the apparatus is applied to the opposite 
 shoulder. The apparatus is seen in Fig. 266. Many surgeons are opposed 
 to the pad in the axilla, believing that it makes too much pressure upon 
 the great vessels and nerves ; and there is no doubt that serious conse- 
 quences have followed its application. To dispense with using the pad, 
 patients willing to submit to the irksomeness of the method, have been 
 placed upon the back, with the head low and with a hair pillow between 
 the shoulders, until the fracture is united, the use of any apparatus being 
 unnecessary. In hospital practice this plan is often ineffectual, because 
 the patients become dissatisfied* supposing that nothing is being done for 
 them. The following is a case in point : 
 
 H. R., aged forty, applied for admission into the Good Samaritan Hospital. 
 Upon examination I discovered a fracture of the clavicle at the middle 
 and sternal third. Upon inquiry I ascertained that he had been in another 
 hospital for ten days. Upon further questioning he informed me that he 
 had obtained his discharge because they did nothing for him, but " put him 
 in an uncomfortable bed." I fixed upon his shoulders the yoke which 
 comes with Day's patent splints, taking care that the extremities of the 
 splint projected a considerable distance beyond the shoulder (far enough to 
 prevent his turning in bed), and placed him in the recumbent position. 
 He became satisfied, endured considerable pain, and made a fair recovery 
 with the bone shortened a quarter of an inch. 
 
 Another simple method for fulfilling the indications of upward, outward, 
 and backward, is by placing a folded towel in the axilla of the injured side, 
 and passing a figure-of-eight bandage around from shoulder to shoulder ; or 
 a padded belt may be placed around each shoulder and drawn together by 
 a strap on the back. 
 
 A dressing of adhesive plaster, as practiced in Bellevue Hospital, was 
 first suggested by a surgeon residing in Western Xew York. Dr. Lewis A. 
 Sayre gives an excellent description of it* " The dressing is prepared by 
 cutting from strong adhesive plaster — that spread on canton flannel or jean 
 is preferable — two strips, from four to six inches in width, and one-half longer 
 than the circumference of the chest. These are to be applied as follows : 
 Begin by fixing the end of one strap upon the inside of the arm of the in- 
 jured side, opposite the insertion of the deltoid ; carry the strap across the 
 belly of the biceps and around the back of the arm. bringing the arm well 
 back. Continue the strap horizontally across the back and around under the 
 nipples to the back (Fig. 267). In fixing the end to the arm, care must be 
 taken not to begin too far back, lest the arm be girded and the circulation 
 arrested. Into the axilla a pad of proper size is to be placed, and the 
 elbow pressed to the side, which carries the shoulder well outward. The 
 hand should then be carried high upon the sound shoulder, and the elbow 
 supported at the desired point, while the second strap is applied as follows : 
 Begin in front of the sound shoulder, and carry the strap over the shoulder 
 diagonally down and across the back, so that its upper edge shall cross the 
 injured arm near the junction of the middle and lower thirds. The plaster 
 is then moulded to the back of the arm and elbow, and dorsal and ulnar 
 surfaces of the forearm, and finally drawn firmly over the back of the hand, 
 overlapping the other end of the plaster on the top of the shoulder (Fig. 
 
 * Bellevue and Charity Hospital Reports, 1S70, p. 131. 
 
FRACTURES OF THE SCAPULA. 
 
 561 
 
 268). It is well to fasten the ends together by a pin, which prevents the 
 possibility of slipping. At the elbow the plaster should be made to fit 
 accurately by cutting nicks in the end and lapping them." There are 
 several other means for the treatment of fractured clavicle, and as has been 
 
 Fig. 267. 
 
 Fig. 268. 
 
 Sayre's Dressing for Fractured Clavicle. 
 First Strap. 
 
 Sayre's Dressing. Front View. 
 Both Straps. 
 
 already mentioned most of them are constructed upon principles similar to 
 that of Fox. 
 
 Morgan's Apparatus for Fracture of the Clavicle is made wholly of sus- 
 pender webbing, H inch wide, with the usual axillary pad as the fulcrum 
 of the extending force upon the elbow and clavicle of the injured side. Buckles 
 are adjusted at the joints of the apparatus, two small ones for the narrow 
 straps suspending the pad, a larger one at their converging point on the 
 acromion, to receive the uppermost back strap (Fig. 269) ; four more of the 
 larger buckles at the four corners of the sling ; and, if desired, the use of 
 other buckles may be resorted to, to render the triangle of counter-extension at 
 the sound shoulder adjustable to patients of different sizes. 
 
 This triangle is obliquely " spherical," its longest side passing over the 
 shoulder, its shortest at right angles with the spine of the scapula, its third 
 across the side of the chest, just below the axillary folds, avoiding all con- 
 tact with these sensitive points. The angle thus formed in front sustains 
 a bifurcated strap, each end of which fits into one of the buckles of the 
 sling ; posteriorly the other two angles support the remaining three straps, 
 going respectively to the pad and- to the back corners, upper and lower, of 
 the sling ; the balance of all being thus perfected. An old coat will afford 
 the best ground on which to figure this system of straps. 
 
 The sling itself is of open work, for ventilation, of two longitudinal, and 
 more numerous transverse pieces, the former beginning and ending at the 
 wrist. Linen may be interposed everywhere, if desired, for cleanliness and 
 comfort, between the webbing and the skin. (Fig. 270.) 
 
 Fractures of the Scapula. — Fractures of the shoulder-blade, especially in 
 the vicinity of the surface articulating with the humerus, are very difficult 
 to diagnose. There is generally so much injury to the soft parts, that the 
 movements necessary to establish diagnosis are with difficulty performed. 
 In fact, a mere blow upon the deltoid may so impair motion, and give rise 
 
 36 
 
562 
 
 A SYSTEM OF SURGERY. 
 
 to so much swelling, that the parts may assume an appearance similar to 
 that of a severe injury of the joint itself. 
 
 Fracture of the acromion and neck of the scapula, dislocation of the 
 humerus downwards, fracture of the neck and head of the humerus,— -all 
 have many of their symptoms in common, and all require careful manipu- 
 
 FlG. 
 
 Morgan's Clavicle Apparatus. Front view. 
 
 lation, thorough anatomical knowledge, and an acquaintance with the signs 
 which may be diagnostic of each. 
 
 Let me illustrate this by a case or two which occurred in my practice, and 
 which caused me considerable anxiety. 
 
 Case I. — A man aged forty-five was driving a loaded wagon which came 
 in contact with a street car. By the violence of the concussion he was 
 thrown upon the pavement, striking on the right shoulder. He was very 
 severely bruised, and being picked up by passers-by, was carried to the 
 office of a neighboring physician. The medical man diagnosed a disloca- 
 tion of the humerus into the axilla, and called assistance for the reduction. 
 Several men were brought in, and after a time the arm was said to be 
 replaced, and the patient was sent to his home. He was placed in bed, 
 and shortly after a severe chill resulted, followed by high fever. The 
 arm still remained powerless at the side, and other physicians were sum- 
 moned. He gradually improved in his general condition, but his arm still 
 hung helpless ; his friends consulted many medical gentlemen, with as many 
 
FRACTURES OF THE SCAPULA. 
 
 563 
 
 different opinions. I saw the patient in consultation. His case presented 
 the following symptoms : There was a prominence over the point of the 
 acromion, but the shoulder was otherwise round. There was a slight de- 
 pression toward the extremity of the spine of the scapula. The arm could 
 be moved in different directions without much pain, and the hand could, 
 
 Fig. 270. 
 
 Morgan's Clavicle Apparatus. Back view. 
 
 with difficulty, be placed upon the opposite shoulder. There was some 
 swelling in the axilla, and I thought that I could detect the head of the 
 bone in that situation. Six or eight weeks had elapsed since the accident, 
 and I was quite at a loss for a correct diagnosis. 
 
 I could not agree with those surgeons who had declared that a downward 
 dislocation existed, nor could I satisfy myself as to the exact nature of the 
 accident. I placed the arm in a sling and supported it well at the elbow, 
 and extended a spiral bandage around the chest. Shortly after, I saw him 
 the second time, and found him not much improved. A few days after this 
 a relapse of fever occurred, and he died in about a fortnight. A post- 
 mortem examination, besides revealing multiple abscesses in the liver, 
 which I am convinced were caused by the severe contusion, showed about 
 three-quarters of an inch of the acromion process fixed firmly to the head 
 of the humerus, and a slightly ligamentous growth extending from the 
 broken extremity of the spine of the scapula to the acromion process. The 
 case was one of great interest to me. I am sure I may assert that fractures 
 
564 A SYSTEM OF SURGERY. 
 
 of the acromion, especially when there is but little displacement, are very 
 difficult to diagnose. 
 
 Case II. — A young lady was thrown violently from a carriage, and struck 
 upon her right shoulder. She was carried to a physician, who stated that 
 nothing but a contusion existed. The arm was powerless, and the pain 
 severe. After a period of some weeks she was seen by her own medical 
 adviser, with whom I saw her in consultation. The head of the bone was 
 in the axilla and to be felt. It moved with the humerus, there was the 
 double inclined plane formed by the muscles of the arm, and I was disposed 
 to regard the case as one of an unreduced dislocation. There was, however, 
 considerable motion of the part. By manipulation and rotation, I brought 
 the parts in apposition, and having them held there, applied a bandage. The 
 shoulder looked well after the dressing was applied, but in two days the 
 patient returned with the arm in the same position as formerly. There was 
 a depression below the acromion, quite well marked. The head of the hu- 
 merus was again in the axilla. The arm could be moved in various direc- 
 tions without much pain, and with but slight difficulty the hand could 
 be placed upon the opposite shoulder. When the arm was raised at the 
 elbow, the shoulder appeared much more natural, but the deformity re- 
 turned when upward pressure was relaxed. The diagnosis was a fracture 
 of the neck of the scapula. A wedge-shaped pad was placed in the axilla, 
 the arm secured to the thorax, and a sling used to elevate the elbow. In 
 both of these cases I could not detect any crepitus, and for this reason I 
 record them. In the latter case, it will be remembered that four weeks had 
 intervened between the accident and the examination, and in the former at 
 least two months. I mention these cases because they are both instructive 
 in several particulars. 
 
 Case III. — A gentleman of forty fell down through a hatchway a distance 
 of over thirty feet. He did not recollect exactly the posture he assumed 
 as he fell, and must have lain for a considerable time, stunned by the 
 severity of the blow. When I saw him, about four hours after the injury, 
 there was immense tumefaction of the shoulder. No depression could be 
 felt under the acromion process. I could not feel the head of the humerus 
 within the socket, nor within the axilla ; accurate measurement showed no 
 appreciable alteration in the limb ; yet, by fixing the shoulder and rotating 
 the arm, crepitus was detected. The elbow could be placed at the side, and 
 could, with much pain, be moved backward and forward. The fracture 
 was no doubt one of the intracapsular variety of the head of the humerus. 
 A simple sling and a narrow oblong axillary pad were all that was required. 
 A good recovery resulted. 
 
 I will now proceed to speak more in detail of the accidents occurring to 
 the shoulder-blade. These injuries cannot be too carefully studied by the 
 surgeon. They give the greatest anxiety to the most experienced, and often 
 present really insurmountable difficulties in diagnosis. 
 
 A fracture of the scapula may occur in the body, as well as at the neck or 
 processes of the bone. It is, in the majority of instances, the result of direct 
 and great violence. Oftentimes there is so much tumefaction that the diag- 
 nosis, especially in muscular or corpulent subjects, is very difficult. 
 
 In examining a patient where such fracture is supposed to exist, the first 
 course to be pursued by the surgeon is to trace with his finger the whole 
 contour of the bone. He should then manipulate, or endeavor to move its 
 body, both above and below the spine, and finally should press gently along 
 the entire course of the spine itself, a fracture of which is more easily recog- 
 nized than that of the body of the bone. 
 
 The forearm should be laid across the posterior wall of the thorax, when 
 there is reason to suspect a fracture of the infraspinatus fossa. The diag- 
 
FEACTUEE OF THE ACROMION PEOCESS. 
 
 565 
 
 Fig. 271. 
 
 nosis is also rendered more difficult by the absence of crepitus. This may- 
 result from the wide separation of the fragments, or from their closely riding 
 one upon the other. Though in fracture of the blade, there is difficulty of 
 motion in the shoulder, yet we must bear in mind that contusion may 
 produce this symptom, especially if the muscles be severely bruised. 
 The most general site of fracture of the body of the 
 bone is below the spine, and it is generally broken 
 transversely. The scapula may also be incom- 
 pletely fractured, of which Prof. Hamilton records 
 an example. 
 
 Treatment. — A (great variety of bandages have 
 been devised for the treatment of this fracture. The 
 simplest of these is probably the best, and this con- 
 sists of a bandage and sling, having at the same 
 time the elbow carried a little backward. The arm 
 should be allowed to hang by the side of the tho- 
 rax, and then bandaged to the body, with the 
 elbow in the position above named ; the forearm 
 should be supported by a sling. 
 
 Fracture of the Coracoid Process. — This portion of 
 the bone is not very liable to be broken, and dis- 
 tinguished surgeons have not, during an extended 
 
 practice, met with it, although there are many well-authenticated cases 
 upon record which prove beyond doubt that such an accident may 
 occur. As a general rule, however, there is more or less complication in 
 these accidents. A case came under my observation in which a man, 
 having fallen from a height and upon the right shoulder, broke off the cora- 
 coid process. The fracture was not recognized for some eight or ten days 
 on account of the amount of swelling. If the fracture is complete and 
 the coraco-clavicular ligament is ruptured, the combined action of the 
 coraco-brachialis, the pectoralis major, and the long head of the biceps, 
 tends to drag down the fractured end of the bone. To fulfil properly the 
 indications in the treatment of this fracture, it will be necessary to fix the 
 body of the scapula by frequent turns of the roller, or by long and broad 
 bands of adhesive plaster well applied. The elbow must then be drawn 
 forwards upon the anterior portion of the thorax, and the forearm placed 
 in a sling. 
 
 Fracture of the Acromion Process. — This lesion is of rare occurrence, and if 
 there be no displacement, it will be next to impossible to obtain a clear diag- 
 nosis. The best method of proceeding is to pass the finger along the spine 
 to the process, where the fracture may be felt. Perhaps crepitus may be 
 detected, or the line of the spine may be broken, and the depression behind 
 the acromion will point to the diagnosis. (Fig. 271.) 
 
 The following may be found useful as diagnostic signs : 
 
 Fracture of the Acromion. 
 
 Limb movable. 
 
 Hand can be placed upon opposite 
 
 shoulder. 
 Deformity remedied by lifting the 
 
 shoulder and by raising the 
 
 elbow. 
 Deformity recurs upon relaxing the 
 
 upward pressure. 
 Crepitus may be detected. 
 Depression found by tracing spine 
 
 toward the acromion. 
 
 Dislocation of Humerus into the Axilla. 
 
 Limb almost fixed. 
 The reverse. 
 
 Arm cannot be lifted to its place. 
 
 Deformity the same; cannot be removed by 
 
 upward pressure. 
 No crepitus. 
 No depression. 
 
566 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 272. 
 
 The apparatus for fractured clavicle, carefully and firmly applied, will 
 generally be found sufficient for fractures occurring behind the acromiocla- 
 vicular articulation ; whereas, if the break 
 is found to be anterior, the patient must be 
 laid upon his back, and the arm fixed 
 nearly at a right angle with his body, 
 thereby relaxing the deltoid, and lifting the 
 fractured extremity to its place. 
 
 Fracture of the Neck of the Scapula. — 
 This accident does not frequently hap- 
 pen. The symptoms which indicate it 
 are more positive than those belonging to 
 the breakage of the processes, which have 
 just been described, and which have many 
 indications in common with downward dis- 
 location of the humerus. The inexperi- 
 enced may mistake the fracture for the dis- 
 location. I have a case in mind, where 
 a man of sixty was placed under the influ- 
 ence of chloroform, and three stout Irish- 
 men were ordered to pull upon his arm. 
 This great pain was unnecessary, for there 
 was no dislocation, but a fracture of the 
 neck of the bone. More than one suit for 
 malpractice has been instituted, and dam- 
 ages recovered for a mistake made by the surgeon in diagnosing a dislo- 
 cation downward of the shoulder, when there was actually a fracture of the 
 neck of the bone. In both we have the head of the humerus in the axilla ; 
 in both we have a depression under the acromion process, the same loss of 
 motion, the same flatness of the shoulder, and the same numbness and 
 pain in the arm. The chief diagnostic signs are : First, the parts may, with 
 moderate facility, be restored to their normal position, but as soon as the 
 sustaining force is removed, the deformity reappears. Secondly, crepitus 
 may be felt, by having an assistant fix the body of the scapula ; then the 
 surgeon, raising the arm upwards with his right hand and manipulating the 
 shoulder with his left, will feel the grating of the fractured extremities. It 
 may be well also to remember that the flatness of the shoulder may assist 
 in diagnosing this injury from fracture of the head of the humerus, and that 
 in the latter, the limb is shortened. 
 
 The treatment is quite simple. Replace the humerus in its normal posi- 
 tion ; keep it there by the sling and pad used in fracture of the collar-bone. 
 Then fix the scapula by a bandage passed around the chest and over the 
 shoulder, or by broad adhesive strips. 
 
 Dr. C. H. Van Tagen* reports a case of fracture of the neck of the scapula 
 treated by means of the third bandage of Dessault, with Fox's ring and 
 sling, which made a good recovery. 
 
 In Fig. 272, an apparatus for fracture of the neck of the scapula is seen 
 (without the sling) which will be readily understood. 
 
 FRACTURES OF THE PELVIC BONES. 
 
 Fractures of the Os Innominatum— Fractures of the pelvis are generally 
 occasioned by great violence. Indeed, when we consider the formation and 
 position of the bones composing this portion of the human skeleton, it 
 
 * United States Medical and Surgical Journal, vol. ii., p. 51. 
 
FRACTURES OF THE OS INNOMINATUM. 567 
 
 would seem that nothing but great force could cause a solution in their con- 
 tinuity ; yet, in my researches upon this subject, I find a case recorded by 
 Cappelletti, in which the ascending branch of the ischium and descending 
 branch of the pubis were broken by muscular contraction. The patient, 
 fifty-four years old, had jumped from a carriage (the horses having run 
 away), with one leg in the greatest possible degree of abduction * 
 
 Mr. Handcockf reports an interesting case of fracture of the descending 
 ramus of the pubis. The patient fell from a height of about fourteen feet, and 
 presented the usual symptoms of shock ; the following symptoms then 
 resulted, which will give a fair resume of what may be found in such cases : 
 " On the tenth day, the patient got out of bed for the first time since the 
 accident, and endeavored to dress himself; but although entirely free from 
 pain in the buttocks, he was unable to raise his left foot from the ground ; 
 and, in attempting to do so, he said he felt something move in the perinaeum. 
 Crepitus was felt close to, but rather higher than the junction of the ramus 
 of the ischium and pubis on the left side. The shape and position of the 
 limb were natural. There was exact correspondence of the length of the 
 limb with its fellow; the leg resting on the bed in its straight position 
 could not be raised beyond about an inch, and then only with great pain, 
 neither could it be abducted beyond a certain distance (twenty-three inches 
 measured from heel to heel). When the patient lay straight in his bed, he 
 could bend his knee, and afterwards approximate the thigh to his body, 
 the foot being in this way entirely raised from the bed. He could not 
 assume the sitting posture without supporting himself on his hands. For 
 ten days the patient always referred his suffering to the left nates and the 
 lower parts of his back, and never to the seat of fracture, but this may be 
 attributed to the bruising of his buttock having been so severe." There was 
 not the slightest injury to the urethra and bladder. Mr. Handcock states 
 that, in examining a patient for this accident, the limb should be abducted 
 to put the adductor and gracilis muscles upon the stretch, and the thigh 
 afterwards rotated upon its axis ; as when rotation and circumduction were 
 employed, whilst the limb was adducted, no crepitus was felt, but after 
 previous abduction, crepitus was distinct. 
 
 This remarkable case, which presents many points to be remembered, 
 recovered without a single untoward symptom, the complete use of the ex- 
 tremity being regained. As will hereafter be stated regarding dislocation 
 of the pelvis, fractures are not necessarily fatal, the danger being as a rule in 
 proportion as the viscera are implicated. 
 
 Hamilton reports several cases of comminuted fracture of the pelvis 
 which it is unnecessary to quote here, as" the work is accessible to all. He 
 is of opinion that there is not much displacement, and if any occur, it is in 
 the upper fragment, which is carried slightly inward, although he admits 
 that occasionally it is displaced upward, outward, or downward. He also 
 quotes from the New York Journal of Medicine, a case reported by Lente, in 
 which a dislocation and fracture' of the alae of the pelvis on the same side 
 were recognized ; the patient died, and " the autopsy disclosed what had not 
 been suspected during life, viz., that the left ilium was broken horizontally 
 about its middle, and vertically through the crest, and also that there was a 
 fracture extending through the sacro-iliac synchondrosis, accompanied with 
 considerable comminution of the articular surfaces. It was also found that 
 a portion of the small intestine was ruptured, and probably by one of the 
 sharp fragments of the broken pelvis." 
 
 The anterior superior spinous process of the ilium is also sometimes 
 
 * Banking's Half- Yearly Abstract of the Medical Sciences, 1848, p. 83. 
 f London Lancet, May 23d, 1846. 
 
568 A SYSTEM OF SURGERY. 
 
 broken. The fragments are generally displaced downwards, and motion and 
 crepitus are distinct. In such cases the patient must be laid upon the back, 
 and the limbs drawn upwards to relax the muscles attached to the process, 
 and a bandage applied. The latter, however, is not absolutely necessary, 
 as cases are recorded wherein a good result was obtained by keeping the 
 patient in the position alluded to. 
 
 Sir Astley Cooper says :* " I have known of three instances of fracture of 
 the os innominatum recover ; two of these were fractures of the ilium, and 
 the nature of the accident was easily detected by the crepitus, which was 
 perceived upon moving the crest of the ilia ; the third was a fracture of the 
 junction of the ramus of the ischium and pubis. In the first two, a circular 
 roller was applied upon the pelvis, and the patient freely bled ; but in the 
 latter no bandage was employed." Mr. Sanford gives the details of a frac^ 
 ture passing through the body of the pubis on the left side, and through the 
 ramus of the left ischium. The patient was aged thirty years, and the acci- 
 dent had been produced by her body being pressed by the wheel of a cart 
 against a lamp-post. This case is too lengthy to quote in this place. The 
 symptoms were crepitus and mobility, easily recognized by placing the pa- 
 tient on the face, one hand on the back of the right ilium, and the other on 
 the pubis of the same side; the posterior spine of the ilium projected up- 
 wards ; a vaginal examination revealed the pubis passing inward into the 
 cavity of the pelvis ; there was also some extravasation of blood, vomiting, 
 cold feet, severe pain, great thirst ; pulse 90 and small ; the right leg was 
 shorter than the left, with numbness of that side. She lived about three 
 weeks ; the autopsy revealed what I have already stated. 
 
 In such cases the extension treatment is the appropriate one, and it ap- 
 pears to me that an excellent apparatus would be the wire-gauze splint of 
 Hamilton, applied with appropriate pads, with an additional band in front. 
 
 It very often happens, as will be seen from the cases mentioned, that frac- 
 tures of the pelvis are comminuted ; the pubis and ischium may be fractured, 
 or a distinct portion of bone may be severed ; these, if they do not unite, 
 must be exsected. 
 
 Fractures of the Acetabulum. — This injury is more difficult to diagnose 
 than any other affecting the pelvis. In this remark I should exclude 
 the breaking off of the rim or lip of the cotyloid cavity, which often hap- 
 pens in the ordinary dislocations of the femur, more especially that on the 
 dorsum ilii. In such cases, crepitus is present when the reduction is being 
 effected, and there is a great tendency for the head of the bone to slip from 
 its socket when the extending force is withdrawn. In such cases permanent 
 extension and a circular pelvic bandage generally suffice. 
 
 The difficulty of obtaining a correct diagnosis when fracture of the ace- 
 tabulum takes place is great, because the symptoms may simulate closely 
 those belonging to dislocation or fracture of the neck of the femur ; and 
 although Mr. Travers assertsf that " very acute pain produced by pressure 
 upon the projecting space of the os pubis, and the inability of the patient to 
 maintain the erect posture immediately after the infliction of a blow or fall 
 which produces the mischief," diagnosticate fissures or cracks in the ace- 
 tabulum, yet there are some other symptoms that must be considered when 
 the fractures are more extensive, especially when by sheer force the head of 
 the femur has been driven through the cotyloid cavity. 
 
 It is well known that there is a junction of the ilium, ischium, and pubis 
 within the acetabulum, and cases are recorded by Earle, and Cooper and 
 Travers, where the bones separated at their anatomical junction. When, 
 
 * Cooper and Traver's Surgical Essays, Phila., 1821, p. 39. 
 f Holmes's System of Surgery, vol. ii., p. 713. 
 
FRACTURES OF THE ACETABULUM. 569 
 
 however, the thigh-bone is driven through the acetabulum, the symptoms 
 are very liable to be confounded with fracture of the cervix femoris, as well 
 as dislocation of the thigh-bone. Mr. Earle* gives four cases which closely 
 simulated fracture, there being eversion of the foot and loss of prominence of 
 the trochanter ; the diagnosis being chiefly made out by the fact that the limb 
 could be drawn outward to a considerable degree without suffering, which 
 cannot be effected without much pain if the bone is broken. 
 
 Another case, however, is recordedf in which the affected limb was two 
 inches shorter than the other. 
 
 Sir Astley Cooper, in the essays already quoted, relates a case that " was 
 admitted to Saint Thomas's Hospital, having the appearance of a disloca- 
 tion backward. The patient lived four days. On examination, the frac- 
 ture was found passing through the acetabulum, dividing the bone into three 
 parts, and the head of the thigh-bone was deeply sunken in the cavity of the 
 pelvis." 
 
 Mr. William M. Tyer gives three cases of a similar injury, two of which 
 were mistaken for fractures of the neck of the femur, and the third for dis- 
 location. It is a curious fact that, in the majority of cases of this variety 
 of fracture, the cervix femoris has been found entire, although I find the 
 record of one case, by Dr. George W, Gibb,J in which not only was the 
 acetabulum extensively fractured, but there was an intracapsular fracture 
 of the neck of the femur. He also gives another interesting case of com- 
 minuted fracture of the pelvis, from which he draws such pertinent deduc- 
 tions that I quote them entire. He says of his case : 
 
 " 1st. There were the symptoms of fracture of the cervix femoris, when 
 that lesion was not present, as eversion of the foot, shortening, crepitus, etc., 
 and great nicety was required in forming a correct diagnosis. 
 
 " 2d. The shortened member could not be drawn down to an equal 
 length with its fellow of the opposite side, neither could it be inverted, and 
 motion in almost any direction gave great pain. 
 
 " 3d. None of the pelvic viscera were injured, although the catheter had 
 occasionally to be used, and blood was passed at stool. 
 
 " 4th. The fracture had become perfectly united, and the patient was on 
 the eve of discharge, whan another cause produced death. 
 
 " 5th. The sequence showing the union of the bones, bent in an irregular 
 manner ; the formation of a ligamentous acetabulum, with the wise provision 
 of nature in the total absence of any new deposit within the articulation 
 which might have interfered with the function of the joint." 
 
 From what I have already written, and as has already been mentioned, 
 from a careful inquiry and research, it has been found that the neck of the 
 thigh-bone is rarely fractured in these injuries ; that in the majority of 
 instances, if the limb is turned outward, the trochanter having lost its 
 prominence, with shortening, and severe pain when moving the limb in any 
 direction, we may be tolerably sure of fracture of the acetabulum. If 
 the foot is inverted, and the head, of the femur cannot be discovered in 
 either of the positions it is known to assume in the various forms of dislo- 
 cation, the fact must be remembered, that often the posterior lip of the 
 acetabulum is broken, and the femur may be dislocated. The presence, 
 however, of the head of the bone on the dorsum will readily diagnosticate 
 the luxation. 
 
 From the record of these cases, it appears that the treatment in most 
 cases of fracture of the innominata, consists, if possible, in reduction of the 
 
 * Medico-Chirurgical Transactions, vol. xix. 
 
 f Cyclopaedia of Anatomy and Surgery. 
 
 X Banking's Half- Yearly Abstract of the Medical Sciences, 1849. 
 
570 A SYSTEM OF SURGERY. 
 
 bones by proper manipulation, for which no especial rules can be laid down, 
 each case being left to the judgment of the surgeon, and proper extension 
 applied. Even the latter is not always necessary, as good recoveries have 
 been made by perfect rest and the body bandage. 
 
 It is a question in my mind, whether the median section of the perinseum 
 would not be a proper step to pursue in cases of rupture of the bladder, 
 when the surgeon is called shortly after the accident, as such measures 
 have lately been resorted to with good results in perforation of that viscus 
 by disease. 
 
 FRACTURES OF THE UPPER EXTREMITY. 
 
 Fracture of the Humerus. — The humerus may be broken in a number of 
 places, either in the shaft or extremities of the bone — the head, the surgical 
 and anatomical neck, the greater tubercle, the condyles, either one or both, 
 are all liable to the accident ; and this bone serving such an important part 
 in the usual avocations of life, it behooves us to study carefully both the 
 nature and treatment of those fractures to which it is liable, and to under- 
 stand especially the relations of the soft parts to the osseous structure, par- 
 ticularly the insertion of the deltoid. The supra- and infraspinatus and the 
 teres minor are attached to the greater tubercle ; the subscapularis to the 
 lesser tubercle ; the triceps behind, and the brachialis anticus and the biceps 
 in front, all give certain direction to the displacements which occur in frac- 
 tures in different portions of the bone. 
 
 There is sometimes a variety of that form of paralysis known as " wrist- 
 drop," which may result from injury to the musculo-spiral nerve, or one of 
 its branches, in fracture of the shaft of the humerus, or in fracture of the 
 condyle ; then the hand falls into a state of pronation and flexion. In the 
 college clinic such a case presented, in which the condyle had been broken 
 off, partial paralysis resulting. 
 
 We may begin by considering that variety of fracture which is perhaps 
 the most simple, viz., fracture of the shaft of the bone. This accident 
 occurs generally about its centre, and, as a rule, it is found more frequently 
 at the lower than at the upper half. It is, in the majority of instances, 
 oblique, and the displacement takes place in different directions accord- 
 ing to the seat of the fracture, and may, in extent, be from a half to three- 
 quarters of an inch. Crepitus is usually well marked, the deformity ap- 
 parent, except in transverse fractures, and the indications of treatment are 
 simple. 
 
 Treatment. — Extension must be made to bring the bones into apposition, 
 and a carved splint, or one of felt or leather, or binder's board, moulded to 
 extend two-thirds of the distance around the arm, be placed on the out- 
 side of the arm and should extend to below the elbow ; this splint must 
 be carefully applied while extension is being kept up by assistants. A 
 second short splint then may be set on the inside of the arm, and both 
 secured by a well applied roller. The forearm is then to be placed in a 
 sling, but without support at the elbow, as the weight of the arm will have 
 a tendency to keep the fragments in apposition. 
 
 In this variety of fracture the leather and wooden splints are found very 
 efficacious. The metallic splint of Levis also can be used, and will give 
 satisfaction. In my own practice I use generally the long outside splint, 
 and apply to the inside of the humerus a light wooden or pasteboard one, 
 which I inclose with the same bandage, and place the forearm in the ordi- 
 nary sling. At times, when there is a strong disposition of the bones to lap 
 over each other, Prof. Hamilton lets the forearm hang, thus promoting more 
 prolonged and powerful extension, and he relates cases where such treat- 
 ment was followed by excellent results. 
 
FRACTURE OF THE HUMERUS. 
 
 571 
 
 t Fracture at the Base of the Condyles.— These fractures generally are occa- 
 sioned by indirect violence, as a blow or fall upon the elbow, although cases 
 are recorded where they have been the effect of a direct blow upon the 
 humerus, immediately at the base of the condyles. The direction of the 
 fracture in the majority of instances is oblique and upward and backward. 
 Difficulty of diagnosis is experienced in distinguishing the accident from a 
 backward dislocation of the radius and ulna, and from complications which 
 may be connected with the fracture. The first duty of the surgeon is to 
 endeavor to discover if there be crepitus, which usually will be found, by 
 slowly and cautiously extending the arm, by which motion the fractured 
 ends of the bone can be again brought into contact. Preternatural mobility 
 cannot be relied upon if the fracture is not ascertained for some time after 
 the accident, and for two reasons : first, because very often the end of the 
 upper fragment may project into the elbow joint; and secondly, from the 
 stretching and bruising of the anterior muscles they become very rigid, in 
 fact as hard as in dislocation. There is shortening of the bone, which, 
 however, may be counteracted by extension, but the deformity returns 
 when the traction is discontinued. There is a large prominence on the pos- 
 terior and lower half of the bone, and the hand and forearm are in a state 
 of pronation. 
 
 Treatment. — An excellent method of treating this fracture is by means of 
 rectangular side-splints, as advised by Dr. Physick (Fig. 273), which may 
 
 Fig. 273. 
 
 Fig. 274. 
 
 Physick's Elbow Splints. 
 
 Hamilton's Elbow Splint. 
 
 be made of binder's board, felt, or leather, or by Johnston's splint, or the 
 well-known carved posterior splint. During the period of healing, the dress- 
 ing should be removed once a week, the fragments steadied, and passive 
 movements made, to prevent anchylosis of the elbow, to which this fracture 
 has a strong tendency. The roller should first be applied, from the arm 
 to the shoulder, then the elbow bent at its proper angle, and the splints 
 applied. The metallic splint of Levis is provided with hinges, and allows 
 passive motion, without much interference with the dressings. In two 
 cases which I recently had under treatment, I obtained satisfactory results 
 
572 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 275. 
 
 from a rectangular posterior splint of sole-leather moulded to the arm and 
 well padded. 
 
 One of the best splints for this accident is that of Prof. Hamilton as 
 seen in Fig. 274. It consists of gutta-percha, moulded 
 to fit the shoulder, arm, and forearm ; this must be well 
 padded, placed upon the limb and secured by the roller. 
 Fractures of the Head and Anatomical Neck of the Hu- 
 merus. — These fractures are generally caused by balls 
 and other missiles, which, entering the joint, complicate 
 the injury, either by fracturing the head of the bone or 
 lacerating the soft parts. Direct force applied to the 
 shoulder may also produce the injury. This fracture 
 may be intra- (Fig. 275) or extracapsular ; if the former, 
 bony union rarely takes place, and resection of the head 
 of the bone may sooner or later be required. The dis- 
 placement differs; sometimes the head of the bone is 
 impacted in the cancellated structure, or there may be 
 very little displacement, or the upper fragment may be 
 turned on its axis ; and cases are recorded where it has 
 been turned completely around. If the fracture be in- 
 tracapsular, undue violence must be avoided in en- 
 deavors to detect crepitus, and the arm and forearm be 
 well supported in a sling. 
 
 Fractures through the tubercles are generally occasioned 
 by forces similar to those producing fractures of the 
 head and anatomical neck of the humerus. There usually is not much dis- 
 placement, because the muscles covering these portions of the bone act over 
 
 a large surface, and equally on all the frag- 
 ments. There may be impaction, or the head 
 of the bone may be forced downward into the 
 axilla. 
 
 Treatment. — This fracture should be treated 
 with a simple sling if there is not much dis- 
 placement. If, however, there should be any 
 moving of the fragments, the apparatus used 
 for fractures of the surgical neck may be em- 
 ployed. 
 
 Fractures of the Surgical Neck. — There is 
 displacement in the majority of these frac- 
 tures, and the accident is one of not infrequent 
 occurrence ; the direction of the displacement 
 is toward the coracoid process. There may be, 
 but not necessarily, impaction. Several kinds 
 of treatment have been adopted, but the best is 
 the outside splint with a shoulder support. 
 
 Prof. E. A. Clark devised an excellent appa- 
 ratus for the treatment of this fracture. It 
 consists of two strips of adhesive plaster three 
 inches in width, applied to the internal and 
 external surfaces of the arm, as high up as the 
 upper and middle third of the humerus. The 
 strips are bound to the arm by a collar bandage, 
 and at their lower end beneath the point of the 
 elbow is fixed a cord to which a sand-bag is 
 attached, weighing from three to four pounds. 
 This sand-bag is attached close to the point 
 of the elbow, and when the patient wishes to walk, the cord to^ which it is 
 
 Fracture of the Ana- 
 tomical Neck of the Hu- 
 merus. (Iutra-capsular.) 
 
 Fig. 276. 
 
FRACTURE OF THE RADIUS. 
 
 573 
 
 suspended is knotted in order to make it shorter. When he lies in bed the 
 cord is loosed and carried beneath the bedclothing over a small pulley- 
 placed at the foot of the bed, and in this way an equal extension is kept up, 
 whether the patient be either in the upright or recumbent posture. The 
 dressing is seen in Fig. 276. 
 
 Fig. 277 represents the appliance of Mr. Richardson for fracture of 
 the upper portion of the humerus, whether through the anatomical or 
 the surgical neck, or through the tubercles. The lower fragment having 
 been drawn down, the upper one is maintained in its position by an axil- 
 lary pad. The outside splint is of sufficient length to reach from the acro- 
 mion midway to the elbow, and is held in position by adhesive straps. The 
 body splint, which tightly fits the side of the thorax, and is attached to the 
 arm splint, is kept in position by adhesive straps passing around the thorax. 
 
 Fig. 277. 
 
 Fig. 278. 
 
 G.TIEMAl^ico 
 
 Apparatus for Fracture of the Surgical 
 Neck of the Humerus. 
 
 Welch's Shoulder 
 Splint. 
 
 The arm is then brought to the side of the chest, and secured by several 
 turns of the bandage, and the hand placed in a sling. 
 
 Probably as efficient splints as can be found are those of Welch (Fig. 278), 
 Ahl, Johnston or Levis, which are readily applied. 
 
 FRACTURE OF THE FOREARM. 
 
 Fracture of the Radius — Neck. — A fracture of the neck of the radius is 
 very rare, indeed its occurrence has been denied by many distinguished sur- 
 geons. Cabinets, however, possess some specimens, though few, of uncom- 
 plicated fracture of the cervix of the bone ; and Prof. Hamilton ssijs of it, 
 while alluding to the single specimen in the Mutter collection, " While, 
 therefore, the presence of what may appear to be the rational diagnostic 
 signs has compelled me to record one case as an uncomplicated fracture of 
 the neck of the radius, and two others as fractures at this point accompa- 
 nied with a fracture of the humerus, or a dislocation of the ulna, I am pre- 
 pared to admit that some doubt remains in my own mind as to whether, in 
 either case, the fact was clearly ascertained, nor do I think, speaking only 
 of the simple fracture, that it will ever be safe to declare positively that we 
 have before us*this accident, lest, as has happened many times before, in 
 the final appeal to that court whose judgment waits until after death, our 
 decisions should be reversed." 
 
 The difficulty in making a correct diagnosis consists chiefly in the absence 
 
574 A SYSTEM OF SURGERY. 
 
 of crepitus, owing to the dense mass of muscular fibre which covers this 
 portion of the bone, and from the lower fragment being drawn away by the 
 powerful action of the biceps, the displacement being thus rendered greater 
 by extending the forearm. 
 
 Treatment.— It is very essential in this variety of fracture to flex the fore- 
 arm upon the arm, and to apply the dorsal splints, with an anterior one of 
 binder's board well secured with a roller bandage, or to use the apparatus 
 devised for the fractures of the olecranon by Dr. E. A. Clark, and which is 
 described when treating of that variety of lesion. 
 
 Fracture of the Shaft. — Before proceeding to detail these accidents, the 
 origin and insertion of the pronators of the forearm should be carefully 
 studied, as by such knowledge the direction of the displacement of the 
 fragments may be understood. If the bone is broken below the attachment 
 of the biceps and above the insertion of the pronator radii teres, of course 
 the counterbalancing action of this and the quadratus is lost, and the biceps 
 continuing its action on the upper fragment completely supinates it. If the 
 break occurs below the insertion of the upper pronator, this muscle, aided 
 by the biceps, draws the upper fragment forward, while the quadratus has 
 a tendency to force the lower fragment toward the ulna, thus making con- 
 siderable displacement. This teaches the surgeon the importance of supi- 
 nating the hand, when bringing the bone into apposition, otherwise if it 
 remain in a state of pronation, though it may be accurately adjusted, the 
 line of the axis of the bone will be lost, and though there may be no 
 apparent deformity, the power of supination is destroyed. 
 
 Treatment. — Supinate the hand as much as possible, and having applied 
 the roller, place a splint on the anterior and posterior face of the forearm, 
 and adjust the arm in a sling. Some surgeons prefer keeping the arm in a 
 state of semipronation, which, if the fracture is far down, answers well. 
 The plaster-of-Paris splint also can be advantageously used. 
 
 Colles's Fracture. — We next are to consider a fracture at the lower ex- 
 tremity of the radius, first described by Colles. This fracture has received 
 
 Fig. 279. 
 
 Fracture of Radius near lower end. 
 
 the attention of many surgeons, and requires such care in diagnosis and 
 treatment, and is so often accompanied with deformity, that it demands 
 all the attention of the practitioner. 
 
 By the term Colles's fracture is understood a fracture of the lower ex- 
 tremity of the radius, from one-half to three-fourths of an inch above its 
 carpal surface, with displacement of the lower fragment backward ; it is 
 generally transverse, although it may be from above downwards and inward. 
 It is, in the majority of instances, caused by a fall upon the palm of the 
 hand, though a force applied to the dorsum may produce it. The head of 
 the ulna points to the inner border of the carpus, and there is much de- 
 formity as well as displacement. (Fig. 279.) The hand takes an outward 
 direction, stretching to a degree the internal lateral ligament, producing 
 often the most excruciating pain. It is also called the " silvw fork " fracture. 
 
 It must be remembered that in a true Colles's fracture the articula- 
 
COLLES'S FRACTURE. 575 
 
 tion of the radius with the carpus remains intact, and that the ulna is not 
 broken. 
 
 There is another fracture which takes place in the vicinity of the wrist- 
 joint, called Barton's fracture, first described by Dr. J. Rhea Barton, of 
 Philadelphia.* It is of rare occurrence, and its peculiarity is that the frac- 
 ture separates either entirely or in part the posterior margin of the articular 
 surface of the radius. This accident is so infrequent that many surgeons 
 have supposed it to be merely a modification of the fracture described by 
 Colles. In all these fractures in the vicinity of the wrist-joint, the junior or 
 inexperienced must be prepared to meet more or less deformity, stiffness of 
 the joint and fingers, and considerable hard and tense swelling, which may 
 remain for months and even for years. This rigidity is caused by the effusion 
 of plastic lymph beneath the annular ligament and along the sheaths of the 
 numerous tendons which traverse the part, as well as spurious anchylosis, 
 which in greater or lesser degree follows in the majority of cases. With refer- 
 ence to this latter deformity I insert the testimony of experienced surgeons. 
 Dr. Mott wrote : " Fractures of the radius within two inches of the wrist, when 
 treated by the most eminent surgeons, are very difficult to manage so as to 
 avoid all deformity ; indeed, more or less deformity may occur under the 
 treatment of the most eminent surgeons, and more or less imperfection in 
 the motion of the wrist or radius is very apt to follow for a longer or shorter 
 time. Even when the fracture is well cured, an anterior prominence at the 
 wrist or near it will sometimes result from swelling of the soft parts." 
 Another says : " As the above opinion of Professor Mott coincides with my 
 own observations both in Europe and this city, as well as with many of our 
 most distinguished surgical authorities, I venture to hope that it may assist 
 in removing some of the groundless and ill-merited aspersions which are 
 occasionally thrown upon the members of our profession by the ignorant 
 or designing." 
 
 Treatment. — A great variety of apparatuses have been invented and used 
 by surgeons for the treatment of fractures in the vicinity of the wrist, all 
 resembling more or less the "pistol-shaped splint." It must be remem- 
 bered that the great object in view is the raising of the lower fragment 
 
 Fig. 280. 
 
 Bond's Splint. 
 
 to its place, and maintaining it in apposition with the upper. Sometimes 
 this may be accomplished by a palmar and dorsal splint applied to the fore- 
 arm, the hand being allowed to drop, and by its weight falling to the ulnar 
 side of the forearm, may preserve the bones in apposition. Some forcibly 
 flex the hand upon the wrist and keep it there. 
 
 Velpeau renounced, in his later years, all bandages which were complex, 
 and used a simple contrivance, the idea of which he stated he received from 
 a Danish surgeon. He says :f " At first I obtain immediately the required 
 position by very strongly flexing the hand upon the forearm at a right 
 angle. The extensor tendons thus constitute a pulley to push back the 
 fragments. The limb is then fixed in this situation ; a dry roller and a 
 
 * Philadelphia Medical Examiner, 1838. * Velpeau's Lessons, p. 27. 
 
576 
 
 A SYSTEM OF SURGEEY. 
 
 Fig. 281. 
 
 graduated compress upon the back of the forearm and the hand ; a splint 
 of moistened pasteboard which moulds itself perfectly, and a dextrine ban- 
 dage maintains the whole." 
 
 The splint I formerly used, and with a good deal of success, was that of 
 Dr. Bond, of Philadelphia (Fig. 280). It can be made by any one having a 
 moderate degree of ingenuity, and is simple and will prove satisfactory. 
 With a little care a properly cut shingle or the side of a cigar box, suitably 
 padded, will make an excellent pistol splint. 
 
 Hamilton's splint (Fig. 281) is made from a wooden shingle, and should 
 extend from half an inch below the bend of the elbow to the metacarpo- 
 phalangeal articulation. The splint should 
 be well padded, and applied on the palmar 
 surface of the arm. 
 
 Dr. Levis's Splint. In the treatment of 
 fracture of the lower end of the radius it is 
 essential that proper allowance be made for 
 the curvature of the anterior or palmar sur- 
 face of this part of the bone. This is insured 
 in this splint, which follows correctly the radial curvature ; and the fix- 
 ing of the thenar and hypothenar eminences of the hand in their moulded 
 beds, maintains the splint immovably in its correct position with reference 
 to the radial curve. 
 
 To the neglect of complete primary reduction of the displacement of the 
 lower fragment, and to inefficient restoration and retention of the normal 
 radial curve, are due the frequent unfortunate sequences of this fracture. 
 
 No dorsal splint is needed, but a small pad will, in most cases, be required 
 over the dorsal surface of the lower fragment. For retention of the splint 
 an ordinary bandage, two inches and a half to three inches wide, is all that 
 is necessary. 
 
 Fig. 282. 
 
 Hamilton's Splint for Fracture of the 
 Radius. 
 
 Dr. Levis's Metallic Splint for Fracture at the lower end of the Radius. 
 
 This splint has the merit of being applicable to all cases of fracture of 
 the lower end of the radius, and also to many other injuries involving the 
 forearm and wrist. (Fig. 282.) 
 
 Professor Moore, in an interesting paper on Colles's fracture, gives a 
 dressing so simple and efficacious as entitles it to notice. He observes that 
 in Colles's fracture especially, there is a luxation to encounter, as well as a 
 fracture, and that the former must be reduced before the latter. He says :* 
 
 Vide Transactions of the Medical Society of the State of New York, 1870, p. 238. 
 
TREATMENT OF COLLES's FRACTURE. 577 
 
 11 The patient may be etherized or not. An assistant holding the forearm 
 of the patient, the surgeon grasps his hand, the right with the right, and 
 vice versa. With the other hand placed under the forearm above the frac- 
 ture, he is enabled to bring the thumb over the back of the ulna, the fingers 
 wrapping around the radius. Traction is first made by extension, then 
 drawing the hand laterally to the radial side, then backward, next keeping 
 it held backward, and while making extension, it is swung toward the ulnar 
 side, bending well laterally, when the extension of the hand is changed for 
 flexion, thus describing nearly a semicircle in circumduction. The position 
 of the hand grasping the forearm undergoes constant change, as it is the 
 antagonist of the other hand in everything but the extension. As the back- 
 ward position of the hand, when it is carried to the extreme ulnar side, is 
 changed to flexion of the hand, the thumb of the surgeon rolls around the 
 border of the ulna, and is below when the manoeuvre is complete. The test 
 of reduction is to be found by the presence of the head of the ulna on the 
 radial side of the ulnar extensor. 
 
 " The head of the ulna rests mediately, through the triangular fibro-car- 
 tilage, on the cuneiform bone, and is restrained from going backward by the 
 annular ligament, holding on each side the tendons of the extensor minimi 
 digiti, and the extensor carpi ulnaris, thus making a concavity correspond- 
 ing in form to a socket. When it is pressed into this socket, and the hand 
 flexed so that the head is supported by the wrist, the position of the hand 
 is also restored in its relation to the radius. As a result of the displacement 
 of the ulna, the ulnar extensor is carried from its place above the styloid 
 process to the opposite side of the ulna in an extreme displacement, but 
 sometimes remains above its centre. To disentangle the styloid and swing 
 the tendon of the ulnar extensor over into its place, is the purpose of the 
 manoeuvre. The hand is drawn toward the radius to pull off (by stretch- 
 ing) the annular ligament. The backward motion, accompanied with ex- 
 tension, renders the ulnar extensor tense, which serves to draw the annular 
 ligament backward. This is effected by pressing the thumb upon the ulna. 
 The circumduction carries the tendon over the side. Its character as a 
 luxation is still further shown by the fact that the restoration is often 
 accompanied by a snap, both tangible and audible. If restored, the reten- 
 tion is effected by a compress and bandage of adhesive plaster. When the 
 manoeuvre described has been completed, the hand is flexed, and the thumb 
 of the surgeon rests on the under side of the ulna. Its head appears on the 
 back of the wrist, and corresponds with the opposite arm in every respect, 
 except the swelling from blood effusion. As in the treatment of any other 
 luxation, the effort should not be abandoned until the deformity is removed 
 and the ulnar extensor in its place — a fact that can be determined at once. 
 The dressing I propose is intended to hold the head of the ulna up in its 
 fascial socket, by bringing the weight of the hand to bear upon the ulna to 
 retain it home. If the thumb of the surgeon is kept under the ulna after 
 reduction, it will be found that the weight of the hand is sufficient to keep 
 it in place. As a substitute for the thumb I placed along the ulna, from 
 the pisiform bone upward, a cylindrical compress about two inches in 
 length, and about half an inch in thickness — in fact, a single-headed roller. 
 This is placed against the ulna, resting also on its radial border against the 
 tendon of the flexor carpi ulnaris. A band of adhesive plaster of the same 
 width is wrapped firmly around the wrist and over the compress, extending 
 downward to the extreme point of the radius, thus grasping the bones neatly 
 and tightly. The ordinary rule of loose dressing on the first visit to a frac- 
 ture is one that I distinctly reject. I propose to bring all the parts into 
 close relation. The patient is allowed to cut the bandages along the back 
 of the wrist in about six hours, if the swelling and pain seem to demand it. 
 
 37 
 
578 A SYSTEM OF SURGERY. 
 
 But I find it is not often done. The thickness of the compress raises the 
 adhesive plaster so far from the anterior surface of the forearm that stran- 
 gulation of the vessels does not take place. Moreover, the compress yields 
 a little, and thus diminishes the pressure. A narrow sling passing under 
 the compress, so as to bring the hand's weight to bear upon the ulna, com- 
 pletes the dressing." 
 
 I cannot close this subject, without allusion to a paper which has ap- 
 peared on the subject of wrist-joint injuries* and which certainly, so far 
 as the explanation of the various appearances resulting from Colles's frac- 
 ture and the great simplicity of the treatment recommended, is the most 
 rational that has yet been offered to the profession. Dr. Pilcher claims, 
 and I think proves, that in the majority of cases it is the severe sprain 
 that always occurs in Colles's fracture that demands the chief atten- 
 tion in the treatment. He explains the manner in which the fracture 
 takes place, as well as the resulting deformity, with accuracy. Owing to 
 the firmness of the articulation between the carpus and the metacarpus 
 they virtually act as one bone, joined to another (the radius) by strong 
 anterior and posterior ligamentous attachments. By forcible extension 
 of the hand backward, of course the ligaments posteriorly are put upon 
 the stretch, while the anterior are somewhat relaxed, by which the end 
 of the radius slips forward as far as that relaxation will allow. If the 
 force be continued in the same direction the bone gives way above the liga- 
 ments, thus making the fracture. He says, " The lower fragment of the 
 radius is now virtually a part of the carpus, with which it moves and by 
 which it is carried backwards. At its inner border it is still tied to the 
 ulna by the triangular fibro-cartilage and by the radio-ulnar ligaments ; at 
 its outer border, being less restrained, the fragment has been displaced to a 
 greater extent than at its inner, as the result of which, a decided inclination 
 to the radial side has been impressed upon the entire hand and wrist. The 
 upper fragment driven downward and forward has become entangled in the 
 lower, near its palmar margin. The impaction is but slight, and disentan- 
 glement is easy when the attempts are properly made. The lower fragment 
 is a broad thin shell of bone. If the upper fragment is driven into it with 
 much force, its comminution is inevitable. That this sometimes occurs, 
 post-mortem examinations have repeatedly demonstrated." 
 
 He then goes on to show that the periosteum on the lower and back part 
 of the radius is very thick, and strengthened by fibres from the posterior 
 ligaments of the wrist, and that this periosteum is not torn but stripped up 
 from the back of the upper fragment, in accordance with the amount of 
 displacement of the lower fragment. 
 
 He says further : " When the radius has given way, and the force of 
 extension is no longer arrested by the insertion of the anterior ligament 
 into its broad margin, this force is felt strongly by that portion of the liga- 
 ment which is inserted into the ulna ; the whole hand with the lower radial 
 fragment is caused to move backward and outward as in supination. The 
 styloid process of the ulna becomes approximated to the radius upon the 
 back of the wrist, while the rounded head of the ulna is brought to project 
 strongly upon the front and inside of the wrist. In this position the parts 
 are firmly held, all rotation in either direction being prevented as long as 
 the backward displacement of the lower radial fragment remains unre- 
 duced." This peculiar appearance, which I own has often puzzled me, and 
 I hav.e never been able to understand, nor have I ever had it satisfactorily 
 explained, is said by Dr. Pilcher to consist in the action of a strong fasciculus 
 
 * Eeason vs. Tradition in the Treatment of Certain Injuries of the Wrist-joint. By 
 L. S. Pilcher, M.D. Proceedings of the Medical Society of the County of Kings, March, 
 1878. 
 
FRACTURES OF THE ULNA. 
 
 579 
 
 of the anterior ligament passing from the front of the cuneiform bone 
 upward and inward to the ulnar side, to be inserted into the anterior border 
 of the styloid process of the ulna. By the backward displacement of the 
 carpus this is put upon the stretch, and limits all rotation until relaxed. 
 
 The points in treatment to be deduced by these anatomical peculiarities 
 are these : First, that always in Colles's fracture there is a severe strain, the 
 treatment of which is of paramount importance. Second, that the mere 
 breaking of the radius transversely entails no permanent disability. Third, 
 that it is the sprain from which those untoward results occur which I have 
 already detailed when speaking of this injury. 
 
 The fracture of course must be first reduced, which is often difficult, but 
 can be accomplished thus : " By simply bending the hand and wrist back- 
 ward, approximating the position in which the parts were when the dis- 
 placement took place, the tense periosteum is relaxed. Slight extension 
 now in the line of the forearm is sufficient to disentangle the rough surfaces 
 of the fragments from each other. Moderate pressure upon the dorsum of 
 the lower fragment causes it to fall into line. The weight of the hand is 
 now sufficient to secure perfect apposition of the fragments ; the periosteum 
 again envelops closely the whole length of the radius ; the tense inner 
 fasciculus of the anterior ligament is completely relaxed ; the radio-ulnar 
 movements are free ; the head of the ulna has ceased to project as if sub- 
 luxated." Therefore we see, for fractures without displacement, that if 
 the wrist is supported in the prone position, and the hand allowed to hang, 
 and appropriate straps applied, a good result may be antici- 
 pated. When there is displacement, the fracture may be re- fig. 283. 
 duced as above directed, and the application of a broad and 
 strong strip of adhesive plaster, two inches wide, around the 
 lower ends of the radius and ulna, sometimes assisted by a 
 compress applied along the inner border of that bone, is all 
 that is required. 
 
 This is the treatment which appears rational in every par- 
 ticular, and certainly the best theoretically. I have not tried 
 the method, but shall as soon as an opportunity offers, and 
 the members of the profession must thank Dr. Pilcher for his 
 information concerning the u untorn aponeurotic dorsal peri- 
 osteal strip, and the inner oblique fasciculus of the anterior 
 ligament " in fractures of the radius, as they have awarded 
 their praises to Dr. Bigelow for his explanation of the action of 
 the ilio-femoral ligament and the obturator internus muscle in 
 coxo-femoral dislocations. 
 
 Fractures of the Ulna. — Any part of this bone may be frac- 
 tured, the accident being generally occasioned by direct vio- 
 lence. The displacement sometimes is not very w T ell marked, 
 but if the injury be near the centre of the bone, the tendency 
 of the inferior fragment is toward* the interosseous space (Fig. 
 283) owing to the action of the pronator quadratus muscle, 
 while the firm articulation of the superior fragment with the 
 humerus will prevent that portion from being thrown inward. the uina. 
 The bone lying superficially beneath the integument on the 
 inner side of the arm, the deformity and crepitus will readily be detected. 
 A fracture of the ulna is often complicated with other injury, especially 
 dislocation of the head of the radius forward. This necessarily increases 
 the deformity and shortens the forearm from one-half an inch to an inch. 
 
 Treatment. — Make extension with the hand supinated, and press w T ith 
 the finger and thumb the broken fragments to their places, and apply 
 dorsal and palmar splints well padded. If the tendency of the lower frag- 
 
580 A SYSTEM OF SURGERY. 
 
 ment be towards the interosseous space, the ringers must be passed along 
 the border of the radius and the parts separated, and a graduated com- 
 press applied on the integument, over which the roller is to be turned, and 
 the splints used as before. If the head of the radius be dislocated, the 
 arm must be flexed to relax the biceps, and counter-extension made by 
 holding firmly the condyles of the humerus, while the head of the bone is 
 pushed into its place. 
 
 Fracture of the Coronoid Process. — This fracture is exceedingly rare, and 
 the cases that are cited of it are all more or less amenable to criticism. 
 Its symptoms are displacement of the ulna backward, its process felt on 
 the anterior face of the elbow-joint, and if broken off it may be drawn up- 
 ward by the action of the anterior brachial muscle. When extension is 
 made with the forearm the resemblance to luxation disappears, to return, 
 however, when the traction is no longer applied. Another important 
 symptom would be, that the olecranon, prominent when the arm was in an 
 extended position, would resume its natural shape when the forearm was 
 flexed (Fig. 284). 
 
 The treatment would be to flex the arm at a right angle, and retain it with 
 angular splints from eight to ten days, then to allow a little motion to pre- 
 vent anchylosis, and the splint reapplied. 
 
 Fracture of the Olecranon. — Fractures of the olecranon process are, in most 
 instances, occasioned by falls or blows upon the posterior surface of the 
 elbow-joint, or, though rarely, by the powerful contraction of the triceps. 
 The direction of the fracture is generally transverse, although sometimes 
 oblique. It is scarcely necessary to observe that the only direction of the 
 superior fragment is upward, owing to the action of the three-headed muscle 
 which is inserted into the process. 
 
 The symptoms are, first, a depression on the posterior surface of the joint; 
 inability to straighten the arm and the absence of crepitus, although some- 
 times this may be produced by extending the arm 
 FlG - 284, and forcing downward the upper fragment upon 
 
 the lower. This is more readily effected when the 
 patient is thoroughly under anaesthetic influence. 
 The fragments sometimes unite with ligament, 
 sometimes with ossific matter. 
 
 Considerable discrepancy of opinion exists as 
 to the position the arm should maintain during 
 the treatment of this fracture, some insisting upon 
 flexion or semiflexion, while others are emphati- 
 cally in favor of extreme extension. Velpeau as- 
 serts positively that " it is not in the least neces- 
 sary to obtain a union of the fragments," because 
 the olecranon is free and analogous to the patella 
 in very many animals, without impairing the 
 movements of the limb, and that the only possi- 
 ble harm that can result is an inability to extend 
 the arm completely ; he considers nothing more necessary for its treatment 
 than the application of a figure-of-eight bandage. 
 
 Notwithstanding such distinguished authority, I think too little impor- 
 tance is attached to the olecranon process. It is true that the actions of some 
 animals, having a species of movable olecranon, are not impaired, but the 
 movements are those of extension and flexion only. The motions of the 
 human arm require the olecranon to be fixed. 
 
 Treatment. — In treating this fracture complete extension should be made, 
 and as a general rule it is better to relax the triceps, and then to bring the 
 parts in apposition with the usual apparatus. The figure-of-eight bandage 
 
FRACTURE OF THE OLECRANON. 
 
 581 
 
 simply applied to draw the fragments in apposition has been employed 
 with success. The apparatus of Sir Astley Cooper, with transverse bands 
 and lateral tapes, is also successfully used. Several folds of the roller are 
 placed securely above the elbow, and a similar number below it. Two 
 lateral tapes are then passed beneath these and drawn tightly together ; 
 above this a straight carved splint or one of felt, leather, or pasteboard is 
 applied. A plaster of Paris bandage may be substituted for the roller. 
 
 Professor Hamilton's method is as follows : " The surgeon will prepare 
 extemporaneously always, for no single pattern will fit two arms, a splint 
 from a long and sound wooden shingle, or from any piece of light thin 
 board. This must be long enough to reach from near the wrist-joint to 
 within three or four inches of the shoulder, and of a width equal to the 
 widest part of the limb. Its width must be uniform throughout, except 
 that at a point, corresponding to a point three inches or thereabouts below 
 the top of the olecranon process, there shall be a notch in each side, or a 
 slight narrowing of the splint. One surface of the splint is now to be 
 thickly padded with hair, or cotton batting, so as to fill all the inequalities 
 of the arm, forearm, and elbow, and the whole covered neatly with a piece 
 of cotton cloth, stitched together on the back of the splint. Thus prepared, 
 it is to be laid upon the palmar surface of the limb, and a roller is to be 
 applied, commencing at the hand and covering the splint by successive 
 circular turns until the notch is reached, from which point the roller is to 
 pass upward and backward behind the olecranon process, and down again 
 
 Fig. 285. 
 
 to the same point on the opposite side of the splint. After making a second 
 oblique turn above the olecranon, to render it more secure, the roller may 
 begin gradually to descend, each turn being less oblique, and passing through 
 the same notch, until the whole of the back of the elbow-joint is covered. 
 This completes the adjustment of the fragments, and it only remains to carry 
 the roller again upwards by circular turns, until the whole arm is covered 
 as high as the top of the splint." - 
 
 The following is a minute description of Prof. E. A. Clark's apparatus, 
 given by himself, he having allowed me the use of the drawing (Fig. 285): 
 
 The apparatus above represented consists of a band of ordinary sole 
 leather, about two inches in width, and of sufficient length to surround the 
 arm, lined with cloth or chamois, and well padded with cotton or hair. In 
 order to give the band additional firmness, and also to secure it around the 
 arm, a strip of common harness leather is stitched upon the outside, to one 
 end of which two small buckles are attached, while the other end, which ex- 
 tends about three inches beyond the band, is split or cut into two straps to 
 correspond with and fasten into the buckles. The band is fastened around 
 the arm above the fractured process, and may be drawn to any degree of 
 
582 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 
 
 tightness necessary to bring the broken fragment down when traction is 
 made upon it. 
 
 The same band may be used on either arm. and may be adapted to an 
 arm of any size. On the outer side of this band, and one inch apart — one on 
 each side of the olecranon — are two buckles or staples, which should be 
 two inches in length and three-fourths of an inch in width, and clinched 
 on the inside of the leather band, from which they project at a right angle. 
 These buckles or staples also have three bars across them, with two tongues 
 made to turn either way. 
 
 In applying this apparatus the arm should be fixed at an angle of forty- 
 five degrees, and a common pasteboard splint bent at that angle placed 
 upon its anterior surface. The leather band is then buckled over this 
 splint, just above the fragment of the olecranon, and the entire forearm is 
 covered with a bandage to hold the anterior splint firm to the arm, and thus 
 prevent any movement of the elbow-joint, which, if allowed, would be con- 
 stantly modifying the force exerted upon the fracture. A common buck- 
 skin glove is then placed upon the hand, to the anterior and posterior 
 surfaces of which are attached two leather straps, which are to be buckled 
 into the staples on the band. By buckling these straps over the bars at a 
 greater or less distance from the band, and tightening them as required, we 
 obtain the necessary amount of leverage to turn the lower edge 
 of the band in upon the arm, and push the fractured process 
 down before it. 
 
 By making traction upon these straps any degree of force 
 may be exerted upon the band necessary to draw the broken 
 fragment down and hold it in perfect apposition with the head 
 of the ulna. 
 
 It may be objected to this method of treatment, that the arm 
 is held in a flexed position, thus increasing the space between 
 the two fragments. But the advantage of this position is ap- 
 parent in the relaxation of the biceps, and prominence of the 
 olecranon. 
 
 Fracture of both Bones of the Forearm. — When both bones 
 of the forearm are broken the fracture is generally about 
 the middle or lower part of the lower third (Fig. 286), the 
 upper parts being so covered by muscular structure that they 
 are more protected from injury. The solution of continuity 
 is generally single, although Dessault treated a patient in 
 which he found six distinct fractures. This, however, must 
 be regarded as a very rare occurrence. The causes are gener- 
 ally direct violence, although a counter-stroke produces the 
 fracture, though such force generally operates upon the radius 
 alone. 
 
 The following are the symptoms : Preternatural mobility of 
 pans which are normally inflexible ; crepitus, which is easily 
 produced ; a depression at the site of the fracture, or some- 
 times, when the displacement is greater, a sharp bony projection distin- 
 guished under the skin ; more or less pain when attempting to move the 
 part, the patient stating, if questioned closely, that quite a noise was noticed 
 at the time of the accident; forearm bent, and the power of supination and 
 pronation is lost. When the fracture occurs near the wrist-joint, the appear- 
 ance of the part may simulate dislocation. In fracture, the crepitus and the 
 position of the styloid processes either above or below the joint, will reveal 
 the true diagnosis. If there be a dislocation, by moving the hand the sty- 
 loid processes remain in their situation ; if there be a fracture they will 
 move with the hand. Displacement in the longitudinal direction is rare, 
 
 Fracture of 
 both bones of 
 the forearm. 
 
FRACTURES OF THE PHALANGES. 583 
 
 on account of the arrangement of the muscles and the interosseous ligament ; 
 but the transverse displacement is generally perceptible, the four pieces then 
 approaching each other and diminishing if not obliterating the interosseous 
 space. There is likewise a tendency of the fragments to ride one upon the 
 other, causing also an angular displacement. 
 
 Treatment — In the treatment of this fracture I formerly followed, and 
 with success, the method of Boyer. as follows : The forearm is to be bent at 
 a right angle with the arm and hand, which must be placed in a position 
 between pronation and supination. An assistant then takes hold of the 
 four fingers of the hand and makes the requisite extension, while the 
 counter-extension is kept up by another assistant, who grasps the lower por- 
 tion of the humerus with both of his hands. The bones are thus restored to 
 their natural situation, and the soft parts can be pushed into place. 
 Two graduated compresses, with their apices to the interosseous space, 
 are then placed, one on the anterior and one on the posterior surface, the 
 depth of the compresses corresponding with the thickness of the forearm. 
 Xext. the surgeon takes a single-headed roller six yards long, and makes 
 three or four turns over the fractured part, and descends upon the hand 
 and up again over the forearm ; two well-padded splints are applied, ante- 
 riorly and posteriorly, and these embraced with the turns of the bandage as 
 it descends. In ordinary cases this method will be found successful. 
 
 A simpler method, however, and one which has given me satisfaction. 
 is that in which adhesive straps are employed. Having set the fracture, 
 take two pieces of adhesive plaster, each about seven inches wide and 
 six or eight inches long, and roll each upon itself as tightly as possible, 
 with the adhesive side out. These are for the compresses. Lay one on the 
 anterior, the other on the posterior surface of the arm, over the interosseous 
 space. Having the splints prepared, place one on the anterior, the other on 
 the posterior surface of the forearm, and hold them in position with straps of 
 plaster, each strap enveloping the part twice. Three strips of this kind will 
 generally be sufficient to hold the fragments firmly. 
 
 Fractures of the Hand. — Fractures of the metacarpal bones are generally 
 easily recognized, although the swelling may be so considerable immedi- 
 ately after the accident, that the injury will not be ascertained for a day or 
 more. In the majority of cases, the mobility, pain, and crepitus are readily 
 discovered; indeed, the latter symptom can be detected by the patient, even 
 when the swelling is considerable. There is. in many cases, a tendency of 
 the fragments to override each other, the anterior generally overlapping the 
 posterior; in which case the surgeon, by passing his finger over the bone on 
 the dorsum of the hand, will readily detect the inequality of surface. 
 
 Treatment. — The best treatment for fracture of these bones is to apply an 
 anterior and posterior splint (each well padded) on the dorsum and paimar 
 surface of the hand, allowing the support to extend almost to the elbow. 
 These splints may be secured by broad strips of plaster, or by the ordinary 
 roller bandage, or by bands of india-rubber. 
 
 Fractures of the Phalanges. — Crepitus and mobility without severe pain 
 are the symptoms most characteristic of this accident. In some cases the 
 displacement is so slight that the break is not at once discovered. 
 
 Treatment. — Extension soon replaces any displacement, and a paste- 
 board splint, or one made of a narrow and light piece of wood, extending 
 to the wrist, and kept in place by strips of plaster, is all that is required. 
 If more than one finger is broken, a carved splint, in which the whole 
 hand may rest, will be appropriate. When the carpal bones are broken, 
 the injury inflicted is generally so severe that amputation or resection must 
 be resorted to. If. however, hopes can be entertained of saving the joint, 
 a splint well padded should be placed on the palmar surface of the hand 
 
584 
 
 A SYSTEM OF SURGERY. 
 
 and secured by plaster placed above and below the seat of injury. By 
 this arrangement the parts may be carefully examined without disturb- 
 ing the dressing. 
 
 FRACTURES OF THE LOWER EXTREMITIES. 
 
 Fracture of the Femur. — The femur is generally broken at the upper 
 portion of its middle third, although its lower third, the cervix, either 
 within or without the capsule, the trochanters or the condyles may be the 
 seat of injury. According to the statistics given by Prof. Hamilton,^ out 
 of one hundred and fifty-six cases treated by him, sixty-seven were of the 
 middle third, sixty-three of the upper third, and twenty-six of the lower 
 third. 
 
 Fracture of the Neck. — This variety of fracture may occur either within 
 or without the capsule, and the symptoms and prognosis as well as the 
 method of union have been the subject of much discussion among surgeons. 
 
 Fig. 287. 
 
 Fig. 288. 
 
 Fracture of the Neck of the 
 Femur. 
 
 External Characteris- 
 tics of Fracture of the 
 Neck of the Femur. 
 
 Fracture within the capsule generally occurs in persons of advanced life, 
 and is usually the result of indirect and even slight violence. The position 
 of this portion of the bone, the greater brittleness of the osseous system in 
 advanced life, and certain constitutional diseases have a material influence 
 in this fracture. Sometimes it may occur from apparently trivial causes, 
 such as tripping of the foot or a slight fall. It has been asserted by some 
 surgeons that if it be possible to ascertain the exact direction in which the 
 force has been applied, we can readily diagnose the locality of the sepa- 
 ration. A fall upon the knee or the foot it is contended will cause an oblique 
 intracapsular fracture, while, if the force be applied in front of the trochanters 
 
 * Fractures and Dislocations, p. 348. 
 
FRACTURE OF THE FEMUR. 585 
 
 the break will be, though still within the capsule, of the transverse variety 
 (Fig. 287). In fractures within the capsule, crepitus is, in the majority of 
 instances, absent. There may be a very slight degree of immediate shorten- 
 ing, which may be temporarily removed by moderate extension. The pain 
 is slight during complete rest, but insupportable when movement is at- 
 tempted. Eversion of the foot almost invariably takes place (Fig. 288), though 
 according to some authorities, inversion has been noticed in a few cases. 
 After a time, as the swelling subsides and the muscular action commences, 
 there may be a sudden shortening of the limb of one to two inches, which 
 results from the sudden rupturing or wearing out of the cervical ligament. 
 In those cases in which, from many contingent circumstances, there may 
 be difficulty in the diagnosis, the thigh must be carefully measured in 
 many directions, and if it be possible the patient raised upon his sound leg 
 for careful and accurate examination. 
 
 The question as to whether these fractures unite by ligamentous or 
 bony union it is not necessary here to discuss, but from the careful inves- 
 tigation of the subject there appears to be no doubt that both osseous and 
 ligamentous union occur, the former most frequently when there is a slight 
 degree of impaction. 
 
 Fracture without the Capsule.— Fracture without the capsule is almost in- 
 variably accompanied with fracture and displacement of both trochanters, 
 which generally are split or divided obliquely downward and forward ; if, 
 however, the fracture should be of the impacted variety, then there will not 
 be so great a displacement of the trochanteric eminences. In these fractures 
 the superior fragment is denominated the acetabular, the latter the trochan- 
 teric. The causes are very similar to those producing the variety of frac- 
 ture last considered. 
 
 The symptoms are: a considerable amount of shortening immediately 
 upon the receipt of the injury, which may reach even two inches and a 
 half. There is pain, lack of prominence of the trochanter, and eversion 
 of the foot. If there be considerable difficulty in bringing the foot and 
 leg to its natural length, then impaction may be suspected. Crepitus can 
 be detected by rotating the bone with the fingers on the trochanter. 
 
 Prof. Hamilton's differential diagnosis between fractures within and with- 
 out the capsule is here introduced : 
 
 FRACTURE WITHIN THE CAPSULE. FRACTURE WITHOUT THE CAPSULE. 
 
 1. Produced by slight violence. 1. Produced by greater violence. 
 
 2. A fall upon the foot or knee, or a trip 2. A fall upon the trochanter major. 
 
 upon the carpet, etc. 
 
 3. Generally over fifty years. 3. Often under fifty years. 
 
 4. More frequent in females. 4. Eelative frequency in males and females 
 
 not established. 
 
 5. Pain, tenderness, and swelling less and 5. Pain, swelling, and tenderness greater 
 
 deep. and more superficial. 
 
 The following measurements are to be made from the anterior superior 
 spinous process of the ilium to the lower extremity- of the malleolus ex- 
 ternus or internus : 
 
 6. Shortening at first less than in extra- 6. Shortening at first greater, almost al- 
 
 capsular fractures, and often not any. ways some. 
 
 7. Shortening, after a few days or weeks, 7. Shortening, after a few days or weeks, 
 
 greater than in extracapsular frac- less than in the intracapsular — that 
 
 tures. Sometimes this takes place is, the amount of shortening changes 
 
 suddenly, as when the limb is moved but little, if at all; if the impaction 
 
 or the patient steps upon it. continues, not at all ; if it does not 
 
 continue, it may shorten more. 
 
586 
 
 A SYSTEM OF SURGERY. 
 
 FRACTURE WITHIN THE CAPSULE. 
 
 8. Measuring from the top of the trochan- 
 
 ter to the inner condyle, or to the 
 malleolus internus, the femur is not 
 shortened. 
 
 9. More mobility of the limb at the joint. 
 
 10. Trochanter major moves upon a longer 
 
 radius. 
 
 11. If the patient recovers the use of the 
 
 limb, it is not restored under three 
 or four months. 
 
 12. No enlargement or apparent expansion 
 
 of the trochanter major, after recovery, 
 from deposit of bony callus. 
 
 13. Progressive wasting of the limb for many 
 
 months after recovery. 
 
 14. Excessive halting, accompanied with a 
 
 peculiar motion of the pelvis, such as 
 is exhibited in persons who walk with 
 an artificial limb. 
 
 FRACTURE WITHOUT THE CAPSULE. 
 
 8. Measuring from the top of the trochan- 
 
 ter to the inner condyle, or to the 
 malleous internus, the femur may be 
 found a little shortened. 
 
 9. Less mobility. 
 
 10. Trochanter major moves upon a shorter 
 
 radius. 
 
 11. If the patient recovers the use of the 
 
 limb, restored in six or eight weeks. 
 
 12. 
 
 13. 
 
 14. 
 
 Enlargement or irregular expansion of 
 the trochanter, which may be felt 
 sometimes distinctly through the skin 
 and muscles. 
 
 The limb preserves its natural strength 
 and size. 
 
 Slight halt. Motion of the hip natural. 
 
 Treatment. — About the same as that for intracapsular fracture. Vide the 
 end of this chapter. 
 
 Impacted Fracture of the Neck of the Femur.— In this variety of fracture, 
 in many instances, the lower end of the upper fragment is forced into the 
 upper extremity of the lower fragment, and generally at the point of union 
 between the cervix and the diaphysis of the bone. In other cases the 
 upper end of the lower fragment is forced into the cancellated tissue of the 
 lower end of the upper portion of the bone. In this variety of fracture the 
 patient may be able to bear weight upon the injured side ; there is no 
 crepitus, but there is shortening and e version of the knee and leg, though 
 the latter is not so well marked as in the non-impacted variety of extra- 
 capsular fracture. Occasionally instead of eversion, there may be inversion 
 of the foot. Dr. J. W. Conklin* records a case, in which the latter symptom 
 was very well marked. The injured limb may also be rotated, abducted, 
 or flexed, although with pain, but great force is necessary to bring the heels 
 to a level, and in some cases such a position is impossible. There is also 
 considerable alteration at the site of the trochanter major, which is drawn 
 upward and out of a line parallel to that of the opposite side. 
 
 It must be borne in mind by the student that there are often injuries, 
 especially falls upon the hip, which simulate fracture of the neck of the 
 femur, and which it may be at first almost impossible to correctly diag- 
 nose. The fact that there may be little immediate shortening of the kg 
 in the intracapsular fracture, and that impacted fractures present no crepi- 
 tation, are the chief sources of uncertainty. An elderly person falls upon 
 the hip, he finds himself unable to move, and is carried to his home, 
 placed upon his bed, and the surgeon is summoned. There is almost total 
 inability to move, the slightest attempt giving rise to severe pain; the foot 
 is everted, the leg may be of the natural length, but more frequently is 
 apparently shorter. No crepitus can be found, and by placing the patient 
 upon the back, the heel of the injured limb may be brought down to a 
 level with that of the sound one. The pain is not always experienced at 
 the site of injury, but along the internal portion of the thigh, and the heel 
 cannot be lifted from the bed. In these cases there is great difficulty in 
 diagnosis, and frequent careful examinations and measurements are 
 necessary before a positive opinion can be reached. In cases of sprain the 
 
 * Medical News, November 25th, 1882. 
 
FRACTURE OF THE NECK OF THE FEMUR. 587 
 
 shortening is apparent, not real ; in intracapsular fractures, the shortening 
 will sooner or later appear. In sprain, the foot is not so completely everted, 
 and there is more muscular power, which increases as the violence of the 
 injury subsides. In such cases, time, watchfulness, careful measurements, 
 the history of the accident, and all minutiae in connection with it must be 
 taken into consideration before a certain diagnosis can be made out. From 
 a knowledge of these facts I here insert thirty " deduced conclusions " 
 relative to fractures of the neck of the femur, taken from the excellent 
 work of Dr. Robert William Smith, of Dublin. This gentleman has con- 
 densed, in a manner remarkable for a judicious conciseness, all the infor- 
 mation appertaining to this subject contained in one hundred and twelve 
 pages of his work on Fractures, and the analysis is well worthy a careful 
 consideration. 
 
 1. " A slight degree of shortening, removable by a moderate extension of 
 the limb, indicates fracture within the capsule. 
 
 2. " The amount of immediate shortening, when the fracture is within the 
 capsule, varies from a quarter of an inch to an inch. 
 
 3. " The degree of shortening, when the fracture is within the capsule, 
 varies chiefly according to the extent of laceration of the cervical ligament. 
 
 4. "It varies according as the fracture is impacted or otherwise. 
 
 5. " In some cases of intracapsular fractures, the injury is not imme- 
 diately followed by shortening of the limb. 
 
 6. " This is generally to be ascribed to the integrity of the cervical ligament. 
 
 7. " In such cases shortening may occur suddenly at a period more or 
 less remote from the receipt of the injury. 
 
 8. " This sudden shortening of the limb is in general to be ascribed to the 
 accidental laceration of the cervical ligament, previously entire, and is 
 indicative of a fracture within the capsule. 
 
 9. " The deposition of callus around the fragments is not necessary for 
 the union of the intracapsular fracture. 
 
 10. " When osseous consolidation occurs in the intracapsular fracture, it 
 is effected by a direct union of the broken surfaces, which are confronted 
 to one another. 
 
 11. "The osseous union of the intracapsular fracture is most likely to 
 occur when the fracture is of the variety termed ' impacted.' 
 
 12. "In the intracapsular fracture, the mode of impaction is different from 
 that which obtains in the extracapsular. 
 
 13. " The degree of shortening when the fracture is external to the cap- 
 sule, and does not remain impacted, varies from one inch to two inches and 
 a half. 
 
 14. " When a great degree of shortening occurs immediately after the re- 
 ceipt of the injury, we usually find a comminuted fracture external to the 
 capsule. 
 
 15. " The extracapsular fracture is accompanied by fracture with displace- 
 ment of one or both trochanters. 
 
 16. " The extracapsular impacted fracture is accompanied by fracture 
 without displacement of one or both trochanters. 
 
 17. " In such cases the fracture of the trochanters unites more readily than 
 that of the neck of the bone. 
 
 18. " The degree of shortening in the extracapsular impacted fracture va- 
 ries from a quarter of an inch to an inch and a half. 
 
 19. " The exuberant growths of bone met with in these cases have been 
 erroneously considered to be merely for the purpose of supporting the ace- 
 tabulum and neck of the femur. 
 
 20. " The final cause of their formation is the union of the fracture through 
 the posterior intertrochanteric space. 
 
588 A SYSTEM OF SURGERY. 
 
 21. " The difficulty of producing crepitus and of restoring the limb to its 
 normal length are the chief diagnostic signs of impacted fracture. 
 
 22. " The position of the foot is influenced principally by the obliquity of 
 the fracture and the relative position of the fragments. 
 
 23. " Inversion of the foot may occur in any of the varieties of fracture 
 of the neck of the femur. 
 
 24. " When the foot is inverted, we usually find that either a portion or 
 the whole of the extremity of the lower is placed in front of the superior 
 fragment. 
 
 25. u In cases of comminuted extracapsular fractures, with fracture and 
 displacement of the trochanters, the foot will generally remain in whatever 
 position it is accidentally placed ; it may be turned either inwards or out- 
 wards, or there may be inversion at one time and eversion at another. 
 
 26. " Severe contusion of the hip-joint, causing paralysis of the muscles 
 which surround the articulation, is liable to be confounded with fracture of 
 the neck of the femur. 
 
 27. " Severe contusion of the hip-joint may be followed at a remote period 
 by shortening of the limb and eversion of the foot. 
 
 28. " The presence of chronic rheumatic arthritis may not only lead us to 
 suppose that a fracture exists when the bone is entire, but also when there 
 is no doubt as to the existence of fracture, may render the diagnosis difficult 
 as to the seat of the injury with respect to the capsule. 
 
 29. " Severe contusions of the hip-joint, previously the seat of chronic 
 rheumatic arthritis, and the impacted fracture of the neck of the femur, are 
 the two cases most likely to be confounded with each other. 
 
 30. " Each particular symptom of fracture of the neck of the femur, sepa- 
 rately considered, must be looked upon as equivocal ; the union of all, can 
 alone lead to the formation of a correct opinion as to the nature and seat of 
 the injury." 
 
 Prof. J. S. Wright,* both from measurements upon the living person and 
 the cadaver, whose soft parts had been removed by dissection, has found 
 that only one person out of every five has lower limbs of the same length, 
 and that this difference in length varies from one-eighth of an inch to one 
 inch. It is, therefore, useless to expect to obtain limbs of the same length 
 after every case of fracture of the femur. Whatever treatment may be 
 adopted, certain cases will inevitably show a shortening of one inch ; and 
 he affirms, that excessive efforts to bring down the injured limb to an equal- 
 ity with the uninjured, are calculated to do harm, since the strong fascia of 
 the thigh offers great resistance. 
 
 Dr. Hamilton appears to place but little reliance in these measurements, 
 and says,f " This cannot be so, for in nine out of every ten cases of fracture 
 of the femur, we do get actual shortening, and how would this happen so 
 constantly, if the fracture had occurred in the longer limb?" 
 
 Fracture of the Shaft of the Femur. — When the upper third of the bone is 
 the seat of injury, the fracture is mostly oblique, and the symptoms so ap- 
 parent as to lead to little doubt in the diagnosis. The limb is shortened 
 from two to three inches, and its superior portion exhibits a convexity of 
 surface with a concavity on the internal side of the limb. This is caused 
 by the overlapping of the lower extremity of the upper fragment over the 
 lower. This displacement forward, as will readily be seen, will be caused 
 by the action of the internal iliac and large psoas muscle, and by that of 
 the pectineus and the short head of the biceps, while the external rotators 
 twist the fragment outward, and the lower fragment is drawn upward by the 
 flexors, and outward by the tensor vaginae, vastus, and glutei. 
 
 * Archives of Clinical Surgery, February, 1877. 
 f Archives of Clinical Surgery, November, 1877. 
 
FRACTURE OF THE SHAFT OF THE FEMUR. 589 
 
 Fractures at the Middle of the Shaft. — This accident is, according to most 
 surgeons, of rare occurrence, although I have treated patients with fractures 
 nearly at the centre of the bone. 
 
 The direction of the fracture is oblique, and the upper fragment projects 
 over the lower ; there is e version of the foot, shortening of the limb, and 
 an unevenness of surface at the site of fracture, which is readily detected 
 both by sight and manipulation. Crepitus is distinct and is more pronounced 
 by extension. 
 
 In fracture of the loicer third, especially if the accident has happened some 
 time before the surgeon is called, and the bone is broken near the joint, the 
 tumefaction may be so great, especially around the knee, that difficulty 
 may be experienced in making a diagnosis. In this fracture there is over- 
 lapping of the ends of the bone, though when broken in the immediate 
 vicinity of the condyles, the fragments do not " ride " upon each other to 
 such an extent as when the fracture is higher up. In some instances 
 complications ensue from the fragments penetrating the joint, thus giv- 
 ing rise to additional serious symptoms. The fractures in this portion of 
 the femur are oblique, the upper fragment overlapping the lower. In other 
 instances the lower extremity of the upper fragment has been known to 
 push the patella upon the tibia, thereby producing the appearance of a dis- 
 location. There is shortening, eversion of the foot, and angularity of the 
 limb, which will suffice to diagnose the accident. 
 
 Treatment. — Very many splints, bandages, and apparatuses have been 
 devised for fractures of the femur. I do not propose a detail of these many 
 contrivances, the greater number of which have been thrown aside and the 
 remainder will soon be consigned to a like oblivion. The greatly simplified 
 means now used relieve the patient of the inconvenience, pain, and discom- 
 fort of the cumbersome and complicated contrivances of the past. 
 
 In treating fractures of the femur most surgeons of the present day pre- 
 fer the straight position of the extremity with extension, to the double inclined 
 plane, which at one time was very much in vogue, and as most of the ap- 
 paratus now employed is equally adapted to fractures of the shaft, as well 
 as of the neck of the bone, I have thought fit first to detail the symptoms 
 of each fracture, and afterwards, in due order, give, a description of the 
 means to be used. This plan will save unnecessary repetition. It is proper 
 to remark in this place that some surgeons prefer both positions in treating 
 fractures of the femur, being guided in the selection of the position by the 
 locality of the fracture. If the separation be below the trochanter minor, 
 the upper fragment is tilted forward and upward by the action of the psoas 
 muscle ; if the fracture occur at the lower third, then the heads of the gas- 
 trocnemius draw the lower fragment downward and backward, and in 
 either case, it is argued, that extension in a straight line will not produce 
 the desired effect. This reasoning is plausible, but I am persuaded, from 
 some experience in the management of these fractures, that properly ap- 
 plied extension with weight and pulley, or by suspension, or both, will 
 effect, in the majority of cases, results equal if not superior to any other 
 methods. 
 
 I am disposed to believe that each surgeon, having become thoroughly 
 acquainted with the application and results obtained by his favorite method 
 of treatment, is loath to change his apparatus, and continues experimenting 
 and arranging his particular device, until it not only becomes better 
 adapted for the purposes to which it is applied, but the surgeon himself be- 
 comes more . perfect in his method of using it. However this may be, I 
 think with these two truly " American methods " all the cases of fracture of 
 the thigh may be successfully treated. It is well known that in Buck's 
 original apparatus, as seen in Fig. 289, there was a perineal band to effect 
 
590 
 
 A SYSTEM OF SURGERY. 
 
 counter-extension. That " instrument of torture"* as Dr Van Buren calls it, 
 is done away with by the elevation of the foot of the bed, and the old and 
 terrific and almost invariable accompaniment of a fracture of the thigh or 
 leg, viz., " a sore heel," is also avoided by the elevation of the foot in the 
 anterior splint, and by extension in the straight method. 
 
 The following is the manner of preparation and application of the straight 
 extension method, as laid down by its great advocate, Dr. F. H. Hamilton. t 
 I quote his own words : 
 
 " Saw from a half-inch board a strip four inches in breadth, and of such 
 length that when made fast to the foot of the bedstead, it shall rise four 
 inches above the toes of the patient as he lies supine upon the bed. 
 
 " Construct a long slot in the upper portion of this strip intended to re- 
 ceive the pulley. 
 
 Fig. 289. 
 
 G*T/£MAMN &C0. 
 
 Buck's Extension Method. 
 
 " Make holes with a gimlet from side to side through the strip, traversing 
 the slot, the holes being about three-quarters of an inch apart. These holes 
 are intended to receive a large wire, which will serve as an axis upon which 
 the pulley will turn. In case a metallic pulley cannot be obtained, a spool 
 will serve the purpose. 
 
 " This piece of board, thus constructed, is to be fastened upright to the 
 foot of the bed. 
 
 " In order to complete the apparatus for extension there will be required 
 a small rope four feet long, a bag of sufficient size to hold twenty-two pounds 
 of sand or of small shot, and a piece of thin board four inches long, and 
 three and a half inches wide, to traverse the sole of the foot and prevent the 
 adhesive plaster bands from pressing upon the malleoli. This traverse 
 must be perforated in the centre to receive the cord, in the end of which a 
 knot is to be made, which will prevent its being drawn through. Half a 
 pound of cotton batting, cotton or woollen rollers, four feet of strong adhe- 
 sive plaster, and two small blocks or bricks to place under the footposts of 
 the bedstead will also be required. 
 
 * Is there an American Method of treating Fractures of the Thigh ?- 
 N. Y., March 30th, 1878.^ 
 
 f Principles and Practice of Surgery, p. 296. 
 
 -Medical Record, 
 
TREATMENT OF FRACTURES OF THE FEMUR. 591 
 
 " The adhesive plaster extending band will be composed of one single 
 piece, which, for adults, must generally be about four feet in length, and 
 three and a half inches in breadth ; but as it approaches the middle, it 
 should widen to about six inches, so that when the traverse is placed upon 
 the middle of the band, the margins of the band may be folded over the 
 sides of the traverse. The rope, having been knotted at one end, is now 
 passed through the hole in the traverse, and while an assistant steadies the 
 foot, the extending band is applied to each side of the leg as high as the 
 knee, the traverse touching the sole of the foot. If the straps are found to be 
 longer than the leg, the ends may be left and folded down upon the roller 
 after the first turns are applied. The application of the roller intended to 
 hold the bands in place will be commenced at the ankle, but first the instep 
 and the back of the leg above the heel must be well covered with cotton bat- 
 ting, and if the patient is very thin it is well to cover the whole length of the 
 spine of the tibia in the same manner. The roller may now be applied over 
 the bands as high as the knee, and the superfluous ends of the bands being- 
 doubled down, it may be made to return a short distance towards the foot. 
 
 " Passing the rope over the pulley, and attaching the weight, extension 
 will be made. The pulley ought to be one or two inches higher than the 
 middle of the sole of the foot, so as to lift the heel gently from the bed. 
 The amount of weight to be employed, or which the patient can endure, 
 will vary somewhat. 
 
 " I have found the maximum to be about twenty -two pounds, and gener- 
 ally patients will not endure for any length of time, over twenty pounds. 
 
 " To render it more certain that the patient will not be drawn towards 
 the foot of the bed by the continuous extension, the foot-posts must be 
 lifted about three or four inches by blocks or a couple of bricks." 
 
 To secure coaptation and support the fragments, four splints, made of sole 
 leather and covered with woollen cloth, must be applied to the circumference 
 of the limb. These splints should not quite touch at their margins. The 
 inside and outside splints ought to be long enough to embrace the condyles, 
 and the posterior splint should be wider than either of the others, and extend 
 from the tuber ischii to a point below the knee. 
 
 The whole is to be secured in place by four or six strips of bandage, and 
 knotted over the front splint and stitched fast to the covers of the side splints 
 to prevent displacement. To obviate the tendency to e version which exists 
 in nearly all fractures of the femur, a long side-splint, four inches wide, and 
 extending from near the axilla to beyond the foot, must be laid outside of 
 the limb, supported on the side next to the limb and body by a long sack 
 filled with cotton batting. From the lower end of this splint a foot-piece 
 should project six or eight inches outward, the more effectually to prevent 
 eversion. The whole is to be secured to the leg, thigh, and body by separate 
 bands of cotton cloth. 
 
 Perhaps it is because I have had more experience with the anterior 
 splint of the late Dr. Nathan E. Smith and the improved splint of Prof. 
 Hoclgen, of St, Louis, that I am partial to their use. In my hands more 
 comfort has been given to the patient and better results obtained by them 
 than by straight extension. Mr. Bryant, of Guy's, prefers the suspension 
 method, and it is used in the Greenwich Hospital in preference to others. 
 In this city (New York) the modification of Buck's method is the one which 
 is preferred, being used in all the larger hospitals and public charities. 
 
 The following is the manner of applying the anterior splint of Dr. N. R. 
 Smith: 
 
 The fracture having been adjusted, the splint is so bent that the upper 
 angle may come up on the abdomen to the anterior superior spinous pro- 
 cess of the ilium ; the lower end is also bent to a convenient angle, to lie 
 
592 
 
 A SYSTEM OF SURGERY. 
 
 over the dorsum of the foot, A roller bandage is then applied to the limb, 
 an assistant keeping the fractured ends of the bone in apposition. A layer 
 of cotton batting should then be placed over the crease in the groin, over 
 the knee, and over the anterior face of the ankle-joint. The splint is then 
 laid on the anterior portion of the leg, and fixed thereto by another bandage, 
 
 Fig. 290. 
 
 Smith's Anterior Splint. 
 
 which must be long enough to extend from the toes to the groin, and thence 
 several times around the body. Over this a thick coating of starch must be 
 applied. The upper hook must be placed nearly over the seat of fracture, 
 the lower one about the middle of the leg ; the cords are then attached and 
 fixed to a pulley, which may be screwed to a frame extending over the bed, 
 or to the ceiling. See Fig. 290. 
 
 Fig. 291. 
 
 Hodgen's Splint. 
 
 The differences between the splint just described and that of Dr. Hodgen 
 are as follows : In the latter, the point of suspension is at an angle from the 
 
TREATMENT OF FRACTURES OF THE FEMTTR. 
 
 593 
 
 seat of fracture, making thus additional counter-extension by the body. It 
 is not an anterior but a lateral splint. Pieces of muslin are pinned or sewed 
 from side to side of the bars, to make a " cradle " for the fractured bone, 
 thus leaving the anterior face of the limb, if necessary, exposed to view, and 
 allowing (by the removal of any of the slips) a wound or ulcer to be ex- 
 amined or dressed without disturbing the fracture. I have used this splint 
 many times with most satisfactory results. Fig. 291 gives a correct idea of 
 it when applied. 
 
 The following is a description of a modification of Hodgen's splint by the 
 late Dr. Clark. The measurements are accurate, so that a splint may be 
 constructed from them. 
 
 Dr. Clark reports six cases of fracture of the femur treated by this splint 
 without shortening or deformity. I can also add my testimony as to its 
 efficacy in many cases. 
 
 The arch should be turned of iron bars (Fig. 292), one-eighth of an inch 
 in thickness and half an inch in width. The top of the arch, H, should 
 stand eighteen inches from the surface of the bed, while the width of the 
 frame at the bottom, L, should be fifteen inches, and its length, K, twenty- 
 
 FlG. 292. 
 
 Clark's Splint. 
 
 four inches. The two arches are braced upon each other by the two slender 
 bars, F F, at either side, and the rail at the top upon which the pulley, P, 
 glides. This rail, to prevent bending, should be made of steel, three-eighths 
 of an inch in width and one-fourth of an inch in thickness, with its broad 
 diameter placed in the vertical position, and fixed with a thumb-screw at 
 one end, so that the rail may be withdrawn to apply the pulley. It will be 
 observed that the arch at the proximal end is cut away at the inner side 
 below where it joins the lateral bar, F, the object of which is to allow the 
 patient to use the other limb more freely. 
 
 The splint of Dr. Hodgen, upon which the limb is mounted, consists of 
 iron rods, A A, one-fourth of an inch in thickness, placed parallel on both 
 sides of the limb, extending its whole length and transversely across the 
 bottom of the foot, much after the manner of Smith's anterior splint. The 
 limb is then adjusted in the splint by placing it in position, and pinning 
 strips of bandage, N N, four or five inches in width, over the bars on either 
 side, constituting the floor of the splint, upon which the limb is allowed to 
 
 38 
 
594 A SYSTEM OF SURGERY. 
 
 rest in the suspended position; adding, however, as will be seen in the 
 diagram, R, a sheet of pasteboard five inches in width, extending from the 
 nates to the knee upon the posterior surface of the thigh, thus giving a 
 more equable support to the limb at the point of fracture. These bars 
 upon which the limb is supported, are prevented approaching too near to 
 each other or to the limb, by an iron bow, E, holding them in position at 
 their upper extremities. The attachment for extension is by means of the 
 adhesive strips, M, extending to near the knee and passing around the 
 foot-piece, I, to which is attached a small bracket, B, which hooks over the 
 lower end of the main splint. Then the limb is suspended by the four 
 hooks, D D, which are attached to thimbles that slide back and forth upon 
 the bars, and are fixed at the desired point by means of thumb-screws in 
 their outer sides. The limb now being suspended, the extension is made 
 by means of the cord, C, attached to the hook in the pulley at S, passing 
 forward between the cords playing over the pulley at O, to drop over the 
 pulley, G, fixed in the slender post at the foot of the bed, and then attached 
 to a sand-bag of sufficient weight to make the necessary amount of exten- 
 sion. The weight ordinarily required for an adult will be from 10 to 15 
 pounds. Now with the limb completely adjusted in the apparatus, the 
 axis of the femur may be changed to any line, by sliding the thimbles 
 nearest the foot, forward or back, which will elevate or depress the leg, and 
 in doing so will produce just the opposite effect in the position of the thigh. 
 Or again, the same can be accomplished by sliding the thimbles at the thigh 
 back or forth. Or the axis of the femur may be still more conveniently 
 adjusted by gliding the pulley, P, back or forth upon the suspension rail, 
 which, as will be seen by a glance at the diagram, if the pulley be drawn 
 towards the body, will have the effect of elevating the thigh and depressing 
 the foot, and vice versa. Then by means of the lateral movement in the 
 pulleys, S, O, the patient is enabled to rotate the limb sufficiently to allow 
 him to lie upon his side if he desires, or if it become necessary. The only 
 counter-extension required with this dressing is the weight of the body, 
 which is quite sufficient in all cases ; for even though the patient should 
 gradually slip down in bed, the extension is constantly the same until his 
 foot reaches the post at the foot of the bed, when, without any assistance, 
 he can draw himself up in bed again, the whole apparatus connected with 
 the limb coming back with the pulley, P, upon the suspension rail, when 
 the body is drawn upwards. 
 
 Dr. H. L. Hodge, of Philadelphia, invented a means of extension and 
 counter-extension which has been introduced into the Pennsylvania Hos- 
 pital, and which is said to pro- 
 FlG - m duce very satisfactory results. 
 
 1^^ It consists (Fig. 293) of an or- 
 ^^g^^k^^ dinary Dessault's splint, to the 
 ^...--a-^^^^^^^** upper extremity of which is 
 
 -:-:^^f^^^^^ made fast an iron bar, so bent 
 
 z?"'-'-" &EB r \ that it passes over the shoulder, 
 
 / and its hooked extremity comes 
 
 — " in a line with the axis of the 
 
 fractured limb. A broad strip 
 
 of plaster is laid along the chest 
 and abdomen, as seen in Fig. 294, a loop left over the shoulder ; it is then 
 carried down the back to the nates. A block is fixed in the loop, and to 
 this a cord is attached, which is tied firmly to the iron hook. To make the 
 counter-extension strap more secure transverse bands are placed around the 
 chest. 
 
 Among the useful additions to surgery is a splint for dressing com- 
 
TREATMENT OF FRACTURES OF THE FEMUR. 
 
 595 
 
 pound fractures of the femur, invented by Dr. E. A. Munger, of Water- 
 ville, N.Y. 
 
 The advantages claimed for this splint are ; 1st, cheapness ; 2d, dura- 
 bility; 3d, simplicity; 4fh, facility for dressing the wound; 5th, ease of 
 
 Fig. 294. 
 
 making extension ; 6th, ease and certainty of regulating the amount of ex- 
 tension. 
 
 These are illustrated by a description of the splint itself. 
 
 Take an ordinary straight splint, such as is described in Liston's Sur- 
 gery, and fit it to the injured limb as if for application. Then divide 
 
 Fig. 295. 
 
 Munger's Splint. 
 
 it at the point of fracture, and remove an inch or an inch and a half 
 from each section of the splint at the point sawn asunder. To the outer 
 edges of the upper or body portion of the splint, A (Fig. 295), screw two 
 iron rods, f, f, three-eighths of an inch in diameter, and a foot or more 
 
 Fig. 296. 
 
 Munger's Splint Applied. 
 
 in length. These rods slide into grooves, g g, in the lower section, B, which 
 are covered with tin to prevent displacement of the bandages. At the up- 
 per end of the lower segment is attached an iron brace, G, through the head 
 of which runs a screw, E, ten or twelve inches in length. The end of this 
 screw strikes against a corresponding brace, D, attached to the upper seg- 
 ment ; by turning this screw the two portions of the splint are forced apart. 
 
596 
 
 A SYSTEM OF SURGERY. 
 
 By this means extension is made and kept up to any desired degree. The 
 iron parts of this splint, as described, can be made in a short time and at 
 trifling cost by any blacksmith, and if well made will last a lifetime. These 
 irons can be easily removed from one splint and applied to another, either 
 long or short, as the case may require. 
 
 Application. — Each section, when made according to the foregoing plan, 
 should be well padded, and the whole is then applied to the limb in the 
 same manner as an ordinary Liston's splint, with rollers and perineal band, 
 excepting only that the space between the sections is not to be covered by 
 the roller, but with a light dressing separate from the rest. By this means 
 a wound may be examined and cleansed as often as necessary without dis- 
 turbing any other portion of the apparatus. It is obvious that with this 
 splint, properly applied, extension may be made with great ease. Placing 
 his thumb and finger upon the head of the screw, the surgeon, with a few 
 turns, easily forces the limb to its natural length. This is done without his 
 being troubled or annoyed, or the limb endangered by the rude efforts of 
 bungling, inefficient, or inexperienced assistants. 
 
 The straight splint of Mr. Liston (Fig. 297), which was used and recom- 
 
 FiG. 297. 
 
 Liston's Splint. 
 
 mended by Cooper and Fergusson, and has been variously modified by 
 many of the patent splint makers, consists of a narrow board about a 
 hand's-breadth in width, and extends from a short distance below the axilla 
 to several inches below the foot ; at its upper extremity are holes, through 
 which tapes are passed to fix it securely to the body, together with a peri- 
 neal band, and at the lower extremity it is notched to receive the extending 
 bandages. This splint was modified by Day, who appended a foot-board, 
 which could be graded to the proper length for each subject, and was 
 divided in its middle, to render it more portable. 
 
 Dr. Physick, of Philadelphia, altered the long splint of Dessault and 
 had it extended from the axilla to the foot, using also an inside splint, 
 keeping up the extension at the perinseum. 
 
 After the splints have been made comfortable for the patient — no matter 
 what kind are used — they should be allowed to remain four or five weeks 
 without being touched, being constantly watched and the bandages kept 
 snugly applied. At the end of the fifth week, the apparatus should be 
 carefully removed, the leg washed and rubbed with alcohol, or arnica, and 
 water, double the quantity of water being used to that of either of the other 
 ingredients; the splints should then be carefully reapplied, and should not 
 be taken off until three weeks have elapsed. Upon the removal of support 
 the patient will have some pain, often swelling, and sometimes discoloration. 
 
 During the next few weeks there should be applied a couple of paste-board 
 splints, one anterior, and the other posterior, which should be retained in 
 situ by either a bandage or straps made of webbing. 
 
 The patient must then use crutches for several weeks, for which a cane 
 must be substituted before he can trust himself without any support. 
 
 In treating fractures of the femur a variety of apparatuses from time 
 to time have been introduced to the profession. Very few of them can be 
 
TREATMENT OF FRACTURES OF THE FEMUR. 
 
 597 
 
 mentioned here. Fig. 298 represents an ingenious and comfortable suspen- 
 sion devised by Dr. George F. Shrady. The iron rods, bent to sustain the 
 limb, as seen in the figure, are fitted with clamps, which allow removal, 
 render the suspensory apparatus easily applied to the sides of the bed, and 
 have the additional advantage of elevating the injured limb to any required 
 height. 
 
 Fig. 298. 
 
 Shrady's Apparatus. 
 
 One of the best contrivances for treating not only fractures of the femur, 
 but hip-joint disease in its early stages, is the fracture-bed of my friend 
 Dr. E. J. Morgan, of Ithaca, New York. The following cut and description 
 will show its admirable workings (Fig. 299) : 
 
 A, represents the rectangular frame which supports the tilting-frame, B, 
 by means of the rack-shaft, C, passing through it ; D, represents the spring 
 
 Fig. 299. 
 
 lever attached to the rack-shaft for elevating the thigh and leg planes, E F ; 
 G, represents the back-plane, and H, the body-plane ; I represents the 
 sound arm, that holds the lifting-frame at any angle ; J, the circle-ratchet, 
 that holds the back plane at any angle ; K K, the pulleys and weights 
 attached for effecting extension ; L, the parallel rods which support the leg- 
 
598 
 
 A SYSTEM OF SURGERY. 
 
 planes; M, the thigh-bars attached to the rack-shaft pendants; N, the 
 circular opening leading to the earth-closet : 0, the earth-closet. This bed 
 may be constructed of iron instead of wood, and fixed upon wheels, which 
 will enable it to be moved from place to place without jar or noise, and 
 without endangering misplacement of the broken ends of the bone. 
 
 Fracture of the Patella. — A fracture of the patella is generally occasioned 
 by the sudden action of the quadriceps, or direct violence ; the separation 
 may be either longitudinal or transverse. In either case the diagnosis is 
 not difficult. In the former, a depression can be felt running along the 
 bone, the chasm being diminished by lateral pressure ; in the latter, the 
 separation of the fragments is transverse, and through the rent in the bone 
 the synovial sac protrudes, which may in itself prevent the replacement 
 of the fragments. This fracture is often the result of direct violence ; and 
 the sudden loss of power, sensation as though something had given way 
 
 Fig. 300. 
 
 Levis's modification of Malgaigne's Patella Hooks. 
 
 at the time of the injury, and the effusion and pain, are sufficient to diag- 
 nose the accident. In the last case of fracture of this bone that came under 
 my care the separation was directly transverse, and was caused by a fall 
 upon the knee, as the patient was stepping from a carriage. 
 
 In some eases both patellae are broken at once, and the bone is often 
 fractured in several places. The union is, in the majority of cases, liga- 
 mentous, although occasionally it may be bony. In some half or three- 
 quarters of an inch of separation remains. 
 
 In the starred or vertical fracture, osseous union generally results. 
 
 Treatment. — In the treatment of fractured patella the chief desideratum 
 is to prevent flexion of the knee-joint, and to keep the fragments as nearly 
 as possible in apposition. This is well effected by a posterior splint, which 
 should be of sufficient length to extend from the tuber ischii to the heel ; 
 this being well padded, should be applied, and a figure-of-eight bandage 
 put on, so to envelop the patella that the fragments are drawn into appo- 
 sition. The hooks of Malgaigne are not much used at present, although I 
 am informed by Dr. Levis, that they still are employed in the Pennsylvania 
 Hospital, and that he has made a useful modification of them. (Fig. 300.) 
 
TREATMENT OF FRACTURE OF THE PATELLA. 
 
 599 
 
 I have never used them. Sir Astley Cooper's method of applying a band 
 around the thigh and drawing it down with lateral bands which pass under 
 the foot, is not much in vogue, and is liable to many objections. 
 
 Dr. W. A. Gibson* describes a ring made of iron, about three-eighths of 
 an inch in thickness, and sufficiently large, after being padded, to embrace 
 the patella closely. All the fragments are gathered within the ring, which 
 is then retained in position by attaching a strap or band on either side, and 
 fastening them around a wooden splint, laid upon the posterior surface of 
 the leg and thigh, the splint being retained in position by a roller bandage, 
 thus preventing any motion of the knee-joint. 
 
 The apparatus of Professor Hamilton is as follows, and is the one which 
 in my hands has been productive of most good (vide Fig. 301). 
 
 " The dressing consists of a single inclined plane, of sufficient length to 
 support the thigh and leg, and about six inches wider than the limb at the 
 knee. This plane rises from a horizontal floor (b) of the same length and 
 breadth, and is supported at its distal end by an upright piece of board (c), 
 which serves both to lift the plane and to support and steady the foot. The 
 distal end of the inclined plane may be elevated from six to eighteen inches, 
 according to the length of the limb and other circumstances. Upon either 
 
 Fig. 301. 
 
 Hamilton's Splint for Fractured Patella. 
 
 side, about four inches below the knee, is cut a deep notch (d). The foot- 
 piece stands at right angles with the inclined plane, and not at right angles 
 with the horizontal floor ; it may be perforated with holes for the passage 
 of tapes or bandages to secure the foot. 
 
 " Having covered the apparatus with a thick and soft cushion (e) carefully 
 adapted to all the irregularities of the thigh and leg, especial care being 
 taken to fill completely the space under the knee, the whole limb is now 
 laid upon it, and the foot secured gently to the foot-board, between which 
 and the foot another cushion is placed. 
 
 " The body of the patient should also be flexed upon the thigh, so as the 
 more effectually to relax the quadriceps femoris muscle. 
 
 " A compress made of folded cotton cloth, wide enough to cover the whole 
 breadth of the knee, and long enough to extend from a point four inches 
 above the patella to the tuberosity of the tibia, and one-quarter of an inch 
 thick, is now placed on the front of, and above the knee (h h). While an 
 assistant presses down the upper fragment of the patella the surgeon pro- 
 ceeds to secure it in place with bands of adhesive plaster (g). Each band 
 
 * St. Louis Medical and Surgical Journal. 
 
600 
 
 A SYSTEM OF SURGERY. 
 
 should be two or two and a half inches wide, and sufficiently long to inclose 
 the limb and splint obliquely. The centre of the first band is laid upon 
 the compress partly above and partly upon the upper fragment, and its 
 extremities are brought down so as to pass through the two notches on the 
 side of the splint, and close upon each other underneath. The second band 
 imbricating the first, descends a little lower upon the patella, and is secured 
 below in the same manner. The third, and so on successively until the whole 
 extent of the compress and knee are covered, is carried more nearly at right 
 angles around the leg and splint ; the last bands passing obliquely from 
 below the ligamentum patellae upwards and backwards. The dressing is 
 now completed by passing a cotton roller (/) around the whole length of 
 the limb and splint, commencing at the toes, and ending at the groin. This 
 is applied lightly, as its object is only to support and steady the limb." 
 
 Fig. 302 represents Turner's apparatus. The thigh and leg pieces are of 
 sheet-iron, which are fastened around the leg and thigh with buckles and 
 
 Fig. 302. 
 
 Turner's Apparatus for Fractured Patella. 
 
 straps, and united to each other by three bars, two lateral and one posterior; 
 to the latter are joined two troughs with a double reversed screw. By turn- 
 ing the screw the troughs can be made to approach or separate from each 
 other. Adhesive straps are applied around these troughs, as seen in the 
 figure, and by turning the screw the fragments are drawn together. 
 
 Dr. James L. Little, the originator of the plaster-of-Paris dressing for frac- 
 tures, devised an application which he claims secures bony union in the 
 patella. His method of dressing the fracture I give in his own words.* 
 
 "Sometimes, when the effusion into the synovial cavity is great, I apply 
 pressure as soon as the patient is able to bear it, by means of a bandage. 
 When the swelling has subsided, which takes from five days to a week, the 
 following dressing is applied : a posterior splint is made of two thicknesses 
 of bleached canton flannel, strengthened in the middle, under the knee, by 
 two extra layers. This is made long enough to reach from a little above 
 the ankle to above the middle of the thigh, and wide enough to cover two- 
 
 * Medical News, March 29th, 1884. 
 
TREATMENT OF FRACTURE OF THE PATELLA. 
 
 601 
 
 thirds of the circumference of the limb above and below the joint, but at 
 the joint it should only just cover the condyles of the femur. Two pieces 
 of canton flannel, of from two and a half to three inches in width, double 
 thickness, one long enough nearly to encircle the limb at the ankle, the 
 other to encircle it at the upper third of the thigh, are prepared at the same 
 time. The pieces designed for the posterior splint are then thoroughly 
 saturated in a mixture of plaster-of-Paris and water, taking care that the 
 mixture is not too thick, and then smoothed out upon a board with the 
 hand, and applied smoothly to the limb. Then the two bands are prepared 
 in the same way and applied around the upper and lower extremities to 
 hold it in position. A dry roller bandage is then firmly applied over all, 
 and the plaster allowed to set. 
 
 "As soon as this is accomplished the bandage is removed, and we have a 
 firm posterior splint secured above and below by transverse bands. Two other 
 strips of a double thickness of canton flannel an inch wide, and long enough 
 to overlap on the posterior surface of the splint, are saturated in a fresh 
 mixture of plaster-of-Paris, and then tightly applied above and below the 
 
 Fig. 303. 
 
 patella, while the fragments are held in position by an assistant, in the same 
 manner as adhesive straps are used for coaptation in this fracture. A dry 
 roller bandage is then rapidly applied, with the figure-of-eight turns, over 
 the strips. The surgeon then, with thumb and finger of each hand over 
 these coaptation bands, forces the fragments into close approximation, and 
 holds them there until the plaster has set (Fig. 1) ; the bandage is then 
 removed and a fresh one applied over the whole length of the limb. The 
 dressing is then complete. Fig. 2 shows the splint with the bandage re- 
 moved. It is a good plan for the surgeon, before applying the coaptation 
 bands, to see that the fragments can be easily approximated. In a number 
 of cases I have found some difficulty in keeping the fragments in the same 
 plane, or in preventing them from tilting, there being a tendency for one to 
 rise above the other. This can be overcome by making pressure with the 
 fingers over the line of fracture while waiting for the bands to harden. 
 
 "This dressing differs essentially from all others, in that the fragments are 
 adjusted by the hands of the surgeon, and the ' setting ' of the plaster 
 keeps them in the exact position in which they were held." 
 
 Dr. Ed. Hornibrook* procures osseous union of the fragments in trans- 
 verse fracture of the patella by the use of the posterior splint, immovable 
 fixture of the lower fragment by means of adhesive straps, and coaptation 
 
 * Monthly Abstract of Medical Science, January, 1877. 
 
602 A SYSTEM OF SURGERY. 
 
 of the upper to the lower fragment by traction, made by weight, pulley, 
 and cord, after the manner of Buck's extension in fractures of the thigh. 
 Adhesive straps, placed lengthwise over the upper fragment, and extending 
 up the thigh three inches, form the means of attachment to the cord. 
 
 Wiring the Patella. — Of late there has been much written concerning 
 wiring the patella, which performed with strict antiseptic precautions has 
 been followed by fair success. The operation consists of exposing the 
 fracture by a transverse incision, piercing the fragments with an awl, and 
 through the holes thus made passing silver wire, turning down the ends of 
 the wire and closing the wound. The success following some of these 
 operations was brilliant, but occasionally very bad results and even ampu- 
 tation and death followed the process, and therefore it must be looked upon 
 for the present with some degree of mistrust. Dr. L. A. Stimson, of New 
 York, lately procured excellent union in a case of fractured patella, by 
 using strong antiseptic catgut in place of the silver wire, and his example 
 is worthy of imitation, although the surgeon must bear in mind that 
 "when these operations are made, he converts a simple into a compound 
 fracture and exposes the cavity of a joint, which are both serious complica- 
 tions. He must also remember that excellent recoveries have taken place 
 even without bony union. 
 
 Fracture of the Tibia. — The tibia may be fractured throughout any por- 
 tion of its extent, although the separation is most likely to occur at the 
 upper extremity of the lower third, or the lower extremity of the middle 
 third, and as a general thing, the fracture is of the oblique variety, and is 
 perhaps more generally occasioned by direct violence. The prominence of 
 the spine of this bone and its exposed position render it very obnoxious to 
 direct force. 
 
 The external malleolus is sometimes broken by a fall upon the foot or by a 
 twist of the ankle ; the latter happens often while running, and I have in 
 mind a case in which, after fracture of the malleolus, there was a compound 
 dislocation of the ankle, which lasted for many months, and only recovered 
 with- a severe stiffness of the articulation. 
 
 The fracture is not, in the majority of instances, difficult to diagnose. 
 The line of the spine of the tibia is broken, and in most instances there 
 can be distinctly felt and seen a sharp projection beneath the skin, which 
 indeed often pierces it, and thus complicates the case. If the fibula re- 
 main intact, we do not look for very much displacement, for the latter 
 bone acts as a splint in keeping the varied muscles in position, and for the 
 same reason we rarely have shortening of the limb, which can only occur 
 when the fracture is high up, above the fibula, or in other complications 
 which are rarely met with. 
 
 The Treatment of fracture of the tibia is very simple. Neither extension 
 nor counter-extension is necessary in the majority of cases; if, in the judg- 
 ment of the surgeon, it may be serviceable to use slight extension, a pulley 
 
 at the foot of the bed, over which a weight 
 FlG - 304 - of five or six pounds is hung, — the other 
 
 extremity of the cord being attached to a 
 traverse at the sole of the foot by means of 
 adhesive strips, — will answer the purpose ; 
 or the limb may be placed over an inclined 
 plane. 
 
 Usually, the felt splints of Ahl, or the 
 wire of Dr. Lewis Bauer, or the metallic 
 plates of Levis, answer the purpose. Dr. 
 Gross used a tin case with a foot-piece, which was accurately adjusted to the 
 leg, and extended up to the knee. 
 
FRACTURES OF THE FIBULA. 603 
 
 Sometimes a good old-fashioned fracture-box, well supplied with cushions 
 (Fig. 304) or pillows, with deal-board splints, effects excellent cures. 
 
 As a rule, to all these fractures, the plaster-of-Paris splint, described on 
 page 46, is applicable, and is my favorite method. 
 
 A simple dressing, and a good one, too, consists of first laying upon a firm 
 mattress four tapes about a yard in length, over these a splint-cloth, which 
 is nothing more than a piece of muslin reaching from the sole of the foot to 
 a little above the knee, and about a yard and a half in width. Having 
 adjusted the bones, place alongside the leg junk-bags, half filled with bran, 
 and neatly adapted to the inequalities of the surface ; lay side-splints flatwise 
 on the splint-cloth, and roll them up firmly, and secure the whole with tapes. 
 
 Fractures of the Fibula. — The position of this bone and its peculiarly 
 slender formation, render it liable to fracture. Slipping, twisting, or turning 
 the foot, stepping from a carriage, or falls, directly or indirectly, give rise to 
 fracture of the fibula. 
 
 The most frequent site of the accident is at the lower fourth of the bone, 
 and the fracture is generally accompanied with dislocation of the ankle, in 
 which the foot is everted, which has been called Pott's fracture. Dr. Jernegan* 
 reports a case of this fracture where there was inversion of the foot. I have 
 lately seen a case, in which I could recognize no displacement. For a time 
 I could not believe the bone was broken, until, by rotation in a certain 
 direction, I obtained distinct crepitus. Sometimes the bone is split upward 
 from the lower extremity, and from a careful study of the anatomy of the 
 joint we can readily see what deformity may exist at the point where such 
 fracture occurs. Great pain is often present, from the rupture of either 
 the deltoid or the external lateral ligament. We generally find that the 
 displacement of the lower fragment is inward toward the tibia. In those 
 cases of fracture of this bone where there is inversion, the internal malleolus 
 is generally broken, while in that already mentioned (Pott's fracture) the 
 internal lateral ligament may remain entire. In some cases of compound 
 fractures, implicating the ankle-joint, amputation or resection may have to 
 be performed. 
 
 A great deal of stiffness remains for a long time after this fracture, no 
 matter how diligently the treatment has been attended to ; and in some 
 cases, even after the lapse of years, in damp and rainy weather, pain and 
 inconvenience are experienced. In a case in which I was summoned to 
 testify as a medical expert, the plaintiff sued for permanent disability 
 ten years after the accident. The treatment had been of the best, and yet 
 a certain degree of pain and stiffness remained. Professor Hamilton men- 
 tions an extraordinary case in which the joint remained almost immovable 
 after twenty years. 
 
 Treatment. — In fractures of the fibula above the middle, with but little 
 eversion or inversion of the foot, the plaster-of-Paris splint (the method 
 of its application being given in the general treatment of fracture) is an 
 excellent apparatus, or a simple .fracture-box is as good an appliance as 
 can be made. When Pott's fracture is to be treated, the old-fashioned 
 Dupuytren's splint is excellent, although Mr. Thomas Bryant, in his late 
 edition, f recommends as preferable a posterior and two lateral splints. 
 
 Dupuytren's splint must extend from the condyle of the femur to two or 
 three inches beyond the foot. Upon this a long triangular pad must be 
 laid, the thickest portion of the triangle corresponding to a point about an 
 inch above the internal malleolus. The bone is then set, and the splint, 
 with the pad resting upon it, applied along the inside of the leg, which is 
 
 * New England Medical Gazette, Dec, 1877, p. 541. 
 
 f The Practice of Surgery, by Thomas Bryant, F.E.C.S., London, 1884. 
 
604 
 
 A SYSTEM OF SURGERY 
 
 secured as seen in Pig. 305, the bandages not covering the site of the frac- 
 ture. Ahl'e felt splints, moulded for the purpose, are very useful in this 
 fracture. 
 
 Fig. 305. 
 
 Fig. 306. 
 
 Dupuytren's Splint. 
 
 Fracture of Both Bones of the Leg. — Fractures of the tibia and fibula are 
 of frequent occurrence, and are often both compound and comminuted. 
 Accidents of all kinds, kicks, blows, falls, or wounds, in 
 which direct violence is applied to the leg, may result in 
 fractures of the leg ^Fig. 306). 
 
 The bones may be broken at the same point, or one higher 
 up than the other, and the direction may be either trans- 
 verse or oblique, but probably that most frequently met 
 with is the former, having its site three or four inches above 
 the ankle. 
 
 The symptoms are generally unmistakable. The super- 
 ficial position of the spine of the tibia, the loss of power, pre- 
 ternatural mobility, and crepitus, generally proclaim the 
 character of the accident. In some cases, when the break has 
 occurred in the vicinity of the ankle-joint, a doubt may arise 
 as to the presence of a luxation, but in these cases the rela- 
 tive normal position of the malleoli with the foot, and the 
 facility of restoring the displacement, should give sufficient 
 evidence of the true nature of the accident. 
 
 In some cases, where the fracture has occurred in the 
 vicinity of either the knee or the ankle-joints, anchylosis may 
 exist for a long period of time. 
 
 Treatment. — A great variety of apparatus has been intro- 
 duced for the treatment of fractures of the leg. In some 
 cases I have used a well applied plaster-of-Paris splint, 
 with success. I have also used Ahl*s splints with advan- 
 tage ; and in former times the anterior splint of Professor 
 Smith; it is so simple and so comfortable that I would ad- 
 vise a trial of its merits. The swing of Dr. Clark I have also seen applied 
 with good results. A description of this I published* by permission of 
 Dr. E. A. Clark, and saw the splint in use in the City Hospital of St. Louis, 
 and have employed it with excellent results. By referring to Figures 307, 
 308, the following description of the splint by Dr. Clark will be readily 
 understood. 
 
 The two arches, represented by the letter H at one end, are made of iron 
 bars one-eighth of an inch in thickness, and three-fourths of an inch in 
 width, and are continuous with the bottom pieces. K. which rest upon the 
 bed, and measure twenty-two inches in length. The arches are also sup- 
 ported on the sides by the two slender bars or rods. F F. while the bar 
 supporting them at the top, upon which the pulley, P, glides, should be 
 made flat, with the long diameter vertical, and of sufficient strength to pre- 
 vent it bending with the weight of the leg. The width of the arches, as 
 
 * Western Homoeopathic Observer. 
 
TREATMENT OF FRACTURES OF THE LEG. 
 
 605 
 
 indicated by the letter L, should be fifteen inches, and their height eighteen 
 inches from the surface of the bed (Fig. 307). 
 
 The bars, A, of the frame or portion of the apparatus in which the leg is 
 suspended, should be about two feet in length, unless when the fracture is 
 so close to the knee that it may be necessary to attach the adhesive straps, 
 M, above the knee, when the bars may extend to near the perinseum if 
 necessary, and the cross-bar passing beneath the foot-piece, I, and upon 
 which the foot-piece rests by means of a suitable hook or bracket, B, should 
 be flattened, the more readily and securely to engage in the hook or bracket, 
 and be five inches in length, so as to allow ample space for the limb to rest 
 
 Fig. 307. 
 
 between the bars ; the space between these bars at the upper end should 
 ordinarily be about six inches. The leg is supported entirely by strips of 
 muslin pinned over the bars on either side, rendering the apparatus more 
 appropriate for the treatment of compound fractures, as the wound may be 
 examined and dressed when necessary, by removing one or more of these 
 strips, which may be replaced by new ones without disturbing the fracture. 
 By means of the pulley at the letter P, the patient is enabled to move his 
 limb, or even his body, forward and back, to the extent of the length of the 
 bar upon which it glides ; and by means of the cord playing over the under 
 wheel in the same pulley, the patient is able (when the fracture is not so 
 near the knee as to necessitate the apparatus extending above the knee), 
 by a very slight effort, to flex or extend the knee by depressing or elevating 
 the foot, while at the same time he can swing the leg from side to side to 
 any extent, within the space of the arches; and by means of the cords 
 playing through the pulleys at 0- 0, the leg can be rotated to any extent, 
 even to allow the patient to lie upon his side if he desires, without disturbing 
 the fracture in the least. It will be observed in the diagrams that at the 
 letter G there is a thimble, which can be made to slide up on the bar, by 
 means of which— sliding this thimble forward or back and fixing it at any 
 point, by the thumb-screw attached to the thimble — the lower end of the 
 leg can be elevated or depressed at the will of the patient. 
 
 The apparatus just described is especially designed for the treatment of 
 compound fractures ; for simple fractures a posterior splint is used (vide C, 
 Fig. 308), constructed either of tin or felt, well adapted to the limb. Dr. 
 Clark afterwards constructed this splint with an aperture at the extremity 
 for the heel to project. 
 
606 
 
 A SYSTEM OF SURGERY. 
 
 A favorite method of treating fractures of the leg is in Pott's position 
 
 • £ o e no ing u-\ C T p( ? S ^ 0f an outside s P lint of angular shape, as seen 
 in big. SOd which should be seven inches in width, constructed of deal- 
 board and with a projection to accommodate the foot; this splint well 
 padded and with a hole with bevelled edges to accommodate the external 
 
 Fig. 308. 
 
 malleolus, and otherwise well cushioned, should be placed on the outside of 
 the limb, which must be flexed on the abdomen and the leg kept at a right 
 
 Fig. 809. 
 
 Pott's Splint. 
 
 IS? 1 ? W H h the thig l\ ; 0I \ the inside of the le S a P added strai g^ splint of 
 ielt, leather, or pasteboard, extending from the ankle to the knee, is placed, 
 
 Fig. 310. 
 
 Keili's Apparatus. 
 
 and the two secured by a roller-bandage. The limb is now allowed to rest 
 on its outer side. 
 
TREATMENT OF COMPOUND FRACTURES. 607 
 
 Fig. 310 represents Neill's apparatus for compound fractures of the leg. 
 The illustration explains itself. 
 
 In very many cases of compound fracture, extension, made with the pulley 
 and weight, and a fracture-box constructed with hinges, that the parts 
 may be examined and dressings applied, answer very well all the indications 
 required. 
 
 Fractures of the Foot. — These accidents are not very frequent, and are 
 generally accompanied with destruction or laceration of the soft structures, 
 which may result in gangrene and require amputation. The toes may be 
 injured by heavy weights, as happens to coal-heavers, quarry-men, stone- 
 masons, and others similarly exposed ; and as amputation is the advisable 
 recourse in most of such cases, the question of greatest importance for con- 
 sideration will be with reference to the site of the operation. Unless, how- 
 ever, the tarsus be involved in the injury, the idea of amputating the foot 
 ought not to be entertained : and, as a general rule, applicable here as in 
 most other parts of the body, the smallest possible degree of mutilation 
 ought to be inflicted consistent with the object of the operation, which is to 
 remove such parts as are irrevocably injured, and at the same time leave a 
 properly formed stump. In instances of fracture of the foot where there is 
 no necessity of resorting to the knife, it is scarcely requisite to use any ap- 
 paratus to keep the fragments in apposition : in the toes, the phalanges are 
 so short, that, if properly adjusted at first, they will remain so, unless the 
 patient injudiciously bears his weight upon the foot at too early a period ; 
 even in the longer metatarsal bones it is not found necessary to employ 
 splints. The application of arnica, etc., at first, and complete rest of the 
 foot for about twenty days afterwards, constitute the most important parts 
 of the treatment. 
 
 Treatment of Compound Fractures. — The management of compound frac- 
 tures is oftentimes troublesome, and requires a great deal of care and atten- 
 tion. In some instances the end of a bone protrudes through the wound 
 in the soft parts and cannot be restored to its natural position ; in such cases, 
 the saw must be applied and a sufficient portion of the bone removed to 
 allow of its reduction. In other instances, when there is a comminution of 
 bone, the spiculse must all be carefully removed, which may require inci- 
 sions in different directions through the soft parts. After either of these 
 operations, the entire wound should be thoroughly washed with a solution of 
 carbolic acid, and the parts brought as nearly in apposition as the charac- 
 ter of the wound will allow, the object of the surgeon being to obtain union 
 of the soft structures as soon as possible, and thus convert the compound 
 into a simple fracture. 
 
 In dressing such fractures the bandage of Scultetus should always be em- 
 ployed next to the skin, in order that the wound may be opened and ex- 
 amined. If the injury be to the thigh, the cradle-splint of Hodgen, or the 
 extension apparatus of Buck, will be of service. If it be the leg, and one 
 bone is broken, the simple fracture-box, filled with bran which has been 
 sprinkled with carbolic acid, should be used. If both bones are broken, 
 and extension and counter-extension are necessary, Neill's apparatus may 
 be employed. An excellent splint is that invented by Dr. A. Hays, which 
 can be made by taking a long side-splint, cutting out a sufficient portion 
 opposite the site of fracture, that free access can be had for dressing and 
 an exit for the discharge, and uniting the two portions of the splint, which 
 are separated, by a convex iron-hoop, which must be securely fastened by 
 screws. The hoop of iron also acts as a protection from the pressure or 
 rubbing of the bedclothes on the affected part. 
 
 _ Dr. Hays remarks : " This plan I found to meet my wishes and expecta- 
 tions very fully. The extension and counter-extension being continued, 
 
608 A SYSTEM OF SURGERY. 
 
 the dressing might be repeated as often as requisite, without in the least 
 disturbing the position of the limb." 
 
 If inflammation and swelling supervene, the bandages must be loosened, 
 and a lotion of arnica or calendula applied to the part ; if the pain be very 
 severe and synochal fever be present, aconite may be prescribed, or if cere- 
 bral symptoms develop themselves, arnica, bella., cuprum, or hyos., may 
 be indicated; if strangury be present, aeon., nux, cann., canth., or some 
 other appropriate medicine must be resorted to. Other indications for the 
 treatment have been already alluded to in the chapters upon Wounds and 
 Abscesses. 
 
 The great object of the subsequent treatment is to prevent the lodgment 
 of matter, by sponging and pressing it out carefully at each dressing, and 
 applying compresses to prevent its accumulation, and, if necessary, to make 
 openings for its exit. In this state of excessive discharge, dry bran, 
 as an absorbent, is one of the best beds the limb can be laid upon. If the 
 patient seems likely to sink under the discharge and irritation, notwith- 
 standing the local application of calendula, and the administration of aeon., 
 bella., china, hepar, mere, and other medicines that have been mentioned 
 for such conditions, amputation is the last resource. 
 
 For further information on this subject the student may refer to the 
 Question of Amputation, at page 353. 
 
 CHAPTER XXXII. 
 
 INJURIES AND DISEASES OF THE JOINTS. 
 
 Wounds — Synovitis — Arthropyosis — Ulceration of the Articular Cartilages — 
 Genuthrotomy — Anchylosis: False and Spurious — Subcutaneous Osteotomy 
 — Chronic Rheumatic Arthritis — Hip- joint Disease — Loose Cartilages in 
 Joints — Talipes : Varus — Equinus — Valgus — Calcaneus — Tenotomy — Spurious 
 Talipes — Weak Ankles — Genu Valgum — Knock-knee — Bow-legs — Trigger- 
 finger— Hysterical Joints — Gonalgia — Disease of the Sacro-iliac Syn- 
 chondrosis. 
 
 Wounds. — The joints are wounded from various causes — from cuts, thrusts, 
 or by machinery. Of these wounds by far the most dangerous are those 
 which penetrate the synovial membrane, allow the escape of synovial fluid 
 and the admission of air into the cavity of the joint. Other accidents as 
 the crushing and severing of articular surfaces, are treated in other portions 
 of this chapter and in that upon fractures. All wounds in proximity to the 
 joints are more or less serious, because sometimes even a slight puncture 
 has been followed by most disastrous consequences. When the cavity of 
 a joint has been opened by a wound and synovia escaped, there may at 
 first be but little pain ; in a few hours, however, symptoms of inflammation 
 become manifest; there is throbbing, severe pain, a tense stifT feeling of the 
 part affected and redness ; with these symptoms there are also decided in- 
 dications of constitutional disturbance, as exhibited first by chilliness, fol- 
 lowed by fever, thirst, anorexia, and aching pains in the bones. The dis- 
 charge which issues from the wound loses its ordinary character ; it is thin, 
 sanious, and I have seen it of a reddish hue. At times suppuration takes 
 place, pus is discharged, and the bones are threatened with caries ; this lat- 
 ter, however, need not always happen, inasmuch as the inflammatory pro- 
 cess may be arrested and terminate in resolution. 
 
 In many persons, especially those disposed to the disease, erysipelas 
 makes its appearance ; or, in other cases, the parts appear to be doing well 
 
SYNOVITIS. 609 
 
 when, either gradually or suddenly, symptoms of tetanus supervene, and 
 the patient, after undergoing the agonies of this disease, either dies or has a 
 prolonged convalescence. 
 
 Treatment. — In wounds of the joints the parts first must be thoroughly 
 cleansed, and the lips of the wound brought as nearly as possible in appo- 
 sition. Absolute rest for a number of days is necessary. The patient 
 should take internally arnica, if there has been much bruising of tissues, 
 but if there is that peculiar coldness of surface which belongs to ledum that 
 medicine must be administered. 
 
 During the first few days of the treatment, the patient must be narrowly 
 watched, and if chilliness, stiffness of the nape of the neck, or other symp- 
 toms of approaching tetanus supervene, the appropriate medicines must be 
 given. The reader may refer to this subject, in the Chapter on "Injuries 
 and Diseases of the Nervous System." 
 
 For erysipelatous inflammation, aconite, bella., rhus tox., apis, lachesis, 
 canth., arsen., and other medicines will be required, according to the charac- 
 teristics. If synovitis ensue, it will be known by the symptoms detailed in 
 the next section of this chapter. 
 
 Synovitis. — Inflammation of the synovial membrane may result from 
 traumatic irritation, or other local causes, or be caused by constitutional 
 disease. Mr. Athol A. Johnstone, the author of the essay on Diseases of 
 the Joints, in Holmes's System of Surgery, divides synovitis into scrofulous, 
 rheumatic, gouty, syphilitic, and pyaemic. Briefly, however, the terms acute 
 and chronic will suffice. 
 
 The disease commences with severe aching in the joints, together with 
 shooting pain, sometimes extending into the surrounding parts. After a 
 short period the joint enlarges, becomes of a reddish hue, is extremely 
 sensitive to pressure, and symptoms of severe constitutional disturbance 
 develop themselves. The fever is intense, with redness of the cheeks, 
 glistening eyes, coated tongue, high-colored urine, and, in some instances, 
 derangement of the digestive functions. The swelling often advances 
 rapidly, and is caused by effusion into the synovial cavity. If the joint 
 be superficial, fluctuation is distinct ; the inflammation may terminate in 
 suppuration, and the formation of purulent secretion, to which the term 
 arthropyosis is applied. In a case which I attended with Dr. Lilienthal, of 
 New York, the symptoms were rather remarkable, the pain being chiefly 
 confined to the rotator muscles of the thigh, the knee also exhibiting the 
 usual symptoms, with profuse perspiration. 
 
 In the syphilitic variety of this disease, it occurs as a tertiary manifesta- 
 tion, and the knee and elbow are the joints most frequently attacked. 
 
 In chronic synovitis, the pain is not so severe and is of a dull aching 
 character, the part is but little sensitive to pressure, and there is experienced 
 a sensation of weakness and relaxation of the limb. The swelling appears 
 a few days after the pain, which in cases of an indolent character may be of 
 trifling moment. After a time, an -effusion takes place within the cavity of 
 the joint ; this fluid contains but a small proportion of lymph, and coagu- 
 lates by the application of heat. The joint is rendered useless and there is 
 a feeling of insecurity that prevents the movement of the parts. To such, 
 the term hydrops articuli is applied. 
 
 The disease may follow local injuries, or be dependent on constitutional 
 causes, as rheumatism, gout, syphilis, scrofula, abuse of mercury, etc. 
 Children are seldom attacked. The knee-joint is generally the site of the 
 affection. In such instances the patella protrudes, and there is fulness on 
 each side of it, and also at the lower and anterior portion of the thigh. 
 At the elbow the swelling is most marked above the olecranon ; at the hip 
 
 39 
 
610 A SYSTEM OF SURGERY. 
 
 and shoulder articulations there is general swelling of the surrounding 
 muscles. 
 
 The disease is considered serious when it arises from penetrating wounds 
 of the joint, as in such instances the constitutional disturbance is so severe 
 that life is brought into imminent danger. 
 
 Delirium and typhoid symptoms are very unfavorable. In severe cases 
 suppuration within the cavity may ensue, or ulceration of cartilage and 
 complete anchylosis result. 
 
 Treatment. — The limb should be kept at rest until the violent inflamma- 
 tory symptoms have been subdued, which may be accomplished in the first 
 stages by the employment of aconite. This medicine is especially indi- 
 cated by the severity of the fever, and when there are drawing and sticking 
 pains in the affected joint, with tension, aching, and gnawing ; when the 
 patient complains of frequent chilliness and thirst, together with prostra- 
 tion and trembling of the limbs. 
 
 I have tried many remedies in the treatment of the chronic forms of 
 synovitis, and must give unqualified preference to the iodide of potash 
 over all other medicines. I must say also that I have been obliged to 
 give it in substance, from three to ten grains at a dose, three times a day ; 
 in addition to this, the diseased surfaces must be kept apart. This is accom- 
 plished by the weight and pulley, five pounds being sufficient in most cases 
 to effect the result. It is astonishing what relief this simple contrivance 
 often gives, and from experience I should lay it down as a rule that this 
 mechanical treatment should not be lost sight of in the management of 
 either the acute or chronic forms of the disease. 
 
 Dr. A. P. Williams records two cases of acute synovitis which were cured 
 at the Homoeopathic Hospital on Ward's Island, by the internal adminis- 
 tration of apis mel* 
 
 Aur., calc, lye, nit. ac, phosph. ac, sulph., together with silic, have been 
 found useful in inflammation of the synovial membrane, in consequence of 
 effects of mercury ; and bry., china, lye, nux vom., rhus, and sulph., when 
 the disease occurs in gouty or rheumatic individuals. 
 
 Calc. carb. and sulph. have been chiefly recommended in lymphatic or 
 scrofulous enlargements of the knee. If suppuration ensue, silic, mere, 
 and hepar; and in cases of serous infiltration, silic. and sulph., or calc, 
 mere, and iodum. 
 
 Other medicines are helleb. (particularly in hydrops articuli), iod., natr. 
 phosph., ruta, stront. 
 
 By the use of some of these medicines motion of the joint may be restored, 
 but if there has been much effusion of plastic material, anchylosis, either 
 spurious or bony, — generally the former, — will result. 
 
 In all cases when the symptoms indicate the presence of fluid within the 
 joint, the aspirator must be used, and if pus follows its introduction, the 
 fluid must immediately be evacuated. There need be no fear in the with- 
 drawal of fluid from the joints by this means. I have repeatedly performed 
 the operation, and often punctured the same joint several times, and have 
 never known an untoward result. Dr. Dieulafoy,t in one hundred and 
 five punctures recorded, finds but one fatal case. * His directions for aspi- 
 rating the knee-joint are as follows : 
 
 " The limb is placed in extension, the joint being surrounded by a caout- 
 chouc or linen bandage, leaving the point exposed towards which the liquid 
 has been pressed, and where the needle has to be passed in. This place of 
 election is the external cul-de-sac of the synovial membrane, opposite the 
 
 * New England Med. Gazette, January, 1877, p. 20. 
 f Abstract of Medical Science, April, 1878, p. 77. 
 
TREATMENT OF SYNOVITIS. 
 
 611 
 
 upper end of the patella, and at about two centimeters exterior to this bone. 
 The No. 2 needle, which is to be exclusively employed, only measures a mil- 
 limeter in diameter, and when passed into the joint is to remain in a fixed 
 position while the fluid is aspirated. All manipulation of the joint is to be 
 avoided as causing unnecessary irritation. When the liquid has been re- 
 
 FlG. 311. 
 
 Fig. 312. 
 
 Fig. 313. 
 
 moved the needle is withdrawn and compression employed. The knee is 
 surrounded by a layer of wadding, pretty firm compression being main- 
 tained by means of a flannel or linen bandage. A roller is also to be applied 
 to the foot and leg in order to prevent the production of oedema. Twenty- 
 four hours afterwards the joint is examined, and if there is no or only very 
 slight reproduction of the liquid, compression is again had recourse to ; but 
 if the effusion has been reproduced in a notable quantity, aspiration should 
 again be performed before reapplying the compression." 
 
 Dr. Sayre's apparatus, already described, for making extension in 
 sprained ankle, and which, from its action, prevents the constant friction 
 which otherwise would take place 
 
 Fig. 314. 
 
 Fig. 315. 
 
 m chronic inflammation of the 
 ankle-joint, is an excellent appli- 
 ance. 
 
 For chronic inflammation of the 
 knee, the same gentleman has also 
 devised an ingenious apparatus. 
 Fig. 311 represents the instrument, 
 made of two steel collars, one being 
 fastened above, the other below the 
 knee; they are connected on both 
 sides by extension rods, which are 
 worked with a key ; strong strips of 
 adhesive plaster one inch wide are 
 then applied longitudinally, as seen 
 in Fig. 312, which are secured by a 
 roller, as shown in Fig. 313, to within 
 an inch of their extremities. The in- 
 strument is then applied, the collars 
 drawn sufficiently tight to be com- 
 fortable, and the ends of the adhesive plaster wound over the collars above 
 and below, as seen in Fig. 314. The limb is then brought down as nearly 
 
612 
 
 A SYSTEM OF SURGERY. 
 
 straight as possible, and the rods extended simultaneously, until pressure 
 can be made on the foot without pain. A sponge is placed in the pop- 
 liteal space, and others around the joint, and the whole kept in position by 
 a bandage saturated with cold water. The apparatus complete is seen in 
 Fig. 315. If this cannot be obtained, the weight and pulley, as recommended 
 on a preceding page, may be advantageously used. 
 
 Ulceration of the Articular Cartilages. — If inflammation continue, the 
 articular cartilages suffer, and finally molecular death occurs — the " ulcera- 
 tion of cartilages" of some authors. In these cases the degeneration takes 
 place in a linear direction, and the surface of the cartilage appears to split 
 into fibres as shown in Fig. 316. In reality, this destruction of the articu- 
 
 FlG. 316. 
 
 Vertical Section of Inflamed Cartilage, showing the Splitting into 
 Fibres of its Surface. From Redfern. — Holmes. 
 
 lar cartilages is not a primary, but a secondary affection. It is caused by 
 an extension of the inflammatory process ; it may follow either acute or 
 chronic synovitis, generally the latter. Scrofulous and syphilitic consti- 
 tutions are especially liable to the affection. When such process goes on, 
 the synovial membrane ulcerates and is finally converted into a thick, 
 pulpy substance, intersected by white membranous lines. This condition 
 has received the name of pulpy degeneration. There is much pain and 
 stiffness, together with considerable swelling of the joint, which is elastic, 
 but there is no fluctuation. The tumefaction presents an irregular ap- 
 pearance, being more protuberant in one part than in another, from the 
 accumulation of fluid or solid matter in the directions where least resist- 
 ance is afforded by the surrounding tissues. Pus often accumulates within 
 the cavity of the joint, and the suppuration is accompanied with much con- 
 stitutional disturbance ; or the matter may be effused into the bursse, into 
 the surrounding cellular tissue, or into that beneath the tendinous sheaths 
 of the muscles in the neighborhood. After a time the capsular ligament 
 ulcerates, the pus is evacuated, and caries of the bone is added to the al- 
 ready alarming disease. 
 
 It has been a matter of some difference of opinion whether in this affec- 
 tion there is enlargement of the articulating extremities of the bone. It is 
 probable that, in the first stages of the disease, they are seldom or never 
 affected, but as abnormal action increases, inflammation and ulceration of 
 the osseous parts ensue. Frequently the knee is the seat of the disease ; 
 
STRUMOUS SYNOVITIS. 613 
 
 and when this articulation is affected, the lymphatic glands in the groin 
 become sympathetically enlarged. The same fact may be noticed when the 
 swelling occurs in the elbow-joint, in which instance the axillary glands 
 participate. 
 
 Fungoid Degeneration. — In other cases from imperfect nutrition a fungous 
 growth makes its appearance. Dr. Ruggi,* in giving his experience on 
 the seat of fungous synovitis of the knee-joint, remarks : That the patient 
 seeks instinctively to diminish the contact of the bones by bending the 
 limb. A case was mentioned, of a scrofulous old woman (age not given) 
 in whom, after a blow, the right knee became swollen and painful, and had 
 to be kept immovable. An amputation was performed. The disease was 
 limited to the articulation between the femur and the patella. This case, 
 the doctor says, demonstrates that fungus synovitis may be limited to the 
 spot where the patella comes into contact with the condyles of the femur, 
 and in this way may be explained the symptoms in cases where the limb is 
 extended. There would then be two forms of synovitis of the knee, distinct 
 in their seats and in their symptoms. 
 
 When the patient has suffered for a considerable time, hectic supervenes, 
 with its alarming train of symptoms, which are always aggravated after the 
 opening of the abscess. Emaciation, excessive debility, loss of appetite, 
 nightsweats, and diarrhoea are also present. In some cases, health is re- 
 stored, and the disease abates spontaneously ; in others, complete cures are 
 effected by careful and judicious treatment. A method of restoration re- 
 sorted to by nature is anchylosis, which may be either ligamentous or os- 
 seous. New bone is deposited, whereby the ulcers become, as it were, cica- 
 trized, and the articulating extremities are joined by firm bony union. The 
 process of ossification is assisted by the effusion of lymph, and consequent 
 thickening and induration of the ligamentous substance exterior to the joint. 
 By such means the parts are retained in exact apposition, and the calcareous 
 matter is regularly deposited, as in fractures retained in situ by the applica- 
 tion of splints. 
 
 This disease, however, may again recur, and both ligamentous and osseous 
 formations be destroyed by the ulcerative process. In many cases, how- 
 ever, anchylosis remains permanent. 
 
 Treatment. — Silic. is the principal medicine in the treatment, repeated 
 every day. If it should not effect a cure, one of the following should be 
 employed and persevered in ; ant. crud., petrol., iod., clem., or sulph. 
 
 In the first stages of the disease, when there is inflammation of the syno- 
 vial membrane, aeon., bell., mez., nit. ac, phosph. ac, lye, sulph., or calcarea 
 should be employed. When the pulpy fungus makes its appearance, phosph., 
 thuja, caust., or sepia may be indicated, In the event of suppuration, silic, 
 hepar, mere, or calend., should be remembered. 
 
 If the swelling is shining, white, soft and doughy, puis, is to be prescribed. 
 In many cases iodine is useful, and may be employed in alternation with 
 puis. When the swelling is red and very painful, bryonia would, perhaps, 
 be more appropriate ; when there is serous infiltration, ledum, calc, iodum, 
 mere, or sulph. may be required. 
 
 Excision of the joint, or amputation, may have to be resorted to in cases 
 resisting all other treatment. 
 
 Strumous Synovitis. — This disease has several stages. The morbid action 
 is continually heaping up new elements, which enlarge the joints, which, in 
 turn, become filled with pus, in which can be found floating cells and 
 nuclei. In the second stage the cartilages become diseased and ulcerated. 
 In some instances, this ulceration is very rapid, in others quite slow, the 
 
 * Monthly Abstract of Medical Science, November, 1876. 
 
614 A SYSTEM OF SURGERY. 
 
 latter being of the most frequent 'occurrence. The first appearance of this 
 abnormal condition is a slight elevated spot, which has a yellowish tinge, 
 and which soon becomes soft, and when examined by the microscope shows 
 that the cartilage corpuscles have become larger and the cells greatly in- 
 creased in number. In the quicker form of ulceration, the process is 
 rapid and eats a hole through the cartilage, which is as cleanly cut as 
 though with a punch. This rapid form of ulceration occurs frequently in 
 cartilages which are subjacent to each other, and, therefore, is found espe- 
 cially in those joints which have been allowed to remain in malposition, 
 but whether the ulceration be rapid or slow, the result in both cases is the 
 same. The ends of the bones are united by a soft granulated tissue, which, 
 beginning at the outside of the bone, penetrates into it, fills the canaliculi, 
 and obstructs the circulation in the Haversian canals. 
 
 The last stage of strumous synovitis consists either in the consolidation 
 of the granulated mass, or the complete degeneration of the ends of the 
 bone ; if the former take place, the reparatory process ensues, which is 
 similar to cicatrization of the soft parts ; if the latter, suppuration occurs 
 and abscesses result, which open around the joint and a fungoid growth 
 protrudes. 
 
 Chronic strumous synovitis is what formerly was designated " white 
 swelling. " The peculiarity of the disease consists in the integuments cover- 
 ing this strumous enlargement of the joint preserving their white appear- 
 ance, while within the joint cavity there is a uniform pulpy swelling 
 formed by complete degeneration of the joint itself. The treatment of this 
 disease is, first, rest, together with which there should be a moderate exten- 
 sion applied, the weight being but a few pounds ; this must be done to 
 separate the cartilages. The internal administration of iodine and iodide 
 of potassium, or of some of the various forms of mercury, is often effica- 
 cious. It is necessary sometimes that a splint be applied to secure perfect 
 immobility of the joint. Cold applications in the acute stage are very 
 efficacious. 
 
 Chronic Contraction of the Knee from Inflammatory Action. — This disease 
 is more common than is generally supposed, and is occasioned by a con- 
 traction of the ligaments about the knee-joint, caused by inflammatory 
 action. The contraction may be permanent, and if not arrested may re- 
 sult in osseous anchylosis. Those cases which result from the contraction 
 of the ham-string tendons, when the internal structure of the joint has not 
 been involved, and where fibrous bands only have formed within the joint, 
 may be remedied by extension and an appropriate splint. But after a time, 
 when the contraction has become chronic and inflammatory action has 
 affected the joint, the head of the tibia is drawn backward, the condyles of 
 the femur are thrown forward, and the ligamentum patelhe is so stretched 
 that in some cases it is partially absorbed, the patella being drawn upward 
 or to one side. Accompanying this deformity there is ulceration of the 
 crucial ligaments, especially the posterior, and also of the lateral ligaments. 
 
 Treatment. — If simple extension, with a splint on each side of the leg, is 
 not sufficient to reduce this dislocation, forcible means may be employed. 
 The patient should be placed under an anaesthetic, and should lie on his 
 face. The surgeon takes the foot of the affected side in one hand and 
 firmly holds the leg above the knee with the other, as the leg is brought 
 forward a slight pressure from behind will have the tendency to force the 
 head of the bone into its position. If this does not suffice the gradual 
 restoration by means of an appropriate splint will be necessary. Several 
 such apparatuses have been invented, as will be seen in Fig. 319. 
 
 Division of the Ham-string Tendons.— Sometimes a simple contraction of 
 the ham-string tendons may be remedied by their subcutaneous division. 
 
ANCHYLOSIS. 615 
 
 The surgeon introduces the tenotome on the flat side close beneath the 
 tendon to be divided, he then turns the cutting edge towards the skin, and 
 with a gentle sawing motion cuts through the tendon. 
 
 In performing this operation on the outer ham-string, care must be taken 
 that the peroneal nerve is not divided (an accident which has happened to 
 myself). This unfortunate occurrence can be avoided by keeping the flat 
 portion of the tenotome closely against the inner edge of the biceps' tendon 
 and th£n turning the edge carefully outward. Very often after the division 
 of the tendons, some bands of fascia may have to be divided. Extension 
 should then be made, and very often in so doing portions of tissue will be 
 torn away ; immediately after the limb is restored it should be placed in a 
 plaster-of- Paris splint, or in an apparatus which will keep it in a straight 
 position, because the shortening of the posterior ligaments, which has been 
 occasioned by the contraction of the tendons, will not allow immediate resto- 
 ration to a straight position. 
 
 Genuthrotomy. — This operation consists in making a free incision into the 
 knee-joint and the introduction of drainage-tubes. The operation should 
 be performed under strict antiseptic conditions. The cases that call for the 
 operation are those of acute serous-gonitis, purulent genuthro-meningitis, 
 osteo-myelitis of one or both epiphyses, and in all cases where there is 
 threatened destruction of the epiphysial cartilages. Dr. Scriba* has col- 
 lected the reports of a dozen cases treated by this operation ; seven of them 
 were acute suppurating synovitis, four were cases of caries and tuberculosis, 
 and one of hydrops articuli. In four of the seven there was perfect recovery, 
 and in three the result was fatal. The four operated on for fungoid disease 
 were fatal, and the one for hydrops successful. These statistics are not very 
 encouraging, but are sufficient to prove the reliability of the operation in 
 cases of simple effusion or suppuration. 
 
 Anchylosis. — Anchylosis, or, as it is sometimes spelled, ankylosis, signifies, 
 in surgical nomenclature, an affection of the joint in which motion is either 
 partially or entirely lost. 
 
 The derivation of the word, however, does not at all indicate that it 
 should be used in such a sense, as the English word " angle " or " angular " 
 comes directly from the Latin uncus, which in turn takes its derivation from 
 the Greek dyxbkoq. According to Celsus, the term was used in ancient 
 times to indicate a contracted joint. 
 
 The loss of motion is occasioned by deposits of a fibrous or osseous char- 
 acter, which are found either within or surrounding an articulation. We 
 have true anchylosis when motion is entirely lost, which is generally occa- 
 sioned by ossific deposits, synostosis being used to designate such a condition ; 
 while false anchylosis indicates that motion is more or less impaired. 
 
 Loss of motion in a joint, in certain cases, may be looked upon as a 
 method of cure, as described by Liston.f Hunter! makes five kinds of 
 bony anchylosis, and, though concise in description, they are very com- 
 plete. They are as follows : 1st. From lateral attachment, where there is no 
 joint — as the union of the tibia and fibula, of two ribs, or of two metatarsal 
 or metacarpal bones. 2d. Bony formations in the surrounding parts. 3d. 
 Between bone and bone, the ossific deposits taking place in the intermediate 
 substance, as betw r een vertebra and vertebra. 4th. By the capsular ligament. 
 5th. By the whole substance of the articulation.§ 
 
 * London Medical Record, March loth, 1877. 
 
 f Elements of Surgery, p. 60, 1837. 
 
 X Lectures on the Principles of Surgery, p. 310. 
 
 \ Connor describes a remarkable case in which there was general anchylosis of all the 
 joints ; and a still more curious case is recorded of a child only twenty-three months old, 
 whose joints were unusually stiff. 
 
616 A SYSTEM OF SURGERY. 
 
 There is also another subdivision made by authors in reference to other 
 circumstances — first as to position : angular or straight ; or as to complica- 
 tion : simple or compound. It has also been noticed, that whenever anchy- 
 losis affects the amphiarthroses, synostosis is the result, but the diarthrodial 
 joints can be affected with either spurious or true anchylosis, although bony 
 union is more frequent in the ginglymoid, and false or spurious anchylosis 
 in the enarthrodial. 
 
 The affection may be produced by various causes, and all those which 
 give rise to inflammations in or around joints, whether arthritic, scrofulous, 
 traumatic, or syphilitic in character, are known to be productive of either 
 one or the other forms of the disease. 
 
 It is not my intention to enter into the great variety of adhesions that 
 may take place in and around the various and complicated joints of the 
 human body, but to proceed at once to detail difficulties in diagnosing 
 the different forms of the disease. In the olden time it was considered 
 impossible to distinguish true synostosis from false anchylosis. Mr. Bon- 
 nett wrote: "We have no certain signs by which we can recognize bony 
 anchylosis;" but since the introduction of chloroform, the diagnosis is 
 made more easy. If anaesthesia had done nothing else, the assistance " it 
 gives the surgeon in this disease, alone would be sufficient to render it in- 
 valuable. 
 
 Any one who has had opportunity of examining and treating these cases, 
 is aware that as soon as any attempt is made to " handle " the limb, the 
 patient, from the consciousness of the suffering he has already undergone, 
 the painfulness of slight motion, the sensitiveness of the joint, and other 
 circumstances, immediately and almost unconsciously resists ; the volun- 
 tary muscles are put upon the stretch and the limb remains fixed; the 
 greater the effort made by the manipulator, the greater will be the exer- 
 tion on the part of the patient to prevent the motion. What a different re- 
 sult is obtained when the patient is fully under the influence of ether ! Let 
 me here offer some rules which I have condensed from Brodhurst,* whose 
 work on this specialty is of high merit, and whose success in the treatment 
 of anchylosis is world-renowned : 
 
 1. Use always the greatest gentleness in handling an affected joint ; let 
 the pressure be gradual and steady. 
 
 2. As a general rule, the sensation of solidity, in bony anchylosis, is un- 
 mistakable in grasping the limb above and below the articulation. Bony 
 consolidation in the movable articulations is so rare, however, that an ex- 
 amination should always be instituted after the full effect of chloroform has 
 been obtained. 
 
 3. False anchylosis is the rule, and it is so common, that adhesions should 
 always be held to be fibrous, until they are proved to be bony. 
 
 4. Immobility alone is not a sign of synostosis ; it not unfrequently exists 
 where the adhesions are fibrous. 
 
 5. Immobility will frequently exist until muscular action is entirely sub- 
 dued by the anaesthetic. 
 
 6. Whenever muscles can be thrown into action so as to render the ten- 
 dons prominent or tense about a joint, the adhesions are not bony. 
 
 These rules are of great service to the surgeon when called upon to give 
 an opinion as to the state of a limb which has a stiffened joint, for very 
 frequently upon his decision, in a case of the kind, the happiness of after 
 life may depend. 
 
 Treatment. — The treatment of anchylosis may be divided into two 
 methods, the gradual, the forcible (brisement force), and either of these ac- 
 
 * Diseases of the Joints. 
 
TREATMENT OF ANCHYLOSIS. 617 
 
 companied by subcutaneous tenotomy. The gradual method is accom- 
 plished by the different forms of apparatus as seen depicted in cuts 318 and 
 319, and may in many cases if comparatively recent accomplish the result. 
 It may also be effected by the hands of the surgeon, applied with careful 
 regularity in making passive motion. 
 
 But the surgeon must not forget, that in many instances anchylosis is a 
 method adopted by nature to cure the patient, and, therefore, must not be 
 interfered with. If, after scrofulous synovitis, or caries, or extensive degen- 
 eration of the articular cartilages, anchylosis result, the best thing to be 
 done is to endeavor, while the bony or ligamentous deposits are taking 
 place, to shape the limb in such position that it may be the most useful to 
 the patient in its stiff position. In applying sudden force, and completing 
 the operation at a sitting or two, the limb must be forcibly flexed and not 
 extended; and when after the joint is comparatively loose, extension is 
 practiced, it should be done with gradual force. It may happen in some 
 cases, that the deformity in the flexed position is so great, that further 
 flexion is impossible. This does not often happen, but I have seen it in 
 several cases at the hip, and at the knee ; in the former the thighs rested on 
 the abdomen, in the latter the gastrocnemius touched the long head of the 
 biceps. In all of these a cure was effected by extension, but it was care- 
 fully exercised. This precaution is given, because in certain cases in which 
 anchylosis has been of long standing, and synostosis has existed, severe 
 and fatal accidents have followed forcible extension. The condyles of the 
 femur, and the upper epiphysis of the tibia have been torn away, gangrene 
 of the limb has followed from pressure on the popliteal vessels, and the 
 artery itself has also been ruptured. This latter has happened in the hands 
 of distinguished surgeons. Dr. Salzer* lately reports five cases, three being 
 under the charge of Billroth, one under Nicolandoni, and one under Gussen- 
 bauer. Gangrene took place in three of the cases, requiring amputation of 
 the thigh, in one amputation of the hip-joint was performed. Two patients 
 perished from septicaemia. 
 
 Great caution must therefore be employed, and constant attention paid to 
 the pulsation of the posterior tibial, and to the temperature and color of the 
 parts while the extension is being practiced. I may also call attention to 
 another fact, in the danger of refracturing a bone, which has been broken 
 in the vicinity of a joint, and from which accident the original stiffness of 
 the joint may have arisen. Such a case lately happened to me. The 
 patient was a sea captain, aged fifty, had suffered from a fracture across 
 the head of the tibia just below the tubercle, had recovered with a semi- 
 flexed limb, which rather unfitted him for work. I divided the ham-string 
 tendons with care, and, in flexing the limb, the callus gave way, and the 
 bone, though not completely fractured, was bent. It was restored to its 
 position, and union resulted. 
 
 In spurious anchylosis, much service may be rendered by passive move- 
 ment of the joint, together with massage, and the internal administration of 
 graph., rhod., rhus tox., sepia, or sulph., and in some instances, cham., bry., 
 lye, and staphis. ; very frequently by the early use of these remedial agents, 
 together with passive movement of the joint, the disease may be cured. I 
 must speak here of the use of Dr. Butler's electro-massage instrument in 
 the treatment of spurious anchylosis, and in applying the proper friction 
 with electricity, after forcible flexion has been used, and also in stiffness of 
 the joints resulting from fractures in their vicinity. In my hands this 
 combination of electricity and massage is more serviceable than any other. 
 The cut will explain itself. 
 
 * Weiner Medizinische Wochenschrift, Nos. 8 and 9, 1884. 
 
618 
 
 A SYSTEM OF SURGERY. 
 
 Frequent friction also, with arnicated oil, has been a favorite and satis- 
 factory adjuvant with me, one part of arnica being mixed with four parts 
 of oil. 
 
 When rigidity of muscles and ligaments produces immobility of the joint, 
 bry., rhus tox., ruta, lye, sulph., should be employed. The patient may 
 
 Fig. 317. 
 
 Butler's Instrument for Electro-massage. 
 
 also be placed in an anaesthetic condition, by the inhalation of ether, and 
 the limb flexed and extended, even if considerable effort be required. 
 
 In several instances I have succeeded in restoring motion to the elbow 
 by an apparatus represented in Fig. 318. It consists of padded bands, a, 
 
 Fig. 318. 
 
 /" ^V 
 
 G.TIEMANN ft. CO 
 
 6, c, d, which are buckled around the arm, forearm, and wrist, having a 
 steel bar on each side of the arm, with a joint at the elbow. A screw works 
 into a cylinder on the anterior face of the arm, which regulates the amount 
 of both flexion and extension. Fig. 319 shows a similar apparatus for the 
 knee; it consists of metal troughs 1, 2, 3, with two lateral bars attached to 
 the shoe, a, with a joint at the knee worked with a key, g. The knee-cap, 
 d, fits well over the patella. The whole is held by buckles, as seen at c, 
 d,ej. 
 
 The methods may be exemplified in the following cases : 
 A young woman, aged twenty-seven years, was brought to me with partial 
 anchylosis of the temporo-maxillary articulation from long-continued rheu- 
 matic inflammation. She was of a strumous habit, and the disease had 
 existed for some considerable time. Having had under my care a case of 
 complete anchylosis of this joint — which I reported some years since in the 
 North American Journal of Homoeopathy — I was prepared with the necessary 
 
TREATMENT OF ANCHYLOSIS. 619 
 
 appliances, and immediately resorted to forcible extension. Having placed 
 her fully under the influence of chloroform, I introduced the jaws of the 
 instrument (which, when closed, resemble an iron wedge, but which are 
 forcibly separated by means of a screw and lever) between the teeth on the 
 affected side, and putting the instrument in motion, succeeded in opening 
 the mouth to its fullest extent. As is usual in such cases, the adhesions 
 gave way with a loud snap, and freedom of motion resulted. Swelling and 
 inflammation followed, during the height of which perfect quiet of the 
 affected parts was enjoined, the jaws being rubbed constantly with cam- 
 phorated oil. So soon as the swelling subsided, a wedge of hickory wood 
 was placed between the teeth during the day, thus keeping the jaws forcibly 
 separated, but she was allowed during the night to have it removed. After 
 two weeks of this treatment the foreign substance was dispensed with, and 
 she was ordered to talk as much as possible — not a very difficult thing for 
 a woman — and to chew constantly through the day portions of hard cracker. 
 By these means motion was perfectly restored. 
 
 A healthy girl of about twenty years of age, a seamstress by trade, had 
 received a very deep burn in the palm of the left hand. During the 
 healing process, the index, middle, and ring fingers were drawn over the 
 palm, rendering them not only useless to her in her avocation, but a source 
 of constant mental irritation from their unsightliness. She could not wear 
 a glove, and generally, in the presence of company, concealed her hand 
 from view. I placed her under the influence of chloroform and endeavored 
 to resort to forcible extension, but the adhesions of the palmar fasciae, and 
 the contraction of tendons, were so great, that I found it was impossible, 
 with prudence, to straighten the fingers. I, therefore, with a tenotom} T 
 knife made subcutaneous section of the tendons, and also in two different 
 places divided the palmar aponeurosis. Her hand was then covered, and 
 she was told to return in a week. At her second visit I found the punc- 
 tures healed, and, having again administered the anaesthetic, straightened 
 the fingers with little difficulty. No apparatus was used in this case, as she 
 was requested to constantly move the previously stiffened joints with the 
 other hand. It is a good rule to allow all punctures to heal before resorting 
 to extension, else, as was often the result in those cases treated by Dieffen- 
 bach and others, a slight puncture may be converted into a severe laceration. 
 
 A boy, aged about twelve years, was thrown from a horse, and fractured 
 the superior extremity of the ulna. After three months he was brought 
 to this city, with his arm at an obtuse angle, and with slight motion at the 
 joint. The parts were swollen, sensitive, and painful, and therefore I re- 
 solved upon the gradual extension plan. An instrument was applied, con- 
 sisting of two plates of German silver united by a hinge, and both plates 
 bent in such a manner that the superior would embrace the lower part of 
 the humerus, and the inferior the upper part of the forearm. These were 
 connected by a screw, by turning which the plates could be brought to any 
 angle required. This apparatus was placed upon the arm, and the parents 
 ordered to turn the screw in one direction in the morning, and the contrary 
 direction at night, with strict instructions, however, that flexion should be 
 made first. This is also an important rule. By resorting first to flexion, 
 the vessels of importance are not so likely to be injured as when extension 
 is used. The case proceeded well, and the father informed me that after a 
 couple of months perfect motion was restored. 
 
 A German boy, aged about nine years, received a severe wound with an 
 axe across the lower part of the condyles of the femur and the upper part 
 of the tibia, involving also the patella. After the wound healed anchylosis 
 resulted. When I saw the boy, his leg was bent at nearly a right angle ; he 
 could not move without his crutches, and his parents were in the greatest 
 
620 A SYSTEM OF SURGERY. 
 
 state of despondency regarding the deformity. I examined him very care- 
 fully, and following the rules already enumerated, came to the conclusion 
 that the case could be at least much benefited. Here I resolved to 
 resort to forcible flexion, and if this proved impracticable, to divide the ten- 
 dons and fascia?, and afterwards endeavor to restore the limb. I placed him 
 fully under the influence of chloroform, and began to put the tendons on 
 the stretch. When the boy was not entirely insensible the voluntary mus- 
 cles would prevent all motion ; but as soon as the anaesthesia was complete 
 very slight mobility was observable. As the flexion was continued, I could 
 distinctly feel the minor adhesions giving way. I still continued the pres- 
 sure, when suddenly, with a report so loud as to alarm the bystanders, the 
 joint became flexible in my hands. Great sensitiveness and pain and 
 swelling followed ; symptomatic fever also was induced, which, however, 
 was controlled by the appropriate medicines. Every day for a week the 
 limb was moved, the patient always having to be placed under the influ- 
 ence of chloroform. An apparatus similar to that used in fractures of the 
 femur, to graduate extension and counter-extension, was put on the boy's 
 limb, and he then came under the care of other physicians of the hospital. 
 The treatment was continued, the flexion and extension being graduated 
 from time to time, and the boy, without his crutches, runs and plays as 
 other children. 
 
 Dr. Reiss relates a case in which kali iod. cured spurious anchylosis. 
 The patient had suffered considerably, and had been under the care of 
 Lutze for a year. The least motion of any limb caused her violent pain, 
 with complete anchylosis (spurious) of the knee and ankle-joints. The 
 prescription was kali iod., grs. v to jfij of water, a teaspoonful twice a day ; 
 the dose was gradually increased, and in a short time a perfect cure was 
 effected. 
 
 Subcutaneous Osteotomy for Anchylosis of the Hip-joint. — In the treatment 
 of synostosis much may be done to relieve the patient, by an operation 
 similar to the famous one of Dr. J. Rhea Barton, of Philadelphia ; an angu- 
 lar limb, totally useless or worse than useless, from its constantly incom- 
 moding the patient and its great unsightliness, may be rendered useful, 
 straight, and of comely aspect. This operation was performed by Dr. Bar- 
 ton on the hip in 1826, and on the knee in 1838. In the one instance a 
 crucial incision, seven inches in length and five in the horizontal direction, 
 was made, and the bone divided transversely between the trochanters ; and 
 in the other, the excision of a wedge-shaped piece of bone above the patella 
 with gradual flexion, succeeded in restoring usefulness to the limb. Dr. 
 Gibson also successfully resorted to it in complete synostosis of the knee. 
 Other surgeons have been successful in the operation. Dr. Buck* reports a 
 case of Barton's operation which is worth perusing. 
 
 A similar operation was performed by D. J. Kearney Rodgers, and Dr. 
 Sayre modified it in 1862,f by making " a curved section of the femur above 
 the trochanter minor, and a straight section a few lines below the first curved 
 cut, thus removing a block of bone." 
 
 Dr. William Adams, however, has the credit of systematizing and per- 
 fecting subcutaneous osteotomy for bony anchylosis of the hip. He says: J 
 " It occurred to me, however, that in these cases of bony anchylosis of the 
 hip-joint, with extreme distortion, a much more simple operation might be 
 performed by the subcutaneous division of the neck of the thigh-bone about 
 its centre, within the capsular ligament, and on the 1st December, 1869, I 
 performed this operation successfully." 
 
 * American Journal of the Medical Sciences, October, 1845. 
 
 f Lectures on Orthopaedic Surgery, p. 423. 
 
 X A New Operation for Bony Anchylosis of the Hip-joint, London, 1871, p. 9. 
 
CHRONIC RHEUMATIC ARTHRITIS. 621 
 
 Mr. Adams describes the particular varieties of anchylosis to which the 
 operation is applicable, and finds that in rheumatic anchylosis, or in anchy- 
 losis after pysemic inflammation, in which the bone is rarely diseased, or 
 after traumatic inflammatory action involving the soft parts only, or in 
 strumous disease of the joint itself which has been arrested at an early 
 stage, — the operation should be performed. Where, however, caries and 
 necrosis of the joint have resulted, and there are fistulas, with discharges 
 of portions of bone, it is not justifiable. 
 
 The operation is performed as follows: A tenotomy knife is entered a 
 little above the top of the great trochanter, and must be carried straight 
 down to the neck of the bone, dividing the muscles, and freely opening the 
 capsular ligament. A small saw must then be carried down in the track of 
 the wound, and the bone sawn through from before backward. The leg is 
 then to be moved freely in all directions ; if this cannot be accomplished, 
 those muscles ofTering the most resistance should be subcutaneously divided. 
 The rectus, the adductor longus, and the tensor vaginas femoris may have 
 to be cut before the leg can be restored to position. So soon as this is ac- 
 complished, the limb must be put into a straight splint and retained, or a 
 weight and pulley may be applied. 
 
 Dr. Geo. F. Shrady has introduced an excellent saw for subcutaneous 
 osteotomy, which is seen in Fig. 320. 
 
 Mr. Brodhurst * makes an incision of one inch in length, and severs the 
 bone by means of a saw immediately above the trochanter. He believes 
 that the free incision is less liable to be followed by suppuration. In the 
 
 Fig. 320. 
 
 Shrady's Subcutaneous Saw. 
 
 Clinical Society, to which he related his views, there was much difference of 
 opinion upon the relative value of the saw and chisel, some advocating the 
 use of the saw, and others that of the chisel. The name was thought to be 
 a misnomer, and it was suggested that the operation should be called " val- 
 vular," instead of subcutaneous section.f 
 
 Chronic Rheumatic Arthritis is characterized by pain, weariness, and 
 rigidity of the larger joints and surrounding muscles, increased by motion, 
 relieved by warmth. The limb spontaneously and easily becomes cold ; 
 the fever and swelling are slight, and generally imperceptible. A difference 
 of opinion exists as to the nature of this affection, some considering it a 
 sequel of acute rheumatism, others as a distinct disease. No doubt it is 
 often either, each case being distinguished by its own symptoms. 
 
 This affection, when it attacks the hip-joint, is so peculiar and so marked 
 that surgeons have given especial attention thereto. It has received the 
 title of morbus coxse senilis, by Mr. Robert Smith. Mr. Benjamin Bell de- 
 
 * Month. Abs. of Med. Sci., March, 1877. 
 f Lancet, February 3d, 1877. 
 
622 A SYSTEM OF SURGERY. 
 
 scribes it as an interstitial absorption of the neck of the thigh-bone. San- 
 difort, Colles, Hamilton, and others consider it as a distinct disease. 
 
 Chronic rheumatic arthritis has not so many varieties as ordinary ar- 
 thritis. It becomes fixed in the loins, hips, and knee, but seldom in the 
 thorax. It differs from other rheumatic affections by the absence of, or 
 the slight degree of fever, the body preserving its natural temperature and 
 the pulse rarely exceeding eighty beats in the minute. The joints are not 
 much swollen, are pale, cold, stiff, and seldom perspire, and are always 
 relieved by warmth. Some individuals are scarcely ever free from pain ; 
 others suffer only before or during damp and changeable weather. The 
 pain is sometimes in the muscles between the joints as well as the joints 
 themselves. 
 
 The disease continues for an indefinite period, and sometimes is incur- 
 able. The affected joint is greatly debilitated, and resembles in some respects 
 the condition produced by paralysis. Inveterate cases give rise to disease 
 of the tendons, bursse, and muscles ; the ligaments also become rigid and 
 thickened, and the joints stiffen. Sometimes a jelly-like effusion is poured 
 into the articular cavity. It affects especially the hip-joint, and in this form 
 is more common in males than in females, and is seen more in the laboring 
 than in the higher classes. The symptoms, when the hip is affected, are 
 dull heavy pains extending down the thigh ; there is weakness in walking. 
 Pressure upon the great trochanter, or forcing the head of the bone into the 
 acetabulum, does not aggravate the pain. As the disease progresses the 
 efforts at rotation and flexion are more and more impeded. Stooping 
 becomes painful, the body is bent forward ; gradually, as changes take 
 place in the joint, the limb shortens, the foot is everted, there is great 
 lameness^ and the patient has frequently to rest himself. 
 
 The buttock of the affected side loses its natural prominence ; gradually 
 the gluteal fold disappears, the muscles are absorbed ; there is pain back 
 of the trochanter major. In the aggravated form of this distressing malady, 
 the capsular ligament becomes much thickened, the ligamentum teres dis- 
 appears, and the notch in the cotyloid cavity is converted into a foramen 
 by the deposition of bone. The acetabulum varies much in shape, be- 
 comes enlarged and porous, and osseous additions are made around the 
 margin. The head of the femur no longer presents its spheroidal shape, 
 and enlarges sometimes to a great degree, and is flattened. In some in- 
 stances the caput falls to a right angle with the shaft. The neck of the 
 bone is either partially or totally absorbed, and the patient, after a miser- 
 able life, dies worn out with suffering. Cold is a common cause of chronic 
 arthritis, even when there has not been pre-existing rheumatic trouble. 
 Violent sprains, strains, and falls upon the trochanter are likewise causes. 
 It may be distinguished from inflammation of the periosteum by the 
 latter being usually seated in the long or flat bones, while chronic rheu- 
 matic arthritis is at or about the joints. The pains of periostitis are very 
 violent during the night, which is the reverse of chronic rheumatic ar- 
 thritis. 
 
 Treatment. — In the advanced stages of chronic rheumatic arthritis very 
 little can be done by internal medicines. In the early stages, however, 
 much good may be effected by the properly selected remedies ; great care 
 must be taken in selecting the medicine and its administration persevered 
 in for a length of time. 
 
 The following are among the medicines used : bry., bell., am., cham., 
 colch., mere, sol., rhus tox., puis., nux, ars., sulph. 
 
 Nitric acid, calc. carb., and perhaps argentum, are valuable medicines ; 
 veratrum pains are increased by the warmth of the bed and by wet weather. 
 
HIP- JOINT DISEASE. 623 
 
 They resemble a bruise, and are lessened by walking; the part affected is 
 weak and trembling. 
 
 By the careful selection of a medicine in chronic rheumatic arthritis, in its 
 early stages, relief is certain, and a cure probable. 
 
 Hip-joint Disease, Morbus Coxarius. — There are certain indications which 
 convey to the practitioner a knowledge of the existence of the disease com- 
 monly and properly called " hip disease," when it is fully established. Of 
 the real nature of the disease there is a diversity of opinion, some consid- 
 ering the affection as scrofulous; Mr. Johnstone* designates it " chronic or 
 strumous inflammation of the joint." Gross speaks of it as "tuberculosis 
 as it affects the hip," and Dr. C. F. Taylor, in the first chapter of his work,f 
 after giving carefully prepared statistics of both hospital and private practice, 
 declares the disease to be " essentially traumatic." Say re J entertains the 
 opinion that the disease is more frequently local than constitutional in its 
 origin, and remarks, " Out of the several hundred cases that I have accurately 
 observed, and taken the trouble to take their history, the immense majority, 
 I may say ninety per cent., occurs in the most vigorous, wild, harem-scarem 
 children ; " although he admits that a scrofulous child, if injured, would 
 more likely be affected than one of a healthy constitution, which probably 
 is the fact ; scrofula, no doubt, being a predisposing cause of the malady. 
 
 The disease has likewise received the name of coxalgia, which term , how- 
 ever, should more properly be applied to the pains which are experienced 
 during the progress of the disorder. The symptoms of hip-joint disease 
 vary materially, especially in its early stages. 
 
 Signs have been laid down for ascertaining whether the inflammation has 
 commenced in a true synovitis (arthritis) ; in the head of the thigh-bone 
 (femoral arthritis) ; or in the cotyloid cavity (acetabular arthritis;. 
 Wherever it may commence, the symptoms are divided into three distinct 
 stages. 
 
 The first stage of hip-joint disease is characterized by limping ; the halt is 
 more observable in the morning, almost disappears during the day, and 
 is absent at night. Exercise or undue exertion may increase the limp, but 
 it often passes away after a day's rest, or is so slight as not to attract atten- 
 tion. Even at this period there may be uneasiness in the knee-joint, though 
 this symptom generally appears later in the progress of the affection. It is 
 in this stage that more can be done by the surgeon than at any other, the 
 main object in the treatment being rest ; but, unfortunately, the patient, in 
 the great majority of cases, is not seen by the practitioner until the second 
 stage is developed. 
 
 The second stage is more pronounced than the first. In it there is intense 
 pain, which frequently is located in the knee-joint and the inner side of the 
 thigh, or sometimes in the posterior surface of the leg. The sufferings are 
 materially aggravated by rotation and abduction. An examination should 
 always be carefully conducted, the child being stripped and laid flat upon 
 a table or mattress. There then will be perceived a slight lowering of the 
 pelvis, and some flexion of the limb ; the gluteal region somewhat flattened; 
 and the gluteal fold sunken. There is likewise an apparent elongation of 
 the extremity, together with abduction and eversion. Motion is much im- 
 paired or entirely lost. The pains during this stage are often excruciating 
 at night, the limb becomes attenuated, and severe constitutional symptoms 
 of fever, debility, perspiration, loss of appetite, emaciation, and hectic pre- 
 sent themselves. It is during this stage that effusion, resulting from the 
 
 * Holmes's System of Surgery. 
 
 f Mechanical Treatment of Diseases of the Hip-joint. 
 
 % Braithwaite's Retrospect, January, 1872, p. 110. 
 
624 A SYSTEM OF SURGERY. 
 
 previous inflammation, takes place within the capsule, and it is the hydrau- 
 lic pressure that causes the limb to be abducted and rotated outward. This 
 fact has been proved by injecting quicksilver within the capsule, and there 
 retaining it; the limb in such experiments being flexed, abducted, and ro- 
 tated outward.* The apparent elongation is also attributable to the same 
 cause, for, says Bauer,f " The sole source of the symptom is the hydraulic 
 pressure from existing intra-articular effusions. I was led to this view from 
 the analogous position of the femur and the immobility of the joint pro- 
 duced by experimental injection." 
 
 In the third stage the symptoms are very different from those just noted. 
 Pus and the effused fluids find an outlet, the muscles have not the resistance 
 to overcome, and gradually the limb assumes a position directly opposite 
 to that noticed in the second stage. It is rotated inward, shortened and 
 adducted. The toes only touch the ground, the pelvis projects somewhat 
 forward, the vertebral column approaches the opposite side, and there is 
 great amelioration of the pains ; indeed, this latter change is often so marked 
 that hopes of improvement are entertained by those ignorant of the nature 
 of the disease, whereas the affection is steadily advancing. During this stage 
 the pus finds an exit on the surface, either in the neighborhood of the joint 
 or in the groin. 
 
 Great structural changes go on in the articulation during the progress of 
 hip-joint disease. The acetabulum enlarges, caries and necrosis of the head 
 of the femur take place, particles of bone being mixed with the discharge. 
 Finally the head of the bone is either entirely or partially destroyed, or is 
 sometimes enlarged. The acetabulum may be pushed up, presenting an 
 appearance somewhat similar to a dislocation on the dorsum of the ilium. 
 This latter lesion, however, is only found in those rare cases, where the 
 shaft, with perhaps a portion of the head of the bone, becomes pushed up 
 through a rent in the capsular ligament. The similarity of dislocation 
 caused Rust to attribute what was formerly supposed to be a spontaneous 
 dislocation of the head of the femur to the action of the contracted muscles. 
 An excellent method of ascertaining the relative position of the femur to 
 the acetabulum is given by Nelaton, and recorded by Bauer, as follows : £ 
 " In drawing a line from the anterior superior spinous process of the ilium 
 to the tuberosity of the ischium, it passes on its way from one point to the 
 other the apex of the large trochanter in the normal position of the femur. 
 It crosses the trochanter more or less below the apex in dislocation." 
 
 If the patient still survive the disease, it may terminate in anchylosis, 
 which, however, is generally spurious, sometimes being partly ligamentous 
 and partly bony ; in rare instances, a true synostosis may occur. Such a 
 case recently came under my own observation ; the disease had existed for 
 sixteen years, the limb was short nearly seven inches, the toes inverted, and 
 the thigh rigidly flexed and adducted. On cutting down upon this bone, 
 the whole cavity of the acetabulum was gone, or rather there was such a 
 complete blending of the head of the thigh-bone and the cavity, that after 
 sawing off a triangular portion of the bone, it required great force to frac- 
 ture the adhesion. 
 
 The pain in hip-joint disease varies in its character, and is caused partly 
 by the unyielding nature of the tissues in which the. inflammatory action 
 is present, and later from the contraction of the muscles, which involun- 
 tarily takes place to prevent motion. I mean by this, that the very con- 
 traction and rigidity of the muscles, which have a tendency to prevent 
 
 * Vide Braithwaite's Ketrospect, January, 1872, p. 109, article on the Treatment of Hip- 
 Joint Disease, by Dr. L. A. Sayre. 
 
 f Orthopaedic Surgery, p. 266. % Bauer's Orthopaedic Surgery, p. 268. 
 
HIP- JOINT DISEASE — TREATMENT. 625 
 
 concussion of the diseased joint, become factors of continuous pressure, 
 which helps to destroy the vitality of the joint and increases the pain. 
 Dr. Charles F. Taylor * thus well puts it : " On the very first intimation 
 of a diminished ability to bear pressure — which is the great obstacle to a 
 spontaneous arrest of any morbid process within a joint — the exigency of 
 arresting motion to save the joint from immediate pain, causes the muscles 
 to take on a contraction of such a rigid and permanent character as to 
 be a condition of perpetual wounding of the parts. Their own excessive 
 action, as well as their elasticity, constitute a continual source of severest 
 injury." 
 
 Treatment. — In the first stage of the disease a cure may be hoped for. 
 The paramount object in the treatment is rest, absolute and continued for 
 a length of time. The patient, therefore, should be placed in bed, and kept 
 there at least a fortnight after all traces of the disease have disappeared. 
 If the patient complain of pain in the knee, belladonna is a medicine by 
 the administration of which, in some instances, in alternation with mer- 
 curius, the disease may be subdued. Aconite may also be used with 
 advantage in the commencement of the affection. If there be tension 
 of the part, with severe pain, colocynth should be employed ; and, if there 
 are evening exacerbations, Pulsatilla is indicated. The chief medicine, 
 however, is belladonna, which, according to Hartmann, is characteristic to 
 the pain in the knee, though this symptom is only symptomatic of the dis- 
 ease of the hip. 
 
 Sulph., lye, hepar, sjlic, zinc, mez., phosph., phosph. ac, bry., cham., 
 puis., staphis., and sepia, should also be remembered in the treatment of 
 this disease. 
 
 Likewise in the first stage, for the purpose of insuring entire rest, it is well 
 to fit to the part a splint of leather, gutta percha, or wire gauze, and secure 
 it with a bandage. Extension should also be used if there are* evidences 
 of the second stage approaching, which is best effected by the weight 
 and pulley, as recommended for fractures of the femur ; or with the anterior 
 splint of Professor Smith, of Baltimore, which latter I have employed with 
 advantage. If the weight and pulley be used, care must be taken not to 
 apply greater extension than necessary — three to eight pounds being suf- 
 ficient. In the second stage, when the pain is intense, relief may be afforded 
 by puncturing the joint, and evacuating the fluid the pressure of which 
 causes the pain. This, however, must be practiced with circumspection. 
 If confinement to a recumbent position prove prejudicial to the health, a 
 different plan of treatment must be adopted, which, thanks to the ingenuity 
 of modern surgery, can be successfully used. 
 
 The splints of Earwell, or that of Hamilton (Figs. 321, 322) are excellently 
 adapted for this purpose. A felt splint or one of sole-leather can also be em- 
 ployed. Dr. Henry G-. Davis, in 1855, conceived the idea of constructing an 
 instrument (Fig. 323) which should allow motion at the same time that ex- 
 tension is kept up. Many modifications have since been made, some of the 
 apparatuses extending to the ankle, some being fastened to a shoe, as Bauer's, 
 and some made with an iron extending some distance below the sole to pre- 
 vent jarring the acetabulum. 
 
 In the mechanical treatment of diseases of the hip-joint, American sur- 
 geons stand pre-eminent. The names of Davis, Taylor, Sayre, Bauer, 
 Knight, Shaffer, and many others, are of world-wide reputation, and the 
 acknowledgment by most foreign surgeons of the superiority of our treat- 
 ment of this affection above all others, is both satisfactory and encouraging. 
 Occasionally, however, we find those who, having claims of their own to 
 
 * On the Mechanical Treatment of Disease of the Hip-joint, p. 13. 
 
 40 
 
626 
 
 A SYSTEM OF SURGERY. 
 
 present, and not understanding how to apply the American methods, con- 
 demn our practices in toto. 
 
 For instance, we read : " Our transatlantic brethren deserve praise for 
 having studied diligently to improve the treatment of these joint affections, 
 but, by ignoring in all their designs the fact that friction is a greater evil than 
 pressure, they have devised method* of less efficacy than those previously in use." 
 
 Fig. 821. 
 
 Fig. 322. 
 
 Fig. 323. 
 
 Our treatment is also designated as " ridiculous malpractice ;" or called an 
 "irrational method ;" or such criticism as this bestowed upon it : " The best 
 commentary on this method is the remarkable frequency with which its 
 principal advocate (Dr. Sayre) has had to perform excision of the joint."* 
 
 These complimentary phrases are from the pen of Dr. Thomas, of Liver- 
 pool, who has a method of his own, viz., " fixation," to introduce. He 
 seems to be in perfect ignorance of the inclined plane, the abduction screw 
 of Taylor, the lateral screw of Shaffer, the platform screw of Sayre, by which 
 " friction " (on which he lays so much stress) is avoided. Had he paid 
 more attention to the literature, and especially the statistics of the treatment 
 of hip-joint disease by the gentlemen whose treatment he ridicules, he cer- 
 tainly would have been more sparing in the use of such harsh and uncalled- 
 for criticism. 
 
 In the mechanical treatment of hip-joint disease a great deal of care must 
 be exercised, or the application of the extension-apparatus will do positive 
 harm. 
 
 Dr. Newton M. Shaffer, surgeon to the New York Orthopedic Dispensary, 
 thus writes on this important subject : " If we apply extension, for instance, 
 to a diseased hip-joint, where flexion of the thigh exists, in a line which 
 corresponds with the long axis of the trunk, we create a lever, where the 
 fulcrum (insertion of the flexors) lies between the power (extension) and 
 the resistance (joint surfaces). It is for the purpose of avoiding joint pres- 
 sure in this condition that the limb is placed on an inclined plane, the patient 
 
 * Diseases of the Hip, Knee, and Ankle-Joints. 
 Liverpool. 
 
 By Hugh Owen Thomas, M.R.C.S.L., 
 
HIP- JOINT DISEASE TREATMENT. 
 
 627 
 
 being in a recumbent position. The extension is then exerted, so far as the 
 conformation of the hip-joint will permit, directly upon the joint, and the 
 contracted muscles yield as the cause of the contraction is modified."* 
 This is an important point to be remembered in the commencement of 
 the treatment of hip-disease, wherein there is much flexion and adduction. 
 For after the splint is applied properly, the limb must be placed on an in- 
 clined plane and raised sufficiently high to bring the lumbar vertebras to 
 ►their proper curve, and then gentle traction made by turning the elongating 
 screw, hereafter to be described. The following is the description of Dr. C. 
 F. Taylor's splint and its method of application, as taken from his excellent 
 monograph on the subject: 
 
 It consists of a hollow rod of steel, reaching from ankle to hip, with a 
 foot-piece, fitting in its lower end and movable up and down, for lengthening 
 
 Fig. 324. 
 
 Fig. 325. 
 
 Fig. 326. 
 
 and shortening, by a key, which works in a rack on the outside of the in- 
 side bar (or top of the foot-piece). The upper end is solid and very strong, 
 and is used, except in special cases, fastened to the pelvic band by a simple 
 bolt at the end. The pelvic band is made of steel, sufficiently strong to 
 support the patient's weight without yielding in the least, and is about two- 
 thirds of the circumference of the pelvis, measured over the trochanter 
 major. It terminates in a strap which fastens into a buckle. From two 
 points in front to two points in the back, perineal straps pass along the 
 perinaeum and under the ischii. These are made of rolls of flannel, covered 
 
 Archives of Clinical Surgery, vol. ii., p. 82. 
 
628 A SYSTEM OF SURGERY. 
 
 with kid or some non-irritating material, and terminating in pieces of leather 
 strong enough to hold in the buckles. They should be near together in front 
 and far apart behind. At the knee-joint there is a leather pad to steady 
 and support the knee, which fastens to a movable cross-piece. A stout 
 leather sole is fastened to the lower part of the foot-piece, to prevent jar 
 in walking on the instrument. A leather strap, passing under the foot, 
 through apertures at each end of the horizontal part of the foot-piece, turns 
 up on each side of the ankle, and fastens the buckles in the adhesive strips i? 
 (Fig. 324). > 
 
 The first important object is to seize the leg in such a manner as to exert 
 against it an unyielding force. This should be done in such a way as will 
 not interfere with the circulation, or injure the knee, by unequal strain 
 either below or above it. In other words, the whole leg should be grasped 
 in such a manner that the knee will be supported. It may be done as fol- 
 lows : A strip of adhesive plaster long enough to reach from the waist to 
 the foot, and from three to five inches wide at the upper, and about one- 
 third that width at the lower end, is taken and cut in five tails as shown in 
 accompanying illustration (Fig. 325). A piece from four to six inches long 
 is cut from the centre tail and added to the lower end to strengthen it ; and, 
 if the patient be strong, one or two more similar pieces are laid on the same 
 place, where a buckle is attached. Two similar straps are prepared, one for 
 the inside and one for the outside of the leg, and laid against the lateral 
 aspects of the leg, the ends with the buckles beginning about two inches 
 above the internal and external malleoli, and the centre tails reaching the 
 entire length of the leg and thigh, to the perineum inside and the trochanter 
 on the outside. The lower strips or tails are then wound spirally around 
 the leg to the pelvis, and afterward the other two pairs of tails, which are 
 cut down to just above the knee, are also wound about the thigh in the 
 same manner. When complete, the thigh is encircled with a network of 
 strips of adhesive plaster (Fig. 326), which act equally and without pres- 
 sure on the whole surface. The leg has about one-fourth of the attach- 
 ments, and the thigh three-fourths, which is found to be the right proportion 
 to protect the knee equally from compression or strain. A few turns of the 
 roller-bandage are then made around the ankle just under the lower ends 
 of the straps, which serve as a protection to the flesh under the buckles, and 
 then it is continued over the straps on the whole leg, as shown in the other 
 figures. Thus prepared, the patient is ready for the splint. 
 
 The instrument should always be applied with the patient lying on his 
 back, and great care ought to be taken that the pelvis is not inclined forward 
 by contractions of the flexor muscles. If such should be the case, the leg 
 should be elevated till the lumbar vertebrae come near the couch ; or, in 
 other words, the spinal column should be made to take its normal shape by 
 elevating the leg till it can do so. The instrument is then applied as first 
 described. But the pelvic band ought not to embrace the pelvis tightly, 
 but there should be room enough for the latter to move freely in it. The 
 anterior superior spine of the ilium ought to be above the pelvic band. When 
 all is adjusted, while the patient still lies on his back, the key should be 
 turned to the right and the instrument elongated, when the whole leg will 
 be gently but strongly drawn downward and the pelvis lifted up with a 
 direct yet easy force, from which there is no escape. In any variation of 
 position or muscular action, the direction and amount of force employed 
 are entirely under the surgeon's control. Nor is this all. The instrument 
 should be so adjusted that there is a little space between the foot and the 
 foot-piece, so that in standing or walking the weight does not rest on the 
 leg, but the whole weight of the body should rest directly on the instru- 
 ment. The patient sits firmly upon the padded straps, which, passing under 
 

 HIP-JOINT DISEASE — TREATMENT. 629 
 
 the ischium and perinseum, are attached to the pelvic band in front and 
 behind. 
 
 This arrangement for supporting the patient on the instrument — besides 
 its independent provisions for extension and counter-extension and abduc- 
 tion — increases the length of the affected leg, when it is fully extended, 
 about one inch. The unaffected leg should have the same amount or a 
 little more added to its length, by means of increasing the thickness of the 
 sole of the shoe worn on that foot. The patient can then progress com- 
 fortably and without . any danger of either lessening the traction on the 
 muscles, pulling off the adhesive straps, or producing pressure or concussion 
 in the joint. The foot is dressed with the shoe in the ordinary manner. 
 
 The splints of Dr. Sayre are provided with a screw for abduction and 
 rotation, and are productive of excellent results ; Dr. Shaffer has invented 
 " a lateral screw," which allows extension in any direction, and can be 
 made to adduct or abduct the limb as occasion may require. This screw is 
 made for application to Dr. Taylor's splint. 
 
 I have employed most of these methods of treatment, and, although they 
 are always troublesome and require much patience on the part of both sur- 
 geon and patient, and frequent watching that the plasters do not slip, or 
 the pressure excoriate, or the screws pinch, or that eczema does not result, 
 yet, on the whole, excellent results can be obtained. Of late, however, 
 I have been in the habit of using what is now known as the physiological 
 treatment, advanced by Dr. Joseph C. Hutchison,* which consists simply of 
 raising the patient on the sound leg by means of an appropriate shoe, and 
 thus, while walking with crutches, the diseased thigh drops down by the 
 weight of the leg, and constant and very easy extension is kept up. The 
 doctor says, that, to seoure immobility of the joint, no apparatus is neces- 
 sary, as nature accomplishes this result very early in the course of the 
 disease, by reflex action, aided by the voluntary efforts of the patient to 
 secure immunit}^ from pain. 
 
 To remove the weight of the body from the limb, to the shoe of the sound 
 limb, a steel plate, corresponding to the sole of the 
 shoe, is attached by two or three upright rods, two FlG - 327 - 
 
 and a half or three inches in length, so as to raise 
 the foot from the ground ; it is the shoe ordinarily 
 used for a shortened leg. (Fig. 327.) This and 
 crutches constitute the apparatus. 
 
 I think, from considerable experience, I can 
 agree with Dr. Hutchison, regarding the advan- 
 tages which the mechanical treatment here de- 
 scribed, possesses over that commonly employed 
 in the management of hip-joint disease. 
 
 (1.) " It saves the surgeon the trouble and annoy- 
 ance of applying and carefully watching the instru- 
 ments in ordinary use, to see tha't proper extension is kept up and undue 
 pressure prevented, while the patient's comfort is greatly promoted by dis- 
 pensing with adhesive plasters which irritate the skin and require removal 
 from time to time, and also with the perineal band which is a constant 
 source of discomfort. 
 
 (2.) "The spasmodic contraction of the peri-articular muscles is overcome 
 by the gentle, persuasive and painless (physiological) extension made by 
 the weight of the limb for several hours each day, whilst forcible extension, 
 either by the ordinary portative instruments, or by the weight and pulley, 
 
 * American Journal of the Medical Sciences, January, 1879. Also, his work in 1880. 
 
630 A SYSTEM OF SURGERY. 
 
 irritates the muscles and stimulates them to resistance and contraction, 
 which must be overcome by main force. 
 
 (3.) " Judging from experience, it is seen that the plan of managing cox- 
 algia, herein described, will shorten its duration more decidedly than can 
 be done by the older methods of treatment. 
 
 (4.) " The apparatus (if so simple a thing deserves the name) is inexpen- 
 sive, and can be made by an ordinary mechanic." 
 
 Dr. V. P. Gibney * in speaking of this apparatus, says that it does not 
 prevent deformity. The question then comes, do any of these splints, as a 
 rule, prevent deformity entirely ? I think not. That, indeed, in some for- 
 tunate cases, where the patient has a good constitution and early and 
 careful treatment has been carried out, excellent results may be obtained, 
 I do not deny, but in the majority of instances in the treatment of the 
 general run of hip disease, deformity cannot be prevented, and I consider 
 the termination of the case fortunate, if the disease be cured with some 
 shortening and a slight halt in the gait. While, therefore, we aim at the 
 cure with a leg of equal length with the other, and a straight foot, yet if the 
 cure of the disease is ultimately effected, even with unequal limbs and par- 
 tial anchylosis, let us be satisfied, and let the patient be told all these con- 
 tingencies before the treatment begins, not after the deformity is settled and 
 the hip disease cured. 
 
 If the patient's health improve, and caries of the bone still continue, 
 excision of the head of the femur is not only practicable but proper. In 
 cases in which I have operated, great deformity was rectified, and the pa- 
 tients restored to health, although sometimes with considerable shortening 
 of the leg. 
 
 The fracture-bed of Dr. Morgan, of Ithaca, which can be found in the 
 Chapter upon Fractures of the Femur, answers all the indications. Dr. 
 Morgan has cured several cases by the extension and rest which are admir- 
 ably secured by his apparatus. 
 
 The question of excision of the hip in morbus coxarius, is still under con- 
 sideration by the profession ; men of large experience taking opposite sides. 
 As yet the exact position of the operation in the domain of surgery cannot 
 be settled. At a meeting of the New York Medical Journal Association, 
 held in February, 1878, Dr. C. F. Taylor asserted that he could not see the 
 advantage in the proceeding, though he was ready to perform the operation 
 if he could be convinced of its efficacy, and considered that the argument, 
 that the disease was arrested and life prolonged, with a more useful limb to 
 the patient, was a mere assumption. Dr. Sayre, who is an advocate for ex- 
 cision, and who has performed the operation over seventy times, declares that 
 when the bone is dead, it must be cut down upon and removed. It appears 
 to me, that with the proper internal medication, and the appropriate me- 
 chanical appliances, most of the cases of hip disease may be cured, but on 
 the other hand, when cases are brought to us in extremis, when a large amount 
 of diseased bone is found, and perhaps imprisoned by the involucrum, pre- 
 venting its removal even by the disintegrating process, I think excision should 
 be resorted to. In the cases I have operated upon, about half were not 
 benefited, while some have been perfectly cured. The surgeon must satisfy 
 himself on these particulars, and resort to the operation if his judgment so 
 dictates. The full directions for performing the operation will be found in 
 the Chapter upon Excisions of Bones and Joints. 
 
 Loose Cartilages in Joints. — These bodies vary in number, from one to 
 twenty-seven having been found in the same joint, and in size from that of 
 
 * The Hip and its Diseases, p. 338, New York and London, 1884. 
 
LOOSE CARTILAGES IN JOINTS — TREATMENT. 631 
 
 a lentil to that of a large kidney bean. Their shape is quite as variable as 
 their bulk ; sometimes they are round or oval, or they may be smooth or 
 irregular. Those resembling in appearance ordinary cartilage, consist 
 chiefly of albumen ; while those that are of a firmer construction contain a 
 considerable proportion of phosphate of lime. The knee-joint is their most 
 frequent location, although they are found in other articulations. 
 
 The etiology of this affection is very obscure ; and, although many opin- 
 ions have been advanced, as yet little positive information concerning the 
 origin and growth of these extraneous bodies has been ascertained. How- 
 ever, certain it is that they commence as pendulous growths upon the 
 synovial membrane ; that the capsular ligament is distended with increased 
 accumulation of synovia ; that they increase in size ; and, that they more or 
 less impede motion. They appear after swelling of a joint, occasioned by 
 a blow or fall ; or they may arise without any assignable cause. In either 
 case, their presence is known by the pain which is experienced by the pa- 
 tient, and by the tumefaction of the part, which increases during rest, but 
 subsides during moderate exercise. Mr. Paget* gives credence to a sugges- 
 tion of Mr. Teale regarding loose bodies which form in the joints, which is, 
 that they may be sequestra : " Just as a blow on bone or tooth may induce 
 necrosis and exfoliation without signs of destructive inflammation, so may 
 it be with articular cartilage ; and the characteristics of these cases will be, 
 that after injury to a previously healthy joint, a loose body is formed in it, 
 having the shape and general aspect and texture of a piece of articular car- 
 tilage, with or without some portion of subjacent bone, and with its cartilage 
 corpuscles arranged after the manner of articular cartilage." This, how- 
 ever, is a ver} r old idea, which has been reproduced by modern surgeons 
 and pathologists. A century ago it was disproved by Morgagni, who, from 
 frequent experiment, found the cartilage of the joint entire and perfectly 
 healthy in those subjects in whose articulations these movable bodies were 
 met with in the greatest number. 
 
 It often happens that, after a time, the pedicle which connects these 
 abnormal formations to the synovial membrane, is ruptured ; and, in such 
 cases, they pass from one part of the joint to the other, and sometimes 
 cause excruciating pain, by becoming impacted between the articular ex- 
 tremities of the bones. In the knee-joint, they are very liable to fix them- 
 selves between the posterior face of the patella and the pulley-like surface 
 of the femur. In some situations, the foreign substances can readily be 
 detected beneath the integument ; and Dessault mentions a case in which 
 they could be seized and twisted with the fingers. f 
 
 Treatment. — In this affection I know of no medicine which is applica- 
 ble, although Dr. B. L. Cleveland, of Saginaw City, Michigan, informed 
 me that he had cured a case of this troublesome disease by the internal 
 administration of rhus tox. The patient was a lumberman, exposed to all 
 kinds of weather, his vocation requiring him to use violent exercise. He 
 fell accidentally into the water, and was taken with severe pains in the 
 joint. These existed for one year and a half, when all the symptoms of 
 loose cartilage presented. Rhus was used for two months, and all the 
 symptoms disappeared. The doctor saw the patient some months after and 
 he still remained cured. The action of rhus in this case would go far to 
 establish the suggestions of Mr. Paget, which have been recorded, and from 
 the known efficacy of rhus in affections of the cartilage, it would seem to 
 have especial affinity for the form of disease under consideration. I know 
 of no other medicine. Two cases have come under my supervision, and 
 
 * St. Bartholomew's Hospital Keports, 1870. 
 
632 A SYSTEM OF SURGERY. 
 
 these were radically cured by the operation described below. As a general 
 rule, strictly surgical means are the only resort. Surgeons have advised to 
 force the cartilaginous formation to a part of the capsule where it will not 
 interfere with the motion of the joint, and there retaining it by bandages, 
 straps, etc., to endeavor to excite adhesive inflammation ; however, such 
 result can scarcely ever be attained, and therefore the operation must be 
 performed. The patient, however, before proceeding with any such means, 
 should be candidly informed of the danger incurred in opening the cavity 
 of the joint, should be told of the ratio of successfully performed oper- 
 ations, and should be allowed to determine what course to be pursued. If 
 he consent to the operation, it should be performed in the following 
 manner : the strictest antiseptic precautions should be used, and the patient 
 having been placed on a mattress, or a table, 'with the leg extended in 
 such a manner that the integument of the joint may be relaxed, the 
 surgeon should search for the foreign body, and, having found it, should 
 bring it to the inner side of the patella, and retain it in that position. The 
 integument immediately over it should then be drawn as tense as possible 
 with the finger and thumb (this may be accomplished with the left hand of 
 the surgeon, or by an assistant), and with a single incision the skin should 
 be divided. The foreign body can then readily be pressed through the 
 opening, and the wound immediately irrigated with the bichloride solution 
 and closed. If there is any connection with the surrounding parts, they 
 may be divided with scissors or a sharp-pointed knife. Forceps, fingers, 
 or any instrument likely to bruise the joint, should never be used. 
 
 The pain of this operation is trifling, unless a branch of the internal 
 saphena nerve happen to be divided. The wound may be closed with anti- 
 septic plaster, and compresses of cotton sprinkled thickly with iodoform ap- 
 plied. It is after the operation that medical treatment is the most impor- 
 tant. To prevent inflammation of the synovial membrane, it would be 
 well to frequently administer doses of aconite, or if other symptoms are 
 present, those medicines already mentioned in the treatment of synovitis 
 must be employed. After the wound has healed, spurious anchylosis may 
 follow, which may be relieved by the administration of ami, rhus, bry., or 
 caust., together with moderate motion, which should be daily increased. If 
 the patient recover with partial stiffness of a joint, the operation may be 
 considered successful. 
 
 Fleshy and gristly tumors may produce symptoms similar to those belong- 
 ing to movable cartilage. The treatment is the same. 
 
 The procedure of Mr. Syme is, however, the best that has heretofore been 
 devised for the removal of movable cartilage, and the results published by 
 those who have had opportunity of testing its efficacy, should lead to its 
 immediate adoption in preference to any other mode. The cartilage is 
 firmly fixed on either side of the joint, and while it is held in situ by an 
 assistant, the skin is punctured by a long tenotomy knife, about two inches 
 from the cartilage, and by a semicircular sweep, the areolar tissue is sepa- 
 rated from the subjacent fascia, and the synovial membrane upon the car- 
 tilage freely denuded. The cartilage is now pressed through the opening in 
 the synovial membrane, and slid along the subcutaneous tract, and there 
 fixed with a pad of lint, adhesive plaster and bandage ; a straight splint is 
 applied along the back of the limb, which is placed at an angle of forty-five 
 degrees, and generally a cold-water dressing is applied. At a proper time, 
 the cartilage is excised, and the remaining portion of the wound heals 
 without difficulty. 
 
 In the treatment of nine cases, the joint was opened thirteen times, and 
 neither pain, inflammatory action, nor any serious symptom occurred in a 
 single case. 
 
TALIPES. 
 
 633 
 
 Talipes — Club Foot. — Talipes, which is generally a congenital affection, 
 although in some instances it may be acquired, is divided by writers into 
 four varieties, equinus, varus, valgus, and calcaneus. There are also other 
 names given to deformities of this class, as they appear to be a combina- 
 tion of two of the above, thus, equino-varus, calcaneo-varus, etc. 
 
 There is also a condition known as talipes cavus or plantaris, in which the 
 deformity is occasioned by the contraction of the plantar fascia. 
 
 The deformity in the majority of cases is caused by paralysis of one 
 set of muscles, which allows the antagonizing ones by their normal traction 
 to displace the position of the foot. The disorder is also thought by some 
 authors to be hereditary, males being more liable to the affection than 
 females. 
 
 When one set of muscles spasmodically contracts, whether the action be 
 rapid or progressive, and not under the control of the will, similar deform- 
 ity results. Such cases are denominated spastic or spasmodic distortions. 
 With reference to the degrees of severity with which patients are affected, 
 Mr. Little writes : 
 
 " It is convenient, for practical purposes, to divide congenital club foot 
 into three degrees of severity : the slightest, that in which the position of the 
 front of the foot, when inverted, is such that the angle formed by it with 
 the inside of the leg is greater than a right angle, and in which the contrac- 
 tion is so moderate that the toes can easily be brought temporarily by the 
 hand of the surgeon into a straight line with the leg, and the heel be de- 
 pressed to a natural position. The second class includes those in which the 
 inversion of the foot and elevation of the heel appear the same or little 
 greater than in those of the first class, but in which no reasonable effort of 
 the surgeon's hand will temporarily extinguish the contraction and de- 
 formity. The third class comprises those in which the contraction of the soft 
 
 Fig. 328. 
 
 Fig. 329. 
 
 Fig. 330. 
 
 Varus. 
 
 Equinus. 
 
 Valgus. 
 
 parts and displacement of hard parts reaches the highest degree, so that the 
 inner margin of the foot is situated at an acute angle with the inside of the 
 leg, sometimes, or even almost in contact with it. Cases of the first and 
 second grades may be respectively converted into the second and third 
 grades by delay in the application of remedies, and by the effects of im- 
 proper locomotion." 
 
634 A SYSTEM OF SURGERY. 
 
 That variety which is most frequently encountered is talipes varus, which 
 is generally accompanied with drawing upward of the heel, and receives 
 the name equino-varus. • 
 
 Talipes Varus. — In this variety of the affection,, the foot is turned inward 
 (Fig. 328), and the patient walks upon its outer edge, the sole looking in- 
 ward ; it is produced by contraction of the tibialis, or the adductors, and 
 when partaking of the equine variety, by the gastrocnemius, and also by 
 the strong contraction of the fascia plantaris. This form of club foot is 
 often congenital. 
 
 Talipes Equinus. — In this deformity, there is extension of the foot more 
 or less complete, the heel is drawn up, the points of the toes touch the ground, 
 which position is caused by contraction of the tendo Achillis, in addition 
 to which there is flexion of the toes (Fig. 329). 
 
 Talipes Valgus. — The foot in this form of the affection turns outward to a 
 greater or lesser degree, in some instances the entire sole looking outward ; 
 in others, there being but slight eversion; the arch of the foot is lost. Flat 
 foot is T. valgus in a modified or slight form. The peroneus longus and the 
 peroneus tertius are the muscles chiefly at fault in this deformity, together 
 with the fascia (Fig. 330). 
 
 In Talipes calcaneus, which is the reverse of equinus, the foot rests upon 
 the heel, the sole looks forward, the toes are pointed upward. The deform- 
 ity is very rare, is generally congenital, and is caused by a contraction of 
 the tibialis anticus and the extensor muscles of the foot, the tendons 
 being protuberant under the skin. 
 
 One or both feet may be affected. If but one, the affected limb is found 
 thinner and more flabby than the other, and, from arrest of development 
 or imperfect nutrition, is weakened and shortened. 
 
 Treatment. — The treatment of club foot should be commenced as early as 
 the deformity is noticed ; frictions and motions in the right direction — early 
 employed, skilfully adapted, and duly persevered with — are alone sufficient 
 to effect a normal relation of parts. Daily and for hours together the dis- 
 torted foot should be held as nearly as possible in a normal position. Many 
 such cases occur; and often it is quite unnecessary to subject the little 
 patients to the pain of tenotomy. 
 
 After a short period adhesive straps properly applied will assist in main- 
 taining the foot in the proper position. 
 
 An excellent method to accomplish this both before and after tenotomy 
 is the plaster-of-Paris bandage. The foot must be placed as nearly as possi- 
 ble in its normal position, and over the inequalities should be placed layers 
 of cotton batting. The bandage should then be carefully applied, and the 
 limb held in position until the plaster has " set." 
 
 In talipes varus, provided both feet are affected, Professor Hamilton places 
 the feet in Scarpa's shoes or in common laced boots. To the sole of each 
 shoe, immediately under the ball of the foot, is placed a steel loop. The 
 heels are then tied together with a tape, a steel bar, four or five inches in 
 length and fitted with a shoulder at each end, is fitted into the loops, and 
 thus keeps the toes well apart and the feet on the same plane. 
 
 Dr. Newton M. Shaffer's* club-foot extension apparatus (Fig. 331), though 
 somewhat complicated, is decidedly the most effective instrument in use. 
 He explains its application as follows : 
 
 " The club-foot extension apparatus, 1, consists of the ordinary uprights, 
 A, A, fastened to the conventional heel-piece, B, by a plain joint on one side, 
 
 * Medical Record, November 28th, 1878. 
 
TALIPES — TREATMENT. 
 
 635 
 
 and an endless screw, 0, on the other. This screw, C, allows us, by using 
 the key, Z), to place the foot-piece of the apparatus, as a whole, in any an- 
 teroposterior position we choose, and to alter it at will, either before or 
 after application to the foot. The dotted line, P, P, is supposed to represent 
 the arc of a circle, the centre of which is the screw, C, That part of the 
 foot-piece, E, which corresponds with the tarsus and metatarsus, is joined 
 by a common extension rod, F (shown in 2), to the portion which lies under 
 the os calcis. With the key, G, we are enabled to extend the anterior part 
 of the foot-piece, E, at pleasure. 2 shows the apparatus lying on its side, 
 with a full view of the under surface of the foot-piece, E, and the extension 
 rod, F. At K, K, is a leather or rubber heel, built up on either side of the 
 extension cylinder, and L represents a wooden sole, which is elevated to a 
 
 Fig. 331. 
 
 T\«AM&tt -"CO. 
 
 height corresponding with the rubber heel. So far as this apparatus is 
 concerned, I may say that it presents no novelty, save the extension rod, 
 and the modifications which this addition to the apparatus makes neces- 
 sary. 
 
 " To apply this instrument, we first, by means of the key, D, place the 
 foot-piece in a position that will exactly correspond with the antero-posterior 
 position of the foot (whether tenotomy has been performed or not). We 
 then secure the heel by tying the heel-strap, H, as represented in 3. We then 
 bind the foot, anterior to the medio-tarsal joint, to the extension part of the 
 foot-piece, E, by means of adhesive plaster, vide 3. We first apply four or 
 five strips to the plantar integument, which are reversed as they pass over 
 the end of the foot-piece, and are then fastened to the under part (wooden) 
 of the foot-plate. Five or six strips are now passed longitudinally over the 
 toes, and underneath, where they are also secured. Transverse pieces are 
 then passed around the tarsus and metatarsus — also underneath the foot- 
 plate — and secured at convenient points. (The plantar strips are not shown 
 in the engraving, and the artist has placed key G too far forward.) A band- 
 age is then applied to protect the adhesive plaster. The key, D, is now 
 used to flex the foot, in overcoming to the desired extent the tendo Achillis 
 resistance." 
 
 Fig. 332 represents the shoes of Dengler. In this apparatus the heels are 
 connected by a chain, to allow some motion. The bar in front is connected 
 with short chains as substitutes for steel springs. The shoes are constructed 
 with coiled wire bands or elastic rubber, which, with a joint at the sole, 
 allows considerable lateral motion. 
 
636 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 333 shows Tiemann's modification of Scarpa's shoe. A spring, a, 
 draws the foot outward, which tension can be increased by fitting the spring 
 into sockets, c. There is a single outside steel bar fitted around the leg by 
 
 Fig. 332. 
 
 Fig. 333. 
 
 Dengler's Shoe. 
 
 Tiemann's Modification of Scarpa's Shoe. 
 
 a belt, d, to this is attached a spring which passes around a wheel fastened 
 to the outside bar above the ankle, and is fastened near the toes on the out- 
 
 Fig. 335. 
 
 G TIEMANN & CO 
 Sayre's Shoe. 
 
 Shoe for Talipes Calcaneus. 
 
 side of the foot. The action of this instrument tends to elevate the toes, 
 and put the tendo Achillis on the stretch. This apparatus also, with reversed 
 action, answers for talipes valgus. 
 
 Dr. L. A. Sayre has introduced a shoe for both varus and valgus, and I 
 have used it many times with excellent results. It consists (Fig. 334) of: 
 A, cushioned iron cup to receive the heel, the leather covering of which is 
 
TALIPES— TREATMENT. 637 
 
 carried over the instep and ankle, and fastened by lacing. N, Elastic tubing 
 to go in front of the ankle-joint, to further secure the heel in position, and 
 fastening at C, an iron hook on outside of heel cup. D, Sole of shoe, 
 cushioned and laced securely in front of the medio-tarsal articulation. E, 
 Ball-and-socket joint connecting sole with heel. F, Elevated plate of iron, 
 properly cushioned, to make pressure against the base of first metatarsal 
 bone. G, Steel bars connecting the shoe with H, strap to go around the 
 calf. K, Joint opposite the ankle. L, Stationary hooks, opposite the 
 toes, for attaching the india-rubber muscles, M M M. These india-rubber 
 tubes have chains attached, for the purpose of making flexion and ever- 
 sion. 
 
 Fig. 335 shows apparatus for talipes calcaneus. 
 
 Dr. Say re lays down the following rule for ascertaining whether the ten- 
 dons, or fascia should be divided. He says :* " Place the part contracted as 
 nearly as possible in its normal position, by means of manual tension, gradu- 
 ally applied, and then carefully retain it in that position ; while the parts 
 are thus placed upon the stretch, make additional point pressure, with the 
 end of the finger or thumb, upon the parts thus rendered tense, and if such 
 additional pressure produces reflex contractions, that tendon, fascia or muscle 
 must be divided, and the point at which the reflex spasm is excited, is the 
 point where the operation should be performed. If, on the contrary, while 
 the parts are brought into their normal position, by means of manual ten- 
 sion gradually applied, the additional point pressure does not produce reflex 
 contractions, the deformity can be permanently overcome by means of con- 
 stant elastic tension." 
 
 Dr. Newton M. Shaffer, f speaking of the importance of properly ap- 
 plied traction in club-foot, and the imperfectness of most of the apparatuses, 
 says : 
 
 " In no part of the human body is the substitution of a purely mechanical 
 force for the power generated by the contraction of muscular fibre — a very 
 difficult proceeding in any event — more easily applied than at the foot. It 
 seems easy to construct an apparatus with a joint to correspond with the 
 tibio-astragaloid articulation, and to make this joint the centre of an arti- 
 ficial movement imparted to the anterior part of the foot through the 
 medium of the foot-plate. But let us see what happens when we attempt 
 to do this with the ordinary forms of apparatus. The centre of motion, so 
 far as the equinus position is concerned, is at the tibio-astragaloid articula- 
 tion. The resistance lies in the post-tibial muscles, and the power is ap- 
 plied in front to the tarsus and metatarsus — the object being simply to flex 
 the foot and bring down the heel. As the anterior part of the foot rotates 
 upon its artificial ankle-joint centre, or as we crowd the os calcis into the 
 heel-cup, and attempt to flex the foot in the same way we would shut the 
 half-opened blade of a knife, the heel, unless restrained, slips forward. One 
 of the effects of mechanical flexion as applied in the customary forms of 
 apparatus, to overcome either a -post-tibial or a plantar contraction, is to 
 crowd the tarsal bones together." If the foot placed in the apparatus could 
 be made to follow the direction imparted to it, our artificial would then 
 correspond to the human mechanism. But it is found through various 
 causes their relations become changed, and the results are often discour- 
 aging. 
 
 Tenotomy. — If the means above mentioned are not sufficient, tenotomy, or 
 the subcutaneous division of tendons, must be effected. 
 
 In talipes equinus, division of the tendo Achillis is usually sufficient. In 
 
 * Lectures on Orthopaedic Surgery, p. 27. 
 
 f Medical Kecord, November 23d, 1878, No. 420. 
 
638 
 
 A SYSTEM OF SURGERY. 
 
 tibialis posticus. 
 
 Fig. 336. 
 
 talipes varus, division of this tendon may suffice, together with the use of 
 mechanical aid. But very frequently it is also necessary to divide the 
 In confirmed cases, the tibialis anticus and extensor 
 proprius pollicis must be added to the list. In talipes 
 valgus, the peronei are divided along with the tendo 
 Achillis. In talipes calcaneus, the tibialis anticus is cut, 
 along with the extensors of the toes. 
 
 The knives which are best adapted to the perform- 
 ance of tenotomy (tenotomes) are thin-bladed, with 
 different-shaped cutting edges and points, as seen in 
 Fig. 336. 
 
 To divide the tendo Achillis. The patient should be 
 placed prone upon a table, with the foot extending be- 
 yond the edge. An assistant should then render the 
 tendon tense, and the surgeon, feeling for the margin of 
 the tendon, should enter a sharp-pointed tenotome flat- 
 wise beneath the skin, and pass it behind the tendon ; 
 the cutting edge should then be turned backward and 
 with a slight sawing motion the cord divided. The sur- 
 geon, during the division of the tendon, should keep his 
 finger on the parts to be cut (Fig. 337), and as soon as 
 they are divided and the knife withdrawn, he should 
 place his finger over the opening, and retain it there for some minutes ; a 
 pledget of lint is then applied, and fixed by strapping. 
 
 Division of the tendon of the tibialis anticus should be performed in the fol- 
 lowing manner : An assistant steadies the knee and the surgeon takes the 
 foot in his left hand, making the tendons as tense as possible by abducting 
 
 Fig. 337. 
 
 Fig. 338. 
 
 Division of the Tendo Achillis. 
 
 Division of the Tendon of the Tibialis Anticus. 
 
 the foot. The knife is then entered flatwise, about in front of the malleolus 
 internus (Fig. 338) perpendicular to the surface, and carried down through 
 the fascia ; the sharp-pointed knife should now be laid aside, and a probe- 
 pointed tenotome introduced behind the tendon, the edge turned forward 
 and the division effected. 
 
 In Valgus it may be necessary to divide the tendons of the peronei. The 
 
SPURIOUS TALIPES — WEAK ANKLES. 
 
 639 
 
 foot must be adducted, the knife introduced behind the external malleolus, 
 between the fibula and the tendons, and the cords divided in the same 
 manner as before. 
 
 The posterior tibial tendon is cut by entering the knife perpendicularly 
 midway between the anterior and posterior borders of the leg on its inner 
 aspect, and penetrating down to its tendons. A probe-pointed tenotome 
 should then be substituted for the sharp-pointed, and carried close to the 
 bone, between it and the tendon ; the edge is turned outward, and division 
 effected by a sawing motion. 
 
 Attention has lately been directed to excision of the bones of the tarsus 
 for the cure of congenital talipes. The opinion of the profession is yet di- 
 vided upon this subject. 
 
 L. Verebelyi * records a case of congenital club-foot affecting both limbs, 
 in which after tenotomy and the plaster-of-Paris bandage had failed, the 
 astragalus was removed by subperiosteal resection, and by the application 
 of proper retentive apparatus a cure was effected. Mr. Davies Colley f re- 
 moved almost the entire tarsus with success. The operation was performed 
 on both feet. 
 
 Hollow Club-foot — Pes Cavus. — This deformity is occasioned by paralysis 
 of the interosseous muscles, with chronic contractions of those tendons 
 which extend to the phalanges and also of those muscles which draw up the 
 toes. The paralysis is chiefly confined to the short flexor and abductor of 
 the great toe as well as the muscles which run to the first phalanges. This 
 disease is always accompanied by a tendency to talipes equino-varus. 
 
 The treatment is, first, to endeavor to stimulate the paralyzed muscles, 
 and second, to divide subcutaneously those tendons which, by their contrac- 
 tion, have a tendency to increase the malformation. The shoe of Scarpa, with 
 a band across the toe, into which screws may be inserted to force down small 
 padded blocks over the toes, and thus keep them in an extended position, 
 may be employed and in some instances without division of the tendons. 
 
 Spurious Talipes — Weak Ankles. — There is a variety of deformity known 
 as weak ankles, or spurious talipes, which generally partakes of the valgus 
 
 Fig. 339. 
 
 Fig. 340. 
 
 Apparatus for Weak Ankles. 
 
 variety, and is found in rapidly growing children. The ligamentous struc- 
 ture gives way, the arch of the foot is lost, and the peronei muscles con- 
 
 * London Medical Kecord, November 15th, 1877. 
 f Archives of Clinical Surgery, vol. L, p. 266. 
 
640 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 341. 
 
 tract. This deformity is also known as flat foot. The affection may be 
 confined to either one or both feet, and if neglected, gives rise to serious 
 deformity as well as lameness. 
 
 Treatment. — In the milder forms, rest and a steel arch placed in the sole 
 of the shoe, are of great service ; but in most cases a shoe giving support to 
 the ankle should be used. As seen in the cut (Fig. 339), a steel bar passes 
 under the shoe, which has a joint, a. The bar is attached above to a band, 
 b, and the ankle is supported by a broad strap and buckle, c. If there 
 should be a tendency to contraction of the tendo Achillis, a strap, e, is 
 affixed (Fig. 340). 
 
 Genu Valgum — Knock-knee. — This affection is caused by a weakness of 
 the muscles and ligaments affecting the knee-joint, in which the internal 
 hamstring tendons have a tendency to contract ; or it may be occasioned 
 either by an enlargement of the inner condyle of the femur, or by atrophy 
 of the external condyle. The affection is so well known as to need little 
 description. 
 
 Treatment. — The first thing to be done in the treatment of knock-knee, is 
 to take the child off its feet, allow it to exercise but a certain period of time 
 each day and then to rest. It is not necessary to put on irons, unless the 
 case is far advanced and the patient cannot be kept in bed. Then an ap- 
 propriate apparatus, very light and carefully made, may be used. When 
 
 the tendons are very much contracted, and 
 the patient several years of age, it is neces- 
 sary to divide the rigid and contracted cords, 
 which I have done in many cases with most 
 excellent results. Fig. 34i represents Tie- 
 mann's apparatus. 
 
 It consists (if the deformity be double) of 
 two lateral stems, with joints at the ankles, 
 knees, and hips, extending from the heel of 
 strong shoes, a, to a well-padded pelvic band, 
 b. The pelvic band is made in two halves, 
 in order to admit of adjustment; the tight- 
 ening of the posterior buckle everts the toes, 
 that of the front buckle inverts them. 
 
 A pair of padded straps, secured to each 
 other crosswise, act in the following manner : 
 End 1 is buttoned to the thigh-stem, c, car- 
 ried from behind, below the inner cond} T le to 
 the front, terminating in end 2, which is but- 
 toned to the leg-stem, d. 
 
 The end 3, buttons to c, is carried to the 
 back of the knee, passing over the inner condyle, and secured to the button, 
 d. In this manner they support both the head of the tibia and femur, 
 whilst their combined direction of force being outwards, gradually corrects 
 the deformity. 
 
 Subcutaneous Osteotomy for Genu Valgum. — It is interesting in this con- 
 nection to note the ages at which rachitic deformities occur. Out of 346 
 cases of rickets, 98 occurred during the first year, 111 during the second and 
 third years, 29 during the fourth and fifth years, 5 from the sixth to the 
 twelfth years, and 3 occurred before birth. 
 
 Genu valgum and varum appears from the first to the eighteenth year, 
 and it is a curious fact that the earlier these deformities appear the more 
 likely are they to be complicated with other malformations, as anterior 
 tibial and femoral curves, and various twists of these bones. As a rule, 
 however, if knock-knees and bow-legs occur after the sixth year they are 
 
 Apparatus for Genu Valgum. 
 
SUPRA-CONDYLOID OSTEOTOMY. 641 
 
 generally uncomplicated. It has been discovered that genu valgum cannot 
 be accounted for by a single curve, but that several inequalities of surface 
 are necessary for the production of the deformity ; for instance, there is gen- 
 erally an internal curve at the lower end of the femur ; out of 166 cases 
 of knock-knees, 120 had internal curves in the lower end of the thigh-bone. 
 In 12 there was an anterior curve at the middle third. In the majority of 
 cases the internal condyle of the femur is elongated and the tibia also is 
 involved, showing a flattening of the external articular surface, or, in other 
 words, the shaft of the tibia is placed at an angle with the head of the 
 bone. 
 
 In Mr. Ogston's operation, the internal condyle of the femur is pushed 
 upward and is placed on a higher level than the external, which produces 
 the irregular articular surface and leaves untouched the tendons on the 
 outside of the joint, and therefore osteotomy below the knee, which was 
 performed by Mayer in 1851, may be the preferable operation. In this 
 the incision is made at a point f of an inch below the tubercle of the tibia, 
 and curved downward to almost surround the front and inner side of the 
 head of the tibia. The flap is then turned upward and the periosteum is 
 cut in the same line. This flap is separated by an osteotome. By means 
 of a round saw, two incisions, each converging towards the posterior part 
 of the tibia, are made to meet about a line and a half from the surface ; 
 this incision does not quite separate the bone into two parts. The wedge 
 is then excised and the sawn surfaces approximated without dividing the 
 fibula. Sometimes double osteotomy, consisting in the division of the 
 tibia and the femur, is necessary, and, in aggravated cases, triple osteotomy, 
 or the division of the femur, tibia, and fibula, may be called for. 
 
 Supra-Condyloid Osteotomy. — Probably, however, the best operation for 
 the relief of the deformity, is that known as supra-condyloid osteotomy, which 
 is thus performed by Macewenn :* The patient having been thoroughly 
 anaesthetized, Esmarch's bandage is applied, and the limb laid upon a sand 
 pillow, which forms a firm support. An assistant holds the upper part of 
 the tibia while another steadies the lower portion of the femur. Two lines 
 are then drawn transversely, one a finger's breadth above the tip of the 
 external condyle, and another half an inch in front of the adductor magnus 
 tendon. Where these lines intersect, a strong sharp-pointed scalpel is 
 entered and made to penetrate at once through the tissues to the bone, 
 and a cut is made longitudinally of sufficient length to admit the finger 
 with the scalpel; the largest osteotome is slid down by the side of the 
 scalpel until it reaches the bone. The scalpel is now withdrawn and the 
 osteotome is turned transversely across the shaft. It must then be drawn 
 over the bone until it reaches the posterior internal border, when the in- 
 strument is made to penetrate from behind forward and towards the outer 
 side. After this incision is completed, the osteotome is turned to the inner 
 side of the bone, severing it as it passes on until it has divided the upper- 
 most part of the internal border, when it is directed from before back- 
 ward towards the outer posterior angle of the femur. After the inner 
 portion of the bone is divided, a finer instrument can be passed over the 
 first, which is then withdrawn and sufficient pressure made to divide the 
 bone. The osteotome is withdrawn and a sponge saturated with one to 
 forty carbolized watery solution is placed over the wound. The surgeon, 
 holding the thigh in one hand, grasps the limb lower down and bends it 
 steadily until the bone snaps or is bent in the proper position. The leg is 
 then wrapped in an antiseptic solution and a similar process adopted with 
 the other leg. 
 
 * JEtiology and Pathology of Knock-knees and Bow-legs, London, 1880. 
 
 41 
 
642 
 
 A SYSTEM OF SURGERY. 
 
 Mr. Chiene operates in the following manner :* " Taking the tubercle into 
 which the tendon of the adductor magnus is inserted as a guide, a vertical 
 incision is made through the skin and fascia ; then, on drawing these aside, 
 the oblique fibres of the vastus externus can be seen in front, and the peri- 
 osteum exposed. The internal articular artery is next secured by a double 
 ligature, and divided. Lastly, the periosteum is raised up, and a wedge- 
 shaped piece of bone is cut, by chisel and mallet, from the substance of the 
 internal condyle. By gentle pressure the leg is now brought to its normal 
 axis. The knee-joint is not opened. In the case exhibited, the wounds in 
 each leg healed in a fortnight, but splints were kept applied for two months. 
 Esmarch's bandage and careful antiseptic measures were used during the 
 operation. The immediate after-treatment is not stated." In some cases, 
 it may be necessary to take wedge-shaped portions of bone from the femur 
 and tibia, as is well illustrated in the following case. 
 
 F. B., aged thirty, came from Minnesota, with a deformity of the leg, 
 which was daily growing worse, was giving him considerable pain, and 
 rendering him incompetent for any business. He had suffered when about 
 fourteen years of age with a softening and disintegration of the cartilages 
 of the knee and the articular extremities of the bone, especially the external 
 condyle, which had finally left him, but in the condition as shown by Fig. 
 342. All appearance of disease had disappeared, and there was not even 
 
 Fig. 342. 
 
 Fig. 343. 
 
 Dotted lines show portion of bone removed 
 with the saw. 
 
 After the operation, from a photograph. 
 
 tenderness of the parts remaining. I first endeavored to relieve the deform- 
 ity by the application of an iron splint, with screws, having previously 
 divided the ham-string tendons. This produced no effect, and he begged 
 that an operation might be performed. The accompanying cut, Fig. 342, 
 taken from a photograph, illustrates the deformity and the peculiarity 
 of the ankle-joint, the patient being unable to set the foot flat upon the 
 ground. 
 
 Accordingly, on the 16th of October, in the presence of several medical 
 gentlemen, the patient was brought fully under the influence of chloroform, 
 
 * Loc. cit, December, 1877. 
 
 
BOW LEGS. 
 
 643 
 
 and the H incisions made ; the two lateral being four inches and a half in 
 length, the transverse uniting the two below the patella and exposing the 
 joint. A triangular portion of bone was then sawn away from the head of 
 the tibia and the condyles of the femur, the patella removed, and the limb 
 brought into a straight position. A gutta-percha splint, moulded to fit 
 the leg, and one to fit the thigh, secured together by straps, was next ap- 
 plied. The apparatus was intended to keep the cut surfaces of the bone in 
 close apposition. 
 
 An anterior splint was then bound firmly upon the limb, which was 
 placed in a straight fracture-box, with hinged sides. After several months 
 the patient made an excellent recovery. Fig. 343 shows the patient after 
 the operation. There was also considerable motion of the joint, much more 
 than could have been anticipated. 
 
 Bow Legs. — In children, though much relief may be obtained by wearing 
 an apparatus such as is seen in the cut (Fig. 344), and which consists in 
 binding to the outer side of the bow leg a spring the tendency of which is 
 to bow outward, and fastening the same by means of a bandage ; the best 
 method of cure is by subcutaneous osteotomy. This operation must always 
 be performed with the strictest antiseptic precautions. A longitudinal in- 
 cision is made through the integuments, of sufficient length to allow the 
 
 Fig. 344. 
 
 Harris's Bow-leg Spring. 
 
 introduction of the chisel-blade. After the incisions through the muscular 
 tissue down to the bone, every small twig of bleeding vessels must be 
 secured, either by the ligature or by torsion, the chisel is turned trans- 
 versely, and the bone partly cut through. The surgeon then takes the shaft 
 of the femur in the left hand and the upper part of the leg in the right, and 
 bends the leg to a straight position. The wound should be carefully closed, 
 and the limb placed in a plaster-of-Paris mould. 
 
 Mr. Ormsby, of Dublin, speaks highly of reducing bow-legs to a natural 
 position by forcibly fracturing the bent bones. This he avers can easily be 
 accomplished by grasping the limb with two hands and laying the one 
 against the other, or by bending the limb across the surgeon's knee. Mr. 
 Ormsby states, " that this operation he has performed very many times, and 
 has never noticed a single complication. He states also that several times 
 
644 A SYSTEM OF SURGERY. 
 
 he produced fracture ; but that he never failed to rectify the deformity and 
 never produced a compound fracture." 
 
 Hysterical Joints — Gonalgia. — There is a variety of nervous disease of the 
 joint, especially noticeable in the knee (to which the name gonalgia is given) 
 which is often very troublesome to treat. From the cases I have observed, 
 I think females are more liable to be affected than males. I have seen it 
 twice in young men, in one of whom I am quite sure it arose from pro- 
 longed masturbation. It is often, though not always, accompanied by 
 hysteria, but is usually connected with uterine symptoms. It is not an 
 uncommon attendant upon the menstrual period, some women suffering 
 intensely during that time. The pains are often aching and boring, and are 
 apparently unbearable, confining the patient to bed during the period. The 
 pains also sometimes attack the wrist, the ankle, the shoulder, and other 
 joints, and intermit or pass away during any mental excitement. 
 
 In some cases, especially in the knee, a cracking sensation is noticed, 
 giving the idea that the joint has given way, with accompanying weakness 
 of the limb. In one of my cases I noticed a peculiar rubbing or grating 
 sound similar to that found in arthritis. Together with these symptoms, 
 there is generally apprehension and fear of moving the joint, from which 
 cause alone stiffness may result. 
 
 Treatment. — It is better that patients with hysterical joints should rest 
 them, and that constitutional treatment should be adopted, such as is de- 
 manded by the symptoms. Of the medicines I have used, ignatia, macrotin, 
 caulophyllin, bryonia, and bromide of potash have done most service, which, 
 combined with electricity, will often suffice. Relapses are frequent, and 
 must be guarded against. 
 
 Trigger Finger (Doigt a Ressort). — This is a rare and very peculiar affec- 
 tion, and consists in a sudden loss of power to flex the finger, or after it is 
 flexed to extend it. The voluntary power, however, of the flexors or ex- 
 tensors is not entirely absent, for by an effort of the will the finger may be 
 partially bent, then suddenly the action of the muscles, to complete the 
 flexion, is lost, and the digit remains semi-bent. If the attempt now be 
 made by mechanical means, or by an increase of will, to forcibly close the 
 joint, the finger suddenly shuts down, or goes back with a snap. For ex- 
 ample: Let the student take out his pocket-knife and open the blade at 
 right angles with the handle. The blade represents the finger, the handle 
 the metacarpal bones of the hand. Let him either fully open the blade, or 
 close it, and the manner in which it shuts or opens with a snap, will repre- 
 sent the mechanical action of " trigger finger." 
 
 The pain during this peculiar " snap " is often intense, and causes the 
 patient to cry out, and, as a rule, mechanical interference is not necessary 
 to complete the acts of flexion or extension ; increased muscular effort being 
 generally sufficient. 
 
 This peculiar lack of power is occasioned either by a nodosity, or a thick- 
 ening in the course of the flexor tendons, at a considerable distance from 
 the articulation. Dr. George W. Jacoby,* who has made an interesting 
 table of. the cases of this affection, writes : " In looking over the cases pub- 
 lished, and which I have tabulated, we find that, of thirty-three cases, 
 twenty-one were in women and only ten in men, two cases not being speci- 
 fied, a preponderance of women which is rather striking. All cases were 
 in adults except two — a case of Berger's, occurring in a child five and a half 
 years of age, and one of Leisrink's in a girl of ten. Occupation does not 
 seem to have any influence upon the production. The fingers affected were, 
 the thumb sixteen times, the ring-finger fifteen, the middle finger six, the 
 
 * New York Medical Journal, June 19th, 1886. 
 
DISEASE OF THE SACRO-ILIAC SYNCHONDROSIS. 645 
 
 little finger twice, and the index only once — a total of forty fingers in thirty- 
 one cases, five cases having more than one finger affected. These fingers 
 show that the thumb and ring-finger are most frequently affected, and the 
 index and little finger least frequently. Either hand may be affected indis- 
 criminately. The aetiology must, in the majority of cases, be sought in 
 rheumatism ; next in frequency comes traumatism (cases of Notta, Dumarest, 
 Vogt, and Blum), and in some cases no direct cause can be found, it being 
 apparently of spontaneous origin. The debut may be sudden, without any 
 prodromal symptoms, but, as a rule, it is preceded by a series of symptoms, 
 and then the affection develops slowly. These symptoms are frequent 
 sharp pains in the metacarpo-phalangeal joint of the affected finger, pains 
 going up along the volar surface of the arm to the elbow, but not localized 
 over any particular nerve-trunks. The diagnosis is easy, as there is no dis- 
 ease with which it could be confounded after once having seen a case, or 
 even having read a description of it. The affection is so characteristic and 
 peculiar, so different from any other disorder of motion, that a mistake can 
 not easily occur." 
 
 Treatment. — In the treatment, electricity is said to be the most service- 
 able agent. I should suppose also that potassium iodide would be of use, 
 together with strychnine, in small doses, or physostigma hypodermically 
 administered. If, however, the nodosity could be discovered, the surgical 
 measure would be its immediate removal. I have never seen a case of doigt 
 a ressort, and can, therefore, speak with no authority regarding treatment. 
 Sometimes splints may be necessary, but according to Jacoby, massage does 
 no good. The removal by the knife, if the nodosity can be found, to my 
 mind presents the best chances of success. 
 
 Disease of the Sacro-iliac Synchondrosis. — This is not a common disease, 
 and is often, from its symptoms and its similarity to other joint affections, 
 very difficult to diagnose. Dr. Charles T. Poore* has written a valuable 
 treatise on the subject, having collected fifty-eight cases, two of which were 
 from his own practice. He finds that 
 
 Males. Females. 
 
 Under 10 years of age, 4 3 
 
 Between 10 and 20, 4 3 
 
 " 20 and 30, . .9 9 
 
 30 and 40, .3 4 
 
 40 and 50, . . . 2 3 
 
 Adults, 7 5 
 
 Over sixty, 1 
 
 Sex not given, 1 
 
 1 30 27 
 
 The symptoms vary somewhat. There is lameness and pain on pressure 
 upon the sacro-iliac synchondrosis. The limp gradually increases, and shows 
 but little alteration either in the morning or in the evening. If direct 
 pressure is made on the great trochanter, pain of more or less aggravated 
 nature is experienced, which is also increased by striking the sole of the 
 foot while the leg is extended. It is not necessary, however, that the pain 
 should be confined to the affected part, for in the most extreme case that 
 came under my observation, most of the suffering was referred to the knee. 
 Another point which makes the diagnosis often difficult, is the flexion 
 of the limb, thereby simulating morbus coxarius. Dr. Sayre believes the 
 disease to be essentially traumatic, and says, with reference to examination 
 for diagnosis, that when the wings of the* ilia are held firm, and then an 
 examination of the hip is made, no pain is experienced. In hip disease 
 
 * American Journal of the Medical Sciences, January, 1878, p. 63. 
 
646 A SYSTEM OF SURGERY. 
 
 the different rotatory motions with abduction or adduction give pain ; in 
 sacro-iliac disease these motions do not ; while pressing the ilia together 
 against the sacrum, and making pressure along the sacro-iliac synchondro- 
 sis always gives rise to suffering. Again he says :* " In sacro-iliac disease, 
 this lengthening of the limb is absolute, while in hip-joint disease it is only 
 apparent." 
 
 Abscesses, both intra- and extra-pelvic, are found in the advanced stages of 
 this disease, in which case there may be flexion of the thigh, which will add 
 also to the difficulty of diagnosis. 
 
 In Dr. Poore's article, already mentioned, the following diagnostic points 
 are mentioned, which I have arranged in a tabular form : 
 
 SACRO-ILIAC DISEASE. HIP- JOINT DISEASE. 
 
 Pain behind hip-joint, or may be referred to Pain in the joint, or in the knee. 
 
 knee or thigh. 
 No flexure of thigh, or if it appears, it Flexure of thigh early, without abscess. 
 
 comes after the formation of intra-pelvic 
 
 No lordosis. Early lordosis. 
 
 Motion of hip-joint smooth, free, and pain- Limited and painful. 
 less. 
 
 Pelvis does not move with thigh. Pelvis moves with thigh. 
 
 No pain on pressure, either below Pou- The reverse, 
 part's ligament, in front or behind the tro- 
 chanter. 
 
 Pressure on ilium, at right angles to body, Contrary, 
 or attempted rotation of this bone causes 
 pain. 
 
 Tenderness over joint. None. 
 
 No sudden pain at night. Sudden attacks of pain at night. 
 
 No shortening. In advanced hip disease always shorten- 
 ing. 
 
 Intra-pelvic abscess may come early. Intra-pelvic abscesses come late. 
 
 Locomotion more painful. Not so painful. 
 
 Attitude different, body thrown to sound Thigh flexed and pelvis twisted, 
 side. 
 
 In the treatment of this affection a good deal may be accomplished with 
 medication, but the essential requisite is rest. To ensure immobility of the 
 joint, a well-fitting wire cuirass, a plaster bandage, or perfect rest in bed 
 must be resorted to. Dr. Sayre recommends the patient to use crutches, 
 and to wear on the sound side a shoe with a sole of sufficient thickness to 
 allow the affected limb to swing clear— thus making extension and counter- 
 extension. 
 
 Fiat-Foot — Splay-Foot. — This deformity, which also receives the name 
 Pes valgus, is one by no means uncommon, but is according to my experi- 
 ence very difficult to cure or to even relieve. The deformity is either con- 
 genital or acquired, and, I am disposed to believe, may result in some in- 
 stances from infantile paralysis. It is often hereditary, several members of 
 one family being frequently affected. Injury of the spinal cord is another 
 fruitful cause of the trouble; indeed, more than half the cases that have 
 come under my notice could be attributed to such accidents, generally 
 occurring during infancy and being overlooked. A badly treated Pott's 
 fracture results often in flat-foot, and, as might be expected, it is frequently 
 found in rachitic patients. In Pes valgus, as the name implies, the lateral 
 and longitudinal arches of the foot are lost, the instep sinks, so that the 
 entire sole of the foot rests upon the ground and is slightly everted, thus 
 causing the weight of the body to be thrown on the inside line of the sole 
 
 * Orthopaedic Surgery, p. 330. 
 
FLAT-FOOT— SPLAY-FOOT. 647 
 
 of the foot, in fact the inner side of the plantar arch falls down because, 
 from one cause or another, the astragalo-scaphoid and calcaneo-cuboid 
 joints give way. The disease generally begins in youth and progresses as 
 the child grows, the weight of the body being placed more and more 
 upon the weakened joints. If the deformity is slight, it almost entirely 
 disappears upon lifting the foot, but as soon as the patient assumes the 
 erect position, the weakness of the joint shows itself at once. Other bones 
 of the tarsus, as the disease advances, become implicated. The entire foot 
 becomes thinner and longer than the other, and the great or the second toe 
 becomes deformed, turning outward and lapping in a greater or lesser degree 
 over the others. With these changes another symptom is noted : the partial 
 dragging of the front portion of the foot, — the patient often stumbling over 
 slight inequalities on the surface of the floor or ground, over which the 
 other foot swings clear. Finally the os calcis may become so displaced that 
 the posterior protuberance can only be brought to the ground with difficulty. 
 It will readily be seen, that from constant traction of the deltoid ligament, 
 the internal malleolus becomes prominent. 
 
 Treatment. — If the deformity is recognized early and does not proceed 
 from any disease of the cord, something may be done, by properly applied 
 mechanical support, to assist in elevating the instep. 
 
 A steel arch can be constructed between the leathers of the sole of the 
 shoe, which will correspond exactly to the curve of the arch of the instep of 
 the sound side — or inside the shoe an artificial instep may be made of cork 
 or of leather, tapering down gradually towards the end of the tarsus; by 
 these means pressure in the right direction may be maintained, while the 
 inner side of the heel and the sole should be raised by additional bits of 
 leather, the heel also being made somewhat longer than that of the opposite 
 side. 
 
 While these mechanical means are being used, severe or prolonged exer- 
 cise should be strictly forbidden. According to my experience, walking on 
 a level road or floor is, up to a certain point, beneficial ; but where there 
 are many stones and through a hilly country, this exercise should be strictly 
 prohibited. The foot is weak, the patient has not the same control over it 
 as he has over the other, slight inequalities cause him to trip and fall for- 
 ward, or if inadvertently a loose round stone is stepped upon, a severe twist 
 is likely to occur. Walking down hill is always bad. The game of lawn 
 tennis is especially to be forbidden ; jumping to strike the balls, or lean- 
 ing far over on one foot to intercept them may be a source of irreparable 
 injury. 
 
 Surgeons and especially Mr. Alexander Ogston, of Aberdeen, have recom- 
 mended and performed operations, the object of which is to establish anchy- 
 losis of the astragalo-scaphoid articulation. Mr. Ogston 's procedure is as 
 follows:* An incision is made on the inner border of the foot, parallel to 
 the sole, beginning an inch from the tibia and carried for an inch and a 
 quarter down to the bone to allow the joint (the astragalo-scaphoid) to be 
 fully exposed. The articular cartilages of the joint are to be removed 
 with a thin lamella of bone ; this is to be done with a sharp chisel half an 
 inch broad. The arch of the foot is then to be carefully restored. When 
 this is accomplished, the bones are held in their new position by wing pegs, 
 passing from one bone to the other. The patient must be kept at rest 
 from two to three months, and perhaps even for a greater length of time, 
 according to the judgment of the surgeon. This operation has been suc- 
 cessful. Dr. Ogston stating that in seventeen operations performed upon ten 
 
 * British Medical Journal, January 19th, 1884, 
 
648 A SYSTEM OF SURGERY. 
 
 patients, all except one were cured, and in that one the peg was extruded. In 
 no case did the temperature rise over 100°, and there were no symptoms 
 of fever developed. 
 
 CHAPTER XXXIII. 
 DISLOCATIONS OR LUXATIONS. 
 
 General Considerations — Varieties — Diagnosis — Treatment — Extension and 
 Counter-extension — Manipulation — False Joint — Ancient Dislocations — Spe- 
 cial Dislocations of Different Joints. 
 
 Surgeons have divided dislocations into different kinds, according to the 
 degree and extent of the injury. Thus we have the simple and compound, 
 the complete and incomplete, the primitive and consecutive, recent and old. 
 The latter terms carry with them their own explanation. 
 
 A simple dislocation is when the articular surfaces are separated, the ad- 
 joining soft parts or bones being but slightly injured. 
 
 A compound dislocation is when the dislocation is accompanied with con- 
 tusion of soft parts, laceration of bloodvessels, fracture, a wound penetrating 
 into the joint, or reaching as far as the dislocated bone. 
 
 A complete dislocation is that in which the head of the bone is separated 
 entirely from its natural position ; the head of the humerus, for example, 
 driven down into the axilla and resting upon the edge of the scapula. In 
 an incomplete luxation the parts still are partially in contact, as when the 
 head of the humerus touches the coracoid process of the scapula. 
 
 In a primitive dislocation the displaced part remains in the place into 
 which it was first forced ; while in a consecutive dislocation it leaves its orig- 
 inal seat and passes into another. 
 
 Congenital dislocations are rare, and these have, in most instances, been 
 confined to the shoulder, wrist, and hip ; sometimes several joints in the 
 same infant are affected. Instances go to establish the fact of their being, 
 at times, hereditary. Of their cause no satisfactory reason has been given. 
 Probably they may be the result either of internal or external force, or dis- 
 ease in the joints of the embryo. 
 
 The bones farthest from the trunk are considered as those dislocated, those 
 of the ankle excepted, in which case the foot is regarded as the fixed part. 
 
 Besides violence, undue muscular action may produce displacement, espe- 
 cially if the parts adjoining the joint are in a relaxed or unhealthy condi- 
 tion. Parts subjected to frequent and extensive movement are most liable 
 to be luxated, therefore the accident is more frequent in the ball-and-socket 
 joints. The middle-aged and those advanced in life are most liable to be 
 affected, and the dislocated part may be thrown either backwards, forwards, 
 upwards, or downwards, according to the formation of the joint and the 
 direction of the force applied. . 
 
 There are certain individuals in whom there is a peculiar looseness of the 
 joints, who are particularly liable to dislocations. M. Tillaux* records a 
 case in which the shoulder was out of joint several times a da}^ and I have 
 in mind a remarkable case, in which by voluntary action a man could place 
 the head of the humerus beneath the coracoid process at will, and of another 
 loose-jointed individual who could throw the head of the femur to the dor- 
 sum ilii whenever he so desired. 
 
 General Diagnosis between Fractures and Dislocations. — In fracture there 
 
 * Monthly Abstract of Medical Science, November, 1876, vol. iii., No. 2. 
 
 I 
 
GENERAL TREATMENT OF DISLOCATIONS. 649 
 
 is increased mobility, crepitus, and when the broken extremities are placed 
 in apposition, they will not thus remain without external support, while 
 in luxations there is unnatural rigidity, and the displaced part remains 
 fixed. These differences are generally discovered ; at times, however, ex- 
 ceptions present themselves. The rasping sound and sensation produced 
 by dislocated bones have by the inexperienced been mistaken for the real 
 crepitus of fractures. There is likewise discoloration, pain, and swelling ; 
 at times temporary paralysis ; the limb is shortened, very seldom lengthened. 
 When the dislocated end of the bone can be felt, it will be found in an un- 
 natural location, and a depression be detected in the place that the extremity 
 of the bone occupied. 
 
 General Treatment. — The sooner the bone is replaced the better. The 
 replacement is then most easily effected, and in a majority of instances can 
 be accomplished without the aid of other means than the hands. To do 
 this with certainty requires an accurate knowledge of the ligaments and 
 muscles. The adverse action of muscles may at times be overcome by di- 
 verting the patient's thoughts, especially at the moment when the final effort 
 is made to replace the bone. He may be startled by having communicated 
 to him intelligence which would be deeply interesting; or by suddenly 
 attracting his attention to surrounding objects, or otherwise so interesting 
 him, that his thoughts may be diverted from the accident and his muscles 
 thereby be somewhat relaxed. 
 
 Unless a dislocation is reduced soon after the accident, a partial or com- 
 plete inability to move the part may continue during life. Even if the 
 replacement has been accomplished in a short time after the occurrence, 
 the movements of the joint may for a considerable period, sometimes for 
 years, be constrained. 
 
 The two forces employed to reduce dislocations are extension and counter- 
 extension. The former is applied to the extremity of the dislocated bone, 
 the latter by retaining firmly and immovably the upper parts nearest to the 
 dislocated extremity. 
 
 If the hands alone are not sufficient to effect reduction, a handkerchief 
 with a clo vehitch (Fig. 345), or a French knot or bandages must be employed. 
 In dislocations of large bones, compound pul- 
 leys or the rope windlass may be required. FlG - 3 ^ 
 In the treatment of individual dislocations, 
 the proper mode of applying these different 
 means will be explained. 
 
 If an anaesthetic be employed during the 
 operation, the method of administration may 
 be found by referring to the chapter upon 
 that subject. 
 
 Reduction of dislocations, even of the 
 larger joints, by manipulation alone, is now 
 attracting much attention. It has been ascer- 
 tained that shoulder and hip luxations, which 
 were formerly supposed to require a great degree of force for their reduc- 
 tion, can, by proper handling, be brought to their natural positions. This, 
 however, requires a perfect knowledge of the mechanical action of the 
 muscles and ligaments surrounding the joints, in order that those which 
 offer the most stubborn resistance be made to relax. 
 
 Among those who have made this subject a specialty are found the names 
 of Professor Nathan Smith, the father of Professor Nathan R. Smith, of 
 Baltimore, who, as far back as 1824, testified under oath : " I do not think 
 that the mechanical powers, such as the wheel and axle, or the pulleys, are 
 necessary to reduce a dislocated hip or any other dislocation." Kluge, Rust, 
 
650 A SYSTEM OF SURGERY. 
 
 Reid, Markoe, Hamilton, and Bigelow have given the subject careful con- 
 sideration — the last-named having given to the profession a treatise on The 
 Mechanism of Dislocation and Fracture of the Hip, reference to which will be 
 found in the section on Dislocations of the Femur. 
 
 After a dislocation has continued for a length of time, various pathologi- 
 cal changes ensue, the functions of the muscles are altered, tendons form 
 new attachments, plastic effusions take place, and adventitious formation 
 of bone often results, the head of the bone has changed its locality, and 
 gradually taken to itself a new resting-place, and a cavity is formed for its 
 reception. A species of cartilage caps the surfaces, and a new or false joint 
 is the result. In some cases it is extremely difficult to diagnose whether 
 such formation has taken place, or if the case is a chronic rheumatic arthritis. 
 While these adventitious growths are taking place, the bloodvessels and 
 nerves of the parts are imbedded in them, or incrusted with new forma- 
 tions, rendering them brittle, and therefore in attempting the reduction of 
 these chronic dislocations, too much force must not be applied. Fatal hem- 
 orrhage has followed such forcible endeavors. 
 
 It would be a source of satisfaction to the surgeon if more light pene- 
 trated a subject unfortunately enveloped in much obscurity, especially if he 
 knew the time required for the formation of false joints, or those plastic 
 effusions, the presence of which renders the reduction of dislocations dan- 
 gerous. This varies so much in different cases, that no specific time can be 
 mentioned. Perhaps it may be admissible to attempt reduction within three 
 months after the accident. The operator, however, must be the judge. 
 
 Dislocation of the Clavicle. — The luxation of the sternal extremity of the 
 
 clavicle is rather an uncommon accident, and is occasioned by great violence 
 
 applied to the shoulder. When the scapula is fixed, the directions are/or- 
 
 ward, upward, and backward. 
 
 Dislocation forward (Fig. 346). — This luxation is sometimes incomplete, 
 
 as I have noticed on two occasions in 
 FlG - ** children. In such instances, the prom- 
 
 inence is well marked, and in the ma- 
 jority of cases the luxation may be 
 reduced by pressing back the shoulders 
 and forcing the end of the bone into its 
 place. When the dislocation is complete, 
 the symptoms are: 
 
 1. Head of the bone forming a tumor 
 on the articulation. 
 
 2. Head of bone depressed and gener- 
 ally pointing downward. 
 
 3. Shortening of shoulder from its 
 prominence to sternum. 
 
 The upward dislocation is very rare. 
 Malgaigne. Hamilton, and Mr. Bryant 
 mention such cases, the latter gentleman having seen both clavicles dislo- 
 cated upward. 
 In this accident. 
 
 1. The shoulder is shortened. 
 
 2. The head of the bone rests on the top of the sternum. 
 
 3. The tumor moves with the shoulder. 
 
 4. The injury is generally apparent from the exposed situation of the 
 bones. 
 
 Dislocation backward is generally caused by direct force, or violence 
 forcing the shoulder forward, or more frequently it may be produced by 
 disease, as in the instance reported by Sir Astley Cooper, in which it was 
 
TREATMENT OF DISLOCATION OF THE CLAVICLE. 651 
 
 occasioned by curvature of the spine. In these cases the principal symp- 
 toms are : 
 
 1. Difficulty of respiration if the bone presses on the trachea, or, 
 
 2. Difficulty of deglutition if the pressure is made upon the oesophagus. 
 
 3. Head generally inclines forward. 
 
 4. Shortening from middle line to the acromion. 
 
 Treatment. — In the dislocation forward, by drawing the shoulder outward 
 and pressing down the head of the bone, reduction may be effected, or by 
 placing the knee between the scapula? as a fulcrum, and drawing the shoul- 
 ders backward, the bone can be pushed to its place. After reduction, the 
 apparatus of Levis for fractured clavicle (see page 561) will answer extremely 
 well, and to keep the head of the bone in position an ordinary truss, as 
 recommended by Nelaton, with the pad on the projecting bone, and the end 
 of the spring in the axilla or on the shoulder, will prove satisfactory. The 
 pressure should be kept up seven or eight weeks. 
 
 An interesting case of this dislocation occurred in the practice of my 
 friend Dr. B. A. Clements, U. S. A. It is well worth reporting, as the result 
 was so satisfactory. 
 
 Sergeant S. Martin, general mounted service, a spare and active man, aged 
 about thirty-six years, fell head foremost down a dry well at St. Louis 
 Barracks, Missouri, on March 6th, 1873. The well was sixteen feet deep, 
 and at ten feet from the top there was a large projecting rock. He struck 
 the latter with the back of his left shoulder. 
 
 The shock of the injury was considerable. On examination, the left 
 shoulder- and the back of his neck and of his left arm were found much 
 scraped and bruised, but there was no fracture. The following morning it 
 was seen that the sternal end of the clavicle was dislocated backward and 
 somewhat downward. 
 
 Pulling the shoulders strongly backward, and at the same time placing 
 the knee between the scapulse, partly restored the bone to its proper posi- 
 tion, but not entirely so, it being also necessary to pull up the end by the 
 fingers, which procedure was not difficult owing to his lack of flesh. A 
 large pad was put between his shoulders and he was laid on his back ; this, 
 however, did not suffice to keep the bone in position, and the ordinary rings 
 and tapes, so useful in fractured clavicle, were applied, and with great 
 success, the end of the bone being kept well in position. 
 
 The apparatus was removed on April 10th, five weeks after the receipt of 
 the injury, and the bone found to be firmly joined to its attachments. He 
 complained now solely of stiffness of his left shoulder, and inability to use 
 his arm as well as formerly. 
 
 He continued under observation until August, and frictions and iodine 
 were used to his left shoulder-joint without much benefit. There was no 
 swelling about the joint, but there was a shrinking of the deltoid — not great, 
 but yet perceptible. He could raise his arm only to an angle of some sixty 
 degrees. No improvement in thfs condition having occurred in the course 
 of four months, he was discharged the service on August 3d, 1873. 
 
 He would seem to have recovered in great measure the use of the deltoid, 
 as a few months after his discharge he was employed in driving a street car. 
 
 This rare injury was caused, as will be observed, by the shoulder being 
 driven forward and inward. The success of the treatment with the ring 
 apparatus for fractured clavicle was perfect, the dislocated bone being firmly 
 held in its position, till reunion of the ligaments took place. 
 
 In the upward luxation, by drawing back the shoulders, reduction is, in 
 the majority of instances, readily accomplished, but it is a very difficult 
 matter to keep the bone in situ. The best that can be done is to apply to 
 the shoulders a figure-of-eight bandage, and to place a compress over the head 
 
652 
 
 A SYSTEM OF SURGERY. 
 
 of the bone, holding it as firmly in place as possible with broad adhesive 
 straps crossing each other at right angles, or the hernia truss, as already 
 mentioned. It is, however, satisfactory to know that both Malgaigne and 
 Hamilton found the function of the clavicle perfectly restored, excepting 
 when an attempt was made to lift weights above the head. 
 
 In the backward variety the same method of drawing back the shoulders 
 must be tried, and as is recorded in Mr. De Morgen's case,* a splint should 
 be placed across the shoulders with a pad between it and the spine, the 
 shoulders being drawn to the splint by a bandage. 
 
 The apparatus of Mayor for dislocation of the clavicle is seen in Fig. 347, 
 a representing sling ; b and c shoulder belts. 
 
 Dislocation of the Lower Jaw. — Luxation of the inferior maxillary bone 
 is the effect of direct violence upon the chin, or it may be produced by 
 muscular action, as laughing, or yawning. From the peculiar formation of 
 the joint, the direction forward is the only one in which the dislocation 
 occurs. The symptoms are (Fig. 348) : 
 
 1. Open mouth. 
 
 2. Condyles rest in front of the base of the zygomatic arch. 
 
 3. Condyloid space vacant. 
 
 4. Prominence beneath zygoma. 
 
 5. Articulation painful and indistinct. 
 
 Treatment. — Having enveloped the thumbs in a piece of stout cloth, they 
 must be placed upon the molar teeth, while the fingers and hand are placed 
 beneath the chin and base of the bone. Pressure must now be made with 
 
 Fig. 347. 
 
 Fig. 348. 
 
 the thumbs whilst the chin is elevated by the fingers ; the moment the bone 
 is slipping into place, the thumbs, protected by a pair of thick gloves, are 
 slipped from the teeth upon the gums. If there be difficulty in reducing 
 both condyles at the same time, one should be reduced before the other is 
 attempted ; this generally is successful. 
 
 In persons disposed to spontaneous dislocation of the jaw from gaping, 
 etc., a return of the displacement may probably be prevented by the exhi- 
 bition of a dose of staphis., ten drops of the 3d attenuation every night and 
 
 Holmes's System of Surgery, vol. ii., p. 805. 
 
DISLOCATION OF THE PUBIS. 653 
 
 morning for three months. Should this medicine not accomplish the desired 
 object, rhus tox., from its known specific action upon ligamentous tissue, 
 might be tried, in like manner. A successful preventive treatment of this 
 accident is much to be desired ; its frequent repetition in some individuals, 
 especially women, is a source of considerable annoyance as well as pain. 
 
 Dislocation of the Pelvic Bones. — Dislocation of the pelvis is the result 
 of great violence, the nature of the force being generally that of crushing. 
 In the majority of instances these dislocations are of serious import, as 
 the force required to separate the bones is very great, internal organs being 
 more or less involved. The danger is to be estimated from the amount of 
 injury sustained by the abdominal organs. In some cases very severe inju- 
 ries of this kind have been followed by recovery. 
 
 Dislocation of the Pubis. — It appears that the separations of the symphyses, 
 or, as they may be called, dislocations of the pelvis, especially those occur- 
 ring at the symphysis pubis, are those which are most likely to be followed 
 by favorable results, especially those that occur during parturition, of which 
 I have known three instances, all of which recovered. In Malgaigne's 
 cases, seventeen of which occurred during labor, ten died and seven recov- 
 ered ; and of the four cases attributed to accident, two died and but one 
 recovered. Dr. Bryant * relates the case of a woman aged 30, under his care, 
 in which the pubic bones were displaced on the right side for more than an 
 inch, leaving a curious deformity, the pubic bone, with the adductor muscle 
 attached, being curved out, leaving a hollow on the inside of the thigh. 
 
 The same author reports a second case in that of a female child, in whom 
 there was great separation of the pubic bones, the contents of the pelvis 
 being pressed out through the opening, a foot of the large intestine, the ute- 
 rus and bladder all being outside. This patient also recovered. 
 
 It is quite proper to mention here, that an accident of this character, viz., 
 separation of the pubic bones, may occur during a labor without either the 
 patient or the practitioner being aware of the accident at the time. A suit 
 occurred in Brooklyn, in which I was called upon to testify, where such an 
 occurrence took place. 
 
 The dislocations which occur from violence are much more liable to 
 implicate the pelvic viscera, and therefore are much more serious. Dr. 
 Lente, of the New York Hospital, reportsf (also quoted by Hamilton), 
 the case of a man set. 18, crushed between two cars ; there was a separation 
 of the symphysis, and the patient died in two days. The post-mortem 
 revealed a rent in the apex of the bladder large enough to admit a man's 
 thumb. 
 
 Sir Astley Cooper gives, also, a case of separation of the symphysis of 
 about two fingers' breadth, which recovered after a considerable period. J; 
 
 The most marked case of separation of the symphysis which I have seen, 
 occurred in the practice of Dr. Lewis Grasmuck, of Kansas, and was re- 
 ported by Dr. S. B. Parsons. § His description of this case shows so well 
 the symptoms of such a condition that I shall quote therefrom, particularly 
 as I was cognizant of many of the facts, and also had the satisfaction of 
 examining the woman myself. 
 
 The patient was the mother of four children ; was married at the age of 
 fourteen. Her first child was born during her fifteenth year. The 'labor 
 lasted nine days, and finally to facilitate the process, large quantities of a 
 decoction of ergot (" half a saucerful every two hours ") were administered. 
 " The pains then became intense and constant, and severe local suffering 
 
 * Practice of Surgery, p. 944, English edition. 
 
 f New York Journal of Medicine. 
 
 % Cooper and Traver's Surgical Essays. 
 
 \ Western Homoeopathic Observer, March, 1866. 
 
654 A SYSTEM OF SURGERY. 
 
 was felt at the symphysis pubis, growing more and more aggravated at each 
 effort of the uterus. So agonizing were the labor throes that consciousness 
 was lost three hours before delivery, and did not return for some time there- 
 after, consequently she knew nothing of what transpired during those ob- 
 livions moments." 
 
 Her recovery was slow, and the following were the symptoms noted, 
 which I have numerically arranged : 
 
 1. Strangury. 2. Irritation and inflammation of the labia. 3. Constipa- 
 tion. 4. Abscesses above the mons veneris, which opened above the clitoris. 
 5. Inability to walk without severe pain at the symphysis pubis, and also 
 at the right sacro-iliac symphysis. 6. Shooting pains along the pubic bone, 
 extending down the thigh whenever movement of the pelvic bones was at- 
 tempted. 7. Crepitus was distinct, and remained for four months and then 
 disappeared, to return at the second, third, and fifth labors. The above- 
 mentioned symptoms were all present, except the abscess, on. each of the 
 occasions. 8. The pains in the symphysis were intolerable, and confined 
 her to her bed during the later months of gestation. In the recumbent 
 position the symptoms were much relieved. 9. When I saw her the arch 
 of the pubis was expanded ; there was considerable swelling of the entire 
 vulva. On the anterior surface of the mons veneris a groove could be 
 readily detected, showing the separation of the pubic bones. 10. The ex- 
 tremities of the bones were sensitive to pressure. 11. The right pubic bone 
 was found also projecting a little anterior to the left. These were the 
 symptoms that were especially noticeable, and I have condensed them as 
 showing what peculiar manifestations may be present, in order to assist in 
 pointing out the true nature of the case, which might be obscure, especially 
 in the hands of the inexperienced. 
 
 The second case of separation of the symphysis which came under my 
 care was congenital, and occurred in that remarkable case of extrophy of 
 the bladder, with one kidney and one ureter, which I have recorded else- 
 where. 
 
 The treatment is, first, the constant use of the catheter, if necessary ; 
 second, perfect rest, in the supine position, a pad on each side of the sym- 
 physis, and a wide roller bandage applied around the hips. This appli- 
 ance is not difficult to put on, but very troublesome to keep in position. 
 It must be secured by perineal bands, which must be fastened at the 
 pubis and the sacrum, to keep the bandage from riding upward. A well- 
 padded leather belt, with appropriate straps and pads, would, in my judg- 
 ment, answer the indications better than any other apparatus. During 
 the period that the patient is in the recumbent position, appropriate 
 treatment (I mean internal medication) must be adopted. Symphy- 
 tum is recommended by some surgeons in this country, as well as by 
 Dr. Ruddock, of England. My preference is for one of the preparations of 
 lime or phosphorus, or both in combination, as the symptoms may indi- 
 cate. 
 
 Separation at the Sacro-iliac Symphysis. — There are not many examples 
 of this accident upon record. In the memoir of M. Viluysken on the 
 subject, which I find condensed in Ranking^ Abstract, vol. vi., 1848, there 
 are five cases reported, and in the Provincial Medical and Surgical Journal, 
 for November 17th, 1847, also quoted in the eighth volume of the same 
 compendium, two others. Besides these cases there is one reported by 
 Phillipi, at Chartres ; another in 1731, by Bassius ; the cases by Enaux, 
 Hoin, and Chaussier ; that of Baron Larrey ; that of Harris, in the Journal 
 of the Medical and Physical Sciences, of Philadelphia, vol. xv. ; and two cases 
 by Heidewreide, in 1839. 
 
 I have condensed the symptoms of several of these cases, as they are 
 
DISLOCATION OF THE EIBS. 655 
 
 especially instructive. In one instance the separation was caused by a fall 
 from a height of six feet upon the left tuber ischii; the patient was a woman 
 aged 24, and the accident occurred on the 7th of May, 1798 ; the suffering 
 at first was intense at the tuber ischii ; there was no crepitation ; the limbs 
 were found to be about the same length. After eight days the pain gradu- 
 ally disappeared, and she was allowed to cautiously exercise. In thirteen 
 days the pain returned ; the left limb grew shorter than its fellow, and the 
 more she walked the more perceptible became the shortening, it amounting 
 to nearly two inches. Every time she endeavored to support herself on her 
 left foot, the body was so suddenly flexed laterally toward the left side, that 
 it might be said that the superior edge of the ilium approached with vio- 
 lence towards the false ribs. The form and motion of the left leg were 
 unimpaired, but the iliac crest of the left side was higher than that on the 
 right side, but upon steady pressure the elevation could be made to descend 
 to its proper level, the limbs being then brought to their proper length. 
 
 The treatment of this case was extension and counter-extension, the pa- 
 tient in the horizontal position, and the parts rendered immovable by an ap- 
 paratus resembling the splint of Dessault ; an elastic band eight inches wide 
 was so applied that its upper border corresponded with a line drawn about 
 an inch above the crests of the ilia, and its inferior edge with the lower 
 parts of the sacrum. The apparatus was put on on the 13th of June, and 
 removed on the 15th day of September, the patient being perfectly cured. 
 In another case the limb was shortened after several days ; the coxo-femoral 
 motions, however, being executed with freedom and without any pain. The 
 posterior part of the ilium was movable and painful, and the crest of the 
 ilium on the injured side was more elevated than the other. A similar ap- 
 paratus was applied and a cure resulted. 
 
 In another case, besides the above-mentioned symptoms, there was pa- 
 ralysis of the rectum and bladder, and the crests of the ilia nearly touched 
 the false ribs. No attempt was made to reduce the bones, and the patient 
 recovered by being merely kept in the horizontal position. 
 
 From these cases, to which I have briefly alluded, and from the study of 
 the few others I have been able to find, we may infer that in separations of 
 the sacro-iliac symphysis, there is not immediate shortening, but that from 
 eight to ten days after the injury this condition may occur ; in this particu- 
 lar resembling the intracapsular fracture of the neck of the femur. The 
 diagnosis, however, may be readily made out by remembering that in the 
 latter there is eversion of the foot, inability to raise the heel from the bed, 
 and inability to perform the usual movements of the coxo-femoral articula- 
 tion. The shortening in the dislocation may be relieved by extension, and 
 pressure upon the elevated crista ilii. In the separation of the bones there 
 may be a sudden falling of the body to one side, when the patient endeavors 
 to stand on the affected limb. The crest of the ilium is also more or less 
 elevated, and may reach almost to the cartilages of the false ribs. There 
 may be crepitus and preternatural mobility at the seat of the joint, and 
 paralysis of the bladder and rectum may also be present. For these cases 
 the treatment consists in extension and counter-extension ; pressure on the 
 elevated crest of the ilium ; a broad belt with appropriate pads around 
 the pelvis, and extension maintained either by Buck's, Hamilton's, or 
 Hodgen's extension apparatus, or perhaps by the anterior splint of Nathan 
 R. Smith. 
 
 Dislocations at the junction of the pelvic bones in the acetabulum, are 
 considered under the head of fractures of those bones. 
 
 Dislocation of the Ribs from their cartilages sometimes occurs, and may 
 be recognized by an unnatural protuberance. 
 
 Treatment. — These cases are managed by placing a compress upon the 
 
656 
 
 A SYSTEM OF SURGERY. 
 
 extremity of the rib, and passing a roller around the chest, to secure the 
 compress, and control in a measure the action of the muscles. 
 
 Dislocation of the Vertebrae can hardly occur without fracture, and is the 
 result of such violence that other symptoms demand our attention. Abso- 
 lute rest is the most important object of treatment. 
 
 Dislocation of the Lower Extremity — Coxo-femoral Dislocations — Dislocation 
 of the Hip-joint. — As ordinarily described, there are four dislocations of the 
 head of the femur. 1. Upward and backward on the dorsum of the ilium 
 (Fig. 349). 2. Upward and backward into the ischiatic notch (Fig. 350). 3. 
 
 Fig. 349. 
 
 Fig. 350. 
 
 niac Dislocation. 
 
 Sciatic Dislocation. 
 
 Downward and forward into the thyroid foramen (Fig. 351, see next page). 
 4. Upicard and forward upon the pubis (Fig. 352, see next page). Besides 
 these there are other or irregular dislocations of the bone, which vary accord- 
 ing to circumstances. 
 
 Dr. M. H. Henry reports an interesting case of the latter* A man (set. 
 19), well developed and muscular, fell from a tree, receiving a blow on or 
 near the trochanter of the left side, and on examination a few days after, 
 a dislocation of the head of the femur on the pubis was discovered. The 
 limb was shortened less than an inch, somewhat flexed, abducted, and 
 everted. * 
 
 After being placed in bed, and ice-bags applied over the surface of the 
 dislocated parts, the limb was extended ; and a week after another unsuc- 
 cessful attempt was made to reduce the dislocation, which was finally 
 accomplished " by strong abduction, combined with extension, and the 
 limb resumed its normal position twenty-six days after the injury." It 
 may be remarked that in the efforts at reduction the adjacent parts, though 
 seriously injured, soon recovered. 
 
 The difficulty in the reduction of hip-joint luxations, and the powerful 
 means often unavailingly employed, have been subjects of careful investi- 
 
 * American Journal of the Medical Sciences, January, 1878, No. cxlix., new series. 
 
DISLOCATION OF THE HIP-JOINT. 
 
 657 
 
 gation by many distinguished surgeons. The fact that, in some instances, 
 after considerable mechanical force had been unsuccessfully applied, a dis- 
 location was reduced by accidental manipulation, has given rise to many 
 experimental researches on the best methods of reducing luxations of the 
 hip. The additional fact that complete muscular relaxation produced by 
 anaesthesia does not overcome either resistance or deformity, plainly evinces 
 that some force other than myotility is exercised to hold the bone so ob- 
 stinately in its unnatural position. * To the capsular ligament this power 
 was attributed by Prof. Gunn in 1853. Prof. Green also was of the same 
 opinion ; but Dr. H. J. Bigelow, of Boston * has, in a satisfactory manner, 
 shown that it is the ilio-femoral ligament and the obturator internus muscle, 
 which offer the chief impediments to the reduction of the hip, and in 
 
 Fig. 351. 
 
 Fig. 352. 
 
 Thyroid Dislocation. 
 
 Pubic Dislocation. 
 
 maintaining the deformity. It will be necessary here, for a proper under- 
 standing of the subject, to give the anatomy of the ligament to which such 
 important agency is ascribed, and likewise that of the internal obturator 
 muscle. 
 
 The ilio-femoral ligament (Fig. 353) arises from the anterior inferior 
 spinous process of the ilium by a strong adhesion, passes downward and 
 slightly outward, and is attached to the anterior intertrochanteric line. The 
 fibres separate slightly as they reach their point of insertion, thus making 
 the ligament somewhat resemble the inverted A- I n many subjects, how- 
 ever, this ligament is so closely adherent to the capsular, that it is difficult 
 to separate the two. Dr. Bigelow names this structure the Y ligament. 
 
 The obturator internus muscle arises for the most part within the pelvis, 
 its attachments being the inner surface of the body of the ischium, the as- 
 cending ramus of that bone, and the descending ramus of the pubis ; the 
 fibres converge from tendinous bands, which, leaving the pelvis by the 
 small sciatic notch, pass horizontally outward to be inserted by a strong 
 tendon into the upper border of the trochanter major (Fig. 354). By keep- 
 
 * The Mechanism of Dislocation and Fracture of the Hip, with the Eeduction of the Dis- 
 location by the Flexion Methods. 
 
 42 
 
658 
 
 A SYSTEM OF SURGERY. 
 
 ing these anatomical relations well in mind, the further description of the 
 mechanism of the dislocation will be readily understood. 
 
 Fig. 353. 
 
 Fig. 354. 
 
 The Inverted a Ligament. 
 
 Internal Obturator Muscle. 
 
 Dr. Bigelow maintains that in the so-called regular dislocations the A 
 ligament remains unbroken, and that in the irregular varieties either one 
 or both branches of it are torn asunder. He states that both branches re- 
 main entire, in 
 
 1. Dorsal. 
 
 2. Dorsal " below the tendon." 
 
 3. Thyroid. 
 
 4. Pubic and subspinous. 
 
 5. Anterior. Oblique. 
 
 That the external branch is broken : 
 
 1. In the supraspinous. 
 
 2. The everted dorsal. 
 
 Thus making in all seven regular dislocations of the bone, besides the 
 irregular ones, which may occur in almost any direction on account of the 
 rupture of the capsular and the Y ligament. 
 
 Nelaton's test, which is an excellent one for dislocation of the hip, con- 
 sists in drawing a line from the anterior superior spinous process of the ilium, 
 to the most prominent portion of the tuberosity of the ischium. If the bone 
 is not dislocated, the top of the trochanter, in all positions of the limb, touches 
 the lower border of this line. In all dislocations, especially backward ones, 
 the trochanter passes above it. 
 
 Dislocation Upward and Backward on the Dorsum of the Ilium. — In this 
 variety, which is the most common, the triceps is put upon the stretch, the 
 gluteus maxim us and medius are doubled over, the capsular and the liga- 
 mentum teres are torn, the former perhaps only sufficiently to allow the 
 head of the bone to escape through the rent. 
 
TREATMENT OF DISLOCATION OF THE HIP- JOINT. 
 
 659 
 
 Diagnosis.— 1. Limb shortened one and a half to three inches. 2. Toe 
 rests upon the top of sound foot. 3. Limb rotated inward. 4. Limb slightly 
 flexed. 5. Knee advanced upon the other. 6. Trochanter major is nearer 
 the anterior superior spinous process than usual. 7. Adduction of limb. 
 8. Abduction almost impossible. 9. Body bent forward. 10. Roundness 
 of hip lost. 11. In the absence of swelling, by rotating the knee, the head 
 of the femur may be felt moving on the dorsum of the ilium. _ 
 
 Fig. 355 represents position of patient suffering from this dislocation. 
 
 Fig. 349, page 656, shows the position of the bone. 
 
 Fig. 356 shows the dislocation of the bone, and the relations of the ilio- 
 femoral ligament, holding the greater trochanter to the pelvis, and thereby 
 inverting the limb. 
 
 In some instances there happens to be what is termed an everted dorsal 
 dislocation," in which the limb is everted and may also be abducted. This 
 
 Fig. 355. 
 
 Fig. 356. 
 
 Position of Patient in Dislocation on the Dorsum. 
 
 Ilio-femoral Ligament Inverting the Thigh. 
 
 condition is believed by Dr. Bigelow to be owing to a rupture of the outer 
 fibres of the ilio-femoral ligament. In such cases the luxation must first be 
 reduced to an ordinary dorsal- dislocation, and then reduced completely. 
 
 Treatment — Manipulation. — As long ago as 1815, Nathan Smith taught re- 
 duction of the dorsal dislocation by manipulation, and it has been practiced 
 frequently by many surgeons. 
 
 The patient should be etherized and placed either upon the floor or upon 
 a hard couch. The surgeon grasps firmly the knee of the affected side with 
 one hand, and the ankle with the other. The leg is flexed on the thigh, 
 and the thigh on the abdomen, which relaxes the ilio-femoral. The knee 
 must then be carried upward across the opposite thigh as high as the um- 
 bilicus, if possible, when it should be rotated across the abdomen to the 
 injured side. The next procedure is to bring the thigh gradually down by 
 abducting the knee, the foot being carried across the sound limb. Fig. 357 
 represents the mechanism, the dotted lines showing the rotation of the head 
 of the femur and the knee. 
 
 Dr. Bigelow asserts that all regular dislocations can be reduced by flexing 
 
660 
 
 A SYSTEM OF SURGERY. 
 
 the thigh on the abdomen to relax the ilio-femoral ligament, and making 
 extension directly forward. 
 
 Fig. 357. 
 
 s 
 
 / 
 
 Mechanism of Reduction of the Hip hy Manipulation. 
 
 Method with Pulleys. — A strong band well padded is placed in the perinseum 
 and made to pass over the outer surface of the pelvis, and made fast to a 
 fixed point. A roller is wetted, and bound above the knee ; over this a 
 towel is placed, made into a clovehitch, to which is attached, by means of a 
 hook or otherwise, the pulley, which must be in a direct line to the perineal 
 band. The knee must be flexed at a right angle, and steady and continu- 
 ous traction put upon the muscles by the pulleys ; as the head of the bone 
 draws near the acetabulum, the surgeon should rotate the limb inward, and 
 the bone will slip into the socket (Fig. 358). It may happen that the ele- 
 
 FlG. 358. 
 
 Reduction by Means of Pulleys. 
 
 vated margin of the acetabulum acts as a barrier to complete reduction ; in 
 such an event, a towel passed around the thigh near the groin, and drawn out- 
 ward, will lift the head of the bone over the ridge and thus facilitate its re- 
 duction. After the limb has been reduced it should be laid parallel to the 
 other, and several towels or a roller passed around both limbs, and the patient 
 kept quiet for a fortnight. Care must be taken in all these efforts, whether 
 by manipulation or extension by pulleys, that the bone be not fractured. 
 
 Fig. 359 represents the " Tripod" for vertical extension as recommended 
 by Dr. Bigelow ; or if this be not at hand the foot, unbooted, should be 
 placed on the pelvis, and the leg lifted from the knee. 
 
 The so-called " automatic method " of reduction of dorsal hip-joint dislo- 
 cations consists of placing the patient on his back on the floor (having him 
 fully anaesthetized), and flexing the legs at right angles with the thighs, and 
 the thighs at right angles with the pelvis. This relaxes the ilio-femoral 
 
TREATMENT OF DISLOCATION OF THE HIP- JOINT. 
 
 661 
 
 ligament. The hands are then placed under the calves of the legs, as close 
 to the knees as possible, and the pelvis raised from the floor, at the same 
 
 Fig. 359. 
 
 Bigelow's Tripod. 
 
 Fig. 360. 
 
 Position of patient with Ischiatic Dislocation. 
 
 Fig. 361. 
 
 Internal Obturator in Sciatic Luxation.— Bigelow. 
 
 time slight abduction being made. This method was accidentally discovered 
 by Dr. S. J. Allen, of Vermont, who, while endeavoring to get a patient suf- 
 
662 
 
 A SYSTEM OF SURGERY. 
 
 fering from hip dislocation in proper position for reduction, lifted him in 
 the manner described above, and had the satisfaction of hearing the head of 
 the bone slip into its place. Dr. Allen mentioned the method of reduction 
 to the late Dr. A. B. Crosby, who practiced it with success in the wards of 
 Bellevue Hospital and published the same to the profession in the Phila- 
 delphia Medical Times* 
 
 Dislocation Upward and Backward into the Sciatic Notch, or, as it is called 
 by Dr. Bigelow, dislocation " below the tendon " (Fig. 350, page 656). 
 
 Diagnosis. — 1. Shortening about an inch. 2. Thigh flexed, more so in 
 recumbent position. 3. Thigh adducted and rotated inward. 4. Great toe 
 of luxated limb touches ball of toe of the sound one. 5. Head of the bone 
 felt in its abnormal position. 6. Knee and foot inward. 7. Heel does not 
 reach to the ground. 8. Knee in advance of the other. 9. Limb fixed ; 
 rotation scarcely possible. 
 
 Dr. Dawsonf speaks of a peculiar symptom, hitherto not mentioned, in 
 ischiatic dislocation. It is shortness of the affected limb, when the thighs 
 
 Fig. 362. 
 
 Fig. 363. 
 
 Recumbent position of patient with Is- 
 chiatic Dislocation (below the tendon).— 
 Bigelow. 
 
 Appearance in Thyroid Dislocation. 
 
 are flexed ; in other words, when the patient lies on the back with extended 
 limbs, there is but a slight degree of shortening ; when the thighs are flexed 
 upon the trunk at a right angle, then the affected knee is considerably 
 shorter, say two inches, than the sound one. This symptom with its ex- 
 planation had been noticed earlier by Dr. Oscar H. Allis.f 
 
 Fig. 360 shows the general appearance of a person with dislocation into 
 the sciatic notch, or ischiatic luxation, as it is sometimes called. 
 
 Fig. 361 is a correct representation of this dislocation, with the position 
 of the obturator internus muscle. 
 
 * Hospital Gazette and Archives of Clinical Surgery, November, 1877, p. 269. 
 f Hospital Gazette and Archives of Clinical Surgery, January 1st, 1878. 
 
TREATMENT OF THYROID DISLOCATION. 
 
 663 
 
 Fig. 362 shows the recumbent position of a patient affected with dislocation 
 upward and backward, in which there is extreme flexion and rotation of the 
 limb from the action of the obturator internus and the capsular ligament. 
 
 Dislocation Downward into the Foramen Ovale — Thyroid Dislocation — Diag- 
 nosis. — 1. Limb two inches longer. 2. In thin subjects, head of the bone 
 felt towards the peringeum. 3. Limb advanced, toes point forward. 4. Body 
 bent forward. 5. Trochanter less prominent. 6. Head of thigh bone below 
 and a little anterior to the axis of the acetabulum. 7. Depression below 
 Poupart's ligament. 8. Limb abducted (Fig. 363). 
 
 Treatment — Manipulation. — Bearing constantly in mind the relations the 
 ilio-femoral ligament has to this dislocation, flex the thigh upon the abdo- 
 men in a state of abduction, the limb being moved inward and brought 
 down in an abducted position until the knee comes within a short distance 
 below the pubes, when the thigh should be rotated inward. (Fig. 364.) 
 
 Bigelow says : " Flex the limb towards a perpendicular, and abduct it a 
 little, to disengage the head of the bone, then rotate the thigh strongly in- 
 
 FlG. 364. 
 
 FIG. 365. 
 
 Reduction of Thyroid Dislocation by Manipulation. 
 
 Reduction of Thyroid Dislocation with 
 Pulleys. 
 
 ward, adducting it and carrying the knee to the floor. The trochanter is 
 then fixed by the (ilio-femoral) ligament and the obturator muscle, which 
 serve as a fulcrum. While these are wound up and shortened by rotation, 
 the descending knee raises the head upward and outward to the socket." 
 
 Extension. — Patient to be laid on the back. A band is placed around the 
 injured thigh to embrace the peringeum. This band should be hooked to a 
 pulley made fast to a point obliquely above the hip. In addition, a counter- 
 extending girth must be placed around the ilium and fastened to a point 
 opposite the injured hip. A gradual strain is made upon the part with the 
 compound pulley, and as the head of the bone moves from the foramen 
 
664 
 
 A SYSTEM OF SURGERY. 
 
 ovale, the surgeon should firmly grasp the ankle and draw it towards 
 the median line of the body, when the head of the bone will pass into the 
 acetabulum. 
 
 This method is seen in Fig. 365. 
 
 Dislocation Forward upon the Pubes.— This variety of luxation is rare, and 
 may be caused by the same forces as occasion the thyroid dislocation. By 
 referring to the wood-cut (Fig. 366), it will be seen what relation the ilio- 
 femoral ligament bears to this variety of dislocation, which being remem- 
 bered, its relaxation by flexion in the manipulation method will be under- 
 stood. 
 
 Fig. 366. 
 
 Fig. 367. 
 
 The Femoral Ligament in Pubic Dislocation. 
 Bigelow. 
 
 Appearance of Patient. 
 Pubic Dislocation. 
 
 Diagnosis. — 1. Limb an inch or more shortened. 2. Knee and foot ab- 
 ducted, and cannot be rotated inward. 3. The head of the bone felt upon 
 the pubis, sometimes above the level of Poupart's ligament, at the outer 
 side of the femoral artery and vein. 4. The trochanter major is nearly lost. 
 5. On rotating the thigh, the head of the bone is felt to move with it. 
 
 Fig. 367 shows general appearance of patient with this dislocation. It 
 is in this that there is both shortening and eversion, and therefore it is neces- 
 ary that care be taken in the diagnosis. In fracture— 
 
 1. The head of the bone cannot be felt. 
 
 2. The trochanter major rotates on shorter radius. 
 
 3. Crepitus is present. 
 
 4. Shortening not so great. 
 
 5. No abduction. 
 
 6. Eversion of the foot not so great and more easily overcome. 
 
 7. Much greater mobility. 
 
 Treatment. — Manipulation. — The patient must be placed upon the back, 
 and brought under anaesthetic influence. The thigh then must be rotated 
 
DISLOCATION OF THE PATELLA. 
 
 665 
 
 and abducted outward, which will in the majority of cases require consid- 
 erable force. By this means the head of the bone is thrown forward on 
 the pubic bones. This being accomplished, the limb must be forcibly flexed 
 and adducted, and then rotation inward performed. In some cases by 
 simply carrying the limb to an extreme abduction, rotating the thigh in- 
 ward, "and pressing upon the head of the bone, the reduction may be effected. 
 In this dislocation the surgeon may try various methods of manipulation, 
 according to the presenting symptoms. 
 
 Extension with Pulleys. — The patient is placed on the sound side, or half on 
 his back and half on his side, a perineal band, well padded, applied over the 
 pelvis and fixed to a point in front of a line with the body (Fig. 368). The 
 
 Reduction of Pubic Dislocation by Extension. 
 
 band is then applied, as before directed, above the knee, to which, by means 
 of the clovehitch, or other appliance, the compound pulleys are attached, 
 which must be made fast to a point behind the axis of the body, that the 
 bone, when traction is made, may be drawn backward. As the bone ap- 
 proaches its natural position, it must be assisted over the pubis and edge 
 of the acetabulum by means of a band or towel. The subsequent treatment 
 consists in rest and a bandage to keep the legs in a horizontal position. 
 
 Dislocation of the Patella.— The patella is luxated laterally, outward or 
 inward, the former being the more common of the two. An upward dis- 
 location can only occur from a rupture of the tendon of the quadriceps. 
 The signs of the outward variety are : 
 
 1. Patella lies at external face of joint; the inner edge being directed 
 forward. 
 
 2. Depression in front of the knee. 
 
 3. Prominence on outside of knee. 
 
 4. Inner condyle of the femur can be felt under the integument. 
 
 5. It is impossible to flex the leg. 
 
 In the inward dislocation the symptoms and appearances are the reverse 
 of the above. 
 
 Treatment. — The patient should be placed supine, and the thigh flexed 
 upon the abdomen. The surgeon then sitting on the side of the bed, places 
 upon his shoulder the lower part of the leg, when, by pressure made by 
 the thumbs from without inward, in the outward dislocation, and from 
 within outward in the inward variety, the bone will slip to its place. 
 
 It is not always necessary to use this manipulation, as any movement 
 having'a tendency to completely relax the tendon of the patella will answer 
 equally well. 
 
 In some instances the bone may be vertically dislocated by a sudden and 
 forcible twist of the joint. In these cases the leg is straight, the outer edge 
 of the bone is prominent, and there is a deep depression upon each condyle. 
 
 Dr. A. N. Dougherty, of Newark, N. J. * relates a " singular " accident of 
 
 * N. Y. Med. Kecord, December 30th, 1876. 
 
66Q 
 
 A SYSTEM OF SURGERY. 
 
 this kind which came under his treatment. It occurred to a young man 
 who was painting a house, and seemed to be caused by a sudden wrench 
 of the knee in turning the body, while a foot was lodged in the gutter of 
 the roof. The left lower extremity was in a state of extreme extension, and 
 the patella was tilted up on its inner edge, the posterior surface of the bone 
 looking directly upward, and the extensor tendon correspondingly tilted up 
 and stretched. Reduction was effected in a few minutes by manipulation, 
 which consisted in depressing with a joggling motion the projecting edge 
 toward the outer condyle. Contrary to the recommendation of Gross, the 
 thigh was not flexed ; next day the patient was walking about, and suffer- 
 ing no inconvenience. 
 
 Treatment. — The thigh must be strongly flexed upon the abdomen, and 
 the knee then suddenly bent, and as suddenly brought into a vertical posi- 
 tion, the surgeon at the same time endeavoring to turn the bone to its place. 
 
 DISLOCATION OF THE LEG. 
 
 Dislocation of the Tibia at the Knee. — This occurs in four directions, — 
 forward, backward, inward, and outward. 
 The last two are rare and incomplete. 
 In dislocation forward (Fig. 369), the signs are : 
 
 Fig. 369. 
 
 Fig. 370. 
 
 Dislocation Forward of 
 Head of Tibia. 
 
 Dislocation of the Head 
 of Tibia Backward. 
 
 1. Patella prominent in front of the joint. 
 
 2. Tibia and fibula prominent in front. 
 
 3. Condyles of femur project posteriorly. 
 
 4. Pain from pressure in popliteal space from stretching of parts. 
 Treatment. — Place the patient on his back, make extension (sometimes 
 
 the pulleys may be necessary), and alternately flex and extend the leg, at 
 the same time making a slight rotary motion, with pressure upon the head 
 of the dislocated bone. The parts must then be placed in splints, and 
 passive motion made for several days. 
 Dislocation of the Head of the Tibia Backward (Fig. 370). — The signs are : 
 
 1. Leg bent forward. 
 
 2. Depression of the ligamentum patellae. 
 
 3. Shortening of the limb. 
 
 4. Projection of the condyles of the femur anteriorly. 
 The accident is easily recognized. 
 
DISLOCATION OF THE TIBIA. 667 
 
 Treatment. — Place the patient in the recumbent posture, and make ex- 
 treme and forcible flexion. This will, in the majority of cases, produce the 
 desired result. If not, extension combined with pressure on the dislocated 
 extremity of the bone will reduce the luxation. 
 
 In Dislocation Inward the following are the marks of the accident : 
 
 1. Tibia projects on the inner side of the joint. 
 
 2. Inner condyle of femur rests on the centre of the head of the tibia. 
 
 3. Joint increased in breadth. 
 
 4. Patella pushed outward. 
 
 5. Outer condyle of femur presents a tumor on the outer side of the joint. 
 Treatment. — Extension for a short time, with pressure in the proper direc- 
 tion, generally effects reduction without difficulty. 
 
 Dislocation' Outward is known by the following : 
 
 1. Tibia projects on the outer side of the joint. 
 
 2. Outer condyle of the femur rests on the articulating surface of the tibia. 
 
 3. Inner condyle of the femur presents a tumor on the inner side of the j oint. 
 
 4. Increase in the breadth of the joint. 
 
 5. Patella pushed outward. 
 
 Treatment. — The same as for dislocation inward, excepting that the pres- 
 sure is reversed. As has been before observed, these dislocations are gen- 
 erally incomplete. When they are complete, they are in most instances 
 accompanied by fracture and other injury demanding immediate amputa- 
 tion. 
 
 The Head of the Fibula may be dislocated, and generally this takes place 
 backward. In some of the cases which have been noticed, the misplacement 
 was occasioned by muscular action. 
 
 The signs are : 
 
 1. Head of the bone felt on the outer and posterior surface of the leg. 
 
 2. Fatigue from walking or exercise. 
 
 Treatment. — The bone is readily replaced, but almost immediately slips 
 from its position. After having reduced the luxation, a solution of arnica 
 should be applied to the part ; this may have the effect of producing ab- 
 sorption of the superabundant synovia ; or ledum may be used, as this 
 medicine acts powerfully upon the knee-joint, and also upon the absorbent 
 vessels generally. After this, a compress should be placed behind the head 
 of the bone, and bound tightly to the tibia, either by a bandage or strap 
 buckled around the upper part of the leg. 
 
 Dislocation of the Tibia at the Ankle-joint. — There is sometimes a confusion 
 of ideas, especially among students, regarding the nomenclature of these 
 dislocations. It should, therefore, be remembered that a dislocation of the 
 lower end of the tibia inward is a dislocation of the foot outward, and that 
 a dislocation of the tibia outward at the ankle-joint is the same as a dislo- 
 cation of the foot inward. 
 
 A majority of these are accompanied with fracture. They are caused by 
 falls and twists of the foot, and are often very serious accidents. The direc- 
 tion of the dislocation which is most frequent is inward. 
 
 Dislocation of the Foot Outward. — The symptoms are : 
 
 1. Internal malleolus very prominent. 
 
 2. Foot everted. (Fig. 371.) 
 
 3. Foot rotates on its axis. 
 
 4. Generally a depression is found three to five inches above the external 
 malleolus, indicating a fracture of the fibula at that point. 
 
 5. Preternatural mobility in a lateral direction. 
 
 6. Patient cannot move the foot. 
 
 In this dislocation there is a rupture of the internal tibio-tarsal ligament, 
 and sometimes a fracture of the internal malleolus. 
 
668 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 371. 
 
 Dislocation of the Foot Outward. 
 
 Fig. 372. 
 
 Treatment. — The patient should be placed in a recumbent position, and 
 the leg flexed at a right angle with the thigh. An assistant should fix 
 
 the thigh firmly, either by grasp- 
 ing it with his hands or by 
 passing a towel or folded sheet 
 beneath the lower extremity of 
 the thigh. Extension should 
 then be made, either with the 
 pulleys or with the hands, late- 
 ral pressure being made on the 
 projecting bone in the direction 
 of the joint, and thus the defor- 
 mity is removed. Dupuytren's 
 apparatus for fracture of the 
 lower part of the fibula is now to 
 be applied, or splints and band- 
 ages, to keep the foot at rest and at a right angle with the leg, and the 
 patient kept in bed five or six weeks. Ten or twelve weeks will have elapsed 
 before the use of the foot is restored. After the eighth week passive motion 
 will be required to restore the mobility of the joint. Causticum, lycopo- 
 
 dium, or rhus, will facilitate the lat- 
 ter object. First, however, the inflam- 
 mation must be attended to, as in all 
 other cases of dislocation. 
 
 Dislocation of the Lower End of the 
 Tibia Outward (Dislocation of the Foot 
 Inward). — This luxation is very 
 serious, and demands the unceasing 
 vigilance of the surgeon. It is caused 
 by the same kind of accidents which 
 produce the former. Fracture of the 
 lower end of the fibula, or of the in- 
 ternal malleolus, or a rupture of the 
 peroneo-tarsal ligaments takes place, 
 and in some instances the astragalus 
 is also broken. The symptoms are : 
 
 1. The foot is inverted. (Fig. 372.) 
 
 2. The tibia is thrown forward and 
 outward upon the astragalus. 
 
 3. Great deformity of the joint. 
 
 4. Astragalus felt beneath inner 
 malleolus. 
 
 5. External malleolus is felt and 
 seen as a prominence on the outside 
 of the ankle-joint. 
 
 Treatment. — The reduction is ef- 
 fected in a manner similar to that de- 
 tailed for the treatment of the inward 
 luxation, while pressure is made 
 upon the luxated end of the bone. 
 
 After the reduction, a pad should 
 be placed upon the outside of the leg, 
 extending from above the ankle, seve- 
 ral inches up the limb. Two side-splints are applied, with a foot-board, 
 and the leg, having been previously lightly bandaged, should be fixed se- 
 curely in the apparatus. Care must be taken to prevent the tibia and fibula 
 
 Dislocation of the Foot Inward. 
 
DISLOCATION OF THE TIBIA. 
 
 669 
 
 Fig. 373. 
 
 from slipping from the astragalus. The limb should then be laid on its 
 outer side. After several weeks, passive motion and friction should be re- 
 sorted to. 
 
 Dislocation of the Lower End of the Tibia Forward (Dislocation of the Foot 
 Backward) (Fig. 373). — The causes of this accident are falls, with twists at 
 the ankle, causing great extension of the foot upon the leg. 
 
 The symptoms are : 
 
 1. Foot fixed. 
 
 2. Foot shortened in front. 
 
 3. Heel projects. 
 
 4. Heel firmly fixed. 
 
 5. Toes point downward. 
 
 6. End of the tibia felt as a tumor on the tarsus. 
 
 7. Extensor tendons well defined in front. 
 
 8. Tendo Achillis rigid and curved. 
 
 9. Sometimes crepitus above the external malleolus marks fracture at 
 that point. 
 
 In many instances there is only a partial dislocation of the tibia on the 
 astragalus, in which case the fibula is broken and the tibia appears to rest 
 half on the scaphoid and half on the astragalus. 
 The symptoms resemble those mentioned, but are 
 not so precisely defined. The foot is shorter, and 
 the toes point downward, while the heel is drawn 
 up, and the foot is immovable. 
 
 In accidents about the ankle, when a frac- 
 ture of the tibia and fibula has occurred, with 
 laceration of the internal and external lateral 
 ligaments, a dislocation of the tibia forward 
 may result from the contraction of the calf mus- 
 cles. 
 
 Treatment. — This dislocation is in most in- 
 stances quite readily reduced, but, according to 
 my experience, there is the greatest difficulty 
 in keeping the parts in situ. This is more espe- 
 cially the case when there has been severe contu- 
 sion and laceration, the tumefaction and ecchy- 
 mosis rendering every touch insupportable. When 
 in connection with this, as happened in a case of 
 my own, the patient is of a rheumatic diathesis, and of a phlegmatic tem- 
 perament, the treatment is often very unsatisfactory. 
 
 The leg should be flexed upon the thigh, and the foot extended, while 
 pressure is made in front of the tibia. When the reduction has been 
 effected, the leg should be placed in a fracture-box, with a foot-board at a 
 slightly acute angle to the base of the box. The leg should be supported 
 by cushions, and dilute arnica constantly applied. Side splints or carved 
 splints, or those made of wire, afford satisfactory support and keep the foot 
 in proper position. Plaster-of-Paris splints are also useful. 
 
 Dislocation of the Lower End of the Tibia Backward — Dislocation of the Foot 
 Forward. — This accident is rather rare, but the symptoms are well marked. 
 
 1. Foot lengthened. 
 
 2. Heel shortened, or obliterated. 
 
 3. Astragalus felt in front of the tibia. 
 
 4. Leg shortened. 
 
 5. Malleoli nearer the ground. 
 
 6. No space between the tendo Achillis and the posterior surface of the 
 tibia. 
 
 Dislocation of Tibia Forward- 
 Foot Backward. 
 
670 
 
 A SYSTEM OF SURGERY. 
 
 In the majority of cases, this luxation as well as others near the ankle- 
 joint is accompanied by fracture of either tibia or fibula, or both, in the 
 vicinity of the malleoli. 
 
 Treatment. — The patient should be placed upon his back, thigh flexed 
 on abdomen, and the leg placed at right angles with the thigh. Counter- 
 extension is to be made by an assistant holding firmly the thigh in its 
 position. The surgeon takes the foot in his hand and draws it gradu- 
 ally though firmly downward, at the same time carrying it backward to 
 restore the astragalus to its proper position. A compress is placed on the 
 heel and splints applied. Some surgeons, after reduction, place the limb 
 over a double inclined plane. 
 
 Fig. 374. 
 
 DISLOCATIONS OF THE FOOT. 
 
 Dislocations of the tarsal bones are occasioned by great violence. The 
 astragalus may be dislocated in several ways, — outward, inward, forward, 
 and backward. Sometimes the bone is either partially or entirely rotated 
 on its axis, or it may be forced like a wedge between the tibia and the 
 fibula. 
 
 Fig. 374 shows a dislocation of the astragalus outward, with inversion 
 of the foot. If the bone is dislocated backward, the tibia is slightly thrown 
 
 to the front, although there is not much 
 alteration in the position of the foot. 
 
 Sometimes there is shortening of the leg, 
 but in most instances, the unusual promi- 
 nence of the bone and the position of the foot 
 are the main indications. 
 
 The prognosis in these cases is bad, gan- 
 grene often results, and amputation may be 
 necessary. In other cases resection may be 
 required. 
 
 Treatment. — To reduce forward disloca- 
 tion, flex the leg at right angles with the 
 thigh ; an assistant grasps the thigh above 
 the knee ; a second extends forcibly the foot ; 
 the surgeon pressing the dislocated bone 
 upward and backward. In the backward 
 dislocation, great difficulty is often experi- 
 enced in effecting reduction, and in some 
 cases it has been found impossible. The 
 foot must be extended, the leg being in the 
 same position as above. The heel must be 
 drawn forward and downward by the assis- 
 tant, making extension, and the surgeon 
 pushes the bone forward and upward. In 
 the outward and inward dislocations exten- 
 sion and counter-extension are made in the same manner, the foot always 
 being forcibly held in an opposite direction. 
 
 Dislocation of the os calcis and astragalus from the other bones of the 
 tarsus may take place. The foot will then be turned inwards, as in talipes 
 varus. 
 
 Reduction is easily effected by extension and direct pressure. The limb 
 should then be supported by splints and bandages. 
 
 Dislocations of the toes, one from another, occur occasionally, and are 
 with facility recognized and easily reduced by extension and counter-ex- 
 tension. 
 
 Dislocation of Astragalus Outward. 
 
 J 
 
DISLOCATION OF THE SHOULDER- JOINT. 
 
 671 
 
 DISLOCATIONS OF THE UPPER EXTREMITY. 
 
 Dislocation of the Shoulder-joint. — The humerus may be dislocated from 
 the glenoid cavity in three directions : downward into the axilla, also called 
 subglenoid; forward beneath the pectoral muscle, also receiving the names 
 subcoracoid and subclavicular ; backward on the dorsum of the scapula, to 
 which the term subspinous is applied. In some the humerus is pushed 
 inward on the coracoid process. This is called the subcoracoid. I have 
 met with one such case; the majority, however, of dislocations of the 
 shoulder being the so-termed downward luxations. Violence, falls, blows, 
 etc., applied to the superior extremity of the humerus, or falls upon the 
 hand and elbow, are generally the causes of this dislocation, in which the 
 scapular ligament is ruptured by violence — the long head of the biceps 
 separated, the supra- and infraspinatus, as well as the coraco-brachialis and 
 subscapularis, all being involved to a greater or lesser degree. It is well 
 to remember here the test of Dr. Dugas, of Georgia, who demonstrates that 
 
 Fig. 375. 
 
 Fig. 376. 
 
 2^?. 
 
 Dislocation of the Humerus Downward. 
 
 External Appearance of Dislocation of Shoulder 
 Downward. 
 
 it is a mechanical impossibility, for any one suffering from either of the 
 dislocations of the humerus, to bring the elbow of the affected arm down to the 
 thorax and place the fingers upon the sound shoulder. The position of the bone 
 is seen in Fig. 375, and the general appearance of the patient in Fig. 376. 
 The symptoms are : 
 
 1. Depression beneath the acromion. 
 
 2. Flatness of the shoulder. 
 
 3. Slight depression at the point of insertion of the deltoid. 
 
 4. Arm somewhat lengthened. 
 
 5. Elbow stands off from the side of the thorax. 
 
 6. Patient supports the elbow and forearm of injured side with the hand 
 of the opposite side. 
 
 7. If the elbow is moved off from the thorax, the head of the humerus is 
 felt in the axilla. 
 
672 
 
 A SYSTEM OF SURGERY. 
 
 8. There is a change in the axis of the humerus, it leading toward the 
 axillary space, and not to the glenoid cavity. 
 
 9. Inability to bring the elbow to the side and place the fingers on the 
 sound shoulder. 
 
 10. Inability to raise the hand to the head. 
 
 11. Rotation lost. 
 
 12. Forward and backward motion generally retained. 
 
 13. Considerable pain from pressure on the brachial plexus. 
 
 Added to these signs, it must not be forgotten, that at times on moving 
 the limb a species of crepitus may be felt, which is occasioned by effusion 
 of serum and synovia into the cellular tissue; it is not, however, that 
 distinct sensation produced by fracture, and disappears for the time by 
 continued motion. 
 
 By referring to the remarks on fracture of the acromion process of the 
 scapula, the differential diagnosis between that injury and dislocation of 
 the humerus downward into the axilla, will be found. 
 
 The diagnosis between fractures of the surgical neck of the humerus and 
 the dislocation now under consideration, consists chiefly in the absence of 
 crepitus and the position of the elbow, which, in fracture, may be placed 
 upon the thorax. 
 
 Treatment. — The treatment by manipulation is as follows : The patient 
 should be seated in a chair, and, if there is severe pain, an anaesthetic 
 should be given. The surgeon flexes the forearm on the arm, and raises 
 the latter to a right angle (or as nearly as possible to that position) with 
 
 Fig. S77. 
 
 Reduction of Shoulder Dislocation, by Heel in the Axilla. 
 
 the chest ; using now the forearm as a lever, the surgeon, having the wrist 
 and elbow well in hand, depresses the hand and forearm, which causes 
 forward rotation of the head of the humerus. Many dislocations may be 
 thus reduced. 
 
 Extension. — The patient is placed upon his back, a ball or pad should be 
 laid in the axilla, and the surgeon, sitting on the side of the couch, and 
 facing the patient, places his unbooted heel upon the ball, and taking hold 
 of the wrist and forearm, makes gradual and steady traction. If this does 
 not effect reduction, a wet bandage may be applied to the arm, and over 
 this a clovehitch, to which an extending band must be applied, and one or 
 more assistants draw steadily upon the arm (Fig. 377). 
 
 Another method is that which is seen in Fig. 378. The patient is seated 
 in a chair, and a bandage passed around the upper portion of the thorax, 
 
TREATMENT OF DISLOCATION OF THE SHOULDER-JOINT. 673 
 
 having an opening through which the arm will pass. This band is tied 
 over the sound shoulder, and given in charge to steady assistants. The wet 
 roller and clovehitch are then placed just above the elbow, and the pulleys 
 applied. After steady traction has been made for some minutes, the surgeon 
 places his foot upon the chair and his knee in the axilla. The acromion 
 
 Fig. 37 
 
 must now be pressed downward and inward with the hand while pressure 
 is made with the knee, by raising the heel. The head of the bone will often 
 enter the glenoid cavity with quite a noisy report. 
 
 In most instances the pulleys are not necessary, and the bone may be 
 replaced in the following manner : The surgeon, having the patient in the 
 same position as described in the last method, stands a little behind him, 
 places his foot on the chair, his knee in the axilla, and fixing the scapula 
 with one hand, rotates the humerus inward. Thus the knee acts as the 
 fulcrum, the humerus as the lever. This method is known as Sir Astley 
 Cooper's (Fig. 379). 
 
 The vertical extension method may be practiced as follows : the patient is 
 laid upon the bed or the floor ; the surgeon seats himself on the injured side 
 and above the shoulder, he then forces the scapula down by pressure made 
 with his heel or his hand, and raises the arm in a vertical direction toward 
 the head. 
 
 M. Tillaux* gives an account of a case of subcoracoid dislocation of the 
 shoulder taking place several times a day. The patient, aged twenty-eight, 
 was subject to epileptic fits ; during one of these, occurring at night, he fell 
 out of bed. "When he recovered consciousness, at the end of about half an 
 hour, he discovered that he could not bring his right elbow to the body, 
 and that the movements of the arm were very limited. After some efforts 
 the arm resumed its position and function, accompanied by a cracking in 
 the shoulder. The same dislocation occurred again and again, ultimately 
 taking place several times a day. 
 
 Generally, the luxation was involuntary, but he could produce it by 
 bringing the arm outwards, a little backwards and upwards. 
 
 M. Tillaux proposes to remedy this by an apparatus which will place an 
 obstacle in the way of the great abduction of the arm. 
 
 * Gazette des Hdpitaux, August 12th, Abstract Med. Science, vol. iii., No. xi. 
 
 43 
 
674 
 
 A SYSTEM OF SURGERY. 
 
 Dr. G. Lapponi* relates the following interesting case of subcoracoid dis- 
 location of the humerus by muscular contraction. A girl, aged fifteen, being 
 seated, and resting her arm horizontally on a piece of furniture, sneezed vio- 
 lently twice, and immediately was seized with severe pain, her arm (being 
 raised from the surface on which it was lying) fell useless. Before this she 
 had suffered from chronic inflammation of the right radio-carpal articula- 
 tion, and had also inflammation of the shoulder-joint, but of these no symp- 
 toms were now present. 
 
 All attempts to move the upper part of the arm produced much pain. 
 When examined, the head of the humerus was found lying beneath the 
 
 Fig. 379. 
 
 Fig. 380. 
 
 Sir Astley Cooper's Method of Operating 
 with the Knee in the Axilla. 
 
 Dislocation of the Humerus Forward. 
 
 coracoid process. Reduction was then effected by making extension on the 
 forearm and rotating the limb outwards, while the head of the humerus was 
 guided by manipulation into the glenoid cavity. 
 
 Dislocation of the Head of the Humerus Forward. — The symptoms are : 
 
 1. Depression beneath the acromion. 
 
 2. The head of the humerus forms a tumor below the clavicle (Fig. 380). 
 
 3. Slight shortening of the limb. 
 
 4. Axis outward and backward. 
 
 5. Elbow outward and backward. 
 
 6. Inability to place hand on opposite shoulder while the elbow touches 
 the front of the chest. 
 
 7. Forward and backward movements are much impeded. 
 Treatment. — In reducing this variety of dislocation, the same means may 
 
 be employed as have already been mentioned for the axillary luxation, with 
 this difference, that extension must be made in a backward direction. 
 
 Dislocation of the Head of the Humerus Backward. — 1. Depression under 
 outer end of the acromion. 
 
 2. A protuberance on the dorsum of the scapula below the spine. 
 
 3. Rotation of the head of the bone in its new position by moving the arm. 
 
 4. A space between the coracoid process and the head of the humerus. 
 
 5. Arm and forearm carried in front of the chest. 
 
 6. Rotation of the humerus inward. 
 
 * American Journal of the Medical Sciences, April, 1878. 
 
DISLOCATION OF THE ELBOW-JOINT. 675 
 
 7. Inability to place the hand on the opposite shoulder while the elbow 
 touches the front of the thorax. 
 
 Dr. P. S. Conner* thus relates a case of backward (Subacromial) Dislo- 
 cation of the Head of the Humerus : remarkable from the fact that the 
 cause of the luxation was never known. 
 
 A patient (set. 39) complained of trouble about his right shoulder, which 
 existed for four weeks. It was considered a case of sprain, and was so 
 treated. Nine years before, the same shoulder had been luxated, and 
 again, three years after some injury had occurred to it, but its exact nature 
 was unknown. There was almost entire inability to lift the arm from the 
 body, and it could not be rotated outward. 
 
 On the 29th day he was etherized, and after much effort, the head of the 
 humerus was replaced in the glenoid cavity, the reduction being accompa- 
 nied by a distinct snap, notwithstanding the completely anesthetized state 
 of the patient. The after history of the case presented nothing of especial 
 interest, and all bandages were removed in two weeks. 
 
 Treatment. — The same methods are employed as have already been given, 
 with the exception of the direction in which extension must be made. In 
 the backward variety, the bone should be pulled downward and forward, 
 while an assistant endeavors to push the head of the bone to its place. Sir 
 Astley Cooper succeeded in reducing this dislocation by exactly the same 
 methods as he employed for the axillary. 
 
 As a general rule, after a luxation of the shoulder has remained unre- 
 duced for twelve or fourteen weeks, attempts at reduction should not be 
 made, although ancient dislocations have been reduced after having existed 
 for a much longer period of time. 
 
 Partial dislocations of the humerus have been described by some authors. 
 Sometimes also the long head of the biceps is removed from the bicipital 
 
 Fig. 381. Fig. 382. 
 
 Apparatus for Frequent Dislocations. Dislocation of Elbow Backward. 
 
 groove. These are rare cases, and the symptoms of each must indicate the 
 method of treatment. The student is referred to the chapter on Injuries 
 an d_ Diseases of the Muscular System. 
 
 Fig. 381 shows an instrument well adapted to prevent partial dislocation, 
 or to be worn by those persons who appear predisposed to a recurrence of 
 luxation. 
 
 Dislocation of the Elbow-joint.— In dislocations of the elbow, both bones 
 may be thrown backward or laterally ; the ulna may be dislocated backward, 
 and the radius forward. 
 
 * American Journal of the Medical Sciences, April, 1878. 
 
676 
 
 A SYSTEM OF SURGERY. 
 
 The backward dislocation of both bones (Fig. 382), occurs most frequently 
 and is known : 
 
 1. By the protuberance on the posterior face of the joint. 
 
 2. Lower extremity of humerus forms a hard tumor in the forepart of the 
 elbow-joint. 
 
 3. A depression is found on each side of the olecranon process. 
 
 4. The forearm and hand are in a state of fixed supination. 
 
 5. Inability to flex the joint. 
 
 Treatment. — The patient is seated on a chair or stool ; the surgeon places 
 his foot upon the seat, bringing his knee in the bend of the elbow ; taking 
 hold of the wrist (Fig. 383), he bends the limb, at the same time pressing 
 on the radius and ulna with his knee, so as to separate them from the hu- 
 
 FlG. 383. 
 
 Fig. 384. 
 
 Reduction with the Knee in the Bend of the 
 Elbow. 
 
 Backward and Outward Dis- 
 location of the Elbow. 
 
 merus, and throw the coronoid process from the posterior fossa of this bone. 
 Whilst the pressure is kept up by the knee, the forearm is slowly and forc- 
 ibly bent upon the arm, and the bones slip into their sockets. 
 
 This reduction may be accomplished also by bending the arm forcibly, 
 but gradually, around a bedpost, or whilst the patient is seated in an arm- 
 chair, passing the arm through the opening in the back or side, thus fixing 
 the body and limb, and reducing the luxation by forcibly bending the fore- 
 arm, with one hand placed upon the olecranon process to lift the bones 
 into their places. The reduction having been accomplished, the forearm 
 must be placed in a sling, the elbow bent at an obtuse angle, and supported 
 with a splint. 
 
 Dislocation of both Bones Backward and Outward (Fig. 384) is known by 
 the following symptoms : 
 
 1. Coronoid process is found resting upon the external condyle of the 
 humerus. 
 
 2. Great projection of the ulna backward (being more marked than when 
 the ulna alone is thrown back. 
 
DISLOCATION OF THE CARPUS UPON THE RADIUS AND ULNA. 677 
 
 3. The radius forms a hard tumor on the outer side of the joint behind 
 the external condyle. 
 
 4. A depression is seen above the head of the bone. 
 
 5. By rotating the hand, the head of the radius is felt to move. 
 Dislocation of both Bones Backward and Inward. — The symptoms are 
 
 easily recognized. They are — 
 
 1. Posterior projection of olecranon. 
 
 2. Head of the radius lies in the posterior fossa of the humerus. 
 
 3. The ulna rests behind the internal condyle. 
 
 4. The external condyle of the humerus forms a large tumor on the outer 
 side. 
 
 Treatment. — In both these varieties of dislocation, the treatment may be 
 conducted upon the same principle as that already mentioned for back- 
 ward dislocation ; the pressure being directed inward or outward, according 
 to the lateral displacement. 
 
 Dislocation of the Ulna Backward. — This variety of dislocation is often 
 quite difficult to diagnose. Its distinguishing features are : 
 
 1. The olecranon can be felt projecting behind the humerus. 
 
 2. Forearm cannot be extended. 
 
 3. Forearm cannot be flexed to more than a right angle. 
 
 In this luxation, the chief marks are the contortion of the forearm and 
 hand with the projection of the olecranon on the posterior face of the joint. 
 
 Treatment. — The surgeon grasps the wrist, places his knee in the bend of 
 the arm (as already shown in Fig. 383, page 676), and drawing the forearm 
 downward, the bone will slip into its socket. 
 
 Dislocation of the Radius Forward. — In this luxation, the head of the 
 radius will occupy the hollow above the external condyle of the humerus 
 (Fig. 385). The indications are — 
 
 1. Slight flexure of the forearm. 
 
 2. Inability to flex the forearm to a 
 right angle. 
 
 3. When a sudden endeavor is made to 
 flex the forearm on the arm, there is a 
 sudden check. 
 
 4. Pronation of the hand. 
 
 5. The head of the radius may be felt 
 by pressing the thumb in front and to 
 the inside of the external condyle of the 
 humerus. 
 
 6. By rotating the hand, the head of 
 the radius moves also. 
 
 Treatment. — The surgeon should make 
 gradual and forcible extension, and, while 
 so doing, should supinate the hand. 
 With the thumb of the other hand, the 
 head of the radius should be pressed down, 
 and the arm placed in a sling. 
 
 Dislocation of the Head of the Radius 
 Backward can be recognized by the partial 
 loss of motion and the tumor formed by 
 the head of the bone on the back of the 
 external condyle. The reduction is effected 
 on the same principles as the last-named 
 dislocation. 
 
 Dislocation of the Carpus upon the Radius and Ulna. — This luxation may 
 occur in two directions, backward and forward, and is occasioned by direct 
 violence to the wrist. 
 
 Fig. 385. 
 
 Forward Dislocation of the Radius. 
 
678 A SYSTEM OF SURGERY. 
 
 The backward dislocation may be known — 
 
 1. Forearm is shortened when measured from the tip of the little finger 
 to the olecranon. 
 
 2. Distance unchanged between olecranon and styloid process. 
 
 3. Prominence of carpus on the back of the forearm. 
 
 4. Prominence in front, caused by the projecting ends of radius and ulna. 
 
 5. Below the last-mentioned prominence is a depression. 
 
 6. Styloid processes are not on the same line as the carpal bones. 
 
 7. The wrist is thicker. 
 
 8. Fingers are semiflexed. 
 
 Treatment, — Extension is made at the wrist, and counter-extension at the 
 forearm ; the surgeon, with both thumbs, makes downward pressure on 
 the carpus. Malgaigne prefers extension to be made at the fingers, by 
 means of a band fastened around the metacarpus. In compound disloca- 
 tions, amputation or resection may be required. 
 
 Dislocation of the Carpal Bones Forward.— In this luxation the carpus is 
 thrown forward on the anterior face of the radius (Fig. 386). 
 
 The symptoms and methods of reduction are the reverse of those last 
 described. The appearance is well shown in the cut. 
 
 Sprains about the wrist, from severe 
 
 FlG - 386 - falls, sometimes assume the appearance 
 
 /"" ^\ of dislocation of these bones, but may be 
 
 I Jj^UL^L^ \^ ■ distinguished from it by there being but 
 
 one swelling in sprain, and that hav- 
 ing come on gradually ; also the rela- 
 tive position of the styloid processes of 
 Dislocation of the carpal Bones Forward. the radius and ulna with the carpus is 
 
 unaltered in sprains. 
 Dislocation of the TJlna from the Radius at the wrist occurs oftener than 
 the last mentioned. It is easily recognized by the altered position of the 
 styloid process, the projection of the ulna above the level of the os cunei- 
 form, and the twisting of the hand. 
 
 Treatment in this case consists in replacing the end of the ulna by exten- 
 sion and direct pressure on the end of the bone, confining it there by means 
 of splints on the back and forepart of the wrist and forearm, and placing a 
 compress upon the end of the bone which has a tendency to displacement, 
 on account of the rupture of the ligament. A roller is then applied to re- 
 tain the compress and splints. 
 
 Dislocation of the Fingers. — The fingers may be dislocated at their various 
 articulations, though more frequently between the first and second pha- 
 
 FlG. 387. 
 
 ^Kw^-_ 
 
 langes. The nature of the injury is apparent, and may be reduced by 
 extension (Fig. 387), made by trie hand alone, with a bandage or tape ap- 
 plied by a clovehitch. 
 
 But a much more convenient apparatus is that of Dr. Levis (Fig. 388), 
 
DISLOCATION OF THE FINGERS. 
 
 679 
 
 which consists of " a thin strip of hard wood, about ten inches in length, 
 and one inch, or rather more, in width. One end of the piece is perforated 
 with six or eight holes. The opposite end is cut away, forming a pro- 
 
 jecting pin, and leaving a shoulder on each side. Towards this end of the 
 strip a sort of handle-shape is given, so as to insure a secure grasp to the 
 operator. Two pieces of strong tape or other material about one yard in 
 
 Fig. 389. 
 
 Levis's Instrument Applied. 
 
 length are prepared. One of these is passed through the holes at the end of 
 the strip, leaving a loop on one side. The other tape is passed through 
 another pair of holes, according as it may be a thumb or finger to which it 
 is to be applied, or varied to suit the length of the finger, leaving a similar 
 
 Charrier's Forceps. 
 
 loop. If a dislocated thumb is to be acted on, the second tapes should be 
 passed through the holes nearest the first. The ends of each separate tape 
 are then tied together." 
 
 Fig. 391. 
 
 Luer's Forceps. 
 
 Fig. 389 shows this instrument applied to the forefinger, though it is 
 especially adapted for the thumb. 
 
680 A SYSTEM OF SURGERY. 
 
 Fig. 390 shows Charrier's forceps, used to reduce dislocations of the pha- 
 langes. 
 
 Fig. 391 represents Luer's, for the same purpose. 
 
 Dislocation of the Thumb. — Luxation of the thumb backward on the dor- 
 sum of the metacarpal bone often takes place. Less frequently in the 
 opposite direction. 
 
 The accident, though easily recognized, is difficult of management. 
 
 Treatment. — A clovehitch, the apparatus of Levis, or Charrier's forceps 
 should be placed upon the first phalanx, and continued extension employed. 
 Strong and steady flexion must be made towards the palm of the hand, 
 and, at the same time, firm pressure applied by the thumb of the surgeon 
 upon the head of the bone. By these means the reduction is often accom- 
 plished. The luxation, however, is sometimes so unyielding, as to require 
 the subcutaneous section of one or both lateral ligaments before the desired 
 result is attained. 
 
 Before, however, the division of the ligaments is made, the following 
 manipulation should be resorted to in difficult cases, and it will generally 
 succeed, as one of the greatest obstructions to the reduction is the lapping 
 of the extremities of the bones, which, from their form, become completely 
 locked. Soak the hand in warm water ; apply a piece of wet leather around 
 the thumb, and over this a clovehitch of strong tape. In dislocation up- 
 wards, a loop of tape embraces the upper end of the phalanx, and is drawn 
 with great force by an assistant perpendicularly upwards. Another loop of 
 tape embraces the lower end of the metacarpal bone, and is drawn down- 
 wards by another assistant. While the extremities of the bones are by these 
 means unlocked, the surgeon draws the thumb, by the clovehitch, towards 
 the palm of the hand, and the bone usually slips into its normal position. 
 
 The metacarpal bones are seldom luxated, except from extraordinary vio- 
 lence, the consequences of which, for the most part, are more serious than 
 the dislocation. 
 
 The carpal bones being strongly connected to each other by short liga- 
 ments, and by a ball-and-socket joint, are with difficulty luxated. Either 
 from relaxation of the ligaments, or from extreme violence, the cuneiform 
 bone and os magnum may be displaced. 
 
 These latter are not only difficult to reduce, but when this is accom- 
 plished, if accompanied with relaxed ligaments, the ends of the bones can 
 scarcely ever be kept in their natural position, to maintain which, band- 
 aging, with appropriate treatment, is necessary. 
 
 After-treatment in Dislocations. — After a bone has been reduced, in all 
 cases, the part should be covered with a cloth wet with a solution of arnica 
 and water, and a bandage applied in such a manner as to prevent motion. 
 In dislocation of the larger joints this rest must be maintained for days, 
 and then motion gradually resumed. It is my custom always after such 
 reduction, to administer to the patient a dose of rhus tox. every three or 
 four hours. I have lately had considerable experience with massage, as a 
 means of removing the stiffness which often remains after the reduction of 
 a dislocation, and can highly recommend it. 
 
INJURIES AND DISEASES OF THE SPINE. 681 
 
 CHAPTER XXXIV. 
 
 INJURIES AND DISEASES OF THE SPINE. 
 
 Concussion of the Spine, including " Railway Concussion" — Nervous Shock — Spina 
 Bifida— Cleft Spine — Rotary Lateral Curvature— Angular Curvature — 
 Pott's Disease— Caries of the Spine — Lordosis — Psoas or Lumbar Abscess. 
 
 Concussion of the Spine is produced by the ordinary accidents of civil or 
 military life ; in the former, horseback exercise, gymnastics, falls, and espe- 
 cially railway collisions ; in the latter, by blows from muskets, falling from 
 horses, falling trees, blows from blunt instruments, etc. Dr. Otis* relates 
 seventy-nine cases of this character, of which he says : "A few proved fatal 
 from fracture or luxation, or from peritonitis, and in one instance, from the 
 complication of small-pox." 
 
 It is a noticeable fact, that slight injuries of the spine, I mean those of 
 apparently so trivial a nature that they may be forgotten by the patient, 
 often produce serious ultimate results, and that the period which elapses 
 between the receipt of such injury and the development of ulterior disease, 
 varies from weeks to months and even years. But a few years since a great 
 deal was said and written by the profession on injuries of the spine caused 
 by railway accidents, and to the disease the name " railway spine" was 
 given. Careful observation, experience, and inquiry, show that the symp- 
 toms of this so-called " new disease " are nothing more nor less than those 
 observable after any great and violent concussion of the spine or shock 
 to the nervous system. It can readily be understood that in a railway 
 accident, besides the actual force with which the person is thrown about, 
 and the injury to the column, there is in addition the horror, the fright, 
 the apprehension, which stirs the nervous S}^stem to its foundations. Then, 
 again, there is a constant "vibration," or as it has been termed "vibra- 
 tory shock" which may tear into splinters the car, and radiates to every 
 fibre of the human body. The ordinary peculiarities of concussion, and 
 may I not add in some cases contusion of the spine, which need careful 
 attention, are, first, the absence of evidence (external) of any injury to 
 the column ; the patient is aware that there has been a wrench, or a blow, 
 or a twist, but there need not necessarily be a bruise or an ecchymosed 
 spot; the patient, in the majority of cases, may be able to go about his 
 ordinary business, with occasionally a stiff or sore feeling ; after a time, 
 however, the symptoms of paralysis of the parts supplied with nerves 
 from the seat of the injury supervene. The symptoms are progressive and 
 gradual, lasting with variations from months to years. Finally the sphinc- 
 ters become affected, a gradual- decay of the entire body takes place, and 
 death results. Again, a severe injury to the back may produce an inflamma- 
 tion of the meninges of the cord, which will ultimately affect the brain itself. 
 
 Dr. Purple reports a remarkable case,f quoted by Erichsen, in which a 
 man was struck on the back of the head and shoulders by the bough 
 of a tree which he was cutting ; this w T as followed by such complete anaes- 
 thesia of the lower limbs that both his thighs were amputated without 
 the slightest pain. Again, an injury to the spine may be communicated 
 by a fall on the vertex. Generally, paralysis follows these cases, it may 
 be hemiplegic or paraplegic, but it is mostly fatal. In patients who are 
 
 * Medical and Surgical History of the War of the Rebellion, vol. ii., part i., p. 426. 
 f Eve's Surgical Cases, p. 90. # 
 
682 A SYSTEM OF SURGERY. 
 
 paralyzed immediately the symptoms are, according to Mr. Erichsen : 
 " 1. A diminution or loss of motor power. 2. Rigidity and spasm of mus- 
 cles. 3. Diminution or loss of sensation. 4. Perversion of sensation. 5. 
 Loss of control over the sphincters. 6. Modification of the temperature 
 of the limb." Beside these there may be hematuria and intestinal haemor- 
 rhage, hiccough, hypermetropia, impairment of the sexual functions, mo- 
 lecular changes in the cord itself, impairment of memory, myelitis, neuralgia, 
 and a host of other affections of serious import. 
 
 One important peculiarity of shock and concussion of the spine is 
 thus forcibly laid down by Mr. Erichsen.* He says : " These symptoms 
 of a spinal concussion seldom occur when a serious injury has been in- 
 flicted on one of the limbs, unless the spine itself has at the same time 
 been severely and directly struck. A person who, by any of the accidents 
 of civil life, meets with an injury, by which one of the limbs is fractured 
 or is dislocated, necessarily sustains a very severe shock; but it is a rare 
 thing indeed to find that the spinal cord or the brain has been injuri- 
 ously injured by this shock that has been impressed on the body. It 
 would appear as if the violence of the shock had expended itself in the 
 production of the fracture or of the dislocation, and that a jar of the more 
 
 delicate nervous structures is thus avoided How the jars, shakes, 
 
 shocks, or concussions of the spinal cord directly influence its action, I 
 cannot say with certainty. We do not know how it is, that when a magnet 
 is struck a heavy blow with a hammer, the magnetic force is jarred, shaken, 
 or concussed out of the horseshoe. But we know that it is so, and that the 
 iron has lost its magnetic power. So, if the spine is badly jarred, shaken, 
 or concussed by a blow or shock of any kind communicated to the body, we 
 find that the nervous force is, to a certain extent, shaken out of the man, 
 and that he has some way lost nerve power." 
 
 Treatment. — The main feature in this treatment is rest. Dr. S. Weir 
 Mitchell,f of Philadelphia, has given the profession some valuable sug- 
 gestions on the importance of rest in all forms of nervous disorders. I 
 have known the great importance of this method of treatment for years ; 
 in fact I never have been an advocate for " early getting up " after any 
 medical or surgical disease, nor have I been as prodigal in my advice " to 
 go out and exercise in the open air " as many of my professional brethren. 
 It is a mistake in the practice of medicine, it is a mistake in the practice 
 of surgery, to urge the patient to exercise. It is like overloading a dys- 
 peptic stomach with strong food ; it does great harm. Rest after injury of 
 the spine must be absolute, and must be prolonged ; it is the factor in the 
 cure, and is a difficult thing to accomplish, because in many cases the 
 injury appears so trifling that patients cannot understand what disastrous 
 results may follow. Arnica internally, and applications of the same in solu- 
 tion to the spine will generally be of service. 
 
 Frictions do harm. I am convinced of the fact from actual experience. 
 The muscles must be rested and pressure taken away from the column. 
 For such the plaster jacket, put on by an experienced hand, would no doubt 
 accomplish much. When secondary symptoms begin to manifest them- 
 selves, aconite, belladonna, phosphorus, nux vomica, strychnia, cicuta, 
 plumbum, rhus tox., veratrum, cantharides, hyoscyamus, Calabar bean, 
 chloral hydrate, opium, and camphor should be used according to the pre- 
 senting symptoms. 
 
 Spina Bifida — Cleft Spine. — This affection or deformity of the vertebral 
 column consists essentially in an arrest of development of some portion of 
 
 * On Concussion of the Spine, Nervous Shocks, p. 156. 
 
 f Rest in Nervous Diseases. Blood and Fat, and How to Make Them. 
 
SPINA BIFIDA CLEFT SPINE. 
 
 683 
 
 Ftg. 392. 
 
 the bones of the spine, through which the membranes of the cord pro- 
 trude ; indeed, it may be said to be a hernia of the spinal cord. The affec- 
 tion is congenital, and often is accompanied by other deformities. In 
 twenty-seven cases, twelve were found uncomplicated with any other de- 
 formity ; in eleven there was incontinence of urine and faeces ; paralysis of 
 the lower extremities existed in four ; hydrocephalus accompanied four 
 others ; nsevus two, and talipes one. Of these cases, the lumbar region was 
 the site of thirteen ; there were four in the lumbo-sacral region, and nine 
 in the sacral. These specifications approximate a correct estimate of the 
 location and complications of the affection. 
 
 In some cases the integument is perfect at birth and afterwards ulcerates, 
 showing the protrusion of the membranes or the cord itself. In other 
 cases, at birth, nothing but a membrane 
 appears to cover the parts. Fig. 392, taken 
 from a photograph, represents a case which 
 occurred in the practice of my friend, the 
 late Dr. J. J. Youlin, of Jersey City, and 
 of which he furnished me a description. 
 The cut gives an example of those usually 
 seen. At birth, the child had in the lum- 
 bar region a dark-colored spot, having 
 somewhat the appearance of a bed-sore, 
 at the base of which was a thin membrane. 
 Upon pressure, this was found to possess 
 considerable elasticity, and became more 
 dense as the tumor developed itself, which 
 rapidly advanced from the cleft, always 
 retaining its dark color and elasticity. It 
 likewise was moist. As it continued to 
 increase, it divided into two parts, as seen 
 in the figure, the lower being the larger. 
 In the centre of the upper part a small orifice soon made its appearance, 
 from which jets of cerebro-spinal fluid were ejected during coughing, sneez- 
 ing, crying, or any rapid movement of the body. The child lived six weeks 
 and died in convulsions. I have seen many similar ones. 
 
 Treatment. — In most cases of cleft spine, death results early, but there are 
 instances of recovery, and those also in which the patients have reached 
 adult life. Hamilton records one of the latter kind coming under his own 
 observation* In ten cases under my supervision six died of convulsions 
 in six to ten weeks. One was operated on by injection, and lived two years, 
 the others survived from one to three years. 
 
 The first care should be to protect the tumor from injury. An excellent 
 method of so doing is with a framework of wire filled with soft cotton-wool. 
 In other instances, cotton applied and kept in position with a bandage 
 answers well, the parts having been previously painted with collodion. It 
 must be borne in mind that a certain amount of pressure is sometimes 
 serviceable, and therefore the band securing the cotton may be drawn with 
 moderate tightness around the protrusion. Tapping the sac and drawing 
 off the fluid (the smallest-sized needle of the aspirator being used) I have 
 also practiced, and as I have stated successfully. The proceeding is often, 
 however, followed by convulsions and death. Gradual constriction of the 
 neck of the sac, when there is but a slight pedicle, may also be tried. In 
 the effort to draw off the fluid the puncture should be made at the side 
 of the tumor, in order to avoid the spinal cord, and the whole amount 
 
 Case of Spina Bifida, from nature. 
 
 Principles and Practice of Surgery, p. 454. 
 
684 A SYSTEM OF SURGERY. 
 
 should never be evacuated at once. If injection be used, after the partial 
 withdrawal, iodine, five or six drops to the drachm of water, may be em- 
 ployed, the strength of the solution being increased if sufficient inflamma- 
 tion is not excited. 
 
 Brainerd's injection, which has been successful, is composed of five grains 
 of iodine, fifteen of iodide of potassium, and an ounce of water. Finally, 
 immediate removal with the 6craseur has been tried. 
 
 M. Mouchet has operated upon spina bifida with success by the elastic 
 ligature,* puncturing the sac in one case before using the ligature, and in 
 another by immediately applying the ligature without previous puncture. 
 Six cases have been reported as treated by this method, of which three 
 succeeded, one failed, and two died. 
 
 Another case is reported by Dr. Baldassare, in which compression with 
 the elastic ligature, lasting sixteen days, was successful^ 
 
 In some cases I have had a moderate degree of success by Brainerd's 
 injection, that is, the lives of the children have been prolonged ; the ma- 
 jority, however, ultimately died. In several other cases, death followed in 
 a day or two after the evacuation of the fluid with the aspirator. 
 
 At best, the results of all these methods have not been favorable, but 
 they are worth trial, as occasionally a case has been cured by their employ- 
 ment. 
 
 Rotary Lateral Curvature of the Spine — Scoliosis. — This affection, which 
 appears to be rapidly on the increase, especially in large cities and among 
 the wealthy and luxurious, is more frequent in girls than in boys, and com- 
 mences in an insidious manner. Patients have informed me that they 
 are certain the affection must have appeared in a few days, because while 
 " trying on a dress," or changing clothes, or bathing, the deformity was sud- 
 denly recognized, it having progressed for a considerable time without being 
 discovered. 
 
 Lateral curvature is produced by a want of harmony in the many antag- 
 onistic muscles which are attached to the different portions of the spine. 
 There is no disease of the internal organs ; in fact, there is no disease any- 
 where. One set of muscles — from bad positions, contracted at school or at 
 home, bad positions in bed, bad positions at table, bad positions in riding 
 and walking — become weakened ; while the other set, acting more forcibly, 
 draw the spine to one side. 
 
 There is a variation in the degree of this deformity, but great or small, 
 there are two curvatures, the one balancing, as it were, the other, the higher 
 equalizing the lower portion of the column. 
 
 I have noticed regularity and precision in the course of these curvatures. 
 Examining the lumbar curve, the column is bent from its base to the left 
 side in the majority of cases, making the concavity to the right, then fol- 
 lowing the general rule, the dorsal curve is deflected to the right, having 
 the concavity on the left side. 
 
 Patients suffering from lateral curvature seem more " dumpy " in their 
 bodies, their arms are lengthened, there is a clumsiness about the waist, the 
 hip is elevated and seems of greater size than its fellow, there appears to be 
 a convergence of the ribs ; as they pass from the vertebral column they ex- 
 pand and enlarge the intercostal spaces. The right shoulder is elevated 
 and bulging and projects backward ; and, in some instances, the chest ap- 
 pears as though it were twisted entirely around. By passing the fingers 
 along the spinous processes, a certain amount of deformity can be recog- 
 nized, but it must be borne in mind that the spinous processes incline to the 
 
 ■ * Monthly Abstract of Med. Science, October, 1876; Obstetrical Journal of Great Britain. 
 f Medical Times and Gazette, August 25th, 1877. 
 
TREATMENT OF LATERAL CURVATURE. 
 
 685 
 
 concave side of each curve, giving the appearance of a tolerably straight 
 column, so far as the tips of the spinous processes are concerned, whereas 
 the bodies of the vertebras are drawn far away in the lateral displacement ; 
 in other words, rotated. 
 
 This condition may be readily explained. If we examine carefully the 
 muscular and ligamentous attachments of the spinal column, it will be seen 
 that the anterior portions of the bodies of the vertebras are almost entirely 
 free from such connections, while the spinous processes and the posterior 
 portion of the bones are much more firmly fixed in the median line by these 
 symmetrical supports. This fact was recognized, and, as far as I am aware, 
 first pointed out by Dr. A. B. Judson* who attributes the rotation observed 
 in cases of lateral curvature of the spine to the peculiarities above noticed. 
 He states also that it is not the disparity of action of a single muscle, or even 
 of sets of muscles, by which the rotation is produced, but to the combined 
 action of all. 
 
 This reasonable explanation would regulate somewhat the application of 
 mechanical contrivances, and although difficulty will always be found in 
 getting the direct pressure upon the bodies of the vertebras, still a general 
 support of the sides of the chest and thorax aids somewhat, if not entirely, 
 in restoring the rotated bodies, at least of preventing further motion in that 
 direction. Dr. Sayre recommends for this reason the plaster jacket in rota- 
 tory lateral curvature. 
 
 Treatment. — As there is no disease existing in lateral curvature, there 
 need be no medicines given internally. If noticed early, the cases may be 
 cured by proper gymnastic exercises, tending to bring strength to those 
 muscles at fault. Dr. Roth and Dr. C. F. Taylor have described very minutely 
 the exercises tending to such a result. The postures of the children must 
 be rectified ; they should be removed from school, and allowed exercise in 
 the open air. Riding, walking, rowing (not boat- 
 ing), all should be practiced. Frictions of alco- 
 hol and salt, or whiskey and water, should be 
 made upon the spinal column, over the affected 
 parts, night and morning. The diet should re- 
 ceive minute attention, all unwholesome food, 
 such as cakes, pastry, candies, etc., being strictly 
 forbidden ; a proper position in bed enjoined, a 
 low pillow only being allowed. 
 
 Daily calisthenics are of great service, and the 
 " movement cure," under the direction of judi- 
 cious specialists, should be resorted to. In the 
 latter stages of the disease, appropriate supports 
 are often beneficial, although they are objec- 
 tionable from the pressure and inconvenience 
 to which they give rise. Of all the methods I 
 have used, I prefer the apparatus of Mr. Bar- 
 well, as modified by Dr. Sayre. I have made 
 some excellent cures with it. At present, how- 
 ever, the application of the plaster of Paris jacket, 
 as described in the next article, is said to super- 
 sede all others. 
 
 In some obstinate cases, section of the latissi- 
 mus dorsi muscle must be resorted to. It was first performed by Prof. Lewis 
 A. Sayre, in 1876.f The muscle was divided subcutaneously, with the effect 
 
 Fig. 393. 
 
 Tiemann's Apparatus. 
 
 * Medical Eecord, April 22d, 1876. 
 
 f N. Y. Medical Eecord, January 22d, 1876. 
 
A SYSTEM OF SURGERY. 
 
 of straightening the patient almost upon the instant, so far as the lateral 
 curvature was concerned, the angle of the ribs upon the opposite side being 
 about the only deformity left. The pain of the operation was trifling, and 
 by means of a suitable apparatus of bands and elastic straps, the body was 
 afterwards retained in a perfectly straight position. 
 
 Angular Curvature of the Spine— Caries or the Spine— Pott's Disease— Spon- 
 dylitis. — Dr. Sayre* objects to the term Pott's disease, and prefers the word 
 spondylitis as being more applicable to the aetiology, course, and termination 
 of the affection. 
 
 Above it was remarked that in lateral curvature no distinct disease ex- 
 isted, but that the deformity of the column was occasioned by a lack of 
 equalizing power of the muscles on each side of the vertebra? ; not so, how- 
 ever, is it in angular curvature, a distinct disease being the cause of the 
 deformity. 
 
 Pott's disease is usually developed in scrofulous children, its immediate 
 cause being, in the majority of cases, some local injury ; in other instances, 
 no local origin can be found, and a slight protuberance in the line of the 
 spinal column is the first indication of the approaching disease. It is said 
 that, in the majority of instances, the affection commences in the inter- 
 vertebral substance, the inflammation extending itself to the bodies of the 
 vertebrae, which become carious and crumble, causing the head and trunk 
 to fall forward and the posterior portions of the vertebrae to protrude. 
 
 In the earlier stages, and especially when the lumbar vertebrae are affected, 
 there is a lateral curvature, together with the forward deviation. This fact 
 must be remembered in making an early diagnosis, as an error at this 
 period would probably be the source of disastrous results. 
 
 There are always some presenting symptoms, generally however obscure, 
 before the " knuckle " is seen ; these manifestations being of a nervous char- 
 acter and occasioned by irritation of the lateral portions of the vertebrae 
 near the foramina giving passage to the spinal nerves. If the disease ap- 
 pears in the cervical region, there is cough and some difficulty of breathing; 
 if in the dorsal, a catch in the breath and an inability to take a full respira- 
 tion ; if in the lumbar, there are colicky pains, constipation, etc. ; all these 
 symptoms, together with the pallor and emaciation which belong to those 
 children afflicted with Pott's disease, suggest that the patient is suffering 
 from some verminous affection. 
 
 An important point also, as noticed by Dr. Lee, is this, that pressure 
 downward on the spinous processes in many cases does not produce pain, 
 but squeezing the sides of the thorax together in order to force the heads 
 of the ribs upon their articular facets, will give rise to more or less suffer- 
 ing. In fact, if the patient is on the face in a recumbent posture, pressure 
 on the spinous processes may relieve rather than aggravate the pain. 
 
 When it is necessary to examine a patient with Pott's disease, he may be 
 suspended by an assistant holding him under the arms, or may be laid upon 
 the lap, having the arms hanging over one knee and the legs over the other. 
 By then separating gradually the knees, traction is made on the column 
 and the patient will breathe better, and perhaps the " knuckle " will not be 
 so well marked. 
 
 When a child, affected with angular curvature, attempts to walk, the ten- 
 dency of the head is forward and there is a loss of the proper equilibrium, 
 to remedy which the patient, as he slides carefully along, having a great 
 liability to trip, places his hands upon the thighs. This position is also 
 assumed when standing. There is likewise a backward inclination of the 
 head and a tendency to carry the body back. By the continuation of these 
 
 * Medical News and Library, vol. xxxvi., p. 49. 
 
TREATMENT OF POTT'S DISEASE. 
 
 687 
 
 Fig. 394. 
 
 motions the angle also is carried back and the " humped-back " becomes 
 more conspicuous. 
 
 When the affection is seated in the dorsal region, the whole thorax par- 
 ticipates in the deformity ; its antero-posterior diameter is increased, and 
 the sternum protrudes greatly, and the well-known " chicken-breast " is pro- 
 duced. 
 
 After a time, a spinal abscess sometimes results, which increases the dif- 
 ficulties. 
 
 In many instances, however, even after the formation and evacuation of 
 pus, solidification of the vertebrae takes place, and the patient recovers, with 
 a deformity, but with good health. Many strong and sturdy humped-back 
 men are seen on the streets pursuing their daily avocations, and apparently 
 in the enjoyment of unimpaired health. 
 
 Treatment. — In the early stages of the disease, a great deal can be done 
 by medication, by diet and rest. The great desideratum is to take the super- 
 incumbent weight off the diseased bone, and the best method to accom- 
 plish this is rest in the horizontal posture. This must be absolute and pro- 
 longed, and during it the patient steadily given proper medicine. Those 
 which have been very efficacious in my hands are especially silicea, asa- 
 fcetida, mezereum, and calcarea. These I give in trituration, a powder every 
 night. Great attention must be given during this period to the bathing 
 and diet of the child. The latter is often . 
 found especially difficult, as children affected 
 with these diseases are much petted and fed 
 without discretion. 
 
 In the mechanical treatment of Pott's dis- 
 ease, I have been successful with the brace of 
 Dr. C. F. Taylor (Fig. 394). I have used also 
 with good success the plaster-of-Paris jacket 
 of Dr. Sayre. One thing is certain. It can be 
 applied in any location. It costs nothing, I 
 mean when compared to the other expensive 
 apparatusus devised for the treatment of this 
 disease, and the results that have been recorded 
 by Dr. Sayre and others in this country and 
 in Europe bid fair to make it yet the appa- 
 ratus for this deformity. It is to be applied 
 as follows, according to Dr. Sayre's own direc- 
 tions :* 
 
 " When you wish to apply a jacket, the pa- 
 tient is to be suspended by means of an appa- 
 ratus prepared for the purpose, consisting of 
 a curved iron bar with hooks at either end, 
 from which pass straps that are attached to 
 pads, that go through the axillse and also un- 
 der the occiput and chin, and are capable of 
 being made shorter or longer, according to the 
 length of the patient's neck. The iron bar is 
 suspended from the ceiling by means of a 
 
 compound pulley, through which gradual extension can be made until the 
 patient is drawn up so that the feet swing clear from the floor. 
 
 " Previous to the suspension, however, a thin flexible leaden strip should 
 be laid upon the spinous processes for the entire length of the spinal column, 
 and bent into all the sinuosities, so that it may take a perfect outline of the 
 
 i/MYNDEBS-GQ, 
 
 * Keport on Pott's Disease, or Caries of the Spine ; treated by extension and the plaster-of- 
 Paris bandage. By Lewis A. Sayre. 1877. 
 
688 A SYSTEM OF SURGERY. 
 
 deformity. This strip is then laid upon paper and its outline marked with 
 ink, and we have a perfect mathematical outline of the irregularities along 
 the spinal column. After the patient has been suspended, the same leaden 
 strip should again be applied along the spinous processes, as in the first in- 
 stance, and another pattern made upon paper by the side of the first. 
 
 a Now we have a means by which comparison can be made, and we are 
 able to determine exactly what changes have taken place in the curve. The 
 shirt, which should be woven or knit without seams, and tightly fitting the 
 body, is next pulled down, and an opening made in front and rear, through 
 which a ribbon or piece of bandage is passed for the purpose of holding in 
 place a handkerchief placed in the perinseum, and at the same time making 
 the shirt fit the hips exactly ; for the tighter the shirt fits, the less number 
 of wrinkles there will be in it. The roller bandages, previously prepared, 
 are now set on end in a vessel containing sufficient depth of water to cover 
 them entirely, and, at first, bubbles of gas will escape through the water 
 freely. When the bubbles cease to escape, the bandages are ready for use. 
 Then taking a roller in the hand, and squeezing it gently so as to remove 
 all surplus water, commence just around the smallest part of the body, go- 
 ing to the crest of the ilium and a little below it, and lay it around the body 
 smoothly, but do not draw upon it at all ; simply unroll the bandage with 
 one hand while the other follows and brings it into smooth close contact 
 with all the irregularities of the surface, over the ilium and dipping into the 
 groin, over the abdomen and dipping into the groin again, and so on, from 
 below upwards in a spiral direction until the entire trunk has been inclosed 
 from the pelvis to the axillae. After one or two thicknesses of bandage 
 have been laid around the body in the manner described, narrow strips of 
 perforated tin are placed parallel with each other upon either side of the 
 spine, from two to three inches apart, and in number sufficient to surround 
 the body, and another plaster-roller carried around the body, covering them, 
 in the manner in which the first bandage was applied. 
 
 " These few strips strengthen the bandage, and obviate the necessity of 
 increasing its weight by the application of a larger amount of plaster. If 
 there are any very prominent spinous processes, which at the same time 
 may have become inflamed, in consequence of pressure produced by instru- 
 ments previously worn, or from lying in bed, it is well to guard such places 
 by means of little pads of cotton or cloth, or little glove fingers filled with 
 wool which is elastic, which are to be placed upon either side of them before 
 applying the bandage. 
 
 u Another suggestion, which I have found to be of practical value, is to 
 take two or three thicknesses of roller bandage three or four inches long, 
 and place them over the anterior superior spinous process of each ilium. 
 These little pads are to be removed just before the plaster has completely 
 set, and consequently leave the bony part free from pressure after the soft 
 parts have shrunken under the influence of the continued pressure pro- 
 duced by the plaster dressing. It is also well, just before the plaster has 
 set completely, to place one hand in front of the ilium and the other over 
 the buttocks, and squeeze the cast together so as to increase this space over 
 the bony prominences. In a very short time the plaster becomes set, suffi- 
 ciently so that the patients can be removed from the suspending apparatus, 
 and laid upon the face or back on an air bed, where they are to remain until 
 the hardening process is complete. A hair mattress answers a very good 
 purpose, but the air-bed is preferable, especially if there is much projection 
 of the spinous processes or the sternum. 
 
 " If there are any abscesses present, they must be freely opened at the 
 most dependent part, and their contents completely extracted by means of 
 the wide rubber cupping-glass. Sometimes large masses of sloughing con- 
 
TREATMENT OF POTT'S DISEASE. 
 
 689 
 
 nective tissue will be found, which look like wads of wet cotton ; all these 
 must be removed. After the abscesses have been thoroughly evacuated, 
 oakum should be placed over the opening, and then covered with a piece 
 of oil-silk, before the shirt is pulled down over the body. A hole is then 
 cut in the shirt, which is to indicate the size of the fenestrum subsequently 
 to be cut in the plaster jacket, and in it is set a folded piece of pasteboard 
 of the same size, and carrying a long sharp pin thrust through its outermost 
 leaf. Now each turn of the bandage can be carried over the pin without 
 crowding it into the abscess below, and you also have a guide in making an 
 opening that shall lead directly to it. When the plaster has nearly set, you 
 can take hold of the pin, and cut around it until the pasteboard is reached, 
 and an opening made sufficiently large to allow of its easy removal. The 
 
 Fig. 395. 
 
 Fig. 396. 
 
 Fig. 397. 
 
 Sayre's Jury-mast. 
 
 Taylor's Apparatus. 
 
 Darrach's Wheel-Crutch and Chair. 
 
 pasteboard removed, you come at once upon the oil-silk, which is to be 
 starred, or cut from the centre into strips, so that when they are reversed, 
 they will cover the edges of the opening in the plaster, where they can be 
 glued down with gum-shellac, and now you have left a fenestrum for drainage 
 that leads directly to the abscess." 
 
 When the disease attacks the cervical vertebrae, Dr. Sayre applies what 
 he calls a "jury-mast," which suspends the head. This appliance is seen 
 in Fig. 395, and is held firmly in place by the "plaster jacket. It is applied 
 after the body has been encased by the application of the bandage twice ; 
 it is then laid over and secured by repeated turns of the roller several times 
 
 44 
 
690 
 
 A SYSTEM OF SURGERY. 
 
 up and down the chest. In Taylor's splint the pressure is made on the 
 chin and the prominent vertebras, thus lifting the weight from the diseased 
 bodies. (Fig. 396.) 
 
 Another contrivance, which has been productive of satisfactory results, 
 is that of S. A. Darrach, of Newark. (Fig. 397.) It will be seen how 
 the weight is taken entirely from the spinal column, while free exercise 
 is allowed to other parts of the body. I have known excellent results 
 
 Fig. 398. 
 
 The Meigs-Case Apparatus for Pott's Disease. 
 
 from this crutch, in connection with the body-brace. The corset is made 
 of hide prepared in a peculiar manner, and readily moulds itself to the 
 parts. 
 
 Dr. Franklin makes, with a plaster bandage around the ilia, what he 
 denominates an artificial sacrum, to support the upper dressings. He also 
 introduced a modification of the jury-mast, to take off pressure from the 
 cervical vertebrae, and render the entire dressing more firm. 
 
 The Meigs-Case apparatus, Fig. 398, I have used also with satisfactory 
 results. 
 
PSOAS OR LUMBAR ABSCESS. 691 
 
 The student must, however, be cautioned against forgetting, through 
 admiration of these newer methods, that there are other ways in which 
 these deformities are cured. Rest, medication, the exercise of certain 
 muscles, and proper braces, will cure the disease, and have so done, long 
 before these admirable plaster contrivances came into general use. It must 
 be also remembered that distinguished and successful specialists, by means 
 of their own contrivances, are constantly producing good results. 
 
 Kyphosis. — This term is given to a general antero-posterior curve, which 
 is noticed in weakly children and in the aged. It is occasioned in infants 
 by allowing them to sit up too early. This can also be cured by the plaster- 
 of-Paris jacket. 
 
 Lordosis, or " saddle-back," is generally produced by congenital dislocation 
 of the hip. It must be considered as a secondary affection. It will easily 
 be seen that in the dislocation of the hip there is a backward displacement 
 of the centre of gravity, which makes the forward inclination of the pelvis 
 necessary to establish the equilibrium. In this variety the cause must be 
 removed, the endeavor being made to reduce and fix in position the dis- 
 placed bone, or if anchylosis exist, performing subcutaneous osteotomy at 
 the neck of the thigh. 
 
 Psoas or Lumbar Abscess. — This disease in most instances, is chronic, the 
 collection of pus being very gradual. Cases, however, may occur, in which 
 the affection is acute, the matter making its appearance in a short time after 
 the premonitory symptoms have been noticed by the patient. 
 
 The first manifestations do not, in many cases, receive sufficient atten- 
 tion, and are allowed to pass unnoticed, until the disorder is far advanced 
 and the danger too proximate to escape attention. In the incipient 
 stage, the patients are unable to walk with their usual facility, there is a 
 degree of uneasiness experienced about the lumbar region, but there is 
 little acute pain ; rigors are frequently present, the patients also being un- 
 able to use any violent exercise. As the disease advances, the testicle of 
 the affected side is drawn up, and there is more or less pain extending 
 along the course of the spermatic cord. Glandular enlargement takes place 
 in the groin, and there is a slight protrusion noticed at that part ; the swell- 
 ing then appears on the inner side of the femoral vessels, beneath the pubic 
 portion of the fascia lata. The precursory symptoms may continue sev- 
 eral months, before rigors, loss of appetite, hectic, and other symptoms which 
 denote suppuration, are developed. Mr. Cooper remarks : " The abscess 
 sometimes forms a swelling above Poupart's ligament, sometimes below it, 
 and frequently the matter glides under the fascia of the thigh ; occasion- 
 ally it makes its way through the sacro-ischiatic foramen, and assumes 
 rather the appearance of a fistula in ano. When the matter gravitates into 
 the thigh, beneath the fascia, Mr. Hunter would have termed it a disease in, 
 not of, the part." 
 
 The swelling is more prominent in the erect position, and is also increased 
 by exertion of the abdominal muscles ; an impulse is also imparted to it 
 when coughing. As the suppuration continues, fluctuation is perceived, 
 generally in some portion of the groin, but large and neglected collections 
 of pus may make their way towards the surface in two or three directions. 
 Lumbar abscess most frequently arises from disease of the vertebrse, but, 
 says a distinguished surgeon, " It must be confessed that we can hardly 
 ever know the existence of the disorder, before the tumor, by presenting 
 itself externally, leads us to such information." 
 
 The pus discharged from a lumbar abscess is generally thin, gleety, and 
 mixed with cheesy flocculi, or with a curdlike substance ; in some rare in- 
 stances, however, the matter has been found laudable. 
 
 From post-mortem examinations on patients who have died from this 
 
692 A SYSTEM OF SURGERY. 
 
 affection, we learn that the purulent secretion is completely inclosed in a 
 cyst, which is often very extensive. If the contents of such abscesses 
 were not circumscribed by such boundaries, the pus would spread rapidly 
 among the cells of the surrounding cellular texture, as does the water in 
 anasarca. The cysts are lined with the pyogenic membrane, that, as has 
 been before mentioned, appears to possess the property of secretion ; indeed, 
 during the treatment of lumbar abscess, it is wonderful to observe the im- 
 mense quantity of pus that is discharged. 
 
 This disease is often attributable to a sprain or wrench of the loins, or is 
 induced by exposure to cold and overfatigue. Occasionally the mischief is 
 confined entirely to the soft parts ; although the vertebrae, a portion of the 
 os innominatum, or the sacrum may be denuded and of irregular surface, 
 evidently the result of the pressure of the abscess. A strong example of 
 this and of the extensive destruction of parts which this affection sometimes 
 produces, may be briefly stated. A large lumbar abscess formed within a 
 few weeks, in consequence of great and continued fatigue and exposure to 
 bad weather. At first it had been trifled with. At last it was opened, in 
 the usual situation in the thigh, and a large quantity of matter evacuated. 
 Thirty-six hours afterwards the patient was suffocated with a flow of puru- 
 lent matter into and through the air-passages. On dissection, the cavity 
 w T as found which opened through the diaphragm into the adherent lung, 
 and communicated with the bronchi. The forepart of the lumbar vertebra? 
 were exposed, and in some instances stripped of their theca ; but there 
 were no cavities in the bone, and no disease of the interposed cartilages. 
 Cases are now and then met with, of abscess in the loins, not originating 
 in any vice, either of the bones or of any other part of the apparatus of the 
 spinal column. Most frequently, however, the collections have their foun- 
 dation in disease of the bodies of the vertebra?. 
 
 The causes of this complaint are generally obscure. It is most prevalent 
 among the lower classes who are scantily clothed and fed, and exposed to 
 vicissitudes of weather, extreme fatigue and other hardships. Individuals 
 affected with scrofula are most obnoxious to the disease, and it is said to be 
 more prevalent in Europe than on this continent. Dr. Gibson* thus wrote : 
 " I have seen only four cases of the disease during the last thirteen years, 
 although professionally connected with extensive hospitals and almshouses 
 during a greater part of the time." 
 
 Dr. Physick also stated, he had never met with a case of psoas abscess in 
 America, unconnected with disease of the spine. 
 
 Treatment. — In the treatment of lumbar abscess, the prognosis is always 
 unfavorable ; the radical cure of the affection can scarcely be effected, even 
 when the patient applies for relief at the earlier stages of the disease, which 
 in far the great majority of instances is not the case, because the pain in the 
 loins, and other premonitory symptoms, are attributed to other causes. 
 
 The following medicines, although they may not effect a cure, will greatly 
 alleviate the sufferings of the patient ; indeed, there have been cases in 
 which, by the careful administration of medicine, the abscess has been par- 
 tially healed, and there are some who maintain that if the diagnosis is 
 formed correctly, at an early period of the affection, a cure may be reason- 
 ably anticipated. 
 
 The medicines chiefly to be used are, ars., asaf., aur., calc. c, hepar, lye, 
 mere, mez., phosph. ac, silic, sulph. 
 
 If there are unhealthy granulations and a disposition of the abscess to spread, 
 silicea may prove beneficial. The treatment, in many cases, may be com- 
 
 * Institutes and Practice of Surgery, vol. i., p. 214. 
 
EXCISIONS OF BONES AND JOINTS. 693 
 
 menced with the administration of sulph., which will prove serviceable as 
 an antipsoric. 
 
 There is some difficulty in diagnosing a lumbar abscess, as it often points 
 very readily at that region where an inguinal hernia would protrude ; how- 
 ever, by carefully examining the patient, and inquiring particularly into the 
 history of the case, the error of mistaking the one disease for the other may be 
 avoided. In opening a lumbar abscess the aspirator should always be used. 
 As the disease is chronic, and the matter has been secreting for some time, it 
 must not be forgotten that the evacuation of a large quantity of pus at once 
 might be productive of serious consequences. 
 
 CHAPTER XXXV. 
 
 EXCISIONS OF BONES AND JOINTS. 
 
 General Kemarks — Instruments — Eesection of Bones in their Continuity — 
 Excision of the Bones of the Hand — Of the Wrist — Of the Forearm — Of 
 the Elbow— Of the Humerus— Of the Shoulder — Of the Scapula — Of the 
 Clavicle — Of the Kibs— Of the Calcis — Of the Toe — Of the Knee — Of the 
 Leg — Of the Hip. 
 
 General Remarks. — Conservative surgery is one of the most interesting 
 fields of science. The vis medicatrix naturse, when not interfered with, is an 
 extraordinary power. Nature restores what man would ofttimes destroy ; 
 and converts into living structure parts of the body which man would reject 
 as worthless. 
 
 Excision of articular surfaces and of bones in their continuity forms an 
 important part of conservative surgery, and the results which are daily 
 obtained by these operations continue to verify their importance. Like all 
 other improvements in science a long period elapsed before resections 
 came into general favor, and though here and there an operation was 
 successfully performed, surgeons, until recently, did not consider conserva- 
 tive operations among the legitimate and systematized proceedings of the art. 
 
 It was proved by Boucher, in 1753, that wounds of considerable severity 
 entering into a joint might be treated by simply removing the fragments of 
 bone. In 1740, Thomas resected the head of the humerus in a child four 
 years old, particulars of which may be found in Guthrie's work on Gunshot 
 Wounds. White made an incision at the upper part of the humerus, 
 dislocated and removed its upper end, which was carious ; the patient 
 lost about two ounces of blood during the operation, and in five weeks 
 the boy had so far recovered as to be able to lift a heavy weight. After two 
 months quite a piece of the remaining bone separated and was removed, 
 after which the wound healed, the patient being perfectly cured in four 
 months. The arm was shortened about one inch. It is worthy of remark 
 that neither splints, bandages, nor the like were used. Gooch reports 
 that he sawed off the heads of the tibia, the fibula, and the radius, 
 and also the second bone of the thumb. A somewhat similar operation is 
 reported to have been performed on a girl at the hip-joint. Syme made a 
 flap in the shape of a V, and then brought out the head of the humerus 
 and removed it. Walther was the first to demonstrate upon the dead subject 
 the practicability of removing the scapula ; and in a case where a tumor 
 had become attached to this bone, it was excised with success by Haymann. 
 Park, wishing to know if he could remove the knee without cutting into the 
 
694 A SYSTEM OF SURGERY. 
 
 popliteal vessels, made various experiments on the cadaver. An incision 
 was made from about two inches above the patella to the same distance 
 below, another across this, just above the patella, extending nearly half 
 around the limb. The two lower angles were dissected up and the 
 knee-cap removed, after which the upper angles were raised, so as to lay bare 
 the condyles of the femur and to allow a small catling to be passed back of 
 the bone, in their rear. The condyles were then sawn off. The head 
 of the tibia was removed, as was also a considerable part of the capsular 
 ligament. On examination it was found that the vessels had incurred little 
 danger during the operation. Excision was next performed at the elbow. 
 An incision was made from about two inches above to the same distance 
 below the olecranon. It was at first attempted to divide the lateral liga- 
 ments, but as it proved very difficult, the olecranon was removed ; the joint 
 was now dislocated with ease, and the lower end of the humerus sawn off, 
 together with the heads of the ulna and radius. This, however, is more 
 difficult when the parts are diseased. Park first performed this operation 
 on a living subject in 1781. It gave him great trouble in the after- 
 treatment, abscesses and sinuses forming, obliging the patient to keep his 
 bed nine or ten weeks, the cure being completed some months after. The 
 patient, in time, went to sea, and was able to do his duty well. The same 
 surgeon soon after performed this operation again, but the patient did not 
 live four months. 
 
 Moreau, Jr., thought that two flaps were needed in excision of the elbow, 
 and that it was unnecessary to remove the olecranon unless it were diseased. 
 
 In our own country great impetus has been given to resection, by the 
 successful removal of almost every bone in the body. The clavicle and 
 scapula, the maxillary bones, the hip, knee, wrist, and ankle-joints, all have 
 been excised by American surgeons, the importance and success of the oper- 
 ations being unsurpassed. The names of the distinguished men who have 
 achieved triumphs in this field are too numerous to mention, but they have 
 won laurels which will never fade, and their names everywhere are honored 
 and respected. 
 
 Dr. Deadrick, of Tennessee, in 1810, removed half of the inferior max- 
 illary, and Charles McCreary, of Kentucky, 1813, exsected the entire clavicle. 
 Dr. Mott, in 1828, performed the same difficult operation, and Dr. Franklin, 
 in 1862, removed the sternal two-thirds of the bone. McClellan, Stevens, 
 Carnochan, Wood, and Rogers, also made resections of the upper and 
 lower jaws. Butt, of Virginia, resected the radius in 1825 ; while Pancoast, 
 Gross, Mutter, Blackman, Ackley, Stone, Hamilton, Buck, and others, are 
 all equally entitled to elevated positions in this field of surgery. 
 
 The conditions which call for resection of bones and joints are caries and 
 necrosis, extensive injuries and malignant disease, and the operations are 
 to be resorted to when all other means have failed. Then the question 
 arises between amputation and resection. In every case where there is a 
 probability of saving the patient a limb, though it be stiff, resection should 
 have the preference. 
 
 Fig. 399. 
 
 The instruments for excision of bones are varied, and consist, first, of the 
 ordinary knives for making flesh-wounds ; metallic retractors to hold the 
 
INSTRUMENTS FOR EXCISION OF BONES. 
 
 695 
 
 soft parts away from the osseous, and strong bone forceps, used either to 
 hold and lift away bone, or to divide the osseous structures. 
 
 Fig. 399 shows a modification of Fergusson's Lion-jawed Forceps. 
 
 Fig. 400. 
 
 Fig. 401. 
 
 G.TIEMANN &C0. 
 
 Bone-cutters are of different shapes. 
 Fig. 400 shows Satterlee's Bone For- 
 ceps; Fig. 401, Liston's Bone Forceps, 
 knee-curve; Fig. 402, Liston's Forceps, 
 curved on the flat. 
 
 These forceps are of various sizes, some large, and with long handles, to 
 give powerful leverage when great force is required. 
 
 Fig. 403. 
 
 w-ca 
 
 Blunt instruments are also used to denude the bone of muscles and peri- 
 osteum. Fig. 403 represents Sands 's interosseous knife, and Fig. 404 the 
 instrument of Dr. Sayre for the removal of the periosteum. 
 
 Fig. 404. 
 
 e.TlEMANN-CO.N.t: 
 
 Sayre' s Periosteotome. 
 
 The saws used are of various shapes and sizes. Fig. 405 is curved and 
 made expressly for the maxilla. 
 
 Fig. 405. 
 
 Maxilla Saw. 
 
 Fig. 406, a narrow, fine-toothed saw, introduced by Dr. Lente, is very use- 
 ful when working in a limited space. 
 
 Fig. 406. 
 
 Lente's Interosseous Saw. 
 
 Besides these, there are other saws bearing the names of the surgeons who 
 devised them. 
 
696 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 407, chain-saw with the rotating handles of Tiemann. 
 
 Fig. 408 shows an instrument devised for carrying the chain-saw. 
 
 Dr. John A. Wyeth* speaks very highly of an instrument for resection, 
 invented by Mr. Gowan, of Guy's Hospital, and which is manufactured in 
 New York, by Tiemann & Co. Dr. Wyeth has employed the instrument 
 
 Fig. 407. 
 
 Fig. 408. 
 
 Instrument for carrying 
 Chain-saw. 
 
 for exsection of the shoulder, elbow, and hip, the radius, the metatarsus and 
 portions of the scapula. The instrument is represented in the cut as made 
 after the model of Mr. Gowan, and is thus described (Fig. 409) : 
 
 " It consists of a handle about a foot long, made of metal and covered partly 
 by vulcanized rubber. This handle is hollowed out for the passage of the 
 steel bar 6, which runs the entire length of the apparatus to act on the jaw 
 of the forceps. On a portion of its inferior edge, at about its middle, cogs 
 are cut in which the teeth of the lever a catch, and the degree of pressure 
 of the jaws c on the bone to be held is regulated by the pressure of the fin- 
 gers of the operator upon the lever a. The saw e is in shape like a chisel, 
 and works into a shield at d. Method of using : The bone to be exsected 
 having been exposed, with its periosteum peeled off in common with all the 
 circumjacent tissues, the operator, holding the handle of the instrument in 
 his left hand (the saw being entirely removed), depresses the lever a, draws 
 back the bar b, and opens the jaws c wide enough to insinuate them about 
 the bone. As soon as this is accomplished the bar b is pushed forward 
 against the heel of the jaw and the lever a is pressed toward the handle. 
 
 * Medical Eecord, March 29th, 1884. 
 
INSTRUMENTS FOR EXCISION OF BONES. 
 
 697 
 
 With the right hand slide the saw into the shield d down until the teeth 
 engage against the bone. A slight oscillation of the handle of the saw car- 
 ries it through the bone with remarkable rapidity, and without wounding 
 or bruising the contiguous soft tissues. The shield d not only rotates, but 
 
 Fig. 409. 
 
 is reversible, and can be changed from one side to the other. In the modi- 
 fied instrument I have had constructed a narrower saw and shield, so that 
 it may be used in exsections of small bones closely related to each other, as 
 the metacarpal bones. 
 
 " The modified exsector is seen in Fig. 410, and is cheaper as to cost and 
 simpler as to mechanism than the preceding. The handles work with a 
 
 V-,-' 
 
 
 Fig. 410. 
 
 double-jointed motion, and have a fixation clamp,/, like the Russian needle- 
 holder. By opening or closing the handle, the jaws, g, are separated or 
 closed. The action of the rotating shield, h, and the saw, I, are the same." 
 
698 
 
 A SYSTEM OF SUEGERY. 
 
 Professor Hamilton has invented a bone-cutter with strong serrated jaws 
 for dividing bone (Fig. 411), and also a pair of bone-forceps (Fig. 412), 
 which are well adapted to the uses for which they are employed. 
 
 Fig. 411. 
 
 Hamilton's Serrated Bone-cutter. 
 Fig. 412. 
 
 Hamilton's Bone Forceps (half-size). 
 
 Resection of Bones in their Continuity. — Many bones of the body, from in- 
 jury or from disease, can be resected in their continuity, and thus the sur- 
 rounding parts be preserved sufficiently to prevent much deformity. When, 
 in such cases, the periosteum can be protected, which should always be the 
 endeavor of the surgeon, the bone may be almost entirely reproduced. 
 There are no operations which have shown more success than those intro- 
 duced by modern conservative surgery, and none which ought to be more 
 acceptable to the public. In olden times where the loss of an entire limb, 
 or a terrible operation about the mouth, was considered absolutely necessary 
 for the preservation of life, it is now certain that diseased portions of bone 
 may be sawed out or cut away, and the ossific structures reproduced. Since 
 the introduction of Esmarch's bandage these operations are much more sat- 
 isfactorily performed, and successful cases of the entire reproduction of bone 
 have been noted in all countries. 
 
 Sometimes bones or portions of bone may be removed by subcutaneous 
 incisions, and when such can be accomplished it saves the unsightliness of 
 a scar. 
 
 Excision of the Bones of the Hand. — Case. — A man presented himself at the 
 clinic with the following history : Many years ago while using an axe he 
 severely bruised the palm of his hand. Intense inflammation followed, 
 with severe pain ; suppuration ensued, and the pus was allowed to find 
 an exit, which it did after a considerable time, on the dorsum of the 
 hand. No professional advice was sought for many months. A probe 
 revealed the roughened surfaces of the middle and ring metacarpals. He 
 was placed under anaesthetic influence ; the arm and hand pronated on the 
 table, and an incision made on the dorsum of the hand, of V-shape ; the 
 apex at the wrist and the ends of the diverging cuts terminating at the 
 
EXCISION OF THE WRIST. 699 
 
 knuckle of each of the diseased bones. This incision was merely car- 
 ried through the integument and fascia, which were dissected up. The 
 muscles and tendons were separated with a blunt periosteotome, and held 
 aside with retractors. Each bone was divided with the pliers, held at right 
 angles with the shaft. The cutting pliers were then reliquished for a pair of 
 lion-jawed forceps, with which each extremity of the bones was raised sepa- 
 rately and dissected away. The flap was brought down, there was no haemor- 
 rhage ; the lips of the wound were united with silver sutures. A compress wet 
 with calendula and water was the only dressing, and the cure was complete. 
 
 If only a single metacarpal bone is to be exsected, a longitudinal incision 
 on the dorsum of the hand over the course of the bone is all that is required. 
 If the metacarpal bone of the thumb is to be removed, the thumb must also 
 be taken with it, as has been mentioned in amputation of that portion of the 
 hand. It is inexpedient to resort to resection of the phalanges. 
 
 Excision of the Wrist. — The diseases which frequently call for removal of 
 the radio-carpal articulation, the carpus and metacarpal joints (which are 
 comprised in excision of the wrist), are synovitis and caries, the latter espe- 
 cially, as well as gunshot and other injuries. The operation may be partial, 
 in which portions of the diseased bones are removed, and complete, when the 
 entire joint and bones entering therein have to be excised. 
 
 Moreau, the younger, is said to have performed the operation of excision 
 of the wrist, and other European surgeons have occasionally resorted to 
 it. In England its revival is due to Mr. Fergusson, who, on August 16th, 
 1851, performed it. On October 9th, 1852, Mr. Simon operated on a lad 
 aged nineteen years. On May 21st, 1853, the same surgeon had recourse to 
 the procedure. In October of the same year, Mr. Erichsen removed the 
 wrist-joint. Mr. Butcher and Mr. Liston have also given great attention to 
 the subject. 
 
 The operation may be performed in several ways ; an excellent method 
 being the following : Two longitudinal incisions are made, one on the radial 
 and the other on the ulnar side of the wrist on its dorsal surface ; these are 
 united by a transverse cut, avoiding the extensor tendons of the fingers and 
 thumb. The supinator tendons and the extensor tendons of the carpus are 
 then divided. The joint must next be flexed forcibly, and cautiously 
 opened. The operator carefully selects the uncut tendons, and having 
 drawn them to one side, places them in charge of an assistant, who protects 
 them from injury. The surgeon, then, with a saw, cutting pliers, or the 
 chain-saw, successively divides the articular ends of the radius, the carpal, 
 and bases of the metacarpal bones. . 
 
 Mr. Fergusson believed a single ulnar incision sufficient, but it appears to 
 me that this method is better suited to partial excision. 
 
 A curvilinear incision answers a good purpose. The knife should be 
 entered at the styloid process of the radius, and be carried downward 
 across the back of the joint, and -around up to the styloid process of the 
 ulna. The extensor tendons of the thumb and fingers on the ulnar side 
 must be avoided, the supinator tendons and extensor carpi divided, and the 
 joint entered as before. 
 
 Lister's method is excellent, and is as follows : The radial incision is 
 made on the dorsal aspect of that bone to avoid the tendons of the extensor 
 ossis metacarpi pollicis, and the extensor secundi internodii. The bones 
 are removed as before. When the bones have been separated, the wound 
 must be thoroughly cleansed with a stream of warm water, and sprayed 
 over with carbolic acid water, the first centesimal dilution (1 to 100). The 
 hand should be laid upon a carved splint, similar to Bond's, with a pro- 
 tuberance at the end over which the fingers may be bent. The thumb 
 should be moved daily, and soon pronation and supination be resorted 
 
700 A SYSTEM OF SURGERY. 
 
 to. Gentle passive motion of the fingers is made in a few days after the 
 operation. The parts must be kept moist with calendula solution. 
 
 Excision of the Bones of the Forearm. — Portions of the radius and the ulna 
 have been removed by different surgeons, leaving, in some instances, little 
 deformity. When the radius is to be exsected, the incision should be made 
 on the posterior and outer aspect of the bone, the structures carefully sepa- 
 rated, and the bone divided in its middle. This greatly facilitates the oper- 
 ation. By seizing one of the divided ends with the lion forceps, it can be 
 raised and taken away, the knife always being kept close to the bone. The 
 ulna is removed in like manner, excepting the incision is made on the inside 
 of the arm. The brachial artery may be compressed, but neither the radial 
 nor the ulnar will be touched in the majority of cases if a moderate amount 
 of care be used in the dissection. 
 
 In removal of the olecranon, a V-shaped incision is made, the flap dissected 
 up and the saw applied. 
 
 Excision of the Elbow. — Excision of the elbow-joint is a standard operation 
 of conservative surgery, and the success which has attended its performance, 
 together with the usefulness of the limb which often remains after the 
 operation, are sufficient inducements for the judicious surgeon to attempt 
 the proceeding. 
 
 Before describing the operation, let us look into the anatomy of the 
 parts concerned. Three bones enter into the formation of the elbow ; 
 and the joint is a compound one, a ginglymoid and a diarthrodial. On the 
 anterior face of the humerus are two muscles, which connect the forearm 
 with the arm. One of these, the biceps, is inserted into the tuberosity of 
 the radius ; the other, the brachialis anticus, is fixed to the lower portion 
 of the coronoid process of the ulna. If we draw a line from the outer side 
 of the axillary space between the folds of the axilla to a point or depression 
 midway between the condyles of the humerus (which depression marks 
 the boundary between the inner border of the coraco-brachialis and biceps), 
 we have the direct course of the brachial artery, which is comparatively 
 superficial in front of the joint, before its bifurcation. These structures, 
 being in front, are, in a measure, out of harm's way. But there is a point 
 in the surgical anatomy of this joint, to which I desire to particularly call 
 attention. It is the course of the ulnar nerve, which comes from the inner 
 cord of the brachial plexus, and lies on the inner side of the artery. From 
 this course it diverges, pierces the inter-muscular septum, and winding 
 around, passes into the groove between the internal condyle of the humerus 
 and the olecranon process of the ulna. It is necessary to preserve this nerve 
 from injury during the operation. 
 
 There are a variety of methods recommended for resecting the elbow- 
 joint; but the truth is, as in all surgical operations, the size of the flaps and 
 their number, and the direction of the incisions, are to be influenced by the 
 circumstances attendant upon each particular case. Perhaps the single 
 straight incision is, as Druitt says, the best theoretically. Moreau preferred 
 the H incision, as does also Professor Hamilton ; although the position 
 of the patient (on his belly), as recommended by the former surgeon, I 
 conceive to be inadmissible on account of the danger from the full and 
 prolonged anaesthesia. Manne made two semi-lunar incisions, and Roux 
 recommended the cut to be made in the shape of the letter T. 
 
 Resection by the single long incision, as recommended by distinguished 
 surgeons, appears to have been performed in London about the same 
 time by Mr. Paget, Mr. Fergusson, and Mr. Erichsen; and considerable 
 time and thought were expended on the merits of the operation before 
 its introduction. The H incision was made first ; then it was discovered 
 that the long cut on the radial side of .the arm could be omitted ; thus 
 
EXCISION OF THE ELBOW. 
 
 701 
 
 the incision was converted into the T-shaped. It is said that Langenbeck 
 showed that the cross-cut could also be omitted, thus leaving the single 
 linear incision. I have practiced the H incision, although an excellent 
 method is the V-shaped cut, the apex of which should terminate above 
 the olecranon (Fig. 413). The flap must be dissected down, the triceps 
 detached, and the parts having been held aside, the saw may be applied 
 in such manner as to divide the olecranon at its base, and the radius at 
 its neck (Fig. 414). The condyles of the humerus are exposed, the ulnar 
 nerve sought after and put aside from the condyle, and the soft parts 
 being well protected, the diseased portions removed with the saw. 
 
 In the following operation the reverse of the preceding was practiced : 
 
 J. T., aged 42, suffered from caries and necrosis of the elbow-joint, of 
 
 many years' duration. The patient was placed on the table so that his arm 
 
 projected over the edge, his shoulders were elevated, and the anaesthetic 
 
 administered. I began by making a straight incision, commencing four 
 
 Fig. 413. 
 
 Fig. 414. 
 
 inches above the joint, and prolonging the same four inches below, carrying 
 the scalpel directly through the tissues down to the bone, opening in its 
 course the fistulous orifice. Keeping the edge of the knife close to the bone, I 
 separated the tissues, and introducing the index finger of my left hand into 
 the lower extremity of the joint, found the head of the radius, loosened the 
 same from its connection, and pushed it through the wound. The retractor 
 was placed under the head of the bone, which was removed by means 
 of the saw. Next I proceeded to excise the condyles of the humerus. It 
 was found necessary to prolong the incision upward, on account of the dis- 
 ease extending far up the shaft of the arm-bone. The tissues were very 
 much diseased and infiltrated with pus, and a transverse incision was made 
 across the joint, about two inches in length, at right angles with the first. 
 After the muscles had been separated, I inserted my finger into the angle of 
 the wound, and distinctly felt the ulnar nerve lying in its groove ; this I 
 pushed over the process, and the lower extremity of the humerus, being 
 disengaged, was sawn oft. The third step was the removal of the ole- 
 cranon, which I took off with the chain-saw ; and after having drawn 
 the wound together with interrupted sutures placed the arm on a pillow, 
 dressed it with calendula lotion, and fixed it in a splint bent at an obtuse 
 angle. 
 After the joint has been resected, it should be flexed at an obtuse angle, 
 
702 A SYSTEM OF SURGERY. 
 
 and an anterior splint of rubber, tin, or felt applied, which may be strapped 
 above and below the joint, thereby giving free access to the wound, and 
 allowing the escape of effete discharges. The cut surfaces are to be treated 
 on general principles. 
 
 It may, in some instances, be a matter of consideration, whether excis- 
 ion of the joint or amputation should be resorted to. If disease has 
 affected the lower portion of the condyles of the humerus, leaving some 
 healthy bone above for the attachment of the flexors and pronators, the 
 extensors and supinators, exsection of the diseased mass should certainly 
 be practiced. 
 
 If the whole of the olecranon be involved, together with the sigmoid 
 notches, and even a part of the coronoid process, leaving, however, a healthy 
 point for the insertion of the anterior brachial muscle, the limb may be 
 saved. If, together with this, the head and neck of the radius be implicated, 
 leaving the tubercle for the attachment of the biceps, exsection is the remedy. 
 But if, on the contrary, both condyles of the humerus and the ridges lead- 
 
 FlG.415. 
 
 Carious Olecranon and Head of Radius, from Author's collection. 
 
 ing to them, together with the shaft of the bone itself, the coronoid process 
 of the ulna, and the tubercle of the radius and body of the bones be in a 
 state of disorganization, nothing but amputation can be performed with a 
 reasonable hope of success. 
 
 According to statistics of Erichsen, of the University College Hospital, 
 the results, after exsections of the elbow, are far more favorable than those 
 after amputation. 
 
 The Surgeon-General's Circular, No. 6, shows that of 315 cases of ex- 
 cision of the elbow, practiced for gunshot injuries, in 16 amputation was 
 necessary, and 62 cases terminated fatally, making an average mortality of 
 21.67 per cent., which is somewhat greater than that resulting from am- 
 putation. 
 
 Fig. 415, drawn from one of my cases, three days after operation, shows 
 the carious olecranon, B, with head of radius, C, united thereto by bony 
 deposits. This was quite a troublesome case, on account of extensive infil- 
 tration of the soft parts. 
 
 Dr. H. J. Bigelow, to avoid cutting the fascia and muscles which unite 
 the arm to the forearm, excises the elbow-joint by the longitudinal incision, 
 
EXCISION OF THE SHOULDER-JOINT. 
 
 703 
 
 Fig. 416. 
 
 first removing the head of the ulna, then the articulating surface of the hu- 
 merus, leaving the condyles, if not diseased, by sawing immediately below 
 them from each side upwards and inwards, and last of all removing the 
 head of the radius. 
 
 Excision of the Humerus in its Continuity. — In some instances from caries 
 or gunshot injury it may be necessary to remove a portion of the shaft of 
 the humerus. Before performing the operation it is well to bear in mind 
 that there is scarcely any likelihood of bony union taking place, and that 
 even if a small portion of the bone is removed non-union will probably re- 
 sult, although there are cases upon record in which such fortunate results 
 have taken place. One has come under 
 my observation in which at least three 
 inches of the shaft of the humerus was 
 excised. There was no attempt made to 
 bring the ends of the bone together. The 
 arm was laid upon a pillow, and the wound 
 allowed to heal. By means of a shoulder 
 brace, with two small steel rods passing to 
 a band which was secured just above the 
 elbow, as seen in Fig. 416, the patient had 
 considerable motion of the arm and per- 
 fect use of the forearm and hand. There 
 was scarcely a noticeable deformity. 
 Therefore when there is disease of the 
 shaft of the bone to that degree that am- 
 putation would otherwise have to be 
 resorted to, the removal of the shaft 
 and the application of the proper instru- 
 ment would be the preferable procedure, 
 giving moderate motion at the shoulder and the use of the elbow and 
 hand. 
 
 The incision, a straight one, as many inches in length as may be desired, 
 should be made on the outside of the arm down to the bone, and the tis- 
 sues removed by careful dissection with blunt instruments and occasional 
 touches with the edge of the scalpel ; beneath the bone a chain-saw should 
 be applied, or the instrument of Butcher, and the bone removed. The 
 wound is then to be syringed with carbolic acid solution, and if but a small 
 portion has been cut away, the ends of the bone brought together and se- 
 cured by wire sutures. If several inches are to be removed, the arm should 
 be placed on a leather or gutta-percha splint, and no attempt at union of 
 bone made. 
 
 Excision of the Shoulder-joint. — This excision is practiced for either dis- 
 ease or accident, and the results of the operation are encouraging. Caries 
 and necrosis of the head of the humerus, generally commencing in a 
 synovitis, or from a wound, and anchylosis of the joint, are the frequent 
 causes that require the operation. Of the 50 cases of excision of the joint 
 collected by Hodges, 8 died, but in seven of the eight cases the articular 
 surface of the glenoid cavity had been implicated. Of 30 cases published 
 by Mr. Thomas Gant, the mortality amounted to 1 in 4. In 575 excisions 
 of the shoulder-joint for gunshot injuries, practiced during the late civil 
 war, in which there were 252 primary and 323 secondary excisions, 165 died, 
 343 recovered, and 67 cases remained with undetermined results ; the per- 
 centage of mortality being 23.8 in the primary, 38.59 in the secondary, or 
 a mean of 32.48. When these figures are compared with those of amputa- 
 tion of the shoulder-joint, the average mortality of which is 39.24, we find 
 a percentage of 6.76 in favor of excision. 
 
704 
 
 A SYSTEM OF SUKGERY. 
 
 Fig. 417. 
 
 According to Esmarch the resection of the right shoulder gives the best 
 returns, although such statement has not been verified .* 
 Thomas, an English surgeon, in 1740, performed this resection, although 
 
 White, of Manchester, in 1768, is generally 
 supposed to have priority in the operation. 
 Vigaroux, of Montpelier, in 1767 ; and Redo- 
 wald, in 1770, also performed excision of the 
 head of the humerus. 
 
 In 1786 the elder Moreau excised completely 
 the joint, including a portion of the acromion 
 and neck of the scapula. After this period the 
 operation fell into disrepute, but was rescued 
 from oblivion, and advocated in 1826 by Mr. 
 Syme. 
 
 The following is the manner of operation, 
 if only the head of the humerus is to be re- 
 moved. A single straight incision from the 
 point of the shoulder near the acromion (see 
 Fig. 417), four and a half inches in length, 
 should be made and carried down to the bone. 
 The tissues must be dissected up and held 
 aside with metallic retractors. If it be possible 
 during this dissection, the long head of the 
 biceps must be saved, and drawn aside ; in some instances necessity 
 may require its division. 
 
 The insertion of the rotator muscles must be carefully divided. The 
 capsule of the joint is next entered, and disarticulation effected by the 
 entire separation of all the tissues. The arm must be pushed upward, and 
 the elbow carried across the chest to expose the head of the bone, which is 
 removed, either with a chain-saw or the ordinary instrument. 
 
 In other cases the U-incision is preferred, especially when portions of the 
 clavicle or scapula are implicated. In such a strong scalpel must be 
 entered near the posterior border of the acromion, penetrating to the bone, 
 and carried downward across the insertion of the deltoid, and upward toward 
 the inner border of the coracoid process of the scapula. The flap is 
 raised, the capsular ligament divided (provided it has escaped the ravages 
 of disease), the humerus rotated and adducted, to carry the head of the 
 bone from the glenoid cavity, and while assistants protect the soft parts 
 with retractors, the bone is sawn off. Pieces of carious bone should 
 be gouged or scraped away, and the flaps approximated with silver sutures. 
 I have found that when the entire joint has been involved, the following 
 incisions exposed it : Commence about two inches from the point of the 
 shoulder and carry an incision along the border of the clavicle outward to 
 the joint. This cut is joined by another of the same length along the upper 
 border of the acromion process. This makes a V incision, the apex of which 
 is the point of the shoulder ; here commence a longitudinal incision and 
 carry the same down the arm to the insertion of the deltoid. This exposes 
 the joint thoroughly and allows room for manipulation with pliers and 
 saw. In a case lately operated upon, where most extensive disease existed, 
 I practiced this method with excellent results. 
 Dr. W. D. Foster,f of Hannibal, Mo., successfully removed the head of 
 
 * Medical Eecord, December 2d, 1872, p. 54, quotation from G. E. Ulrich, " De Ossium 
 Resectione." 
 
 f Western Homoeopathic Observer, 1867, vol. iv., p. 13. 
 
EXCISION OF THE CLAVICLE. 705 
 
 the right humerus in 1865. The case gave rise to considerable discus- 
 sion. 
 
 Dr. L. H. Willard,* of Allegheny City, reports a successful excision of the 
 humerus ; also one of the tibia, in a boy. 
 
 My colleague, Dr. Liebold, while surgeon in the army, performed several 
 successful resections. 
 
 Excision of the Scapula. — The shoulder-blade has been removed a number 
 of times for necrosis and for tumors of malignant character, the former 
 operation being generally the easiest and safest ; the latter in most instances 
 being protracted and bloody. I notice that Mr. Symef is given the credit 
 of having first successfully performed the operation for the removal of 
 the scapula and its processes in 1856; other operators allowing the neck 
 to remain. Walther, of Bonn, ten years previously, performed the opera- 
 tion with good result. In 1837, Dr. Mussey, of Cincinnati, removed the 
 scapula and a great portion of the clavicle with wonderful result, 
 the wound healing almost entirely by first intention, and the man en- 
 joying good health when heard from thirty-four years after the opera- 
 tion. In 1838, Dr. George McClellan also removed the bone, and Gilbert 
 and Gross report successful cases. Dr. A. Hammer, of St. Louis, has 
 exsected the scapula and part of the clavicle with success; the patient 
 was a female, and when I saw her had considerable motion of the 
 arm. 
 
 M. Pean extirpated the scapula of a man aged nineteen, at the Hospital 
 St. Louis, Paris, April 14th, 1877, the operation being followed by a rapid 
 recovery. X 
 
 It is* impossible to give explicit directions for the removal of this 
 bone, as the size of the tumor or the direction of the sinuses will often 
 indicate the line and length of the incisions. 
 
 The patient having been etherized, the subclavian artery must be com- 
 pressed by an assistant, to restrain haemorrhage from the subscapular 
 and its branches. The integument must then be dissected entirely 
 away from the tumor and turned back. The growth must be pulled 
 away from the body, and the muscles on the vertebral border of the bone 
 severed rapidly from the inferior angle upward. As the arteries are divided 
 they must be secured. The division of the clavicle should be deferred to 
 the last, as the weight of the tumor and arm draw away the bone from im- 
 portant structures underneath. If the bone is to be removed for necrosis, 
 the lines of incision must be made according to the sinuses, or the diseased 
 portions of the bone. 
 
 Excision of the Clavicle. — The collar-bone has to be removed for caries, 
 necrosis, tumors, and gunshot wounds. The operation is one of difficulty 
 and delicacy, on account of the underlying important structures, and must 
 be performed with deliberation and care. There must be no hurry and 
 no "flurry." According to Gross, Mr. Davie, of Bungay, "many years 
 ago excised the inner extremity of the clavicle, in a case of dislocation back- 
 ward from deformity of the spine ; the luxated head causing such a degree 
 of pressure upon the oesophagus as to endanger life from suffocation." In 
 1813, Dr. Charles McCreary ; in 1828, Dr. Mott ; in 1849, Dr. Gross ; in 1852, 
 Dr. Wedderburne ; in 1856, Dr. Blackman and Dr. Curtis ; and in 1862, Dr. 
 Franklin removed either a great portion, or the entire clavicle. When the 
 bone is to be removed for caries or necrosis, a single longitudinal incision 
 is made over the entire part to be removed. The knife must be kept close 
 
 * Loc. cit., vol. vi., p. 92. 
 f Holmes's System of Surgery, vol. v., p. 670. 
 
 J Monthly Abstract of Medical Science, September, 1877 ; Lancet, July 28th, 1877. 
 
 45 
 
706 A SYSTEM OF SURGERY. 
 
 to the bone, and the handle used as much as possible ; the chain-saw be 
 applied cautiously, and the bone carefully removed. When there exists a 
 large tumor, the risk is still greater, and still more caution must be employed. 
 The lines of incision should be left to the judgment of the surgeon, and the 
 handle of the knife be more in requisition than its point or its edge. The 
 arteries must be tied as they are divided. Time is no object in these try- 
 ing and difficult operations. Dr. Mott was four hours in his excision of 
 this bone, and applied over forty ligatures. 
 
 Excision of the Ribs. — As a general rule there is not much difficulty in the 
 removal of portions of the rib. In the cases that have fallen under my 
 observation, two of which were from gunshot wounds received during the 
 war, the chief trouble was the thickness of adipose tissue ; I have learned 
 from this, that in such cases the incision should be very long, and should 
 extend considerably beyond the diseased bone. The parts are freed, and 
 the chain-saw or that of Hey applied. In the dissection the knife must 
 be kept close to the bone. The saw is applied from the top of the rib down- 
 ward. 
 
 Excision of the 0s Calcis. — There is a special tendency for the calcaneum to 
 become inflamed independently of other bones of the tarsus. Being larger 
 than any other tarsal bone, it has the greater share in bearing the weight of 
 the body ; so that, in pressure during standing and locomotion, its vertical 
 growth may be arrested, and the anterior calcanean process becomes by 
 degrees depressed. Disease of the os calcis usually remains restricted to 
 this bone and does not spread to other osseous parts of the foot, while a 
 remarkable immunity in scrofulous disease of the tarsus is seen. Out of 
 52 cases of caries of the tarsal bones reported by Czerny the calcaneum was 
 affected in 13. The reader is referred to the chapter on Caries for treatment 
 other than surgical. I would say, however, that complete excision offers 
 better chances of success than any other resource if the disease be well 
 advanced. 
 
 The removal of the os calcis, either in part or entire, was formerly regarded 
 as impracticable, for two reasons : First, because it was a well-known fact 
 that this bone sustains about half the weight of the entire body; and 
 second, because it was formerly held that division of the tendo Achillis 
 deprived the limb of a great amount of mobility. Some surgeons (among 
 whom was Moreau) even taught that if the tendo Achillis be destroyed, 
 amputation was the only feasible resort. Pare regarded a fracture of this 
 bone as a fatal injury. These opinions, however, have proved erroneous; 
 and both the division of the tendon and the removal of the bone can be 
 effected with slight resulting deformity. 
 
 In an interesting paper, " On the entire Excision of the Os Calcis," 
 by F. A. Burrall, M.D., of New York, a tabulated statement of forty-eight 
 cases is given. An analysis of this table is interesting as regards the 
 history of the cases requiring operation. We find that young persons 
 of the male sex were the subjects on whom it was most frequently 
 performed, the ages being from ten to twenty years. There were five 
 between the ages of forty and fifty-four. Of the forty-six cases in which 
 the sex is recorded, thirty-eight were males and but eight females. The 
 diseases which called for the operation were in forty-three cases caries and 
 necrosis, the others being accidents, — pressure, friction, etc. 
 
 Only one death occurred, and that was but indirectly attributable to the 
 operation. One was afterward lost from diphtheria, one from pyaemia, and 
 two from phthisis ; of the latter it may be said that the disease reappeared 
 in one case in eighteen months, and in the other four years after the opera- 
 tion. Seven secondary amputations were necessary. 
 
 The lessons w T e learn from these cases are : that complete excision of the 
 
EXCISION OF THE OS CALCIS. 707 
 
 os calcaneum can be practiced with success, leaving a good foot; that caries 
 and necrosis furnish by far the greater part of the cases for the operation ; 
 that the young are more liable to the diseases requiring either resection or 
 excision ; and that the male sex is more prone to them than the female. 
 
 Besides the forty-eight cases to which we have alluded, there is an ac- 
 count of three cases of " Excision of the Os Calcis," by Dr. Hunter McGuire, 
 of Richmond, Va.* In his report, the ages were twenty-one, seventeen, 
 and twenty-three years, all males ; the disease in each was caries, and 
 caused in every instance by injury. Thus in Case I. the patient was 
 wounded by a nail driven into the heel. In Case II. the heel was severely 
 bruised by a cricket ball, and Case III. was that of a wound from a shell. 
 In all these there was but a slight limp resulting from the operation. 
 
 At the termination of the paper, Professor McGuire gives two interesting 
 records to show with what facility a patient can walk after the destruction 
 of the heel-tendon. 
 
 Complete excision of the bone must always give rise to deformity, as the 
 arch of the foot is taken away. In the majority of instances, caries does 
 not invade the entire substance of the bone, its posterior surface being 
 generally affected. In such instances it is well to remove the posterior por- 
 tion of the os calcaneum, and ascertain the depth to which the ulcerative 
 process has extended, and then, if possible, remove with the gouge and 
 chisel the diseased masses. Of this proceeding Dr. Heyfelder says : 
 
 " Partial resection is to be preferred to extirpation, when possible, both 
 for the sake of leaving intact the joint and adjacent bones, as well as to 
 preserve the muscular and ligamentous attachments. But partial resections 
 of the calcaneum are not always successful [five failures in fifty-four cases], 
 and amputations of the foot [twice] or extirpation of the bone [once] have 
 been necessary. In sixty cases of partial excision, in which superficial or 
 deeper wedge-shaped portions, or even larger parts of the bone were removed, 
 none ended fatally. Relapses occurred in five out of fifty-four cases, ren- 
 dering amputation necessary in three."! 
 
 According to these remarks of the German surgeon, the results of partial 
 resection are very good, and it is so desirable to save the arch of the foot, if 
 possible, that it appears to me that the partial resection should at least be 
 first attempted. Then if, after the posterior portion of the heel has been 
 sawn off, the disease proves to have extended far into the plantar surface, 
 the entire bone must be removed, unless the caries can be reached with the 
 gouge, and can be taken away with that instrument. 
 
 There are several methods of operating for excision of the os calcis. 
 The chief point is to keep the incisions without the sole of the foot, as the 
 cicatrices are liable to inflame from friction, and afterwards to suppurate 
 and ulcerate. 
 
 Mr. T. Holmes's method is as follows : Enter the knife at the inner border 
 of the tendo Achillis, cany it steadily around the back and outer side of 
 the foot, along the upper margin of the os calcis, to a point midway between 
 the heel and the projection of the fifth metatarsal bone, which point marks 
 the calcaneo-cuboid articulation. From the anterior extremity of the inci- 
 sion a second one is commenced, and carried downward and into the sole 
 of the foot, terminating near the inner border of the os calcis, thus avoid- 
 ing the posterior tibial artery and its branches. The joint between the cu- 
 boid bone and the astragalus is laid open, and the bone, having been grasped 
 with the lion forceps, is strongly everted, and the soft parts on its inner side 
 detached, keeping the edge of the knife close to the bone. 
 
 * Medical Times, October, 1870. 
 
 f Bellevue and Charity Hospital Keports, 1870, p. 202. 
 
708 A SYSTEM OF SURGERY. 
 
 This operation commends itself for its simplicity, and from the fact that 
 the incisions avoid the posterior tibial artery ; however, I do not think that 
 the bone is so easily reached as in the dissection proposed by Erichsen, and 
 recommended by Dr. Gross, which is practiced in the following manner : 
 
 So soon as perfect unconsciousness is obtained, an incision is commenced 
 in the mesian line of the heel, an inch above the insertion of the tendo 
 Achillis, and carried perpendicularly down to the sole ; a second incision 
 is then made around the margin of the os calcis, joining the lower end of 
 the first cut as it passes around the sole of the foot, and extending farther 
 on the outer than on the inner margin of the bone. The lateral flaps are 
 dissected up, the gouge applied, and the carious parts removed. If, 
 however, the whole posterior surface is involved, the tendo Achillis must 
 be cut through, the sole-flap dissected away from the bone, and with a 
 metacarpal saw the posterior surface sliced off. The gouge and gouging- 
 forceps are used freely, and all the diseased portions removed. The flaps 
 are brought together, and united by silver sutures. A dressing of prepared 
 oakum, iodoform, and antiseptic cotton should be applied. 
 
 If the entire bone is to be taken away, the lateral incision must be longer, 
 and the joint opened from the inside, the bone seized with the lion forceps 
 an I dissected out. 
 
 Recently in two cases, one of removal of the posterior portion of the os 
 calcis, the other of the entire bone, I found that by careful dissection the 
 posterior tibial vessels can be retained in the flaps, by the method of opera- 
 tion last named. In both, which were entirely successful, there w r as but 
 little trouble from bleeding ; the dissection, however, was very tedious. 
 
 Excision of the Astragalus. — This bone may be removed when in com- 
 pound fracture, or dislocation, its unnatural position gives rise to untoward 
 symptoms; in such cases the capsular ligament is torn, and the bone 
 thrown either partially or entirely from its socket, and can generally be re- 
 moved with comparative ease. In other cases, the incision must be carried 
 in front of the dorsum of the foot down to the bone, the foot having mean- 
 while been forcibly put upon the stretch. After the incision, the assistant 
 flexes slightly the foot, and the muscles and tendons are turned off and 
 held out of harm's way by retractors. The pliers may be put into requi- 
 sition, and the head of the bone cut off. Disarticulation is then readily 
 effected. 
 
 The cuboid, cuneiform, and scaphoid bones may also be exsected, in rare in- 
 stances, but in the majority of cases amputation, either by Syme's, Chopart's 
 or Pirogoff's method, is followed by better results than excision. In several 
 cases after long and tedious dissections, I have found the disease so exten- 
 sive that amputation was necessary. 
 
 Excision of the Joint between the Os Calcis and Astragalus. — This opera- 
 tion is comparatively new, and has been practiced and thoroughly studied 
 by Mr. Thomas Annandale. The object is to save the foot, and to do 
 away, in some instances, with the complete excision of the os calcis or 
 the astragalus. I will give the operation in Mr. Annandale's own words : 
 
 " The importance of recognizing and treating early disease originating 
 in this articulation, especially after suppuration has taken place, must be 
 acknowledged, for, owing to the situation and connections of this joint, 
 there must always be a peculiar risk of the gradual implication of the sur- 
 rounding bones and joints. 
 
 " Having carefully studied the anatomical relations of the joint under 
 consideration, I found that its entire extent could be best exposed without 
 injury to surrounding structures in the following way : The foot having 
 been placed in the extended position, and resting on its inner aspect, an in- 
 cision commencing about an inch above the tip of the external malleolus 
 
EXCISION OF THE ANKLE-JOINT. 709 
 
 and carried along its posterior border in a curved direction to the calcaneo- 
 cuboid joint, thoroughly exposes the posterior and external portion of the 
 joint, when the peroneal tendons have been drawn outwards and some liga- 
 mentous bands divided. This incision will be found to run along the in- 
 ner border of the tendon of the peroneus brevis muscle. The anterior 
 and internal portion of the joint can then be exposed by placing the foot, 
 still in the extended position, on its outer aspect, and making an incision 
 from the tip of the internal malleolus along the course of the tendon 
 of the tibialis posticus, as far as the prominence of the scaphoid bone, 
 drawing forwards this tendon, and carefully drawing backwards the other 
 tendons and the posterior tibial vessels and nerve. By making the first 
 incision through the skin and cellular tissue only, and so ascertaining the 
 exact position of the tendons likely to be injured, then cutting down 
 through the periosteum to the bone, and with a periosteal scraper separat- 
 ing to a sufficient extent the periosteum, together with all the other superfi- 
 cial tissues, there is little risk of injuring any of the tendons or other 
 important structures. 
 
 "Both aspects of the joint having in this way been exposed, it will be 
 found that by means of the chisel and mallet the articular surfaces can be 
 easily and accurately removed, the posterior portion being removed through 
 the external incision, and the anterior portion through the internal one. 
 Should there be any disease in the hollow or fossa between the two articu- 
 lar surfaces, it can be readily reached and removed with the chisel or gouge 
 through either incision." 
 
 Excision of the Ankle-joint. — The lower ends of the tibia may have to be 
 removed after compound dislocations, and also portions of the fibula cut 
 away. It appears from excellent authority that the operation is much bet- 
 ter as a secondary than as a primary one. Mr. Hancock* gives nineteen 
 successful cases, and points out very forcibly the advantages of total over 
 partial excision of this joint. 
 
 Mr. Hey, of Leeds, w T as the first surgeon who resected the lower ends of 
 the tibia and fibula for disease, which operation was performed in 1766. 
 Moreau, in 1792, did the same for like cause. Mr. Thomas Bryant gives 
 to Mr. Hancock priority in resection of the entire joint. 
 
 The following is a description of the operation as practiced by Hancock, 
 modified by Barwell, and published in Bryant's Practice of Surgery : " The 
 foot is first laid on its inside, an incision is made over the lower three inches 
 of the posterior edge of the fibula. When it has reached the lower end of 
 the malleolus it forms an angle, and runs downward and forward to within 
 about half an inch of the base of the outer metatarsal bone. The angular 
 flap is reflected forwards, the fibula for about two inches above the malleo- 
 lus is cleared sufficiently of soft parts to allow cutting forceps to be placed 
 over it, and the bone is then nipped in two, and carefully dissected out, 
 leaving the peronseus longus and brevis tendons uncut. The foot is now to 
 be turned over. A similar incision is made on the inner side, the portion 
 in the foot terminating over the projection of the inner cuneiform bone. 
 The flap is to be turned back and the sheath of the flexor digitorum and 
 the posterior tendons exposed, the knife being kept close to the bone, avoid- 
 ing the artery and nerve. The internal lateral ligament is then carefully to 
 be severed close to the bone, and now the foot is twisted outward and the 
 astragalus and tibia will present at the inner wound. A narrow-bladed saw 
 put in between the tendons, into the inner wound, projects through the 
 outer. The lower end of the tibia, then the top of the astragalus may be 
 sawn off in a proper direction." 
 
 * London Lancet, 1867. 
 
710 
 
 A SYSTEM OF SURGERY. 
 
 I may say here that in several cases I have succeeded in curing caries of 
 the ankle-joint, which threatened a necessity for resection, by entire rest, 
 and the prolonged and frequent use of silicea. I speak emphatically here 
 of the trituration as superior in its efficacy to the dilution, and of the almost 
 specific influence of this medicine upon the bones of the ankle-joint. 
 
 Excision of the Toes. — In the majority of cases amputation is to be pre- 
 ferred to excision of the bones of the toes. If, however, the metatarsus 
 is to be removed, an incision must be made on the dorsal surface of the 
 diseased bone and the tissues held aside, while with a strong pair of pliers 
 held perpendicularly the bone is divided, which greatly facilitates the 
 operation. Its extremities are then raised by means of lion-jawed forceps, 
 and, keeping the edge of the knife close to the bone, each half is succes- 
 sively removed. 
 
 Excision of the Knee-joint. — To Mr. Henry Park, of Liverpool, belongs the 
 credit of having originated the operation of resection of the knee-joint. He, 
 however, gives the credit of the first actual performance of the operation to 
 Percival Pott, the date of which was July, 1781. Soon after the publica- 
 tion of the Park pamphlet, Mr. Filkin, of Norwich, declared that he had 
 performed the operation as early as 1762. On the 5th day of November, 
 1789, Dr. Simmons performed a similar operation. M. Moreau, in 1792, 
 excised the whole of a carious knee-joint ; in 1809, Mulder removed it; in 
 the year 1823, Sir Philip Crampton, and in 1829 and 1830, Mr. Syme re- 
 sected the articulation. These latter operations were not successful, and 
 the procedure gradually fell into disrepute until it was revived by Mr. 
 Fergusson in 1850. 
 
 In the following table, altered a little from Butcher, the names of the 
 surgeons, the dates of the operations, and the results are shown, embracing 
 a period of eighty-seven years or up to the time of its revival : 
 
 DATE. 
 
 SURGEON. 
 
 SEX. 
 
 AGE. 
 
 RESULT. 
 
 1762 
 
 Filkin. 
 
 Male. 
 
 
 Recovered in three months. 
 
 1781 
 
 Pott. 
 
 Male. 
 
 33 
 
 Recovered in one year. 
 
 1789 
 
 Simmons. 
 
 Male. 
 
 30 
 
 Died in four months. 
 
 1792 
 
 Moreau, Sr. 
 
 Male. 
 
 20 
 
 Died in three months. 
 
 1802 
 
 Moreau, Sr. 
 
 Male. 
 
 18 
 
 Died in four months. 
 
 1809 
 
 Moulder. 
 
 Female. 
 
 34 
 
 Died in three and a half months. 
 
 1811 
 
 Moreau, Jr. 
 
 
 
 Recovered. 
 
 1816 
 
 Roux. 
 
 Male. 
 
 32 
 
 Died. 
 
 1823 
 
 Crampton. 
 
 Female. 
 
 23 
 
 Died. 
 
 1823 
 
 Crampton. 
 
 Female. 
 
 22 
 
 Recovered. 
 
 1829 
 
 Syme. 
 
 Male. 
 
 8 
 
 Recovered. 
 
 1829 
 
 Syme. 
 
 Female. 
 
 7 
 
 Died. 
 
 1830 
 
 Jaeger. 
 
 Male. 
 
 28 
 
 Recovered. 
 
 1832 
 
 Textor. 
 
 Female. 
 
 26 
 
 Died. 
 
 1832 
 
 Fricke. 
 
 Female. 
 
 8 
 
 Recovered. 
 
 1832 
 
 Fricke. 
 
 
 
 Died. 
 
 1835 
 
 Fricke. 
 
 
 
 Died. 
 
 1835 
 
 Demme. 
 
 Male. 
 
 36 
 
 Recovered. 
 
 1836 
 
 Fricke. 
 
 Male. 
 
 18 
 
 Recovered. 
 
 1839 
 
 Textor. 
 
 Female. 
 
 23 
 
 Died. 
 
 1840 
 
 Lang. 
 
 Male. 
 
 24 
 
 Died. 
 
 1842 
 
 Textor. 
 
 Female. 
 
 23 
 
 Recovered. 
 
 1842 
 
 Demme. 
 
 
 
 Died. 
 
 1842 
 
 Demme. 
 
 
 
 
 1845 
 
 Textor. 
 
 Female. 
 
 44 
 
 Amputation; recovered. 
 Died. 
 
 1845 
 
 Textor. 
 
 Male. 
 
 29 
 
 1848 
 
 Heusser. 
 
 Male. 
 
 20 
 
 Recovered. 
 
 1849 
 
 Heusser. 
 
 Male. 
 
 32 
 
 Died. 
 
 1849 
 
 Heusser. 
 
 Male. 
 
 6 
 
 Recovered. 
 
 1849 
 
 Textor. 
 
 Female. 
 
 29 
 
 Died. 
 
 1849 
 
 Heyfelder. 
 
 Male. 
 
 21 
 
 Died. 
 
 I find,* in addition, the record of thirteen cases performed by conti- 
 nental surgeons since 1850. Thus : three times by Mr. Fergusson, six times 
 
 * Medical Times and Gazette, 1853. 
 
EXCISION OF THE KNEE-JOINT. 711 
 
 by Mr. Jones, once by Mr. Page, once by Dr. Stewart, and twice by Dr. Mac- 
 kenzie. Of these cases two died from the operations, one from dysentery, and 
 the remaining ten recovered, with limbs not very serviceable, but all of them 
 in better condition than if amputation had been performed. Butcher gives 
 a second table of fifty-one cases operated on from 1854 to 1856. Of these 
 there were twenty-two cured, fifteen having recovered when the table was 
 made, one was relieved, and one in a precarious state. The deaths only 
 numbered ten. 
 
 Since that period the operation has been performed many times and 
 with success, both in this country and in Europe. In America we 
 have the record of an operation performed by Gurdon Buck, at the New 
 York Hospital, in the month of October, 1844. The operation was resorted 
 to in order to straighten a limb, which was bent at right angles.* Dr. 
 Bauer, formerly of Brooklyn, now of St. Louis, records an interesting case 
 in which the operation was performed for genu valgum,f with traumatic 
 diastasis of the lower epiphysis of the left femur. 
 
 Diseases Calling for Resection of the Knee. — The disease which properly 
 directs to resection of the knee is generally a strumous inflammation of the 
 joint. This may commence either in the synovial membrane, or in the 
 spongy structure of the long bones, which become filled with strumous de- 
 posit, and are much degenerated, enlarged, and softened. The inflammatory 
 action is generally of the subacute character ; there is increase of tempera- 
 ture of the parts involved ; the cancellated structure of the bone is filled 
 with a reddish grumous deposit; the patients waste in flesh, have feverish 
 exacerbations at night, and become sallow and cachectic in appearance. If 
 this process is not arrested in due time, the pain increases, and there takes 
 place within the bone-cells a lardaceous or oily deposit, and, the disease 
 increasing, a chemical change is effected in the constituents of the bone. 
 The calcareous matter lessens, or even, in severe cases, may be entirely de- 
 ficient, and the compact structure is reduced to a mere shell. The perios- 
 teum also becomes very much thickened, and is less adherent to the bone 
 than normal. Suppuration then may follow, and the debris is cast out 
 with an ill-conditioned and sanious pus. This disease, no doubt, has been 
 often mistaken for caries of the ends of the bones ; but there is a consider- 
 able difference between the two, one belonging more especially to the 
 simple ulcerative process, the disintegration, molecule by molecule ; the 
 other being accompanied by, or essentially consisting in, an absolute de- 
 generation of the spongy structure, and a deposit and infiltration of stru- 
 mous matter in the cancellated structure of the bone itself. In such an 
 affection, after suppuration has occurred, the joint should be excised. 
 
 Other affections which may lead to resection are : white swelling, degen- 
 eration of the cartilages, caries of the extremities of the bones, deformity of 
 the legs, injuries of the joint, etc. 
 
 There is a question of some import in relation to the removal of the pa- 
 tella, in this operation. If the bone be diseased, remove it ; if it is not, refresh 
 its under surface, that it may adhere to the parts below. I am quite certain 
 that the rule adopted by some surgeons that the patella, whether implicated 
 or otherwise, should be removed, is not a good one. The excision requires 
 considerable dissection ; it leaves a cavity which has to fill by granulation ; 
 it increases the suppuration, and prevents the application of an anterior 
 splint, if such be necessary. In resection of the knee-joint, I have divided 
 the hamstring tendons before the operation was performed, with the idea of 
 preventing muscular contractions from separating the extremities of the 
 
 * Velpeau's Operative Surgery, vol. i., p. 810. 
 f Bauer's Orthopaedic Surgery, p. 193. 
 
712 
 
 A SYSTEM OF SURGERY. 
 
 bones, but I found that the spasmodic action still would occur and occa- 
 sion great pain. I should therefore rely on the internal administration of 
 ignatia, cuprum, chloral, or the bromide of soda, or sometimes a few drops 
 of tine, hyoscyami. Again, surgeons have recommended that, after the 
 extremities of the bones have been sawn off, an opening be made in the 
 popliteal space, in order to allow drainage. I should think that this would 
 be an excellent suggestion in some cases, but would much prefer to wait 
 
 Fig. 418. 
 
 Fig. 419. 
 
 Fig. 420. 
 
 Butcher's Saw 
 
 until the symptoms of extensive suppuration developed, because with calen- 
 dula, carbolic acid, iodoform, the bichloride of mercur}^, and strict anti- 
 septic measures, I believe we have great control over the suppurative process. 
 I have positive evidence of the reliability of these agents, and have per- 
 formed the operation without removing the first dressing for two weeks, the 
 wound healing almost entirely by first intention. 
 
 The best incisions, as a general rule, are those which will freely expose 
 
EXCISION OF THE KNEE-JOINT. 713 
 
 the joint, and allow the removal of the bones with greater facility. The 
 sweep of the knife may be semicircular, commencing at a point opposite 
 the inner condyle, and extending below the tubercle of the tibia to a point 
 opposite the external condyle. 
 
 Mr. Park preferred the crucial cut, as did also Mulder. Moreau operated 
 by two lateral incisions in front of the ham, which were united by a hori- 
 zontal cut below the patella (Fig. 419). The H incision for many cases is 
 the most desirable. The incisions should be about four inches in length on 
 each side, beginning at the condyles, and extending downward ; they should 
 be crossed by a second cut, which will open the joint; the flaps are 
 turned aside, and the condyles rapidly freed with careful strokes of the 
 knife ; the leg is then forcibly flexed, and the crucial ligaments divided • 
 retractors of metal should now be slid behind the head of the tibia, which 
 must be removed first (Fig. 420). The condyles of the femur are treated in 
 like manner. Butcher's saw (Fig. 418) can be used with advantage in the 
 operation, as it cuts from behind forward, and by the screw the blade can 
 be made to assume any angle that may be necessary. 
 
 The after-treatment is very essential, and requires care in its man- 
 agement. I have no hesitation in recommending the swinging splint of 
 Dr. Hodgen, the modification of that by Dr. E. A. Clark, or Smith's ante- 
 rior splint. The method of application of each of these can be found 
 in Chapter XXXL, p. 592. Sometimes, however, a fracture-box filled 
 with bran, to absorb the discharge, is very useful in many particulars. To 
 illustrate the operation, the accidents which may be expected, the beneficial 
 effects of treatment, and good recovery with a straight limb, shortened but 
 one-eighth of an inch, the student is referred to pages 641-643. 
 
 Professor Volkmann, of Halle, proposes a new operation for resection of 
 the knee, by a cross-section of the patella. A horizontal incision is made 
 over the patella, which is sawn in half, the parts to be reunited by catgut 
 sutures after the completion of the operation. The following will explain 
 the method more fully. 
 
 The incision extends horizontally across the patella from the anterior 
 border of the epicondyle on one side, to the anterior border of the epicon- 
 dyle on the other side. The joint is opened on both sides of the patella 
 and the index finger passed under the bone, which is then divided with the 
 saw or knife. The lower half of the patella is now drawn downwards and 
 secured out of the way, while the lateral and crucial ligaments are divided 
 and the end of the femur resected. The head of the tibia is next pressed 
 forward into the wound, and the semilunar cartilages are seized at their 
 posterior borders and removed along with the remains of the crucial liga- 
 ments, and the greater part of the adipose tissue which covers the posterior 
 surface of the ligamentum patella?. The head of the tibia is then laid bare 
 and resected, the capsule is dissected out, and any carious spots in the re- 
 sected bones or in the patella are- gouged out. Finally the resected surfaces 
 of the femur and tibia are brought together by two strong catgut sutures 
 placed internally, and the two halves of the patella are united also by two 
 catgut sutures. The sutures are introduced into both the epiphyses and 
 the patella by means of strong curved needles. The operation should 
 always be preceded by an exploratory incision, which will enable the 
 surgeon to examine the joint by both finger and eye ; for this purpose 
 the incision should at first only be carried from the epicondyle as far as 
 the border of the patella. If this exploratory incision shows that the 
 operation can possibly be avoided, a drainage-tube should be introduced 
 and the wound dressed antiseptically. The patella will sometimes be 
 found firmly attached to the femur, but it can be easily separated with 
 the chisel. 
 
714 A SYSTEM OF SURGERY. 
 
 Mr. William Knight Treves* thus describes his method of removal of the 
 knee-joint : 
 
 First. A semilunar incision about three inches in length on each side of 
 the joint is made, the lowest point of each being dependent for the exit 
 of pus or serum. 
 
 Second. The division of the lateral ligaments on each side and reflection 
 of the tissues till the synovial cavity in front is opened. 
 
 Third. A metal retractor is inserted in front of the bones to secure from 
 injury the tissues in front, which are loosened from the sides, whilst the 
 bones are being sawn ; a saw is passed behind the joint, and, this being con- 
 nected with its frame, a thin slice is cut from the end of each bone ; the 
 sawn surface is examined, and, if it appears to be healthy, the wound 
 should be closed and dressed antiseptically. 
 
 The advantages gained by this method are : 
 
 1. Decided improvement in the after-appearance of the limb. 
 
 2. Increased power of extension, for by this operation the patient can 
 lift the leg even before union is firm, and thereby have increased advantage. 
 
 3. The extensor tendon being still attached to the tibia in front, the bones 
 are not so loose, and the leg is more under control. 
 
 4. This is more like a subcutaneous operation ; the sawn surfaces are still 
 left under their natural covering, are not exposed under an extensive 
 wound, and, being protected, unite more readily than after the usual opera- 
 tion. 
 
 With very little practice, it may be said to be not difficult to perform. 
 
 Excision of the Bones of the Leg. — The fibula may be resected in its entire 
 extent or in part, the weight of the body not falling upon that bone. The 
 operation was first suggested by Dessault, and executed by Percy, Suetin, 
 and others. The incision must be a longitudinal and long one, and the 
 bone denuded, and if possible the periosteum saved, by using the blunt 
 instruments shown in the first portion of the chapter. The bone should 
 be divided by pliers, and the ends lifted by means of the lion-forceps and 
 removed. The peroneal artery is frequently divided, and there is often a 
 good deal of haemorrhage from other vessels. 
 
 Portions of the tibia may also be resected with a good result. An in- 
 teresting case came under my care some years since. It was a compound 
 fracture which had never been reduced. The broken bones had united, pre- 
 senting a hideous deformity. The foot was twisted entirely around, and three 
 inches of the tibia, covered with a thick crop of dark-red granulations, 
 protruded from the leg. There was a suppurating and offensive ulcer on 
 the posterior portion of the right leg, occupying the whole belly of the gas- 
 trocnemius ; another sore about the hip-joint, together with rigid contraction 
 of the toes and knee-joint. The patient was also much emaciated, with a 
 dry, brown, hard tongue, pulse one hundred and thirty beats to the minute, 
 tympanites, and all the well-marked symptoms of typhus gravior. The 
 extent and gravity of his injuries, the exhausting suppuration, the depri- 
 vation of proper nourishment, were certainly data on which to found a 
 very unfavorable prognosis. 
 
 The first medicine prescribed was arsenicum 3, about two grains every 
 three hours, while brandy and water three times a day, with occasional 
 spoonfuls of beef essence, were administered. The ulcer on the right leg 
 was dressed with calendula lotion, which was also applied over the pro- 
 truding extremities of the fractured bones. It was some days before much 
 improvement was noticed ; but gradually the symptoms began to abate 
 in their severity, excepting excessive pain in the region of the hip-joint ; 
 
 * Braithwaite's Retrospect of Practical Medicine and Surgery, July, 1877, Part 75. 
 
EXCISION OF THE HIP- JOINT. 715 
 
 the acute pain beginning at evening and lasting through the entire night. 
 The screams of the boy were such that the other patients in the ward 
 were unable to sleep. The application of compresses saturated with 
 strong tincture of aconite gave relief in time to this distressing symptom. 
 The tympanites was relieved by turpentine in three to five drop doses 
 taken once in four hours, and the remaining symptoms combated as they 
 presented with bryonia, rhus tox., and sulphur. About this time a diar- 
 rhoea became troublesome, but was successfully treated with phosphorus 
 and phosphoric acid. During this treatment stimulants were constantly 
 given, and their good effect was very appreciable. At length the disease 
 was overcome. 
 
 As the danger to life passed, the deformed and misshapen limb began to 
 claim the attention it deserved, and which it should have received when the 
 injury was first inflicted. 
 
 My first impression, and I believe that of those who saw him, was that 
 amputation must be resorted to, but upon reflection, I thought that resection 
 might be practiced, and upon consultation it was agreed to attempt it. 
 
 On the 2d of March, assisted by and in the presence of several medical 
 gentlemen, having placed the boy fully under anaesthetic influence, I 
 began the operation by dissecting from the protruding bones the mass 
 of granulations ; then, beginning about five inches above the site of frac- 
 ture, I made a longitudinal incision along the spine of the tibia, and 
 continued it three or four inches below the protruding bones ; this in- 
 cision was crossed at the centre by a second transverse cut, and the four 
 flaps dissected up. Keeping the edge of the knife close to the bone, the 
 aponeurosis of the tibialis anticus was divided, and the anterior tibial 
 artery protected from injury. The ends of the bones were then sawed 
 off, about two inches being taken away, and the bony adhesions of the 
 fibula, which had united firmly with the shin-bone, were, with consid- 
 erable force, refractured. The foot was then twisted back, placed in its 
 position, and fixed securely in a splint, leaving a space between the 
 divided extremities of the bones, from which two inches of the ends had 
 been removed. During the operation the haemorrhage was not impor- 
 tant, but when I visited the patient in the evening, there had been so pro- 
 fuse a discharge of blood, that I feared the teeth of the saw had wounded 
 the anterior tibial artery. All dressings were therefore removed, but I found 
 the bleeding to arise from the medullary canal. Compresses wet with a 
 solution of the liquor Jerri persulphatis were applied, which, after two days, 
 arrested the haemorrhage. 
 
 On the 5th of March the limb was placed in a fracture-box, extension 
 made to keep the leg the proper length, and bran packed closely around it. 
 This bran dressing was most serviceable; the leg was never moved from its 
 position ; the wound could be cleansed readily and as often as was necessary, 
 could be examined at any time', and could receive the benefits of the cold 
 calendula lotion, which was constantly applied. Moreover, as suppuration 
 took place the pus was absorbed by the bran, which it formed into hard 
 masses that were easily removed, and the space refilled with fresh material. 
 On the 25th, a sequestrum came away. On the 27th, the leg was taken out 
 of the bran, the fracture-box cleansed, refilled and reapplied as before. On 
 April 4th, the whole apparatus was dispensed with, a slight splint applied on 
 the inside of the leg, and held in situ by adhesive strips. The boy was soon 
 about the house ; has a leg of the same length as the other, though not quite so 
 strong. 
 
 Excision of the Hip-joint. — There are several forms of hip-joint disease, 
 some requiring excision of the head and neck of the femur, and others for- 
 bidding the same. The different locations of the inflammatory process in the 
 
716 
 
 A SYSTEM OF SURGERY. 
 
 hip have been already alluded to. It may commence in the soft structure 
 within the joint, or in the head of the femur, or in the interarticular carti- 
 lage, or in the acetabulum. When, however, there is undoubted caries of 
 the head of the bone, or it has been dislocated and thrown outward and 
 backward upon the acetabulum, the operation presents fair hope of sac- 
 cess, especially if the pelvic bones be free from disease : if together with 
 this the patient be healthy, is young, and originally of good constitu- 
 tion, though prostrated by continued profuse discharge and hectic, the 
 removal of the head and neck of the bone is perfectly justifiable. Th> 
 true conservatism, and when compared with the terrible alternative, ampu- 
 tation at the hip-joint, the comparative ease of the performance of excision, 
 the alight shock, the less amount of haemorrhage, the comparative quickness 
 of healing, the size of the wound, and above all. the saving of a useful limb, 
 there can be no doubt of the preponderance of argument in favor of ex- 
 cision. 
 
 The operation may be performed either by a single long incision directly 
 over the head of the bone, or by a T incision, made somewhat obliquely, or 
 a Y-shaped cut < Fig. 421"'. These incisions should be made directly down 
 to the bone, and an assistant on either side, with broad metallic retractors. 
 should separate the structures with the handle of a scalpel, or with an in- 
 
 FlG. 421. 
 
 Fig. 422. 
 
 Incision for Excision of Hip-joint. 
 
 Chain Saw applied. 
 
 strument slightly curved upon the flat, fixed in a stout handle, with a blade 
 about four inches in length, and a blunt cutting-edge similar to that recom- 
 mended by Dr. Gross for separating the structures from the inner side »of 
 the condyle of the inferior maxillary, when that bone is to be removed at the 
 articulation. The soft parts remaining must be separated from the bone, 
 and. by a rotary motion, the head may be abducted, and a chain-saw 
 passed beneath the head of the bone, and. with a rapid though gentle mo- 
 tion, the caput and as much of the cervix as necessary may be taken away 
 (Fig. 422 . In some cases the long bone-forceps of Liston may be used, or, 
 having placed a retractor or a towel beneath the bone, to prevent the soft 
 structures from being injured, the ordinary amputating-saw can be used. 
 
EXCISION OF THE HIP-JOINT. 
 
 717 
 
 I much prefer, however, the saw of Mr. Butcher (Fig. 418), which is so 
 arranged that it cuts from within outward, by the direction the saw is 
 made to take. I have already mentioned that disease of the acetab- 
 ulum and head of the thigh together, does, as a general rule, contra- 
 indicate the operation, though there are some surgeons who hold a 
 contrary opinion. The celebrated Mr. Hancock thus expresses him- 
 self: 
 
 " In deciding upon this operation, we would be guided by the condition 
 of the patient, and not by any arbitrary stages of the disease, and whilst I 
 always have and still continue to deprecate unnecessary and ill-considered 
 operations, I believe it to be our duty, when we have assured ourselves that 
 the case is one of hip-disease, that the patient is dying, and there is no hope 
 of saving him by the ordinary means, to perform, or at all events to propose 
 the operation, without reference as to whether, Fig 423 
 
 pathologically speaking, the disease be in this or 
 that stage, or whether the bone be dislocated, 
 the acetabulum healthy or not." 
 
 There is great truth in these remarks, and 
 from late successful operations, in which not 
 only the head and cervix of the femur but also 
 parts of the pelvic bones have been removed, it 
 would seem to be the duty of the surgeon to 
 attempt operative measures even in extreme 
 cases. At all events, an exploratory incision 
 may be made from the anterior inferior spi- 
 nous process of the ilium to the trochanter 
 major, and the feasibility of the operation as- 
 certained. 
 
 The following are the directions of Dr. Lewis 
 A. Sayre : " When the disease has gone on to 
 another stage, when sinuses have occurred and 
 discharged pus, when a probe leads down to dead 
 bone, there is nothing to be done but to exsect it 
 by making a small incision above the trochanter 
 major, midway between it and the crest of the 
 ilium, over the top of the acetabulum — a semilu- 
 nar incision, the belly of the D covering the pos- 
 terior part of the trochanter major, going straight 
 down to the bone, through the periosteum. You 
 then pull the soft tissues on one side, and, taking 
 a small but strong curved bistoury, go as far wire Breechei 
 
 around the bone on each side as you can reach, 
 
 at right angles to your first incision, so as to divide the periosteum com- 
 pletely ; you then take a strong firm periosteal elevator, with a large handle 
 and the end slightly curved, and go into this little triangle ; you peel off 
 the periosteum, and, as a matter of course, all the muscles with it ; by open- 
 ing the joint thoroughly and turning the head of the bone out, the periosteum 
 is peeled off from the inner portion ; you then saw off the bone above the 
 trochanter minor. I believe that this is better than cutting through the 
 neck. If you go through the neck, the trochanter major comes over the 
 hole and prevents discharges; whereas by cutting off the trochanter major 
 along with the neck of the bone you leave a perfectly free opening for the 
 discharges from the diseased joint ; and by peeling off the periosteum in 
 the way which I have described, you carry with it all the muscles that move 
 the joint; and if you then keep the leg pulled out to its proper length, by 
 
718 A SYSTEM OF SUEGERY. 
 
 putting on a pair of wire breeches (Fig. 423) you can send the patient out 
 into the air the very next day."* 
 
 In my operations I formerly used the T incision, but have in more 
 recent ones resorted to the cut of Sayre, already described, carrying the 
 knife down to the bone, turning back the flaps, removing the head of the 
 bone with the chain-saw, applying the gouge and chisel, if necessary, to 
 remove all traces of diseased bone, and then placing the patient in a Smith's 
 anterior splint, according to the directions given for this appliance in the 
 Chapter on Fractures of the Femur. Bauer's wire breeches are also of 
 great service. They keep the parts in good apposition. 
 
 Dr. J. H. McClellan, of Pittsburgh, reports a successful case of excision of 
 both condyles of the femur at the Pittsburgh Homoeopathic Hospital. 
 
 Dr. H. W. Kcehler, of Louisville, Ky., reported an excellent case of resec- 
 tion of the neck and trochanter major of the femur.f 
 
 CHAPTER XXXVI. 
 
 INJURIES AND DISEASES OF THE HEAD. 
 
 Wounds — Gunshot Wounds of the Scalp — Fractures of the Skull — Concussion 
 and Compression — Application of the Trephine— Cerebral Motor Localiza- 
 tions. 
 
 Wounds of the Scalp. — Mr. Pott has observed that though the scalp be 
 called the common integument of the head, yet from its structure, connec- 
 tions, and uses, injuries inflicted upon it by external violence become of 
 much more consequence than those of other parts of the body. It is a 
 well-known fact that wounds, however slight, when inflicted on the head, are 
 very liable to be followed by inflammation and suppuration either within 
 or without the cranium. In some instances the lips of the wound will 
 unite readily, and little inconvenience result ; in others, however, adhesion 
 will take place only at certain points, while suppuration will occur at others ; 
 this is particularly noticed in contused wounds, in which the integument 
 has immediately been destroyed by the violence of the injury, or in cases 
 in which the scalp has suffered considerable laceration. 
 
 Small wounds, that is, such as are caused by instruments or bodies which 
 pierce or puncture, rather than cut, are in general more liable to become in- 
 flamed, and are known to be productive of greater constitutional disturb- 
 ance than those which are of a greater extent. 
 
 If the wound affect the cellular membrane only, and has not reached the 
 aponeurosis or pericranium, the inflammation and tumefaction involve the 
 whole head and face : the latter frequently assuming a jaundiced hue, and 
 being covered with small bulla? containing yellow serum. 
 
 Treatment. — If a blow on the head has caused extravasation of blood 
 beneath the scalp (cephalhematoma), and if there be visible increase of the 
 accumulation of fluid, the surgeon may suspect that an artery has been 
 divided ; in this case the course of the vessel, if possible, should be ascer- 
 tained, and pressure made in order to arrest the haemorrhage; after which, 
 compresses saturated with a solution of arnica should be applied to the 
 contused part. If the scalp be nearly or quite detached, it should be care- 
 
 * Braithwaite's Retrospect, January, 1872, p. 114. 
 
 f Western Homoeopathic Observer, July and August, 1870. 
 
FRACTURES OF THE SKULL. 719 
 
 fully washed and replaced as nearly in situ as possible, and aqua calendulx 
 be used as a lotion ; the parts should be brought together with adhesive 
 straps, and a bandage lightly placed around the cranium ; sutures in the 
 generality of instances should be dispensed with, as the punctures made 
 by the needle are liable to become the seat of inflammatory action. If 
 erysipelas supervene, bell, or rhus radicans may be administered inter- 
 nally ; the latter exerting a beneficial action over erysipelas of the scalp. If 
 the fever be high, aconite and bell, may be administered, in accordance 
 with symptoms that have already been mentioned in various places in this 
 work. 
 
 Should symptoms of effusion within the cavity of the cranium be pres- 
 ent, am., bell., hell., cup., or zincum are the most appropriate medicines. 
 If suppuration ensue beneath the scalp or occipito-frontalis muscle, the pus 
 should be evacuated by early incision, and calend., hepar, mere, or silicea 
 be exhibited. If extravasated blood be noticed beneath the scalp, there 
 is no need of incision, for by enjoining perfect rest, with the employment 
 of arnica externally and internally, absorption of the clot will in all prob- 
 ability take place. 
 
 Gunshot Wounds of Scalp.— Of 3420 cases of this variety of wound which 
 could be traced, occurring during the war of the Rebellion, the fatal cases 
 amount to 2.09 per cent., or about 1 in 48 cases. The British annals oi 
 the Crimean war give a mortality of 1.83. From these figures, it will be 
 seen that gunshot fractures of the scalp are rarely fatal, and when they 
 are, death is occasioned by secondary complications. These are encepha- 
 litis, erysipelas, gangrene, ulceration, and sloughing. In this variety of 
 wound, primary bleeding seldom occurs, while secondary haemorrhage is 
 frequent, especially during the separation of sloughs and sequestra. In 
 some cases tetanus follows, and typhoid symptoms are not uncommon. 
 
 According to the Surgeon-General's report, 72.6 per cent., or nearly three- 
 fourths of gunshot wounds of the scalp, are caused by small-arm missiles, 
 and it is a remarkable fact, that the scalp may be wounded by the largest 
 projectiles, even from artillery, without injury to the skull, or concussion of 
 the brain. 
 
 It is also important to bear in mind, that, in the majority of instances, 
 when there is sufficient contusion of the scalp to produce ecchymosis, even 
 without any solution of continuity of the scalp, brain symptoms may be 
 expected. 
 
 Treatment. — The wound must be washed thoroughly, and compresses wet 
 with a solution of arnica, one part to five, be applied, and a few drops of 
 the same medicine administered internally. So soon as suppuration has 
 begun, calendula must be substituted for the arnica and silicea, or sulphur 
 must be given. 
 
 Fractures of the Skull. — This accident frequently occurs, and is occa- 
 sioned by blows and falls upon the head. It may be either a simple 
 fissure, or a separation of the entire bony structure. There are several 
 varieties of the accident, thus : simple, compound, comminuted, or depressed. 
 The external table may be the seat of injury, or the internal may be 
 broken, or both may be implicated. Again, there is fracture with depres- 
 sion of the bone, and breakage without any such untoward circumstance. 
 In simple fissure or fracture without depression, there is nothing to do 
 but to keep the patient in a quiescent condition and apply to the part a 
 compress saturated with a mixture of arnica and water, at the same time 
 arnica is to be given internally. When the fracture is accompanied with 
 depression, the case is far different, as the depth of the depressed frag- 
 ments may regulate the amount of compression upon the brain. There 
 may be considerable depression without symptoms of compression manifesting 
 
720 A SYSTEM OF SURGERY. 
 
 themselves. Again, there may be a severe fracture, the tables being broken 
 into many pieces, and spiculse of bone so pressing upon the meninges as to 
 render inflammation and suppuration inevitable. Under these circum- 
 stances, the correct course is to elevate the bone and remove the spiculse 
 with the forceps. If the injury shows but slight depression, it is conserva- 
 tive to wait and watch the case carefully. 
 
 A " starred " fracture is one in which the fissures radiate in all directions, 
 often involving more than one bone, and extending to the base of the cra- 
 nium. Such fractures may also be " guttered," or " saucer-shaped," accord- 
 ing as the instrument is blunt, as when inflicted with a spade; or round, as 
 when made with a hammer. 
 
 Fracture with Depression. — When there is much depression the symp- 
 toms are well marked. The patient is more or less comatose, the pupils 
 are dilated, and the breathing stertorous. In such cases the diagnosis is 
 apparent, and the trephine should immediately be used. I cannot under- 
 stand, when the symptoms call so greatly for relief, why there should be 
 any delay in the application of the proper remedial means; there can 
 certainly nothing be gained by delay, and every moment of hesitation 
 gives the patient less hope of recovery. Many fractures of the skull are 
 compound, the scalp being more or less torn and lacerated. Often the 
 wounds are filled with dirt or other extraneous matter, particularly if 
 the fracture be caused by a severe fall. In these cases, after having 
 cleansed the wound thoroughly, the depressed bone must be elevated and 
 all spicule removed ; this having been done, the edges of the wound may 
 be approximated with sutures. A blow or a fall upon the top of the head, 
 or upon the occiput, may cause a longitudinal fracture at the base of the 
 skull. When this takes place haemorrhages occur from ears, nose, and 
 mouth, caused by tearing of the sinuses of the dura mater. There are 
 likewise immediate and well-marked symptoms of compression. After a 
 day or two, or longer, a thin watery discharge takes place from the ear, 
 supposed to be the fluid from the sac of the arachnoid. An injury 
 inflicted upon the frontal bone may fracture the anterior fossa of the base. 
 In all fractures about the head, care must be taken to distinguish between 
 those symptoms which belong to compression and those which signify 
 concussion, and it must be borne in mind that symptoms of the former 
 may be occasioned by the formation of clots within the ventricles. Frac- 
 tures at the base of the skull are always considered dangerous, as the 
 patients generally succumb in a few days. 
 
 From what has been said it will be seen that three symptoms, when 
 appearing together, point conclusively to fracture of the base of the 
 skull : these are, 1st, haemorrhage from the ear ; 2d, discharge of a watery 
 fluid from the ear; 3d, facial paralysis. Each of these may exist alone 
 without fracture, but when they present together the diagnosis is cer- 
 tain. 
 
 In most cases, especially those which recover, in which the cerebro-spinal 
 fluid exudes, the flow comes from the fractured labyrinth. If this should 
 be cerebro-spinal, there must be a considerable rent in the dura mater — in 
 itself an almost fatal injury — and the tear must gape considerably to allow 
 the fluid to pass for a considerable time. In the former case, the fluid may 
 exude without any inflammatory meningeal symptoms. 
 
 There is another fracture of the skull which is denominated a punctured 
 fracture. This is caused by a nail, a spike, the sharp extremity of a pick- 
 axe, of a rail, or a bar of iron being driven into the skull. In this latter 
 accident, there is always more or less injury done to the brain, and more 
 or less depression of both tables. The symptoms of compression are not 
 
FRACTURES OF THE SKULL. 721 
 
 always imminent, but the accident must be considered serious, and calls 
 for the immediate use of the trephine. 
 
 James McA., a slater by trade, while performing his avocation on the 
 roof of a three-story brick house, lost his balance and was precipitated head- 
 foremost to the street below. He struck upon a pile of paving-stones with 
 the right side of his head, and lay for a time insensible. I was in the 
 neighborhood at the time and was called to the accident. I found him 
 bleeding profusely from an extensive scalp-wound, which beginning at the 
 temporal ridge extended downward to the right eye, thence across the eye- 
 lid to the internal canthus. The upper part of the eyeball with the inser- 
 tion of the trochlear muscle were distinctly visible. The flesh was rolled 
 up and the wound filled with dirt. The bleeding was so profuse that I was 
 obliged to ligate the anterior and middle temporal arteries in the street 
 where he was lying, and, having extemporized a stretcher, I sent him to 
 the Good Samaritan Hospital. 
 
 Upon cleansing the wound and carefully inserting the finger, several 
 pieces of loose bone (one an inch square) were detected and taken away, 
 the larger one forming a part of the outer rim of the orbit, and a part of 
 the base of the zygoma. The wound was brought together with silver su- 
 tures, and the other injuries examined. There was a Colles fracture of the 
 left arm, which was dressed with a carved splint made for the purpose ; 
 not so perfect as Levis 's apparatus, but sufficient to make an excellent 
 cure. A dislocation of the right elbow-joint (olecranon backwards) was 
 then reduced, and a severe contusion of the right knee bandaged. Arnica 
 3 was given internally, and the patient, much exhausted from his suffer- 
 ings, allowed to rest. Fever, delirium, and coma set in, which were 
 controlled by aconite during the first days, and opium thereafter. Slowly 
 the young man recovered from his injuries, and a good constitution carried 
 him through. 
 
 An orphan boy about five years of age, was leaning from the third-story 
 window of a schoolhouse, when he fell forward violently, striking his head 
 upon the ground. He was insensible, and was brought a distance of 
 five miles to the hospital. When I saw him, about six hours after the 
 injury, I found him still deprived of consciousness, his urine had passed 
 involuntarily, the pulse was hard, full, and slow, the mouth drawn 
 to one side, with other symptoms of an alarming character. Upon ex- 
 amining the wound I found a depression in the skull on the right side, 
 caused by an irregular fracture of about an inch and a quarter in length. 
 This was, with a little difficulty, raised with the elevator, and the external 
 wound allowed to remain open. Six hours after, a slight return of con- 
 sciousness was indicated by sensibility to pain. He was given arnica 6th 
 every two hours, and arnica solution applied to the open surface. The 
 next day the wound was brought together, and the patient rapidly re- 
 covered. 
 
 Ambrose Pare" is said to have been the first who pointed out that 
 the inner table of the skull may be fractured without the external being 
 broken, or there may be a depressed fracture of the inner table without a 
 breakage of the outer, though the latter may be divested of its periosteum. 
 This curious condition is chiefly found in gunshot fractures of the cranium. 
 The breakage of the internal table, until the year 1865, was supposed to be 
 due to the greater brittleness of the vitreous bone, but Mr. Treevan has 
 proved that fracture always commences in the line of extension, not that of 
 compression. 
 
 If there is apparently a simple fracture of the skull, and there be 
 doubt about its diagnosis, the proper method is to cut down upon it 
 and ascertain its nature and extent. This is in direct opposition to 
 
 46 
 
722 A SYSTEM OF SURGERY. 
 
 the rules of all the older surgeons, who saw in scalp wounds, erysipelas, 
 haemorrhage, and death. Experience, however, proves this to be the best 
 rule, and it may be followed in every case of the kind. 
 
 Concussion of the Brain may be divided into three stages. The first, 
 that of insensibility and derangement of the bodily powers, which immedi- 
 ately succeeds the accident. While in this condition the patient is appar- 
 ently insensible to external impressions, but can generally be aroused, the pulse 
 is intermitting, the extremities cold, and breathing difficult, but in the gene- 
 rality of instances without stertor. The pupils may be dilated or contracted, 
 or one may be dilated and the other contracted. This stage has a short 
 duration, and is succeeded by the second, in which the symptoms gradually 
 disappear, the pulse and respiration become more natural, and though 
 not entirely normal, are sufficient to diffuse warmth throughout the extreme 
 parts of the body, and to maintain life. As the effects of the concussion 
 still diminish, the capability of exerting the mind becomes increased, the 
 patient can reply to questions, and refers the chief cause of his sufferings 
 to the head. Vomiting often occurs at this time, and is not an unfavorable 
 symptom. As long as stupor remains, inflammatory action appears to 
 be moderate, and as the former abates, the latter increases ; and this con- 
 stitutes the third and most important stage of concussion. Death, how- 
 ever, sometimes instantaneously supervenes, from cessation of the heart's 
 action. 
 
 These are the symptoms that are laid down as belonging to concussion. 
 The question, however, arises in the fatal cases as to how much contusion 
 there is of the brain-substance. Mr. Bryant* makes the following remark- 
 able statement : " At Guy's Hospital , during the last fifteen years, no case is 
 recorded of death from concussion without change of brain structures." He also 
 says: 
 
 11 Mr. Hewett states : ' In every case in which I have seen death occur 
 shortly after, and in consequence of an injury to the head, I have invari- 
 ably found ample evidence of the damage done to the cranial contents f and 
 Mr. Le Gros Clark, of St. Thomas's Hospital, says : ' I have never made nor 
 witnessed a post-mortem after speedy death from a blow on the head, where 
 there was not palpable physical lesion of the brain ;' and Dr. Xeudorfer, of 
 the Austrian army, declares that he has never seen concussion, properly so- 
 called, except in apparently trivial injuries. 
 
 "M. Fano, a recent French writer, has also come to the conclusion, ' that 
 the symptoms generally attributed to concussion are due, not to the concus- 
 sion itself, but to contusion of the brain, or to extravasation of blood.' In 
 fact, all now agree, when death follows a severe shaking of the brain, or 
 concussion, that contusion or bruising of the brain is invariably found." 
 
 Treatment. — The medicine that is most serviceable in the treatment 
 of concussion, is arnica ; and its early administration, if the injury be 
 not severe, will not only prevent many of the evil consequences that 
 may result, but by its influence upon the vessels may limit extravasa- 
 tion of blood within the cavity of the cranium. If the injury be severe, 
 and there is extreme restlessness and jactitation of the muscles, quick 
 small pulse, rigors, and delirium, bell, must be employed. If there be 
 jerking of the tendons of the extremities or clenched hands, with foam at 
 the mouth, stram. will be of service. If the patient roll the head from side 
 to side, and there is much depression, stertorous breathing, hiccough, etc., 
 hyos. is indicated. The medicines that are homoeopathic to irritation, 
 and which should be employed at the commencement of the third stage, 
 are ignatia and cicuta virosa. It would be the better practice, when the 
 
 * * The Practice of Surgery, p. 63, Fourth American Edition. 
 
COMPRESSION OF THE BRAIN. 723 
 
 cause of the affection is considered, to alternate arnica with other medi- 
 cines which the symptoms may render applicable. Aconite should not 
 be forgotten, when after the injury the mental faculties of the patient 
 appear considerably impaired, as inability to think, weakness of memory, 
 vertigo on raising the head, blackness before the eyes, nausea, and some- 
 times vomiting ; when the latter symptom is prominent and the matter 
 ejected is blackish or brownish, with prostration of the vital powers, are. 
 should be employed. 
 
 Compression of the Brain. — The brain may be compressed in four ways : 
 1st, from effusion of inflammatory products ; 2d, extravasated blood ; 3d, 
 from suppuration, and 4th, by depressed bone. Assistance in the diagnosis 
 from either of the above causes is derived from a knowledge of the time at 
 which the symptoms of compression occur. Thus a blow with a hammer, 
 fracturing both tables of the skull, produces immediate symptoms. An 
 extravasation of blood takes place more slowly, and the symptoms follow 
 gradually in severity as more fluid is poured out. Effusion from inflam- 
 mation takes a longer time for its appearance than the extravasation of 
 blood, and suppuration, which is generally caused by the presence of a for- 
 eign substance, occupies a still longer period, while depression of bone, 
 either of one or both tables, produces in many cases immediate symptoms. 
 
 The records of surgery furnish numerous examples of recovery after 
 extensive depressions, from which the patients sustained little incon- 
 venience, and for the relief of which no operations were performed. On 
 the other hand, cases occasionally occur in which from depression of both 
 tables or from extensive fracture of the inner, urgent symptoms have 
 resulted, but have been speedily relieved upon elevating the bone to its 
 natural level. 
 
 The symptoms of compression resemble those of apoplexy. If the cere- 
 bral functions cease totally or partially in consequence of the pressure of 
 extravasated blood upon the brain, the symptoms of nervous apoplexy or 
 paralysis are present, which in many respects closely resemble those pro- 
 duced by violent concussion. The patient is extremely pale, with pulse 
 feeble and irregular, and the whole body appears totally paralyzed ; vomit- 
 ing sometimes occurs. In some instances, after such a condition has existed 
 for a time, the pulse becomes fuller, the face assumes a more natural color, 
 or becomes very red, and all other symptoms of hyperemia make tbeir 
 appearance, precisely as after concussion. 
 
 In other cases the patient is deprived of consciousness or sensation, is 
 totally or partially paralyzed, faeces and urine pass off involuntarily, or the 
 latter may be retained ; the breathing is stertorous, the pulse is hard, full, 
 and slow, the eyelids droop as if paralyzed, the mouth is drawn to the side, 
 and the eyes are staring and protruded, with insensible and often dilated 
 pupils. In many cases the patient vomits, and the face looks livid and 
 turgescent. Pus, or coagula formed by extravasated blood, may also pro- 
 duce compression. Suppuration, however, does not immediately follow an 
 injury of the skull, and often proceeds from irritation occasioned by the 
 shattered fragments of the internal table. Mr. Bryant lays down the fol- 
 lowing important diagnostic points : 
 
 " When a patient receives a direct blow upon one side of the head, and a 
 fracture with depression of the bone ensues, associated with paralysis of the 
 opposite side of the body as an immediate result of the injury, and a fixed 
 and dilated pupil on the side of the injury, the conclusion is inevitable that 
 the depressed bone is the cause of the paralysis, by producing pressure upon 
 the brain ; the depression must, however, be very great to give rise to such 
 symptoms. 
 
 " When another patient sustains a similar injury, with or without depres- 
 
724 A SYSTEM OF SURGERY. 
 
 sion of the bone, but followed after a distinct interval of time by paralysis 
 of one side of the body, whether of the injured side or not, it is quite fair 
 to infer that hemorrhage has taken place inside the skull, and is the cause 
 of the compression. 
 
 " In both of these cases a local injury is followed by local mischief, 
 causing a local paralysis, and surgical treatment is of great promise. In 
 these cases the mode of production of the injury and the history form the 
 surgeon's best guide to its nature. These cases are, however, very rare." 
 
 The following is the differential diagnosis between concussion and com- 
 pression : 
 
 CONCUSSION. COMPRESSION. 
 
 Symptoms immediate. Interval from a few minutes to a quarter of 
 
 an hour. 
 
 Patient, able to answer questions, with diffi- Power of speech lost. 
 
 culty, and in monosyllables. 
 
 Power retained by special senses. Not retained. 
 
 Nausea and sometimes vomiting. Stomach not active. 
 
 Relaxed bowels. Torpid bowels. 
 
 Respiration, without much noise. Stertorous. 
 
 Passage of urine involuntary , power re- Atony of bladder. 
 
 tained. 
 
 Contracted pupils, lids movable. Dilated and unaffected by light. 
 
 Treatment. — The first act of the surgeon, when called to a patient suffering 
 from compression of the brain, is to administer a dose of arnica. This 
 medicine is employed by many distinguished surgeons in the treatment of 
 this injury. If symptoms are present that in a measure call for the 
 exhibition of other medicines, they may be administered in alternation with 
 arnica. 
 
 Veratrum should be employed when there is coldness of the whole person, 
 with distorted and protruded eyes, disfigured countenance, flabby muscles, 
 trismus, and imperceptible breathing. Coffea by the mouth and anus has 
 frequently succeeded in relieving such symptoms. 
 
 Aconite is an important medicine in the treatment of compression, and 
 belladonna has frequently produced desirable results. 
 
 Opium also restores the reactive power of the organism, and is indicated 
 when there is stupor, with coma, stertorous breathing, red, bloated face, full 
 slow pulse, and profuse sweat. 
 
 Lauroc, hyos., stram., mere, plumb., and iodine, are useful medicines ; 
 the latter especially when there are violent pulsations of the whole body, 
 with anguish and dyspnoea. Other remedial agents may be called for, 
 but want of space will not permit their insertion. When this treatment 
 does not relieve the patient, and there is reason to believe that the brain 
 is still oppressed by a coagulum, the trephine must be resorted to, and the 
 foreign substance removed. 
 
 If after injury inflicted upon the skull, a depression is observed and there 
 are but slight symptoms of compression, the surgeon must remember that 
 fragments of bone, though at first producing little irritation, may after a 
 time provoke the inflammatory process, which may terminate in suppura- 
 tion, and thus disastrous consequences may ensue. The question of 
 operation in this, as in all other cases, requires serious consideration. 
 
 The Application of the Trephine. — The use of the trephine was known 
 from remote ages. Bones have been exhumed from the tombs of the Incas 
 in Peru which present undoubted signs of having been perforated with this 
 instrument. From this we learn that the trephine must have been known 
 prior to the times of Cortez. 
 
 At present there is perhaps no subject within the domain of sur- 
 gery upon which surgeons are so divided in opinion as that of the applica- 
 
TREATMENT OF COMPRESSION OF THE BRAIN. 725 
 
 tion of the trephine in injuries of the head. Mr. Gamgee has well stated 
 that " the lesson very impressively taught by a careful study of the subject 
 is this, that whereas the trephine was almost indiscriminately employed 
 before surgery attained to the position of a science, its use has steadily 
 decreased as enlightened experience has accumulated.."* From a careful 
 study of the literature of this subject, I believe that the presence of brain 
 symptoms, or, in other words, the appearance of those symptoms which 
 indicate that the brain itself is being much interfered with, and that 
 the lesion is on the increase, is the indication that the trephine should be 
 employed. Listonf thus wrote years ago: "When fracture of the skull 
 is complicated with wound of the scalp, the surgeon will not in general 
 mend matters much by trephining, as has been advised, merely because 
 there is a wound ; if the depression is pretty extensive, and unless he has 
 a better reason to give for the proceeding than the mere circumstance of the 
 fracture being compound, as it is called, he will often thus add as much to 
 the injury and to the risk which the patient is subjected to by it, as he 
 would by dividing the scalp in simple fractures." 
 
 And to-day, after a careful review and comparison of the practice of 
 various surgeons, Mr. Gamgee thus finishes his scholarly lecture : 
 
 " Many surgeons, from being advocates of the trephine, have gradually 
 abandoned it ; but, so far as my researches have extended, I cannot find an 
 instance of conversion to the practice of trephining by a surgeon whose rea- 
 son indisposed him to adopt it, or whose experience had once led him to 
 relinquish it. That there may be cases of compound depressed fracture of 
 the skull justifying operative interference, I do not deny, and I myself had 
 occasion to operate successfully on such cases in this theatre. For the pres- 
 ent, I shall limit myself to again impressing upon you my conviction that, 
 in compound depressed fractures of the skull, without brain symptoms, the 
 proper course of practice is not to trephine." 
 
 In a report of 106 cases of fracture of the cranium, by M. C. Sedillot.J 
 it is found " that in fracture of the internal table of the cranial vault, with 
 displacement of fragments, trephining is the only means of preventing com- 
 plications which are almost inevitably fatal." 
 
 Of the 106 cases of fracture collated, 77 were trephined : of the remaining 
 26 cases, no operation was performed. Of the latter, but a single one 
 recovered. 
 
 Of the 77 patients who were trephined, 30 recovered and 47 died ; 9 were 
 operated upon before the appearance of any untoward symptoms ; of these 
 6 recovered and 3 died. 
 
 Of the 21 cases in which the operation was performed before the sixth 
 day, 8 ended in recovery, and 13 in death. Of the remaining 47 patients 
 who were trephined after the sixth day, 15 recovered and 32 died ; showing 
 that the mortality is in direct proportion to the time of operating. Two- 
 thirds of the cases were cured by preventive trephining ; more than one- 
 half by early trephining (before the sixth day), and less than one-third by 
 late trephining (on or after the sixth day). 
 
 Cerebral Motor Localizations. — In injuries of the head there is consider- 
 able discussion among surgeons as to whether, disregarding depressing frac- 
 tures, the application of the trephine should be determined by internal 
 symptoms, or, if the operation has been decided upon, to localize the spot 
 
 * On the Treatment of Compound Depressed Fractures of the Skull, bv Sampson Gamgee, 
 Esq., F.E.S. ; Braithwaite's Am. Ed., January, 1877, p. 116. 
 
 f Practical Surgery, p. 45. 
 
 i American Journal of the Medical Sciences, April, 1877, also Gaz. Medicale de Paris, 
 No. 39, 1876. r 
 
726 A SYSTEM OF SURGERY. 
 
 where the instrument should be applied by the presenting subjective symp- 
 toms. Especially in recent cases of traumatism is this method of deter- 
 mining the point of operation said to be the most serviceable. According 
 as one or another set of muscles are implicated, the surgeon may be able 
 to determine the particular motor centre that has been injured. It should 
 be, however, borne in mind that by reflex nerve irritation remote parts may 
 be affected, and symptoms, therefore, being only secondary, trephining at 
 the wrong point might be indicated. 
 
 This, however, we know, that, if there exists a convulsion, and, above all, 
 paralysis of a group of muscles, there also exists some lesion of a motor 
 centre, and since physiology teaches where these centres are, it should be 
 an easy matter to refer them to their corresponding points in the cranium. 
 M. Lucas Championniere tells us, that what are termed the cortical centres 
 occupy a space limited to the vault of the cranium, and that all the 
 centres and all the convolutions which form them, are grouped around 
 the fissure of Rolando, and immediately below the anterior half of the pa- 
 rietal bone. The method of finding it is thus described. It is known that 
 in man the fissure of Rolando commences fifty -three millimeters behind the 
 bregma ; fifty-five millimeters are to be measured behind it and marked on 
 the skull. Next we must measure behind the external orbital process a 
 horizontal line, seven centimeters long, and erect a line at right angles to its 
 extreme edge, three centimeters long, and the point thus found will corre- 
 spond with the inferior extremity of the fissure of Rolando. If, between 
 these two points, we mark on the integument a straight line, we obtain the 
 " line of Rolando ," and if the trephine be applied exactly over this line, the 
 fissure of Rolando is met with invariably. These measurements are rather 
 less in females. 
 
 It must be remembered that, although this method of measurement is 
 true for certain regions, individual convolutions vary somewhat in their 
 positions, and are not always constant towards the vertex, and that the size 
 of the crown of the trephine must be taken into consideration according to 
 the presumable exactness of the diagnosis * 
 
 MM. Charcot and Pitres have made some interesting experiments, and 
 arrived at conclusions which will materially assist in the more precise 
 localization of the cerebral motor tracts, and, if carefully studied, will 
 give the operator valuable assistance, as to the spot whereupon to place his 
 trephine. I have taken the conclusions drawn by these distinguished 
 authors, from a notice of their labors, in the editorial columns of a recent 
 medical periodical^ These conclusions are as follows : 
 
 1. The cortex of the cerebral hemispheres in man may be divided, func- 
 tionally, into two parts ; motor and non-motor, according as destructive 
 lesions do or do not cause permanent paralysis of the opposite side of 
 the body. 
 
 2. The non-motor zone comprehends : a. All the prefrontal region of the 
 brain (orbital lobe first, second, and third frontal convolutions). 6. All the 
 occipitoparietal region (occipital lobe, superior and inferior parietal lobules). 
 c. All the tempero-sphenoidal lobe. 
 
 3. The motor zone includes only the ascending frontal and ascending pa- 
 rietal convolutions and the paracentral lobule. 
 
 4. The paralyses produced by destructive lesions of the motor zone have 
 different clinical forms according to the location of the lesion. Thus com- 
 plete hemiplegias of cortical origin are produced by diffused lesions of the 
 ascending convolutions ; partial paralyses are produced by circumscribed 
 
 * Monthly Abstract of Medical Science, vol. iv., No. viii. 
 f Medical Eecord, November 10th, 1883. 
 
TREATMENT OF COMPRESSION OF THE BRAIN. 
 
 727 
 
 Fig. 424. 
 
 lesions of these same convolutions. The location of the lesion in some of 
 these partial paralyses or monoplegias can be determined. MM. Charcot 
 and Pitres announce the following as data for such determination : a. The 
 brachio-facial monoplegias coincide with lesions in the inferior half of the 
 ascending convolutions, b. The brachio-crural monoplegias coincide with 
 lesions in the upper half of the ascending convolutions, c. The facial and 
 lingual monoplegias depend upon very circumscribed lesions of the lower 
 extremity of the ascending convolutions, particularly of the ascending 
 frontal, d. The brachial monoplegias depend upon a very limited lesion of 
 the motor zone ; particularly of the middle third of the ascending frontal. 
 e. The crural monoplegias depend upon very limited lesions of the para- 
 central lobule. 
 
 5. "Whether those paralyses caused by destructive lesions be general or 
 limited, they will in time be followed by secondary contractures of the 
 paralyzed muscles with descending degenerations oi the voluntary pyra- 
 midal tracts. 
 
 6. Irritative lesions of the cortex can give rise to epileptiform convul- 
 sions (partial or Jacksonian epilepsy), which are different from those of 
 true epilepsy. They begin with a motor aura, and may be either general- 
 ized or limited. 
 
 7. In general the irritative lesions, which cause epileptiform convulsions, 
 are located at or near those centres which, if destroyed, would cause paral- 
 yses in the muscles affected by the convulsion. But these lesions may be 
 even in the non-motor zone, and their relations to the functionally affected 
 centres is not so close as is that of 
 
 paralyses and destructive lesions. 
 
 In conclusion, the authors reaf- 
 firm their belief that no facts op- 
 posed to the doctrine of cerebral 
 motor localizations have been es- 
 tablished. Their own observations 
 and studies, as shown above, do 
 not so much add that which is 
 new, as they make definite and 
 certain our previous views. They 
 contradict, to some extent, the con- 
 clusion of Esner, regarding the 
 existence of diffused and over- 
 lapping centres. We are inclined 
 to believe, however, that the 
 method employed by Charcot and 
 Pitres is more trustworthy than 
 the unusual one adopted by Es- 
 ner. 
 
 The instruments to be employed 
 are found in the trephining cases, 
 or are placed in the ordinary amputating, resecting, or general operating 
 cases of the day. They consist of a couple of scalpels, a lenticular-shaped 
 knife, a trephine or two which can be set in one handle (Fig. 424 represents 
 the shape of the ordinary instrument ; Fig. 425 shows Gait's trephine, and 
 Fig. 426 the handle), the ordinary artery forceps and tenaculum, a brush 
 to clean the trephine, a sharp-pointed piece of wood, or a wire or toothpick 
 to clean the groove made by working the instrument. 
 
 The patient generally being in a comatose condition, or in a state of par- 
 tial insensibility, an anaesthetic agent is unnecessary. If the fracture is 
 compound, it may be requisite to enlarge the incision. If the fracture is a 
 
 Plain Crown Trephine. 
 Fig. 425. 
 
 Gait's Trephine. 
 
 Fig. 426. 
 
 T/CMANN:00 
 
 Trephine Handle. 
 
728 
 
 A SYSTEM OF SURGERY. 
 
 simple one, with depressions, then incisions may vary according to the 
 judgment of the operator. They may be made either of the above shapes 
 
 Fig. 427. 
 
 U + "1 A 
 
 (Fig. 427). After having raised the flap sufficiently, the crown of the tre- 
 phine is placed over the part to be removed, and fixed in its place by press- 
 
 FlG. 428. 
 
 Fig. 429. 
 
 ing down the pin in the centre, which must be, by a little rotation and 
 pressure, fixed in the skull ; the instrument is then rotated — without pressure 
 
 Fig. 430. 
 
 An extensive depressed fracture of the vertex of the skull which has been elevated by trephining. 
 The mark of the trephine is seen at the corner of the sound bone, a, and it has also just touched the end 
 of the depressed bone, b, and the traces of Hey's saw, which has been used to take off the over-hanging 
 edges of the sound bone, are very distinctly marked, c. The depressed bone has all been very fairly 
 elevated, and the operation did temporarily relieve the symptoms of compression, as the patient became 
 a little more sensible, and was able to speak, but he only lived a few hours. Death was caused mainly, 
 as it seems, by haemorrhage between the bone and dura mater, the source of which was not precisely 
 ascertained. The fracture passed across one of the main grooves for the middle meningeal artery, but 
 the vessel itself appeared uninjured. The dura mater was not torn, but the lower part of the middle 
 lobe of the brain was contused on each side. The depression seen at the back of this preparation 
 appears to be due to some old injury, but nothing is known about it. — St. George's Hospital Museum, Ser. 
 i., No. 16.— Holmes. 
 
 — backward and forward, being removed from time to time to clean away 
 the dust with a brush, and to cleanse the groove with the quill ; as the lower 
 
INJURIES AND DISEASES OF THE NOSE. 729 
 
 table of the skull is reached more care is required, and when the " button " 
 is sawn out it may be lifted away with the forceps, elevator, or a gimlet 
 made for the purpose. If it is possible, in using the trephine, the sinuses 
 of the dura mater and the large vessels should be avoided. It may also be 
 borne in mind that there is often space enough left between the fractured 
 bones to introduce an instrument and elevate the depressed portion without 
 applying the trephine. Again, it is not always necessary, when endeavoring 
 to elevate a portion of bone, to remove the entire circle with the trephine ; 
 all that is required is sufficient space for raising the fragments ; this may 
 be done by fixing the pin on the edge of the sound bone, and removing 
 with the saw only the segment of a circle. Figs. 428 and 429 show the 
 methods of operating, and Fig. 430, from Holmes, shows the method of 
 placing the crown of the trephine partly in sound bone. 
 
 CHAPTER XXXVII. 
 
 INJURIES AND DISEASES OF THE NOSE. 
 
 Malformations — Foreign Bodies — Epistaxis — Lipoma Nasi — Ulceration— Oz^na 
 — Polypus Nasi— Myxoma — Naso-pharyngeal Polypus— Osteo-plastic Eesec- 
 tion — Rhinoscopy. 
 
 Malformations. — The nose is occasionally subject to malformations, the 
 chief of which is a deviation of the septum from the centre to one side, or 
 in some instances, downward. 
 
 In two cases that came under my supervision, I was enabled to remedy 
 the deformity by excising the misplaced septum. In one case I was obliged 
 to cut through the central cartilage, and in the other to slice off a portion of 
 it, and restore it to position by plugging with tinfoil the nostril encroached 
 upon. In both instances I was astonished at the amount of blood lost, 
 although no vessels were large enough to ligate. 
 
 Foreign Bodies. — Foreign bodies, such as beads, peas, bits of wood, cotton, 
 pieces of pencil, etc., are thrust into the nose, especially by children. They 
 often occasion not only a good deal of inconvenience and fright, but lead to 
 serious ulceration, if not speedily removed. If they can be seen, a small 
 pair of curved and delicate forceps, with the blades spread widely apart, 
 should be introduced carefully along the floor of the nares and the foreign 
 
 Fig. 431. 
 
 TIEMANN-CQ NY 
 
 Bristle Probang. 
 
 body grasped and removed. If this is not sufficient, a bristle probang 
 closed (Fig. 431) should be passed into the nostril and the handle with- 
 drawn. This bends the bristles, fills the nares, and the body is removed. 
 In other cases longer instruments are required. On all occasions gentleness 
 
730 A SYSTEM OF SURGERY. 
 
 and patience should be employed, and in the majority of instances an anaes- 
 thetic should be used. Strong snuff may sometimes produce sufficiently 
 violent sneezing to dislodge the foreign body. 
 
 Epistaxis — Haemorrhage. — Bleeding from the nose is a frequent occurrence, 
 especially in young subjects. It may occur as a critical discharge and be 
 considered favorable, or it may appear in enfeebled constitutions and be a 
 dangerous symptom. Some persons are more prone to epistaxis than others, 
 the bleeding occurring upon slight provocation, or in many instances with- 
 out any assignable cause. Puberty and old age are the periods at which 
 haemorrhage from the nose is most likely to occur. In some cases it is so 
 profuse as to cause great prostration ; indeed, instances are recorded which 
 terminated fatally. 
 
 Treatment. — The Materia Medica furnishes a number of medicines which 
 are efficacious in the treatment of nosebleed, even of a violent character. 
 Among these are : aeon., carbo veg., china, crocus, erigeron, ham.,nux vom., 
 verat., secale. 
 
 When there is passive haemorrhage in old people, carbo veg. is excellent. 
 Trillium also may be employed. 
 
 Thlaspi bursa pastoris, arsenicum, pulsatilla, rhus tox., mercurius, and 
 agaricus, are also medicines of importance. 
 
 If these fail in arresting the bleeding and the patient is sinking, or shows 
 symptoms of prostration, I have frequently stopped the haemorrhage by 
 
 Fig. 432. 
 
 Bellocq's Canula. 
 
 cutting strips of cotton cloth, half an inch wide and six inches in length, 
 twisting them upon themselves, and then, having dipped them in a solution 
 of alum or tannin, passed them into the nostrils with a female catheter. 
 In other instances it may become necessary to plug the posterior nares. 
 This is effected as follows : Prepare two dossils of lint, each somewhat larger 
 than the openings of the posterior nares (Ende's styptic cotton would answer 
 admirably for this purpose), and having secured them by tying around their 
 middle a strong cord, pass into the nostrils a Bellocq's canula (Fig. 432) with 
 the piston drawn out ; having carried the instrument carefully along the floor 
 of the nares, its curve will project down behind the velum palati : then push 
 forward the piston, which brings the spring, with the eyelet at its extremity, 
 into the cavity of the mouth. Into the eyelet pass the end of the cord at- 
 tached to one of the dossils of lint, and draw out the piston ; this brings for- 
 ward the thread, and the dossil is forced into one of the openings of the nares. 
 A similar, proceeding is adopted with the other nostril. The plugs should 
 be allowed to remain a day or two, before they are carefully removed. 
 
 Professor Weber discovered that when a person breathes entirely through 
 the mouth, the posterior nares are closed by the soft palate ; therefore the 
 nasal douche should be employed. The water should be hot, and contain 
 a small quantity of liquor Jerri persulphatis. 
 
 Dr. Beverly Robinson* records a most severe case, in which styptics had 
 
 * Medical Record, March, 1876. 
 
ULCERATION — OZiENA. 
 
 731 
 
 failed, but pressure on the facial (made with pads of lint) on the superior 
 maxillary bones, just before the vessels reach the ahe, was successful. 
 
 Hypodermic Use of Ergotin. — Dr. Porak* speaking of epistaxis, arrested by 
 subcutaneous injections of ergotin, remarks, that he used a solution of 2 
 grms. (30 grs.) of Bonjean's Ergotin in 30 grms. of glycerine, and injected 
 20 drops into the lip or cheek. He records three cases of persistent epistaxis, 
 in each of which the haemorrhage was controlled by a single injection of 
 ergotin under the skin. 
 
 Lipoma Nasi — Hypertrophy. — This affection consists of a hypertrophic 
 condition of the integumentary substance of the nose, which may arise from 
 various causes: often from acne rosacea of long standing, and from deposi- 
 tions of fatty substance around the alse nasi. The growths, as we most 
 commonly see them, are globular or lobed, and vary in number and size. 
 Cases are upon record in which they attained such magnitude, that they 
 hung down on the chin, interfering with respiration and speech. In other 
 cases, these growths may be flattened, and again in others, they may be 
 pedunculated. They are gristly and hard when cut into, and though they 
 may attain a remarkable size — growing externally — they never invade 
 either the mucous membrane or cartilaginous substance of the nose. 
 
 The color of lipomata is dusky red, or purplish; and they rarely appear 
 in persons under fifty years of age. 
 
 Treatment. — Nothing but the knife will be of any avail. The growths 
 must be cut away, or better, a flap of integument dissected from them, and 
 then enucleation effected. There is often a good deal of nicety required in 
 the dissection to prevent the cartilages from being cut through. To obviate 
 this, the surgeon should keep his finger constantly in the nostril. 
 
 Ulceration — Ozaena. — This affection is a troublesome ulceration of the lin- 
 ing membrane of the nostrils, attended with fetid purulent discharge. Occa- 
 sionally it is followed by destruction of the nasal 
 cartilages, and by caries of the nasal bones. In 
 some instances the senses of smell and taste are 
 entirely destroyed. 
 
 Though the origin of the disease is somewhat 
 obscure, yet there is reason to believe that, in 
 most instances, it is connected with the primary 
 or secondary forms of syphilis; and in others 
 with a purely scrofulous diathesis. The most 
 disagreeable feature of the affection is the ac- 
 cumulation of inspissated mucus or incrusta- 
 tions within the nasal cavities, which sometimes 
 form in such considerable quantity as to entirely 
 close the passages. After ulceration is fairly es- 
 tablished, not only is the cartilaginous septum 
 affected, but the ethmoid, the spongy, and other 
 bones of the nose ; and, in the worst cases — par- 
 ticularly when there is complication with syphi- 
 litic or mercurial disease — even the palate and 
 superior maxillary bones exfoliate, and in con- 
 sequence of such ravages the contour of the nose 
 is destroyed, and frightful deformity of the face 
 results. 
 
 Treatment. — The medicine which has been productive of most beneficial 
 results in my hands is the bichromate of potash. The secret of success is 
 its prolonged use, sometimes it being steadily taken for months. I use 
 
 Fig. 433. 
 
 The Medical Record, November 16th, 1878, No. 419. 
 
732 
 
 A SYSTEM OF SURGERY. 
 
 the third trituration, and give one powder per day. In addition to this 
 every morning the nasal douche (Fig. 433) is employed, the water being 
 at a temperature of 68° or 70°, and containing salt sufficient to render 
 it brackish. Patients, in the majority of cases, express themselves as 
 experiencing great relief after its use. In some cases, it cannot be borne, 
 giving rise to pain and sometimes even haemorrhage. In such, of course, 
 cleanliness must be obtained by the use of a small syringe. With reference 
 to the insufflation of alum or tannin, or the local application of various sub- 
 stances by means of steam atomizers, I cannot speak in very high terms, 
 
 nor can I of the injections of carbolic acid, per- 
 FlG - 434 - manganate of potash, sulphate of copper, and 
 
 other drugs. The properly selected medicine 
 and cleanliness are much more successful than 
 local measures, according to my personal ex- 
 perience. 
 
 Other remedies which have chiefly been em- 
 ployed in this affection are : alumina, teucrium, 
 puis., sulph., calc, magnes. mur., bryonia, 
 bell., lycopod., natr. mur., and causticum, in 
 the first stage ; when the secretion has been 
 transformed into pus, and the nasal bones are 
 affected, with fetid odor from the nose and 
 loss of smell, mercurius and aurum are to be 
 administered. These may be followed if re- 
 quired, in ozsena scrofulosa, by sulph., sil., acid, 
 nit., phosph., conium, or kali bich. In syphi- 
 litic ozsena, mercurius constitutes the principal 
 remedy ; if, however, the patient has been sub- 
 jected to an injurious course of treatment 
 with this medicine, potassium iodide is pre- 
 ferred, and sometimes nit. acid, hepar, asafce- 
 tida, conium, or thuja. 
 
 Baptisia, hydrastis, phytolacca, and sangui- 
 naria, are recommended in The New Remedies, 
 by Drs. Hale, Powers, and others, for this 
 troublesome affection. 
 
 Polypus Nasi. — A polypus of the nose may 
 arise from any portion of the Schneiderian 
 membrane, but it originates most frequently 
 from either the superior or inferior spongy 
 bones. Occasionally the seat of the tumor is 
 so high, that instead of falling toward the an- 
 terior nares, it takes a backward direction, 
 hanging behind the palate, and sometimes even 
 reaching the pharynx. It is commonly 
 pyriform, narrow at its base and expanded 
 below, though this depends much upon the 
 natural form of the cavity in which it is situ- 
 simcock's Polypus Forcei a * e( ^ i sometimes the base of the tumor is ex- 
 
 ceedingly large. Either one or both nostrils 
 may be affected, and when the latter the patient breathes with much diffi- 
 culty, and with a peculiar rattling noise. In damp weather the tumors 
 often project beyond the exterior of the nostrils, but assume their former 
 position upon the reappearance of a dry atmosphere. 
 
 The consistence of nasal polypi is not less variable than their form. In 
 some instances they are soft, and in reality consist of enlarged mucous sub- 
 
POLYPUS NASI. 733 
 
 stances ; to these the term myxomata is given. These are the most amen- 
 able to treatment. The fibrous polypus is a dangerous and obstinate growth. 
 It is not frequently met with, has none of the softness of the first variety, 
 grows from the periosteum, is opaque, reddish in color while in situ, being 
 traversed with large vessels. When it projects into the pharynx, the term 
 naso-pharyngeal polypus is given to it. It often produces by its pressure 
 caries of the ethmoid and spongy bones, inflammation of the brain, etc. 
 
 Treatment. — The medicines which have proved most efficacious are calc. 
 carb., teucrium, sulphur, and phos. j* puis., silicea, staph., carbo an., and 
 sepia may also be called for in some cases. 
 
 The best remedies are undoubtedly calc. carb., teucrium, phosphorus, 
 and sulph. I treated successfully a case of returned polypus, for which 
 an operation had been performed in New Orleans, by teucrium, phosph., 
 and filix mas, with occasionally a dose of calcarea carb. and sulph. 
 
 Dr. John E. James speaks highly of freshly powdered sanguinaria cana- 
 densis root, blown through a quill or other cylindrical tube over the whole 
 polypus ; in many, if not most cases, three applications, at intervals of from 
 three to seven days, being sufficient to effect a radical cure, and should the 
 polypus be so large as to necessitate forcible removal, the application once 
 or twice will give temporary relief before the operation. 
 
 Dr. Thomas Bryant, after an experience of three or four years, also speaks 
 highly of the use of tannin in a similar manner. 
 
 Sometimes it is necessary, when medicines cannot effect a cure, to remove 
 the polypus by mechanical means; this may done in a variety of ways, 
 but in most cases the use of the forceps is preferable. These should be 
 stronger than the ordinary dressing forceps, well serrated and slightly curved. 
 The patient is seated on a low chair, before a powerful light, with the head 
 moderately thrown back and firmly supported ; the surgeon carefully intro- 
 duces the instrument with its blades expanded, grasps the tumor firmly at 
 its root, and by twisting rather than pulling removes it. 
 
 Although in many surgical works the extraction of a polypus is treated 
 as an easy operation, yet my experience proves that a strong polypus, 
 situated far back, with the greater part of its bulk posteriorly, is by no 
 means readily detached. In the first place, the straight forceps usually found 
 in pocket cases is not long enough, either in the handle or in the blades, 
 and from its shape is not well adapted to the meati. The better variety of 
 instrument should be eight inches in length, with a curve in the blades, 
 with deep serrations at their extremities for the purpose of grasping firmly 
 the polypus. Even these may sometimes have to be repeatedly introduced 
 before a successful result is obtained. 
 
 A better instrument is that of Simcock, Fig. 434. Its handle is well de- 
 pressed, and there are fenestra in the extremities of the blades, which are 
 long and narrow. 
 
 . Fig. 435. 
 
 Gooch's Canula for Nasal Polypus. 
 
 Ligature is employed often with success when the polypus cannot be 
 extracted with the forceps. Many kinds have been used, as silk cord, silver 
 or iron wire, catgut, etc. ; probably the best is that composed of the latter 
 and silver wire twisted together. A double canula should be introduced as 
 
 * For several interesting cases of polypi nasi, cured by the three former of these medicines, 
 see British Journal of Homoeopathy, vol. viii., p. 283 ; and vol. x., p. 484. 
 
734 
 
 A SYSTEM OF SURGERY. 
 
 far as possible into the nares, and the loop of ligature pushed back to 
 embrace, if possible, the foreign growth; this is aided by the introduction 
 of the ringer into the pharynx. The growth must then be constricted. 
 
 For this purpose the canula of Gooch answers better than the old- 
 fashioned double cylinder, Fig. 435. 
 
 Naso -pharyngeal Polypus. — In consequence of the difficulties experienced 
 in obtaining access to the naso-pharyngeal polypus many operations 
 have been recommended as preliminary measures to the extirpation of the 
 growth itself. Hence we have the division of the external nose, advocated 
 by Hippocrates ; the total resection of the superior maxilla, as performed 
 by Syme in 1832, and by Flauvert in 1840 ; but this always left great 
 disfigurement and functional disturbance, and for this reason was opposed 
 by Langenbeck in 1861, who proposed to make the resection in such a 
 manner that, after the second or fundamental operation is performed, the 
 divided bone can be restored to its normal position. 
 
 Probably the most satisfactory operation for gaining access to the seat 
 of this form of polypus is that advised by Professor Bruns, of Tubingen, 
 which he calls an " Osteoplastic Resection of the External Nose for the 
 Removal of Naso-pharyngeal Polypi." It consists of a temporary resection 
 of the bony skeleton of the external nose, allowing the bony and cartilag- 
 inous portions in connection with covering soft parts to be turned sideways. 
 Either one-half or the whole external nose, according to circumstances, requires 
 the opening of one or both nasal cavities. In the first instance the opera- 
 tor divides, temporarily, the processus nasalis of the superior maxilla, and 
 the nasal bone of the same side, then, by violently forcing asunder the 
 suture of both nasal bones, the hinge movement is obtained ; while in the 
 second case, a temporary resection is made of the processus nasalis, of the 
 superior maxilla, of the septum nasi, and of both nasal bones ; and here 
 the movement proceeds at the junction of the nasal bones and of the pro- 
 cessus nasalis of the superior maxillary of the opposite side. In order that 
 the modus operandi may be fully understood, suppose a case where the whole 
 
 external nose is to be laid over on 
 fig. 436. the right cheek. The first incision 
 
 is made in the skin, beginning just 
 below the inferior edge of the right 
 ala nasi, and is carried in a hori- 
 zontal direction through the upper 
 lip toward the left as far as the first 
 molar of that side. The section is 
 made through the inferior bony 
 edge of the apertura pyriformis, 
 and there the point of the knife 
 is directed obliquely upward in 
 order that the parts where the mu- 
 cous membrane passes over into the 
 gums may be uninjured. 
 
 The second incision runs hori- 
 zontally over the root of the nose, 
 corresponding to the naso-frontal 
 suture, the point of beginning and 
 ending being one continuation in- 
 ward and upward from the internal 
 angle of the eye. 
 
 The third incision connects the 
 extreme left points of the two horizontal incisions, extending from the inner 
 angle of the left eye, somewhat obliquely outwards and downwards along 
 
NASOPHARYNGEAL POLYPUS. 735 
 
 the left lateral wall of the nose, and forming a junction with the inferior 
 incision at the first molar on the same side. These incisions are seen in 
 Fig. 436. 
 
 All these cuts must be carried through the periosteum down to the 
 bone. With the saw, the nasal spine is divided at its base, and with the 
 bone-scissors the section is carried still farther in the bony septum of the 
 nose. A pointed saw is now inserted in the left inferior angle of the pyri- 
 form opening, and following closely the incision in the skin, cuts its way at 
 first horizontally outward through the superior maxilla and then obliquely 
 upward and inward along the course of the third incision to the naso-frontal 
 suture. During this act, the point of the saw is constantly in the nasal 
 cavity, and the internal wall of the maxillary cavity is not opened unless 
 it has already been perforated by the tumor, but the exterior end of the 
 inferior concha of the nose is cut through. The bases of both nasal bones 
 are divided with a saw along the naso-frontal suture. There now only re- 
 mains the vertical division of the septum narium, which is accomplished 
 by the scalpel or bone-scissors, carried obliquely backwards, partly from the 
 upper and partly from the lower half of the cross cut, thus forming in the 
 septum an angle open in front. Now, by inserting a lever in the upper end 
 of the vertical sawed cleft, the connection of the nasal bone and of the 
 nasal process of the superior maxilla will be forced asunder and the 
 entire external nose laid over on the right cheek (see Fig. 437). Thus the 
 
 Fig. 437. Fig. 488. 
 
 whole nasal cavity on both sides becomes directly exposed, and the space 
 thus gained may be further enlarged by removal of the concha by horizontal 
 incision and lateral dislodgment, or total removal of the septum, according 
 to circumstances, whenever the neoplasm does not itself push away these 
 parts or render them atrophied. The posterior wall of the palate can now 
 be easily reached, and also the base of the skull, which usually forms the 
 seat of naso-palatinal polypus (Fig. 438). 
 
 In Fig. 437 the normal relations of the parts after operation are exhibited, 
 and the same are shown in Fig. 438 after the removal of the septum and 
 the concha of the left side. 
 
 While such a procedure is demanded for the removal of very large polypi, 
 the opening of one cavity only will be sufficient in lighter cases, as when 
 one nasal cavity is filled by the neoplasm and is greatly dilated by dislo- 
 cation of the septum towards the opposite side. The measures adopted in 
 
736 A SYSTEM OF SURGERY. 
 
 such a temporary resection of one side of the external nose differs but 
 slightly from the one already described. The incision through the integu- 
 ment is the same, only both horizontal sections begin somewhat nearer 
 the median line. A modification might be also made in the lower hori- 
 zontal incision by putting the knife into the external angle of the nostril, 
 dividing the lower edge of it, and then continuing the cut in a lateral 
 direction. 
 
 The section is thus made somewhat smaller and does not touch the upper 
 lip ; but the continuity of the aperture of the nostril remains intact. 
 The sawing through of the bone with the pointed saw, begins at the lower 
 external angle of the apertura pyriformis, at first horizontally, and then as 
 before, upward and inward to the naso-frontal suture. From here the base 
 of the nasal bone, on the same side, is sawn across to the median line ; 
 then, by the use of the lever, the suture connecting both nasal bones is 
 opened, and the one-half of the nose is by the hinge movement turned over 
 to the opposite side. 
 
 This portion of the operation requires but a few moments, and presents 
 no serious difficulties. The solution of continuity causes very slight func- 
 tional disturbance, if any. None of the neighboring parts are in danger 
 of being injured, except the lachrymal duct, which might be wounded by 
 sawing too closely to the inner angle of the eye, but which can readily be 
 avoided. 
 
 The haemorrhage in this region is never great, and generally ceases 
 spontaneously, as no large bloodvessel is cut through. 
 
 Having finished the temporary operation, the nose remains in its lateral 
 position, till the fundamental one, removal of the polypus, is completed. 
 In favorable cases the preliminary and the fundamental operations are 
 executed at the same time; immediately followed by reposition and re- 
 union of the nose. But in difficult cases the complete extirpation of the 
 polypus is not advisable at the first operation, as when it has exten- 
 sive attachments to the walls of the nose and palate, or when the opera- 
 tion has to be interrupted on account of fainting or great haemorrhage. 
 By the tampon, the bleeding from the tumor is stopped, filling up the 
 whole cavity with lint or cotton, and by this means the wound is kept open 
 till in one or more consecutive sittings all the foreign growth is removed. 
 In one case, reposition of the nose was performed only after twelve days, 
 and in another after twenty-one days. It has been found possible to delay 
 the replacement of the nose for several weeks, and this fact is of consider- 
 able importance to those surgeons who see in the supplementary application 
 of caustics to the seat of the growth, a provision against a reappearance of 
 the polypus. During this time nutrition is maintained by anastomosis with 
 the sound side, so that no alteration in color or temperature of the skin 
 appears on the divided parts. When reposition is adopted immediately, 
 the application of a few sutures soon effects speedy union, except when 
 the division of the bony sutures is imperfect or jagged, then strips of adhe- 
 sive plaster will aid in keeping the parts in direct apposition. Where re- 
 union is delayed, the edges of the wound must be lightly freshened, and 
 the necrosed bony edges removed with the bone-cutting forceps. 
 
 Reunion takes place in a few days, and the sequestration is never ob- 
 served. In immediate reunion the cicatrix is only linear and scarcely 
 visible, but in later cases the eschar is somewhat broader, and the disfigure- 
 ment more apparent.* 
 
 Professor Tiffanyt relates a successful case of the removal of a naso- 
 
 * For the description of this important operation, I am indebted to my friend Dr. Lilienthal, 
 who translated it from the original German. 
 
 f The Medical Record, October 26th, 1878, No. 416. 
 
RHINOPLASTY. 737 
 
 pharyngeal polypus by the temporary depression of both upper jaws, as 
 follows : 
 
 The polypus was growing from the base of the skull, occluding the right 
 nostril, and had been removed, but returned in four months. It was then 
 decided to depress the two upper maxillary bones and perform a provisional 
 tracheotomy. Six days later, the operation was resumed. "An incision 
 was carried down on either side of the nose, at the juncture of the nose and 
 cheek, then around the ala and through the middle line of the upper lip 
 into the mouth ; the cheeks were then freely dissected from the upper jaws 
 as high as the nasal bones, infra-orbital foramen, and malar bones ; the nose 
 was separated from the upper jaws and turned up towards the forehead. 
 Both upper jaws were depressed, hinging upon the pterygoid processes, and 
 the polypus thus removed." 
 
 Besides the methods already alluded to, the operation of Furneaux 
 Jordan* demands consideration. The object of the proceeding is to thor- 
 oughly uncover the nasal cavity, and this is done by making a triangular 
 flap of the upper lip and the side of the nose. A curved bistoury is carried 
 under the lip into the affected nostril and made to cut its way out, and then 
 the soft part of the nose is divided at one side of the middle line, in a line 
 with the cut in the lip ; a few strokes of the knife will allow the flap to be 
 turned well outward. The nasal cavity is then well open and defined, and 
 easy for manipulation. By passing one or two fingers into the pharynx, 
 and one or two in front, the tumor may be readily detached by snips of the 
 scissors. If the bone opening be too small it may be enlarged by the points 
 of the forceps. 
 
 Rhinoplasty. — The nose is often destroyed by disease, by accident, or by 
 caustics. It may be that either a portion or the whole is removed, including 
 the septum, turbinated bones, lips and roof of the mouth, making hideous 
 deformity, thus rendering the patients revolting not only to themselves 
 but to others. In such cases, the operation of rhinoplasty has accomplished 
 changes of a satisfactory character. Dr. G-urdon Buck and Dr. Hamilton, 
 of New York, Drs. Pancoast and Gross, of Philadelphia, the Warrens, of 
 Boston, together with many European surgeons, have made successful 
 rhinoplastic operations. 
 
 Rhinoplasty may be performed by either sliding the flaps forward from 
 each cheek, by jumping them by a twist, or by taking them from remote parts. 
 
 To remedy a partial destruction of the nose is an operation which may 
 be often completely successful ; but to restore the entire organ, is a much 
 more difficult task. 
 
 If one or both alee of the nose be destroyed, a flap "jumped "from the 
 cheek and twisted by half a circle, may prove satisfactory. The following 
 case was successful. 
 
 Mrs. T., a middle aged and respectable married lady, applied to me to 
 ascertain if any means could be devised to remedy a deformity of the nose 
 which was produced in the following manner : 
 
 She had some time since a painful tubercle on the right ala nasi, which 
 had caused her much worriment ; and being fearful of malignant dis- 
 ease, she had consulted a cancer doctor(?), who applied a paste which 
 took away the tubercle, and with it the whole ala of that side, causing a 
 severe ulceration, which extended to the internal angle of the eye. This 
 solution of continuity had healed, leaving an ugly cicatrix. I explained to 
 her the nature of the operation which could be performed for the restora- 
 tion of the absent ala, to which she assented, and which was per- 
 formed on the second day after our interview. The edge of the gap next 
 
 * British Medical Journal, May 5th, 1885. 
 47 
 
738 
 
 A SYSTEM OF SURGERY. 
 
 to the face was very thin ; indeed, was formed of a portion of the cicatrix 
 already mentioned ; while toward the tip of the nose the border was full, 
 healthy, and prominent. The trouble, if there should be any, would evi- 
 dently be at the thin margin during the process of cicatrization. 
 
 The operation was thus performed : Before she was brought under anaes- 
 thetic influence, a piece of wet parchment was laid over the nose, and cut 
 the exact shape of the cavity to be filled, though one-third larger all around. 
 This was turned back upon the cheek and its outline marked with a pen 
 and ink, by dotted lines. The patient was then rendered insensible, and 
 the flap dissected up, leaving a pedicle. I did not, however, make an inci- 
 sion perpendicularly through the tissues to the cellular substance, but en- 
 tered the scalpel in an oblique direction, thus making a bevelled edge around 
 the entire flap, leaving the pedicle as near as possible to the ala nasi. In a 
 similar manner the edges of the entire gap were refreshed, thus making two 
 tolerably broad raw surfaces. The flap was then twisted to its place, and 
 secured by pins of pure silver, around each of which a single turn of silk 
 was passed. The ends of the pins were then cut with the nippers, and 
 when fully recovered from the anaesthetic, the patient was allowed to return 
 home. On the third day after, I visited her, and removed two of the pins, 
 and applied a strap across the face and over the nose, extending from one 
 cheek to the other. In two days I removed the remaining pins and a single 
 suture which I had applied to draw the flap close down to the septum. 
 The recovery was complete, and the astonishing manner in which the new 
 ala has been rounded off by nature, and the almost imperceptible scar which 
 
 remains from the wound in the cheek, 
 render the operation one satisfactory both 
 to patient and surgeon. 
 
 If the whole nose is destroyed, the flap 
 "jumped " from the forehead is generally 
 preferred, as seen in Fig. 439. 
 
 Having moulded a piece of wax, the 
 size and shape of the organ to be repro- 
 duced, over it a piece of wet parchment 
 should be laid and accurately fitted ; this 
 should be turned back upon the forehead, 
 and twisted over the mould two or three 
 times, until an " accurate fit " is obtained. 
 Many measurements and many adjust- 
 ments are always necessary. Having 
 fitted the pattern, it must be flattened 
 out, laid on the forehead, and a line 
 drawn an eighth to a quarter of an inch 
 from its margin around it. The nostrils 
 should then be filled with rolls of tenax, 
 '■ prepared tow," and the flap raised. The 
 edges of the chasm must then be carefully 
 pared, in an oblique direction, and the 
 flap brought downward, placed in position and secured by twisted silver wire. 
 After the parts have regained their vitality , the restoration of the columna 
 may be attempted. Of this Mr. Liston wrote, years ago : 
 
 " Restoration of the columna is an operation which, in this and other 
 civilized countries, must be more frequently required than the restoration 
 of the whole nose. This latter operation came to be practiced in conse- 
 quence of the frequency of mutilations as a punishment ; but the punish- 
 ment for some of our sins is left to nature, and she generally relents before 
 the whole of the organ disappears. The columna is very frequently de- 
 
INJURIES AND DISEASES OF THE MOUTH AND THROAT. 739 
 
 stroyed by ulceration. The deformity produced by its loss is not far short 
 of that caused by destruction of the whole nose. Happily, after the ulcer- 
 ation has been checked, the part can be renewed neatly, safely, and without 
 much suffering to the patient. The operation, which I have practiced suc- 
 cessfully for some years, and in many instances, is thus performed : The 
 inner surface of the apex is first pared. A sharp-pointed bistoury is then 
 passed through the upper lip — previously stretched and raised by an assist- 
 ant — close to the ruins of the former columna, and about an eighth of an 
 inch on one side of the mesial line. This incision is continued down, in a 
 straight direction, to the free margin of the lip ; and a similar one, parallel 
 to the former, is made on the opposite side of the mesial line, so as to 
 insulate a flap about a quarter of an inch in breadth, and composed of 
 skin, mucous membrane, and interposed substance. The frsenulum is then 
 divided, and the prolabium of the flap removed. In order to fix the new 
 columna firmly and with accuracy in its proper place, a sewing-needle is 
 passed from without through the apex of the nose, and obliquely through 
 the extremity of the elevated flap ; a few turns of thread over this suffice 
 to approximate and retain the surface. It is to be observed that the flap 
 is not twisted round, as in the operation already detailed, but simply ele- 
 vated, so as to do away with the risk of failure. Twisting is here unneces- 
 sary, for the mucous lining of the lip, forming the outer surface of the 
 columna, readily assumes the color and appearance of integument, after ex- 
 posure for some time. The fixing of the columna having been accomplished, 
 the edges of the lip must be neatly brought together. " 
 
 A third method is that known as the Italian, and was first practiced by 
 Taliacotius. It consists in removing the flap from the arm, and bringing 
 the arm over to the head, and fixing it by means of a cap and jacket made 
 of strong drilling. 
 
 Dr. McFarland, of Philadelphia, performed this operation in a successful 
 manner; but since the introduction of antiseptics it is seldom if ever 
 done. 
 
 For the treatment of lupus, epithelioma, and fracture of the nasal bones, 
 the student is referred to the consideration of those subjects in other por- 
 tions of this work. 
 
 CHAPTER XXXYIIL 
 
 INJURIES AND DISEASES OF THE MOUTH AND THROAT. 
 
 Hare-lip — Double Hare-lip— Restoration of the Upper Lip— Epithelioma — 
 Enlarged Labial Glands— Cysts of the Lip — Vascular Tumors — Restor- 
 ation of the Lower Lip — Cleft Palate and Staphylorraphy — Gingivitis 
 — Tumors of the Tongue— Glossitis — Abscess of the Tongue — Hypertrophy 
 — Amputation of the Tongue — Malformation of the Fr^num — Ranula — 
 Salivary Calculus and Fistula — Tonsillitis— Quinsy — Rhinoscopy — Pharyn- 
 gitis — Gangrenous Pharyngitis — Post-pharyngeal Abscess — Elongation of 
 the Uvula — Spasm and (Edema of the Glottis. 
 
 Hare-lip — Labium Leporinum — Cheiloplasty. — It is scarcely necessary to 
 state that the first two terms are used to designate a fissure, generally in the 
 upper lip,* involving all the structures concerned in its formation ; in most 
 instances situate to one side of the mesian line, and extending to and often 
 within the nostrils. Cheiloplasty is the operation for restoration of the parts. 
 
 * There are two exceptions to this rule mentioned by Christopher Seliger and Nicati. 
 
740 A SYSTEM OF SURGERY. 
 
 The arrest of development is more frequent in the male than in the female, 
 in the proportion of 70 to 30, and it is said that a complicated hare-lip seldom 
 occurs in a female child ; although Butcher, of Dublin, has recorded several 
 cases of this remarkable deformity, and I have seen two cases. 
 
 The malformation may be single, consisting of one fissure, or double, con- 
 sisting of two ; simple, or complicated with other malformations, Fig. 440. 
 
 The causes of hare-lip appear to have perplexed the minds of many 
 medical and surgical writers. In some instances the fissure has been attrib- 
 uted to an impression excited on the mind of the mother during the period 
 of utero -gestation. M. Moulin relates the case of a woman who in the 
 fifth month of her pregnancy, was much startled by the sight of a hare, 
 which her husband had skinned in her presence. During the last months 
 
 Fig. 440. 
 
 Different Varieties of Hare-lip.— Bryant. 
 
 of her pregnancy her imagination presented to her the sight of a hare de- 
 nuded of its skin, and she feared that her child would be subject to hare-lip. 
 Her prediction was verified by the event. M. le Professor Roux has ob- 
 served precisely a similar fact.* 
 
 There is undoubted evidence, however, that children are born with such 
 malformation — if the affection may so be termed — when it can be referred 
 to no such cause. Others are of opinion that the cleft in the lip arises 
 from an arrest of development ; that, in their earlier formation, the lips 
 have three or even more points of growth, a middle or two or more lateral, 
 and that the deformity is occasioned by an arrest in the development in 
 one of these primitive notches or fissures, proof being found in the occur- 
 rence of the cleft in the majority of instances to one side of the mesian 
 line. This idea, viz., the arrest of development in the substance of the lip, 
 was advocated by Blumenbach, Meckel, and others. Dr. Grossf writes, 
 " Of the causes of hare-lip we are entirely ignorant ; that it is the result of 
 arrest of development is certain, but how this result is produced is a circum- 
 stance in the history of foetal life which has not been satisfactorily ex- 
 plained." VelpeauJ differs from the above ; he says : " Numerous researches 
 on embryos and the foetus at every period, induce me to believe that these 
 ideas are the results of erroneous observations or gratuitous suppositions. 
 Hare-lip is not always without loss of substance, and the lips are no more 
 formed of two, three, or four portions, at three, four, six or eight weeks, 
 than at three or four months Hare-lip, like most other monstrosi- 
 ties, has appeared to me to be much more frequently ascribable to some 
 disease than to a defect in its natural evolution." M. Cruveilhier is of like 
 opinion. 
 
 Churchill§ on this point says : " I shall, in the remainder of the chapter, 
 notice hare-lip and cleft-palate, which are arrests of development, and imper- 
 forate anus, which is a malformation." 
 
 Bouchut|| thus writes : "The force of growth which presides at the dis- 
 position of parts, at their juxtaposition, at their reunion, interrupted in its 
 
 * Vide Bouchut, On Diseases of Children, p. 389. 
 
 f Operative Surgery, vol. ii., p. 613. J Operative Surgery, vol. iii., p. 329. 
 
 \ Diseases of Children, p. 405. || Diseases of Children, p. 390. 
 
TREATMENT OF HARE-LIP. 741 
 
 efforts, ceases to act, and the lips formed from three points of increase, one 
 median and two lateral, which this force incites to fusion, remain separated 
 so as to resemble the lip of the hare. When the reunion does not take 
 place at all, the hare-lip is double, when it takes place between two of these 
 points only, the median and a lateral, the hare-lip is single, and is only- 
 observed on one side of the mouth." 
 
 Todd and Bowman* believe that the hare-lip does not arise from an 
 arrest of development as does cleft-palate, for, say they, speaking on this 
 point: " The fissure of the lip seems to arise from the alteration of the deeper 
 parts, for as such a fissure exists at no period of embryonic life in the soft parts, 
 it cannot, like the bony fissure above described, be dependent upon an 
 arrest of development." Rokitansky takes a somewhat similar view of the 
 matter ; he believes the cleft to be occasioned by an arrest of development, 
 but not in the substance of the lip, but that it can be referred to the bony 
 casement beneath ; he says :f " The most common and important cases of 
 arrest of development are : fissures of the upper lip, on either or both sides 
 of the mesian line, corresponding to the union of the intermaxillary with 
 the superior maxillary bones, which may or may not present the fissure 
 also." 
 
 As is usual in these discussions, nothing definite has been reached. 
 
 Treatment. — The treatment is essentially surgical, and although the opera- 
 tion for the relief of the simple variety of the deformity is not generally 
 a difficult proceeding when carefully performed,! yet there are cases, 
 particularly those of a complicated nature, which require a steady hand 
 and a good knowledge of the parts, not only during but after the operation, 
 for, writes Dr. Mott,§ " There is no operation in surgery apparently so for- 
 midable, and which may so frequently be made so in reality, by want of 
 delicate and adroit manipulation in the operator, as this of hare-lip in 
 infants, in all its forms." Yet there are some points of interest which have 
 arrested the attention of the greatest surgeons in the world, to which due 
 importance should be given, and among these we notice, the period of time 
 which should be allowed to elapse after birth before the operation is re- 
 sorted to. 
 
 Much discrepancy prevails on this point. 
 
 Dr. Mason Warren || recommends the performance of the operation at as 
 early an age as possible, he having frequently resorted to it twenty-four 
 hours after birth, and with better success than in older children. He states 
 that at this period less resistance is offered by the child, and the healing 
 process being great at that age, it is enabled to suckle almost as soon as if 
 nothing abnormal had been present. 
 
 Dr. Dawson, of Dungannon, operated seven hours after birth ; the pins 
 were removed in forty-eight hours, and in two days more the union was so 
 perfect that the adhesive straps .were removed. Dr. Dawson is confirmed 
 in his determination to operate in similar cases soon after birth. If 
 
 Anselm also states that long experience has convinced him of the expe- 
 diency of early operation. Bonfils, of Nancy, also coincides in these views. 
 
 M. Guersant observes that there are three periods at which this operation 
 may be performed with different chances of success. The best is offered 
 within the first fifteen days from birth. At a later period a favorable termi- 
 nation is less frequent, and when the child has reached an age of from twelve 
 to fifteen years, the successful result is more certain. 
 
 * Physiological Anatomy, p. 877. f Pathological Anatomy, vol. iii., p. 17. 
 
 % Operative Surgery (Velpeau), vol. i., p. 28. 
 
 | American Journal of the Medical Sciences, No. xxx., pp. 327-28. 
 || Union M^dicale, No. lxxvi. 
 % Ranking's Half- Yearly Abstract, June, 1847, p. 218. 
 
742 A SYSTEM OF SURGERY. 
 
 M. Paul Dubois has also expressed himself in favor of early operations.* 
 
 Grossf writes, " the most eligible period is from the third to the sixth 
 month, or a short time before the appearance of the milk-teeth ; the opera- 
 tion is then generally borne well, there is no danger of convulsions, and the 
 adhesive process generally proceeds kindly." 
 
 Mr. Bransby Cooper says : " For my own part, I agree entirely with Sir 
 Astley Cooper, in regarding it as unsafe to operate upon infants before 
 weaning." This opinion is also advocated by Roux, and also by Velpeau.J 
 
 I was formerly of the opinion that this operation should not be performed 
 until the sixth or the eighth month, but from a more extended experience 
 I have changed my opinion. I have performed the operation for double 
 hare-lip, with complications, on the third day after birth, and quite fre- 
 quently within the first week, without a single untoward symptom ; and 
 although there may be some advantages in waiting for several months, 
 chiefly shown in the increased development of the flaps, thus giving more 
 integument to the operator, and requiring less delicacy of manipulation, 
 yet on the whole, often for the sake of the feelings of the family, the opera- 
 tion should be made at a very early age. 
 
 If the early operation has been determined upon, chloroform is not 
 necessary, especially if the parts are painted a few times with a 4 per cent, 
 solution of cocaine. This method I have employed with gratifying results, 
 the child being easily held, particularly if enveloped in a large strong towel. 
 If, however, the infant has reached the age of six or eight months, or a 
 later age, a few inhalations of the anaesthetic will be found of service, and 
 during the operation it is well to put the child in a strongly made pillow- 
 case and draw the strings around the neck. 
 
 Some operators prefer scissors to the knife, among whom may be noted 
 Dr. Wheeler, Mr. Butcher, Malgaigne, and Mr. Thomas Smith. The first 
 named gentleman has invented an admirable scissors (Figs. 441 and 442), 
 which is made either straight or curved. These instruments are so con- 
 structed (see figure) as to prevent bruising the tissues. A small-sized, 
 sharply-pointed, keen scalpel, with a firmly set handle, or a sharp teno- 
 tome, is the best instrument that can be used ; for no matter how sharp may 
 be the edge of the scissors, there is necessarily some bruising of structure, 
 which is unfavorable to the adhesive process by the first intention, and is 
 liable to leave a much larger cicatrix. Together with the scalpel, the sur- 
 geon should provide himself with the proper variety of sutures (the ordi- 
 nary hare-lip pins, silver wire, curved needles, or the silver button of Mr. 
 Wood), a pair of wire nippers, sponges, adhesive straps, collodion, etc. It 
 is a rare case when the coronary arteries require ligature, the haemorrhage 
 being readily controlled by pressure, and by the apposition of the parts. 
 There is, however, one point in this connection which must be remem- 
 bered, and that is, that blood may escape into the mouth, and by passing 
 into the larynx cause the death of the patient ; there is a case of this 
 kind, mentioned by M. Roux,§ in which but little blood was lost during 
 the operation, but what there was remained in the mouth ; a large clot of 
 blood being swallowed by the infant, a portion of it passed into the larynx 
 during deglutition, and occasioned such extreme asphyxia that the surgeon 
 believed the child to be dead. By the introduction of a catheter into the 
 larynx the coagulum was withdrawn and life preserved. There are some 
 other cases upon record in which the haemorrhage was profuse, but these 
 may certainly be considered as the exceptions. 
 
 The method which I consider the best in the performance of the operation 
 
 * Banking's Half- Yearly Abstract of the Medical Sciences, 1849, p 257. 
 
 f Operative Surgery, vol. ii., p. 613. J Operative Surgery, vol. ill., p. 341. 
 
 I Banking's Half- Yearly Abstract of the Medical Sciences, 1846, p. 138. 
 
TREATMENT OF HARE-LIP. 
 
 743 
 
 for hare-lip is the following, and is known as Malgaigne's : The operator 
 seats himself with his face toward the window, and places a small pillow 
 upon his lap, upon which is spread a sheet of thin india-rubber. The nurse 
 having passed a towel around the arms of the child, faces the operator, and 
 places the head of the patient on the pillow. Two assistants kneel, 
 one on each side of the surgeon, each taking between his thumb and 
 forefinger the side of the cleft nearest him, making sufficient pressure to 
 arrest the circulation in the coronary arteries. The surgeon takes a small 
 
 Fig. 441. 
 
 Fig. 442. 
 
 Dr. Wheeler's Straight Hare-lip Scissors. 
 
 Curved Scissors (open). 
 
 Fig. 443. 
 
 Fig. 444. 
 
 narrow sharp pointed knife (I generally use a tenotome), and inserts its 
 point, with its cutting edge toward the chin, into the cleft of the fissure on 
 the right side, and marking with his eyes the size of the flap to be made, 
 cuts with a gentle sawing motion entirely through the thickness of the lip 
 to the vermilion border, or a few lines beyond. The knife is then with- 
 drawn, and a similar method of paring 
 proceeded with on the left side (see Fig. 
 443) ; b and V represent the incisions, and 
 a and a' the flaps. An assistant then 
 draws downward the flaps (see Fig. 444), 
 a, a', leaving the raw surfaces b and b'. A 
 hare-lip pin, held in a stout forceps, with 
 a depression in the jaws, in which the 
 head of the pin fits, is then passed through 
 the flap (two-thirds of its thickness), on the right side, at the vermilion 
 border, entered at a point directly similar on the opposite flap, and brought 
 
744 A SYSTEM OF SURGERY. 
 
 out about a quarter of an inch from the pared edge on the left side. A 
 second pin is then introduced nearer the nostril in the same manner, and 
 while the assistant still holds the flaps downward, the threads, figure-of- 
 eight fashion, are to be applied. A needle threaded with fine silk or catgut 
 is now passed through the flaps, and tied sufficiently tight to bring the raw 
 surfaces neatly together. The points of the pins are to be cut off with the 
 nippers, and the little teat formed by the flaps allowed to remain ; this 
 shrinks considerably after a month or two, and then may be snipped off 
 with the scissors. 
 
 The old, and no doubt an excellent method, is to insert a piece of thin 
 wood or stiff pasteboard under the lip (Fig. 445), and to refresh or pare 
 the margins of the cleft with a sharp straight bistoury. There need not 
 be much dread of taking away too great a part of the flesh, and it is 
 better to make a free incision than not to cut out enough of the labial 
 substance. The knife is laid aside, and a hare-lip pin, composed of steel 
 or silver, is passed into the lip, nearest the prolabium, on the right side 
 from below upward, and on the left side from above downward, beginning 
 about a quarter of an inch or more from the cut surface, and bringing out 
 the point in the centre of the thickness of the lip ; the point is then entered 
 
 Fig. 445. Fig. 446. 
 
 at a corresponding part of the refreshed edge of the opposite side, and 
 brought out at the healthy skin at the same distance from the cut as 
 it was entered on the other side. Another pin is introduced in a similar 
 manner, above the first, and, if necessary, a third just below the nose. 
 Beginning at the upper pin, a figure-of-eight suture is wound around it. 
 Use a separate piece of silk for each pin. I have found that one ligature 
 extending from one pin to the other materially interferes with the circula- 
 tion. After the wound is thus thoroughly closed the points of the pins 
 must be cut off with the wire nippers (Fig. 446), and the blunt ends 
 covered with pieces of white wax, and the whole lip, pins, ligatures, 
 etc., covered with a thick coating of collodion. So soon as this applica- 
 tion is thoroughly dry, two adhesive straps, of sufficient length to extend 
 from ear to ear, are to be applied upon the cheeks, crossing each other 
 on the upper lip, at the site of the wound. If the points of the pins 
 remain uncovered they may catch in the pillow, or in the clothes of the 
 mother, and, by a single motion of the child's head, the work of the sur- 
 geon is destroyed ; or a severe catarrh may set in on the second or third day 
 after the operation, and an acrid discharge from the nostrils may irritate 
 the wound, prevent adhesion, and thus spoil the whole performance. Such 
 an unfortunate result is obviated by the collodion, while the strips of 
 plaster prevent too great traction being made upon the pins, and assist 
 materially in closing the wound. 
 
TREATMENT OF HARE-LIP. 
 
 '45 
 
 The application of straps, which are always at hand, is a modification 
 oi the spring truss invented by Dr. Dewar, of Aberdeen, which is known 
 by the name of Dewar's Compressor, and which, if the surgeon can procure 
 it. may be used in preference to the plaster. 
 
 Dr. Buck contrived a needle for the more exact coaptation of the wound : 
 ; ' The instrument consists of a needle, of the slightness of an ordinary 
 knitting-needle, fixed on a handle and slightly curved (Fig. 447). It 
 grows a little larger round for half an inch near its point. Its extremity is 
 bevelled off to a sharp point on its concave side, and perforated lengthwise 
 on its bevelled face like the stem oi a hypodermic syringe, such as ifi in 
 common use. The mode of using it is as follows : The edgee of the wound 
 intended to be brought into coaptation, having been traversed by the con- 
 ductor guided by one hand, a pin held between the thumb and fingers of 
 the other hand is engaged by its point in the perforated hole at the end of 
 
 Fig. 44: 
 
 the conductor, and held steadily in place, while the conductor is withdrawn 
 and the pin made to follow it. which it does with unerring certainty. A 
 soft iron or silver wire may be inserted in the same manner as the pin. if it 
 is intended to employ a wire suture." 
 
 Mr, Wood, oi Gloucester Hospital, introduced what is termed the burton 
 hare-lip suture. This apparatus is composed of two perforated silver disks, 
 having wires soldered to their backs, over which a double ligature is tied, 
 after having been passed through the lip. Mr. Wood believes that by thus 
 avoiding the pinching and rigidity of the needles he obtains a more efficient 
 and unobjectionable mode of union, and recommends the same suture in 
 cases of divided perinaeum. 
 
 Dr. J. Marion Sims placed the most reliance on the silver suture. Accord- 
 ing to his direction the wires should not be further apart than three-six- 
 teenths of an inch, or even less, thus affording good support and perfect coap- 
 tation. He says further. " As it is important to prevent any mark from their 
 unequal pressure, a thin plate of some transparent material may be placed 
 like a delicate splint on the coapted edges, over which the wire maybe tied. 
 thus preventing the tender cuticle of the child's lip from their cutting pres- 
 sure A clarified goose<:juill. split into sections, and softened in boil- 
 ing water, and then flattened out by heavy pressure, fulfils every indication 
 in this hare-lip suture." 
 
 Another method of curing hare-lip is by what is termed the s ture, 
 
 which mode is highly recommended by surgeons of the present day. The 
 same inverted V incisions are made, taking care, however, not to carry the 
 
746 
 
 A SYSTEM OF SURGERY. 
 
 knife entirely down to the lip ; the flap is then turned down, and the sides 
 of the lozenge-shaped opening, which is thus made, are placed in contact 
 by one or more sutures ; now, even if these should yield to the pressure, the 
 living suture still holds, and by degrees the hole that is left becomes oblit- 
 erated. The advantages claimed for this form of suture are these : that the 
 edges of the wound soon swell and become covered with healthy granula- 
 tions and a natural suture is thus produced and remains, even if, by mis- 
 management or accident, the other sutures are displaced, at that very point 
 where structure is most needed, and where a cleft so often remains. 
 
 Erichsen, after having tried many methods, prefers the simple interrupted 
 suture without using any pins ; he states that he has treated many cases of 
 the malformation occurring in children from a few days to four years of age, 
 with perfect success, and with less marking of the lip than when union is 
 effected by the twisted suture. 
 
 Dr. Smith recommends the following mode of procedure : " Take two of 
 the forceps invented by Dr. Alden March, of Albany ; provide them with 
 catches like artery forceps, and have transverse lines marked upon them 
 
 Fig. 448. 
 
 Hutchinson's Forceps. 
 
 at distances of a quarter of an inch, so that a means may be furnished 
 of exactly and rapidly determining the situation of the sutures. I modify 
 the method of operating by applying these two exactly similar forceps, 
 one to each side of the cleft, fastening them there by the catch, introducing 
 the sutures about half an inch from the margin of the forceps, exactly 
 opposite the transverse lines, and finally cutting away the margins of the 
 cleft inclosed in the forceps. Nothing now remains to be done but to 
 close the cleft, which, on account of the mechanically exact introduction 
 of the sutures, is effected instantaneously. Metallic sutures being used, 
 their prior introduction does not expose them to the danger of being cut. 
 According to Lisfranc's method I would not, at the labial margin, entirely 
 sever the portion pared from the margin of the cleft, but would suffer it to 
 remain on each side, until the cleft being accurately adjusted, these parings 
 may be shortened to suit, a suture being passed through them, forming a 
 decided V-shaped projection downwards. I deem this precaution necessary, 
 in addition to curving the lines of incision after the manner of Celsus, 
 because I never yet saw any one, years after the operation, in whom an 
 unseemly notch did not exist." 
 
 Fig. 448 represents a pair of forceps devised by Hutchinson to facilitate 
 the operation and render the parts perfectly adapted to each other. 
 
 Malgaigne's operation consists in paring the edges of the fissure so as to 
 
RESTORATION OF THE UPPER LIP. 
 
 747 
 
 leave two angular flaps at the vermilion border, which when brought 
 together would prevent the prolabial notch. 
 
 This notch of the prolabium is often difficult to prevent. It consists in 
 an imperfect closure of the wound, which by cicatrizing and contracting 
 leaves an indentation in the upper lip. 
 
 Double Hare-lip. — In cases of double hare-lip, much has to be left to the 
 judgment of the surgeon, particularly with reference to the disposal of the 
 intermaxillary bones ; if these be on the same plane with the other sides of 
 the fissures, the operation for simple hare-lip must be repeated on the other 
 cleft. Frequently, however, the intermediate portion is composed of a 
 rounded protuberance of bone and skin, which is connected with the septum 
 narium. It may be horizontal or oblique, contain the germs of the incisor 
 teeth, and very frequently exists with cleft palate. 
 
 In such cases, especially when the projecting intermaxillary bone is very 
 prominent, it is necessary to cut it away with the forceps before adjusting 
 the fissure. Thert is always a good deal of haemorrhage following the 
 operation, which torsion or pressure controls. The integument must be 
 left pendent in view of forming a columna afterward. If the hare-lip is 
 complicated with cleft palate, the latter must be first attended to, if it be 
 desirable to attempt its closure. For directions for performing this operation, 
 see "Staphylorraphy." 
 
 Restoration of the Upper Lip. — Several plans have been adopted for the 
 production of a new upper lip. Berard made almost vertical incisions to 
 
 Fig. 449. 
 
 86dillot's Operation. 
 
 Teale's Operation. 
 
 include a portion of the cheek on each side of the nose, and brought the 
 flaps downward and connected them in the median line. 
 
 Sedillot cut out a square portion of the skin from the cheek, a, b, as 
 shown in Fig. 449. The centre piece was then pared, and b brought down 
 to b'. The mucous surfaces formed the border of the lip, where the parts 
 w r ere united in the centre. 
 
 Mr. Teale made a crucial incision at its point of intersection below the 
 septum of the nose (Fig. 450), each limb of the incision being about one- 
 
 FiG. 451. 
 
 ^UJ 
 
 Fig. 452. 
 
 Dieffenbach's Method. 
 
 half an inch in length. The two limbs on each side diverge moderately as 
 they pass outward from the cheek, and inclose between them a flap of an 
 acute angle composed of skin and fascia. The parts marked out by the 
 
748 A SYSTEM OF SURGERY. 
 
 incision are loosened from their attachment by a few strokes of the scalpel, 
 the knife being inserted close to the bone. The flaps thus formed are then 
 drawn across the mouth, the one dove-tailing into the other, and are held 
 in position by a pin and twisted suture. 
 
 Dieffenbach made an incision similar to the letter " s " on each side of the 
 alas of the nose, and having dissected up the flaps secured them in the 
 median line. (Figs. 451 and 452.) 
 
 Epithelioma of the Lip. — Cancer rarely attacks the upper lip, while the 
 lower is subject to epithelioma. In the commencement, there is observed, 
 beneath the integument covering the vermilion portion of the lip, a small 
 round tumor, resembling a shot, which, when pressed upon, rolls under 
 the finger. The tumor in this state gives no pain, but if frequently 
 handled by the patient, or otherwise irritated, grows rapidly and soon 
 adheres to the surrounding parts. In other cases, a firm and immovable 
 lump of considerable size, is, from the first, deeply imbedded in the 
 substance of the lip. This gradually approaches the swface, finally ulcer- 
 ates, and throws out a prolific fungus of a dark-red color, so large as 
 in some instances to envelop the whole mouth. A third variety is found 
 in the form of a chocolate-colored warty excrescence ; this never attains a 
 large size, but is constantly casting off scabs, the places of which are 
 speedily supplied by others. These tumors are all capable of contami- 
 nating by extension the adjoining portions of the neck, especially the 
 lymphatic glands, and when this occurs, there is very little hope of the 
 patient's recovery. Venereal ulceration of the lip and lupus have been 
 mistaken for cancer, and treated accordingly. The surgeon should be on 
 his guard, and never without full investigation, pronounce decisively as to 
 the nature of the complaint, or propose an operation, unless well assured of 
 the existence of cancer. 
 
 Treatment. — I have treated many cases of epithelioma of the lip, and 
 have found this variety more amenable than any other form of cancer. 
 It appears, from considerable experience, that the enucleation process of 
 Marsden and McLimont (see Treatment of Cancer), has had more decided 
 effect than any other. This, combined with the internal administration of 
 arsenic, hydrastis, or phytolacca, has proved efficacious; indeed, cures have 
 been performed by this combination of caustic and medical treatment. I 
 employ the escharotic first, and afterwards continue the medical treatment 
 for at least a year. 
 
 The chief medicine in cancer of the face is arsenic. This medicine 
 is the basis of most of the "far-famed" remedies for this disease; and, 
 writes Dr. Wurmb, of Vienna, " There is no affection, except ague, in 
 which it has been, and still is, so often administered. Even among the 
 ancients it was considered a specific against cancer, and at the present day 
 it has the same reputation ; it was also known then, as well as now, to be 
 capable of producing cancerous ulcers. The whole difference, therefore, 
 between ancient and modern practice, lies in fact, that now it is known, or 
 might be known, or ought to be known, that the therapeutic employment 
 of arsenic in cancer, rests on the law of similarity ; but that it is no absolute 
 specific against that disease, because there exists no such thing as an abso- 
 lute specific ; further, that we possess certain indications for its exhibition, 
 and understand the method of giving it in suitable doses. 
 
 " As regards the choice of arsenic in cancer of the lips, it is an easy task 
 for the physician, well acquainted with the positive effects of medicines, 
 to distinguish the cases in which arsenic suits, from those in which other 
 remedies are indicated. Thus, arsenic is to be preferred before belladonna, 
 baryta carbonica, or conium, in very malignant ulcers, which increase on 
 all sides, bleed easily, and have not been caused by any external injury, 
 
ENLARGEMENT OF THE MUCOUS GLANDS OF THE LIP. 749 
 
 such as blows or bruises, but from the first, show plainly that they are the 
 outward sign of a deeply-seated inward disease, and are, therefore, often 
 met with in cachectic individuals. Carbo veg., indeed, approaches very 
 near to arsenic in this respect ; yet the latter is to be preferred uncondi- 
 tionally when the tendency to destroy the surrounding parts is distinctly 
 marked in the ulcer."* 
 
 Arsenic may sometimes be required in alternation with some other 
 medicine, but it is, undoubtedly, the most valuable when the cancerous 
 dyscrasia has contaminated the organism; it is a reliable medicine for 
 cancer of the nose, tongue, and alveola?. 
 
 Clematis is asserted to be useful in carcinoma of the lips, arising from 
 syphilitico-mercurial ulcers. 
 
 Aurum met. is also serviceable for cancer complicated with syphilitic or 
 mercurial symptoms ; or this medicine maybe adapted to scirrhus, appear- 
 ing in individuals of a scrofulous diathesis. The muriate of gold is also 
 recommended for this disease, and may, in aggravated cases, be alternated 
 with arsenic. 
 
 Mercurius may be of service if the bones have already become affected ; 
 or nit. acid may be useful if the sore be irritable and bleed profusely. 
 
 Conium has been employed with success in carcinomatous affections aris- 
 ing from contusions ; it is particularly indicated by a scrofulous diathesis, 
 and when the ulcers on the face and lips spread rapidly, present a blackish 
 appearance, and discharge a bloody and fetid ichor. 
 
 In cancer of the lip, when the patient complains of violent burning pain 
 in the ulcers, which may be covered with large scurfs that spread rapidly 
 and become very thick, sepia is often the appropriate medicine ; it is also 
 of importance when there exudes from beneath the scab a corrosive ichor, 
 which, by irritating the surrounding parts, essentially favors the extension 
 of the disease. The disposition of the patient should also be remembered 
 when this medicine is to be prescribed. 
 
 Dr. Attomyrf relates the following cure of cancer of the lip: " Aloysia 
 Lyde, six years old, lost the left half of the upper lip, and the soft parts 
 extending upward to the zygoma, and sideways a considerable portion round 
 the angle of the mouth, by a cancerous ulcer. Arsenic (6th dilution), re- 
 peated every eight days, brought about the healing of the ulcer in six 
 weeks. As a detergent application, the decoction of marshmallows was 
 used outwardly." To my mind this case is open to doubt. 
 
 When it is necessary to remove the lip, which is easily effected, provided 
 the caustic treatment has not already been employed, a V-shaped incision 
 embracing the whole mass should be made, and the parts brought together 
 with hare-lip pins and the figure-of-eight suture. It is astonishing how 
 much of the lip may be removed, and yet how little deformity may remain 
 afterward. Ligatures are not required, as the nice approximation of the 
 wound is generally sufficient to arrest haemorrhage. 
 
 Enlargement of the Mucous Glands of the Lip. — This affection, which 
 amounts to hypertrophy, and which is by some authorities classed as such, 
 consists of a protrusion of the lip, the mucous membrane being everted. 
 A cause of this may be a vicious habit of biting the lip, and I have seen 
 it accompanied with immobility of the jaws, and destruction of the cheek. 
 
 Treatment. — With a pair of good strong scissors, an elliptical portion of 
 the mucous membrane and a portion of the subjacent structures must be 
 removed, the edges are then brought together and held in position with wire 
 sutures. 
 
 * British Journal of Homoeopathy, vol. iv., p. 250. 
 f British Journal of Homoeopathy, vol. iv., p. 257. 
 
750 
 
 A SYSTEM OF SURGERY. 
 
 Vascular Tumors of the Lip. — These tumors may involve a portion of or the 
 entire lip. They are, in the majority of instances, aneurisms by anasto- 
 mosis, and in many cases are not amenable to treatment. Sometimes, how- 
 ever, as in Pancoast's case, acupressure may arrest the flow of blood. The 
 only true remedy is excision, if there can be found sufficiently healthy 
 structure in which to make the incisions. Fig. 453 represents a case in 
 
 Fig. 453. 
 
 Author's case of Vascular Tumor of Lip. 
 
 which I tied both facial arteries and used acupressure on the inferior dentals 
 with but slight temporary improvement, having previously tried both 
 digital and instrumental compression. The former was effected by a class 
 of students, and was continued for over twenty-four hours ; the latter by 
 tortoise-shell clamps and screws. In such cases ligation of the carotids 
 may be resorted to, but it appears to me too serious an operation. The end 
 would scarcely justify the means. 
 
 Restoration of the Lower Lip. — The best operation for restoring the lower 
 lip is that of Buchanan, who as long ago as the year 1835 made use of it 
 
 Fig. 455. 
 
 Fig. 456. 
 
 Buchanan's Method. 
 
 Chopart's Method. 
 
 for the removal of cancer of the lower lip. It is thus described by its 
 originator.* 
 
 The line aa, Fig. 454, represents the commissure of the mouth, the line aba 
 
 * London Gazette, vol. v., p. 79. 
 
CLEFT PALATE AND STAPHYLORRAPHY. 751 
 
 the incision by which the carcinomatous mass was removed. The new lip 
 was formed by means of two flaps taken from the side of the chin, each, 
 however, by a curvilinear incision dc and a straight one be, these flaps were 
 raised and brought together in the median line as seen in Fig. 455. 
 
 Chopart performs a different operation. From the angle of the lip on each 
 side he makes a straight incision and carries it below the chin. The second 
 incision, beginning sufficiently below the cancerous mass to be made in healthy 
 texture, is carried transversely from one incision to the other. The balance 
 of the quadrilateral flap is then dissected up and drawn upward and fixed 
 to the angles of the upper lip, as seen in the figure (Fig. 456). 
 
 Mr. Syme thus describes his own operation :* " Two incisions are made 
 from the angles of the mouth AC so as to meet at the chin B, and thus the 
 morbid part is removed, in a triangular form. The lines AB and BC in 
 the figure (Fig. 457) are supposed to represent these incisions. I cut from 
 the point B downward, and outward on each side to D and E in a straight 
 direction, and then with a slight curve outward and upward to F and G. 
 The flaps ABDG and CBEF are next detached from their subcutaneous 
 connections, and raised upward so that the edges AB and CB come into a 
 
 Fig. 458. 
 
 horizontal line, while those represented by BD and BE meet together in a 
 vertical direction, and the latter extends to F and G. Allow sufficient free- 
 dom to prevent any puckering or straining." 
 
 Cystic Tumors of the Lip. — Tumors of a cystic character are generally 
 found in the lower lip beneath the mucous membrane. By cutting off the 
 tops of the cysts (not merely incising them), they are generally cured. 
 
 Cleft Palate and Staphylorraphy. — Cleft palate is an arrest of development 
 in the osseous structures of the roof of the mouth, accompanied by a 
 deficiency in the corresponding soft parts. It is, therefore, a fissure in the 
 hard and soft structures of the roof of the mouth. It may exist either with 
 or without hare-lip, but the two generally are found together. 
 
 It may also coexist with deformities of the posterior nares. 
 
 The palate, in common parlance, means the whole of the roof of the 
 mouth, from the superior alveolar arch to the pharynx, and includes the 
 velum palati. The surgeon divides it into two parts, the hard and soft 
 palate. The hard palate extends from the internal surface of the upper 
 teeth to the velum. It is formed by the horizontal plates of the palate 
 and superior maxilla, a fibrous structure, and mucous membrane. It is 
 supplied with arteries, veins, and nerves. The bony portion forms the roof 
 of the mouth by its inferior surface, and its superior is the floor of the 
 nares. 
 
 The soft palate or velum pendulum palati is a movable fold of mucous 
 membrane, inclosing muscular fibres, aponeuroses, vessels, nerves, and mu- 
 cous glands; it is suspended from the posterior border of the hard palate, 
 like a curtain, and forms an incomplete septum between the mouth and 
 pharynx. 
 
 The arched structure of the mouth, with the curtain that divides the oral 
 
 * Miller's Practice of Surgery, p. 163. 
 
752 A SYSTEM OF SURGERY. 
 
 cavity from the pharynx behind, exerts powerful influence on articula- 
 tion, moulding the sounds which are created in the larynx, and giving 
 them scope and reverberation. In its normal state it gives smoothness 
 and sweetness to the varied tones of which human language is composed. 
 In the cleft state, every agreeable quality of tone is lost, and the nasal, 
 guttural, and half-suffocative sounds that are produced often prevent 
 even the ordinary intercourse of man with man, and frequently cause 
 the sufferer to avoid society, and, from the seclusion which naturally 
 follows, to become unhappy and misanthropic. Many of the simplest ele- 
 mentary sounds of our language are unutterable by those afflicted with 
 cleft palate. The hard sound of "g,"for instance, is made by pressing 
 the root of the tongue against the uvula in order to close the throat, as in 
 beginning to articulate the word " go ", without the " o." 
 
 Again, the sound of " 1," which is a vocal-lingual- dental sound, and is 
 made by pressing the tongue against the upper gums, hard palate, or roof 
 of the mouth, is rendered imperfect, and indicates the deformity. So 
 also with " w, u, v," and many other letters. If, therefore, these element- 
 ary sounds are wholly wanting, or even imperfect, it may well be imagined 
 how defective utterance will be. 
 
 In order to completely understand the subject, I shall call attention more 
 minutely to the anatomical structure of the parts. Those who are familiar 
 with the anatomy of the base of the skull, must bear in mind the relative 
 position of the pterygoid processes of the sphenoid with the horizontal plates 
 of the palate bones, for it is to these that the muscular portions of the 
 velum are attached. 
 
 These muscles are nine in number ; four on each side, and a central strip 
 of muscular fibres — the azygos uvulae. They may be divided into elevators 
 and depressors. The elevators are the levator palati and the tensor palati 
 or circumflexus palati. The depressors are the palato-glossus and palato- 
 pharyngeus. The levator palati has its origin from the inferior surface of 
 the apex of the petrous portion of the temporal bone and from the under 
 and internal portion of the cartilage of the Eustachian tube. The fibres 
 descend and enter into the pharynx above the superior constrictor muscle, 
 and then expand to assist in the construction of the soft palate ; thus, with 
 its fellow of the opposite side, it forms a stratum of muscular fibres, which 
 is also in conjunction with the two planes of palato-pharyngeus muscle. 
 
 The circumflexus palati, or tensor palati, as it is often called, is a small, 
 narrow band of muscular fibres, partly tendinous, between the pterygoid 
 muscle and the internal pterygoid plate of the sphenoid bone. It is attached 
 to the scaphoid fossa, at the base of the pterygoid process, and also to the 
 Eustachian tube. Besides these, there are some smaller fasciculi which 
 have their points of origin from the vaginal process of the temporal bone 
 and extend to the spinous process of the sphenoid. The fibres at the lower 
 part of the muscle end in a tendon which winds around the trochlea or 
 hamular process of the internal pterygoid plate of the sphenoid bone, and is 
 inserted into the posterior border of the palate. 
 
 Of the depressors of the palate, the palato-pharyngeus is the largest, and 
 assists in the formation of the posterior pillar of the fauces. The muscle 
 arises from the posterior border of the thyroid cartilage, and ascending 
 behind the tonsil, enters the side of the palate, where it separates into two 
 fasciculi ; the anterior, which is deeper and much the stronger of the two, 
 enters the substance of the palate between the levator and tensor, and joins 
 also at the middle line a corresponding portion of the opposite muscle. In 
 the palate, the muscle incloses the levator palati and azygos uvulae between 
 its fibres. 
 
 The palato-glossus assists in the formation of the anterior pillar of the 
 
CLEFT PALATE AND STAPHYLORRHAPHY. 753 
 
 fauces, and extends to the sides of the posterior surfaces of the tongue ; or 
 it may be said to arise from this point ; and then, passing a little upward 
 and backward, in front of the tonsil, it completes the triangular space for 
 the lodgment of the tonsil, and is inserted into its fellow of the opposite 
 side. 
 
 The azygos uvula? muscle arises from the posterior nasal spine, situated 
 at the posterior junction of the processes of the palate-bone. This muscle 
 forms the substance of the uvula, and has no insertion, the tip of the muscle 
 hanging free in the fauces. A small band of the palato-pharyngeus sepa- 
 rates the posterior surface of this muscle from the mucous membrane, by 
 which it is enveloped. 
 
 These muscles are covered with mucous membrane, and, it will be seen, 
 are more or less blended or interlaced at their points of insertion, and act 
 upon the soft palate as follows : 
 
 The levatores palati elevate the velum. The tensores palati muscles, by 
 their contraction and arrangement of the tendons around the hamular pro- 
 cesses of the pterygoid plates, draw each side of the palate outward. The 
 palato-pharyngeus acts downward and backward, the palato-glossus down- 
 ward and forward. It is important to consider the normal action of these 
 muscular fibres for the proper understanding of the surgical anatomy of 
 cleft palate. 
 
 It is necessary to bring to notice another muscle, or at least a portion of 
 muscular fibres known as the superior constrictor of the pharynx. As usually 
 studied, points of origin are situated anteriorly, but where one of these 
 is in a state of division, its origin should be considered as the median 
 raphe on the posterior wall of the pharynx, together with the aponeu- 
 rosis of the same. The fibres pass around on either side of the pharynx, 
 and are inserted in the inner surface of the internal pterygoid plate (par- 
 ticularly the lower third), in the hamular process, the posterior part of 
 the mylo-hyoid ridge, the mucous membrane of the mouth, and the sides of 
 the tongue. Particular attention should be given to the upper border, 
 which consists of arched fibres, with which the levator and tensor palati 
 muscles are connected. 
 
 Having now in mind the elevators and depressors of the velum, let us 
 give Mr. Fergusson's idea on the subject. He tells us that the extreme 
 mobility of two portions of the cleft palate has long been noticed, but 
 that not much attention has been given to the moving powers. If a per- 
 son with cleft palate be desired to swallow a little water slowly, with the 
 mouth partially open, the back parts of the fissure may be seen to ap- 
 proach each other, and it is this approximation which was formerly sup- 
 posed to render the case favorable for an operation. The cause of this 
 movement had escaped the notice of the physiologist for two hundred 
 years, and even so close an observer as Malgaigne had allowed it to pass 
 unobserved. " The semicircle," says Mr. Fergusson, " which these mus- 
 cles form on the back and sides of the pharynx is, during deglutition, 
 drawn almost into a straight line ; the fibres come forward, inward, and 
 downward, so that the soft structures immediately in front — being the two 
 portions of the split palate — are pushed in similar directions, and thus the 
 posterior part of the fissure is made to close." It was from a careful study 
 of these words that I thought it preferable, when speaking of the origin 
 and insertion of the superior constrictor, to reverse the usual manner of 
 describing it, because it is easier to understand how, by the superior 
 arched border of the muscle, the margins of the cleft are pushed together. 
 In other essays on the subject, he speaks of three conditions in which 
 the flaps of a cleft palate are noticed to be acted upon by the muscles 
 in question. 
 
 48 
 
754 
 
 A SYSTEM OF SURGERY. 
 
 First. When the parts are not irritated, and are in a quiescent condition, 
 the lateral flaps are distinct, the posterior nares and the upper part of the 
 pharynx being observed above and behind. 
 
 Second. If the flaps are touched or irritated, they are pressed upward by 
 a motion that appears to commence at the middle of each. 
 
 Third. If the parts be still further irritated by pressing the finger against 
 them in the fissure, each flap is forcibly drawn upward and outward, and 
 can scarcely be distinguished from the rest of the parts which enter into 
 
 Fig. 459. 
 
 Fig. 460. 
 
 Whitehead's Gag in position. 
 
 the formation of the sides of the nos- 
 trils and throat. These peculiar actions 
 will be understood after study of the 
 preceding anatomical details. 
 
 The next point to be remembered is 
 the position of the Eustachian tubes, 
 which open on each side of the upper- 
 part of the pharynx, at the back of 
 the inferior meatus; just below and in 
 front of these openings, we have parts 
 of the muscles which it is necessary to 
 divide for the successful termination 
 of staphylorraphy. The arteries are 
 the posterior and inferior palatine, one 
 being given off from the internal max- 
 illary and the other from the facial. 
 These vessels may be divided in form- 
 ing the flaps, and it is well to recol- 
 lect what has been said regarding per- 
 formance of a part of the operation at 
 one time. 
 
 Staphylorraphy. — By this term is understood the operation for the closure 
 of cleft palate. Synonymous with this word are the terms cionorraphy, 
 uraniscorraphy, kionorraphy, and velosynthesis. 
 
 Surgeons now agree that the division of the palatine muscles is an essen- 
 tial step in the operation. It is not easy to imagine a more delicate pro- 
 
 l 
 
CLEFT PALATE AND STAPHYLORRAPHY. 
 
 755 
 
 ceeding than a carefully conducted operation for cleft palate. The follow- 
 ing are the most important considerations : 
 
 First. Preparation of the patient: For some time before the operation, 
 the patient should accustom the parts to the presence of foreign bodies, 
 by introducing substances into the fauces, and while touching the sides of 
 the cleft, endeavor to control the muscles, and thus avoid their being 
 
 Fig. 461. 
 
 G TIFMANW X, 
 
 Whitehead's Needle. 
 
 Fig. 462. 
 
 pressed aside or spasmodically contracted. The operation should never be 
 attempted until the child has arrived at an age to appreciate its difficulties, 
 and be willing to bear a little pain for the benefit to be derived from surgical 
 interference. 
 
 Second. A favorable condition of the weather is a desideratum, and the 
 operation should not be performed unless the day be bright and clear. A 
 room facing the sun should, if possible, be chosen, and the curtain blinds 
 removed from the windows to allow a full supply of light. 
 
 Third. The patient should be placed on the table, with his head sup- 
 ported by a pillow. The jaws should be separated with Whitehead's gag, 
 Fig. 459. 
 
 Fourth. If anaesthesia be used, chloroform is preferable, as it is less likely 
 to produce salivation. There is some diver- 
 sity of opinion as to the employment of 
 anaesthetics in these operations. In my 
 opinion they should be used. 
 - Fifth. There should be at least three as- 
 sistants, one to give the anaesthetic, a sec- 
 ond to assist the operator, and a third to 
 throw light into the mouth by means of a 
 good-sized mirror. This last precaution is 
 of great importance, though not generally 
 mentioned by writers on the subject. 
 
 For this purpose I now use the electric 
 light, already alluded to. 
 
 Sixth. The instruments are : a long for- 
 ceps with bent handles, and the jaws armed 
 with fine teeth, whereby the flaps can be 
 held ; a pair of long curved scissors in case 
 the operator prefers it to the knife*. Several 
 knives with long handles and shanks (Fig. 
 460), but with a short cutting edge; also 
 two knives, each with a double edge, and 
 the blade at right angles with the handle, 
 to separate the flaps from the hard palate ; a periosteotome ; several small 
 curved needles not more than an inch in length, with a double edge, and 
 a needle to carry silver wire; a needle-holder, or Whitehead's needle, 
 Fig. 461 ; a dressing forceps, slightly curved at the jaws, to seize the 
 needles after they have been passed into the flaps ; a pair of long curved 
 scissors ; two lead or silver plates, with perforations to correspond with 
 the proposed sutures. Several perforated buckshot; an instrument to 
 forcibly compress the shot ; also one shaped somewhat like an ordinary 
 
 Staphylorraphy. 
 Paring the edges with scissors. 
 
756 A SYSTEM OF SURGERY. 
 
 fork, which may be affixed to the end of forceps, or set in a handle, for 
 passing the shot up to the cleft before it is closed ; several sponges, set in 
 sponge holders, to cleanse the blood from the throat, and also to remove 
 the mucus which often accumulates ; a hypodermic syringe charged with 
 brandy. 
 
 Seventh. The surgeon should sit on the right of the patient with a steady 
 assistant on his left, with forceps or hook. The lower portion of the margin 
 of the left side of the fissure is seized and put gradually on the stretch. 
 The surgeon is then ready to commence. 
 
 Eighth. If the fissure be large, it is better not to attempt to close it at 
 one operation, on account of the danger which may arise if both palatine 
 arteries be divided, when the thin flaps would be imperfectly nourished, 
 and thereby sloughing ensue. By allowing some weeks to pass between the 
 first and second operation, the collateral circulation becomes established, 
 and this danger is avoided. 
 
 Ninth. The assistant having put the flaps on the stretch by the forceps, 
 the edges may be pared from below upward, if it be designed to close the 
 soft parts first. If, on the contrary, it is deemed requisite to unite the parts 
 of the hard palate, the knife, or scissors, is entered at the anterior margin 
 of the cleft, and the edges refreshed to as great an extent as is deemed 
 advisable. (Fig. 462.) In paring the edges, care must be taken, on the one 
 hand, not to take .off too much, and thus widen the gap ; but, on the other, 
 a sufficient amount of tissue must be removed to allow a fair chance for the 
 healing process. 
 
 Tenth. If the hard palate is to be closed, the soft structures must be 
 loosened with one of the double-edged knives with the cutting surface bent 
 at right angles with the shank. The pointed edge of the knife is introduced 
 close to the bone, and by a lateral motion the flap is, as gently as possible, 
 separated. Great care must be taken not to bruise the flaps. 
 
 Eleventh. The next step is the division of the palatine muscles, which, 
 if the flaps do not drop together, should be done with care, and by means 
 
 Fig. 463. 
 G.TIEMANN&CO. 
 
 Whitehead's, Forceps. 
 
 of a sharp-pointed, double-edged and long-handled knife, after the flaps 
 have been put upon the stretch. 
 
 Dr. Whitehead has invented a forceps (Fig. 463), which grasps the 
 muscle and much facilitates its division. 
 
 Twelfth. The next step is the introduction of the sutures. All things 
 considered, silver wire, well annealed, forms the best. The needles should 
 not be more than three-quarters of an inch in length. They are to be 
 armed with wire, and inserted into the needle-holder at any angle which 
 may be most convenient. Beginning at the lower margin of the fissure, 
 a needle should be passed through the flap. So soon as the point is 
 seen in the cleft, the needle-holder is opened, and the needle drawn out 
 into the cavity of the mouth by means of an ordinary forceps held by 
 an assistant. The needle is then again inserted into the holder, and 
 introduced at a point directly opposite, on the other margin of the cleft, 
 and again drawn out into the mouth. It is well, as the wires are drawn 
 without the buccal cavity, to mark them, in order that when the sutures 
 are tightened, the operator may not become confused, or lose time in 
 disentangling them. A very good plan is to tie a single knot on the end 
 
CLEFT PALATE AND STAPH YLORRAPHY. 
 
 757 
 
 Fig. 461 
 
 of the first wire, two knots in the second, three knots in the third, and 
 four knots for the fourth. Three, four, or even more sutures may be 
 required. 
 
 Another excellent method, especially for surgeons who are not ambidex- 
 trous, is that of Mr. Mason.* A curved needle, fixed in a handle with an 
 eye in its point, is armed with a thread and passed through the palate at 
 about a quarter of an inch from the free edge. When the point appears in 
 the cleft, the thread may be grasped by a tenaculum or forceps and the 
 needle withdrawn. This leaves a loop 
 of thread in the mouth, which may be 
 drawn forward. The needle is now re- 
 threaded and passed through the oppo- 
 site side in the same manner and the 
 needle withdrawn. One loop is then 
 passed through the other, and by making 
 traction on the free end of one of 
 the loops the other is readily drawn 
 through. It now only remains to draw 
 one end of the loop out, and the passage 
 of the thread is complete. (Fig. 464.) 
 
 Thirteenth. We'are now ready to close 
 the fissure. This is easily effected : 
 Take one set of wires which are outside 
 of the mouth, untie the knots which 
 have been made for marking them, and 
 pass the ends through a thin plate of 
 lead or silver which has been perforated 
 at points to correspond to the sutures. 
 Do this with all the wires on both sides, 
 and slide the plates up to their places, 
 on each side of the fissure. Slip a per- 
 forated buckshot on the end of each wire, 
 and taking hold of it with the jaws of 
 the compressor, slide . it gently to its 
 place, and press it firmly up to the hole in the plate. The wires are cut off 
 quite near to the shot, and their ends bent over, to prevent injury to the 
 tongue, and to hold the parts together. 
 
 Fourteenth. After-treatment : The patient should sit up in bed for several 
 nights, or lie with his shoulders well elevated, in order to prevent any dis- 
 charge from irritating or tickling the fauces, and thus avoid the risk of 
 coughing, sneezing, or hawking. 
 
 He must not be allowed to talk; let him make his wants known, or answer 
 any necessary questions by writing. All hawking or actions with the throat 
 must be avoided. Xo solid food is to be allowed ; the diet being soups, 
 gruel, milk, or other liquid substances. 
 
 The sutures may be taken away between the fifth and the ninth day, 
 according to the circumstances of the case ; but it is preferable not to be 
 in a hurry if the parts are doing well. To remove them it is necessary 
 to hold the shot with forceps, and with a curved scissors clip the wire 
 between the plate and the shot. 
 
 Sir William Fergusson detached a piece of bone on each side of the cleft, 
 and then forced the bone, periosteum, and mucous membrane towards the 
 middle line, and fixed them there. After division of the levatores palati 
 and palato-pharyngei muscles by means of a rectangular knife, he pared the 
 
 Method of passing and tying the sutures in 
 fissured palate : b shows the single suture 
 passed through the left half of the palate, the 
 double suture through the right, and the end 
 of the single suture passed into the loop of the 
 double one, which is drawn out of the mouth 
 for that purpose, a shows the loop drawn 
 back again, carrying the single thread with 
 it, which now lies across the cleft, c shows 
 the running knot made by casting a knot on 
 one string and passing the" other end through 
 it before it is tightened. 
 
 * Hare-lip and Cleft Palate, by Francis Wm. Mason, F.E.C.S., London, p. 83. 
 
758 A SYSTEM OF SURGERY. 
 
 mucous membrane from the edges of the cleft, and then, close to the edge 
 on each side of the fissure, he made two apertures with an awl. Fine 
 silk sutures were passed through the holes into the nasal cavity, and after 
 traversing the floor of the nares, they were made to enter the mouth 
 through the corresponding holes on the other side. When the hard and 
 soft palates were operated upon at the same time, he put two sutures 
 into the hard palate, and three into the soft, and tied them in the fol- 
 lowing order : first, from before backwards, the second suture in the hard 
 palate, then the three in the soft, and last, the foremost suture in the 
 hard palate. Lint was packed into the apertures in the hard palate, and 
 allowed to remain from two to four days. The hard palate soon became 
 so consolidated that, in a few months, it appeared bony throughout. Mr. 
 Mason is of opinion that by this method the bone is likely to exfoliate, to 
 prevent which, he says:* u I have since applied a very simple method, 
 which I brought before the notice of the profession in 1874. It consists in 
 boring holes with an ordinary brad-awl on each side straight through the 
 hard palate, exactly in the line in which the chisel is to be applied." He 
 then employs a small " screwdriver with a sharp edge " for cutting between 
 the holes drilled in the bone, of which he says the least pressure will " at 
 once divide the bone without splintering." 
 
 Dr. Parsons, of St. Louis, has reported a successful operation. 
 
 Before closing this subject, attention should be given to the use of nitric 
 acid, as suggested by Mr. Mason in the treatment of cleft palate. He thinks 
 that this method of effecting union is applicable to cases in which the cleft 
 is of average extent, and even where the hard palate is partially impli- 
 cated. In more severe instances the ordinary operation may be required. 
 Mr. Mason finds that the application of the acid is attended with no pain 
 or inconvenience, and although the cure is more slowly accomplished, 
 it has the advantage of being sure, and of completely closing the fissure 
 in a perfect manner, without the risk of the parts giving way, either 
 wholly or partially, as too often happens after the usual operation of 
 staphylorraphy. A further gain seems to be that the cases may be dealt 
 with as out-patients, as in all the examples now under notice. Mr. Mason, 
 after many trials, prefers the strong nitric acid to any other form of caustic. 
 He says : " I first produce a raw surface by carefully applying with a stick 
 (not a glass rod), the acid, nitric, of specific gravity 1.500, and in a few 
 days afterward, I use in the same way the acid, nitric, specific gravity 
 1.420 (Ph. Brit.), about twice a week to the part, especially the fork of the 
 cleft. "f He states that others besides himself have succeeded with this 
 method. 
 
 Gingivitis. — The gums often become inflamed; the inflammation may 
 confine itself to the alveolar dental membrane, or that lining the socket of 
 the tooth, constituting periodontitis. The disease is known by an uneasy 
 feeling in the alveoli when the teeth are pressed together ; they are some- 
 times forced outwards, in consequence of which they cannot be precisely 
 placed in contact. The pain is throbbing. The inflammation may extend 
 and be manifested on the outside of the gums, the teeth may loosen, and 
 pus, which has been formed, may be discharged between them and the gums. 
 In some cases the alveoli become carious, and a fistulous ulcer of the gum 
 ensues; the tooth or teeth then become permanently loose, occasioning, 
 especially in chewing, much annoyance and pain. The causes of this 
 disease are cold and hot fluids taken into the mouth, and exposure to cold 
 and moisture. 
 
 * Monthly Abstract of Medical Science, January, 1876; Lancet, November 6th, 1875. 
 f Hare-lip and Cleft Palate, by Francis Mason, F.K.C.S., London, p. 77. 
 
ABSCESS OF THE TONGUE. 759 
 
 The dental membrane itself also becomes inflamed, constituting endodon- 
 titis, or inflammation of the lining membrane of the teeth ; it cannot in the 
 majority of cases be diagnosed from neuralgia. 
 
 Acute local inflammation of the gums proceeding rapidly to suppuration 
 often occurs, the symptoms of which are swelling, redness, heat, throbbing, 
 and pain ; this inflammation may terminate in suppuration or gumboil, 
 parulis, apostema paridis. The gums sometimes shrink away, to which 
 condition the term ulatrophia is given ; this produces looseness of the teeth, 
 and they sometimes fall out without being decayed. The causes are 
 mercurials and the accumulation of tartar around the necks of the 
 teeth. 
 
 Treatment. — For sore gums, which become detached from the teeth, bleed 
 readily when touched, and are very red, with looseness of the teeth, and 
 bad odor from the mouth, and if occasioned by mercury, also if the gums 
 are painful during mastication, or look pale and bleed readily, with frequent 
 pains in the sound teeth, potassium iodide from 3 to 5 grains at a dose, 
 three times a day, will generally effect a cure. 
 
 Sulphur for swelling of the gums, with tendency to suppuration. Staphi- 
 sagria is the specific for excrescences on the gums, also when such morbid 
 growths arise on the inner cheek ; and for white, pale, painful, and swollen 
 gums. 
 
 I will not enter into the details of symptoms, nor the specific remedies 
 for these affections. Physicians are not often called upon to treat these 
 ailments separately, as they generally fall into the hands of dental surgeons. 
 These morbid conditions being readily recognized, no difficulty will be 
 experienced in ascertaining the appropriate remedies. 
 
 Diseases of the Tongue. — Wounds of the tongue bleed profusely, but from 
 the cases I have seen, heal with marvellous rapidity. Sutures are neces- 
 sary, if the wound be of any magnitude. I have known the tongue nearly 
 severed by the teeth, the patient being kicked on the chin by a horse. In 
 this the sutures were removed in three days, when the wound was per- 
 fectly healed. I advise that the mouth be washed with a solution of calen- 
 dula. 
 
 Glossitis. — Inflammation of the tongue is frequently met with in children, 
 and is not, in the main, a dangerous disease, but acute glossitis, occurring 
 in the adult or the aged, must always be regarded as a serious affection. 
 The causes are not always recognizable ; atmospheric changes, malarial 
 poison, irritating substances taken into the mouth, are numbered among 
 them. The patient generally has a prodromic stage of " miserableness," 
 when the tongue begins to swell, and rapidly attains a large size ; indeed, 
 in many instances, it protrudes from the mouth and may threaten suffoca- 
 tion from closure of the glottis. Salivation is profuse, is often very offen- 
 sive, and the teeth and gums are covered with sordes. The superior surface 
 of the tongue is hard and dry, often immovable, speech and deglutition 
 are impaired, but the temperature of the patient rarely rises higher than 
 102° or the pulse to 100. The disease runs a rapid course, and may termi- 
 nate in resolution or abscess. 
 
 Abscess of the Tongue. — Acute abscess of the tongue, or suppuration 
 following rapidly upon acute glossitis is a rare affection, and is scarcely 
 alluded to by many surgical writers. Chronic abscess is more frequently 
 seen, and has been mistaken for cancer. In such cases there is swelling 
 and redness, but not pronounced to such a degree as in the acute form. 
 The formation of pus takes place slowly until finally a circumscribed 
 tumor, on one side or the other of the tongue, is formed. When the pus 
 is evacuated, the disorder rapidly subsides. I have seen a singular and 
 fatal case of acute abscess of this organ in consultation with Prof. St. 
 
760 A SYSTEM OF SURGERY. 
 
 Clair Smith, of which the following is an abstract: The gentleman was 
 about 72 years old, had always enjoyed fair health, and was of robust 
 constitution. He had been feeling unwell for several days, when with- 
 out any apparent cause, his tongue began to enlarge and salivation of 
 fetid character developed. His pulse was not very rapid, nor was his 
 temperature very high. I saw him with Dr. Smith on the fifth day after 
 the attack, and found him as follows : He was lying quite flat on his back, 
 the tip of his tongue protruding from his mouth, and his teeth had sordes 
 upon them, which had to be constantly removed. The top of the tongue 
 was hard and dry, and the odor from the mouth offensive, although not so 
 much so as it had been. Deposits of exudation were seen in little points 
 beneath the tongue, but were easily removed and showed no ulceration 
 beneath them. Upon pressing down the tongue, which was difficult to 
 accomplish on account of the swelling and pain, the arches of the palate 
 were seen flexible and but little swollen. t His breathing was moderately 
 good, but occasionally inclined to be stertorous, and his articulation in- 
 distinct, though we could understand what he said. By reflected light, the 
 top of the velum could be seen, which was not abnormal, and was flexible 
 and moist. The medicine prescribed by Dr. Smith was lachesis, and the 
 report of the case on the next night was that there was no especial change, 
 excepting the tongue was a little broader on the right side. While this 
 report was being made the patient died suddenly. The post-mortem ex- 
 amination revealed a deep abscess at the root of the tongue, which had 
 burst into the trachea. Such a case, namely, acute abscess of the tongue, 
 is extremely rare, and I mention it for the sake of speaking of the treat- 
 ment. 
 
 Treatment. — In the early stages when the disease is appearing, the best 
 medicine is aconite, but when salivation commences, mercurius solubilis in 
 the second or third trituration should be given every two hours. If the 
 tongue assume a bluish appearance, lachesis is the appropriate medicine. 
 Perhaps tarantula cub. would be advisable in such a case. If, however, 
 the fever continue, and there are no symptoms pointing to resolution, and 
 the tongue is still swollen, — instead of the old-fashioned method of scarify- 
 ing the dorsum of the organ, I would recommend that an aspirating needle 
 of medium size be entered at the tip of the tongue and pushed gradually 
 towards its back part. If there be pus it will probably be found, and if 
 not no harm can result. I am taught this by the experience elicited from 
 the case just recorded. 
 
 In chronic abscesses, which are usually of small size, there is not much to 
 fear from apncea, and an incision made over the swelling and the free evacu- 
 ation of the pus will speedily remedy the evil. It is a question for the sur- 
 geon to decide, whether the application of leeches at the early stage of the 
 disease would not be advisable, to reduce swelling and prevent oedema of 
 the glottis. 
 
 Malignant Tumors of the Tongue having all the appearance of scirrhus, 
 frequently arise from disorders of the digestive organs, or from irritation 
 produced by carious and ragged teeth. Sometimes the whole tongue be- 
 comes enormously enlarged, fills the mouth, and hangs below the chin. 
 Many cases of this kind are recorded, and in particular two remarkable 
 ones by Percy. The tongue is likewise studded over with small excres- 
 cences, having broad tops and narrow pedicles, resembling mushrooms. 
 At other times deep fissures or irregular cracks occupy the whole surface 
 of the organ. The genuine epitheliomatous or carcinomatous ulceration, 
 which is recognized by the hard, rough, broad-bottomed, wart-like tumor, 
 is usually situated about the middle of the tongue towards the tip ; this 
 sometimes appears as a ragged, ill-conditioned sore, covered with a fungous 
 
HYPERTROPHY OF THE TONGUE. 761 
 
 growth, bleeding from the slightest irritation, accompanied by deep-seated 
 lancinating pain, extending to the throat and base of the skull, and termi- 
 nating, if its progress be not interrupted, in the total annihilation of the 
 organ. There are two varieties of epithelioma, the superficial and deep; the 
 first having mild symptoms of itching and burning, and raised papillae ; the 
 second presenting severer manifestations, as related above. Children are 
 occasionally subject to this disease, but it occurs more frequently in persons 
 beyond middle age. 
 
 Carcinomatous affections of the cheek and nose commence in the same 
 manner, and pass through the same stages as have been noticed in other 
 forms of cancer. 
 
 The proximate causes may be blows or contusions, the injudicious treat- 
 ment of ulcers, indurations, or excrescences on the face, suppression of natu- 
 ral secretions, the smoking of clay pipes, etc. 
 
 Treatment. — The medicines for cancer of the tongue are the same as those 
 for cancer elsewhere. The student will find them at page 185. If one 
 medicine appears to have more effect on the tongue than another, it is 
 galium aperinum. The formula for its use can be found on that page. 
 
 If an operation be deemed necessary the ligature, the galvano-caustic 
 wire, or the ecraseur may be selected. These will be described further on 
 in this chapter under "Amputation of the Tongue." 
 
 Hypertrophy of the Tongue. — Rokitansky* says very little about this 
 affection, and that almost indirectly, when speaking of hypertrophy in the 
 system of voluntary muscles. Jones and Sievekingf have the following 
 paragraph : " The tongue is liable to be affected with an extraordinary 
 hypertrophic enlargement, in consequence of which it protrudes from the 
 mouth, sometimes as much as two and a half inches; the structure is 
 altered, becoming much more dense than natural ; but it has not been de- 
 termined exactly in what the alteration consists. In one case, recorded by 
 Mr. Liston, the enlargement of the organ seemed to have been occasioned by 
 the development of a nsevus-like substance." 
 
 Cooper I mentions enlargements of the tongue consequent upon various 
 diseases, and Dr. M. Reese, in his valuable appendix to the same work, re- 
 cords in a few lines the following facts, viz. : That Dr. Thomas Harris, of 
 Philadelphia, twice performed amputation of the tongue for hypertrophy of 
 that organ ; and that Dr. Mutter also successfully resorted to the same oper- 
 ation. That in 1838, Dr. Mussey, of Cincinnati, and in 1836, Dr. Donnelan, 
 of Louisiana, removed portions of the tongue, the latter gentleman by using 
 ligature in preference to the knife. . Mr. Muller has two paragraphs on the 
 subject, including symptoms and treatment, the latter chiefly consisting in 
 the administration of the iodide of potassium and the application of leeches, 
 and these means failing, recommending operative procedure. 
 
 Neither Paget nor Cragie makes allusion to the subject, but Gross is much 
 more explicit. He tells us that all the structures which enter into the for- 
 mation of the organ may be separately or conjointly affected, that the pro- 
 jecting substance is dense and rigid, " protruding considerably beyond the 
 teeth, and causing serious obstruction to the functions of the mouth, and 
 a wasting discharge of saliva." 
 
 For a description of the affection I will narrate a case that came under my 
 supervision : 
 
 The patient, a girl aged eleven and a half years, was admitted to the hos- 
 pital with a congenital hypertrophy of the tongue (Fig. 465); the organ at 
 
 * Pathological Anatomy, vol. iii , p. 233. 
 
 f A Manual of Pathological Anatomy, p. 453. 
 
 X Surgical Dictionary — article, Tongue. 
 
762 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 46-5. 
 
 The Author's Case of Hypertrophy of the 
 Tongue ; from a Photograph. 
 
 times became enormously enlarged, and protruded from her mouth from three 
 to four inches. The sufferer had been, during her life, subject to catarrhal 
 
 fever upon exposure, at which times the 
 enlargement increased considerably. She 
 was somewhat emaciated, and the saliva 
 dribbled from her mouth to such a degree 
 that she was obliged to wear thick cloths 
 across her chest, which for cleanliness and 
 comfort had to be frequently renewed. 
 The jaws never having been brought to- 
 gether, the rami of the inferior maxillary 
 did not form the usual angle with its 
 body ; and the growing teeth, having con- 
 stantly upon them the superincumbent 
 weight of the tongue, projected from the 
 lower jaw more like the tusks of an animal 
 than the regularly developed masticating 
 organs of a human being ; they also, im- 
 pinging upon the under surface of the hy- 
 pertrophied mass, caused extensive fissures 
 and ulcerations. On the superior surface 
 of the tongue, two longitudinal and rough depressions were seen. 
 Fig. 465. from a photograph, will give an idea of the deformity. 
 Treatment. — In such cases, compression is of no avail, and amputation of 
 the tongue, or the superabundant part of it. is the only resource. 
 
 Amputation of the Tongue. — W. G. Delaney * M.D., reports an operation 
 for congenital glossocele or hypertrophied tongue, in which the V-shaped 
 incision was used, and in which the appearances were similar to the case I 
 have reported. 
 
 Mr. Humphrey 'sf case was very like the above, the parts being removed 
 by the knife. That gentleman further says, after the operation : " The lips 
 could not at first be brought together, and the thick stump could always be 
 seen, though never protruding." 
 
 Mr. Cross's case was one in which pressure with bandages soaked in a 
 solution of alum water, after a long period produced the desired effect. 
 
 Mr. Syme removed the protruding portion in another case, by the knife. 
 but the patient died of inflammation of the tongue and parts about the 
 larynx. 
 
 Mr. Listen recorded a case in which the haemorrhage, after operative 
 procedure, was so great that ligatures had to be applied to both lingual 
 arteries ; inflammation, suppuration, sloughing, and death followed in rapid 
 succession. 
 
 Mr. Hodgson's case was operated upon by means of a ligature. After the 
 parts had sloughed away ; " the tongue was quite within the lips, but very 
 thick in the horizontal direction: the altered shape of the lower jaw pre- 
 vented its being brought into contact anteriorly with the upper." 
 
 At present amputations of the tongue are performed by the ecraseur 
 or the galvano-caustic wire, the latter being in every way the better instru- 
 ment. The following interesting case will show a method which was suc- 
 cessful : 
 
 The patient was placed in a chair facing a window, her head being sup- 
 ported by an assistant: when the anaesthetic influence was complete. I 
 
 * American Journal of the Medical Sciences. October, 1S4S. 
 f Banking's Abstract, 1S53, p. 126. 
 
AMPUTATION OF THE TONGUE. 763 
 
 inserted the teeth of a hooked forceps into the substance of the tongue and 
 drew it forward, handing the instrument to an assistant to retain it in that 
 position ; then standing on the left and a little to the rear of the patient, I 
 passed the chain of the ecraseur diagonally across the protruded portion of 
 the organ, allowing the handle or cylinder to touch the right angle of the 
 lip (Fig. 466). The screw was turned, the chain tightened, constricted, 
 and cut through the substance, which was as hard as gristle. After 
 that portion had been removed, I changed my position to the right of the 
 patient, allowed the handle of the ecraseur to touch the left angle of the 
 mouth, and worked it as before until the part was removed. It will be 
 seen that by this method I was enabled to point the tongue, and though 
 the apex at first was rather sharp, it has since been a source of grati- 
 
 FIG. 466. 
 
 fixation that I adopted this. plan. The whole proceeding occupied about 
 twenty minutes, and the amount of blood lost did not exceed half an 
 ounce. 
 
 The patient was placed in bed with her shoulders elevated, and an iced 
 solution of calendula„was applied to the cut surfaces. 
 
 For two weeks after the operation the tongue was swollen enormously, 
 but it gradually declined as the raw surfaces healed, until it could with ease 
 be retained within the mouth. 
 
 It is gratifying, however, to witness the manner in which nature healed 
 the wounded parts ; instead of leaving them angular, as necessarily left by 
 the chain of the ecraseur, they are rounded almost as well as though the 
 original margin of the organ remained. 
 
 The girl, never having brought her jaws in apposition, had a tendency 
 to allow the inferior maxillary to drop on account of the shortness of the 
 branches of the bone. 
 
 I therefore procured a piece of gutta-percha, bent it and made an oval 
 gag or mouth-piece, cutting in the centre a small opening sufficient to admit 
 air, but not large enough to allow her to protrude her tongue. To keep the 
 bone in apposition and at the same time to endeavor to force back the 
 symphysis, I used the splint and strap for fracture of the jaw-bone. 
 
 The cure was complete, and to this day the girl speaks and sings without 
 impediment. 
 
 In the performance of either partial or complete amputation of the tongue 
 it is necessary to remember the position of the genio-hyoid and genio-hyo- 
 glossus muscles, and the relations of the lingual and the ranine arteries. 
 The division of these muscles allows the tongue sometimes to fall backward, 
 thus closing the epiglottis and producing symptoms of suffocation. It must 
 
764 A SYSTEM OF SURGERY. 
 
 be remembered, that operations upon the tongue often are followed by 
 alarming hemorrhage, due to the great vascularity of the structure. 
 
 Partial Amputation, which I have successfully employed, is thus per- 
 formed. In place of the ordinary wire ecraseur the galvano-caustic wire 
 may be used. 
 
 A needle, armed with a double thread, is passed through the tip of the 
 tongue, the needle cut off and the loose ends tied, enabling the organ to 
 be drawn out. Goodwillie's mouth-gag, without the tongue piece, is then 
 applied at the corners of the mouth to hold the jaws apart. A stout pin 
 is inserted through the tongue from above, to compel the chain of the 
 Ecraseur to start properly in the sound tissue behind and inside the tumor. 
 The ecraseur chain is applied by means of a needle through the base of the 
 tongue from below upward, which being united to the ecraseur is worked, 
 cutting anteriorly in the direction toward the tip, almost in the median 
 line. The Ecraseur chain looped is next passed backward, the diseased 
 portion of the tongue protruding through the loop, and marked out by 
 three pins, which form a fence, outside of which the chain works at right 
 angles with the tongue ; the screw is gradually turned, cutting laterally. 
 Calendula applications and ice-water gargles should be used. 
 
 If the galvano-caustic wire is employed, the entire diseased mass should be 
 marked out with pins, passed through the sound tissue, the loop of wire is 
 then applied outside the fence, the battery put in operation, and the dis- 
 eased part slowly removed. 
 
 In many amputations that I have made of the tongue, I have been care- 
 ful to notice three facts : first, that the tissue of this organ is rapidly repro- 
 duced, owing, I suppose, to the plentiful blood supply ; second, that removal 
 of large portions of the tongue does not materially impair articulation ; third, 
 that the operation above described, with pins and the ecraseur, or the gal- 
 vano-caustic wire, is preferable to the more severe proceedings of Syme or 
 Nunnely. 
 
 Removal of the Entire Tongue is thus performed : It is a modification of 
 that of Mr. Syme. The object is to allow the application of the ordinary 
 or the galvanic ecraseur to the base of the tongue above the os hyoides. 
 The incision is made in the median line of the chin, plividing the lower lip 
 and extending to the hyoid bone ; this will allow a sufficient dissection of 
 the lip on either side, which should be raised about a quarter of an inch. 
 A hole is made on both sides of the symphysis of the jaw, which must be 
 divided with a fine saw. The halves of the bone must be drawn aside with 
 hooks, and the genio-hyo-glossi muscles cut with scissors. The attachment 
 of the genio-hyoid muscles must not be cut. With the aid of the fingers 
 and scissors the tongue must be raised with the sublingual glands and 
 mucous membrane, until it is free to the hyoid bone. By means of a 
 cord passed through the tip of the tongue it must be drawn downwards, 
 which will put the palato-glossi muscles on the stretch, which must be 
 divided with blunt-pointed scissors. The chain, or wire, should be passed 
 around the base of the tongue close to the bone, and the parts gradually 
 severed, either by turning the handle of the screw or the action of the 
 battery. As the parts are separated the operator must be prepared with a 
 stout needle set in a handle, and threaded, to pass through the stump in 
 case it should fall backward. 
 
 A piece of wire should be passed through the holes previously made in 
 the jaw, and twisted securely, to bring the bone into its natural position, and 
 its ends turned up between the bone and the lip. The lip is then brought 
 together with the hare-lip pins and figure-of-eight suture .* 
 
 * Vide A Course of Operative Surgery, by Christopher Heath, F.K.C.S. Philadelphia, 
 1878. P. 55. 
 
MALFORMATION OF THE FR^ENUM LINGUA. 765 
 
 Mr. Whitehead* has successfully performed ablation of the entire tongue, 
 with the scissors, without division of the symphysis or submental incision. 
 A mouth-gag was inserted as usual, and the tongue secured by a ligature 
 passed through its tip. This thread was firmly taken hold of and traction 
 made ; the fraenum and muscular tissues were divided successively. The 
 tongue was then drawn out of the mouth and severed by cutting first on 
 one side and then on the other. Two vessels were ligated, but secondary 
 haemorrhage coming on, recourse was had to the thermo-cautery. 
 
 Dr. George F. Shrady,f in an excellent article on ligation of the lingual 
 artery, prior to the extirpation of cancerous or other diseases of the tongue, 
 arrives at the following conclusions : 
 
 " 1. In cancer of the tongue, whenever it is possible, the disease should 
 be removed through the mouth. 
 
 " 2. Ligation of the lingual artery is a very necessary preliminary to such 
 a procedure. 
 
 " 3. Ligation of the lingual artery, if performed at all, should be near the 
 origin of the vessel, as by that means the whole of the blood-supply of one 
 side of the tongue is completely cut off. 
 
 " 4. The operation of ligation of the lingual artery, even in that situation, 
 is less difficult than the securing of the vessel in the wound during the 
 operation of extirpation of the tongue, and when there is free haemorrhage 
 deep in the mouth. 
 
 " 5. The distance between the external carotid and the point of ligature 
 is sufficient for the formation of a firm clot and the prevention of secondary 
 haemorrhage. 
 
 " 6. The use of the scissors and the knife place the wound in a condition 
 more favorable for rapid healing than when the 6craseur or any variety of 
 cautery is used. 
 
 " 7. Ligation of the lingual may have a tendency to retard the return of 
 the disease." 
 
 In the case which he records, the vessel was ligated just at the point 
 where the artery passes under the posterior edge of the hyo-glossus muscle. 
 
 Malformation of the Fraenum Linguae. — It sometimes happens, though by 
 no means so frequently as is imagined, that children are born with the 
 fraenum of the tongue so short that they are unable to raise the organ to 
 the palate, and consequently sucking is materially impeded. This condi- 
 tion is made apparent by raising the point of the tongue with a spatula. 
 If the surgeon should fail in this attempt and the tongue appear, upon ex- 
 amining it laterally, to be unnaturally confined, little doubt can remain of 
 the fraenum being defective. 
 
 Treatment. — This complaint is readily removed by an operation which, 
 however trifling it may be considered, is one which should not be lightly 
 performed, nor upon every ordinary occasion. Petit relates two instances 
 in which death followed from the fraenum being so much loosened as to 
 permit the tongue to fall backwards into the pharynx, thereby occasioning 
 suffocation; other cases are recorded of fatal haemorrhage following the 
 operation from wounds of the ranine arteries and veins. 
 
 A pair of probe-pointed scissors are used. The tongue should be pressed 
 upwards by means of the index and middle fingers of the left hand, 
 and the fraenum should be divided in its transparent portion as far as 
 may be deemed necessary; at the same time taking care to direct the 
 point of the instrument downward, keeping as close to the lower jaw as 
 possible, that the arteries and veins may be avoided. If carefully per- 
 
 * Medical Times and Gazette, December 15th, 1877. 
 f Medical Kecord, September 14th, 1878. 
 
766 A SYSTEM OF SURGERY. 
 
 formed, there is scarcely any haemorrhage ; but, if bleeding should result, 
 it may be arrested by applying small pieces of sponge, a solution of alum, 
 gun-cotton, or other styptics. 
 
 Ranula. — By the term ranula was formerly understood an obstruction of 
 one or more of the ducts of the sublingual glands, giving rise to the forma- 
 tion of a semi-pellucid tumor, supposed by the older anatomists to resemble 
 the belly of a frog, hence the name. 
 
 More recent investigations have demonstrated that the affection is pro- 
 duced by obstruction of the mucous glands situated beneath the tongue, 
 such as the glands and ducts of Rivini. 
 
 From six cases observed by Professor Michel,* of Nancy, he concludes 
 that, in the majority of cases, it originates in the areola of the connective 
 tissue about the frsenum of the tongue. In none of the cases •" could a 
 reaction resembling that produced by saliva be obtained," and the micro- 
 scope only revealed tessellated and globular epithelium and crystals of 
 cholesterin. 
 
 The swelling may attain a considerable size, interfere with deglutition, 
 or even displace the teeth ; the tumor is cystic, and is generally filled with 
 a fluid resembling albumen, but not saliva. It arises from a natural im- 
 perfection or adhesion of the duct, or from the lodgment of a calculous 
 concretion within its passage. This disease chiefly affects children. 
 
 Treatment. — The medicines which have been successful in this affection 
 are mere, sol., calc, and thuja. Mercurius should be employed where there 
 is an excessive secretion of saliva, with soreness of the surrounding gums, 
 and there is disposition to profuse sweat ; the sufferings being aggravated 
 at night. 
 
 Calcarea carb. is an excellent medicine, and is particularly adapted to 
 children affected with scrofulosis; when there is violent burning in the 
 buccal cavity, with difficulty of speech. 
 
 Thuja should be employed when the disease is accompanied with sore- 
 ness of the whole palate, and with swelling of the salivary glands. 
 
 Other medicines are petrol., puis., silicea, stram., staph., and sulphur. 
 
 If medicinal means fail, an attempt must be made to open the ducts 
 from within, which may often be difficult. The better plan is to raise the 
 upper part of the cyst with a pair of forceps or a tenaculum , and cut off 
 the upper surface ; then introduce cotton or lint soaked with a solution of 
 iodine. If there should be great enlargement of the glands, an incision 
 should be made on the outside through the integument, as cutting deeply 
 within the cavity of the mouth might result seriously. I have succeeded 
 in several cases by passing a double silken ligature through the base of 
 the tumor and tying the threads on either side, thus producing strangu- 
 lation. 
 
 An excellent and efficacious treatment of ranula is that introduced by 
 Professor Panas,f which consists of injecting from three to eight drops of 
 a solution of ^ in strength of chloride of zinc, without withdrawal of the 
 fluid. He states that ranulse, which had resisted treatment by excision, 
 suture, and drainage, were promptly cured by this method. 
 
 Salivary Calculus. — Calculi are found in the ducts of the salivary glands, 
 but are chiefly confined to Wharton's duct, and are often present with 
 ranula. The formation no doubt originates in a deposit from the secre- 
 tion of the gland. These calculi are not generally larger than a pea, 
 although I have seen one, more than .an inch in length, removed by the late 
 
 * Monthly Abstract of Medical Science, September, 1877 ; Gazette Hebdom., No. 16, 
 1877. 
 f American Journal of the Medical Sciences, January, 1877, p. 255. 
 
TONSILLITIS. 767 
 
 Dr. Hartshorne, of Philadelphia. A cautiously made incision directly over 
 the calculus will allow its removal. 
 
 Salivary Fistula.— After operations upon the mouth and jaws, in which 
 Steno's duct has been necessarily divided, or as a consequence of abscess, a 
 salivary fistula is formed. The saliva flows from the wound over the cheek, 
 and there is a corresponding dryness within the buccal cavity. Mr. Holmes 
 gives the following operation for its cure : 
 
 " The disease is to be treated by restoring the passage for the saliva 
 from the gland into the mouth. For this purpose the proximal part of the 
 duct (i. e., the part of the duct which is still in connection with the gland) 
 should be found by examination of the wound ; then the cheek should be 
 everted, and along the natural opening of the duct, in the interior of the 
 mouth (which is generally found without difficulty, opposite the second 
 upper molar tooth), a probe or leaden string is to be passed across the wound 
 and along the duct in the direction of the gland. The probe or string is 
 fixed in its position by bending its extremity round the commissure of the 
 lips on to the cheek, where it can be secured. When the saliva is thus 
 guided into the mouth the fistula will probably heal, either of itself or on 
 its edges being refreshed and brought together. In some cases the opening 
 of the duct in the mouth cannot be found, and when this is the case, the 
 distal opening of the duct as well as the proximal must be sought in the 
 wound; or if that part of the duct is obliterated, an artificial passage must 
 be made and kept open ; but such cases are far less promising. And indeed 
 many cases of salivary fistula present very considerable difficulty, from the 
 rottenness of the tissues surrounding the wounded duct, which renders them 
 very unapt to unite when brought together, and favors the percolation of 
 the saliva through the wound which it is intended to unite." 
 
 Tonsillitis — Quinsy, — (Squinsy or squinancy of old writers ; the cynan- 
 che or angina of the medical books ; paristhmia, from -apa and ta^aoq, 
 literally, morbus faucium, or throat affection ; the signification of angina 
 is strangulation; the patient complains of difficulty in swallowing.) No 
 matter which part or parts be affected, there is swelling of the mucous 
 membrane of the fauces, pain, redness, and glossy appearance ; dryness 
 in the first instance, but subsequently a secretion of ropy mucus, which in- 
 creases the difficulty of deglutition. When the inflammation extends to 
 the uvula, it swells, and there is a constant desire to swallow (empty deglu- 
 tition), and there is nausea and retching in consequence of the irritation 
 produced in the throat by the elongated uvula and the secreted mucus. 
 The smell, hearing, and breathing often become impaired in consequence 
 of the disease spreading into the posterior nares, the Eustachian tube, 
 and top of the larynx. The food is sometimes returned by the mouth, 
 and solids are more easily swallowed than liquids ; in consequence of some 
 muscular fibres only being able to act, the particles of fluid, having but 
 little cohesion, slip from each other. There is a constant desire to hawk up 
 mucus, and the patient breathes with his mouth open. If the angina be 
 excessive, the jugular veins swell, the face becomes purple and livid, there 
 is headache, delirium, and other symptoms of febrile excitement. When 
 the inflammation attacks the tonsils, constituting cynanche tonsillaris or 
 amygdalitis, the following group of symptoms present. At first, slight 
 chills, followed by much fever, with uneasiness in the fauces, and more 
 or less difficulty of deglutition, with a sensation of a foreign body in the 
 throat during the effort ; after a while pain is experienced in the tonsils, 
 the difficulty of swallowing increases, or it is impracticable; one or both 
 tonsils, on examination, are found much enlarged, and the surface of the 
 fauces red and somewhat swollen. The tongue is white and covered with 
 a thick layer of transparent, viscid mucus, and is swollen ; the pain shoots 
 
768 A SYSTEM OF SURGERY. 
 
 from the fauces into the ears, particularly when attempting to speak 
 or swallow, and the mouth is opened with great pain and difficulty : a 
 thick ropy mucus adheres to the inflamed surface and impedes respi- 
 ration : the adjoining parts are red and swollen, but the principal pain 
 and difficulty of breathing arise from the enlarged tonsils, which may 
 easily come in contact, confining the swollen uvula behind them, or press- 
 ing it forwards into the mouth. The outside of the throat opposite to 
 the tonsils is always somewhat swollen, and tender to the touch. In 
 some instances the mucous membrane is less vividly red, or is red in 
 spots, and covered with a pappy, gray, white-yellow mucus, which ex-- 
 tends to the tongue. One tonsil is generally inflamed first, the left 
 sooner and more violently than the right. Sometimes slight ulcerations 
 take place, which arise from small, yellowish pustules. These burst 
 and pour out a lymph-Hke fluid, which hardens into a whitish, pseudo- 
 membranous layer on the surface of the tonsil; this after awhile sepa- 
 rates, leaving the part bright-red, eroded, and discharging a purulent 
 matter. 
 
 This disease may terminate in resolution, suppuration (abscess of the 
 tonsil', gangrene, very rarely; or in permanent enlargement of the tonsils 
 (chronic hypertrophy). 
 
 The causes are such as induce other inflammatory affections — wearing 
 damp linen ; cold applied to the neck ; sitting in damp rooms ; getting the 
 feet wet; violent exertion of the voice ; blowing wind instruments ; suppres- 
 sion of customary evacuations ; acrid substances irritating the fauces. 
 
 The circumstances indicating resolution are less fever, freer respiration, 
 deglutition not so much impeded, the inflammation being of a lighter 
 red color, with copious salivation. If about to terminate in suppuration, 
 dyspnoea and difficulty of swallowing increase, and it is altogether im- 
 possible to open the mouth. The pus may be discharged suddenly with 
 immediate relief, by hawking or coughing, or the matter may be dis- 
 charged without an aggravation of symptoms and be swallowed by the 
 patient. 
 
 The disease is supposed to affect particularly the young and sanguine. 
 but this does not accord with general experience. It is often met with in 
 adults and in different temperaments. After having occurred several times, 
 unless treated by specifics, it appears to establish a peculiar habit or dia- 
 thesis ; in such it can be readily excited and by slight causes. 
 
 Treatment. — The principal medicines for cynanche tonsillaris are aeon., 
 bell., mere. sol., mere, subl., hepar sulph.. chain., ars., ignatia, nit. ac, nux 
 vom.. baryta, silicea, and sulphur, also gelsem., phytolac, sanguin., and 
 podophyl. 
 
 In the first stages, when the patient is troubled with an undue secre- 
 tion of saliva, inducing constant and painful deglutition, and when the 
 inflammation is accompanied by synochal fever, aconite should be pre- 
 scribed. After the fever has been subdued, bell, is particularly efficacious, 
 and frequently in alternation with aconite cures the affection. It is espe- 
 cially indicated by the following symptoms : Phlegmonous redness of the 
 tonsil, with shooting pains during deglutition ; sensation as if the fauces 
 were spasmodically constricted, with slimy white mucus on the throat and 
 tongue. 
 
 In chronic enlargement and induration of the amygdala?, the medicines 
 are chiefly bell., baryta c. mere, silic, sulph. or sep.. puis., ars.. nit. ac, etc. 
 Chronic enlargement of the tonsils is a disease which for successful treat- 
 ment requires patience and perseverance, not only of the practitioner, but 
 of the patient. The medicines must be well selected and administered at 
 considerable intervals ; at the same time it is of great importance that the 
 
Treatment of tonsillitis. 
 
 769 
 
 patient should observe the proper dietetic rules, and avoid exposure to a 
 damp or cloudy atmosphere. It may be asserted that from negligence of 
 patients, and want of perseverance of practitioners, many cases quite curable 
 are abandoned as hopeless. 
 
 It is suggested by Dr. Porter * that the enlarged tonsils be injected with 
 a watery solution of iodine three drops to ten. The instrument used is a 
 hypodermic syringe with a long needle. Half the quantity is to be injected 
 into each. 
 
 I have succeeded in removing tonsils without the aid of the knife, by the 
 application of caustic paste. 
 
 Dr. Fournier, of Paris, reports fifty-two cases cured by the application of 
 the Vienna Paste ; the minimum time required was two weeks, the maxi- 
 mum, one month. Dr. Morrell Mackenzie, of London, has introduced what 
 he terms the London Paste, which I have used in many cases with success. 
 Dr. Ruppanerf reports one hundred and twenty-three successful cases 
 operated upon in this manner. The following is the method recommended 
 by Dr. Ruppaner. 
 
 The London Paste is prepared of equal parts of caustic soda and lime, 
 moistened with a little alcohol. It must be kept in a well-stoppered bottle, 
 since caustic soda and lime have a powerful affinity for carbonic acid. If 
 exposed, therefore, to the air, the causticity of the paste is lost. Various 
 tests have satisfied me, that it is necessary to employ absolute alcohol in 
 its preparation. 
 
 I proceed as follows : A quantity of equal parts of finely pulverized 
 and well-mixed caustic soda and unslacked lime is kept prepared. When 
 an application is to be made to the tonsils, a little of the powder is 
 
 Fig. 467. 
 
 put into a small porcelain cup, a few drops of absolute alcohol, which 
 is kept near at hand, are added, the two are carefully mixed with a glass 
 rod, when the paste is ready for use. The patient must be placed in a 
 good light, a tongue-depressor used, and the paste applied and allowed 
 to remain for several seconds, until an eschar is produced. Then it is 
 washed off, and the parts allowed to slough, when it must again be applied. 
 Care must be taken to apply the escharotic only to affected parts. If too 
 
 * U. S. Medical Investigator, December loth, 1877. 
 f Medical and Surgical Reporter, November 20th, 1869. 
 49 
 
770 
 
 A SYSTEM OF SURGERY. 
 
 much is placed upon the rod, some of it may drop off, and cause excoria- 
 tion. 
 
 When excision is preferred, it is to be performed in the following manner : 
 The patient is seated in a chair, before a good light, and the mouth kept wide 
 open. In examining the mouth and throat, some tact is required, especially 
 in children ; in looking for enlarged tonsils, in diphtheria, and other affections 
 of the pharynx, as well as in operating for cleft palate, or examining the 
 pharynx, a suitable tongue-depressor is essential, especially if the examina- 
 tion has to be prolonged. Fig. 467 represents Elsberg's tongue-depressor. The 
 surgeon passes the ring of Fahnestock's tonsillotome (Fig. 468) around about 
 half the tonsil (it is not necessary as a general rule to remove the whole glandj, 
 
 Fig. 468. 
 
 Fahnestock's Tonsillotome. 
 
 slides the pin through, and draws back the handle. The after-treatment con- 
 sists of gargling with calendula and water. 
 
 Fig. 469 shows Tiemann's one-bladed tonsillotome, which seizes the gland 
 as it is removed. Some surgeons prefer a hook and a curved bistoury, as 
 
 Fig. 469. 
 
 One-Bladed Tonsillotome. 
 
 seen in Figs. 470 and 471. The hook is inserted into the tonsil, and drawn 
 forward, and the tonsil, or a portion of it, removed by a stroke or two of 
 the knife. 
 
 An ordinary curved probe-pointed bistoury, wrapped with a piece of 
 cotton, or an instrument prepared for the purpose, will answer in lieu of the 
 tonsillotome. 
 
 Rhinoscopy. — By the term rhinoscopy is understood an inspection of the 
 nose and its cavities. It may be divided into anterior and posterior, the 
 former being through the nostrils, the latter (called also choanoscopy), be- 
 hind, through the fauces. 
 
RHINOSCOPY. 
 
 771 
 
 The ordinary bivalve speculum is often sufficient for anterior rhinoscopy, 
 or the speculum of Folsom (Fig. 472) answers well ; oftentimes by throwing 
 the head back, and allowing strong sunlight to shine into the nostrils, and 
 
 Fig. 470. 
 
 Fig. 471. 
 
 Fig. 472. 
 
 Folsom's Nasal Speculum. 
 
 Hook and Knife for 
 Excising Tonsils. 
 
 Khinoscope and Tongue Depressor in Position. 
 
 pressing the thumb lightly on the tip of the nose, an examination can 
 be made. Metz's nasal speculum consists of two instruments or curved 
 
772 A SYSTEM OF SURGERY. 
 
 spatulse, slightly concave and polished ; one is held in the right hand, the 
 other in the left, and thus the alse of the nose are held apart. 
 
 In posterior rhinoscopy, either sunlight or artificial light is to be used; the 
 mirror may be placed upon the head of the operator, or the laryngoscope 
 used. The patient is so seated that the light may be caught upon the re- 
 flector and directed within the mouth. The operator, taking a blunt flat 
 hook, set in a long handle and curved somewhat to keep the hand out of 
 the way of vision, introduces it behind the uvula, which is gently drawn 
 forward. The mirror, also set in a long curved handle, like that used in 
 laryngoscopy, being slightly warmed, is introduced, the glass looking up- 
 ward and forward. The glass may be moved backward and forward until 
 the nares are well examined. Several examinations are often required 
 before the parts are brought "into sight, some persons being more easily 
 managed than others. However, even an unsatisfactory view throws light 
 on diagnosis, and facilitates the performance of operations. 
 
 Another method is that of depressing the tongue with an ordinary right- 
 angled spatula, and introducing the mirror as seen in Fig. 473. 
 
 Pharyngitis. — The pharnyx is liable to inflammation, constituting the 
 disease called angina pharyngea or pharyngitis. 
 
 The same tissues are attacked as when other portions of the isthmus of 
 the fauces are affected. If the inflammation be high up, it may be dis- 
 cerned by an examination of the mouth, when the parietes of the posterior 
 wall of the isthmus will be perceived to be inflamed. Deglutition is pain- 
 ful, and, from the dryness of the parts, much impeded ; the food frequently 
 returns by the nose, and a violent and spasmodic cough is produced 
 in the endeavor to swallow. The voice is sometimes hoarse ; the inflam- 
 mation spreads to the nasal fossae and larynx, but respiration is not often 
 affected. It frequently accompanies amygdalitis, and often follows angina 
 faucium. 
 
 The throat-inflammation in hydrophobia is somewhat similar to that of 
 angina pharyngea, and sometimes ends in suppuration. 
 
 The stylo-hyoidei, stylo-glossi, mylo-hyoidei, hyo-glossi, stylo-pharyngei, 
 and the constrictor muscles of the pharynx are those affected. 
 
 Gangrenous Pharyngitis. — The pharynx is also liable to gangrenous inflam- 
 mation ; angina maligna, putrida, ulcerosa ; ulcerated, putrid, or malignant sore 
 throat. This disease is an inflammation of a peculiar kind. Although it 
 is true that ordinary pharyngitis may terminate in gangrene, still such a 
 result is rare. 
 
 This variety is marked from the first by peculiar symptoms, which are 
 typhous in character. It is perceived in scarlatina, but is not peculiar to it, 
 as it sometimes appears without, at others with, the scarlet rash ; it may be 
 sporadic or epidemic. The symptoms, from the first, are of the most alarm- 
 ing kind. 
 
 The disease seems to depend upon a humid or peculiar atmospheric con- 
 dition, attacking chiefly children, and those of weak, lax fibre. When one 
 member of a family is affected the others seldom escape, and hence its 
 contagious character is inferred. It sometimes follows measles of a malig- 
 nant kind. 
 
 Its first symptoms are : shivering, nausea, vomiting, and anxiety, followed 
 by heat, thirst, dyspnoea, and restlessness; the face is flushed, the eyes 
 bloodshot, the neck stiff, respiration hurried, accompanied with hoarse- 
 ness and sore throat ; the internal fauces are of a dark-red color, the tonsils 
 slightly inflamed, but not sufficiently so to obstruct respiration or deglutition ; in 
 a short time, sloughs, in color between a light ash and a dark brown, can be 
 seen on the tonsils, velum pendulum palati, and uvula ; the tongue is cov- 
 ered with a thick brown fur, the breath is highly offensive, the insides of 
 
TREATMENT OF PHARYNGITIS. 773 
 
 the lips are covered with vesicles, which contain an acrid matter, which 
 excoriates the corners of the mouth and other parts. There is also a dis- 
 charge of corrosive pus from the nostrils. Diarrhoea occurs, especially in 
 infants, the thin ichorous fasces excoriating the anus. From the first, the 
 fever is high, the pulse small, frequent, and irregular ; the temperature in 
 the morning being 102°, in the evening 104°. There is loss of strength, 
 low muttering delirium, or coma. On the second or third day, large patches 
 of a dark-red color appear about the face and neck, which by degrees dis- 
 perse themselves over the body, even to the extremities of the fingers, which 
 are swollen and stiff; these red patches continue for about four days, 
 and disappear without producing any change of symptoms. The inflam- 
 mation sometimes spreads along the Eustachian tubes to the internal ear, 
 where it produces ulceration, and indeed destroys the structure of that 
 organ. In other cases, the parotid, maxillary, and other glands become pain- 
 ful and swollen ; the entire neck swells and assumes a dark-red color. As 
 the sloughing spreads, the parts become darker-colored, the spaces between 
 the sloughs assume a purple hue, new spots appear, and the whole internal 
 fauces become covered with thick sloughs, which after their separation 
 leave deep ulcerations. 
 
 If the case be aggravated the fauces become black, the ulceration becomes 
 deeper and deeper ; these disturbances spreading through the alimentary 
 tube often terminate in gangrene, with which increase of symptoms, colli- 
 quative diarrhoea appears. 
 
 An unfavorable prognosis must be given if there be sudden abatement 
 of violent symptoms, as of pain ; the tonsils becoming dry, flaccid, and 
 unequal, and of a pale-brown or livid color; the inflammation changing 
 to a dull-red, interspersed with spots of a dark hue (so long as the specks 
 remain white, less apprehension may be experienced); the pulse becomes 
 small, weak, and irregular, the face cadaverous. If clammy, cold sweat, 
 and cold extremities, fetid breath, great anxiety, subsultus tendinum, foam 
 at the mouth, coma and delirium appear, or the tonsils become so large 
 as to threaten suffocation, the prognosis is bad. 
 
 The eruption is not uniformly diffused, but appears in blotches or small 
 points, scattered over the trunk and extremities, of a dark purple or livid 
 hue, and which terminate with scanty desquamation. 
 
 Treatment. — The remedies for these conditions are : 
 
 Aconite in the beginning of the affection, when there is dulness and fever, 
 should be given. 
 
 Belladonna is frequently called for, especially in persons of full habit, 
 with tendency to cerebral hyperemia, flushed face, and extreme conges- 
 tion of the mucous membrane. It -is especially useful in those cases 
 where there is great dryness and purple hue of the pharynx. 
 
 Mercurius is next in importance to belladonna. This remedial agent 
 is indicated in those anginas which appear on the slightest change of 
 weather, and in individuals who have suffered from and are consequently 
 liable to angina ; also in those anginose affections which occur after acute 
 cutaneous diseases, which arise from a slight cold ; they appear in spring 
 and autumn in young robust individuals. When catarrhs are frequent, 
 such subjects are exempt from them but are affected with angina. 
 
 Arsenicum is the medicine when there is a rapid failing of strength, with 
 intense burning thirst, drinking often and but little at a time; dry and 
 black patches in the mouth, fetid breath, hard, dry, and black tongue, 
 watery diarrhoea, rapid emaciation, and profuse sweating. In fact, in gan- 
 grenous pharyngitis, this medicine in alternation with lachesis is generally 
 indicated. 
 
 Chamomilla, in mild cases of angina pharyngea, may be useful, but rather 
 
774 A SYSTEM OF SURGERY. 
 
 for the collateral or consensual symptoms. It is also adapted to cases of 
 children, or where the disease is brought on by checked perspiration. 
 
 Nux vomica is adapted to inflammation of the uvula, tonsils, and phar- 
 ynx, especially the latter, if arising from gastric derangement, indicated by 
 eructation of a burning fluid which constantly irritates the pharynx. These 
 varieties are often connected with catarrhal complaints. When the uvula 
 itself is affected, nux vomica is the remedy. 
 
 Pulsatilla is indicated when the inflamed surfaces are dark red, with vari- 
 cose enlargement of the bloodvessels. 
 
 Ignatia is called for when there is a feeling of a plug in the throat, with 
 red and inflammatory swelling of the tonsils and palate. 
 
 Dulcamara is specific for angina when produced by exposure to wet and 
 when the secretion of mucus is excessive. It acts more promptly and 
 effectually if preceded by mercurius, or if given in alternation with bell. 
 and mere. 
 
 Cantharides may be given where the tonsils are inflamed and covered 
 with vesicles, together with an astringent sensation in the pharynx, and 
 burning, which sometimes extends down the oesophagus into the stomach. 
 It answers well at the commencement of some cases of angina, or at the con- 
 clusion of the disease, especially when there are suppuration and destruc- 
 tion of the mucous membrane. 
 
 Baryta carb. should be given if there be a chronic disposition to inflamed 
 throat, and indurated tonsils resembling scirrhus. 
 
 Iodine, mixed with an equal portion of glycerine, may be used topically 
 in the gangrenous variety, and cases have been much benefited by the 
 hydrochlorate of pilocarpine, one-tenth grain three or four times a day. 
 
 Post-pharyngeal Abscess. — Inflammation of the connective tissue in the 
 posterior portion of the pharynx, whether occasioned by disease of the 
 bones of the vertebrae or otherwise, sometimes terminates in suppuration, 
 the tumor bulging forward into the pharynx, and causing, in accordance 
 with its size, symptoms of suffocation. If the bone is diseased, the prog- 
 nosis is bad ; if the inflammation has been produced by ordinary causes, 
 and the pus is discharged by the mouth, a cure may result. In several 
 instances I have succeeded in drawing off the fluid with the aspirator, 
 although, when the children are young, I have found it difficult to keep 
 the needle in position. 
 
 Professor Bokai, of Pesth, in a paper in Jahrbuch fur Kinder heilJcunde* 
 gives the particulars of 144 cases of this disease, observed and treated by 
 him, in the Children's Hospital at Pesth, between the years 1854 and 1876. 
 Of these, 129 were idiopathic ; 3 were secondary to abscesses in the neck ; 
 4 were secondary to spondylitis cervicalis ; 7 occurred during the course of 
 scarlet fever, and ought properly to be classed with the idiopathic cases, as 
 the anatomical processes were the same in both ; and 1 case was of traumatic 
 origin. In addition, he observed 43 cases of lymphadenitis retropharyn- 
 gealis, which he classed with the idiopathic retropharyngeal abscesses, 
 because he believed that the latter always result from the former. 
 
 In idiopathic retropharyngeal abscesses, Professor Bokai found at first 
 a firm tumor, as large as a hazelnut or a pigeon's egg, behind one or other 
 tonsil, not often in the middle of the retropharyngeal space. These 
 tumors could be felt externally by deep pressure near the angle of the jaw. 
 Later they became soft and elastic, fluctuated, and gave exit to pus when 
 opened. Only 11 of the 144 cases proved fatal. Spontaneous opening of 
 the abscess occurred in 19 cases. In 2, pus discharged into the trachea, 
 
 * Medical Record, November 18th, 1876. 
 
SPASM AND (EDEMA OF THE GLOTTIS. 775 
 
 and asphyxiated the children, but respiratory movements and cough were 
 excited by the application of electricity, and life was restored. Facial 
 paralysis occurred in 3 cases. 
 
 The medicines used in the treatment are those employed for abscess. 
 Mercury and hepar are the most useful. Continuous spray from a steam 
 atomizer should be kept up on the parts as long as the patient can bear 
 it, and repeated frequently. 
 
 Elongation of the Uvula. — The uvula frequently becomes elongated from 
 various causes, sometimes from an angina, sometimes from inflammation, 
 and in some cases from sympathetic action in gastric derangements. Some 
 persons are more predisposed to the disorder than others, and if the elonga- 
 tion is not removed, severe sympathetic irritation may extend to the throat 
 and lungs. 
 
 The symptoms are dry hacking cough, caused by titillation in the throat, 
 which is worse when lying down; a constant desire to swallow; oftentimes 
 nausea is occasioned by the constant tickling. Children are subject to the 
 affection, and the common expression, having "the palate down," finds an 
 explanation in this unnatural relaxation. 
 
 Treatment. — The medicines to be relied upon are aconite, belladonna, 
 coffea, ignatia, lachesis, nux vom., and phosphorus. As there are but few 
 
 Fig. 474. 
 
 Sajous's Uvula Scissors 
 
 symptoms, the selection of the medicine must depend upon the peculiar 
 idiosyncrasy of each patient. Great temporary relief is obtained, especially 
 at night, when the cough prevents sleep, by sucking small pieces of ice or 
 gargling the throat with cold water, or with a solution of alum, grs. xx-|j. 
 Ferric alum or sulphate of zinc may be used in the proportion of grs, 
 xii-Jj. The medicines which have given me most satisfaction are cham., 
 ignat., coffea, and nux vomica. My usual practice, however, is to end the 
 trouble by excising the lower part of the uvula. A pair of forceps will 
 readily seize the end of the uvula, which, being drawn forward, may be cut 
 off at its lower half with a pair of long-handled scissors, such as are found 
 in the uterine sets. An excellent instrument has been devised by Dr. 
 Sajous for this purpose. (Fig. 474.) 
 
 Spasm and (Edema of the Glottis. — The glottis or upper part of the larynx 
 is sometimes affected with spasm, the aperture closing, and often producing 
 fatal dyspnoea. The symptoms are well marked when the disease is fully 
 established, but the attacks are insidious, beginning merely with a short 
 dyspnoea, which lasts but a moment, and is often overlooked. As the dis- 
 order advances, a sudden whistling, crowing noise is made during the efforts 
 
776 A SYSTEM OF SURGERY. 
 
 at deglutition, coughing, or sneezing. The face becomes purple, the veins 
 turgid, and all the symptoms of death from suffocation are present. If the 
 spasm subsides, in a short time the patient regains his ordinary appearance, 
 and all symptoms disappear until another attack follows. 
 
 The disease may be caused by injuries from, and the presence of, foreign 
 bodies in the air-passages, or the pressure of tumors or aneurisms upon the 
 nervus vagus. 
 
 Treatment. — The medicines are chiefly bromine, iodine, spong., cuprum, 
 plumbum, and moschus. 
 
 Dr. Carroll Dunham advised bromine water. In the cases which have 
 come under my care, iodine has been most satisfactory. To persons liable 
 to attacks, I always advise that a small vial of chloroform and a hand- 
 kerchief be kept in readiness, as a few inhalations will generally relieve the 
 spasm. If the spasm should be caused by the pressure of a tumor, or 
 should be so great as to present symptoms of imminent danger, tracheotomy 
 must be immediately resorted to. The inhalation of nitrite of amyl has 
 been used with success. 
 
 (Edema of the Glottis. — This disease, which often proves fatal, notwith- 
 standing skilful treatment, consists of a serous infiltration of the submu- 
 cous cellular tissue of the glottis and adjacent structures. There is no 
 vascularity in the swelling, which is of a yellowish color, like the surface 
 of an ordinary blister. It may occur during an attack of scarlatina, small- 
 pox, tonsillitis, or typhoid fever, or from the inhalation of steam, flame, 
 or swallowing hot liquids. Its effect is to produce mechanical obstruction 
 
 during inspiration, while expiration remains un- 
 FlG - 475 - embarrassed. The dyspnsea is marked, and con- 
 
 stantly increases as the disease advances. The 
 voice is altered, and a dry, croupy, convulsive 
 cough, with frequent paroxysms of suffocation 
 soon exhaust the strength of the patient. With 
 the above is a sense of fulness in the throat, with 
 great soreness but an almost entire absence of 
 pain. As the symptoms are both alarming and 
 distressing, some relief must be soon gained, or a 
 fatal termination will speedily follow. 
 
 Treatment. — Among the medicines, iodine is 
 the best. It can be administered in the form of 
 inhalations of vapor or spray, and given inter- 
 nally. Bromine may afford relief. Other medi- 
 cines to be remembered are apis, lach., musk, 
 
 ffidema Glottidis. and rhus tox. 
 
 When the symptoms are very urgent, the swol- 
 len parts should be freely scarified with a long probe-pointed bistoury,* 
 thus giving vent to the effusion, after which the iodine vapor may again 
 be used. 
 
 If, however, these means fail, and the waning strength and dark livid hue 
 of the skin show that the blood is becoming carbonized, then tracheotomy 
 must be performed, and many desperate cases have recovered after this 
 procedure. 
 
 The cut (Fig. 475) represents oedema of the glottis. 
 
 * A knife admirably adapted for this purpose, was invented by Dr. Buck, of New York. 
 
ABSCESS OF THE ANTRUM HIGHMOMANUM. 777 
 
 CHAPTER XXXIX. 
 
 INJURIES AND DISEASES OF THE JAWS. 
 
 Abscess of the Antrum Highmorianum — Tumors of the Antrum — Osteo-Plastic 
 Operation for Exposing the Cavity of the Antrum — Epulis — Cystic Tu- 
 mors — Necrosis of the Jaw-Bones — Phosphorus Necrosis — Excision of the 
 Upper Jaw — Excision of the Lower Jaw— Of the Entire Lower Jaw — An- 
 chylosis of the Inferior Maxillary. 
 
 Abscess of the Antrum Highmorianum. — Abscesses of the antrum high- 
 morianum fortunately are not of frequent occurrence; they are, in the 
 majority of instances, tedious to cure, and productive of much pain. The 
 disease may arise from blows on the face, chronic inflammation of the 
 pituitary membrane lining the nostrils, exposure to a cold and damp atmos- 
 phere, but more frequently from decayed teeth, which, by the irritation 
 they occasion in the membrane lining the cavity, produce the inflammatory 
 process which terminates in the formation of pus. 
 
 This affection in its early stages is difficult to diagnose; the first inti- 
 mation the patient receives is pain, which is generally referred to a carious 
 tooth, and laboring under such a mistake, several teeth are often extracted ; 
 this, however, does not relieve the suffering unless one of the fangs has 
 penetrated through the floor of the antrum, and, being removed, allows 
 exit to the matter that has accumulated in the cavity. If this is not 
 the case the pain continues, extending farther up, and more in the direc- 
 tion of the nose and orbit than is the case in ordinary, toothache ; but 
 even this does not lead the patient or practitioner to suspect the true 
 nature of the affection ; in fact, such pain may often be present in facial 
 neuralgia, without any disease of the antrum. The sufferings of the patient 
 continue for a length of a time, increasing in violence, until finally a 
 tumor becomes perceptible below the malar bone; this enlargement may 
 extend over the whole cheek, but there is a circumscribed hardness situated 
 above the posterior molars. The pus may be evacuated through the cheek, 
 or the matter may move towards the palate, forming a swelling there, and 
 rendering the bone in the vicinity carious, unless the patient is relieved ; 
 or a portion of it may be discharged through the nose, when the patient is 
 lying with his head low, and on the side opposite to that which is affected ; 
 or the matter may trickle down between the fang and the socket of the 
 tooth. The pus that is discharged is often so extremely fetid that no one 
 can enter the room without being disgusted with the odor, and the patient 
 is rendered disagreeable to himself on account of the matter flowing into 
 the mouth and throat when lying down. The pain is severe and generally 
 throbbing ; sometimes it remits for a short period, returning again with 
 increased violence. 
 
 The formation of pus in the antrum is often attended with disease of the 
 superior maxillary bone, and is in all instances tedious, and in many cases 
 difficult to cure. 
 
 Treatment. — The first step must be to evacuate the pus, after which the 
 surgeon can more readily ascertain the condition of the cavity, whether 
 there be caries, or if any morbid growth be present within ; the selection of 
 remedial measures consequently being rendered more certain. 
 
 All the grinding teeth of the superior maxillary bone, excepting the first 
 molar, correspond with the floor of the antrum. These teeth sometimes 
 extend into it, and the fangs are only covered by the membrane lining the 
 
778 A SYSTEM OF SURGERY. 
 
 cavity ; therefore, the simplest method of evacuating the pus is by drawing 
 one of the teeth. A carious tooth or a continued ache in one of the molars 
 should decide the practitioner which tooth to extract; but if all appear to 
 be sound, the surgeon should gently strike each one of them, and that which 
 appears most tender, or gives rise to most pain, should be removed. 
 
 The third or fourth molar generally is extracted, after which, if the pus 
 is discharged, no further operation is required ; if the matter does not 
 follow the removal of the tooth, a stilet or small trocar must be pushed 
 into the cavity to produce the desired effect. After the evacuation of the 
 pus, a probe may be gently inserted into the antrum, and the condition 
 of the bone, etc., ascertained. After the contents of the cavity have been 
 discharged, the part should be cleansed by means of an injection thrown 
 into it from a small syringe, with a somewhat curved pipe. A piece of 
 bougie must also be worn, to allow the matter that collects to be evacuated, 
 and hepar, ars., lye, or silic. be administered, or other medicines (men- 
 tioned in the Chapter upon Abscesses) employed, according to the presenting 
 symptoms. 
 
 " Dr. Gullen, of Weimar, from experience in several cases, strongly recom- 
 mends ars. and lye. in this complaint. Arsenic generally removes the 
 dreadful throbbing, divulsive pain, w T hich assumes the quotidian type for 
 the most part ; and lye. is useful in arresting the thick yellow discharge, 
 which frequently continues after the pain has ceased. Dr. Gullen recom- 
 mends the higher dilutions of both these remedies, and the use of silic. after 
 the discharge has abated."* 
 
 To obviate the necessity of extracting teeth, La Morier, of Montpellier, pro- 
 posed to perforate the antrum above the alveolar processes, immediately over 
 the third grinder ; but, says Dr. Gibson, " the disease, however, so seldom 
 occurs without being accompanied or caused by carious teeth, that such an 
 operation, though practicable, can scarcely ever be rendered necessary." 
 
 After the evacuation of pus, the cavity must be carefully examined 
 by means of gentle probing. If the internal lining membrane be diseased, 
 calc c, mez., or phos. ac. may prove serviceable, if other syptoms cor- 
 respond ; should, however, the affection have been produced by a decayed 
 tooth, its extraction and the discharge of the matter will afford great relief, 
 and the exciting cause being removed, the medicines will exert their 
 beneficial actions. But too frequently the disease has extended, not only 
 to the membrane lining the cavity, but also to the bone itself; in such 
 instances, the treatment, of course, must be directed to the carious bone. 
 
 The medicines that have proved serviceable for disease of the osseous 
 structure, are: calc, lye, mere, phos. ac, silic, staphis., sulph. ; or ars., 
 asaf., aur., hepar, nit. ac, or Hecla lava. 
 
 From numerous cases that have been recorded, we learn, that phosph. is 
 an excellent medicinal agent for diseases of the bones, particularly caries 
 or necrosis. Long ago, the British Journal of Homoeopathyf gave an inter- 
 esting account of a child that became affected with diseased bones from 
 the vapor of phosphorus. Such testimony as this should lead the prac- 
 titioner to investigate more thoroughly the action of medicines, as in 
 these instances especially, the power of drugs over diseases is distinctly 
 perceptible. 
 
 Aurum and nit. acid are excellent medicines when the patient has pre- 
 viously been affected with syphilis ; mez. will be found efficacious in miti- 
 gating, and often arresting, the intolerable burning pains which are present, 
 particularly at night. 
 
 * British Journal of Homoeopathy, vol. i., p. 407. 
 f Vol. vi., p. 284. 
 
TUMORS OF THE ANTRUM. 779 
 
 This medicine, perhaps, is better adapted to the disease when the bone 
 itself has not been implicated, but when the lining membrane of the 
 cavity is in an abnormal condition, mezereum acting more particularly on 
 periosteum than on bone. 
 
 Kali hydriodicum is a medicine that has been frequently overlooked in the 
 treatment of this disease ; it is suitable not only to those cases that have 
 originated from syphilitic poison, but is likewise serviceable when the 
 characteristic nightly aggravation pathognomonic of periostitis is present, 
 together with excessive accumulation of saliva. 
 
 As palliatives for the pain, which is often so severe as to be almost 
 unbearable, spigelia, nux vom., china, or phosph., will be found of much 
 service. 
 
 Tumors of the Antrum. — There are several varieties of tumors affecting 
 the antrum, the chief of which are myeloid and spindle-celled. The descrip- 
 tion of these tumors will be found in the chapter on this subject. The 
 remedy is removal. Formerly it was supposed necessary to excise the whole 
 bone, but recent operations, termed osteoplastic, mostly performed by the 
 German surgeons, have given brilliant results. 
 
 Osteoplastic Operation for Exposing the Cavity of the Antrum for the Re- 
 moval of Tumors. — The patient having been thoroughly etherized, enter the 
 knife a few lines below the inner canthus of the eye, and carry it down to 
 the ala of the nose. This incision must extend through the periosteum 
 down to the bone. With a fine saw, such as is seen in Fig. 406, the nasal 
 process must be divided ; the instrument is then temporarily relinquished, 
 and the knife entered at the superior extremity of the first incision, and 
 carried parallel with the lower margin of the lid, a little beyond the 
 external canthus. The saw is now resumed, and the bone freely divided. 
 Again the knife must be used, with its point entering the lower end of the 
 first incision, passing around the ala nasi, and terminating within the 
 nostril; its course must then be changed, by bringing the edge directly 
 downward, thus dividing the upper lip. The saw is now introduced within 
 the nostril, and the hard palate divided ; by inserting a strong elevator into 
 the last incision, the bone may be turned directly outward. This latter 
 proceeding requires considerable force, but when the bone is displaced, 
 the cavity is fully exposed, and any tumor or abnormal growth which 
 may exist within the antrum or nares can readily be removed. The 
 bone is replaced, and held in situ, either by silver wire around the teeth, 
 or wire sutures through the bone itself. The skin-flaps are approxi- 
 mated in the usual manner, and comparatively little deformity follows the 
 operation. 
 
 Trendelenberg recommended, in 1869, what he termed prophylactic 
 tracheotomy, with tamponing the trachea, in all bloody operations upon 
 the larynx, or in the buccal, nasal, or faucial cavities, thus preventing the 
 escape of blood into the air-tubes. Edmund Rose more recently recom- 
 mended that, for the same purpose, the patient should be placed in the 
 supine position, with the head thrown backward almost to a right angle, 
 and that the operation be made with the parts in this position. By the 
 old methods there is always more or less danger from suffocation, and 
 Nussbaum noticed that even the frequent sponging of the fauces to pre- 
 vent such untoward occurrence was followed by abscesses and irritation of 
 the parts. 
 
 There is said to be little danger in retaining the head in this position 
 for a length of time, and that its evil results have been much overes- 
 timated. This is proven by the position (standing on the head) taken 
 by gymnasts in their performances. To make the matter more certain, 
 experiments were made by several physicians and medical students, who 
 
780 A SYSTEM OF SURGERY. 
 
 found that the position could be maintained for three-quarters of an hour 
 without inconvenience, save some unpleasant feeling during the first few 
 minutes, and that conversation and discussion were kept up during the 
 time. 
 
 The position would appear to favor the administration of anaesthetics, 
 for experiments have proved that neither death nor asphyxia has been 
 known to occur in patients in the inverted position, indeed, when such 
 danger threatened, Nelaton especially recommended the suspension of the 
 patient. During anaesthesia the cerebral bloodvessels are in a state of 
 anaemia. There can be no doubt that often venous haemorrhage may be 
 increased by this position, and to prevent this Volkmann frequently per- 
 forms the division of the soft structures with the patient in the ordinary 
 posture. 
 
 Those who have operated upon persons in this position say, that they 
 appear more bloody because all the blood runs on the floor and is seen, 
 which certainly is preferable to having the fluid pass unnoticed into the 
 trachea. 
 
 Rose operated successfully in this manner for cleft palate, restoration of 
 the nose (rhinoplasty), and also resected the upper and lower maxillary 
 bones. Burow removed an alveolar sarcoma of the hard palate. Hahn 
 extracted a ball from the upper maxilla. Maas extirpated the larynx and 
 removed a cancerous tongue, and others have, with the patient in this 
 position, exsected the nerves and performed tracheotomy. 
 
 Epulis. — This is a peculiar recurrent fibroid or fibroplastic growth arising 
 from the jaw. It first appears in the form of a small papilla, which gives 
 little pain; in some instances, it grows rapidly and may have two or 
 three lobes, which appear attached to the gum by a pedicle, whereas 
 they, in all instances, are attached to the periosteum or bone. Epulis 
 may be distinguished from myeloid tumor by its density, its similarity to 
 surrounding tissues, its tolerance of manipulation, the comparatively healthy 
 condition of adjacent structures, and the absence of sympathetic irritation 
 of the neighboring glands ; there is also little tendency to ulceration. It is 
 flabby, does not readily bleed, and if cut off speedily recurs. Even the 
 actual cautery has but little effect upon it. I have applied the hot iron 
 many times in those cases which have come under my observation, with but 
 temporary relief. The only sure method is to remove the portion of bone 
 from which the disease springs. 
 
 Cystic Tumors. — Cysts are sometimes developed in the jaw-bones. I mean 
 primary cysts, not those tumors which are formed from degeneration of 
 certain tumors. In these cases, as the cysts enlarge the bones expand, 
 and form a covering for the tumor. The fluid found in them is serous, 
 gelatinous, sometimes even sanguinolent. The most peculiar variety, and 
 that to which attention is especially directed, is known as " dentigerous 
 cyst" In such cases the cysts are associated with a diseased condition of 
 the fang of the tooth. They may occur from the misplacement or from 
 the presence of supernumerary teeth. A singular fact is noticed, that 
 the disease is known to attack only the permanent teeth. The cysts are 
 called by Holmes " tooth-bearing" and are actually to be looked upon as 
 complications of the natural process of dentition, and are found when 
 there is a deviation in the anatomical distribution of the teeth. Jourdain 
 records the case of a girl, in which the first and second molars (perma- 
 nent) on the right side were inverted, and a serous cyst had formed in 
 the cavity of the antrum around them. The pressure of the tumor had 
 distorted the face and closed the nostril. There are other interesting cases 
 on record, proving the fact that deviation of the second set of teeth is the chief 
 factor in the production of the disease. The symptoms are local. There is 
 
EXCISION OF THE UPPER JAW. 781 
 
 at times, after long continuance of the disease, some constitutional disturb- 
 ance, the bone expands, and there is a kind of "crackling" or "crepitation " 
 of the tumor under the finger. If the bone becomes sufficiently thinned, 
 fluctuation is apparent. 
 
 The chief sign, which may be regarded as pathognomonic, is this : If a 
 patient presents himself with a tumor, with fluctuation about the jaw, 
 and the mouth is carefully examined, and teeth are found wanting, or not 
 arranged in their anatomical order, and their absence cannot be accounted for 
 by accident or extraction, the diagnosis of dentigerous cyst will be generally 
 correct. 
 
 Treatment. — The cyst must be evacuated, and the teeth or tooth removed ; 
 then a portion of the expanded bone should be cut away from the tumor, 
 and the balance will be, in time, removed by absorption. The tooth is gen- 
 erally discovered at the bottom of the cyst. 
 
 Necrosis of the Jaw-bones is not an uncommon affection. It is noticed 
 in children after severe forms of exanthematous affections, the disease 
 ease making its appearance on the decline of the fever. The swelling com- 
 mences round the gums, suppuration rapidly follows, fetor emanates from 
 the mouth, and in some instances the entire bone is destroyed. In many 
 cases the reproductive power appears to be as great as the disintegrating 
 process, and the entire mass of dead bone is thrown off as a sequestrum, 
 and a new bone, not so perfect in its contour as the old one, is formed. I 
 have seen several cases of this kind. In the majority, however, the disease 
 is confined to the alveolus. 
 
 Phosphorus Necrosis, not so common since the improved method of manu- 
 facturing matches has been introduced, was first clearly described in Eng- 
 land by Dr. Wilks.* He says : " I have seen several cases of it in my own 
 practice, and in a case wherein I removed the entire lower jaw, the patient 
 had been in the habit of holding the illuminating ends of matches in the 
 mouth ; indeed, after the removal of the bone, small portions of the sticks 
 were found in the alveolar sockets. In this disease, the pain is first referred 
 to the teeth, the patient complaining of toothache. In a short time, and 
 without very much pain, the bone appears to enlarge. During this period 
 the constitutional symptoms are well marked ; there are rigors, sweats, loss 
 of appetite, emaciation, and great depression. Necrosis rapidly supervenes 
 with great fetor. The teeth become loose and drop out, and fluctuating 
 points are observed in the gum. The point where the pus is discharged 
 varies in different cases, but when it is carried off, as is usual, the patient's 
 sufferings are greatly relieved. Many sinuses form, leading hither and 
 thither throughout the bone, and the swelling in some cases becomes per- 
 fectly enormous, puffing the face to the forehead, shutting the eyes and nose, 
 and everting the lips. Around the diseased bone a large amount of exuda- 
 tion takes place, which is fibro-plastic in its nature." 
 
 A peculiarity of phosphorus "disease, and one of interest to our school, 
 is the liability of those affected, to suffer with different diseases of the 
 lungs and bronchi. Asthma, especially, has been noticed as a compli- 
 cation. 
 
 If portions of bone are diseased, they may be removed with the chisel and 
 gouge ; if the entire bone is affected, it must be taken away. 
 
 For the medicines for necrosis, the reader is referred to the Chapter on 
 Diseases of the Bones. 
 
 Excision of the Upper Jaw.— There are a variety of tumors, both simple and 
 malignant, solid and semi-solid, which, growing upon the superior maxilla, 
 demand its removal. Besides these affections, caries and necrosis, especially 
 
 * Guy's Hospital Reports. 
 
782 
 
 A SYSTEM OF SURGERY. 
 
 that last considered, and abnormal conditions of the antrum, call for 
 excision of either a portion or the whole of the bone. 
 
 The method of Sir William Fergusson is often adopted. In this the 
 upper lip is divided to some distance within the nostril. The incision is 
 carried around the ala of the nose up to the inner angle of the eye, and 
 from thence parallel with the lower margin of the lid to the external can- 
 thus. By this means the large vessels and nerves are avoided. The hard 
 palate is sawn through and other bony attachments severed, either with 
 bone-cutters or the saw, and the bone is thus removed. The lion-jawed 
 forceps will be found most useful in steadying the bone and in breaking it 
 away from its attachments. The surgeon must bear in mind, while perform- 
 ing this operation, the course of the internal maxillary artery, as fatal haemor- 
 rhage might ensue were it divided low down. 
 
 Another method is that, I think, originally devised by Mr. Liston, and 
 which I have practiced with success, and although in the first incision 
 there is generally quite profuse haemorrhage, this can usually be arrested 
 by acupressure. The operation is as follows : Enter the knife at the outer 
 commissure of the lip and make a curvilinear cut, the convexity of which 
 is toward the angle of the jaw extending to the centre of the malar bone. 
 From this a second incision is carried beneath the lower lid to the inner 
 angle of the eye, as seen in Fig. 476, which was made from a photograph 
 
 Fig. 476. 
 
 Fig. 477. 
 
 Incision for Excision of the Upper Jaw. 
 
 Chain Saw Applied. 
 
 of a patient of mine, who suffered from malignant disease of the upper 
 jaw from which he subsequently died. The soft structures must be dis- 
 sected off and the bone entirely denuded of its covering. The palatine 
 process must be sawn through, and the junction with the malar bone 
 separated with the chain-saw, as seen in Fig. 477, or with pliers ; other 
 connections are severed, until the whole mass can be taken from its place. 
 During these operations chisels, gouges, and various bone forceps are 
 
EXCISION OF THE UPPER JAW. 
 
 783 
 
 required. According to Dr. Chisholm * the operation of Dieffenbach is 
 far superior to all others for removing the upper jaw. In the communi- 
 cation referred to, he states a remarkable fact, that in the recent works of 
 Holmes, Erichsen, Fergusson, Gross, and Gant, the operation is not even 
 mentioned ; and I confess that it was entirely new to myself. 
 
 
 Fig. 478. 
 
 G. TIE MANN S* CO 
 
 Dr. Chisholm thus describes the mode of procedure : " Commencing at 
 the root of the nose, an incision slits the nose and the upper lip in the 
 median line; a short incision, joining the first at right angles, extends from 
 the root of the nose to the inner angle of the eye. The lower lid being 
 drawn downward the knife is carried along the entire length of the con- 
 junctival cul-de-sac, separating this lid from its orbital connection, and 
 
 utilizing the entire length of the lower lid in the horizontal flap. When the 
 flap, as defined by the vertical and horizontal incisions, is dissected up, it 
 will lay bare the entire front, and if necessary, the side of the face, without 
 having divided any large bloodvessel or important nerve branch. With 
 such an exposure the superior maxillary bone can be isolated with great 
 ease, as every surface of contact with neighboring bones can be clearly 
 brought into view. With no additional incision I found no difficulty in 
 
 removing from the living subject the superior maxilla, malar and palate 
 bones, which enabled me to extirpate a large fibroid with extensive adhe- 
 sions to the roof of the pharynx. 
 
 " After the removal of the maxilla, when the flap is brought back to its 
 normal position and carefully adjusted by several points of suture, union 
 speedily ensues. This operation leaves so little deformity, that in the ma- 
 jority of cases the line of the incision will escape detection unless the scar 
 
 be sought 
 
 Ft«. 481. 
 
 G.TIEMANfo &C0 
 
 Dr. D. H. Goodwillie, of New York, has published an interesting mono- 
 graph on Resection of the Maxillary Bones without External Incision, and has 
 invented instruments for operations of this kind. 
 
 Fig. 478 shows a cheek-holder, which can be used at any angle. 
 
 Figs. 479 and 480 illustrate periosteotomes for denuding bone. 
 
 Medical Kecord, April 1st, 1873. 
 
784 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 482. 
 
 Fig. 481 represents an oral saw, consisting of a handle fixed with a U 
 shank, so contrived that knives and saws of different sizes may be set 
 into it, and which can be made to cut in four directions. 
 
 Excision of the Lower Jaw. — Resection of the lower jaw is a standard 
 operation, and is frequently performed. Prof. Valentine Mott was the 
 first to excise half of the bone at its articulation on one side for osteo- 
 sarcoma ; and I am of opinion that he never laid claim to anything further. 
 His first operation was performed November 17th, 1821. Velpeau* gives 
 the credit to Dupuytren ; he says : " Nevertheless, facts of this kind had 
 remained without application until Dupuytren came to the determination 
 to amputate almost the entire body of a cancerous lower jaw, by a method 
 entirely new, and which has been received into practice under the title of a 
 surgical conquest." 
 
 The priority of resection belongs, however, to a Western surgeon, Dr. W. 
 H. Deaderick, of Rogersville, Tenn., who performed the operation, February 
 6th, 1810, for a tumor of the bone, on a patient aged fourteen years. In 
 some instances it may be necessary to disarticulate the bone on both sides. 
 This operation was first performed in Europe by Walther, of Bonn, in 1826, 
 and in this country by Carnochan, of New York, in 1851. 
 
 There are several methods of removing the inferior maxillary. An in- 
 cision may be commenced at the mesian line of the lower lip, and carried 
 
 to the chin ; from this another 
 incision can be carried around 
 the lower margin of the body 
 and ramus of the bone (Fig. 
 482). This large flap must be 
 dissected up, the facial artery 
 secured, and the bone sawn 
 through at a point some dis- 
 tance beyond the diseased por- 
 tion. Holding that part to be 
 removed with a pair of lion 
 forceps, the structures connect- 
 ing the jaw with the mouth 
 must be dissected away, keep- 
 ing the edge of the knife close 
 to the bone. If the disease 
 has extended to the articulation 
 additional care is necessary; 
 and it is well, as we approach 
 the joint, to separate the soft 
 parts with an instrument de- 
 vised for the purpose by Dr. 
 Gross. Having reached the zy- 
 goma, with a pair of scissors 
 with round ends, carefully snip 
 the tendon of the temporal 
 muscle from its connection with the coronoid process, and then turn the 
 bone outward, to more fully expose the joint, and move the internal sur- 
 face as much as possible from the internal maxillary artery, which lies in 
 close proximity. Then carefully open the capsular ligament of the joint 
 in front, turn out the condyle, and the removal is completed. Do not 
 imagine that this is easy of execution. Many difficulties arise, which com- 
 plicate the proceeding. There is a great tendency of the tongue to fall 
 backward and close the glottis ; and when the entire jaw is to be removed, 
 
 Incisions for Removal of the Jaw. 
 
 * Operative Surgery, vol. ii., p. 713. 
 
EXCISION OF THE ENTIRE LOWER JAW. 785 
 
 as a precautionary measure, a needle armed with a strong cord should be 
 passed through the tongue near its tip, and given to an assistant to hold 
 during the entire operation. When the flaps are brought down, a large acu- 
 pressure pin should be passed through the integument, near the submaxillary 
 glands, and caught into the several ends of the glossi muscles, and these 
 pinned down to the neck until a sufficient period has elapsed for their adhe- 
 sion. The wound must be thoroughly washed out before the edges are 
 united, and great nicety is necessary in coaptating the vermilion border of 
 the lip. There is another accident to which I would direct attention ; it is 
 the escape of blood into the trachea; this sometimes causes much embar- 
 rassment, therefore there should always be on hand several sponge probangs 
 to clear the throat of clots. 
 
 Some surgeons prefer leaving the border of the lip entire, and begin the 
 incision below the vermilion edge. Again, large portions of the bone have 
 been removed by what is termed the single linear incision, which extends 
 around the jaw on a line corresponding to the lower margin of its body. 
 
 Excision of the Entire Lower Jaw. — In some cases, either for tumors or 
 diseases of the bone itself, it may be necessary to remove the entire lower 
 jaw. 
 
 It is in the excision of this bone that periosteal surgery has made some 
 of its wonderful triumphs. The celebrated case of Dr. James R. Wood, 
 in which the bone was reproduced entire, is well known. The new jaw, ob- 
 tained after the death of the patient a number of years after the operation, 
 travelled over Europe, the admiration of all surgeons* Dr. Gouley f has 
 collected valuable statistics of this operation, to which the student is referred. 
 
 Dr. R. A. McLean J reports reproduction of bone four months after exsec- 
 tion of half of the inferior maxilla of a child four years of age. It is, there- 
 fore, necessary, in every instance, to elevate the periosteum, and retain as 
 much as possible thereof if we wish for reproduction of bone. 
 
 In the month of May, 1867, I was requested to see a lad suffering from 
 necrosis of the inferior maxillary bone, and, if necessary, to take such sur- 
 gical measures into consideration as would prove efficient for his relief. 
 Upon visiting the patient, I found him in apparently good health, but 
 with an excessively swollen face. Upon depressing the lower lip, the sym- 
 physis of the inferior maxillary, entirely necrosed, could be seen, and was 
 movable in a vertical direction ; lateral motion, however, was so slight, that 
 at the first examination it was doubtful whether the diseased action had in- 
 volved the entire bone; further and more minute investigation decided me 
 in the opinion that its complete excision was the only resource. 
 
 Operation. — An incision was commenced at the middle of the vermilion 
 border of the lower lip, and carried down to the chin ; from this point, a 
 second cut was made along the lower border of the bone almost to the con- 
 dyle on the left side, and a similar division effected on the right. These 
 flaps were dissected up and the bone was found bare. In endeavoring 
 to remove the left ramus it broke, but with slight traction with the pliers 
 the part was taken away. The right side was much more firmly fixed 
 at the articulation, and required an extension of the external incision, and 
 a separation of the soft parts from the bone, together with some prying with 
 the handles of the bone-forceps before it could be enucleated. It came away 
 entire. After the extraction of some spiculse, and the ligation of several 
 vessels, the wound — a gaping and extensive one — was brought together and 
 held in position by interrupted sutures. I was informed by letter, that the 
 
 * Lancet, June 2d, 1877. 
 
 f Transactions of the International Congress, Philadelphia, p. 60o. 
 
 X Western Lai.cet, April, 1877 ; Monthly Abstract of Medical Science, June, 1877. 
 
 50 
 
786 A SYSTEM OF SURGERY. 
 
 cuts healed almost entirely by first intention, and in the remarkably short 
 
 space of twelve or fourteen days. 
 
 The following cut (Fig. 483), copied from a photograph taken two years 
 
 after the operation, shows the appearance of the boy. A strong fibro-car- 
 
 tilage, which may have ere this become ossi- 
 FlG - 483 - fled, had formed, and the patient was in the 
 
 enjoyment of perfect health. 
 
 The most difficult and critical part of the 
 operation is the disarticulation of the bone. 
 After the flaps have been made as directed, 
 the tendon of the temporal muscle must be 
 divided at its insertion into the coronoid pro- 
 cess. With blunt instruments or periosteum 
 knives the structures are to be separated on 
 the inside of the mouth, keeping the instru- 
 ments close to the bone, to prevent injury to 
 the internal maxillary artery, which is in 
 close proximity to the ramus. The joint then 
 
 The Author s Case of Removal of the ,\ j r ±i j.*ji vj.j.1 
 
 entire Lower Jaw. must be opened from the outside and a little 
 
 forward, and the condyle turned forward by 
 depressing the bone. If the bone is turned outward, the artery may be 
 twisted around the condyle and accidentally severed, giving rise to severe 
 and troublesome haemorrhage. The disarticulation will be materially facili- 
 tated by sawing the bone through at the symphysis, seizing the fragment 
 with a lion forceps and depressing it. 
 
 Drs. Beebe, Beckwith, Franklin, and Hall have removed, successfully, 
 parts of the inferior maxillary bone. 
 
 The after-treatment consists in the application of carbolated calendula, 
 or a solution of the latter, to the parts. The pins ought to be removed on 
 the third to the fifth day. 
 
 Mr. Stanley * before operating on the lower jaw, took the precaution to 
 apply an acupressure pin to the facial artery, which effectually checked the 
 haemorrhage. On several occasions I have adopted this procedure. 
 
 It appears, from an examination of surgical literature, that immense 
 tumors, bony and others, have been removed with the entire bone, or por- 
 tions of it, with success. 
 
 Anchylosis of the Inferior Maxillary. — Anchylosis of the lower jaw may 
 occur in three localities : 
 
 First. The head of the condyle may become fixed in its glenoid cavity. 
 This is the most frequent form, examples of which are recorded by Sandi- 
 fort, Blandin, Cruveilhier, Howslip, Holscher, Hyrtl, and others. 
 
 Second. The coronoid process may attach itself to the zygomatic arch ; 
 of this but few observations are recorded,f and these chiefly b} r Sebastian, 
 in his essay, published at Grceningen, 1826. 
 
 Third. Alveolar processes may become conjoined ; of these there are four 
 examples on record, which are to be found in Walther's Museum of Anatomy, 
 in Rust's Magazine, and in Bennett's cited from K unholz, and in the British 
 and Foreign Medico- Chirurgical Review. 
 
 Of the fifteen cases of anchylosis collected by Dr. Lewis, both sides of 
 the jaw were affected in seven cases, and one side in eight. In the three 
 examples of osseous connection of the alveoli, the incisors were somewhat 
 separated. It has been supposed by Cruveilhier and others that anchylosis 
 of one side entails that of the other, by the complete immobility it induces; 
 but in seven of the fifteen cases quoted, the joint on one side remained quite 
 
 * Vide Simpson on Acupressure. f Museum of Anatomy, vol. iv. 
 
ANCHYLOSIS OF THE INFERIOR MAXILLARY. 
 
 787 
 
 free. To what degree prolonged immobility is a cause of anchylosis may 
 be judged by the case I record, in which it had continued seven years, and 
 by others in which it had lasted for nearly a quarter of a century. 
 
 Immobility of the inferior maxillary bone, causing closure of the jaws, 
 is an affection which is of comparatively rare occurrence ; and as the em- 
 ployment of poisonous doses of mercury is decreasing such unfortunate 
 occurrences will be still less frequent. 
 
 Speaking of this deformity, Dr. Gross* remarks : " The most common 
 cause, according to my observation, is profuse ptyalism, followed by gan- 
 grene of the lips, cheek, and jaw, and the formation of a firm, dense, un- 
 yielding modular tissue, by which the lower jaw is closed and tightly pressed 
 against the upper. Such an occurrence used to be extremely frequent in 
 our Southwestern States during the prevalence of the calomel practice, as it 
 was termed, but is now fortunately rapidly diminishing." 
 
 The same author appears to have encountered a number of such cases 
 during his residence in Kentucky, and upon referring to Dr. Mott's record, 
 published in the appendix to Velpeau's Surgery, it will be. perceived that 
 the majority of persons suffering from this affection who applied to him 
 for relief, resided in the Southern and Western portions of the United States. 
 The prevalence, therefore, of such disorders in the West and South, can 
 truly be attributed to the too free exhibition of mercurials in the fevers 
 peculiar to those sections of country. 
 
 Besides the abuses of mercury just referred to, other causes may be 
 enumerated, as anchylosis, in consequence either of arthritic disease or trau- 
 matic lesion, in either of which cases, an effusion of plastic element may be 
 thrown around the joint, which finally may be converted into cartilaginous 
 or osseous formations, effectually impeding the motion of the jaws. Again, 
 the pressure of a neighboring tumor may produce a similar result, and an 
 entire osseous connection may take place between the jaws in any part where 
 the previous disease has manifested itself, 
 either between the ramus of the inferior 
 and the boss of the superior maxillary, 
 or between the alveolar processes ; or, as 
 Mott observes, " by means of a bony 
 plate which extends from the coronoid 
 process to the superior maxillary bone." 
 
 From no matter which of the above- 
 mentioned causes the closure proceeds, 
 it is a difficult and tedious affection 
 to treat, and the prognosis is doubt- 
 ful and cannot be hastily formed, be- 
 cause it is impossible to state certainly 
 by what means the jaws are closed ; 
 perhaps it may be by one, perhaps 
 another of the tissues mentioned ; or, 
 as in the case seen in Fig. 484, two 
 or three substances may firmly unite 
 the maxilla?. In his chapter on this 
 subject, Dr. Mott says : " It is, in our 
 opinion, an important surgical subject, 
 and especially so since it is one which is frequently very difficult to treat." 
 Gross, also, in his article, writes as follows: "When the immobility depends 
 upon the presence of modular tissue, the proper remedy is excision of the 
 offending substance, an operation which is both tedious, painful, and bloody, 
 
 Fig. 484. 
 
 The Author's Case of Anchylosis of the Jaw, 
 with destruction of orbit, eye, and cheek. 
 
 * Operative Surgery, vol. ii., p. 584. 
 
788 
 
 A SYSTEM OF SUKGERY. 
 
 and unfortunately not often followed by any but the most transient relief, 
 owing to the tendency of the parts to reproduce the adhesions, however 
 
 carefully and thoroughly they may have been removed The great 
 
 difficulty, however, is the obscurity of the diagnosis." 
 
 In general, however, the joint is affected with spurious anchylosis, true 
 synostosis not having occurred within the capsule, while along some portions 
 of the bone osseous connections may have been thrown out. Nevertheless, 
 muscular contractions, fibrous tissue, cicatrices, or even fibrous degenera- 
 tion of the articular cartilage, may hold the jaw perfectly immovable. In 
 the diagnosis of such cases it is well to bear in mind the advice of Brodhurst,* 
 who thus writes: "False anchylosis is the rule; it is so common, that 
 adhesions should always be held to be fibrous until they are proved to be 
 bony. Immobility alone is not a sign of synostosis ; it not unfrequently 
 exists where the adhesions are fibrous. And even where chloroform has 
 
 been administered immobility may be as great as before Whenever 
 
 the muscles can be thrown into action, so as to render the tendons promi- 
 nent and tense about a joint, the adhesions are not bony." 
 
 Treatment. — The parts must be carefully dissected away from the jaws, 
 and one of the instruments depicted in Fig. 485 or Fig. 486 inserted be- 
 
 FlG. 485. 
 
 FIG. 486. 
 
 G.T1EMANN-C0 
 
 tween the teeth ; then with a steady turn of the screw, the jaws are gradu- 
 ally opened. As the jaws open the adhesions separate with a loud snap. 
 Fig. 484 shows a case in which the patient had suffered from ptyalism to 
 such a degree that there was necrosis of the lower jaw, together with death 
 of the external angular process of the frontal bone, which entirely destroyed 
 the eye. Her cheek also ulcerated and the jaws became so firmly locked 
 that teeth which had decayed and dropped into her mouth she was obliged 
 to swallow, not being able to separate the jaws sufficiently to expel them. 
 After many operations, I succeeded in making a cure of this remarkable 
 case. 
 
 * Practical Observations on the Diseases of the Joints involving Anchylosis, and on the 
 Treatment for the Eestoration of Motion. London, John Churchill, 1861. 
 
CUT THKOAT. 789 
 
 Formation of an Artificial Joint. — In some, perhaps the majority of cases, 
 the tendency to the reformation of cicatricial bands cannot be prevented, 
 and the last state of the patient becomes worse than the first. The construc- 
 tion of an artificial joint then becomes necessary. Keil and Rizzoli about 
 the same time (1855) suggested and performed division of the lower jaw 
 below the cicatricial bands. This was done by dividing the bone within the 
 mouth with a strong pair of forceps, and inserting a slice of india rubber 
 between the ends. 
 
 Esmarch later practiced the excision of a wedge-shaped portion of bone, 
 the apex of which pointed to the alveolar border. This is to be done with 
 a small saw, through an incision on the outside, made at the lower margin 
 of the bone. Even in this operation there is great difficulty in preventing 
 bony or fibrous reunion. The most thorough operation is that of removal 
 of the condyle of the bone, which should be performed for synostosis of the 
 joint, especially if other means have failed. This is a delicate procedure, 
 on account of the close proximity of the internal maxillary artery. The 
 operation, as done by Konig, is as follows : The first incision — about an 
 inch or an inch and a half in length — is made over the lower border of the 
 zygomatic process. A second cut, starting from the end of the first, which 
 is nearer to the ear, is then made downwards at right angles, and about an 
 inch in length. The latter, to avoid severing the facial nerve, is only skin 
 deep. The masseter muscle must be divided and the joint exposed. A 
 small chisel is then applied to the neck, and the condyle severed and 
 carefully removed. 
 
 The late Dr. Little performed the operation in 1873, the elder Gross in 
 1874 (he, however, making a single semilunar cut in front of the articula- 
 tion), Dr. J. Ewing Hears in 1875, Dr. Robert Abbe in 1879, and Dr. Hears 
 again in 1884. On the Continent, Ranke, Hagedorn, Langenbeck and Konig 
 have all reported cases. The operation is one of rarity, there being up 
 to the present but fifteen reported cases. 
 
 CHAPTER XL. 
 
 INJURIES AND DISEASES OF THE NECK. 
 
 Cut Throat — Torticollis, Wry Neck. Diseases of the Glands of the Neck — 
 Parotitis, Mumps— Abscess of the Parotid— Gangrene of the Parotid — 
 Malignant Diseases of the Parotid — Extirpation of the Parotid— Affec- 
 tions of the Duct of Steno — Diseases of the Submaxillary Gland — Cystic 
 Tumors of the Neck— Goitre— Bronchocele — Derbyshire Neck. Diseases 
 of the oesophagus — rupture of the (esophagus— oesophagitis, inflammatio 
 (Esophagi— Stricture of the (Esophagus— Foreign Bodies in the (Esophagus 
 — Introduction of Tubes— CEsophagotomy. Surgical Affections of the 
 Larynx and Trachea — Syphilitic Laryngitis— Foreign Bodies in the Lar- 
 ynx and Trachea— Bronchotomy— Laryngotomy— Tracheotomy— Tracheot- 
 omy with the Thermo-Cautery— Intubation of the Glottis— Laryngoscopy 
 — Neoplasms — Extirpation of the Larynx. 
 
 Cut Throat. — It is not as well understood as it should be, that many of 
 the incisions which are made, by suicides or murderers, in the neck are not 
 fatal. Because of the prevalent opinion, that if the windpipe is opened, 
 death is inevitable, the incisions are generally made in the front of the 
 neck, and, the great vessels and nerves of the lateral portions being intact, 
 the patient recovers. 
 
790 A SYSTEM OF SURGERY. 
 
 Holmes asserts that of 158 unselected cases the wound was situated 
 
 Above the hyoid bone in . . 11 ca^es. 
 
 Through the thyro-hyoid membrane in 45 " 
 
 Through the thyroid cartilage in 35 " 
 
 Through the crico-thyroid membrane in 26 " 
 
 Into the trachea in 41 " 
 
 The respiratory tract was open in about two-thirds of the cases. How- 
 ever, there is often considerable bleeding from the thyroid arteries and sev- 
 ered veins. Death, also, may ensue from the flowing of blood into the 
 air-passages and lungs. 
 
 Treatment. — The first care of the surgeon, of course, is to arrest the bleed- 
 ing, and to wait a considerable time to ascertain that no internal haemor- 
 rhage is taking place. If the cut has been made high up, at the junction 
 of the neck and chin, a portion of the epiglottis may be cut off; if a part 
 is left hanging, it should be excised. If the wound is lower down, the rings 
 of the trachea may be brought together by passing fine silver wire through 
 the perichondrium, and twisting it, allowing the ends to protrude through 
 the wound. 
 
 If muscles are severed, they must be treated in like manner. 
 
 The head must be placed in such position that there be no traction on 
 the sutures, and the parts covered with compresses wet with a solution of 
 calendula and water. 
 
 Torticollis — Wry Neck. — This distortion and consequent unnatural posi- 
 tion of the head may be either congenital or acquired, paralytic or spastic. 
 Sometimes the manipulations of the accoucheur during a tedious labor 
 may produce it. When thus noticed it increases gradually, the head being 
 drawn from one side or the other, until great deformity results. In other 
 cases it may arise from scrofula, rheumatism, or from the sloughing conse- 
 quent upon burns, lacerated or gunshot wounds. The head leans to the 
 side of the contracted muscles, and may be drawn slightly forward. The 
 chin is directed to one side, and the ear approaches the shoulder. The 
 affected muscles are first and most frequently the sterno-mastoid, next the 
 trapezius and scaleni. The fascia sometimes plays an important part in 
 the affection. 
 
 The sterno-mastoid and trapezius muscles are supplied by the spinal 
 accessory nerve, and any cause exciting an irritation of its tract may pro- 
 duce torticollis. Indeed, a reflex irritation from the pneumogastric has 
 been known to produce the spasmodic variety of this disease. There may 
 be also a clonic torticollis and a tonic torticollis, and the surgeon must be 
 careful not to mistake the tonic contraction which occurs on one side for 
 the paralytic condition of the other. There is a peculiar form of this 
 affection noticed by Dr. Mills ;* it is " bilateral spasm of the muscles sup- 
 plied by the accessorius ; it is not common, and, when it does occur, is a 
 most striking and curious affection, causing peculiar and alternate or syn- 
 chronous movements of the head — a form of the nodding or salaam convul- 
 sions particularly observed in children." 
 
 Treatment. — If torticollis arise from improper positions assumed by the 
 patient, braces or other mechanical means to prevent an indulgence in the 
 pernicious habit must be employed. If the inclination of the head is 
 caused by glandular swellings, the medicines that are suitable for such in- 
 durations will probably rectify the evil. Among these may be rhus, carbo 
 an., conium, mercury, potash, baryta carb., calc. 
 
 * Spasmodic Torticollis, Am. Journal of the Medical Sciences, October, 1877, p. 431. 
 
TORTICOLLIS — WRY NECK. 
 
 791 
 
 Puncture for Torticollis. 
 
 If wry neck is occasioned by rheumatic or other inflammatory affections, 
 it may be advantageously treated with bry., puis., bell., aeon., etc. For 
 pains as if the cervical vertebrae were dislocated, which are often felt in the 
 affected part, bry., nux vom., and cinnabar may be suitable. For the con- 
 traction of single tendons of the cervical muscles, natrum muriat., rhus tox., 
 strain., hyos., dulc, zincum, selen, or arsenicum, are appropriate medicines. 
 
 In the absence of any mechani- Ftg 487 
 
 cal contrivance, a band of adhesive 
 plaster well applied around the fore- 
 head, to which a second extending 
 to the back is attached, will often 
 meet the indications. An extem- 
 poraneous apparatus may be formed 
 by a skull-cap made of stout cloth, 
 having an india-rubber band at- 
 tached near the forehead; this band 
 must extend to the back, and be 
 fastened to a strap passing around 
 the thorax. 
 
 The instrument-makers construct 
 many props and supports, which 
 are preferable to the old-fashioned 
 one of Jorg. In most cases, how- 
 ever, the subcutaneous division of 
 the tendons at fault, may be prac- 
 ticed. If only the sternal portion 
 of the sterno-mastoid should be 
 the tendon affected, which can be 
 ascertained by its spastic rigidity, the patient being etherized, the finger 
 of the left hand must be inserted under the tendon, and a delicate 
 tenotome passed flatwise beneath it, the edge of the knife is turned 
 forward, an assistant makes traction on the head, and the tendon often 
 snaps when divided. If the clavicular portion of the sterno-mastoid is 
 also to be cut, a second puncture must be made, and this had better 
 be somewhat further above the bone than the puncture at the sternal 
 end, as the fibres come more closely over the bone at the clavicular 
 than the sternal margin. After having made this puncture with the sharp- 
 pointed knife, it must be relinquished, and a probe-pointed tenotome sub- 
 stituted; this must be introduced flatwise, and the cutting edge turned 
 forward, and with a sawing motion of the handle the fibres divided. 
 Fig. 487 shows the introduction of the instrument in division of the 
 clavicular fibres. After the attachments have been divided, either of the 
 following apparatuses may be used. Fig. 488 represents that made by Mr. 
 Reynders. 
 
 It consists of a well-padded pelvic band, a, to which an upright steel 
 bar, b, is attached, passing upwards along the spine to the upper dorsal 
 region. A cross-bar, c, is fixed to its upper end, passing from one axilla 
 to the other, and fastened to two crutches, k, fitting well under fie 
 arms. These are connected to the pelvic band by two lateral bars, m, 
 which by means of a slot and screw can be raised and lowered some- 
 what, at will. The part of the apparatus so far described is applied 
 firmly to the trunk by means of straps passing over the shoulders and 
 fastened to the axillary cross-bar at c c. A firm hold of the head is secured 
 by a pad (sheet steel inside), reaching almost from eye to eye backwards 
 around the skull, with apertures for the ears, and fastened to the head by 
 straps over the forehead and under the chin. To its back part, a steel bar 
 
792 
 
 A SYSTEM OF SURGERY. 
 
 is riveted, d, which connects the upper part of the apparatus with that 
 applied to the trunk. The lower end of this steel bar is ratcheted and ad- 
 justed in a slide at the upper end of the steel rod, passing up along the 
 spine, and held in a desired position by a thumb-screw, shown near the 
 
 Fig. 488. 
 
 Fig. 489. 
 
 Reynders's Apparatus for Wry Neck. 
 
 Markoe's Apparatus for Torticollis. 
 
 letter h (on the figure). This connecting bar is intercepted by three different 
 joints, e, /, and g, by which flexion can be made in any direction when 
 worked by the key. At the joint, g, flexion can be made to the right or left, 
 at/, forward and backward, and at e rotation. 
 
 The advantage of this apparatus over others is, that a firm hold is 
 maintained on the head and trunk, and that the head can be brought in 
 a proper position by a true and irresistible mechanism. The instrument 
 when worn is almost hidden under the clothing, and patients cannot 
 easily withdraw themselves from its action. 
 
 Markoe's apparatus, Fig. 489, is in principle the same as above-named. A 
 ball and clamp socket-joint allows movements of the head in the proper 
 position. A short stem projects backwards from the back of the headband, 
 terminating in a ball, which is grasped by a clamp at the end of the upright 
 bar passing along the spine. The pressure of this clamp is regulated by a 
 thumb-screw, which is tightened after the head has been brought into proper 
 position. 
 
 Diseases of the Glands of the Neck. — The parotid gland is subject to inflam- 
 mation, abscess, and sometimes to tumors, which are generally malignant. 
 Its duct is in rare instances the seat of calcareous bodies, of wounds, and 
 of fistulas. 
 
 Parotitis or Mumps is an idiopathic inflammation of this gland, and 
 almost wholly confined to the young. It is a contagious disease, and gen- 
 erally appears as an epidemic, being more frequent in males than in females. 
 Although painful, it is ordinarily a simple affection, but may become dan- 
 gerous when, by metastasis, it extends to the brain or testicle ; it may prove 
 fatal in the former case, and in the latter may result in atrophy or loss of 
 function. The severity of the symptoms may generally be controlled by 
 
THE DUCT OF STENO. 793 
 
 bell., mere, and rhus. For further treatment the student may refer to works 
 on the practice of medicine. 
 
 Abscess of the Parotid may be the result of simple inflammation, direct 
 injury, or of erysipelas, typhoid fever, small-pox, and other eruptive dis- 
 orders. In consequence of its proximity to certain important nerve 
 branches, it often proves a painful affection. In many instances, by reason 
 of the firmness of its coverings, the presence of pus is difficult to deter- 
 mine, and may be allowed to burrow along the sheath of the muscles or 
 large cervical vessels, causing much destruction in the cellular tissue. 
 This disastrous condition may be avoided by making a free vertical incision 
 in the most prominent part of the swelling, and keeping the wound 
 open until the abscess is obliterated. The administration of the proper 
 remedies will materially hasten the cure. 
 
 Gangrene may appear in this gland during a severe attack of erysip- 
 elas, scarlatina, small-pox, or typhoid fever, especially when these assume 
 the adynamic type. When this complication occurs the yeast or charcoal 
 poultice should be applied, and the appropriate remedy administered. 
 Arsen., carbo veg., and lach. are frequently demanded. For further treat- 
 ment see Gangrene and Mortification. 
 
 Extirpation of the Parotid should only be attempted when it becomes the 
 seat of a simple or benign growth. These tumors, in common with those 
 situated in the submaxillary gland, are fibro-cartilaginous. They are mostly 
 encysted, have a peculiar, hard, elastic feel, and often attain great size ; their 
 early removal is advisable. 
 
 In performing the operation of extirpation the surgeon makes an incision 
 directly over the tumor, well down to the capsule, and then endeavors to 
 enucleate the mass. It will be necessary to proceed with the greatest cau- 
 tion when attempting to free the deep-seated parts, lest the facial nerve, or 
 the internal carotid artery, or the jugular vein be wounded. The danger 
 of this occurrence should be explained to the patient previous to the opera- 
 tion. In total extirpation of the gland the motor branch of the seventh 
 pair of nerves is divided, resulting sometimes in temporary and sometimes 
 in permanent paralysis of the face on that side. It is always well to remove 
 the gland from below upward, for by this means the external carotid is 
 brought into view during the first stage of the operation, and can be placed 
 under control. Immobility of the gland contraindicates the operation. 
 
 Malignant Tumors of the Parotid should be rarely disturbed ; on exami- 
 nation they seem fixed, diffuse, and deeply seated. Any attempt at motion of 
 the part causes pain, and paralysis of the facial nerve is generally pres- 
 ent. They are fibrous, scirrhous, melanotic, or encephaloid in character, 
 and prove fatal by constitutional irritation, or by ulceration and profuse 
 discharge. 
 
 The Duct of Steno. — The excretory canal of the parotid may suffer in 
 face wounds, or from ulceration, abscess, or gangrene. Such an occurrence 
 is unfortunate, as it may establish an obstinate form of salivary fistula. 
 If the canal is divided by a wound the ends should be carefully adjusted 
 and held in place by the twisted suture and a compress. This will ordi- 
 narily effect a cure. When the fistula is the result of the other causes 
 mentioned, a cure is not readily obtained, but may be accomplished by 
 cauterizing the parts, thus causing the external orifice to close by granulation. 
 If, however, the oral end of the duct is obstructed, it will be necessary 
 either to open it by a probe passed through the fistula into the mouth, or 
 by forming a new opening near the oral end of the duct. This should 
 be kept open by a seton, till a free channel for the saliva is established, 
 when, upon the removal of the seton, the external opening will con- 
 tract and close itself. If the process of cicatrization is tardy, it may be 
 
794 
 
 A SYSTEM OF SURGERY. 
 
 hastened by the application of caustics. Should these measures fail, a plas- 
 tic operation can be resorted to. 
 
 A Salivary Calculus may sometimes obstruct this duct. If the attending 
 symptoms are severe, it must be removed by opening the duct within the 
 mouth, which is easily accomplished. 
 
 The Submaxillary Gland occupies a position so well protected that it is 
 rarely the seat of any disease demanding surgical interference. It is sub- 
 ject to enlargement and indurations caused by decaying teeth, cancer of the 
 tongue, or affections of the neighboring lymphatics ; but this condition will 
 subside on removal of the cause of irritation. 
 
 In common with the parotid, it may be attacked by the same forms of 
 malignant disease to which that gland is liable. A careful distinction 
 should be made between simple and malignant disease of this organ ; for in 
 the former case, the removal of the cause is followed by speedy recovery, 
 while in the latter, no permanent benefit may be expected. See chapter on 
 Tumors. 
 
 Operations in this region involve the facial and the sublingual artery 
 and the hypoglossal nerve, which are to be avoided. 
 
 Calcareous Formations are occasionally found in the excretory duct of this 
 gland also, and give rise to symptoms similar to those found in obstruc- 
 tion of Steno's duct ; swelling of the side of the tongue and jaw, with pain 
 and difficulty of mastication. They may be removed by incision. 
 
 Cystic Tumors of the Neck. — Cysts develop in the neck either beneath the 
 ear and jaw or above the clavicle. If lying beneath the deep cervical 
 fascia, they are at their inception somewhat difficult to diagnose, as the 
 tense fascia covering them obscures their fluctuation and increases their 
 elasticity, thereby mixing their more obvious characteristics. These neo- 
 plasms are painless, the suffering arising from the pressure symptoms. For 
 further information the reader is referred to the latter part of the chapter 
 upon Tumors (vide Cystic Tumors, page 190). 
 
 Goitre, Bronchocele* or Derbyshire Neck is a chronic enlargement of the 
 thyroid gland. It usually affects both lobes (see Fig. 490) ; in some cases 
 it is confined to the isthmus of the gland. The swelling varies in size from a 
 slight increase of natural structure, to the bulk of an adult head ; Aliberti 
 
 relates a case in which the hypertrophied 
 gland hung as low as the thigh. Goitre 
 seems to be endemic in certain parts of Swit- 
 zerland and England. It is more common 
 in women than in men, and in some cases 
 seems to be hereditary. It is found associated 
 with cretinism, and also with " exophthal- 
 mic goitre," generally known as Basedow's or 
 Graves's disease. 
 
 Other tumors of the neck may be mistaken 
 for goitre, but the latter may readily be diag- 
 nosed, by directing the patient to imitate the 
 act of swallowing ; if the tumor follows the 
 motions of the larynx and trachea, and at 
 the same time occupies the natural situation 
 of the thyroid gland, there can be little 
 doubt of its nature. The causes of the dis- 
 ease have not been satisfactorily explained. 
 By many it is supposed, though erroneously, 
 to be a scrofulous affection, Unwholesome 
 diet, intermittent fevers, and drinking of snow-water, have been imagined 
 by others to give rise to it ; but all these causes are hypothetical. 
 
 Fig. 490. 
 
 Bronchocele. 
 
TREATMENT OF GOITRE. 795 
 
 Treatment. — The principal medicine in the treatment of this disease is 
 iodine, which has been used by practitioners from a remote date, but with 
 inconsiderable success from its improper administration ; indeed, in many 
 instances, the drug, instead of ameliorating, has aggravated the affection. 
 The iodine should be used in drop doses, and, according to Mr. Cameron,* 
 repeated every second day. 
 
 Natr. carb., continued for some time, relieved a globular and somewhat 
 indurated enlargement of the upper part of the thyroid gland. In another 
 case calc. carb. afforded speedy relief. Staphis., together with lye, has also 
 been of service. Spongia is a medicine of power in producing relief, if it 
 does not absolutely cure the disease. 
 
 Halef recommends phytolacca dec. and podophyllum as successful, and 
 iris vers, would seem from its provings to be useful. 
 
 Dr. Craig has found sal ammoniac more successful than any remedy here- 
 tofore tried by him. 
 
 M. Maumene, a French chemist, says, that in countries where goitre pre- 
 vails, fluorides are contained in the water ; he declares that he has proved 
 it and has artificially produced goitre with fluoride of potassium in animals. 
 
 In addition to these medicines, a judicious hygienic treatment should be 
 adopted. In districts where chalk, lime, or magnesia abound, the water 
 should be filtered or distilled before using. The practice of placing solid 
 iodine in the room occupied by the patient, and thus keeping the air im- 
 pregnated by its exhalations, has produced happy results. An ointment 
 of iodine may be applied with benefit, and Dr. Mouat, of Bengal, speaks J 
 highly in favor of an ointment composed of biniodide of mercury, three 
 drachms to one pound of lard. This is to be rubbed upon the tumor 
 thoroughly, then the patient allows the rays of the sun to fall upon the 
 parts as long as they can be endured. In a short time another application 
 is made, and in many instances no further interference is necessary. He 
 reports an almost incredible number of cases cured by this method. I have 
 used this treatment with success in several cases, substituting the heat from 
 a kitchen-range for the rays of the sun, and administering iodine internally. 
 Sometimes a better heat may be obtained by allowing the patient to sit in 
 the sun, bringing its rays to a focus by means of a convex lens upon the 
 enlarged gland. 
 
 Some surgeons have recommended and practiced the injection of tinct- 
 ure of iodine into the tumor, while other speak favorably of the use of the 
 seton. At present, electrolysis is perhaps the most successful method of treat- 
 ing goitre. See chapter on Minor Surgery. 
 
 Extirpation of the gland has been practiced, and the later results are some- 
 what more favorable than the earlier; however, the operation is scarcely jus- 
 tifiable, especially since Prof. Bruns, of Tubingen, has noted that when the 
 thyroid body has been completely removed, the patients within two or three 
 years began to waste and became* cachectic, and finally died. 
 
 Dr. John A. Wyeth has, however, successfully removed the thyroid gland 
 on two occasions, and Burckhardt, of Stuttgart, has operated seventeen times 
 with success.§ He first exposes the capsule of the gland by an incision in 
 the median line or along the border of the sterno-cleido mastoid. The ves- 
 sels above and below are carefully ligated, and the cyst laid open. The sac 
 must then be enucleated with the fingers, every adhesion being tied in two 
 
 * An interesting and important paper on Bronchocele, by H. Cameron, Esq., M.K.C.S.E.,. 
 British Journal of Homoeopathy, vol. iii., p. 469. 
 f New Bemedies, pp. 771 and 817. 
 X India Annals of Medical Science, 1857. 
 | Centralblatt fiir Chirurgie, No. xliii., 1884. 
 
796 A SYSTEM OF SURGERY. 
 
 places, and severed between the ligatures. Drainage tubes are finally in- 
 serted and the wounds closed. Dr. W. W. Green, of Maine, reported three 
 operations successfully performed by him. 
 
 Ligation of the arteries which supply the gland (" starvation of the tumor ") 
 has been tried with varying results, the cases reported as cured by this 
 method being few. 
 
 In exceptional cases the tumor may so compress the trachea as to render 
 tracheotomy necessary. 
 
 I have received from Dr. E. J. Whitney, of Brooklyn, a synopsis of Dr. 
 Mackenzie's treatment of goitre. Dr. Whitney spent a season in London 
 visiting Dr. Mackenzie's clinics, and speaks highly of the success of the 
 treatment: he informs me that Mackenzie divides bronchocele into seven 
 classes : 1. Adenoid or simple. 2. Fibrous. 3. Cystic. 4. Fibro-cystic. 5. 
 Fibro-nodular. 6. Colloid. 7. Vascular. 
 
 The first class require little treatment except of a constitutional character, 
 as the disposition of these growths tends toward recovery without local 
 interference. 
 
 In fibrous bronchocele, the treatment consists of a seton passed trans- 
 versely through the whole of the gland. The seton is composed of from 
 six to twelve threads of cotton twine, according to the size of the tumor, and 
 its insertion may be rendered comparatively painless by applying a spray 
 of ether to the points of entrance and exit of the needle. These threads 
 are allowed to remain until suppuration is well established, when they must 
 be withdrawn and the tumor treated as an abscess. 
 
 The cystic bronchocele varies greatly in size, but is always of a globular or 
 ovoid form. As a first step in the treatment of this variety, he empties the 
 cyst by entering a small trocar as near the median line as possible, and at 
 the most dependent portion of the tumor ; having pierced the wall of the 
 cyst, the trocar may be withdrawn, and the canula stopped by a key or 
 plug. If the growth should be multilocular, the canula may be moved 
 about within the tumor, breaking down the walls of the several cysts, which 
 having been accomplished, the plug is removed, and the fluid contents 
 allowed to escape through the tube. He then injects into the sac about one 
 drachm of a solution of ferri perchloridi, 3ij of the salt to water 3j, replaces 
 the plug and retains the canula in position with adhesive plaster. This 
 process is repeated at intervals of two or three days, until suppuration 
 takes place, when the tube is removed and a poultice applied, as in abscess. 
 When several cysts exist, by opening them within the tumor much dis- 
 figurement from scars may be avoided. It will be seen that the treatment 
 -consists in converting the tumor into a chronic abscess, and following with 
 the appropriate after-treatment. 
 
 Mackenzie states that out of 39 cases of cystic goitre, 38 underwent this 
 operation, and it proved successful in every instance. 
 
 In fibro-cystic bronchocele the treatment is a judicious combination of the 
 seton and puncture. 
 
 The fibro-nodular has not been treated with much success. 
 
 Colloid bronchocele has been treated with electricity, but the results 
 are not satisfactory. It is believed that the seton could be used with 
 benefit. 
 
 The seventh form, the vascular bronchocele, is so rare that no treatment 
 is recommended. It is improbable that a case would be met with in the 
 course of a long and extended practice. 
 
 Rupture of the (Esophagus. — The oesophagus may be ruptured during life ; 
 it may be occasioned in different ways. The common causes are perfora- 
 tions made by abscesses, by aneurisms, by the sharp projections of foreign 
 bodies, or by sloughing from caustics. These cases are not uncommon. 
 
STKICTURE OF THE OESOPHAGUS. 797 
 
 Others are caused by straining during vomiting, or by the effort to expel 
 impacted bodies. Dr. George. C. Allen, of Boston, recorded such a case, 
 and Dr. Fitz* has given much time to looking up its literature. He states 
 that Boerhaave, Ziesner, Dryden, Kade, and others, who have reported 
 cases of ruptured oesophagus, find that pain is not a prominent early 
 symptom, and that nausea and vomiting and sometimes vomiting of 
 blood are always present. In conclusion he remarks : " The patient falls 
 into a condition of great exhaustion after the violent straining, from 
 which he rallies in the course of twenty-four hours, when fever is evident. 
 The emphysema advances, the patient has difficulty of breathing, there 
 may be orthopncea even, also slight cyanosis, and death may occur 
 within fifty hours, or may be postponed seven or eight days. When 
 the disease assumes a protracted course, it is essentially a gangrene of 
 the mediastinum, combined with gangrenous pleurisy ; there are con- 
 tinued fever, great prostration, mild delirium, pains in the stomach and 
 chest, and bloody stools after a time. Tetanic convulsions may occur, 
 if the inflammation in the mediastinum involves the nerves along the 
 spine." 
 
 All these symptoms are equivocal, and Hamberger says, "We must 
 admit that up to the present, the diagnosis is first made on the corpse, 
 and often contrary to all expectation." In the treatment little can be done, 
 but small quantities of food must be taken at a time. If by any means a 
 proper tube could be passed from the mouth to the stomach, and the 
 patient fed through it, an opportunity might be given for the rent to heal. 
 I am not aware that this method has been tried, or even recommended by 
 any one, but it strikes me as feasible. 
 
 Oesophagitis, Inflammatio (Esophagi. — This is a disease of infrequent 
 occurrence and cannot be seen by an examination. There is local pain 
 behind the trachea and between the shoulder-blades towards the heart, 
 along the spine, under the sternum or xiphoid cartilage; the pain is 
 constant, and of an aching, stinging, and burning kind. There is little 
 fever, although much thirst, which the patient cannot gratify in con- 
 sequence of the pain occasioned by swallowing. Food passes with pain 
 and difficulty, and is at times thrown upward in consequence of a 
 spasmodic action of the parts; there is nausea, vomiting, much tena- 
 cious mucus in the mouth, hiccough with anguish, distorted and pale 
 face, pulse small and contracted, congestion of blood to the head, con- 
 vulsions. 
 
 Treatment. — The medicines for this disease are : Belladonna, arnica, coc- 
 culus, arsenicum, sabadilla, rhus rad., rhus tox., daphne mezereum, lauro- 
 cerasus, carbo vegetabilis, mercurius solubilis. 
 
 Stricture of the (Esophagus is a disease possessed of interest both to 
 the surgeon and the physician.- Its causes are various : sometimes they 
 are attributable to the action of irritants ; sometimes to injuries ; at times 
 to compression from external growths, and frequently to an irritation of 
 the tube arising from chronic indigestion. 
 
 When we consider the anatomical structure of the oesophagus, and 
 the great variety of substances that are taken into the stomach, both 
 hot and cold, sour and sweet, the rich and highly seasoned compounds 
 of the kitchen and the indigestible aliment of the confectioner, all of 
 which pass, over the mucous membrane of the tube ; it is a matter of 
 surprise that more disease is not developed in this portion of the alimen- 
 tary tract. 
 
 * American Journal of the Medical Sciences, January, 1877, p. 17. 
 
798 
 
 A SYSTEM OF SURGERY. 
 
 So far as my observation and reading extend, I believe that stricture of 
 the oesophagus is rarely idiopathic, being generally accompanied by disease 
 of other portions of the digestive apparatus, notwithstanding cases have 
 occurred in which it can be attributed to the action of medicinal substances. 
 Wolf* reports the case of a man, aged twenty-six, who accidentally swal- 
 lowed some oil of vitriol; great inflammation followed, contraction of the 
 oesophagus resulted, and increased to such a degree that, upon his admission 
 into the hospital, he had lost all power of swallowing — a perfect stricture hav- 
 ing formed. A similar case, arising from swallowing carbolic acid, occurred 
 in my practice. 
 
 There are three varieties of stricture : first, the spasmodic ; second, the 
 chronic induration ; third, the malignant; the latter arising from carcinoma, 
 and attended with ulceration and perforation. Many excellent authori- 
 ties make but two divisions, the first being the spasmodic, the second the 
 organic, the latter embracing the chronic induration and the malignant 
 variety. 
 
 In spasmodic stricture the circular muscular fibres are the seat of the 
 affection ; the disease occurs at intervals, the patient suddenly finding him- 
 self incapable of swallowing, at the same time experiencing a sensation of 
 choking ; added to this, there is not much emaciation, although there is 
 generally great nervous irritability of the whole system. The disease is 
 more prevalent among females than males, and is amenable to internal 
 medicines. 
 
 One of the most interesting cases of this kind has been recorded by Dr. 
 B. F. Joslin, Jr., of New York. The patient suffered extremely, and, not- 
 withstanding the best-directed efforts, finally suc- 
 cumbed to the disorder. The post-mortem ex- 
 amination revealed a small, hard, osseous tumor, 
 an inch long, and half an inch in breadth, with 
 various spiculae of bone projecting from it, situ- 
 ated just above the bifurcation of the trachea ; 
 a nerve was found very intimately connected with the 
 anterior face of this tumor. Dr. Joslin considers this 
 filament to have been a cardiac branch of the 
 pneumogastric nerve, the irritation of which, by 
 the presence of the tumor, caused the difficulty 
 in swallowing. The writer says, the bony tumor 
 " did not press on the oesophagus, and was only 
 loosely attached to the trachea; it was firmly 
 adherent to the posterior portion of the vena 
 cava superior ; it could only be implicated in the 
 production of the symptoms by its relations with 
 the pneumogastric nerve, "f 
 
 In organic stricture (Fig. 491) the symptoms 
 are different : there is always accompanying in- 
 digestion, and the symptoms of dysphagia are 
 generally the same ; there is a peculiar expres- 
 sion of face, the features being pointed and 
 exhibiting tokens of anguish and distress ; ema- 
 ciation is marked. The patient swallows food 
 or drink, or at least passes it through the 
 fauces and along the oesophagus until it meets with the stricture, there 
 it remains for a moment and is regurgitated. The constant effort made 
 
 Fig. 491. 
 
 Organic Stricture of the 
 Oesophagus. 
 
 * Banking's Abstract, No. xviii., p. 246. 
 
 f A Singular Case of Spasmodic Stricture of the (Esophagus. 
 North American Journal, No. xxxiii., p. 134. 
 
 By B. F. Joslin, Jr., M.D., 
 
TREATMENT OF STRICTURE OF THE OESOPHAGUS. 799 
 
 by the patient to effect an entrance into the stomach, and the presence of 
 the food immediately above the stricture, in time develop an enlargement 
 of the part, so that in many cases of organic constriction there is formed 
 above the site of the disease an expansion or pouch. This sacculation 
 may be enormous. Rokitansky mentions a case in which the passage was 
 large enough to admit a man's arm. Mott* refers to a case in which a 
 pouch was formed four inches in diameter ; and there are other cases noted 
 in which the dilatation was considerable. Mott's case is interesting because 
 it points to the fact that beside the mucous and submucous tissues, muscular 
 fibre also may enter into the formation of organic constriction ; in which 
 view, Gross and Miller coincide, although the former states that only in the 
 aggravated cases the last-named constituent assists in the formation of the 
 stricture, while in ordinary cases, the mucous and submucous coats are 
 affected, there being a deposit of plastic material in the part, causing thick- 
 ening of the tube.| The seat of stricture is said to be generally opposite 
 the cricoid cartilage. 
 
 In the carcinomatous stricture, the disease is generally scirrhus, and begins 
 in the submucous tissue, posterior to the thyroid cartilage or upper, por- 
 tion of the trachea. There is difficult deglutition, with severe pain, 
 often of a burning character, when swallowing, liquids being more easily 
 managed than solids. The pain in some instances is referred to the thorax 
 and sometimes to a spot between the shoulders. The lancinating pains 
 common to cancer are always present, as are the constitutional symptoms, 
 viz., general emaciation, sallow, cadaverous skin, entire loss of appetite, and 
 prostration. The patient may die of hectic, inanition, or haemorrhage from 
 ulceration. 
 
 Treatment. — The medicines that are adapted to the treatment of the dis- 
 ease are bell., hyos., and conium. These agents, judging from their patho- 
 geneses, would be most appropriate ; indeed, the latter (hyos. and con.") are 
 recommended by allopathic authority ; other medicines may be required, 
 among which are lye, nux, stram., acid, sulph., verat., etc. 
 
 Dr. B. F. Joslin, of New York, has given the pathogeneses of several medi- 
 cines applicable to stricture of the oesophagus, to which the student may 
 refer. See note, page 798. 
 
 For carcinomatous stricture the medicines are : arsen., phytolacca, apis, 
 carbo veg., lachesis, gallium aperinum, and those which have already been 
 noted in the chapter on Cancer. 
 
 Should the administration of these fail to relieve the patient, they may 
 be employed together with the use of the bougie, which instrument should 
 be curved to correspond to the passage. The patient should be directed to 
 throw his head well back, and to swallow while the surgeon introduces the 
 bougie, which should be warmed, and passed steadily and gradually from 
 the posterior part of the pharynx to the seat of stricture. The instrument 
 is to remain a short time within the oesophagus, and the operation repeated 
 once or twice a day, or at longer or shorter intervals, according to the judg- 
 ment of the surgeon. 
 
 A good method of treating stricture of the oesophagus is that introduced 
 by Jameson, who used eight or ten separate graded probangs, each consisting 
 of a stick of whalebone having affixed to one of its extremities a spindle- 
 shaped piece of ivory. The instrument first introduced is small, but after the 
 stricture has been removed sufficiently to readily admit the passage of one 
 probang, a larger size must be selected. The operation must be frequently 
 
 * Operative Surgery, vol. iii., p. 499. 
 
 f Gross's Operative Surgery, vol. ii., p. 656. 
 
800 A SYSTEM OF SUKGERY. 
 
 repeated, each time using a larger-sized instrument, until the obstruction 
 is removed. These probangs are now made of hard rubber. Electrolysis, 
 however, is the best method. In a severe case of Stricture of the oesophagus, 
 which had been pronounced incurable by a distinguished specialist, and 
 in which I had patientty tried dilatation, the patient was entirely cured by 
 electrolysis in the hands of my friend Dr. Butler. In applying this, no one 
 but a skilled specialist should be trusted. The operation is difficult and 
 delicate, and unless the operator is familiar with the use of the electrodes 
 injury and danger may be apprehended. 
 
 Foreign Bodies in the (Esophagus.— Extraneous matters frequently lodge 
 in the oesophagus; particularly articles of food, portions of which, from 
 hurry or voraciousness in swallowing, are impacted in the superior portion 
 of the tube; such articles are beef, gristle, tripe, cheese, etc. On other occa- 
 sions the patient is choked from having accidentally swallowed articles 
 carelessly placed in the mouth, as coins, pins, needles, etc. In these days 
 of cheap false teeth, many more cases of obstructed oesophagi are noted, 
 most of them being the accidental displacement of poorly-fitting artificial 
 teeth. ( Vide section on (Esophagotomy.) Death has ensued from such acci- 
 dents. 
 
 Dr. Aschenborn* relates the following interesting case : 
 
 "A young man felt severe pains during respiration, but had two days 
 before suffered pains in the epigastric region and along the gullet after 
 swallowing what he supposed was a hard morsel of bread. On the fifth 
 day an incision was made in the posterior wall of the pharynx, yielding an 
 offensive sanious fluid of a dark color, but no pus. During the night a 
 copious stool of pure blood was passed. He rallied somewhat during the 
 day from the use of port wine and camphor, but without warning, immense 
 haemorrhage from the mouth ensued, and he died soon after. The necropsy 
 revealed a rent two-fifths of an inch in the oesophagus, about four inches 
 from the cardia, at right angles to which was found a needle about two 
 inches long, piercing both walls of the descending aorta from before 
 backwards." 
 
 Treatment. — The foreign substance in many instances is lodged between 
 the thyroid cartilage and the cornua of the os hyoides ; in this situation, 
 
 Fto. 492. 
 
 Burge's OZsophagotomy Forceps. 
 
 if the body be large, it may be reached and extracted with the fingers ; 
 if small, as a fishbone, a pin, or a needle, forceps should be employed. 
 Fig. 492 shows Burge's forceps, which are curved, with handles at a right 
 angle. Sometimes, by tickling the fauces with a feather or by exciting 
 vomiting by emetics, the irritating substance can be expelled. Curved 
 and other forceps have been employed, but when the surgeon is called 
 to a patient who is in imminent danger of suffocation, these instruments 
 may not be at hand, and delay occasioned in procuring them may 
 prove fatal. In such instances the handle of a spoon, the fingers, or 
 other convenient article should be selected, and the foreign substance 
 
 * The American Journal of the Medical Sciences, April, 1878, No. cl. 
 
INTRODUCTION OF TUBES, 
 
 801 
 
 either dislodged, withdrawn, or, if the article be digestible, forced into the 
 stomach. The ordinary probang — a whalebone rod with a round piece of 
 sponge attached to one end and a blunt hook to the other — is the instrument 
 used by surgeons for this purpose. 
 
 A forceps known as the alligator forceps (Fig. 493) is useful for ex- 
 tracting foreign bodies. By referring to the figure, the mechanism can be 
 
 Fig. 493. 
 
 Alligator Forceps. 
 
 understood. The bristle or umbrella probang is also a serviceable instru- 
 ment, as is the flexible tube of Tiemann (Fig. 494). 
 
 Fig. 494. 
 
 ^p g*3Z55gfrw^/£Z aBS 
 
 BWrrifrw i rJnrfMtt . T-«—/Trtrs- , 'iirtr(i-fi7^ 
 
 Tiemann's Spiral Throat Forceps. 
 
 After the extraneous matter has been dislodged, the patient should gar- 
 gle the throat frequently with a weak solution of arnica, and the same 
 medicine should be administered internally. 
 
 Introduction of Tubes. — The successful passage of tubes, whether for the 
 dilatation of stricture, or the introduction of the stomach-pump, must de- 
 pend upon a knowledge of anatomy and dexterity in manipulation of the 
 
 Fig. 495. 
 
 instrument. The stomach-tube should be twelve to eighteen inches in 
 length, and should be well oiled. The patient then opening the mouth 
 wide, with the head thrown backward, the surgeon should pass the tube 
 directly backward to the fauces ; when it touches the posterior wall of the 
 pharynx it will, if of sufficient flexibility, be made to glide into the oesoph- 
 agus and down into the stomach without difficulty. In cases of cancer of 
 
 51 
 
802 
 
 A SYSTEM OF SURGERY. 
 
 the pharynx and oesophagus, or in organic stricture, it may be necessary to 
 inject food into the stomach ; in cases of poisoning, the injection into the 
 stomach of large quantities of water, and the withdrawal of the same with- 
 out moving the instrument, is a great desideratum ; for this purpose the 
 stomach-pump is furnished with valves in the piston, which may be opened 
 and shut by turning the handle. The cut (Fig. 495) represents an improved 
 pump, which possesses many advantages. 
 
 To empty the stomach use the instrument as represented in the cut. 
 
 To pump fluids into the stomach attach the catheter to the piston nozzle, b, 
 and the soft tube to a. 
 
 (Esophagotomy. — It may be necessary, when foreign bodies are lodged in 
 the oesophagus, to perform oesophagotomy, otherwise ulceration, perfora- 
 tion, and death may ensue. It was first done in France. In the year 1738, 
 Goursauld removed a piece of bone one inch long and six inches in breadth, 
 by opening the oesophagus ; the operation was afterward performed in 1833 
 in England, and to Dr. Cheever, of Boston, is said to belong the credit of 
 the first operation in this country. 
 
 The operation is not so difficult as is supposed, and is often followed 
 by gratifying results. In twenty-one oesophagotomies for the removal 
 of foreign bodies, seventeen were successful and four fatal. The opera- 
 
 Fig. 496. 
 
 «SK2(. ^ 
 
 (Esophagotomy. 
 
 tion is to be performed at either side of the neck, the point of selection 
 being, if possible, determined by the presence of the foreign substance ; if 
 it be felt from the exterior, the incision should be made over it, the tube 
 passing rather to the left than to the right side of the neck ; the former 
 situation might be more favorable. The head of the patient should be 
 thrown back, and taking the sterno-mastoid muscle as a guide, an incision 
 four or five inches in length should be made through the integument and 
 platysma myoides, in a line of the depression between the larynx and the 
 sterno-mastoid, from a point near the upper border of the thyroid cartilage 
 to near the sterno-clavicular articulation (see Fig. 496). The carotid sheath 
 and the sterno-mastoid must be drawn outward with one retractor, and the 
 larynx drawn inward by a second. By passing a canula into the mouth, 
 
CBSOPHAGOTOMY. 803 
 
 and down to the foreign substance, a guide is made for the incision, which 
 may be done from without, or, if the canula is armed with a trocar, the tube 
 can be opened from within. The foreign body must then be brought away 
 with the forceps. The wound should be allowed to heal, few sutures being 
 used. For the first few days the patient must be fed through a tube passing 
 beyond the wound. 
 
 Dr. Le Roy McLean, surgeon to the Troy Hospital, X. Y., reports* two 
 cases of this operation for the removal of gold and silver plates, with teeth 
 attached, which had been accidentally swallowed, and Dr. La Garde,t U. S. A., 
 gives an interesting case, in which, for a similar purpose, he performed 
 a successful cesophagotomy. Dr. McLean operated as follows: Chloroform 
 having been administered, an incision was made on the left side of the neck, 
 midway between the margin of the sterno-cleido-mastoid muscle and the 
 thyroid cartilage, extending to within half an inch of the sternum. The 
 parts containing the carotid were then separated from the trachea and held 
 aside by retractors, as was the left lobe of the thyroid body after careful 
 dissection. The inferior thyroid artery having been exposed and pushed 
 aside, the oesophagus was plainly seen. A large-sized lithotomy staff was 
 passed through the mouth, it being more easily introduced than a 
 stomach-tube, and the oesophagus pushed well forward and to the left. This 
 served as a guide, and held the oesophagus in position, rendering the in- 
 cision into it less difficult than it otherwise would have been, owing to the 
 spasmodic efforts of swallowing, which were very frequent after the admin- 
 istration of the anaesthetic. The incision was made longitudinally from the 
 staff to the side of the cricoid cartilage, and the plate removed by the finger 
 with some difficulty. Forty-eight hours after the operation the patient 
 swallowed fluids readily, and eighteen davs later the wound had closed, 
 and he resumed his business. After this the voice, which had been faint 
 and husky since the accident, gradually grew stronger, until it reached 
 its natural standard. In the second case, the difficulty of swallowing being 
 felt only at intervals, and the patient suffering no essential inconvenience, 
 the teeth were for some time supposed to have passed into the stomach, and 
 the operation was not determined upon until eleven months from the date 
 of the accident. It was then performed in the same manner as de- 
 scribed, the incision being made as near the top of the sternum as possible. 
 The silver plate was grasped and brought up by forceps, but the teeth be- 
 coming detached passed into the stomach, and were voided by the rectum. 
 Thirty-two hours after the operation the patient drank half a pint of coffee 
 without losing a drop, and his recovery was rapid and complete. The voice 
 suffered no injury. 
 
 The same surgeon has since operated on three other cases, with one death 
 from exhaustion, and in his pamphlet J gives a table of 33 cases, which is 
 inserted on the following page. 
 
 (Esophagotomy for cancerous formations, however, is an operation which 
 at this period is sub ju dice. 
 
 Dr. S. W. Gross § in an exhaustive paper has collected important sta- 
 tistics on the subject, It is found that of 21 operations, 12 died from the 
 performance of it and 5 were lost from exhaustion; and of the 4 surviving 
 not one lived over 16 months, and one died in 2 months, making a mor- 
 tality so large that the judicious surgeon would hesitate before submitting 
 any patient to it, 
 
 * New York Medical Record, April 29th, 1876. 
 f American Journal of the Medical Sciences, April, 1884, p. 406. 
 
 X Successful (Esophagotomv for the Eemoval of Foreign Bodies, bv Le Eoy McLean, 
 M.D., 1884. 
 
 § American Journal of the Medical Sciences, July, 1884. 
 
w 
 
 K 
 
 3 
 
 c 
 
 to 
 
 S 
 
 e 
 
 c 
 c 
 
 <3 
 > 
 o 
 
 Ph- 
 is 
 W 
 & 
 
 P5 
 O 
 
 o 
 
 EH 
 
 O 
 
 o 
 <J 
 
 W 
 
 Ph 
 
 o 
 
 CO 
 
 e 
 
 P5 
 W 
 H 
 
 X! 
 
 ph 
 o 
 
 0Q 
 
 
 
 
 
 .2 
 
 © 
 
 
 
 
 c 
 
 .j 
 
 
 
 j=i 
 
 
 s? 
 
 
 =3 
 
 © 
 
 ft 
 
 O 
 
 
 
 
 
 © -w 
 
 d 
 
 
 2 -s ■ 
 
 5 -d » 
 
 d 
 
 T3l 
 
 o 
 d 
 
 03 
 
 hH 
 
 | 1 3 
 
 * 2 2 
 
 £ c * 
 
 S -< 5h 
 
 2* 
 
 s3 
 
 a 
 
 © j © © d-d'd 
 
 a © a a ga§ 
 
 
 O O © 
 
 o «eq 
 
 0) 
 
 ■^ 
 
 Q 
 
 Q 
 
 >» o >. >. s o «r 
 
 CO O CO CO hhC0"<3 
 
 d 
 
 © 
 
 Q 
 
 (H 
 
 o 
 
 HI 
 
 GO 
 
 
 
 
 
 
 a 
 is 
 
 
 
 c«a a 
 
 03 c C «h 
 
 J3 d-d 
 
 e ©"as- 3 
 
 P «-c © © 
 
 O toos 
 . w JJ" « © 
 
 ©d 
 
 d°d 
 c3 a, 
 
 
 
 
 
 
 
 
 
 
 
 
 
 o3 "X3 
 
 •a 2 
 
 o © 
 
 a a 
 
 
 
 P.© © a 
 
 ._m^3 5 d 
 
 g-«0.J3 
 
 .2 ©-d 5a "3 © oj © 
 
 ^•°^Sg6© ft 
 5-OoM|2s 2 : 
 
 
 
 
 
 
 
 
 O 
 
 
 
 
 
 
 C® 
 
 
 
 *Q bCM ©.d 
 
 © "3 +j s3 
 
 oj © s3.m 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Ph 
 
 
 
 o 
 
 Ph 
 
 Ph 
 
 
 
 
 
 
 
 
 
 
 
 
 R 
 
 d 
 o 
 
 
 oi 
 GO A< 
 >. © 
 
 ■a l & 
 
 (M to "d 
 
 c3 
 
 d 
 
 oa oa>d © °° ^ K 
 ^j 2 S3 ©.M © ^ 
 © © -S © ? © 
 
 3 
 
 
 
 
 
 d dSgd 5|d 
 
 
 
 
 fl 
 
 
 d c 'd 
 
 d 
 
 H 
 
 T3 dd 
 
 ■d 
 
 ^2 
 
 d 
 
 •d .d <m 
 
 ^ -d si 
 
 CO 
 
 d d£sd dr-nddd 
 © oS-s ©_©©© 
 
 M M X © M M d t- t- M 
 
 d d ^-^ d 3' H S33 
 
 
 © © a 
 
 
 
 © 
 
 -*j © +i 
 
 S3 & s3 
 
 
 
 
 
 
 
 
 
 3 3d 
 
 d 
 
 © 
 
 d 
 
 © d© 
 
 © 
 
 
 O DO 
 
 u 
 
 ft 
 
 O 
 
 Q OP 
 
 p 
 
 o o o o ooo 
 
 d* 
 
 
 
 
 l„« 
 
 
 "3 
 
 1 
 
 
 
 
 
 o 
 
 
 
 
 •E» 
 
 
 
 
 
 
 g 
 
 
 
 
 d2 
 
 
 © 
 
 
 
 
 
 H, 
 
 
 
 
 i^ 
 
 
 
 
 
 
 
 O 
 
 <m 
 O 
 © 
 
 a 
 
 EH 
 
 
 : >> 
 
 : as 
 
 :d 
 :.d 
 
 ■ is 
 
 -d 
 
 ©^,^-J 
 
 .« -ft^ 
 «3 SW^ 
 
 X2 t» 
 
 03 
 
 . - . d 
 b'd -h si 
 
 ^2 ^ o? 
 
 S © 'd 
 
 s3 
 
 d 
 
 rd 
 
 • oa 
 
 ^» ^' ;d 
 
 •d ^ ^ d g* 
 ^ « ^ a d 
 
 
 
 
 
 
 
 
 
 ■* CO OS 
 
 
 rH -<J< tO CO C<1 
 
 
 
 © 
 
 © e 
 P o 
 
 il 
 
 "So 
 
 P. :£ 
 
 o 12 
 
 *» : ft 
 03 I'd 
 -m : d 
 ft :cs 
 
 3d :& 
 
 © £ : © 
 
 -d 
 
 i 
 
 ft 
 
 <0 
 
 o 
 
 Si. 
 
 of 3 
 
 sjS 
 
 a» 
 
 3i 
 
 od 
 
 03 
 
 > B 
 
 d 
 
 B t 
 
 eg? 
 ©ifo 
 
 a^^ 
 
 
 -©•a edd a s a 
 
 -d^ d • -d 
 
 §^ 5 .2 5 s « 
 
 -S 8 | 3 | | 
 
 ©s3©g^g g^g S 
 
 
 
 M 
 
 *> o : £ 
 ^ :8 
 
 
 %s£%s§£§ 
 
 
 
 
 •«} :ft 
 
 w 
 
 H 
 
 
 
 P5 < 
 
 ; -g 
 
 j © 
 
 i a 
 
 3 M _ 
 
 - d 
 < -; &o 
 
 ill 
 
 p 
 
 s3 
 
 ft 
 
 1 
 
 Cm 
 
 O 
 
 M 
 
 s3 
 ft 
 
 M • 
 © 03 
 
 O &H C 
 
 1 a§g"s 
 
 -- v.-a^. 
 
 fs§§I! 
 
 ) H «5 
 
 
 
 d 
 o 
 
 © 
 
 a 
 
 o 
 
 .a 
 
 '3 
 
 Ph 
 
 o© ij3 
 
 d-d :"g 
 
 g'-g IS 
 
 © d : 
 £° :-d 
 ?S -o 
 §<2 :.g 
 
 be-- : B 
 csd • 
 •G fi : t> © 
 
 §•1 :ss 
 
 fl-ir 
 
 u 
 
 03 
 ft 
 
 09 
 
 O 
 
 |a 
 
 Ch 
 | 
 
 e3 
 
 ft 
 
 o 
 
 ■u 
 
 ft 
 
 fe: d 
 
 ■d 
 
 -2 . 
 
 ^d 
 
 «1 
 
 ft© 
 
 03 
 
 Sc© 
 
 * tJD 
 
 ft.a 
 
 E6 
 
 s s 
 
 © 
 
 > ,- 
 
 S 5 
 a • E 
 
 o © i 
 d? a « 
 fe p 
 
 1 M 
 
 < ra <« 
 9 .«h ? 
 
 2§° sf 
 
 -J ft ^ 
 
 -© o ft 
 
 3 ©-M C 
 
 i|© I 
 
 IBIS'S 
 
 5*3 &2 p. 
 
 5 d ftd 5* 
 
 5 O ^ 
 
 
 
 d 
 
 o 
 W 
 
 d 
 
 .SP 
 
 '© 
 
 o 
 
 ft 
 
 O 
 © 
 
 be : 
 d : 
 o : 
 
 S : 
 
 © : 
 
 £sj 
 
 £2 : 
 
 -° : © 
 
 Ob ;g 
 
 52 :o 
 
 o X : o 
 
 o5 
 
 d 
 o 
 
 © 
 
 g a 
 
 d ta 
 
 dg 
 
 © © 
 d > 
 
 d o 
 
 © 
 
 o 
 
 J2 
 
 O 
 
 © 
 
 d 
 o 
 
 «M 
 
 © © 
 
 d ,© 
 
 o -S d 
 
 a3 
 © 
 2 
 ft 
 © 
 
 © © >-"n 
 
 ■s a d 
 
 S3 O S 
 
 <m x> ,2 
 
 J3 d J 
 
 a 2 ~ 
 ^ d . « 
 
 . © as § 
 
 © "S 03 o 
 
 d ^ ««d ^ 
 
 Oft o ©< . 
 
 ^ « M d o © 
 
 «« 5 -s-d-g ■»» a 
 
 ° o «-• ©2© d 2 
 
 d S2 ft-2 m © °P 
 
 d 
 
 d"S= : pi 
 ■rt-O :-2 
 o « : o 
 
 d 
 o 
 
 ©d 
 
 fln? 
 
 d 
 c 
 
 d « 2 
 
 o =: a 
 
 o3 
 
 «d 
 
 03 
 
 -s 
 
 g © 
 
 o 
 
 © a s 
 
 © 
 d 
 
 -d d2 -Md^ &c©© 
 
 m ^d dc 0, ^a* 
 
 
 ft :ft 
 
 Ph 
 
 |5=i 
 
 Ph 
 
 Ph CO PH 
 
 O 
 
 Ph O P^ O PhSJCh 
 
 
 CM CM — J • 
 
 <n (n:s d 
 ■o ^ K g 
 
 ii 
 
 > d 
 
 " rt o3 
 
 >l 
 
 
 lO 
 
 <N i-5 d c4" !N (N C-4 
 
 CM O " « N«N 
 
 ia ff ^ co ioiCio 
 ft r oc „- ft ft ft 
 
 - 0D rH CM „ r „ 
 
 ft . rf m d-ftft 
 
 © ^; S >d © © © 
 pg ^_ ^ g tfPHa3 
 
 
 P. p, ."d 
 
 .>d 
 
 _f ft ft 
 
 ft 
 
 .3 
 
 a 
 
 Cm 
 O 
 
 A Pi°a 
 
 1^ 
 
 "3 H 
 
 ►»5 
 
 ^^ 
 
 © r r 
 
 t^CO ft ft 
 
 eg . © © 
 
 ft 
 © 
 
 Ph «.m • 
 
 
 7^ 
 
 M, d tf P4 
 
 Ph 
 
 3 |^o 
 ft ft"?' "7 
 
 s s^a 
 
 O © c3 O q. © 
 
 ^a 
 
 ■Sr 2 
 
 <;&h 
 
 S § 3 3 
 
 M -5 o o 
 
 3 
 
 s 
 w 
 
 3 §• ^ I 133 
 
 ft Ph r ftftft 
 
 © - ya oS's 
 
 >, 'p.. ^ >>>>>» 
 o £51 © © .Cob 
 
 d W ft § ^gdCd 
 O i° ^ (N O O O 
 
 g 
 
 '5 5^ . 
 
 i-H O 
 
 §8 .§ 
 
 03!N 
 © . 
 {HP. 
 
 O M © ."d Sh 
 2^03^ o 
 
 :>h • p d 
 fcc|7 ft o o 
 
 5 
 
 o 
 co 
 
 d d .Jg 
 
 
 C eS . 
 
 d 
 
 
 ft© O-Ph^ 
 
 d:d 
 
 S 
 
 » — >** U 2 -"S ri"^ 2c S 
 
 o d-^ t^'-Ht-.P-coo 
 
 
 Ph PQ<J 
 
 <{ 
 
 0Q 
 
 W 
 
 Ph Ph Ph 
 
 pq 
 
 WO P5 PQ PhPhCh 
 
 •9SV 
 
 
 
 s 
 
 
 
 
 
 : !§ S 
 
 PUB X8g 
 
 § IS 
 
 3_ 
 
 
 
 c 
 
 a 
 
 ^3 
 
 o 
 
 CO 
 
 §3 
 
 OO 
 
 s s a 
 
 PH 
 
 
 : S fe g SSS 
 
 •3iBa 
 
 c 
 
 c 
 r 
 
 O :r 
 
 o ■« 
 
 "• : c 
 
 ■H CM 
 
 i 
 
 
 
 
 
 t*< 00 CO 
 
 ao oo oo 
 
 § 
 
 o? oo oo oo ao°°*> 
 
 "ON 
 
 1 
 
 * 
 
 >o 
 
 « 
 
 t>- 00 © 
 
 
 — 1 t-. »M 1H J-H » 
 
 
 - 
 
=5 8 
 
 < s 
 
 
 «2 
 
 i; - 
 
 as 
 
 g 
 
 £3 
 
 >> 
 
 - 
 
 _op_ 
 
 6 
 
 5 x 
 
 > < 
 
 2 5 b t» 
 
 5»S b« 
 
 < < ; 
 
 p, -2 — .= > 
 
 § i £ § I o 
 
 -5 - r. - r 
 
 ^2 
 
 ft . 
 
 as 
 
 ^ ft 
 
 ba a ba b£ 
 | «|| | 
 
 £ ~- £ £ 
 
 CO Ph 
 
 x 2 
 
 = - 
 
 is 
 
 c - 
 
 c; - o 
 d|^ 
 oSP-g 
 
 3 x x ■- 
 
 g >> >> 3 
 
 a 5 2 5 ■ ° 
 
 — >— E ■— E *o 
 — ' — . - c 
 
 
 oss a 
 
 
 c — 
 
 S8 
 
 ° .5 ft = ~ S o it I o > ' 
 
 
 S .. tC Z ~ 
 
 
 ft 
 
 i 1 
 
 ■| 3 5~i ®Jj§ 
 
 * S 2 s^-slS . 
 
 g a S-g o 3 M § "^ 
 
 I = 5 1 - •- 1 * B S g 
 
 z s z IT 
 
 O ® H 
 
 & s 5 
 
 ©■S* 
 
 
 C = 
 
 5 ft = 
 
 o r o 
 
 03 « (E & 
 
 — --• 'E. -r -' -f 
 
 §58 |^ 
 
 :T% *£? 
 
 - — u — « 
 
 ::>: § ► . 
 
 igafl i^ 
 
 b n n 8 
 
 a - - s ■ 
 
 P4 S r - - 
 
 . = > ^ > 
 
 •9Sy 
 
 PUB X3S 
 
 •91^(1 
 
 •ox 
 
 I 2 
 
 
 S & 
 
 &: s 
 
 S S S5 So 
 
 K 
 
 x 
 
 i. 
 
 ^ 
 
 X 
 
 N 
 
 X 
 
 ^ 
 
 j 
 
 _; 
 
 ■d 
 
 „• 
 
 - 
 
 o 
 
 u 
 
 
 > 
 
 > 
 
 S 
 
 > 
 
 
 a 
 
 t. 
 
 y 
 
 
 v 
 
 
 y 
 
 - 
 
 — 
 
 ^r 
 
 - 
 
 — 
 
 — 
 
 ■ 
 
 — 
 
 ai 
 
 
 
 
 s 
 
 s 
 
 < 
 
 - 
 
 •-r 
 
 gg 
 
 
 90 
 CO 
 
 
 2 - 
 
 - 
 
 - 
 
 h 
 
 "S 
 
 S 
 
 s 
 
806 A SYSTEM OF SURGERY. 
 
 SURGICAL AFFECTIONS OF THE LARYNX AND TRACHEA. 
 
 Syphilitic Laryngitis. — This affection is very common, and oftentimes in- 
 tractable. The use of the laryngoscope has facilitated the diagnosis of the 
 different forms of secondary syphilitic disease which are found in the 
 larynx, and which, before the use of the instrument, were much involved in 
 obscurity. The more simple form is that of erythema, in which slightly 
 elevated mucous patches are seen, of a dark reddish hue, accompanied by 
 dryness of the fauces, hoarseness, and sometimes a slight tickling cough ; 
 after a time, a syphilitic ulceration results, which extends frequently to the 
 pharynx and throat. In the tertiary form of the disease, elevations and 
 ulcerations are discovered throughout the mucous membrane, the former 
 resembling condylomatous growths. They also occur in the shape of sub- 
 mucous patches and tubercles, which readily ulcerate. 
 
 Treatment. — In the treatment of erythema of the larynx the following 
 remedies will be found indicated : Aurum, arsenicum, kali iod., mere, sol., 
 nit. ac. 
 
 Mucous Tubercles will readily yield to argent, nit., calcarea, nitric ac, 
 puis., or thuja. If the disease extend into the nose, favorable results will 
 follow the use of argent, nit., aurum, kali c, creasot., lycop., mere, corr., nit. 
 ac, phos. ac, puis., rhus, sepia, staph., and thuja. For deep-seated tubercles 
 administer arsen., carbo veg., natrum mur., and zincum. 
 
 For further treatment the student is referred to the Chapter upon 
 " Syphilis." 
 
 Foreign Bodies in the Larynx and Trachea. — Although the presence of 
 foreign bodies in the air-passages is to be regarded as a serious occur- 
 rence, it is astonishing what a length of time a foreign substance may 
 be impacted in the larynx, and the patient be unaware of its presence, 
 attributing the symptoms to some other cause. Both Gross and Hamilton 
 record cases of this description, and many others are upon record. In 
 my practice I have seen several examples of this kind. In one case, a 
 subject to epilepsy accidentally swallowed during a convulsion a plate to 
 which were attached two artificial teeth. He supposed he had lost them, 
 and was shortly after seized with cough, which continued with profuse 
 expectoration for many months, accompanied with night-sweats, emacia- 
 tion, and hectic. He was seen by distinguished stethoscopists, who pro- 
 nounced the case one of laryngeal phthisis. (This was before the days 
 of laryngoscopy.) He was regarded as incurable. Upon one occasion, 
 when a procession was passing the house, he was supported at a window; 
 in attempting to cheer some friends whom he recognized, he was seized 
 with a fit of coughing and the foreign substance was expelled. The pa- 
 tient made a good recovery. 
 
 In another case, a child swallowed a bone button, and, with the excep- 
 tion of occasional attacks of dyspnoea, suffered nothing for three years, 
 when the button was expelled. A number of cases in which the offending 
 substance was removed without resorting to artificial means are upon 
 record. 
 
 Goodall, of Dublin, pointed out the fact that foreign bodies were more 
 likely to lodge in the right bronchus than in the left, owing to the large 
 size of that tube. The symptoms are those of stenosis of the air-passages, 
 and at times there is difficulty in diagnosing whether these manifesta- 
 tions are those of disease or of mechanical obstruction. There is violent, 
 abrupt, convulsive cough, coming in paroxysms, accompanied with blue- 
 ness of the face and stridulous breathing. The cough remits and recurs 
 often upon the slightest exertion. The voice is altered, sometimes being 
 entirely gone and at others only impaired. It must be remembered that 
 
TRACHEOTOMY. 807 
 
 death may occur, not alone from the presence of the foreign substance, but 
 from spasm of the glottis induced by its presence. If the surgeon is unable 
 to determine whether the foreign body is in the larynx or pharynx, the 
 patient should be made to swallow; if the obstruction is in the latter, there 
 will be difficulty, and vice versa. 
 
 Treatment. — The first thing to be done when called to see a case in which 
 a foreign substance has become lodged in the air-passages, is to raise the 
 patient by the heels and slap him upon the back, giving him an occasional 
 shake. It must be borne in mind that this procedure may have a tendency 
 to shut the glottis, and, therefore, the surgeon must be prepared for an 
 emergency. In general, it is necessary to perform bronchotomy. 
 
 Bronchotomy. — Bronchotomy is a general term applied to the operation 
 of opening the windpipe, and includes three separate operations, known as 
 laryngotomy, tracheotomy, and laryngo-tracheotomy, and which derive their 
 names from the parts involved in the procedure. The object of either of 
 these is to admit the passage of air into the lungs when some obstruction 
 exists, or to remove a foreign body or morbid growth from within the air- 
 passages. The conditions which render one of the above advisable, are 
 foreign bodies in the air-passages, acute or chronic laryngitis, oedema glotti- 
 dis, polypi, tonsillitis, abscess of tonsils or pharynx, aneurism of the carotid 
 artery, and membranous croup. Sometimes a mass of food may become 
 impacted in the oesophagus, and by its pressure on the trachea so obstruct 
 respiration that an operation becomes necessary; and the same thing may 
 be called for occasionally in suspended animation. 
 
 Laryngotomy is an operation by no means difficult, and is rarely de- 
 manded, except in adults, when some obstruction exists above the rima 
 glottidis. Place the patient upon the back with the head thrown back- 
 ward and the shoulders elevated ; make an incision in the median line from 
 the top of the thyroid cartilage to the base of the cricoid, dividing succes- 
 sively the integument and superficial fascia. The only important vessel 
 likely to suffer is the crico-thyroid artery, which may be controlled by 
 torsion or the ligature. It only remains to divide the crico-thyroid mem- 
 brane in the line of the wound already made. 
 
 Tracheotomy. — According to Dr. Charles A. Leale,* tracheotomy was first 
 successfully performed in 1782 by Dr. John Andree, of London. In 1825 
 Bretonneau was successful, and in 1832 Trousseau followed his example. 
 Voss has collected 1249 cases with 249 recoveries. 
 
 According to the statistics published by Sanne in 1877, and presented by 
 Dr. John C. Petersf to the New York Academy of Medicine, in March of 
 the same year, in 2290 cases there were 516 recoveries. 
 
 Gay+ finds that in the Boston City Hospital, out of 206 cases of trache- 
 otomy performed within twenty years, there were 65 recoveries, or about 31 
 per cent., and Agnew§ shows that in 11,000 cases, the recoveries are about 
 30 per cent. 
 
 The operation is not always simple, and the difficulties attending its 
 performance are sufficient to demand coolness and caution. It may be 
 necessary to work rapidly, but hurried movements may cause unfortu- 
 nate complications. Tracheotomy in children is especially troublesome, 
 on account of their short thick necks, and the cries and struggles by 
 which they resist any manipulations ; for this reason, an anaesthetic should 
 be administered whenever practicable. The incision begins immediately 
 below the cricoid cartilage, and extends for two or two and a half inches 
 
 * Medical Record, March 24th, 1877. f Loc. cit. 
 
 X Reference Hand- Book of the Medical Sciences, vol. ii. Croup. New York, 1886. 
 | Principles and Practice of Surgery, vol. iii., 1885. 
 
808 
 
 A SYSTEM OF SURGERY. 
 
 along the median line towards the top of the sternum. With the handle 
 of the scalpel, the sterno-hyoid and sterno-thyroid muscles of each side 
 are separated and held apart by blunt hooks ; the plexus of thyroid veins 
 are then brought to view, and drawn aside by a retractor. The left index 
 
 Fig. 497. 
 
 Fig. 499. 
 
 Tracheal Dilator. 
 
 Fig. 498. 
 
 Tracheal Dilator. 
 
 Chassaignac's Tracheal Dilator. 
 
 finger serves as an excellent guide, and should be kept constantly in the 
 wound until the rings of the trachea are felt, then the parts should be 
 carefully separated with the knife handle until the white cartilaginous 
 rings of the trachea can be seen, and when this point has been reached, 
 the trachea may be opened by entering the knife at right angles to the 
 
 Fig. 500. 
 
 Fig. 501. 
 
 plane of the wound, cutting upward in the line of the incision. Care must 
 be taken to avoid wounding the isthmus of the thyroid gland, but if this 
 accident should occur, the haemorrhage is to be controlled by ligatures. 
 The tracheal incision should be at least one inch in length, and is at once 
 indicated by a rush of air, blood, and mucus. 
 
TRACHEOTOMY. 
 
 809 
 
 As soon as the rings of the trachea are opened, a dilator, as seen either in 
 Fig. 497 or in Fig. 498, should be introduced into the wound, and the 
 handles opened until the trachea is sufficiently dilated to admit the tubes. 
 Fig. 499 shows the tracheal dilator of Chassaignac. 
 
 Through this opening the canula (Fig. 500) with its pilot, is introduced 
 and confined by tapes passing around the nape of the neck (Fig. 501). 
 
 Fig. 502. 
 
 Forceps for extracting Foreign Bodies through the Canula. 
 
 If a foreign substance is the offending object, the opening may be dilated 
 by retractors, when it will generally be expelled, or may be sought for by 
 the forceps (Fig. 502). 
 
 Mr. Stohlmann has modified the double canula of Mr. Durham, of England. 
 The instrument has an outer tube with a sliding portion which works in a 
 collar and is fixed by a screw. This allows the tube to be either shortened 
 
 Fig. 503. 
 
 or lengthened in accordance with the depth of the trachea. The inside 
 tube is flexible, and is furnished with a blunt " pilot " which also bends. 
 When the canula is entered, the " pilot " is withdrawn and the inner tube 
 inserted in its place (Fig. 503). 
 
 Dr. I. T. Talbot, of Boston, has performed tracheotomy many times, and 
 expresses himself to me on the subject : 
 
 " Since June, 1855, when I had my first successful case of tracheotomy, the 
 first, so far as I have been able to learn, in this country, I have performed 
 the operation seventy-six times. This has been invariably done as a last 
 resource ; forty-two of these, a little over fifty-five per cent., have recovered. 
 One ceased breathing while preparing for the operation and two did not 
 rally from the operation, although artificial respiration was resorted to and 
 continued for some time, with all three. Three others required artificial 
 respiration, and rallied to life under it and made successful recoveries. 
 
810 A SYSTEM OF SURGERY. 
 
 " Of late years I have found membranous croup more frequently connected 
 with diphtheria than formerly, with offensive breath and enlarged cervical 
 glands. 
 
 " If the respiration is impeded above the trachea and albuminuria has 
 not supervened, even in cases of diphtheritic croup the operation is often 
 successful. 
 
 " A cushion of gauze moistened in warm carbolized water, placed directly 
 over the open tube, obviates the necessity of the cumbersome steam appa- 
 ratus and the high temperature. The efficacy of homoeopathic medicine is 
 nowhere exhibited so efficaciously as in croup after tracheotomy." 
 
 My friend Dr. Doughty has performed tracheotomy for diphtheritic croup 
 with encouraging success. His mortality rate so far is the best in the 
 country. 
 
 The period of time that the tube is allowed to remain in the trachea 
 varies according to the character of the disease for which the operation has 
 been performed. I have seen a case of sub-glottic oedema, in which I per- 
 formed tracheotomy upon an apparently moribund patient, where it was 
 necessary to allow the tube to be worn for two months. Thrice I removed it, 
 and within twenty-four hours the symptoms of suffocation were so immi- 
 nent that I was obliged to reinsert it. As a general rule, I have taken out 
 the tube in ten days to a fortnight without untoward results. In cases of 
 stenosis from tumors and other causes, the canula may have to be worn 
 permanently. 
 
 Laryngo-tracheotomy, a combination of the two operations already de- 
 scribed, is performed when the division of the crico-thyroid membrane does 
 not afford an opening sufficiently large to accomplish the result desired. 
 It is readily performed by dividing the balance of the cricoid cartilage 
 with two or three of the upper rings of the trachea. The only attendant 
 danger consists in wounding the isthmus of the thyroid gland and the su- 
 perior thyroid artery. 
 
 After these operations the air of the room should be kept moist and warm, 
 the wound cleaned, the tube freed of mucus, and a piece of gauze should 
 be worn over the orifice to prevent the inhalation of foreign particles. In the 
 case of infants it will be found difficult to make an opening sufficiently 
 large below the thyroid isthmus ; in which case the incision may be 
 made immediately below the cricoid ring, and even this may be divided 
 if more space is required. 
 
 Dr. Smith, of Bristol, Penna., has introduced new instruments for trache- 
 otomy. He believes that by their use the haemorrhage is much less, and 
 that union of the wound is in no way impeded; he says : " In the course 
 of a series of experiments on respiration, performed some time since, I had 
 occasion very frequently *to perform tracheotomy on animals, and being 
 generally without an assistant, experienced much delay and embarrass- 
 ment from the extreme caution necessary to prevent troublesome haemor- 
 rhage. This led me to seek for some instrument for the division of the 
 tissues between the skin and the trachea, which should be safer than a 
 knife, and more expeditious and certain than the fingers or the handle of 
 the scalpel. Accordingly I had two instruments made, resembling the hook 
 used in the operation for strabismus, but stronger and somewhat more 
 pointed at the extremity. Taking one of these in each hand, and operat- 
 ing something as one would with dissecting-needles, I was enabled to divide 
 one layer of tissue after another with the utmost safety and dispatch. 
 The points of the instrument were so blunt as to render it almost impos- 
 sible to penetrate the coats of a vessel, and hence the liability to haemor- 
 rhage, which constitutes the chief danger in this operation, was avoided. 
 Indeed, I have often opened the trachea almost without shedding a drop 
 
INTUBATION OF THE GLOTTIS AND LARYNX. 811 
 
 of blood, except that from the skin and from the trachea itself. In an 
 operation recently performed upon a child by the aid of these instru- 
 ments, I did not find it necessary to employ a sponge during the whole 
 operation." 
 
 Tracheotomy with Thermo-cautery * — The platinum knife of the thermo- 
 cautery, at a dull red heat, is made, 1st, to slowly incise the skin and 
 superficial fascia from above downwards, by one stroke in the median 
 line of the neck, beginning immediately below the lower border of the 
 cricoid cartilage ; 2d, to pass slowly, as before, through the intermuscular 
 tissue down to the trachea by a single stroke ; 3d, the point of the knife 
 is made to pass perpendicularly into the trachea, the incision rapidly en- 
 larged, and the knife withdrawn as quickly as possible. The operation 
 requires but a minute, is attended by no haemorrhage, and can be per- 
 formed without assistance. The thermo-cautery of Paquelin was employed 
 by MM. Poinsot and Mauriac, who have operated with success by this 
 method. 
 
 Intubation of the Glottis and Larynx. — Dr. Joseph O'Dwyer, of New York, 
 has recently introduced a method of intubation of the larynx, which, 
 although it has not been long enough before the profession to become 
 established, yet has been sufficiently successful to demand serious consid- 
 eration. 
 
 The method consists of introducing into the larynx, between the vocal 
 cords, certain peculiarly shaped tubes, which allow free access of air, thus 
 dispensing with tracheotomy. 
 
 Dr. Ingalsf states that the operations may be called for : 
 
 " 1. For diphtheritic and croupous stenosis of the larynx occurring in 
 children under three and one-half years of age. 
 
 " 2. For cases of the same affections in older children in which from any 
 cause the physician wishes to defer the operation of tracheotomy. 
 
 " 3. For those cases in which consent to tracheotomy cannot be obtained. 
 
 " 4. For those cases in which proper nursing could not be secured. 
 
 " 5. For severe cases of spasmodic croup in children less than ten years 
 of age. 
 
 " 6. For simple stenosis of the larynx, not diphtheritic, in children. 
 
 " 7. With proper-sized tubes it might be of value in the treatment of va- 
 rious forms of laryngeal stenosis in adults." 
 
 According to recent statistics X the largest number of " intubations " 
 have been performed by Dr. F. E. Waxham, of Chicago, who reports 17 
 cases and 8 recoveries. 
 
 Dr. D. Brown has had 15 cases with 4 recoveries, and E. F. Ingals, 2 cases 
 with 2 deaths. This may appear a large mortality, but when it is remem- 
 bered that the cases were all those of pseudo-membranous laryngitis, the 
 figures compare favorably with those of tracheotomy for a similar condi- 
 tion. 
 
 The following description of the instruments and methods of introduc- 
 tion are taken from that furnished by Tiemann & Co. 
 
 The numbers on the scale (Fig. 506) indicate the years for which the cor- 
 responding tubes are suitable. For instance, the smallest tube when ap- 
 plied to the scale will reach to the first line, marked 1, and is intended to be 
 used up to the age of twelve or fifteen months ; the size marked 2 is suit- 
 able for the next year, 3 and 4 for these years, and so on. When the proper 
 
 * Monthly Abstract of Medical Science, January, 1878 ; London Medical Record, March 
 15th, 1877 ; Gazette MeMicale de Bordeaux, September 20th, 1876. 
 f Journal of the American Medical Association, February 6th, 1886. 
 j Medical Record, April 24th, 1886. 
 
812 
 
 A SYSTEM OF SURGERY. 
 
 tube is selected for the case to be operated on, a fine thread is passed through 
 the small hole near its anterior angle, and left long enough to hang out of 
 the mouth, its object being to remove the tube should it be found to have 
 passed into the oesophagus instead of the larynx. 
 
 The obturator is then screwed tightly to the introductor, to prevent the 
 possibility of its rotating while being inserted and passed into the tube. 
 
 The following is the method of introducing the tube, which is done without 
 the use of an anaesthetic. The child is held upright in the arms of a nurse, 
 
 Fig. 504. 
 
 Fig. 505. 
 
 O'Dwyer's Instruments for Intubation of the Larynx. 
 
 Fig. 504.— Mouth Gag. 
 
 Fig. 505.— Larynx Tubes and Introducer. 
 
 Fig. 506.— Scale. 
 Fig. 507.— Extractor. 
 
 and the gag (Fig. 504) inserted in the left angle of the mouth, well back be- 
 tween the teeth, and opened widely ; an assistant holds the head, thrown 
 somewhat backward, while the operator inserts the index finger of the left 
 hand to elevate the epiglottis and direct the tube into the larynx. 
 
 The handle of the introductor (Fig. 505) is held close to the patient's 
 chest in the beginning of the operation, and rapidly elevated as the canula 
 approaches the glottis. The tube is pushed downwards, without using much 
 force. It is then detached. The joint in the shank of the obturator is 
 for the purpose of facilitating this part of the operation. As soon as the 
 obturator is removed, and it is ascertained that the tube is in the larynx, 
 the thread is removed, but at the same time the finger is kept in contact 
 with the tube to prevent its being also withdrawn. 
 
LARYNGOSCOPY. 813 
 
 It is important that the attempt at introduction be made quickly, as 
 respiration is practically suspended from the time that the ringer enters the 
 larynx until the obturator is removed. It is, under the circumstances, 
 safer to make several abortive attempts than one prolonged effort, even if 
 successful. 
 
 For the purpose of removal the patient is held in a similar position, ex- 
 cept that the head is not inclined backwards, or very slightly so, and the 
 extractor passed into the tube guided by the index finger of the left hand, 
 which also fixes the epiglottis, and is brought in contact with the head of 
 the canula. Firm pressure with the thumb is then made on the lever above 
 the handle while the tube is being withdrawn. If secondary dyspnoea super- 
 venes at any time, the tube should be removed and a larger one substituted. 
 To avoid accidents it is essential to have some preliminary practice on the 
 cadaver, particularly in extracting, which is the more difficult operation, 
 owing to the aperture of the tube being so much smaller than that of the 
 larynx. These tubes will also prove valuable as dilators in chronic stenosis 
 of the larynx or trachea. 
 
 Laryngoscopy. — In 1827, Senn, of Geneva, endeavored, by means of a 
 small mirror introduced into- the mouth, to examine the larynx, In 1829, 
 B. C. Babbington introduced the glottiscope. In 1837, M. Sellique made 
 for Trousseau an instrument for the same purpose. In 1838, Baumes, of 
 Lyons, invented a laryngeal speculum. Liston, in 1840, conceived the idea 
 of examining the larynx with a small mirror in the fauces. In 1844, War- 
 den used artificial light and a prism. Avery, in 1854, is said to have con- 
 structed a laryngoscope, but did not publish an account of it. Garcia, 
 in 1855, conceived the simplest method of auto-laryngoscopy, viz., standing 
 
 Fig. 508. 
 
 .TIEMANN SCO. NY. 
 
 Elsberg's Laryngoscope. 
 
 with his back to the sun with a small mirror in the fauces. Dr. Ludwig 
 Tiirck was the next to follow in the construction of the instrument, and in 
 1858 Czermak followed in a measure the suggestions of Tiirck and Tobold. 
 
 In Tiirck's laryngoscope the mirror was fitted to the forehead and sup- 
 ported by a spring. 
 
 Tiemann has invented an excellent mirror for the head, which may be 
 used for any illuminating purpose. 
 
 Fig. 508 represents Elsberg's pocket laryngoscope ; and Fig. 509 shows 
 the position of the patient and examiner, with illumination adapted to 
 Tobold's. 
 
 As seen in Fig. 509, the operator is seated in front of the patient, who 
 sits directly to one side and behind the instrument; the tongue is pro- 
 jected from the mouth and held down by a small napkin ; the mirror is then 
 thoroughly cleaned and warmed over the light. The patient opens his 
 mouth and is requested to say " Ah ! " and prolong the sound. This raises 
 the velum pendulum palati, and the mirror, with a rapid though gentle move- 
 
814 
 
 A SYSTEM OF SURGERY. 
 
 ment, is placed face downwards in the fauces, holding up in a measure the 
 palate. There must be no wavering or uncertainty in the introduction of 
 
 Fig. 509. 
 
 the mirror, otherwise there may be gagging or even vomiting. Since the in- 
 troduction of the electric light, an excellent adaptation of it for the laryn- 
 
 Fig. 510. 
 
 1 ■ ■■■'■■ *■■■,■,,, | 
 
 [ 
 
 Sajous's Electric Lamp. 
 
 goscope has been made by Sajous, of Philadelphia, as seen in Fig. 510. a rep- 
 resents the storage-battery ; 6, the incandescent light ; and c, the circuit-closer. 
 
GROWTHS IN THE LARYNX. 815 
 
 The laryngoscope, like the ophthalmoscope, has greatly facilitated the 
 diagnosis of most laryngeal affections and insures greater certainty in the 
 performance of surgical operations. The point to be established is to 
 ascertain what medicines are applicable to the varied abnormal condi- 
 tions, and to render unnecessary so much local treatment, to which, I am 
 persuaded, too many laryngoscopists direct their entire attention. 
 
 Neoplasms. — There are several varieties of new growths which are found 
 in the larynx; indeed, since the introduction of the laryngoscope, they 
 are discovered to be more frequent than was formerly supposed. It is 
 asserted by some that two per cent, of all diseases of the larynx are 
 local in their nature, and consist of abnormal growths ; of these, in 
 244 cases, there were warty, 110 ; fibrous, 23 ; sarcomatous, 52 ; adeno- 
 matous, 6 ; cystic, 14 ; cartilaginous, 4 ; epitheliomatous, 19 ; not clearly 
 indicated, 16. Of these, 158 were recognized during life, and 86 after 
 death.* 
 
 Whatever be the nature of the growth in the larynx, the symptoms are 
 much the same. There is always more or less dyspnoea caused from the 
 size of the neoplasm obstructing the windpipe, or from the pressure upon 
 the laryngeal nerve ; the voice becomes husky, hoarse, or even extinct ; or, 
 in some instances, there may be only spasmodic difficulty of breathing, at 
 times the patient being perfectly well. A tumor may exist for a long 
 time in the air-passages without the patient being aware of its presence ; 
 indeed, as will be seen by referring to the figures above, many are not 
 recognized during life, and are only discovered after death. Growths in 
 the upper part of the air-passages may cause dangerous symptoms, and 
 even death by spasm of the glottis or oedema-glottidis. In general, 
 inspiration is more difficult than expiration, excepting in those cases 
 in which the growth is low down, when both the acts are performed 
 with difficulty. The cough is slight in some cases ; in others more 
 severe, and is accompanied with mucous or muco-purulent expectora- 
 tion. 
 
 Many of the symptoms which are present from foreign bodies resemble so 
 closely those of spasmus and cedema-glottidis, or the pressure of tumors, that 
 before the introduction of the laryngoscope great difficulty of diagnosis 
 obtained ; however, since the era of reflected light in surgery, a new age has 
 dawned upon diseases of the windpipe. 
 
 Warty Growths generally arise from the mucous membrane of the upper 
 part of the larynx, and often are multiple ; they resemble a cauliflower in 
 shape and are in some instances pedunculated. Sometimes portions are 
 detached and expectorated, while at others the growth is so rapid as to 
 demand tracheotomy. 
 
 Polypi. — The fibro-cellular growths are round, oval, and generally pedun- 
 culated ; they are solitary, and partake of the nature of these tumors in 
 other parts of the body. The symptoms are those already described. 
 
 Adenoid Growths. — The color of this variety of abnormal formations, 
 when examined by the laryngoscope, is at first reddish, but as they grow 
 it becomes of a paler hue. They change more rapidly than any of the 
 laryngeal tumors, an attack of ordinary catarrh or catarrhal laryngitis 
 causing rapid enlargement. When they are sessile, they cover quite a 
 large extent of surface, and are lobulated. They are generally found at 
 the base of the epiglottis, or growing from the mucous membrane, covering 
 the arytenoid cartilages. 
 
 Cystic Tumors and, indeed, osseous growths, together with carcinoma, some- 
 times occur in the larynx, all demanding the use of the laryngoscope. 
 
 * Holmes's System of Surgery, vol. iv., p. 575. 
 
816 
 
 A SYSTEM OF SURGERY. 
 
 Treatment. — I have not had much experience in the treatment of growths 
 in the larynx, and but little with the laryngoscope, and as the use of the 
 instrument and the treatment of those diseases which it has taught us to 
 detect and relieve is an established specialty, it is probable that ere long some 
 member of our school will publish a full description of laryngeal affections 
 and their treatment. 
 
 For the warty growths, I should recommend thuja, cale, sepia, lye, or 
 sulphur, according to the symptoms. 
 
 For the glandular, one of the different preparations of mercury, or perhaps 
 kali iod., nit. acid, lachesis, kali bromat., calcarea, or silicea. 
 
 For the cancerous, those medicines which are already mentioned in the 
 chapter upon the Treatment of Malignant Tumors. 
 
 The surgical treatment varies considerably. It may be deemed neces- 
 sary, especially if the growth is large, to perform tracheotomy {vide page 
 807) before proceeding to remove the tumor, which may be done in one 
 
 Fig. 511. 
 
 Seeger's Brush-holder with Flexible Stem. 
 
 of two ways, viz., either through the natural passages by the aid of the 
 laryngoscope, or by incisions from without. In the first method, which is 
 generally preferred, the patient is seated and examined by the laryngoscope, 
 and if caustics are to be used, the brush, as seen in Fig. 511, applied to the 
 
 Fig. 512. 
 
 Fig. 513. 
 
 TIEMAtiH. CD 
 
 parts, to thoroughly cleanse them ; after this it may be desirable to apply 
 medicines directly by means of the atomizer. 
 
 Figs. 512-13 show the working of the instruments. In Fig. 512 the 
 medicated substance is placed in the graded bottle ; in Fig. 513 it is placed 
 in the cup. The chief substances inhaled are aqua picea mixed with alu- 
 mina, or amm. mur., or zinci sulphat. Zinci iodidum, acid, tannic, and 
 hydrarg. bichlor. have also been used. These are, however, for affections 
 of the larynx other than tumors. 
 
 To growths, the solid nitrate of silver, nitric and chromic acids, the 
 
TREATMENT OF GROWTHS IN THE LARYNX. 
 
 817 
 
 Vienna paste, and the London paste, already described in the article on 
 " Tonsillitis," have all been successfully applied. These escharotics should 
 
 Fig. 514. 
 
 be used with the greatest caution, and a concealed caustic carrier, as seen 
 in Fig. 514, must always be employed. 
 
 In removing neoplasms with the forceps, it is often necessary to repeat 
 the operation at several sittings. Of those best adapted, are the alligator 
 forceps, a cut of which is seen on page 801. 
 
 Fig. 515. 
 
 Fauvel's Laryngeal Polypus Forceps. 
 
 Fig. 515 shows Fauvel's laryngeal forceps, and Fig. 516 illustrates Tie- 
 mann's laryngeal scoop. 
 
 Fig. 516. 
 
 Tiemann's Laryngeal Scoop. 
 
 The knife is sometimes preferred to the forceps ; in such cases that of 
 Semelder, properly curved, is the best. The growth must be carefully 
 raised before the knife is used. 
 
 Galvano-caustic Wire. — In the half dozen cases that have come under 
 my observation, the removal of the growths has been satisfactorily accom- 
 plished by the galvano-cautery. Tracheotomy is generally necessary, and 
 in one instance the trachea was opened and the laryngeal growth, a fibroid, 
 successfully removed through the opening with caustic wire. 
 
 In making incisions from without the cut must be in the mesial line, the 
 cavity of the larynx laid open, and the growth removed with the galvano- 
 caustic wire or the ecraseur. This would certainly be the best method. In 
 these operations the cricoid cartilage should, if possible, be left intact. 
 
 52 
 
818 A SYSTEM OF SURGERY. 
 
 Extirpation of the Larynx.— According to Paul Berger * it was Koeberle* 
 who made the first suggestions toward the removal or extirpation of the 
 larynx. This was about 1856. In 1870, by experiments performed on 
 dogs, Czerny demonstrated that the operation could be successfully per- 
 formed ; but to Billroth is due the credit of having made the first success. 
 He removed the larynx, in 1873, from a patient affected with cancer ; the 
 wound healed in two months, and the patient was enabled to speak, though 
 in monotone, with great distinctness. The contrivance for articulation has 
 since received the name of Gussenbauer's tubes. 
 
 Throughout the medical periodicals, since Billroth's exploit, there are 
 a number of records of operations of this character. 
 
 The incisions must vary somewhat in accordance with the disease, but 
 the point to be observed is to prevent foreign matters (blood, pus, or other 
 discharges) from entering the air-tubes. The incision should extend from 
 the lower border of the hyoid bone to a point about an inch below the 
 centre of the cricoid. Then, the soft parts are to be carefully dissected 
 away from the alee of the thyroid, and also from the thyro-hyoid membrane. 
 
 Here, the operator should stop, secure any vessels that are bleeding, and 
 wait a few moments for the oozing to cease. The trachea is then to be 
 pulled forward and divided at its first ring. The next step is to prevent 
 blood from entering the trachea, as the operation proceeds, which may be 
 done by a silver or india-rubber siphon, or a cork with a tube through it, 
 or whatever contrivance the surgeon may think best. The lower extremity 
 of the larynx is thus freed. The remainder of the operation depends 
 mainly on the extent of the disease. If the upper margins of the thyroid 
 can be left, it is advisable to keep them in the wound, as they arch over the 
 parts and prevent the collapse of the tissues. If, however, they are dis- 
 eased, they should be removed, and the arytenoid may answer the purpose, 
 or even the cornua may assist in holding open the parts sufficiently. 
 
 After the disease has been thus extirpated, the upper end of the trachea 
 must be securely fastened by wire or catgut to the surrounding tissues, and 
 leaving in position the tracheotomy, or other tube, the wound allowed to 
 heal. 
 
 In some cases of extirpation of the larynx the incisions may be made as 
 follows, the dissection being from below upward instead of from above 
 downward, as practiced by Dr. Von Brune :f Tracheotomy need not be 
 performed at the commencement. An incision is made from the lower jaw 
 to the sternum in the median line and the deep dissection continued until 
 the hyoid bone, the thyro-hyoid ligament, the thyroid cartilage, and the 
 upper rings of the trachea are laid bare. No great bleeding takes place, and 
 the operation is not a protracted one. 
 
 The following interesting case is reported by Dr. D. Foulis.J A man 
 (set. 28) complaining of hoarseness, had a warty-looking growth projecting 
 under the anterior end of the left vocal cord, which was removed by external 
 incision, and proved to be a papilloma ; but a nodule had reappeared on 
 the old site, growing steadily. Thyrotomy was performed, the growth 
 clipped out, and its seat cauterized. Again it reappeared, and with the 
 consent of the patient removal of the larynx was decided on. 
 
 The incision began at the lower edge of the hyoid bone and ran down 
 the middle line to about an inch below the cricoid cartilage, lint being 
 applied to prevent blood entering the air-passages. The soft tissues were 
 carefully dissected and any small vessels ligatured that were bleeding. The 
 
 * Hayem's Kevue des Sciences Medicales, t. ix., part 1, p. 298. 
 
 f London Medical Record, January 15th, 1879. 
 
 X The American Journal of the Medical Sciences, January, 1878. 
 
INJUEIES OF THE CHEST. 819 
 
 operation lasted two hours and a half, and recovery took place without any 
 accident. The last feature in the treatment was the introduction of Gussen- 
 bauer's artificial vocal apparatus — not, however, until the wound was fairly 
 healed and contracted. 
 
 Cohen, in his tables of removal of the larynx, states that the opera- 
 tion has been performed 65 times — 5 for sarcoma, 4 for non-malignant 
 disease, and the remainder for carcinoma. Of the non-malignant cases 2 
 died. All those performed for sarcoma recovered ; of the 56 remaining, 
 42 died and 14 recovered, of which 6 only were alive one year after the 
 operation. 
 
 CHAPTER XLI. 
 
 INJURIES AND DISEASES OF THE THORAX. 
 
 Wounds of the Chest — Hydrothorax— Empyema — Aspiration of the Thorax — 
 Thoracentesis — Puncture of the Pericardium — Pleurotomy — Thoracic Grad- 
 ual Drainage — Apnosa : from Drowning, from Hanging — Mammary Lym- 
 phangitis—Mastitis—Carcinoma of the Mamma — Benign Tumors — Amputa- 
 tion of the Breast. 
 
 Injuries of the Chest. — In wounds of the lungs, danger is to be appre- 
 hended from inflammation, suppuration, or haemorrhage. The patient 
 generally experiences great dyspnoea, with a sense of suffocation. Arterial 
 blood, mixed occasionally with clots, is expectorated, or, if the wound 
 be extensive, there may be profuse haemorrhage from the mouth. Inflam- 
 mation always supervenes, and, unless the abnormal process be prevented, 
 profuse suppuration, hectic, and debility result. 
 
 Treatment. — If the external opening be large and the lung protrude 
 (pneumocele), it should be returned by gentle pressure, and retained within 
 the cavity by means of bandages and compresses. It is important that 
 the latter be moistened with a solution of arnica, as by such applica- 
 tion bleeding may be restrained, inflammation prevented, and the healing 
 process advanced; the internal administration of the same medicine, in 
 alternation with aconite, if the -fever be intense, will assist in accomplish- 
 ing a favorable result. 
 
 If the intercostal artery has been wounded, it must be ligated, even 
 though extension of the opening be necessary. If extraneous matter have 
 lodged within the lung or surrounding textures, it should be gently re- 
 moved, otherwise profuse suppuration may follow, and the patient be de- 
 stroyed. Secondary haemorrhage may be arrested by the internal admin- 
 istration of aconite, arnica, crocus, diadema, phosphorus, and, in some 
 instances, bryonia ; the latter particularly is applicable when, with the 
 cough, there is expectoration of blood-streaked mucus, with stitching or 
 sticking pains, especially when the pleura is attacked by the inflammatory 
 process. Phosphorus is an important medicine when, after granulation 
 has commenced, there is threatened inflammation of the parenchyma of 
 the lung, with prostration, and dulness on percussion. 
 
820 A SYSTEM OF SURGERY. 
 
 The external wound should be closed with lint, plaster, and bandage, the 
 patient kept perfectly quiet in a well-ventilated apartment, and all causes 
 of excitement avoided. 
 
 In simple contusion, a bandage should be placed around the chest, arnica 
 administered internally and externally, and inflammation of the contents 
 of the thorax combated by those means already adverted to. 
 
 Hydrothorax. — By the term hydrothorax is understood an accumulation 
 of fluid in the cavity of the chest; empyema may be included in this 
 definition ; but generally by the latter term surgeons understand a collec- 
 tion of pus within the thorax. In this place hydrothorax is applied to an 
 accumulation of serous fluid in one or both pleural cavities. In the incip- 
 ient stage, the symptoms are uncertain, and may be mistaken for those of 
 affections of the lungs, heart, etc. There is transitory oppression of the 
 chest, after exercise, talking or ascending an eminence, with increased 
 dyspnoea in the evening. This condition may pass away with expectoration 
 or profuse sweat ; but it is liable to return, particularly in the warm season. 
 The difficulty of breathing increases, the patient is unable to lie down on 
 account of the gravitation of the fluid, there is palpitation of the heart, 
 livid countenance, disturbed sleep, and dulness on percussion. If the 
 effusion is on one side only, the patient lies most comfortably on that 
 which is affected. The above symptoms are paroxysmal; in time, sopor 
 and insensibility supervene. There is often cough, with extreme irritation 
 of the chest. Where the percussion-sound is faint the respiratory murmur 
 disappears ; and when there is much effusion bronchial respiration is some- 
 times heard. The vibrations of the thorax when talking are feeble or 
 entirely absent. 
 
 It is important that the practitioner should remember that the diaphragm, 
 liver, and spleen are often forced downward into the abdominal cavity, 
 presenting appearances analogous to those observed in ascites. 
 
 Persons of advanced age, with weak lungs, occasioned by frequent re- 
 turning catarrhs, are peculiarly liable to this affection. Malformations of 
 the thorax, curvatures of the vertebral column, and deformities of the ribs 
 and sternum, also engender the disease. 
 
 Treatment. — Ars. alb. is one of the principal medicines ; it corresponds 
 to many of the symptoms, particularly the dyspnoea and torturing feeling 
 of suffocation. Other indications which call for its exhibition are the com- 
 plete prostration of the patient and burning thirst, together with nocturnal 
 exacerbations. 
 
 Ipecac, pulsatilla, and ignatia may, in some cases, be called for. Scilla 
 is an efficient medicine when there is constant cough, with expectoration 
 and dyspnoea. When there are rheumatic and constrictive pains in the 
 chest, palpitation of the heart, restlessness, and excessive anxiet}', carbo veg. 
 is indicated, particularly when the disease arises from excessive loss of 
 animal fluids. 
 
 Lycopodium should be prescribed when, together with the dyspnoea, there 
 is excessive palpitation of the heart, occurring principally after a meal, 
 with cold feet. Hartmann* states that he has cured hydrothorax with 
 ammonium carb. 
 
 Other medicines are bry., china, colch., dig., hell., kali carb., spigelia, and 
 sometimes stannum and dulcamara. 
 
 Frequently by the exhibition of these medecines the disease is arrested. 
 
 Empyema. — Empyema is a collection of pus within the cavity of the 
 thorax ; it may be the result of acute inflammation, whether traumatic or 
 idiopathic. The symptoms are similar to those of hydrothorax. 
 
 * Chronic Diseases, voL i., p. 194. 
 
ASPIRATION OF THE THORAX. 821 
 
 Empyema may result from certain inflammatory conditions, from severe 
 contusions, and as a sequel of certain diseases. In two of the worst cases 
 that have come under my observation, one was caused by a severe fall 
 down a hatchway, in which the patient not only suffered from the contu- 
 sion, but fractured the surgical neck of the humerus ; in the other the 
 purulent effusion followed malignant diphtheria. With reference to the 
 diagnosis between collections of pus and the ordinary effusions, there is 
 always some difficulty, the history of the case and the constitutional symp- 
 toms being the most reliable signs. I cannot agree with Professor Bacceli, 
 who makes the extraordinary statement* that the denser the fluid, the less 
 clear will be the sound of the voice. According to all physical laws, the 
 contrary is the case, and wherever I have had an opportunity of putting 
 the same to actual experiment, I have found that the sounds of the voice 
 were much more clear in empyema. 
 
 Emphysema, or a collection of air within the pleura, may be caused by 
 wounds of the lungs, fractures of the ribs, and penetrating wounds of the 
 chest. According to Hastings,f " There is absence of respiratory murmur 
 upon the affected side, where it is caused by wound of the lungs, with an 
 exceedingly clear sound on percussion, with immobility of the ribs. On 
 the sound side there is puerile respiration. When the injury is dependent 
 upon the bursting of an abscess, a metallic tinkling is audible, and upon 
 directing the patient to cough, a drop of fluid falls from the orifice in the 
 lung, and drops to the bottom of the chest with this peculiar sound; or if 
 the chest be shaken, the fluid can be heard to splash." 
 
 Aspiration of the Thorax. — The most practical divisions of effusions into 
 the thorax are : 1st. Those resulting from acute diseases ; 2d. Those from 
 chronic diseases ; and 3d. Those consisting of pus accumulations. In the 
 first variety the effusions should, in the majority of cases, be left to nature, 
 though there may happen cases of such severity and so imminent in dan- 
 ger, that it may be necessary to withdraw the effused material. In the 
 second variety, where the fluid is gradually and steadily poured out, the 
 danger is much greater. In empyema, there should be free drainage, not 
 always with the expectation of a radical cure (although such may take 
 place), but for the sake of relieving the patient of distressing symptoms, 
 and of prolonging life. I have had under my charge several other dis- 
 tressing cases of empyema, and have been surprised at the relief which 
 has been immediately experienced by aspirating the thorax, and also at the 
 number of times the chest may be punctured without detriment. In a 
 case of Dr. Minton, of Brooklyn, in which I operated at midnight upon a 
 patient almost in articnlo, and withdrew a large basinful of pus, the patient 
 sank into a slumber and recovered rapidly, while in another case I think I 
 aspirated the thorax at least sixty times. 
 
 After aspiration the cavity of the thorax must be washed out with some 
 antiseptic fluid, and the best is'salt and water. I was led to this method 
 by reading the remarks of M. Howze de l'Aulnot.J The operation of thora- 
 centesis had been performed and the cavity washed out each time with 
 an antiseptic fluid without success, when a concentrated solution of salt 
 and water produced a cure. 
 
 Dr. Goodheart,§ of Guy's Hospital, has analyzed 350 cases of pleuritic 
 effusions, and the results are in the main unfavorable to operation for the re- 
 moval of the ordinary acute forms of the disease. For the withdrawal of pus 
 
 * American Journal of the Medical Sciences, July, 1876. 
 
 f Practice of Surgery, p. 248. 
 
 X Medical Kecord, November, 1878, No. 419. 
 
 \ British Medical Journal, November 4th and December 18th, 1877. 
 
822 A SYSTEM OF SURGERY. 
 
 the results also are not encouraging, so far as cure is concerned. In 26 not 
 operated upon for the ordinary forms of effusion there were 15 recoveries, 
 and in 51 operated upon, 28 recovered and 23 died. 
 
 Dr. Wilson Fox, who has collected 15,000 cases, finds the mean mortality 
 to be from 10 to 17 per cent. In pleurisy the ratio is greater after paracen- 
 tesis. In empyema the results are encouraging, but are not such as to lead 
 us to expect much save temporary amelioration. 
 
 In aspiration some surgeons prefer the spaces between the sixth, seventh, 
 or eighth ribs in which to introduce the needle. From my experience I 
 think I may state that it may be introduced at the spot where the fluctua- 
 tion is most distinct, either on the anterior or posterior walls, high up or 
 low down, and that the operation may be performed upon the child or the 
 adult. A case is reported* in which aspiration was performed upon a child 
 two years old. I have entered the needle at many sites, and never, but in a 
 single case, was there any untoward result, and in that instance, the symp- 
 toms, though instantaneous and severe, lasted but a short time. The pre- 
 caution of using the dome trocar needle, which conceals the point after its 
 introduction, should always be taken. 
 
 Before proceeding to aspirate the thorax, it is well for the surgeon to in- 
 form the friends of the patient that the operation is not by any means free 
 from danger, and that immediate death may result from it. Indeed, the 
 sudden and rapid evacuation of the fluid may produce pulmonary oedema 
 to an alarming extent. Again, syncope may cause death ,f or, as has been 
 supposed, the very puncture has, from reflex action, caused the death of the 
 patient from cessation of the heart's action. 
 
 In drawing off the fluid, whether by the aspirator or trocar, it must be 
 done with caution, and allowed to run slowly ; indeed, it may be better to 
 make two operations, and allow the lung to expand from the compres- 
 sion made upon it by the fluid, and thus prevent the venous blood from 
 being forced in too great quantity into the right heart, for if this were to 
 happen to any considerable degree, cardiac paralysis and death would cer- 
 tainly result. 
 
 Thoracentesis. — To evacuate the fluid, the operation of thoracentesis may 
 be preferred, and is thus performed : An incision into the chest is made with 
 a knife and a canula passed into the opening ; or a trocar may be thrust 
 directly into the cavity, the stilet withdrawn, and the canula, to which an 
 india-rubber tube is attached, the end of which tube should rest in a basin 
 containing water, allowed to remain. In this operation care should be 
 taken, while passing the instrument within the cavity, that the lung be not 
 irritated, else troublesome cough will be the consequence; the part selected 
 for the operation should be as dependent as possible, and the patient placed 
 with the face up and the head and shoulders thrown back. Whichever 
 method is resorted to, the instrument should be made to pass in close prox- 
 imity with the superior edge of the sixth or seventh rib, to avoid wounding 
 the intercostal artery, which courses along the inferior margin of the bone. 
 The opening should be valvular, to prevent the passage of air into the 
 cavity ; this can readily be effected by drawing tense the integument over 
 the place of entrance ; it will be found that when the instrument is with- 
 drawn, the skin will roll over the aperture, thus forming an integumental 
 valve. 
 
 Thoracic Gradual Drainage. — Dr. Southeyt recommends highly the use 
 of a capillary drainage-tube, allowed to remain in the chest for a con- 
 
 * Medical Eecord, April 12th, 1874. 
 
 f M. Tenneson, Union Medicale, February 22d, 1876. 
 
 X American Journal of the Medical Sciences, No. cliv. 
 
PLEUROTOMY. 823 
 
 siderable time. These drainage-tubes are attached to a very fine canula, 
 and are of different sizes. I have employed this method in several cases 
 with excellent results ; the idea being not to entirely empty the chest at 
 once, but to allow the fluid to gradually drain away and the lung to expand 
 as the pressure is removed. 
 
 The operation of thoracentesis is facilitated by the construction of instru- 
 ments for the purpose. Fig. 517 shows Flint's apparatus for thoracentesis. 
 Dr. Flint preferred the posterior portion of the chest, between the eighth 
 and ninth ribs, for the introduction of the trocar, which is plunged into the 
 
 Fig. 517. 
 
 Flint's Apparatus for Thoracentesis. 
 
 intercostal space, withdrawn, and the tube attached. The stopcock is to be 
 turned while the attachment is being made; by using the hand-ball the 
 fluid is withdrawn. 
 
 Pleurotomy. — An opening made into the pleural cavity by incision, and 
 the establishment of free drainage, is preferred by many surgeons to aspi- 
 ration. Dr. Herbert Clapp * gives excellent advice in the performance of 
 this operation, which I quote : " The patient generally being in the semi- 
 recumbent position, an incision of from one to two inches is made, usually 
 in the sixth, seventh, or eighth intercostal space, in the posterior axillary 
 line, or a little back of it. This location may be varied somewhat, accord- 
 ing to the thickness of the muscles, the possible bulging between the ribs, 
 or for other reasons. Marshall (London Lancet, March, 1882) recommends 
 the fifth space in front, where nature oftenest makes her opening (or a 
 spot on the same level in the axilla), but every other authority that I re- 
 member is strongly opposed to an anterior opening. Having made such 
 an opening in one case in the hospital several years ago, I should not 
 want to try it again. When the patient, as very often happens, is quite 
 weak and confined to the bed, it is exceedingly awkward to wash out and 
 drain the pleural cavity from an opening in front, and most patients do not 
 relish being turned on their faces for this purpose. One of the prime requi- 
 sites being a good position for drainage, the first impulse would naturally 
 be to select the very lowest intercostal space in the back where pus could 
 be found; but this is not wise, because, owing to the anatomy of the lower 
 part of the pleural cavity, the diaphragmatic and the costal pleura? might 
 unite above the opening after drainage had been established, leaving a large 
 pus-cavity undrained above. Such an occurrence is a matter of record. 
 The diaphragm and other structures also have been wounded by too low an 
 
 * Twentv-four Cases of the Radical Operation for Empyema, by Herbert Clapp, M.D., 
 Boston, 1886. 
 
824 A SYSTEM OF SURGERY. 
 
 operation ; and in case none of these accidents happen, the tube is apt to 
 push against and irritate the diaphragm. At first I used to open the chest 
 by one incision through skin and all the subjacent tissues, running the knife 
 down the groove of an exploring needle, as the manner of some is ; but I 
 soon abandoned this method, and now divide carefully one layer after 
 another. Thus there is less danger of wounding the intercostal artery and 
 the rib ; the internal opening can be made shorter than the external, which 
 to some extent prevents the disagreeable burrowing of pus and air into the 
 subcutaneous cellular tissue, and the parts can be more neatly adapted to 
 the tube. It is generally advisable to pursue exactly the same course, even 
 if nature has already made an opening through the parietes in front, or into 
 a bronchial tube. The old-fashioned methbd of making two openings, and 
 passing a fenestrated rubber tube through both, and tying the ends on the 
 outside, is now seldom resorted to. It acts as a seton, and perpetuates the 
 formation of pus. 
 
 " Resection of a part of one or two ribs has been occasionally made by 
 some operators, in order to gain room for more thorough washing out, when 
 the intercostal space is originally narrow, or when the ribs gradually ap- 
 proximate more and more during contraction of the chest, as they often do. 
 Resection of three or four ribs has also been tried sometimes, when other 
 measures have failed, in old cases where the lung cannot expand, and the 
 chest-walls cannot without this help fall in sufficiently to obliterate the 
 large cavity. In the latter case it should not be done until plenty of time 
 has elapsed to wait for nature, assisted by art, to do the same thing ; and 
 not in the former case at all, if it can be avoided — certainly not in a routine 
 manner. In case of necrosis of the rib from periostitis, resection is of course 
 desirable." 
 
 Puncture of the Pericardium. — I have performed this operation several 
 times with great relief to the patient ; in one case often, and without any 
 bad results. In all, the patients succumbed to the disease, but the aspirator 
 was a boon to them during the time they survived. 
 
 The student must remember in the performance of this operation, that 
 the internal mammary artery runs perpendicularly behind the cartilages of 
 the ribs about half an inch from the sternum. The apex of the heart can 
 be found by marking a point about two inches below the left nipple, and 
 about an inch towards the sternum. This point will be between the fifth 
 and sixth ribs, at which space the bulging will generally be found. The 
 needle should be a fine one and cautiously introduced. 
 
 Dr. Villeneuve, in the Archives Med. Beiges* reported the case of a child 
 five years old, who suffered from pericarditis with effusion, the trouble 
 dating from a fall two months before. The symptoms becoming alarming, 
 and medical treatment affording no prospect of success, the tumor was 
 punctured at its most prominent part by a Dieulafoy's aspirator, and 
 two syringefuls of clear yellowish fluid were withdrawn. The result was 
 marked relief. The wound continued open and discharging for six months. 
 The matter was at first clear, and afterwards became purulent. The fistula 
 finally healed, and recovery was complete. 
 
 It must be borne in mind by the young surgeon that all drainage-tubes 
 are liable to slip into the thoracic cavity. Indeed, it is remarkable how 
 many cases of this accident have been recorded.f To prevent this the drain- 
 age-tube must be carefully secured, either with bits of adhesive plaster or, 
 as I prefer, with a large diaper-pin. 
 
 * Journ. de Med., August, 1875 ; New York Medical Eecord, June 8th, 1876. 
 f Drainage-tubes Accidentally Lost in the Pleural Cavity. By F. Huber, M.D. Medical 
 Becord, January 3d, 1885. 
 
APNCEA FROM DROWNING. 
 
 825 
 
 Apnoea from Drowning. — As soon as the body of a person who has been 
 submerged for a length of time in water has been recovered, the face should 
 be turned downward, the mouth opened, and the water allowed to drain 
 away for a moment ; then the finger should be pushed backward toward 
 the fauces, and the effort made to allow further escape of the fluid ; 
 the tongue may be drawn forward to favor the same result. The clothing 
 must be removed, the patient placed in a warm bed, and frictions to the 
 entire body be kept up with the hands of several persons. Flannels should 
 be wrung out of warm water and placed on those portions of the body that 
 are not being rubbed. During this time, if there are no signs of life, artifi- 
 cial respiration must be employed. There are two methods of performing 
 artificial respiration, one known as Marshall Hall's, the other as Sylvester's. 
 
 HalVs Ready Method. — The patient is to be placed prone on the face; 
 pressure with both hands is then gently made on the back ; the body is 
 turned on the side, and then turned on the face again, and pressure used 
 on the back. This manoeuvre must be made about sixteen times in a 
 minute. 
 
 Sylvesters method, which is preferable, is as follows : The patient is laid 
 on the back, or what is better, on an inclined plane ; the tongue is drawn 
 
 Fig. 518. 
 
 Sylvester's Method of Performing Artificial Respiration. First Position. 
 
 forward, and the operator, standing at the head of the patient, flexes the 
 forearms on the arms, and brings the elbows over the front of the body 
 until they almost meet in front of the chest. (See Fig. 518.) Then the arms 
 are rapidly drawn away from the sides of the body and upward until they 
 meet over the head. (Fig. 519.) It is by these movements expansion of the 
 chest takes place. By the pectoral muscles being drawn out, a vacuum is 
 created, and a species of inspiration produced. The arms are made to retrace 
 the curve they have already taken, and again are forced to meet at the 
 epigastrium. This motion should be made for at least fifteen minutes, at 
 
826 
 
 A SYSTEM OF SURGERY. 
 
 the rate of sixteen times to the minute. Each movement should therefore 
 occupy about four seconds. 
 
 In all forms of apncea or suspended animation the nitrite of amyl should 
 be remembered. It must be given cautiously by inhalation, and from 
 
 Fig. 519. 
 
 Sylvester's Method. Second Position. 
 
 its powerful influence on the heart's action, will often restore circulation 
 when other means have proved unavailing. 
 
 Apncea from Hanging. — A person may be suspended by the neck for five 
 minutes and be resuscitated, provided no injury has been inflicted upon the 
 spinal cord. Death, however, may occur almost immediately from disloca- 
 tion or fracture of the first or second vertebra, causing concussion and 
 pressure on the cord; in other instances, the constriction of the jugulars 
 may give rise to apoplexy. The patient must be immediately cut down, 
 and frictions made to the extremities, ammonia applied to the nostrils 
 and artificial respiration (as already directed) made for a considerable 
 time. 
 
 Mammary Lymphangitis, Mastitis, although frequently occurring in fe- 
 males who are nursing, may be present in women who have never been 
 pregnant ; indeed, by some writers we are informed that men have been 
 affected with the disease. 
 
 A patient about to suffer from this affection experiences, for a day or two 
 before the local inflammation manifests itself, general lassitude, restlessness, 
 and uneasiness, together with slight soreness of the gland. Afterwards, 
 there may be coldness of the body and shiverings ; the mamma becomes 
 enlarged, heavy, painful, and may assume a redness all over its surface, or 
 the tint may be deeper in some parts than in others. If the glandular por- 
 tion be most affected, the breast appears, when handled, to be tabulated and 
 hard ; but if the skin and cellular tissue are the seat of the disease, the tense- 
 ness is uniform throughout. As inflammatory action proceeds, the pain 
 
TREATMENT OF MAMMARY LYMPHANGITIS. 827 
 
 becomes throbbing, extends to the axilla, is often intense, and the patient 
 is unable to bear the slightest pressure upon the part, even the contact 
 of clothing aggravating the sufferings. The disease is most common about 
 two or three weeks after delivery, or during the weaning period, when 
 a large quantity of milk, by distending the breasts and obstructing the 
 lymphatic channels, gives rise to the inflammatory process which termi- 
 nates in the formation of pus, thus producing mammary abscess. It is said 
 that when the inflammation is confined to the integument, suppuration 
 follows more speedily than when the true glandular substance is affected. 
 After the symptoms have continued for four or five days, unless the 
 progress of the inflammation has been arrested, suppuration may be ex- 
 pected ; but there are cases in which the process proceeds so slowly that 
 pus is not formed for a much longer period, during which time the patient 
 becomes exhausted by loss of rest, excessive pain, and the accompanying 
 fever. 
 
 The common causes of this variety of abscess are, besides suppression of 
 milk, a current of air upon the breasts, an accumulation of milk through 
 some fault in suckling the child, from weaning, external injuries, or stimu- 
 lants, which are too frequently allowed to nurses or mothers suckling their 
 children. 
 
 There is a somewhat peculiar abscess of the mammary gland, first noticed 
 by Mr. Hey. The inflammation is deep-seated, the process tedious, and 
 when suppuration has supervened and the matter has extended towards 
 the surface, it is discharged through several openings, which become fistu- 
 lous, and when these sinuses are opened, a soft, purple fungus is discovered 
 beneath them ; the surrounding parts of the gland are hard and lobulated. 
 This form of mammary abscess is difficult to heal ; the discharge continues 
 for a length of time, hectic is superinduced, and the patient may be placed 
 in a precarious position. This is the chronic interstitial abscess of modern 
 writers. 
 
 Treatment. — In the first stages of mammary inflammation, suppuration 
 may be prevented by medicine and rubbing. The nurse should stand be- 
 hind the patient, who should be seated in a chair ; the breast be supported 
 by one hand of the nurse, passed under the arm of the patient, and gentle 
 friction from the circumference of the gland to the nipple be continued for some 
 time, the parts having been first covered with warm lard. 
 
 I cannot speak too highly in this place of the treatment of mastitis by 
 pressure, applied over the entire breast and around the body, with an ordi- 
 nary roller bandage. The relief is often immediate, and suppuration pre- 
 vented ; or the handkerchief bandage may be used as follows : The diseased 
 breast is covered with a layer of cotton-wool, and a bandage applied, which 
 is known in minor surgery as the bandage of Ma} 7 or or the triangular bon- 
 net of the breast. The form of the handkerchief is a triangle, a yard in 
 length from one extremity to the other, and fifty centimeters (nearly twenty 
 inches) from the apex to the base. The base of the triangle is placed 
 obliquely under the diseased breast, one of its extremities is directed under 
 the corresponding armpit and the other over the opposite shoulder, and 
 there united behind the shoulder-blade. The apex of the triangle is then 
 lifted in front of the diseased breast, is carried over the corresponding 
 shoulder and firmly fixed behind. 
 
 In the cut, Fig. 520, an excellent method of bandaging the breast is 
 shown. It may answer either for mammary abscess, pendulous breast, or 
 to support the parts after the gland has been removed. It consists of a 
 large bandage with two tails, one of which is fastened around the waist, the 
 other supports the breast from the opposite shoulder, and is fixed to the 
 first behind. 
 
828 
 
 A SYSTEM OF SURGERY. 
 
 If, after the chilliness, the patient experience a tensive, burning, or dart- 
 ing pain in the breasts, if they are somewhat swollen and red, bryonia should 
 be prescribed ; or, if before the symptoms above mentioned appear, and 
 there is only slight swelling, aconite. These two medicines are often suffi- 
 cient to produce resolution ; the child, however, should be allowed to suck, 
 though pain is produced. In some instances the breast-pump is service- 
 able, when the female is desirous of weaning the infant, but often it may 
 
 Fig. 520. 
 
 Method of Bandaging the Breast. 
 
 be dispensed with, the treatment being sufficient to cure the affection. If 
 the milk continue to be secreted in too great quantity, and bryonia does not 
 relieve, puis, will be found of service. Calc. carb. has been used with suc- 
 cess, and lycop. was effectual in an obstinate case. The drug which has 
 proved in my hands most efficacious is kali hydriod. in five-grain doses 
 three or four times daily. 
 
 Belladonna must be given when there is, together with the throbbing 
 pain, a shining erysipelatous redness; and when the inflammation is caused 
 by suppression of the milk by violent emotions, if the patient be robust, 
 with tendency to congestions. If this does not relieve, and the patient com- 
 plains of chilliness and shuddering, which at this stage indicate the forma- 
 tion of pus, mercurius should be administered, or, if the symptoms require, 
 hepar should be prescribed. If these are not sufficient and suppuration is 
 progressing, phosph. has been recommended by Dr. Croserio; he says: 
 " Since I have seen the marvellous effects of phosph. in abscess of the 
 breasts, I have employed no other medicine when there have been evident 
 signs of suppuration." 
 
 So soon as fluctuation is distinct, the abscess should be freely opened. 
 My plan is to use a sharp-pointed curved bistoury, and cut from within 
 outward. The parts are to be covered with a poultice and calcium sulphide 
 administered. After a day or two the poultice must be removed and a sim- 
 ple dressing of carbolic acid and glycerin applied. 
 
 If indurations remain, conium, mere, phosph. ac, or sulph. may be 
 administered. 
 
 If the inflammation be consequent upon bruises, arnica may be applied 
 externally, in a weak solution, and internally in the 2d dec. dilution ; and, 
 
CARCINOMA OF THE MAMMA. 829 
 
 should much pain or fever be present, in alternation with it, aconite may 
 be prescribed. 
 
 When called to treat old cases, in which there are several sinuses, I first 
 inject them with a preparation of hydrastis 3j to 3j of water, and apply 
 over the parts compressed sponge, which I tightly strap to the breast; 
 as the fluids exude the sponge expands, and constant pressure is thus 
 kept up. 
 
 Carcinoma of the Mamma. — This disease frequently arises from small 
 indurations, which are sometimes discovered in the breasts at an early age. 
 If these do not receive timely attention they frequently enlarge and become 
 painful at the critical period. 
 
 The usual origin and development of epithelial cancer of the mammary 
 gland is as follows : 
 
 A hard tumor is discovered in the breast, appearing either spontane- 
 ously, or in consequence of pressure, shock, etc. At first the growth is 
 round and movable ; as it increases in dimensions it becomes uneven ; 
 other swellings develop which appear to be united by cords of indurated 
 cellular tissue. These tumors enlarge, combine into one, involve the 
 whole glandular structure, and sometimes spread to the axilla. Lanci- 
 nating pains at this stage are experienced, extending to the shoulder and 
 arm, and not aggravated by pressure. The integument, if invaded, as- 
 sumes a streaked, cicatrized appearance, and the follicular glands are 
 frequently filled with a blackish substance. The skin in a short time 
 adheres to the tumor, which becomes elevated and inflamed. These 
 symptoms may disappear, but finally the nipple retracts, forming a cavity, 
 the skin breaks and reveals a spreading ulcer, with hard, dark red, shining 
 edges and an unclean bottom ; the discharge is neither very copious nor 
 fetid, and the ulcer resembles a deep fissure devoid of excrescences. The 
 axillary, the glands in the clavicular region, and the cervical ganglia, 
 may enlarge, provided swelling has not taken place previously. At this 
 period, when the tumor is seated, immovable, and hard, the patient com- 
 plains of a troublesome feeling of heaviness, with almost constant sting- 
 ing, boring, shooting, lancinating pains, proceeding to the shoulder, 
 and from the mamma in various directions; also, of rheumatic pains 
 in various parts, particularly in the loins and thighs. The reproduc- 
 tive process suffers considerably ; the face assumes a pallid appearance ; 
 the arm of the affected side commences to swell, its movement is im- 
 peded, and at length excruciating .pains and supervening colliquations 
 produce death. 
 
 Besides these phenomena, there are a variety of conditions that may 
 occur during the course of carcinoma of the mamma. Sometimes the 
 disease remains for a long time latent; at others its development is quite 
 sudden, and it extends with rapidity, attended with severe symptoms of 
 constitutional disturbance. Ulceration of the tumor is frequently produced 
 by external violence — a blow, a fall, or a bruise, may create suppuration 
 and degeneration, or sometimes the ulcerative process is established imme- 
 diately after the suppression of the menstrual discharge. 
 
 There are cases in which cancerous ulcerations are accompanied with 
 slight pain ; in the generality of instances, however, the suffering is severe, 
 and their peculiar lancinating character is almost unbearable. The dura- 
 tion of the suffering, when it is severe, is less than when it is not so excru- 
 ciating, and from this circumstance a distinguishing characteristic may be 
 drawn between acute and chronic cancer of the mammas. The former 
 commences with a hard, deep-seated tumor in the breast, which adheres to 
 the integument for a time, the skin becomes slightly discolored, the whole 
 mamma gradually partakes of the induration ; elevations may be observed 
 
830 
 
 A SYSTEM OF SURGERY. 
 
 in some portions of the gland, while at others there are marked depressions ; 
 the surface becomes soft, and presents those appearances that designate the 
 presence of fluid ; the pain becomes sharper, and resembles in many re- 
 spects that experienced by patients suffering from whitlow. The ulcerative 
 process progresses rapidly, the pains increase, the countenance exhibits an 
 expression of anxiety, the skin has a jaundiced appearance, and the patient 
 is much debilitated and very desponding; the edges of the ulcer are raised, 
 and present those characteristics of cancerous ulceration that have already 
 been mentioned. 
 
 True Scirrhus is dry and of a cartilaginous hardness, and shrinks after 
 having attained a certain degree of development, the contraction and 
 shrivelling of the integument forming various indentations; the accom- 
 panying pains are not great, and by proper treatment the disease may 
 remain in this condition for a considerable length of time. This form of 
 
 Fig. 521. 
 
 Medullary Cancer. " From a lymphatic gland— secondary to hard cancer of the breast. This form of 
 cancer differs from the scirrhous only in the proportion of the cell element to the fibrous stroma— the 
 cells being here seen to be still of the epithelial type, and lying close together without any visible inter- 
 cellular substance." From Arnott (Holmes). 
 
 cancer is most frequently encountered in elderly women of spare habit of 
 body, and of dry rigid constitution. In certain cases a secondary medul- 
 lary cancer may develop in the axillary glands, the breast being affected 
 with scirrhus. (See Fig. 521.) 
 
 Encephaloid cancer is not so hard as scirrhus, and the superficial veins are 
 much enlarged ; as the tumor grows, it presents on the surface one or more 
 purplish and fluctuating spots, which, as the tissue degenerates, give way, 
 and haemorrhage is the result. As soon as ulceration begins, the discharge 
 is excessively fetid. The surface of the ulcer is covered with the peculiar 
 brain-like substance from which the disease takes its name, haemorrhages 
 are frequent, the constitution breaks down rapidly, and death ensues. 
 
 Treatment. — The scirrhous indurations in the breasts of young girls, which 
 arise without any assignable cause, sometimes yield to phosphorus, Phyto- 
 lacca, hydrastis, or chimaphila. 
 
 The medicines best adapted to cancer, not only when it affects the 
 mamma, but in any other organ, are arsenicum and conium ; the former 
 has been used, with more or less success, from a very remote date ; and the 
 famed " cancer curers " of the present day, no doubt, following the example 
 
BENIGN TUMORS OF THE BREAST. 831 
 
 of their predecessors, employ the arsenical pastes. Conium is a superior 
 medicine, and should be remembered in the treatment of this affection, 
 particularly when contusion or abrasion of surface has hastened the carci- 
 noma. When I administer conium internally, I apply the same medicine 
 in the shape of the hemlock plaster, over the entire affected mamma. The 
 plaster made by Seabury & Johnson, of New York, has served an excellent 
 purpose, and may be employed, not only in hard scirrhous tumors, but in 
 any variety of hard nodule in the breast. The prognosis is always to be 
 formed with foresight and judgment, but in the generality of cases it has 
 been found unfavorable. 
 
 A great deal has recently been written regarding the aetiology and prog- 
 nosis in cases of carcinoma of the breast, and many have gone so far as to 
 express their conviction, that the disease is originally local, that amputation 
 ought always to be performed, and even if the axillary glands are impli- 
 cated, their thorough removal will prevent recurrence. This sweeping asser- 
 tion I do not believe. In the majority of cases the disease will return 
 sooner or later, but I am, on the other hand, convinced that early 
 and complete removal of the breast, together with the extirpation of every 
 suspicious morsel of gland or flesh, will not only prolong life but save an 
 immense amount of suffering. 
 
 Benign Tumors. — The most frequently encountered growths are, fibroid, 
 cystic, fibro-cystic, and adenomatous. In regard to the diagnosis of all 
 tumors of the breast, the fact of their being capsuled or not is of great 
 import. 
 
 In the treatise on Innocent Tumors of the Breast, by Labbe and Coyne,* 
 the relation between cancerous and non-malignant growths is clearly set 
 forth. It is there shown that the microscopical characteristics of a growth 
 at any particular time, are not sufficient in and of themselves to determine 
 definitely as to the malignity of that growth, for the pathology of tumors is 
 thoroughly to be known only by clinical study combined with anatomo- 
 pathological study. It is further held, that the idea of a specific morpho- 
 logical element or " cancer cell" (as held and taught by Lebert and others, 
 in 1854), is without foundation, for what was called the u cancer cell " is not 
 always found in the cancerous, and may often be found in the non-cancer- 
 ous tumors. Mode of life rather than structure, is to be consulted in the 
 diagnosis and classification of all, and especially of cancerous tumors. All 
 benignant tumors of the breast have, however, one common character : they 
 are limited by a fibrous capsule, whose formation is explained by the anat- 
 omy of the breast, and by the point of departure of the morbid processes, 
 and they derive their origin from a modification of the parts that compose 
 the primitive lobule of the mammary gland. The conclusions arrived at 
 regarding these benignant growths, may be summed up as follows : 1. A 
 group of tumors exists in the breast that may be called benignant tumors. 
 The character of benignity they all offer in different degree, is due to the 
 special anatomical fact that they are clearly limited by a fibrous capsule 
 that isolates them from the rest of the gland and the surrounding tissues. 2. 
 These growths are of different classes, varying in anatomical character, and 
 in the symptoms shown in each, but all benignant as compared with can- 
 cer. 3. Simple enucleation constitutes an incomplete operation ; partial or, 
 — as in the case of sarcomas, myxomas, or any voluminous tumors of rapid 
 development, — total amputation of the breast must be resorted to for a com- 
 plete operation. 
 
 * Vide American Journal of the Medical Sciences, July, 1877, p. 137. 
 
832 A SYSTEM OF SURGERY. 
 
 Amputation of the Breast. — When it becomes necessary to remove a 
 mamma, the operation should be performed in the following manner : The 
 patient should be placed on a table of proper height, the light being so ar- 
 ranged that it will fall directly upon the part to be removed. As soon as 
 anaesthesia is complete, the arm is drawn away from the body, and held in 
 that position by an assistant. The breast should be washed with corrosive 
 sublimate solution 1 to 2000. A saturated solution of iodoform in ether 
 is then poured over the tumor. The surgeon, marking with his eye the 
 part to be removed, makes an incision through the integument only, around 
 the outer portion of the gland. In the generality of instances this cut 
 should have its concavity toward the clavicle. The second incision 
 should be made above the tumor, and should join the first at its extrem- 
 ities, thus making an oval cut, which should embrace the tumor and 
 about two inches around it. The knife is then carried quickly below the 
 growth in the line of the first incision, down to the pectoral muscle, and the 
 tumor dissected out. After removal, the wound should be carefully exam- 
 ined, and every particle of suspicious tissue removed. If the axillary 
 glands are enlarged, or even present a doubtful appearance, the incision 
 should be extended and their removal effected. After the breast has been 
 extirpated, it is my invariable custom to wash the parts thoroughly with a 
 solution of corrosive mercury. I also lay great stress on the importance 
 of ligating all the arterial twigs with carbolized gut. It takes a little 
 more time, but saves trouble afterward. The wound must again be thor- 
 oughly irrigated with bichloride solution, and three or four sutures of strong 
 silver wire passed through the flaps an inch from the cut margins, down 
 to the bottom of the wound and through on the other side. Before these 
 sutures are drawn, tight, a decalcified bone drainage tube should be placed 
 in the angle of the cut nearest the axilla, and the deep portions of the 
 wound should be brought together by traction made on the wires, which 
 should be secured with leaden buttons on each side. The lips of the cut 
 are then to be carefully stitched together with a continuous gut suture and 
 the entire breast again washed with the bichloride water ; over this a dress- 
 ing of sublimated absorbent cotton encased in borated gauze should be 
 placed, upon which a piece of oiled silk is laid, and held in position by a 
 carbolized bandage around the chest. As a rule this dressing need not be 
 removed for ten or fifteen days, and when it is, the cut has entirely healed. 
 
 CHAPTER XLIL 
 
 INJURIES AND DISEASES OF THE ABDOMEN. 
 
 Wounds of the Abdominal Viscera — Suturing the Intestine — Artificial Anus 
 — Abscess of the Abdominal Parietes — Hepatitis — Diseases of the Gall 
 Bladder — Gall Stones — Cholecystotomy — Hepatic Abscess — Paracentesis — 
 Obstruction of the Bowels — Operations for — Colotomy — Perityphlitic 
 Abscess — Gastrotomy and Gastrostomy — Splenectomy — Resection of the 
 Pylorus— Digital Divulsion of the Pylorus. 
 
 Wounds of the Abdominal Viscera. — Wounds of the abdominal viscera have 
 generally been considered more perilous than those of other parts of the 
 body ; the danger, however, must depend on the organ that is wounded, 
 and the extent of the injury inflicted. Superficial wounds of the abdomi- 
 
TREATMENT OF WOUNDS OF THE ABDOMEN. 833 
 
 nal muscles, or their integuments, are seldom of much consequence, and 
 should be treated according to common principles. When the wound is 
 penetrating and extends deeply into the cavity, the peritoneum is involved. 
 Inflammation of this membrane constitutes the chief source of danger in 
 all wounds of the abdomen. But though it is liable to inflammatory ac- 
 tion, cases have occurred in which balls, swords, or bayonets have passed 
 through the abdomen, transfixing the peritoneum and several convolutions 
 of intestine without proving fatal, and giving rise to but few untoward 
 symptoms. 
 
 In general, however, the patient first exhibits symptoms of collapse. 
 These are paleness of the face, profuse perspiration, rapid fluctuating 
 pulse, coldness of the extremities, great restlessness and sometimes in- 
 voluntary discharge of fecal matter. In the majority of instances the 
 small intestine is involved, although cases are recorded in which the large 
 bowel has been ruptured or received a stab wound. In addition to shock, 
 and speaking clinically, emphysema is always present and when associated 
 with the collapse is sufficient evidence of the seat of the injury. Together 
 with the manifestations mentioned there is generally extravasation of 
 fecal matter, and when faeces make their appearance at the seat of the 
 injury, the diagnosis is certain ; it must be remembered in this connec- 
 tion, that extreme extravasation and the escape of fecal matter may take 
 place within the peritoneal cavity and may not be discovered until the 
 abdomen be explored. A fecal odor arising from the wound is always 
 suspicious and generally indicates that the coats of the viscera have been 
 punctured or ruptured. The amount of shock in each particular case de- 
 pends on the nervous irritability of the patient ; in some individuals the 
 shock is rapid and profound, but the length of its duration must be re- 
 garded as more important than its intensity, prolonged shock being con- 
 sidered worse than its profundity. Other symptoms which may be noticed 
 are the following : 
 
 A tympanic sound over the liver would lead to the suspicion that there is 
 perforation of the bowel in that neighborhood. Sudden distension of the 
 abdomen, with persistent pain in one locality with rapid perspiration, reten- 
 tion of urine, bloody passages, sinking pulse and temperature are all symp- 
 toms which indicate a rupture of the intestinal tract. In these cases suturing 
 the intestine must be resorted to. 
 
 Wounds of the duodenum are more dangerous than those of the larger 
 intestines, as there is greater difficulty in nourishing the patient, and more 
 risk of effusion. 
 
 Wounds of the stomach may be known by the seat of injury, great de- 
 pression, vomiting of blood, and by the matter that escapes. In wounds of 
 the intestines, faeces sometimes are extravasated into the peritoneal sac, 
 giving rise to excruciating pain.. In these the danger always is immi- 
 nent. 
 
 Wounds of the substance of the liver are almost certainly fatal, from the 
 great vascularity of the organ. From slight injury of this viscus, patients, 
 however, recover. 
 
 Wounds of the kidneys may be suspected from the position and direction 
 of the injury, and a discharge of bloody urine ; this accident is dangerous 
 from three causes, — haemorrhage, inflammation, and profuse and continued 
 suppuration. 
 
 Treatment of Wounds of the Abdomen. — When the surgeon is called to 
 treat a wound of the abdomen, probing should be dispensed with as much 
 as possible — such examinations made thoughtlessly, are productive of 
 mischief. If an intestine protrude, it should be replaced ; or, if this be im- 
 practicable on account of the distension of the gut with flatus, etc., a dose 
 
 53 
 
834 A SYSTEM OF SURGERY. 
 
 of nux vomica should be prescribed ; or, if there be considerable vomiting, 
 and cold, clammy skin, and great prostration, a dose or two of veratrum 
 in alternation with the nux. When the distension abates, and vomiting and 
 other symptoms are relieved, the intestine should be returned, and the lips 
 of the wound brought together and silver sutures applied. 
 
 If there be no solution of continuity of the external parietes, and the 
 peritoneum has sustained injury from external violence, arnica should be 
 prescribed internally, and at the same time a diluted tincture of the medi- 
 cine should be externally applied. If either from blows or from wounds 
 the symptoms of peritoneal inflammation arise — which are, painful tension 
 and tumefaction of the abdomen, with excessive sensibility to touch, and 
 frequently ischuria and constipation — aconite, bell., bry., should be em- 
 ployed in accordance with the presenting symptoms. Nux vom. is the 
 proper medicine when there is painful sensibility and distension of the 
 abdomen, with vomiting and other symptoms of gastric derangement, to- 
 gether with ischuria. 
 
 Mercurius should be employed when there is quick, weak pulse, nocturnal 
 sweats, and prostration. 
 
 When the features are collapsed, and there is rapid sinking of the vital 
 energies, and if the inflammation appear to have extended to the upper 
 portion of the alimentary canal, with vomiting of blackish matter, arsenicum 
 is indicated ; in other instances, carbo veg. is demanded. 
 
 If the kidney is the seat of injury, the wound should be treated in ac- 
 cordance with principles already laid down ; and the inflammation of the 
 gland combated with the means employed in the treatment of nephritis. 
 
 If the intestine or part of the stomach that protrudes from the wound is 
 divided, the parts may be brought together with fine silver wire, or carbo- 
 lized animal ligatures, which may be cut off close to the knot, and returned 
 into the abdominal cavity. In this operation, care should be taken to bring 
 the edges together in such a manner that the two surfaces of the outer or 
 serous membrane be applied to each other, as adhesion does not take place 
 as well between mucous surfaces. 
 
 Enterectomy — Suturing the Intestines. — Since the recent improvements in 
 abdominal surgery, combined with cleanliness and disinfection, it has been 
 found that the intestines may not only be readily sutured, but that portions 
 of the bowels may be excised and the cut surfaces joined together, the 
 patients making good recoveries. These operations may be performed in 
 several ways. An incision is made in the linea alba, and the abdomen 
 explored until the diseased intestine has been found ; then two pairs of 
 forceps, their blades having been wrapped with antiseptic flannel, or in- 
 cased in pieces of rubber drainage-tube, are applied, one on each side of 
 the gut to be removed. This is to prevent extravasation, or the extrusion 
 of fecal matter during the progress of the operation. The gut is cut away 
 between the blades of the forceps, and a V-shaped piece of the mesentery is 
 removed with it. 
 
 The relation of the mesentery "with the gut is a very important point in 
 all cases of wounds of the intestines, and is one which must influence the 
 surgeon in his decision regarding resection, and that is, how far the mesen- 
 tery is separated from the bowels. It has been shown by Zesas * that the 
 removal of the mesentery from the gut, interferes so materially with the 
 circulation of the part, that gangrene is likely to result, and that, there- 
 fore, if in a wound of the intestine the mesentery has separated from the 
 bowel, it should be resected at once ; and, on the other hand, if an inch or 
 more of the mesentery remain attached to the wounded gut, resection is 
 
 * Archiv fiir Klinische Chirurgie, Bd. xxiii., Heft 2 ; Medical News, May 29th, 1886. 
 
ENTERECTOMY. 
 
 835 
 
 not required. These important considerations must be carefully weighed 
 by the surgeon in questions of resection of the intestine. 
 
 The sutures for the purpose should be made of carbolized catgut or 
 silkworm gut, and may be introduced in several ways. The needle should 
 
 Fig. 522. 
 
 Fig. 523. 
 
 Lembert's Suture for the Iutestine. 
 
 Continuous Suture. 
 
 be a fine round one, and should be introduced in such manner that the 
 serous surface of the intestine can be brought into good apposition. To 
 
 Fig. 524. 
 
 Fig. 525. 
 
 Jobert's Suture for the Intestine. 
 
 accomplish this object Lembert thus proceeds : The needle is entered 
 about a quarter of an inch from the side of the wound, and should 
 pass as far as the submucous tissue, it is then brought out about one- 
 sixth of an inch from the cut on that side, and is made to enter the 
 
836 A SYSTEM OF SURGERY. 
 
 opposite side of the rent, one-sixth of an inch from the edge of the cut, 
 and brought out at one-fourth of an inch from the cut surface, or, in other 
 words, at a similar distance from the wound on the side in which it was 
 introduced. These stitches must be very numerous, must all be passed 
 before they are tightened, and should not be more than a line apart. 
 (Fig. 522.) It will be seen that when the strings are drawn together, 
 the serous surface of the intestine will be approximated. The end of the 
 ligature should be cut short and the gut returned into the abdominal 
 cavity. 
 
 The continuous or glover's suture may also be used with advantage, as 
 seen in Fig. 523. 
 
 When the intestine is completely divided, the lower end is turned in, while 
 the upper is simply pushed within the former and united by fine sutures, 
 so that only the serous surfaces are in contact. The mesentery is previously 
 torn from the intestine for a short distance on both sides (Jobert) (Figs. 
 524 and 525.) 
 
 Artificial Anus not unfrequently follows gunshot wounds of the intestines ; 
 or it may be the sequence of a penetrating wound, an abscess, or ulcera- 
 tion. " In all examples of this description I have seen," writes Dr. Gib- 
 son* " spontaneous cures have taken place, after the contents of the bowels 
 have been discharged, for several weeks, through the fistulous opening." 
 
 There are two varieties of artificial anus : one in which the adhesion 
 takes place between the outer wall of the gut to the internal parietes of the 
 abdomen, the side of the intestine having previously sloughed ; in this 
 variety the canal remains open. In the second the adhesions take place 
 in the same manner, but a knuckle of intestine having sloughed, there 
 remains a membranous partition between the two portions of the canal 
 formed by the inner wall having been folded upon itself. 
 
 Treatment. — The first variety generally gets well, as already mentioned, 
 spontaneously. For the second, the following is the operation of Physick. 
 It consists in passing a ligature through the septum and tying it upon the 
 tissues ; this is allowed to remain eight or ten days, during which time ad- 
 hesions are formed between the peritoneal surfaces, when as much of the 
 septum may be cut away as necessary. 
 
 Dupuytren's enterotome consists of a forceps with oval fenestrated blades, 
 which are made with a screw in order to compress the septum. 
 
 The principal medicines in this affection are calcarea, causticum, phosph., 
 silic, and sulph. 
 
 Abscess of the Abdominal Parietes. — When, as a consequence of wound or 
 contusion, abscess of the abdominal parietes takes place, the location of the 
 secreted matter is generally between the layers of tissue constituting the 
 walls of the abdomen. In the first stages a hard and painful tumor is 
 observed, which increases in size, becomes softer, and, in some instances, 
 fluctuation may be felt. 
 
 The seat of these abscesses is generally in the posterior abdominal walls, 
 the lumbar and iliac regions, the anterior parietes being not often affected, 
 unless the disease is connected with abscesses of the internal organs, as 
 the appendix vermiformis, liver, spleen, etc. 
 
 I have seen a case of anterior abdominal parietal abscess, in consultation 
 with Dr. T. F. Allen, of New York. The purulent collection was immense ; 
 the pus had formed between the oblique muscles, and required a deep in- 
 cision for its exit. The patient made a good recovery. 
 
 In this variety there is tendency of the pus to burrow, and if the tumor 
 
 * Institutes and Practice of Surgery, vol. i. 3 p. 185. 
 
INFLAMMATION OF THE LIVER. 837 
 
 does not rupture internally, the matter may find its way between the apo- 
 neuroses and along sheaths and tendons, and discharge at a distance from 
 the original site of the inflammation. 
 
 If suppuration be the result of a wound, a free incision should be made 
 as soon as possible ; some surgeons recommend that an opening be made 
 with a knife in the most prominent part of the tumor, before the inflam- 
 matory process terminates in suppuration, and thus avoid the danger that 
 the contents of the abscess will be emptied into the cavity of the abdomen, 
 and, as a further result, be followed by ulceration of the intestines. This, 
 however, is not a warrantable proceeding. The case must be watched, and 
 when symptoms of suppuration show themselves, an exploring needle or 
 the aspirator be used. After this, a free incision should be made and the 
 pus evacuated. 
 
 Hepatitis — Empresma Hepatis — Inflammatio Hepatis — Inflammatio Jeci- 
 noris. — The symptoms of hepatitis are a dull heavy pain occurring in the 
 right side, increased by pressure, cough, or deep respiration, sometimes 
 relieved by bending the body forwards ; the pain may be either stinging, 
 cutting, burning, tensive, dull, or aching; sometimes an acute pain is ex- 
 perienced in the right shoulder, clavicle, or arm, as though numb ; the same 
 want of feeling may be experienced in the entire right half of the body, with 
 pain along the vertebral column. If the size and consistence of the liver be 
 increased, it projects beyond the false ribs, and extends more or less into the 
 abdomen ; the pulse is hard and frequent ; the patient lies on the right side, 
 being often unable to rest either on the left, or on his back ; respiration 
 and digestion are interfered with ; sometimes a slight, dry or hollow, and 
 deep cough is present ; the conjunctiva and the skin acquire a yellow tinge ; 
 there is also constipation, the faeces being grayish and discolored. The 
 hepatic region may be covered with red spots, and throbbing in the hypo- 
 gastric region may attend the disease. If the convex surface be affected, 
 hepatitis simulates pneumonia or pleurisy ; if the concave, gastric symp- 
 toms predominate. The affection may assume a chronic form. The ter- 
 minations of inflamed liver are various : it may end in resolution, suppura- 
 tion, or gangrene. When resolution takes place, the symptoms disappear 
 gradually ; when it suppurates, hectic fever appears, also tumefaction and 
 increased weight in the hepatic region ; and if adhesion take place between 
 the peritoneal covering of the liver and the peritoneum proper, the matter 
 finds its way externally. In India, where this organ is frequently affected, 
 the tendency to abscess is great, the pus forming in the parenchyma of the 
 organ. The liver enlarges from hyper semia ; it becomes hypertrophied, when 
 its tissues exceed a healthy size, and may be atrophied from defective nutri- 
 tion. It also becomes softened, or indurated, or assumes a yellow color (cir- 
 rhosis of the liver), as well as granulated and tuberculated ; these granula- 
 tions are found to vary in size from that of a large shot to a cherry, and are 
 found at the surface and within the organ; the liver is smaller than natural 
 and shrivelled, and its tissue more dense. These granulations are red, 
 brown, or yellow ; some are of a canary color. 
 
 Melanosis of the liver is that condition wherein the tissue is converted into 
 a black, hard, homogeneous mass, near which ulcers or cavities form, owing 
 to the softening of the substance itself, or of some other morbid tissue, of 
 tubercles especially. 
 
 Inflammation of the liver is distinguished from pneumonia by the pleu- 
 ritic pains being less- severe, and chiefly confined to the course of the 
 phrenic nerve (ascending to the top of the shoulder) ; by the pain in hepa- 
 titis being increased by pressure, while in pneumonia this is not the case ; 
 by the difficulty in pneumonia of lying on the affected side, the reverse 
 being true in hepatitis ; by the sallow countenance ; by the physical signs 
 
838 A SYSTEM OF SURGERY. 
 
 revealed by auscultation and percussion. From enteritis it is distinguished 
 by the seat of the disease, which is discovered by tenderness upon pressure, 
 by the sympathetic pain in the clavicle and shoulder, by the prostration 
 being less, by the greater fulness of the pulse, by the color of the stools and 
 urine. 
 
 The causes of hepatitis are those which induce inflammation : emetics, 
 drastic cathartics, acrid bile, biliary concretions, external injuries, violent 
 passions, intense heat, the inordinate use of spirituous drinks, metastasis of 
 piles, of inflamed joints, diarrhoea, dysentery. 
 
 Treatment. — This should begin with aconite, especially if the fever be 
 high, the pains in the liver shooting, and the pulse full, accelerated, and 
 irregular, more so than when it is hard and frequent. If icteric symptoms 
 be present, and the disease be produced by chagrin, chamomilla affords 
 relief. 
 
 Bryonia. — When the pain is oppressive, increased by touch, coughing, 
 moving, breathing, especially upon inspiring, together with a congestive 
 condition, the fever increasing at night. 
 
 Belladonna. — For restless nights; vertigo; congestion to the head, with 
 dimness of vision ; burning thirst ; restlessness, sleeplessness. It is suited 
 to those cases where the inflammation exists chiefly in the lower surface of 
 the liver, when the pain is increased by cough, pressure, inspiration ; the 
 pains resembling those of pleuritis. 
 
 After belladonna, mercurius is frequently required ; also in enlargement 
 and hardening of the liver, and when suppuration has taken place. 
 
 Nux vomica for induration and enlargement, and when there are gastric 
 symptoms in the chronic form. 
 
 Diseases of the Gall-bladder. — The gall-bladder is a membranous pear- 
 shaped reservoir, situate in a superficial depression at the inferior surface 
 of the right lobe of the liver. It receives, by the hepatic and cystic ducts, 
 a portion of the bile secreted when the stomach is empty ; which becomes 
 in it more thick, acrid, and bitter. It receives the cystic artery ; its veins 
 empty into the vena porta ; the hepatic plexus supplies its nerves ; and its 
 lymphatic vessels unite with those of the liver. Idiopathic inflammation 
 of this receptacle is not of frequent occurrence, but it is a concomitant of 
 affections of the liver, and also of biliary calculi. The symptoms are de- 
 scribed as sudden, acute, agonizing pain at the margin of the false ribs, 
 increased by pressure, by inspiration, and lying on the back ; the patient 
 can scarcely straighten himself, and lies on the left side with the lower 
 limbs drawn up; the paroxysm of pain continues a few hours, and as it 
 subsides, jaundice appears; dyspeptic symptoms and vomiting are present; 
 fever, temperature 103° ; great thirst; no shivering, nor heat of skin. The 
 intensity of the disease may render it fatal, or the gall-bladder may be per- 
 forated and the bile poured into the peritoneal cavity, producing peritonitis. 
 The remedies for this disease are those adapted to biliary calculi. 
 
 Calculi Fellei sen Biliarii— Gall-stones. — These stones are not of infre- 
 quent formation ; when in the gall-bladder they are not necessarily pro- 
 ductive of uneasiness, but in their passage through the ducts they give rise 
 to what is denominated " hepatic colic." When in the gall-bladder their 
 presence is known by pressive pain in the right epigastric region, ex- 
 tending towards the side and back, with some disorder of the stomach ; 
 sometimes by cramps with vomiting ; the skin becomes at the same time 
 yellowish. Collections so large as to be detected by external examination, 
 and even producing enlargement under the cartilages of the ribs, have in 
 some instances occasioned little inconvenience. But when moving through 
 the ducts, the paroxysms of pain are intense in the region of the stomach 
 
CHOLECYSTOTOMY. 839 
 
 and liver. There is vomiting; the abdominal muscles become violently con- 
 tracted, the extremities cold and the body covered with sweat. A diagnostic 
 sign is the pulse not being altered. After these symptoms have lasted awhile, 
 there may be an interval of rest, to be followed by a recurrence of the pain. 
 If the fseces be examined, biliary calculi will be observed. These stones 
 consist of a peculiar fatty substance, coloring matter, cholesterin combined 
 with soda, picromel, mucus, soda, phosphate of soda, phosphate of lime, 
 and chloride of sodium. Some are almost pure cholesterin, which is an 
 inodorous, insipid substance, in white shining scales, fusible and crystalliz- 
 ing on cooling in radiated fibres. Others are composed of resinous matter, 
 the real nature of which is not ascertained. The greatest number, however, 
 consist of thickened bile and cholesterin. Young children are not often 
 affected ; persons aged between 40 and 50 are most obnoxious to the dis- 
 ease ; women suffer more frequently than men. 
 
 Causes : quantities of fat animal food, sedentary life, scanty use of water 
 as a drink, choleric temperament. 
 
 Treatment. — I wish to call attention to two remedies which I have used 
 in this disease ; the one highly recommended by Dr. Thayer, of Boston, 
 the other by Dr. Kimball, of New Jersey. They are china and berberis. 
 I have given them with surprising results, and have cured many cases, 
 some of which were alarming and chronic. The china I give in the first 
 decimal trituration ; the barberry in infusion. For the agonizing pain oc- 
 casioned by the passage of gall-stones, it is necessary to give hypodermic 
 injections of morphia sufficiently often to relieve the pain. To prevent a 
 recurrence of the sufferings, the medicines above named should be given, 
 or colocynth, nux vomica, mercury, podophyllin, or ipecac. 
 
 Cholecystotomy. — In certain cases of obstruction of the gall-ducts the 
 operation of cholecystotomy must be performed, or in cases of malignant 
 disease, the operation of Langenbuch, known as " cholecystectomy," may 
 be done. 
 
 Musser and Keene* in an exhaustive treatise on cholecystotomy, state 
 that there are four conditions, all of them well pronounced, which may call 
 for operative procedure ; they are obstructive jaundice, as differentiated from 
 jaundice by suppression ; an enlarged gall-bladder, protruding as a tumor 
 in the right hypochondriac region ; symptoms of suppuration and fre- 
 quent attacks of paroxysmal and severe pain. It is said that the itching 
 which is present in many cases of jaundice indicates the obstructive variety. 
 Of this, however, I am not sure, as I have in mind two cases of such se- 
 vere itching accompanying jaundice that the patients were rendered nearly 
 frantic by the pruritus. One was emaciated to a skeleton, and could only 
 lie on the bed naked and covered with a sheet, not being able to bear the 
 contact of ordinary clothing, which he would actually tear from his person, 
 in the irresistible desire to scratch. Both of these patients would recover 
 by changing climate, neither had any of the pain of obstruction, but both 
 would relapse after six months or a year's exemption. 
 
 Besides gall-stones, the biliary ducts can be closed by parasites, by ex- 
 ternal tumors, by adhesive inflammation, or the cicatrization of ulcers; all 
 of which will necessarily give rise to the symptoms alluded to. 
 
 An enlarged gall-bladder presents itself in the right hypochondriac region, 
 and is generally globular. Sometimes the swelling partially disappears 
 (as in a case of my own) to recur again with severe paroxysmal pain. An 
 indication stated by Musser and Iteene as being one of the proofs that a 
 tumor presenting in that locality is the enlarged gall-bladder, is, that intes- 
 
 * American Journal of the Medical Sciences, October, 1884. 
 
840 A SYSTEM OF SURGERY. 
 
 tine is never found in front of the growth. To make the diagnosis certain, 
 the small aspirating needle must be employed. The dreadful pain that 
 accompanies the passage of biliary calculi is well known to all surgeons, 
 and when such is frequent, and the patient shows symptoms of great ex- 
 haustion, then the operation is indicated. It must be remembered that 
 severe biliary colic may be present without jaundice, and yet the stones be 
 found in the gall-bladder and in the cystic duct. Symptoms of internal 
 suppuration would in these days call at least for explorative laparotomy. 
 
 In an interesting and original paper on this subject, Dr. A. C. Bernays* 
 submits the following conclusions, which are worthy of much thought. 
 He says : 
 
 " I. The causes which indicate an operative interference with the system 
 of gall-vessels are : a, jaundices ; b, paroxysmal pain or a tumor in the right 
 hypochondriac region ; c, suppuration ; rf, peritonitis ; these conditions to 
 be either collectively or singly recognizable, the presumable origin being 
 biliary calculi ; e, malignant disease. 
 
 " II. Explorative laparotomy must be preferred to acupuncture or aspi- 
 ration as a diagnostic measure. 
 
 " III. The incision in the linea alba is preferable when there is much 
 doubt regarding the seat of the obstruction, because the large ducts can be 
 reached much better from this incision than from the incision parallel to 
 the free border of the ribs. 
 
 " IV. The escape of bile through an abdominal fistula is not injurious to 
 the process of normal digestion. The bile is an excretion, and probably of 
 no more use in the intestinal canal than the urine in the bladder. 
 
 " V. Jaundice, when caused by an obstruction of the common duct, is no 
 contraindication to natural cholecystotomy. We may often save life by its 
 early performance. 
 
 " VI. Cholecystotomy, natural and ideal, and cholecystectomy are the 
 three operations at our service ; cholecystenterostomy may be useful, but it 
 has not yet earned a place among approved surgical procedures. 
 
 " VII. Ideal cholecystotomy is indicated when the bladder is normal in 
 structure and when the gall-ducts have been cleared of obstructing calculi. 
 
 " VIII. Natural cholecystotomy is indicated when the bladder is ulcer- 
 ated or suppurating, or when there are permanent obstructions beyond 
 reach at the time of operation. 
 
 " IX. Cholecystectomy should be limited to cases of otherwise incurable 
 or malignant disease of the gall-bladder." 
 
 There are several methods of performing cholecystotomy ; one being the 
 incision into the gall-bladder, the removal of the stone, and the establish- 
 ment of a biliary fistula ; another, that of removal of the stone and after- 
 wards stitching together the wound of the gall-bladder, returning the same 
 into the abdominal cavity, and closing the wound as after ordinary lapa- 
 rotomy, and another known as cholecystenterostomy, which consists in the 
 formation of an opening between the gall-bladder and duodenum. I have 
 read of several interesting experiments made upon dogs by Dr. J. McF. 
 Gasten,f of Atlanta, to restore the course of the bile, and to prevent the loss 
 of the secretion through abdominal fistula. As above noted, Bernays pre- 
 fers the incision in the linea alba, Dr. Lange J made his cut six inches in 
 length "through the external border of the rectus abdominis," Tait§ makes 
 
 * Ideal Cholecystotomy, I. H. Chambers & Co., St. Louis, Mo., 1885. 
 
 f Gaillard's Journal, October, 1884. 
 
 j Annals of Surgery, May, 1886, p. 381. 
 
 § Surgical Treatment of Gall-Stones, Lancet, 1885, vol. ii., p. 239. 
 
HEPATIC ABSCESS. 841 
 
 a vertical incision from the margin of the ribs downwards over the hepatic 
 notch. Musser and Keene prefer a cut three inches long over the centre 
 of the tumor and "parallel to the free border of the ribs." Whichever be 
 the line of incision selected, the knife should be carried carefully through 
 the tissues, each bleeding point secured with haemostatic forceps, until the 
 peritoneum is reached. The vessels — every one of them — should be secured 
 with fine catgut and the forceps removed. The peritoneum should be 
 opened and incised with scissors on a director. Two fingers or the hand 
 may then be introduced into the abdominal cavity, and the nature of the 
 tumor ascertained, and the points if possible where the obstructions (gall- 
 stones or other impediments) are located. If the latter be found and are 
 movable, the surgeon should gently attempt to push them into the duo- 
 denum. If this be impossible, they should be pressed into the gall-bladder. 
 The tumor should then be aspirated, care being taken not to allow the bile 
 to enter the cavity of the abdomen. The wall of the gall-bladder should 
 now be carefully drawn forward through the cut and held by a pair of 
 forceps, while an incision is made into it ; the finger or a scoop should be 
 used to extract the foreign body or bodies. This is often difficult, and in 
 some cases, in the hands of distinguished operators, a stone has been allowed 
 to remain, being so impacted that the force required for its removal would 
 have been dangerous to the patient. The margins of the cut bladder must 
 be stitched to the abdominal walls and a drainage-tube inserted. 
 
 Bernays, however, has accomplished a better result by stitching the cut 
 walls of the gall-bladder together with the Czerny-Lembert suture, and 
 closing the abdominal wound. Cholecystotomy was first proposed by 
 Thudichum, and though other surgeons had given attention to it, Dr. Bobbs 
 first opened the gall-bladder in June, 1867, and Dr. Sims arranged and 
 practiced it in 1878. The results of the operation as given in Musser and 
 Keene's tables, show but ten deaths in thirty-five cases. 
 
 Hepatic Abscess. — The occurrence of hepatic abscess is less under homoeo- 
 pathic than allopathic treatment, because by the administration of homoeo- 
 pathic medicines, the inflammation existing in the liver is generally subdued 
 before suppuration ensues. 
 
 There are cases that, notwithstanding the best-directed efforts to procure 
 resolution, terminate in suppuration, and among these may be classed those 
 that are occasioned by wounds or other injuries; or when the disease is 
 present in individuals who are weakened by constitutional affections, biliary 
 concretions, or the presence of worms in the biliary duct. 
 
 Kirkland* relates a remarkable instance of the latter; and also Dr. 
 Thomas Bond,f and Dr. Gibson,J of Philadelphia. The latter gentleman 
 writes : " A very beautiful preparation, made by the late Dr. Wesenhall, of 
 Maryland, of a liver, the substance and ducts of which are filled and per- 
 forated in every direction, by numerous and very large lumbrici, which de- 
 stroyed the child by irritation and suppuration, is contained in my surgical 
 cabinet deposited in the University.' 1 
 
 In abscess of the liver, or rather before suppuration has been estab- 
 lished, the patient experiences a stinging, burning pain in the right hypo- 
 chondrium, below and around the false ribs, frequently extending to the 
 epigastric region or sternum, and in some instances, even to the thorax. 
 This pain may be severe, or it may be a continual, dull aching, aggravated 
 by lying on the affected side, or by external pressure ; there is also more 
 or less pain experienced in the right shoulder. 
 
 * Inquiry into the Present State of Medical Science, vol. iii., p. 186. 
 
 t Medical Observations and Inquiries, vol. i., p. 68. 
 
 % Gibson's Institutes and Practice of Surgery, vol. i., p. 209. 
 
842 A SYSTEM OF SURGERY. 
 
 There are also present gastric symptoms, such as hiccough, loathing, 
 eructations, attended with anguish, or there may be nausea, vomiting, 
 bitter taste, and yellow tongue. Rigors generally precede the immediate 
 formation of pus, and swelling may appear in the right side, and, as the 
 disease progresses, fluctuation be perceived. The pus burrows in various 
 directions, in accordance with the situation of the abscess ; it may proceed 
 to the region of the hip, along the dorsal vertebrae, or be discharged into 
 the transverse colon, stomach, duodenum, or into the lung ; the latter is an 
 unfavorable situation, as the patient frequently dies of hectic .* 
 
 After the abscess has opened, the pus discharged changes its character ; 
 at first it is thick and creamy, but after a time it becomes greenish, fetid, 
 or of a dark-brown color. Large cavities are formed in the liver, and in 
 some instances the whole structure of the organ may be destroyed, and 
 there are cases on record where this has been the case, as revealed by post- 
 mortem examinations. 
 
 It is well known that there are many points of exit through which hepatic 
 pus may pass, and patients have been known to recover after the rupture of 
 large hepatic abscesses ; on the other hand an operation is attended with 
 some risk, and not many have survived its performance — I mean recovered 
 their wonted health. Again, we know that many at once succumb to the 
 inflammatory action engendered by the purulent matter from the liver 
 escaping into other parts of the body. 
 
 It is interesting to observe how many points have been the site of rup- 
 ture of large hepatic abscesses. Cragief says that, besides the abscess 
 discharging into the abdominal cavity, the pus may pass through the air- 
 cells into the bronchi, by the adhesive process into some part of the intestinal 
 canal, the stomach, transverse arch of the colon, or even the duodenum ; 
 and Rokitansky,J with his usual sj^stem and accuracy, mentions several 
 other outlets, as into the gall-bladder, or one of the larger branches of the 
 hepatic duct, through the diaphragm into the pericardium, and even into 
 large vessels, as the vena cava. He mentions a case in which communica- 
 tion was established between a hepatic abscess and the vena portae and the 
 duodenum. 
 
 Another hazard is much to be dreaded. On this point Budd § writes : 
 " A source of far greater danger is the circumstance which has been before 
 noticed, that the inflammation which leads to abscess is often confined to 
 the substance of the liver, and does not involve its capsule. As the abscess 
 approaches the surface, adhesive inflammation of the peritoneum imme- 
 diately above it usually takes place, and a small quantity of lymph is poured 
 out, which causes adhesions between the wall of the abscess and the parts 
 with which it is brought into contact. These adhesions are often of very 
 small extent ; sometimes they do not form at all, and as I have before re- 
 marked, the abscess bursts into the cavity of the peritoneum, causing speedy 
 collapse and death. By opening an abscess of the liver before adhesions 
 have formed, we may be directly instrumental in bringing on this fatal 
 issue ; the pus may escape into the cavity of the peritoneum, and the patient 
 die in a few hours, obviously in consequence of the operation." Another 
 danger is encountered in allowing air to enter the cavity of the abscess ; 
 then decomposition of both air and pus results, and fresh inflammatory 
 action is developed. 
 
 In a case of my own I was for a time puzzled, because the pus was 
 
 * Sometimes the abscess has discharged itself into the pericardium. See London Lancet, 
 August, 1845, p. 154. 
 
 f Pathological Anatomy, 859, 860. J Ibid., vol. ii., p. 108. 
 
 § Diseases of the Liver, p. 323. 
 
HEPATIC ABSCESS. 843 
 
 dark brown or reddish. Upon consulting authorities upon the subject, 
 I found that the suppurative process in the liver generally ended in the 
 formation of the ordinary purulent matter. Budd* says : " The matter 
 in a hepatic abscess is usually white or yellowish, and is free from odor, 
 unless it is in close proximity to the lungs, where it sometimes becomes 
 decomposed and fetid from the admission of air." He then goes on to state 
 that many of the older writers described the pus of abscesses of the liver 
 as being generally red or claret-colored ; but according to his experience, 
 such observations are incorrect. It is well to bear this statement in mind 
 in order to explain wherein Mr. Budd is right, and wherein also the " old 
 writers " are correct. This will appear from the following facts. Roki- 
 tanskyf states : " In reference to its contents, the hepatic abscess presents 
 considerable differences at different periods, depending in part upon the 
 communication established in the biliary vessels ; and a large abscess of 
 long standing invariably contains pus, mixed with a considerable amount 
 of bile, which arises from a communication which is established between the 
 larger gall ducts." Jones and SievekingJ have also the following, which is 
 worthy of remark: "When an enlarging abscess reaches a hepatic duct 
 branch, it does not set up inflammation in its walls and cause its obstruc- 
 tion, but it ulcerates through its tunic, and establishes a communication 
 between the efferent channel and its own cavity. Hence it occurs that 
 the pus contained in large abscesses is always mingled with a consider- 
 able amount of bile, while that of the smaller or recent abscesses is almost 
 pure." 
 
 From these facts we would draw the deduction that in the majority of 
 cases examined by Mr. Budd, the abscesses were recent and of limited ex- 
 tent, while the observations of the older authors were probably based upon 
 the appearances derived from large collections of hepatic pus. 
 
 In the present case the admixture of the bile no doubt was the cause of 
 the peculiar color of the liquid, and the explanation is readily found, as 
 mentioned in the above quotations, in the destruction of the walls of the 
 vaginal hepatic ducts. 
 
 Treatment. — We may here pause, to speak of the various methods that 
 have been devised for the opening of these abscesses, premising that the 
 aspirator is the instrument par excellence, but I have met with cases in 
 which, though I introduced the largest needle, the fluid was so thick 
 that the suction of the air-pump failed to relieve. In such, other meth- 
 ods must be employed. We must recollect the dangers that are to be 
 encountered ; these are two, the first being the risk that adhesion has 
 not taken place between the peritoneum and the wall of the abscess ; and 
 that by the puncture an opening may be made that would allow a quan- 
 tity of pus to escape into the cavity of the peritoneum, thereby causing 
 inflammatory action and speedy death ; and secondly, the danger of 
 the admission of air into the cavity, thereby setting up decomposition 
 of the pus already formed, and exciting the pyogenic membrane lining 
 the abscess to fresh production of purulent matter. To obviate the 
 first difficulty, viz., the discharge of pus into the peritoneal cavity, the 
 following process has been devised by Dr. Graves, and is recommended 
 by other surgeons, viz. : to make free incisions through the muscular 
 parietes of the abdomen, and to press to the bottom of the wounds thus 
 made, pledgets of lint, thereby exciting adhesive inflammation between 
 
 * Suppurative Inflammation of the Liver, p. 107. 
 f Pathological Anatomy, vol. ii., p. 107. 
 % Ibid., pp. 510, 511. 
 
844 A SYSTEM OF SURGERY. 
 
 the reflected layer of the peritoneum and that covering the abscess, thus 
 making sure that no pus can enter the abdominal cavity after the punc- 
 ture. The admission of air can also be prevented, first, by making a valvu- 
 lar opening, or by having screwed to the canula, a bladder with a stop-cock 
 attached (as recommended in the puncture of the thoracic walls) ; by turn- 
 ing the valve the air is prevented from passing through the canula, and 
 the bladder may be emptied at pleasure ; taking, however, the precaution 
 of drawing the integument well over the spot at which the puncture is to 
 be made, and holding it firmly in that position while the trocar is entered 
 obliquely, it will readily be perceived that so soon as the canula is with- 
 drawn, the skin by its natural elasticity will retract to its usual position, 
 and thus effectually close the opening. 
 
 The medicines which have been detailed in the chapter upon Abscess 
 must be given, especially in the earlier stages, with the hope of producing 
 resolution. The most serviceable in effecting such a result are, aeon., bell., 
 bry., cham., mere, nux vom., sulph. The indications for their use will be 
 found in any work upon the practice of medicine. 
 
 The medicines that are adapted to hepatic abscess are, ars., bell., hepar, 
 mere, silic, sulph. If the matter has made its way towards the surface, 
 the prognosis is more favorable than when it is discharged into any of the 
 surrounding tissues or organs. If the pus has commenced to form, hepar 
 should be administered, or if the process of formation be slow, mere, and 
 silic. may hasten the suppuration, and allay pain ; the latter is the better, 
 particularly where there is hardness of the surrounding parts, with disten- 
 sion, or if there is a continual stitching pain below the floating ribs ; mer- 
 curius is to be preferred, when there is burning in the region of the liver, 
 with distension from within outwards, accompanied with perspiration, that 
 is excited by the slightest motion. 
 
 If the swelling appear to protrude through the intercostal spaces, the pus 
 should be immediately evacuated, by means of the lancet or aspirator, or 
 trocar ; if this be not done, the matter may be discharged in another direction, 
 and give rise to unfavorable symptoms. 
 
 If, after the opening is made, the discharge continue, and become thin, 
 sanious, and unhealthy, ars., carbo veg., or nit. acid must be administered ; 
 the directions for their use have been already mentioned in a preceding 
 portion of this work. If the opening have a tendency to become fistulous, 
 calc, silic, sulph., or phosph. should be exhibited. 
 
 In all cases, the patient should be kept at perfect rest, and if extremely 
 weak, a moderate stimulus should be allowed. 
 
 In some instances, when there is a large quantity of pus, it should be 
 evacuated by openings, at longer or shorter intervals ; to determine this, 
 however, the general constitutional symptoms of the patient must be taken 
 into consideration. If he be robust and previously healthy, and the in- 
 flammation has gone through its stages rapidly though completely, there 
 need be no fear in allowing free vent to the purulent secretion. If the 
 patient has been long suffering from previous disease, the constitution 
 weak, temperament nervous, and the signs of a chronic hepatitis have 
 been present, care should be taken that the removal of a large quantity 
 of matter does not produce alarming symptoms of debility and exhaus- 
 tion ; it is then better to practice the method recommended by Abernethy, 
 already alluded to in the chapter upon Abscess, or apply the aspirator. 
 
 Ascites. — By ascites is understood a dropsical effusion in the cavity of the 
 peritoneum ; it may be complicated with hydrothorax or general anasarca. 
 Dyspnoea, cough, dryness of the skin, diminished secretion of urine, loss 
 of appetite, constipation and prostration of strength, are symptoms which 
 
PARACENTESIS ABDOMINIS. 845 
 
 are generally present in the commencement of the affection ; these are 
 succeeded by fulness of the abdomen, and by a sense of fluctuation 
 easily recognized by percussion, which should be performed by pressing 
 one hand on the side of the abdomen and striking it with the other on the 
 opposite side. 
 
 The causes are disease of the viscera : the kidneys and heart, the liver, and 
 pancreas. In some instances, an immense amount of fluid collects in the 
 cavity of the peritoneum. 
 
 The prognosis depends upon the nature of the case, and the age and 
 temperament of the patient. When combined with organic disease of 
 the abdominal viscera, or when occurring in individuals of a sickly con- 
 stitution, or in persons of advanced age, apprehensions may be entertained 
 of an unfavorable termination. 
 
 Treatment. — The principal medicines in the treatment of ascites are, ars., 
 apocy., cann., bry., china, hell., ledum, lye, mere, sol., sulph., apis mel., 
 digital., iris v., senec, grac. 
 
 In some instances, in the first stages of the disease, aconite is useful to 
 allay vascular excitement ; after which hellebore should be prescribed, if 
 there is a tendency to torpor, prostration, extremely scanty secretion of urine, 
 with shooting pains in the extremities. 
 
 Other medicines are euphorb., solanum, kali carb., conium, sulph., iod., 
 zincum, ol. tereb. 
 
 Dr. Stephen Mackenzie* recommends abdominal compression in the 
 treatment of ascites. It is said that compression hastens the resorption 
 of the fluid, when this has been begun by other methods, and that it seems 
 to possess the power of exciting absorption without the intervention of other 
 treatment. Dr. Mackenzie relates a case in which, after some treatment, a 
 flannel bandage was tightly applied to the abdomen, the pressure, at first, 
 causing a feeling of nausea ; but soon after it appeared to afford relief. It 
 was in a few hours replaced by an elastic abdominal supporter, tightened 
 considerably, and the ascites gradually disappeared and in three years had 
 not returned. 
 
 The doctor is convinced that in spite of the abnormal condition of the 
 liver, the recovery may be regarded as perfect, since the portions of the or- 
 gan that remained healthy were sufficient to perform its necessary work. 
 
 Paracentesis Abdominis. — This operation is frequently called for in the 
 advanced stages of the disease, to palliate the sufferings of the patient. It 
 is performed as follows : 
 
 The patient is seated on the side of the bed, or on a chair, the bladder hav- 
 ing been previously evacuated, and a broad bandage placed around the 
 abdomen in the following manner : Its middle should be on the anterior 
 wall of the abdomen, and its ends should be of sufficient length to be 
 brought around the body and firmly held by an assistant. In the centre 
 of this band, in the lower part of the abdomen, and directly opposite the 
 linea alba, an opening should be made, sufficiently large to admit of the 
 introduction of the trocar, which with its canula should be thrust through 
 the abdominal parietes at the point aforesaid, in an oblique direction ; after 
 it has pierced through the integuments the trocar should be withdrawn, 
 allowing the canula to remain, through which the fluid generally passes in 
 a continuous stream. If the intestine or omentum obstruct the passage 
 of the fluid, it should be gently removed by the introduction of a probe 
 through the canula ; and if, after a considerable portion of the water has 
 
 * Medical Record, August 31st, 1878, No. 408. 
 
846 A SYSTEM OF SURGERY. 
 
 been withdrawn, the stream lessens, the bandage may be tightened by trac- 
 tion made upon its extremities, which compressing the abdominal parietes 
 forces out the remaining fluid. 
 
 Care is necessary, in the performance of this operation, that the evacua- 
 tion of the abnormal secretion be not too speedily effected, lest the pa- 
 tient, already somewhat debilitated by the loss of so large an amount 
 of fluid, incur great risk from extreme prostration ; indeed, in most in- 
 stances, when the water has been withdrawn slowly, towards the end of 
 the operation a feeling of faintness is experienced, to relieve which, a small 
 quantity of brandy and water is required, after which china or arsenicum 
 may be administered. 
 
 Obstruction of the Bowels. — There are many causes which give rise to 
 obstruction of the bowels, exclusive of hernia, which will receive special 
 attention in another place. Of these, besides congenital malformations, we 
 have foreign substances lodged in the bowels, twists, false membranes, 
 invagination, as the mechanical causes ; and, as the result of diseased ac- 
 tion, constipation, chronic peritonitis, strictures, and tumors. Substances 
 of an indigestible nature taken into the stomach become a nucleus 
 around which other matter forms, and thus the bowel is occluded. The 
 pits or stones of fruit or large quantities of undigested food occasion such 
 obstruction. In one of my cases there was complete impaction and fecal 
 vomiting, occasioned by a quantity of green apples being taken into the 
 stomach. 
 
 Volvulus. — When twists cause the symptoms, the rotation is usually found 
 either in the sigmoid flexure, the caecum or small intestine, and the pain 
 is aggravated from the first; it is agonizing, is circumscribed and accom- 
 panied with constipation ; the abdomen soon distends, and the convolu- 
 tions of the intestines may be distinctly seen. The pain is very severe, 
 and is paroxysmal ; there is vomiting, first of ingesta, then of bile, and 
 afterwards of faeces. Finally, gangrene of the intestine or perforation 
 takes place. In twists of the bowels, a predisposition to such a condition 
 exists which may be either congenital or acquired, and which consists in a 
 large, flabby, or loose mesentery. 
 
 Again, strangulation may be occasioned by false membrane binding down 
 two portions of the intestine, as in one of my cases, or a loop of omentum 
 may twist around the small intestine, giving rise to alarming symptoms. 
 
 Intussusception of the bowels, or invagination, as it is sometimes called, 
 consists in an inversion of the intestinal tube into the gut immediately be- 
 low, in the same manner as we invert the top of a stocking when we desire 
 to draw it over the foot. In rare instances the lower part of a gut is pushed 
 into the upper part of the tube. The symptoms are much the same; great 
 desire to go to stool, with passage of blood and mucus. The pain is gen- 
 erally located in the region of the ileo-caecal valve, and there is vomiting of 
 ingesta, bile, and faeces. 
 
 After the invagination has continued, a change rapidly takes place 
 in the implicated intestine ; congestion and inflammation supervene, and 
 often the entire peritoneum is involved, giving rise to diffuse peritonitis. 
 Finally, the constricted portion may become gangrenous and the slough be 
 passed per anum and the patient recover. Holmes records a case in which 
 eight inches of the ileum, the caecum with its appendix, with four inches 
 of colon, were passed by the rectum and the patient recovered, the bowels 
 acting regularly. 
 
 Constipation is another cause of obstruction of the bowels. The follow- 
 ing table, taken from Mr. Hinton, will show the causes of intestinal ob- 
 struction in 135 cases in the order of their frequency : 
 
OPERATION FOR INTESTINAL OBSTRUCTION. 
 
 847 
 
 Diseased uterus, 
 Stricture of ileum, . 
 
 . 1 
 . 1 
 
 Brought up, 
 
 . 19 
 
 Cancer of small intestine, 
 
 . 2 
 
 Calculi, foreign bodies, . 
 
 . 7 
 
 
 
 Doubtful, 
 
 . 8 
 
 INTERNAL HERNIA : 
 
 
 Peritoneal adhesions, 
 
 . 9 
 
 Inguinal, high up, . 
 
 Diaphragmatic, 
 
 Mesocolic, 
 
 ' I] 
 . 2^ 8 
 
 Stricture sigmoid flexure, 
 " colon, 
 " rectum, 
 
 . 10 
 . 11 
 . 11 
 
 Obturator, 
 
 Fecal accumulation, . 
 
 • 3J 
 . 3 
 
 Intussusception, 
 
 By bands, adherent dive 
 
 . 24 
 •ticula, 
 
 Twist of sigmoid flexure, . 
 
 . 4 
 
 etc., .... 
 
 . 36 
 
 19 
 
 135 
 
 Treatment. — In the treatment of any of these varieties of obstruction, it 
 may be laid down as a rule that drastic purgatives do harm, even when the 
 case is that of constipation. Knowing the value of certain medicines in 
 relieving strangulation and restoring the peristaltic action of the intes- 
 tines, we can in many instances relieve intussusception. All the mechanical 
 means of relief must come from the anus upward, excepting in those 
 rare cases in which the invagination takes place from below upward, 
 and the injection must be made through the long tube, passed as nearly 
 •as possible to the seat of stricture, and the enema pumped into the 
 abdominal cavity in large quantities (by the gallon, if necessary). The 
 injection should contain soap and ox gall. 
 
 If we have reason to suspect that there is obstruction from twist, volvulus, 
 or invagination, opium, plumbum, nux, verat., aeon., bella., may in some 
 instances be required. 
 
 Dioscorea villosa, given in the form of decoction, a wineglassful at a 
 time, has produced in four of my cases more marked results than any other 
 medicine. Inflation of the intestines with air, after the suggestion of Hip- 
 pocrates, has proved curative. The best method of performing this is by 
 an ordinary good-sized bellows. 
 
 If we have reason to believe that impaction causes the obstruction, olive 
 oil may be given in considerable quantities with the injection as already 
 mentioned. I have known these means result in the cure of a severe and 
 aggravated case. 
 
 Operation for Intestinal Obstrnction. — When laparotomy has been decided 
 upon, the following is the best method : The incision is made in the linea 
 alba, and as soon as the cavity is reached it will be found in the majority 
 of instances that the dilated portions of the gut are usually nearest the 
 surface. The surgeon should carefully examine these, and if he discovers 
 one portion of the intestine more purple or crimson than the other, he 
 must follow the coils until he reaches the seat of obstruction. Of course, 
 as the bowel is drawn from the abdomen or as it protrudes it should be 
 covered with layers of hot flannel or with a large sponge which has been 
 saturated with a hot carbolic or boracic solution, and by tracing the dark- 
 ened portion of the intestine we will be certain to arrive at the seat of 
 obstruction. If there be such distension that the examination cannot be 
 satisfactorily made, the gut may be punctured and the wound sutured. A 
 good rule is that which is laid down by Mr. J. Greig Smith, when he says : 
 " Never consider an operation for intestinal obstruction finished until the 
 bowels are relieved from over-distension." If the volvulus occur at the 
 sigmoid flexure, at which point it is found to be the most frequent, the 
 following treatment may be adopted : and I am not sure that frequent, pro- 
 longed, and forcible injections tend to increase rather than diminish the 
 twist in the gut; however, injections of oil, water, and ox gall, as solvents, 
 may be used, and if no result is accomplished then laparotomy should be 
 
848 A SYSTEM OF SURGERY. 
 
 performed. It is necessary, after the cavity of the abdomen has been 
 opened, to puncture the gut immediately, allow the imprisoned air to be 
 evacuated, and attempt its reduction. If these means fail the volvulus 
 may be unfolded and an artificial anus be made, which would be about 
 at the summit of the sigmoid flexure. 
 
 In acute intussusception, after the abdomen has been opened, the invagi- 
 nation should be reduced by gently pressing the upper end of the gut with 
 one hand while steady traction is made on the end of the intestine with the 
 other. If a moderate degree of pressure does not suffice, the gut must be 
 resected, and the abdominal wound closed with silver or catgut sutures. 
 For the methods of resection of the intestine, and to prevent repetition, the 
 student is referred to the chapter on Hernia, Resection of the Gangrenous 
 Gut, and to the section in this chapter on Suturing the Intestine. 
 
 Mr. Howard Marsh reports a successful abdominal section for intussus- 
 ception in an infant seven months old. Mr. Henry Howse also gives one 
 in which he operated similarly upon an adult, with cure. Mr. Jonathan 
 Hutchinson reports a case in which death resulted after reduction. He 
 advises that the lower end of the intussusception should be first sought and 
 brought into the wound. The sheath should be drawn " downwards from 
 off its contents, instead of drawing the contents upwards from within the 
 sheath." In a discussion in the Royal Medical and Chirurgical Society, it 
 was brought out that failure to reduce by all other means, and the appear- 
 ance of blood in the stools, formed the justifiable indications for section of 
 the abdomen. There was a difference of opinion upon the length of the 
 incision, Mr. J. Hutchinson saying that he would not make a larger cut 
 than was absolutely necessary. In each the bowel was withdrawn from the 
 abdominal cavity before reduction was effected. In the infant's case at least 
 one-half of the colon and an equal part of the small intestine were invagi- 
 nated. In the adult, the length of the included bowel was eighteen inches. 
 Both recovered without an untoward symptom. The third case (Mr. Hutch- 
 inson's) was that of an infant six months old, in whom the intussusception 
 involved the whole length of the colon and ileo-csecal valve. Considerable 
 difficulty was encountered in replacing the intestines within the abdomen. 
 They were accordingly punctured in two or three places, and to these punc- 
 tures the operator attributed the fatal issue, which took place within six 
 hours afterward from peritonitis * Dr. Sands,f of New York, has also made 
 a successful operation. 
 
 Formation of an Artificial Anus — Colotomy. — In giving the varied condi- 
 tions which call expressly for this operation, I cannot do better than quote 
 from Mr. Bryant, who perhaps has had a larger experience in the operation 
 than any other surgeon, he having, up to the present time, performed 
 eighty-two colotomies — surely a very large number for one surgeon. He 
 says that lumbar colotomy should be performed : 
 
 1st. In all cases of cancerous stricture of the rectum or colon, including 
 the annular, which are not amenable to lumbar colectomy or anal excision, 
 right or left lumbar colotomy is strongly to be advocated, with the well- 
 grounded hope of relieving suffering, retarding the progress of the disease, 
 and prolonging life for five or six years. 
 
 2d. That lumbar colotomy is valuable as a curative operation in syphilitic 
 and simple ulcerations of the bowel which resist other treatment, including 
 cases of recto-vaginal fistula, and that it is remedial in examples of volvulus 
 of the sigmoid flexure, as well as of obstructions caused by tumors. 
 
 * Lancet, December 18th, 1875. 
 
 t Month. Abs. of Med. Science, February, 1876; Med. Times and Gazette, January 8th, 
 1876. 
 
FORMATION OF AN ARTIFICIAL ANUS — COLOTOMY. 849 
 
 3d. To secure these advantages it is necessary that the operation be per- 
 formed before the pernicious effects of obstruction occur. 
 
 There are three methods which can be employed for the formation of 
 artificial anus, one of which is known as Littre's, one as Callisen's, and the 
 third as Amussat's. The first consists in opening the abdomen and peri- 
 toneum, and the formation of an artificial anus in their walls by opening 
 the gut and stitching the cut surfaces to the parietes of the belly ; the second 
 (Callisen's) in opening the left loin, should the obstruction be found seated 
 higher than the rectum ; or, third, if the trouble exist in the sigmoid flexure 
 or the transverse colon, the operation of Amussat. Whether it be the right 
 or left loin that is to be opened, the same principles guide us, with the dif- 
 ference that Callisen advised a vertical incision, while Amussat preferred 
 and used the transverse. This latter may be used on either side. The 
 operation is thus performed : The patient should be placed on his right side 
 with a cushion beneath him, that the loin may be bent. The quadratus 
 lumborum and the latissimus dorsi muscles must be sought after and their 
 location fixed. An incision six inches in length should be made in front 
 of the latissimus, or in the outer border of the quadratus muscle; this 
 latter can be found half an inch posterior to the centre of the crest of the 
 
 Fig. 526. 
 
 Left Lumbar Colotomy. 
 
 ilium. The integument and fascia are to be divided, the latter upon a 
 director. The abdominal muscles are carefully to be cut through. During 
 this proceeding there may be hemorrhage from muscular branches ; the 
 vessels must all be secured before further steps are proceeded with. We 
 next come upon the transversalis fascia, which must be raised and divided 
 upon a director, after which we generally encounter adipose tissue, which 
 must be opened in the same manner; beneath this last layer the gut is 
 found. The intestine should be hooked up with a stout curved needle, and 
 two strong ligatures passed through one lip of the wound into the gut and 
 
 54 
 
850 A SYSTEM OF SURGERY. 
 
 out again through the other lip of the wound. These ligatures should 
 only pass through integument and gut, the muscles being left out of the 
 way. By this means the intestine is brought up even with the cut surfaces. 
 A longitudinal incision should be made in the intestine over the ligatures, 
 and, in the majority of cases, a gush of feculent matter and gas passes. 
 The centre of each ligature should afterwards be drawn out and divided, 
 thus making four ligatures, two on each side, which, when tied, fix the 
 margins of the gut to the abdominal Avails ; to make the whole more 
 secure, an additional suture or two may be made, and the artificial anus is 
 complete. It is well to oil the cut surfaces after the operation to prevent 
 the irritation of fecal matter. The direction of incision is well illustrated 
 in Fig. 526. 
 
 After the wound has healed, a folded napkin secured by a roller can be 
 worn, or an ivory ball made to fit the artificial anus and fastened by a 
 spring answers the purpose. x 
 
 Some surgeons advise an india-rubber ball with a portion of its surface 
 cut away, to be placed over the wound ; being cup-shaped it can receive any 
 accumulation which may pass through the artificial anus. Sometimes a 
 contraction of the artificial opening takes place ; in such instances a sponge 
 tent is the remedy. 
 
 Perityphlitis. — The connective tissue which attaches the csecum and the 
 colon together, is often attacked with inflammation. The symptoms are 
 intense pain in the csecal region, tenderness on pressure, general debility, 
 high fever, worse at night, and varying in intensity during the day ; tym- 
 panites is often present ; the bowels are constipated, and all the symptoms 
 of severe inflammation present. We also have a secondary perityphlitis, 
 which begins with a chill, and presents many symptoms of pyaemia. The 
 acute disease is caused by cold or traumatic agencies ; the secondary is found 
 during the course of typhus, in puerperal fever, or from absorption of septic 
 material ; often the inflammation terminates in suppuration ; we then have 
 the perityphlitic abscess, the surgical treatment of which must be considered. 
 The operations are varied, but in my cases, I have invariably used the as- 
 pirator, enlarged the opening if necessary, and washed out the abdominal 
 cavity with carbolic acid solution, 1 to 200, in the same manner as after 
 ovariotomy. I give the early history of this operation, as it is a feature in 
 surgical literature. 
 
 Perityphlitic Abscess. — Prof. Erskine Mason and Dr. Gurdon Buck ob- 
 served* that the first published account of it is contained in the London 
 Medical Gazette for 1848. This refers to a case related by Mr. Hancock to 
 the Medical Society of London, the operation having been performed April 
 17th, 1848. Little notice was taken of the announcement, either in England 
 or in this country; and it was not until 1867, when Dr. Willard Parker f 
 published his paper, giving the history of four successful cases, that the 
 operation became fully established. Dr. Parker's first operation was in 
 1843, thus antedating those of all others. 
 
 In December, 1875, three cases were described by Dr. L. Weber before the 
 New York Academy of Medicine.! The operations were performed on the 
 7th, 8th, and 9th days respectively. In all, he followed Dr. Willard Parker's 
 method, by making a long incision over the region of the suspected abscess 
 until the fascia transversalis was reached. At this point the operation was 
 suspended, and the abscess ruptured spontaneously, after a short time in 
 one case, and in the remaining two, under the pressure of the finger, while 
 searching for fluctuation. Perfect recoveries ensued. 
 
 * Medical Kecord, January 1st and June 10th, 1876. 
 t Ibid., March 1st, 1867. 
 X Ibid., January 1st, 1876. 
 
PEKITYPHLITIC ABSCESS. 851 
 
 Dr. Gurdon Buck reports a case in detail,* which affords a good example 
 of the method preferred by him. The patient was a gentleman, aged 26, of 
 good constitution and regular habits. On the eleventh day of the disease, 
 the precise seat of sensitiveness having been determined by careful and re- 
 peated examinations, a puncture was made through the skin at the point 
 chosen upon the surface of the tumor, and a sharp-pointed canula was 
 advanced cautiously through the parietes of the abdomen to the depth of 
 over one inch, when pus escaped. The canula serving as a guide, a sharp- 
 pointed bistoury was conducted into the cavity of the abscess, and its open- 
 ing enlarged. At the same time, the external wound was extended nearly 
 two inches, and the entrance of the abscess further dilated by the introduc- 
 tion of a dressing-forceps. A discharge of fetid pus followed, together with 
 an abundant escape of gas. On the twenty-eighth day after, the wound had 
 healed, and the patient was out of doors. 
 
 A case which terminated fatally seventy-four days after the abscess had 
 been freely opened, has been related by Prof. Erskine Mason.f His theory 
 as to the cause of the fatal result is, that some foreign body passing from 
 the intestine had become lodged in a recess in the walls of the abscess, 
 and, failing to be removed by the daily injections, had excitated irritation 
 and ulcerative action, which resulted in perforation into the peritoneal 
 cavity. 
 
 A case is reported by Edgar Holden, M.D., of Newark, N. J.,X of a stout 
 robust man, in which, on the twelfth day of the disease, no satisfactory 
 evidence of actual suppuration had presented. An operation was performed, 
 and twenty-three days after the wound had entirely closed, and the patient 
 appeared well. 
 
 Dr. J. C. Adams, of Lake City, Minn., performed the operation in the 
 case of an Irish woman, forty years of age, and the mother of eleven chil- 
 dren.! Two weeks later, the wound was almost closed, and the patient 
 fast regaining her usual health. 
 
 Leonard Weber, M.D., in a paper read before the New York Academy of 
 Medicine,|| gives the history of three cases since 1874. In all, the opera- 
 tion was done in the same way, and it is a good one — I have employed 
 it a number of times with success. The incision is made as follows : Put- 
 ting the thumb of the left hand in the inguinal fold close to Poupart's 
 ligament, the four fingers are laid upon the upper circumference of the 
 abscess, making gentle but firm pressure downward. Midway between 
 thumb and fingers thus placed, skin, fascia, and the fibres of the external 
 and internal oblique muscles are to be divided, the exploring needle 
 entered at a point where there is certainty from previous repeated exam- 
 inations that pus will be found, and, when obtained, the knife is carried 
 through the remaining tissues by a single cut. Immediately after the opera- 
 tion, the cavity of the abscess should be washed with carbolized water, 
 and twice daily thereafter until the discharge has lost its fetid character, 
 and the wound has become too small for the further introduction of a 
 drainage-tube. 
 
 The following case was noted in the service of Dr. H. B. Sands, attending 
 surgeon, New York Hospital.^ Five days after admission, and fifteen days 
 after the onset of the disease, suppuration was detected low down in the 
 abdomen, near the median line. Thereupon an incision, about two inches 
 in length, was made, parallel with Poupart's ligament. The discharge of 
 pus was great ; and the finger being introduced into the cavity of the 
 
 * Medical Record, Jan. 15th, 1876. f Ibid., June 10th, 1876. 
 
 i Ibid., December 23d, 1876. \ Ibid., March 24th. 1877. 
 
 I) Ibid., January 19th, 1878. If Ibid., February 18th, 1878. 
 
852 A SYSTEM OF SURGERY. 
 
 abscess, it was found to extend upward and outward in the direction of the 
 caput coli. The pus was offensive, but contained apparently no fecal 
 matter. The temperature at once fell to the normal standard, and the pa- 
 tient recovered, the only drawback being difficulty in passing urine, which 
 continued for a few days. 
 
 Gastrostomy. — An article by Dr. J. H. Pooley, of Columbus, Ohio* con- 
 tains a table of 11 cases of gastrostomy performed for removal of foreign 
 bodies, dating from 1613 up to 1856. All but one of these cases recovered. 
 He gives a similarly arranged table of 18 cases of gastrostomy, performed 
 for stricture of the oesophagus, from 1849 to 1872. The result in all these 
 was death. 
 
 Verneuilt gives an account of the first successful case of gastrostomy on 
 record. The operation was performed on a boy of seventeen, in whom 
 the stricture was caused by swallowing a solution of caustic potash. An 
 oblique incision two inches in length was made parallel to the cartilagin- 
 ous border of the false ribs. When the stomach presented itself, it was 
 immediately transfixed and held in the wound by two long acupuncture 
 needles. Fourteen metallic sutures were then passed through the skin, 
 parietal peritoneum and wall of the stomach; the acupuncture needles 
 were withdrawn, and an incision made through the wall of the stomach, 
 just large enough to admit a large gum catheter, which was secured in posi- 
 tion by tapes and collodion applied over the abdomen. The slight haemor- 
 rhage was controlled by haemostatic forceps, a dozen or more pairs of which 
 were used to secure the parietal layer of the peritoneum while apply- 
 ing the sutures. The antiseptic method was strictly followed. There was 
 no fever. The sutures fell out spontaneously, and a small portion of the 
 gastric wall included between them sloughed, so that the opening became 
 larger than at first. The patient was fed through the catheter with soup, 
 milk, eggs, wine, etc. In two months he had completely regained his 
 strength and energy. He experienced hunger, and fed himself with all 
 sorts of food. 
 
 The operation, however, is a doubtful one, and is well described by Mr. 
 Bryant (ether or chloroform may be administered) : " The patient should 
 be placed upon his back, and an incision made below the ribs on the left 
 side, the object of the surgeon being to find the cardiac end of the stomach 
 in preference to the pyloric. The line of the linea semilunaris is the ordi- 
 nary one that has been used for the incision, a cut three or four inches 
 long being made carefully through the tissues seriatim down to the fascia 
 lining the muscles, every vessel being twisted or tied as it bleeds. In my 
 own operation I made an oblique incision along the lower borders of the 
 ribs, commencing at the linea semilunaris, with the view of catching the 
 cardiac end of the stomach, and I may say that I picked the stomach up 
 with my fingers very readily ; the fascia and peritoneum are then to be 
 divided. With the thumb and finger the stomach is now to be sought, and 
 when caught, held. This is best effected by the passage of a needle armed 
 with a double silk through its coats, the silk being left with long ends ; a 
 second should also be passed about three-quarters of an inch lower down. 
 The surgeon has then to fasten the stomach to the margins of the wound, 
 and the quill suture seems to be the best means to use. To do this he may 
 first pass the needles that have already traversed the stomach, and are still 
 armed, through one side of the wound, and with a second needle draw the 
 free ends of the ligature, when threaded, through the other. The stomach 
 should then be opened over the ligatures that have been passed through it, 
 
 * Medical Record, November 26th, 1876. 
 f Gaz. MeU de Paris, October 28th, 1876. 
 
RESECTION OF THE PYLORUS — PYLORECTOMY. 853 
 
 the incision being made in the line of the wound ; the centre of the double 
 ligatures will then be exposed, and these should be drawn well out and 
 divided. There will then be two double ligatures through each side of the 
 opening in the stomach and the margin of the wound. On tying the two 
 ends over two pieces of bougie, one introduced against the inner surface of 
 the stomach, and the other upon the integument, the parts are secured, the 
 bougies admirably compressing the thin walls of the stomach against the 
 integuments, and retaining them there. One or two other sutures will 
 -probably be required to close the wound, and an additional one at either 
 end of the opening in the stomach to keep it in its place ; the operation is 
 then completed. When the quill suture is not used, the stomach must 
 be stitched to the margins of the wound in the ordinary way, but a more 
 accurate adaptation of the parts and greater security is acquired by the 
 quill suture than any other, and what is more, the pieces of bougie are 
 capital guides to the orifice into the stomach, the slightest traction upon 
 them rendering it patent for purposes of feeding ; for this purpose one of 
 the sutures should be left long on either lip of the wound. After the opera- 
 tion it is well to desist from giving food a few hours, to give the stomach 
 rest. Where enemata can be tolerated they should be used. After a day 
 or so, according to circumstances, liquid nourishment should be adminis- 
 tered in small quantities through a tube ; milk and eggs being probably the 
 best, or milk alone. Care should be observed that too much food is not 
 given, as it retards progress, a quart or three pints of milk in twenty-four 
 hours being ample. The edges of the wound should be carefully protected 
 by oiled lint. The sutures may probably be removed, wholly or in part, on 
 the fifth or sixth day." 
 
 Resection of the Pylorus. — Pylorectomy. — This operation was first per- 
 formed by Pean in 1879, the patient living but a few days ; the next case, 
 which was still more unsuccessful, was operated upon by Rydygier in 1880, 
 and survived but a few hours. To Billroth belongs the credit of having 
 performed the first successful resection of the stomach. The patient was a 
 woman, her age 43 years, and she made such rapid recovery that I have 
 been assured by my colleague, Dr. Wilcox, who was present at the opera- 
 tion, that within a day or two after the removal she was fed upon butter- 
 milk, and on the twenty-first day ate and digested a mutton-chop. Since 
 Billroth's operation, the procedure has been repeated several times with 
 varying success. 
 
 Method of Proceeding. — The patient several days before the operation 
 should be fed upon easily digested liquid food — milk and eggs, oatmeal 
 gruel, soup, beef tea, porridge, and the like. The skin should be bathed 
 and the bowels attended to. An hour before the operation the stomach 
 should be washed out with the stomach-pump, to remove mucus and any 
 secretions that may have accumulated. Twenty minutes before the patient 
 is brought to the operating room, she should have a hypodermic injection 
 containing ^ gr. morphia and y-^ gr. atropine. When laid upon the table 
 and under anaesthetic influence, the entire surface of the abdomen should 
 be washed with corrosive sublimate solution (^Vtr)* an d a saturated solu- 
 tion of iodoform in ether poured on the site of the intended wound. The 
 incision should be made over the tumor, above the umbilicus, about three- 
 quarters of the cut being to the left of the mesian line. As the parts are cut 
 through (the muscular fibres of the abdominal muscles being divided trans- 
 versely) there will he quite free bleeding from small vessels. These must 
 be tied with carbolized gut. The peritoneum must be divided upon a 
 director, and the lips of the wound held open by retractors. This brings 
 the greater omentum in view, which must, together with the lesser, be very 
 carefully separated from the parts until the pyloric extremity of the stomach 
 
854 A SYSTEM OF SURGERY. 
 
 comes in view. Here the operator, having cleansed his hands, and having 
 a perfectly antiseptic flat and large sponge ready, inserts his fingers or hand 
 within the cavity, and gently draws forward the pylorus. If it is not ad- 
 hered to the surrounding parts, and can be drawn through the wound, the 
 operation should be continued. If, on the contrary, it is bound down by 
 adhesions, the operation should be abandoned. 
 
 The pyloric end of the stomach and the duodenum to be excised, are laid 
 upon the sponge, and a pair of forceps with long jaws — the latter protected 
 by bits of antiseptic rubber tubing — should be made to transversely em- 
 brace the duodenum. Another pair should grasp the stomach — the space 
 between the blades of the two pairs of forceps being that to be removed. 
 The stomach is first to be cut through with the scissors, and next the duo- 
 denum. The blades of the forceps will prevent any extrusion of the con- 
 tents of the bowel or stomach. The forceps are now removed, and the cut 
 surfaces — duodenum on one side, stomach on the other — brought into 
 apposition. Of course the circumference of the stomach-wound being much 
 greater than that of the gut, the former, before adaptation can take place, 
 must be fitted to the latter. This is effected by cutting a > shaped piece 
 from the lateral wall, or the superior or inferior curvature of the stomach. 
 The parts should first be brought together with a continued suture (vide 
 Fig. 523, page 835), and over this the Lembert suture (vide Fig. 522, page 
 835) employed. From fifty to seventy sutures may be required. The 
 stomach is then returned to the cavity of the abdomen and the wound 
 closed and dressed as already directed. 
 
 The statistics of pylorectomy are not favorable. Winslow* shows that 
 of 61 cases, a little over fifty per cent, died of shock within twenty-six hours, 
 and no case survived three years with immunity. Of 82 cases collected by 
 Kramer,f there were 61 deaths. Of these 72 were for carcinoma, of which 
 55 died in a short period, and, indeed, only one proved a success. Speaking 
 of Billroth's cases, Dr. Stenn says : J " Such' statistics in the practice of this 
 most eminent surgeon, should definitely settle this question in the mind of 
 any surgeon whose humanity has not succumbed to a morbid desire for 
 transient fame." 
 
 Enterectomy. — For the method of performing this operation the student 
 is referred to " Enterectomy in Gangrenous Hernia," in the following 
 chapter. 
 
 Digital Divulsion of the Pylorus.— In certain cases of stenosis of the pylo- 
 rus of non-malignant character, this operation may be performed. It was 
 originally devised by Loreta, of Bologna, and performed by him in Sep- 
 tember, 1882. The incision is to be made parallel with the ribs, about five 
 inches in length, and the same precautions taken as have already been 
 described in the operation for excision of the pylorus. The stomach is 
 drawn forwards and an incision made between the lesser and greater cur- 
 vature, of sufficient length to admit the two index fingers. Gradual traction 
 is then made until the pyloric orifice is opened for two or three inches. 
 
 Dr. McBurney§ records an interesting case of this kind ; he made his in- 
 cision " about five inches long from a point one inch below and one and a 
 half inches to the left of the ensiform cartilage, downward to the right, par- 
 allel with the border of the ribs." The orifice was easily found, was much 
 thickened, so that a rectal dilator was used for its first expansion. The 
 fingers were then substituted and the orifice opened three inches. 
 
 Splenectomy — Extirpation of the Spleen. — This operation has been per- 
 
 * American Journal of the Medical Sciences, April, 1885. 
 
 f Medical News, May 22d, 1886. 
 
 X Address on Surgery before the American Medical Association, May 5th, 1886. 
 
 \ Annals of Surgery, May, 1886. 
 
SPLENECTOMY — EXTIRPATION OF THE SPLEEN. 855 
 
 formed about thirty times, and curiously enough, when traumatism was 
 the factor, the results have been more favorable than when the organ was 
 removed for disease. In eighteen of the cases in which the operation was 
 performed for disease, all died. There appears to be a peculiar liability to 
 secondary shock and secondary haemorrhage, after the removal of the spleen. 
 A fact derived from the study of these cases is that all the patients upon 
 whom the operation was performed had immediately an increase in the 
 white blood-corpuscles, which appears to prove the recent physiological 
 idea that the function of the organ is the conversion of white into red 
 blood-corpuscles. After a time, the normal quantity of red blood returns, 
 the office of the spleen being in a measure supplied by the thyroid gland. 
 Blum draws the conclusion that when hernia of the spleen results from a 
 wound, the surgeon is justified in cutting off the protruding portion, and 
 that these operations are generally successful; that, per contra, the operation 
 should not be undertaken either for cancer or for hypertrophy, as the results 
 are uniformly bad. In movable spleen extirpation may be practiced, as it is 
 comparatively easy; and in conclusion, it is remarked that though the opera- 
 tion is practicable, yet it is rarely indicated and is likely to terminate in death 
 either from haemorrhage or shock. A transverse or curved incision is made 
 over the body of the organ, and the parts divided, layer after layer, on a di- 
 rector, until the spleen is reached. The adhesions must be sought for and 
 broken away and the organ turned out; the splenic arteries and veins are to 
 be secured by a double strong carbolized catgut ligature, and the spleen cut 
 off above them. The patient must be carefully watched for several days, and 
 especially the first few hours. The operation as yet has hardly taken its place 
 in the regular domain of surgery. 
 
 Prof. Billroth reports a case of removal of a greatly enlarged spleen (at- 
 tended with leucaemia, the red globules being five to one of the white). 
 The operation was on a woman of forty-five. The patient rallied from the 
 anaesthesia, but died four and a half hours after from haemorrhage due to 
 the giving way of one of the ligatures on account of a strain. Another case 
 is reported in which the hypertrophied spleen was removed from a man of 
 twenty years ; this patient also rallied, spoke, and seemed not unduly 
 collapsed, but in making an effort to sit up he fell back and died.* 
 
 Mr. H. L. Brownef relates his experiments in Extirpation of the Spleen 
 for Rapid Hypertrophy : 
 
 "A man (set. 20) had been in good health till six months ago, when he 
 began to grow fat ; had no fever, ague, or syphilis, nor had his family. 
 Without receiving any benefit from the use of purgatives and diuretics, the 
 symptoms growing worse, extirpation was decided on. 
 
 "There were no adhesions, nor any pedicle of a distinct kind, and no 
 haemorrhage. The tumor — a simple hypertrophy of the spleen — was 18? 
 pounds in weight. The patients youth and the absence of other disease 
 were the reasons why the operation was performed." 
 
 * American Journal of the Medical Sciences, July, 1877, p. 261. 
 f Ibid., January, 1878. 
 
856 A SYSTEM OF SURGERY. 
 
 CHAPTER XLIII. 
 
 HERNIA— RUPTURE. 
 
 Abdominal Hernia — Frequency and Sites — Varieties and Nomenclature — Medi- 
 cal Management — Diagnosis — Taxis — Puncturing the Intestine — Reduction 
 by Esmarch's Bandage — Trusses — Herniotomy — Kelotomy — Enterectomy for 
 Gangrenous Hernia — Radical Cure — By Ligature of Sac — Heatonian 
 Method — Wood's Operation — Inguinal Hernia— Surgical Anatomy — Differ- 
 ential Diagnosis— Operation — Femoral Hernia — Diagnosis — Operation — 
 Ovarian Hernia— Umbilical Hernia — Obturator Hernia — Ischiatic — Dia- 
 phragmatic — Pudendal. 
 
 In surgical literature there is scarcely a subject that covers so wide, 
 important, and interesting a field as that of hernia. There are so many 
 varieties of the affection and so many individuals who suffer from it, so nu- 
 merous are the operations and apparatus recommended for its relief, and 
 its symptoms are so important and yet of such variable character — at the 
 one time indicating rapid dissolution, and at another endured for years 
 with apparently slight inconvenience — that we cannot but regard it as every 
 way worthy of careful thought, reading, and experiments of both the physi- 
 cian and surgeon. 
 
 The Frequency and Sites of Hernia.— The frequency of hernia has given 
 rise to much discussion, and, from Malgaigne's tables, the number of males 
 suffering from it is 1 to 8 ; and of females, 1 to 13. The figures showing 
 the relative frequency of the different varieties of rupture indicate the 
 far greater frequency of oblique inguinal, than of any of the other forms 
 of protrusion. The reports from the Surgeon-General's office in this respect 
 are instructive. Out of 334,321 recruits examined for army admission, no 
 less than 17,296 were rejected for hernia in one form or another, showing a 
 ratio of about 50 per thousand ; and this percentage may be considered a 
 tolerably fair estimate of the relative frequency of hernia among the labor- 
 ing classes. Of these the right inguinal are by far the most numerous, be- 
 ing 8598 ; the next is the left inguinal which numbered 5420 ; the double 
 inguinal, 1166 ; thus making the number of inguinal hernia? — single and 
 double — 16,178, out of 17,296. If we take into consideration that from 
 the total must be deducted 651 cases of unspecified hernise, the immense 
 proportion of inguinal over every other variety of rupture can at once be 
 perceived. 
 
 In Kingdon's reports we are told that in every 100 cases of rupture, there 
 are 84 inguinal, 10 femoral, and 5 umbilical ; and that in a total of 96,886 
 persons applying to the Truss Society for relief, no less than 78,394 were 
 males, and 18,492 females, making the proportion of males to females as 
 4 to 1. It has been found that the average age of those suffering from 
 strangulated inguinal hernia is 43, while those affected with strangulated 
 femoral hernia was 55.* 
 
 Nomenclature. — By the term hernia, may be understood a protrusion of 
 the contents of any cavity of the body ; thus by encephalocele we mean a 
 hernia of the brain, and by pneumocele a hernia of the thorax ; the term 
 by common consent is now restricted to those protrusions that occur from 
 within the abdominal cavity through natural openings or such parts as 
 
 * Bryant's Surgery, Am. Ed., p. 487. 
 
HERNIA. 857 
 
 are but comparatively slightly covered by the tissues. Hernia taking place 
 through rents in the abdominal walls is known as " Ventral hernia." 
 The varieties of hernise may be thus classified : 
 
 A. Abdominal hernia proper through so-called natural openings. 
 
 B. Abdominal ventral hernia through rents in the abdominal walls. 
 
 A. ABDOMINAL HERNIA PROPER ACCORDING TO ANATOMICAL SITE. 
 
 1. Inguinal or Supra-pubian j q,,. 
 
 The difference between these two varieties is indicated by the terms 
 designating them. In the first, the gut protrudes through the external ring, 
 having pushed with it the conjoined tendon of the internal oblique and 
 trans versalis muscles ; while in the second the intestine, entering the ingui- 
 nal canal at the internal ring, passes through the entire length of the ingui- 
 nal canal, taking as one of its coverings a few of the lower fibres of the 
 internal oblique muscle (cremasteric fascia), and protruding through the 
 external ring. In certain cases of direct hernia the gut passes out of the 
 abdomen through Hesselbach's triangle. 
 
 2. Femoral, Crural. — Escaping through the crural canal. 
 
 3. Infra-pubian, or Obturator. — Escaping through the opening giving pas- 
 
 sage to the obturator vessels. 
 
 4. Ischiatic. — Escaping through the sciatic notch. 
 
 5. Diaphragmatic. — Escaping through the diaphragm. 
 
 6. Ovarian. — When an ovary enters the abdominal ring. 
 
 7. Umbilical. — Escaping through the umbilicus. 
 
 B. VENTRAL HERNIA. 
 
 1. Epigastric. — Escaping through linea alba above the umbilicus. 
 
 2. Hypogastric. — Escaping through the linea alba below the umbilicus. 
 
 3. Perineal — Escaping through the levator ani muscle. 
 
 Abdominal Hernia according to the parts protruded. 
 
 1. Enterocele. — If the intestines be alone displaced. 
 
 2. Epiplocele. — If the omentum be alone displaced. 
 
 3. Entero-epiplocele. — If both the intestines and omentum protrude. 
 
 4. Gastrocele. — If the stomach fills the sac. 
 
 5. Splenocele.— If the spleen fills the sac. 
 
 6. Hepatocele. — If the liver fills the sac. 
 
 7. Cystocele. — If the bladder protrudes either above the pubes in the male 
 
 or through the vagina in females. 
 
 8. Rectocele. — The rectum protruding through the vagina. 
 
 Abdominal Hernia according to the Condition of the Gut. 
 
 1. Reducible. "| 
 
 I hlcarc^ltd. The tems explaining themselves. 
 4. Strangulated. J 
 
858 A SYSTEM OF SURGERY. 
 
 The first variety may partake of the nature of the last two : thus we may 
 have an inguinal hernia (direct) which may be an entero-epiplocele and 
 irreducible. 
 
 Besides the terms already given as designating the varieties of gut and 
 omental protrusions, there is as yet a nomenclature to be explained which 
 has often caused confusion in the student's mind ; thus 
 
 Congenital Hernia occurs soon after birth. At this time the intestine or 
 omentum passes out of the abdomen, accompanies the testicle in its descent 
 and becomes lodged in the pouch of peritoneum which forms the tunica 
 vaginalis testis, tubular vaginal process, before its communication with the 
 general peritoneal cavity has become obliterated. The sac of this hernia is", 
 therefore, formed by the tunica vaginalis testis, having all the other cover- 
 ings of the oblique variety. 
 
 The Congenital Form of Hernia — Malgaigne's Hernia of Infancy — according 
 to Birkett, is that form of the congenital which may appear in after life, 
 from the tubular vaginal process not having been entirely closed; from 
 some effort on the part of the patient the adhesions give way, and the gut 
 descends. 
 
 This hernia also receives the name of " Hernia into the vaginal process of 
 the peritoneum." 
 
 Infantile Hernia of Hey — Encysted Hernia Infantalis of Sir Astley Cooper — 
 is an acquired hernia, is more complicated than the latter, because it has, 
 as it were, two sacs. The communication between the cavity of the tunica 
 vaginalis and that of the abdomen is closed at its upper part, but the former 
 is unusually large and continues high up the cord, and contains more or 
 less serous fluid. Behind this is found a hernia invested by the ordinary 
 peritoneal sac. 
 
 Funicular Hernia — Birkett. — If the tubular process of the peritoneum 
 closes over the testicle and yet leaves a pouch above, into which a gut 
 descends, then we have " a hernia into the funicular portion of the vaginal 
 process." 
 
 Interstitial Hernia is the same as that known as " inter-parietal " or the 
 hernia en bissac of the French. It is formed by the stretching of the neck 
 of the vaginal process to such a degree that it becomes a sac, and insinuates 
 itself between the abdominal tissues upwards or downwards as seen in the 
 cut. 
 
 The following diagrams with their explanations I have taken from 
 Bryant. They are the best descriptions of the different varieties of hernia 
 that I have seen, and convey to the eye of the student an explanation of 
 many important points in the nomenclature. 
 
 Reducible Hernia. — In this variety the tumor increases in size or descends 
 1 when the patient is erect, and diminishes or disappears during the recum- 
 bent position. 
 
 Sufficient inflammation has not taken place to cause adhesion of the sac 
 or rings, and no stricture exists to prevent the return of the bowel. 
 
 The symptoms are well marked : when the gut returns to the abdomen, 
 either spontaneously or by taxis, a peculiar gurgling sound is heard by the 
 surgeon and patient. The tumor is larger after a meal, and an impulse is 
 communicated to it when the patient coughs. If the tumor contain omen- 
 tum, a peculiar doughy sensation is communicated to the hand of the ex- 
 aminer. The hernia may, however, consist of both intestine and omentum 
 (entero-epiplocele) . 
 
 If suffered to increase, a reducible hernia may become enormously large, 
 and the patient not only experience great disorder of the digestive organs, 
 but be constantly liable to strangulation of the gut. 
 
IRREDUCIBLE HERNIA. 
 
 859 
 
 Irreducible Hernia is that form in which there exists a protrusion of the 
 bowel which cannot be returned to the abdomen. 
 
 Fig. 527. 
 
 Fig. 528. 
 
 Fig. 529. 
 
 Fig. 530. 
 
 Fig. 531. 
 
 Fig. 527.— The diagram illustrates the tubular vaginal process of peritoneum open down to the testicle, 
 into which a hernia may descend ; when the descent occurs at birth it is called " congenital" ; when at a 
 later period of life the ''congenital form " of hernia, Birkett's " hernia into the vaginal process of peri- 
 toneum," or Malgaigne's 'hernia of infancy." 
 
 Fig. 528. — The same process of peritoneum open half-way down the cord, into which a hernia may de- 
 scend at birth or at a later period. Birkett's "hernia into the funicular portion of the vaginal process of 
 the peritoneum." 
 
 Fig. 529.— The same process undergoing natural contraction above the testicle, explaining the hour- 
 glass contraction met with in the congenital form of scrotal hernia as well as in hydrocele. 
 
 Fig. 530.— Diagram showing the formation of the " acquired congenital form of hernia," the " encysted 
 of Sir A. Cooper," "the infantile of Hey," the acquired hernial sac being pushed into the open tunica 
 vaginalis which incloses it. 
 
 Fig. 531. — Diagram illustrating the formation of the "acquired" hernial sac distinct from the testicle 
 or vaginal process of peritoneum, which has closed. 
 
 This condition is caused either by adhesion of the sac to its contents, or 
 to the parts into which it has passed, by membranous bands extending across 
 the mouth of the sac, by enlargement of the gut, or by contraction of the 
 opening through which the tumor has descended. From the greater or less 
 obstruction to the passage of fecal matter, and the fact of its being a foreign 
 
 Fig. 532. 
 
 Fig. 533. 
 
 Fig. 534. 
 
 Fig. 535. 
 
 Fig. 532.— Illustrates the neck of the hernial sac pushed back beneath the abdominal parietes with the 
 strangulated bowel. 
 
 Fig. 533.— Shows the space in the subperitoneal connective tissue into which intestine may be 
 pushed through a rupture in the neck of the hernial sac ; the intestine being still strangulated by the 
 neck. 
 
 Fig. 534.— Diagram showing how the neck of the vaginal process may be so stretched into a sac 
 placed between the tissues of the abdominal walls either upwards or downwards between the skin and 
 muscles, muscles themselves, or between the muscles and the internal abdominal fascia— forming the 
 intraparietal, intermuscular, or interstitial sac; hernia en bissac of the French; "additional sac" of 
 Birkett. 
 
 Fig. 535.— Diagram illustrating the reduction of the sac of a femoral hernia en masse with the strangulated 
 intestine. 
 
 body, an irreducible hernia gives rise to certain symptoms, such as dragging 
 in the abdomen, sickness at the stomach, vomiting of an obstinate character, 
 colic, and constipation. 
 
 If the patient be corpulent, the above symptoms are more troublesome ; 
 and if it be a woman, and she become pregnant, these conditions will be 
 aggravated. These tumors are, of course, exposed to all the consequences 
 of violence and injury, hence several cases are recorded in which the pro- 
 truded bowel has been ruptured by falls or blows. 
 
860 A SYSTEM OF SURGERY. 
 
 A Strangulated Hernia is one in which the contents of the intestines 
 are prevented from passing to the anus and the venous circulation is 
 impeded. 
 
 A hernial tumor may become strangulated when the contents of the sac 
 increase its size, or it becomes enlarged from inflammation. The symp- 
 toms are, in the majority of instances, so well expressed as to allow easy 
 recognition. Yet it occasionally happens that the abnormal condition is 
 confounded with ileus and other intestinal affections. The tumor resists 
 the impression of the fingers, is painful to the touch, and the pain is in- 
 creased by coughing, sneezing, or standing upright. 
 
 If not relieved, these symptoms are soon followed by sickness of the 
 stomach, frequent retching, stoppage of alvine discharges, hard, frequent 
 pulse, high fever, and great pain all over the abdomen. Convulsive hic- 
 cough sets in, and all these conditions continue to increase in severity. 
 Vomiting, first of ingesta, then of bile, and finally of faeces, results. 
 
 If relief is not afforded, the patient in a short time becomes perfectly 
 easy, and all the previous symptoms subside. But the skin becomes cold 
 and moist; the eyes glassy; the tumor has an emphysematous feel, and 
 communicates crepitus to the fingers. This indicates gangrene. Even now 
 the gut may return spontaneously or by gentle pressure, and the patient 
 express himself relieved, but death will almost inevitably follow in a short 
 time. 
 
 An Incarcerated Hernia is one in which the protruded portions of the 
 abdominal contents are retained in their abnormal situation without being 
 strangulated or giving rise to the inflammatory process. The generation of 
 gases or the accumulation of fluids and solids in the sac may prevent its 
 reduction. 
 
 General Diagnosis. — Of all considerations connected with hernise, the diag- 
 nosis is most important. The cough impulse, the disappearance of the sivelling 
 in the recumbent position, the inability to introduce the finger into the rings 
 are the main general symptoms which satisfy the surgeon in regard to the 
 nature of his case. All this is simple, j^et on the other hand, there is nothing 
 more difficult than to diagnose a complicated rupture ; indeed I have some- 
 times been puzzled to distinguish, especially in women, a femoral from an 
 inguinal protrusion. It is well known that a femoral hernia turns itself 
 upward and rides over Poupart's ligament and when this is the case, and 
 the hernia is irreducible, it requires great care and considerable time to get 
 the gut sufficiently down, that the finger may be introduced into the in- 
 guinal ring, which in the female, is much less open than in the male and is 
 sometimes difficult to find even by dissection. This fact may be made evi- 
 dent, in the performance of Alexander- Adams' operation for shortening the 
 round ligament, for uterine misplacement. I have known an hour to be 
 expended in the endeavor to find it. 
 
 The specific forms of diagnosis will be pointed out when treating of the 
 varied forms of rupture, but an important symptom is that shown by 
 urinary analyses. 
 
 Albuminuria. — It has recently been proven by Dr. I. Englisch * that when 
 strangulation of the bowels takes place, the presence of albumen in the 
 urine may be detected. How this occurs is not accurately determined, 
 but it probably arises from disordered nerve force, and the arrest in the 
 functions of assimilation and digestion. 
 
 It is therefore important that in cases of strangulated hernia, the urine 
 be carefully examined, for if the case be one of enterocele, albuminuria will 
 
 * Wiener Med. Jahrbiicher, Heft. 2, 1884. 
 
MEDICAL TREATMENT OF HERNIA. 861 
 
 be present, and if it be epiplocele, this substance will be absent. If in ad- 
 dition to the albumen, casts or blood be present, with rapid increase in these 
 elements, collapse and death may be expected. 
 
 Cough Impulse. — The cough impulse is a symptom of great importance, 
 and when perfect may make a diagnosis clear in a moment, but it must 
 be remembered, that not only may this symptom be obscure, but be absent, 
 especially in cases of epiplocele. I have lately operated upon two such cases 
 (one complicated with hydrocele) in which there was not the slightest im- 
 pulse from coughing ; both cases were oscheoceles, and both irreducible. 
 In such I can see no method of making a diagnosis, save by exclusion, ex- 
 perience, or an exploratory incision. 
 
 It must be borne in mind that abdominal organs may lodge in the in- 
 guinal canal, and give rise to a protrusion that may be difficult to diag- 
 nose. Dr. E. C. Went mentions the case of an old woman, aged eighty-five, 
 who had died of various senile disorders, and who had worn a truss for 
 years for a supposed inguinal hernia; the post-mortem examination re- 
 vealed the right kidney in the canal, a portion protruding externally, with 
 a short ureter, no pelvis, and connected by a firm fibrous band to the 
 uterus.* 
 
 It is not well to neglect the examination of apparently trivial cases, for 
 hernia in some instances may be mistaken for simple orchitis ; and a no 
 less distinguished surgeon than ' Dr. Valentine Mott plainly stated that he 
 was willing to stake his surgical reputation in a case presented to him by 
 Dr. Post, of New York, that the patient was suffering from a traumatic 
 orchitis, when, as the result proved, he had a large knuckle of intestine 
 within the scrotum. And a still more remarkable case is reported by Voght, 
 in which there was a hernia of the stomach into the scrotum. 
 
 Medical Treatment of Hernia. — In the treatment of hernia there is no 
 doubt of the efficacy of medication, not only in the early stages of strangu- 
 lation, but in advanced states of this disorder, even after fecal vomiting has 
 commenced. I am positive in this assertion, and speak from experience 
 in many cases, so much so indeed that I am not obliged to operate for 
 strangulated inguinal hernia nearly as often as formerly. 
 
 With the femoral, though I have not been so successful, yet medicines 
 have sometimes given satisfactory results, the principal being nux vom., 
 opium, and veratrum. Others that are efficacious are aconite, sulph. ac, 
 lycopodium, and in some cases rhus tox. and sulph. 
 
 Aconite should be employed when there is inflammation of the affected 
 part with excessive sensibility to the- touch, accompanied with considerable 
 fever, and quick, hard, and full pulse. 
 
 Dr. H. G. Dunnell, of New York,f reports the cure of a strangulated in- 
 guinal hernia, after stercoraceous vomiting had set in, and after Prof. 
 Willard Parker had pronounced the case incurable without an operation. 
 Opium 1, three grains every two hours, appears to have produced the 
 most decided effect in this case ; although aeon., arsen., nux, sulph., and 
 verat. were employed. 
 
 Nux vomica for its specific action is, however, the most important medi- 
 cine in the treatment, and is to be preferred when respiration is laborious 
 and oppressed, when the tumor is sensitive to pressure, but not in so great 
 a degree as when aconite is called for. When there is bitter vomiting, and 
 when strangulation has been occasioned from errors in diet or exposure to 
 cold, nux is demanded. 
 
 * Medical Record, December 20ih, 1884. 
 
 f North American Journal of Homoeopathy, November, 1861. 
 
862 A SYSTEM OF SURGERY. 
 
 Perhaps a surer method of treatment in the generality of instances, unless 
 the particular indications of a single medicine are very prominent, would 
 be to exhibit nux and aconite in alternation ; both should be administered 
 in tincture. 
 
 According to Hartmann, sulph. ac. is a specific not only for certain cases 
 of hernia, but for the chronic diathesis which leads to intestinal protru- 
 sion. 
 
 If the above medicines do not produce the desired effect, and there be 
 cold moist skin, coldness of the extremities, and profuse vomiting, vera- 
 trum should be given; but if after a few doses of this medicine relief 
 be not obtained, and there be vomiting of fecal matter, with hard dis- 
 tended abdomen and a somewhat comatose condition, opium should be 
 exhibited. 
 
 Dr. Laurie* gives some practical remarks of Mr. Traub on the homoe- 
 opathic treatment of strangulated hernia. The latter gentleman, from his 
 own experience, recommends highly nux vomica, sulph. ac, lycopodium, 
 belladonna, and, moreover, remarks concerning aconite, that, although it 
 does not often, in the series of symptoms that it is capable of producing, 
 exhibit those which accompany the formation and incarceration of a hernia, 
 yet it cannot be dispensed with as an intermediate auxiliary remedy in 
 certain forms of incarcerated displacement, on account of the unlimited in- 
 fluence which it exercises upon the vascular, and especially upon the cap- 
 illary system; and accordingly not only comprises among its symptoms 
 the type of inflammatory fever, but also the state of acute local inflamma- 
 tion. 
 
 The Use of Coffee. — An interesting item in this particular regarding the 
 use of coffee in strangulated hernia is mentioned by Sarra, who relates 
 that he was called one evening to attend a man, 63 years of age, suffering 
 from a strangulated femoral hernia. The patient was nearly moribund, 
 there was no appreciable radial pulse, the face was pinched, the extremi- 
 ties cold, and the attempts to vomit were almost incessant. Happening to 
 remember the report of a similar case relieved by coffee, Dr. Sarra ordered 
 an infusion of this substance to be employed as a drink and also exter- 
 nally, and took leave of the patient, warning the family that death was in- 
 evitable unless a prompt amelioration ensued. Upon returning early the 
 next morning, he was surprised to find his patient in perfect health. The 
 man stated that soon after taking the coffee, he experienced a feeling of 
 warmth and returning strength, then a large quantity of gas was expelled 
 above and below, and when he put his hands upon the tumor, it at once 
 slipped back into the abdominal cavity, much to his astonishment as well 
 as joy. 
 
 Taxis. — By taxis is understood the endeavor to reduce hernise by certain 
 manipulations, for the purpose of restoring the protruded intestine to its 
 normal position. 
 
 It is the opinion of the writer that taxis, in the majority of cases, is over- 
 done, and performed often too roughly ; that instead of restoring the intes- 
 tine, it frequently excites so much additional inflammation that further 
 strangulation occurs, and the life of the patient is additionally imperilled. 
 The proper pressure to be made should be inversely to the course of the gut in 
 its descent. 
 
 The position of the patient during taxis is of importance, and attention to 
 it will often facilitate the success of the operation. The pelvis should be 
 placed higher than the shoulders, and the patient avoid as much as possible 
 
 * Homoeopathic Practice of Physic, page 503. 
 
taxis. 863 
 
 every exertion of the abdominal muscles. There are several postures, each 
 or all of which may be tried in performing taxis. 
 
 1. Place the patient upon the back, flex the leg upon the thigh, the thigh 
 upon th^ abdomen, and by rotating the limb inward relax the columns of 
 the ring. With the patient in this position I have been able to reduce 
 hernia where others have failed. 
 
 2. Advantage may be derived by elevating the hips and depressing the 
 trunk, together with flexion and rotation of the leg. 
 
 3. By inversion of the patient I have known a severe case of strangulated 
 hernia reduced. I had been called to perform herniotomy, but was unable, 
 from a previous engagement, to proceed at once to the house of the 
 patient. In the meantime my friend, Dr. Youlin, was sent for. Arriving, 
 he turned the sufferer " topsy turvy," and suddenly with a gurgling sound 
 the gut returned into the abdomen after having been strangulated nearly 
 two days. 
 
 4. The patient placed upon the side on which the hernia exists, in the 
 semi-prone position, with the thigh flexed upon the body. 
 
 5. The upright position may be a novel one, yet it is urged by those who 
 have had experience in the reduction of hernia, that it succeeds after other 
 means fail. 
 
 Dr. F. H. Nichols, of Cumming, Ga.,* in giving his opinion of taxis 
 says : " I hold that every case of strangulated hernia can be reduced and 
 can be cured by the hands alone. And I also believe that active cathartics 
 or powerful anodynes are seldom useful or necessary in such cases." Dr. 
 Nichols follows a plan of local treatment similar to that which I have 
 often adopted, viz., hot cloths, saturated with chloroform. Of the more in- 
 tractable strangulations, the doctor says : " In such cases I do not despair. 
 I carefully readjust the pressure, reduce or lessen the tumor as much as 
 possible, holding the part, and making the pressure close to the point of 
 stricture with one hand, and with the other, after holding it in cold water 
 a few minutes, I suddenly seize the abdomen below the navel, and carry it 
 upwards, at the same time using a little more force or pressure with my 
 other hand at the stricture. 
 
 " I know this by experience, and I fully believe that it is the remedy l par excellence ' 
 in every obstinate case of strangulated hernia. This retractive power can be 
 excited at our will, can be united with external pressure, is without risk to 
 the patient, and in my hands has always proved successful." 
 
 The various manipulations employed in the ordinary operation of taxis 
 are substantially as follows : 
 
 It will generally be found desirable that the bladder and rectum be 
 thoroughly evacuated. 
 
 The patient having assumed that position (among those already de- 
 scribed) best calculated to relax the constricted parts, ether should be 
 administered, to the extent of complete obliviousness in all severe cases. 
 
 Having obtained a thorough relaxation of the system, the surgeon grasps 
 the tumor in his right hand and draws it gently downward, in order to dis- 
 engage it from the neck of the sac, and at the same time give it the proper 
 direction in relation to the opening through which he desires it to return 
 into the abdomen. 
 
 This being done, a gentle, steady, uniform pressure is applied to the 
 tumor with the right hand to force out its contents, while the left thumb 
 and index-finger encircle the upper part of the tumor to fix it at that 
 point and thus facilitate reduction. The direction of the pressure must 
 
 Medical and Surgical Keporter, Philadelphia, January 4th, 1873. 
 
864 A SYSTEM OF SURGERY. 
 
 correspond inversely to the course and situation of the hernial protrusion. 
 In oblique inguinal hernia the force should be directed obliquely upward and 
 outward, in the course of the inguinal canal ; whereas in the direct variety 
 the parts should be pushed directly upward, or upward with a slight incli- 
 nation outward. Acting upon the same principle in femoral hernia, the 
 tumor is first pushed directly backward until fairly beyond the reach of the 
 ligament of Hey, then the pressure being made in an upward direction, the 
 reduction is accomplished. If in any case the hernial tumor be of large 
 size, the manipulations should be performed with both hands, but always 
 with caution, lest the parts sustain further injury. 
 
 Soon after the continuous application of this pressure, the operator will 
 generally be aware of some diminution in the size of the tumor, from the 
 escape of gas or fecal matter, and by steadily continuing the treatment, will 
 find one portion after another receding, until, with a distinct gurgling 
 sound, the sac is emptied of its contents. 
 
 Sometimes a trifling pressure is sufficient for complete replacement, 
 while at others considerable force is required. 
 
 The length of time that may be devoted to these efforts will vary accord- 
 ing to circumstances. 
 
 In general an old hernia will bear pressure better and longer than one 
 of recent date, and one of large size will be found more tolerant than a 
 smaller one. 
 
 An excellent evaporating lotion, used by my friend Dr. Belden, is com- 
 posed of equal parts of alcohol, nitrate of potash, and vinegar. The salt 
 must be dissolved with the acid, and the alcohol quickly added and applied 
 before using taxis. 
 
 Puncturing the Intestine. — I believe that puncturing the intestine, where 
 reduction is impracticable, will in many cases supersede other operative 
 measures. The common-sense of the proceeding is evident. From the cases 
 that have already been relieved in this manner, it should be attempted before 
 resorting to herniotomy. Mr. Thomas Bryant, of Guy's Hospital, is much 
 in favor of this method and has adopted it with success; in several instances 
 I have resorted to it. A fine aspirating needle should be carefully intro- 
 duced into the tumor, and the fluid cautiously and slowly withdrawn. The 
 puncture may be made, as I practiced several times, with a good-sized 
 hypodermic syringe. 
 
 In a severe case of intestinal occlusion, in which the entire abdominal 
 wall was incised, it was impossible for either Dr. Talbot or myself to return 
 the intestines into the abdominal cavity, until several punctures were made, 
 whereupon an immense amount of gas escaped, and the intestines were 
 easily replaced. 
 
 Traction in Taxis. — It must be remembered in attempting taxis, that 
 traction is efficacious, and really by this means it is, that the method of 
 Dr. Nichols above mentioned, is successful. 
 
 Dr. Karl Nikolaus* has made some interesting experiments to show how 
 difficult it often is, to push up intestine through a constricted ring. If a 
 portion of intestine, two or three feet long, is passed through a piece of tub- 
 ing a couple of inches in length, and the protruding end of the gut be filled 
 with water, it will be found difficult, if not impossible, to force the water by 
 pressure through the tube ; but if suction be made at the other end, the fluid 
 soon passes upward. The position, therefore, of a patient suffering from 
 strangulated hernia should be upon the knees, with the shoulders on the 
 bed, or in the ordinary Sims' position (the patient resting on the side opposite 
 the hernia), with the hips much elevated. 
 
 * Centralblatt fur Chirurgie, February, 1886. 
 
TRUSSES. 865 
 
 By this position suction is produced, which may be increased by the 
 bladder and rectum being thoroughly emptied. The incarcerated gut is 
 also emptied, and the intestine, partly by suction and partly by gravity, 
 will be drawn within the abdominal cavity. 
 
 Reduction of Hernia by the Rubber Bandage. — Another method of reduction 
 is by the use of the india-rubber band. It is applied by first placing the 
 patient in a recumbent position. A linen bandage is wound around the 
 body two or three times and attached to the rubber band; the latter, if it 
 be an inguinal or umbilical hernia, is then wrapped quite firmly around 
 the base, and carried more loosely over the remaining portion of the incar- 
 cerated bowel. The amount of pressure is regulated by the number of 
 folds of the elastic. This will generally force some, or all, of the contents 
 of the strangulated bowel back into the abdominal cavity, after which 
 the reduction can easily be effected by taxis. 
 
 Dr. Maisonneuve has an instrument for hernia, which consists, first, in 
 a lumbar plate, which rests upon the small of the back, and on either ex- 
 tremity carries a small hook ; second, in a screw arranged nearly like a 
 Petit's tourniquet. It consists in a slightly concave pad, above which, and 
 playing upon a cylindrical endless screw, is a metallic rod, about eight inches 
 long, and armed with hooks. The pad is fitted over the hernia and the 
 hooks at the extremities of the lumbar pad connected by rubber bands to 
 the hooks of the metallic rod. The pressure of the pad upon the hernia 
 can .be intensified or diminished by elevating or lowering the rod, and in 
 this way increasing or lessening the tension of the rubber bands. This 
 apparatus is especially adapted to small hernise. 
 
 M. Chapelle* mentions two cases of strangulated hernia reduced by 
 Esmarch's bandage after all other means had failed. One was of scrotal 
 hernia, the patient being seventy -two years old ; the other a femoral hernia 
 in a female. 
 
 Trusses. — At the present day there are a great variety of trusses, which 
 have been devised for retaining the bowel within the abdomen after the 
 reduction of hernia. Some of these present advantages, and others are worse 
 than useless. I am well assured of one fact, that a truss that will be of 
 service in one case, may fail in another, and a truss may suit a case of hernia 
 at one time and not at another. A truss is nothing more than a pad which 
 fits upon the rings, with a spring or a bandage to keep this pad in place. 
 In many instances, besides the spring, a perineal band is necessary. An 
 inguinal hernia is more readily kept in position than a femoral, and there 
 are but one or two trusses that I have found that are of any service in 
 the latter variety. There are some that have no circular spring, but are 
 supported by elastic bands ; of these the Mocmain lever and the Rainbow 
 elastic are good examples; they are peculiarly suited to elderly people, 
 where the inguinal rings require but little support, but in younger per- 
 sons, especially those of the laboring classes, the pressure upon the rings is 
 not sufficient to prevent the escape of the intestine. 
 
 It would be impossible to enter into the description of many trusses. 
 I can pimply repeat that different cases require different trusses, and that 
 those instruments which combine lightness, elasticity, steady pressure, and 
 are hot likely to shift position from the varied movements of the body, are 
 the best. 
 
 The instruments made by the New York Truss and Bandage Institute 
 appear to be reliable. In the radical cure truss, Figs. 536 and 537, the 
 
 * The Medical Record, October 12th, 1878, No. 414. 
 55 
 
866 
 
 A SYSTEM OF SURGERY. 
 
 front pads are made rights and lefts, and each consists of a ring with a 
 metal foundation, which is made of felt or blanket covered with kid or 
 buckskin on the inside and calfskin on the outside, in the centre of which 
 is an ivory ball attached to an adjusting spring connected by screws to the 
 spring and a piece of metal termed a fork. These forks are made also as 
 
 Fig. 536. 
 
 Fig. 537. 
 
 Haskell's Double Radical Cure Truss. 
 
 Single Radical Cure Truss. 
 
 rights and lefts. The springs are constructed of tempered steel and sus- 
 ceptible (by the aid of a pair of pliers) of being shaped to the form of the 
 body, and the pressure regulated by the same instrument from one ounce 
 to fifteen pounds. The back pad is so constructed that it forms a bridge 
 over the spine, the entire pressure is on each side of the column and 
 directly over the rupture ; the spring is so fitted that there is no pressure 
 on the body from it. The form of the front pad is such that when it is 
 in its proper place it closes the internal ring and thereby prevents the 
 escape of any part of the rupture, while, at the same time, the pad creates 
 an external irritation which may ultimately produce an obliteration of the 
 
 Fig. 538. 
 
 Fig. 539. 
 
 Single Ball and Socket. 
 
 Double Ball and Socket. 
 
 ring. By continuing to wear the truss a sufficient length of time to create 
 an induration, a radical cure can be effected. 
 
 Haskell has an excellent palliative instrument (Figs. 538 and 539) con- 
 structed as follows : The interior of the front pad "is a metal plate, to 
 which is riveted another in which is a metal ball working in a socket, 
 which, is attached to a carriage piece having a flange to receive the 
 spring, and is fastened by a stud-screw having a head for fastening the 
 strap. The back pad is similar to the radical cure truss, and is applied 
 
HERNIOTOMY. 867 
 
 in the same manner. The merit of this instrument consists in a front 
 pad working in the ball and socket. When the truss is properly applied, 
 it covers the internal ring and will remain in place no matter in what 
 position the body may be. The spring may move, but the pad will not be 
 affected. 
 
 I have used a truss manufactured by Pomeroy, known as the "finger pad" 
 which held a hernia that had eluded many other instruments. 
 
 After a truss has been applied, the patient should run, cough, and strain, 
 in order to see if any portion of the intestine escape beneath the pad, for 
 if it does the truss is not adapted to the case, and may be a source of great 
 danger. 
 
 General Considerations regarding Herniotomy — Kelotomy. — Having ex- 
 hausted all the previously described methods of relief without success, or 
 having decided from the extreme severity and urgency of the symptoms that 
 nothing less than operative procedure can be of avail, measures should be 
 taken for performing herniotomy. 
 
 This operation should not be regarded as the dernier ressort, to be de- 
 ferred until all hope is lost, for indeed in many instances it may be con- 
 sidered as the first resource. 
 
 The danger from the operation is but slight compared with that which 
 threatens the patient if the strangulation is allowed to continue for a length 
 of time. The more severe the symptoms, the more urgent the demand 
 for prompt and positive removal of the cause. 
 
 Premising that, in all cases which are severe enough to demand operative 
 interference, some ansesthetic has already been administered during the 
 taxis, the division of the constricted part should be performed while 
 the patient is insensible. The character of the operation will be deter- 
 mined by the seat of the stricture and the condition of the strangulated 
 protrusion. 
 
 The constriction may be situated either in the tissues surrounding the 
 neck of the sac and forming the hernial opening, within the neck of the sac, 
 or in the contents of the sac. 
 
 According to the Register-General's report as given by Mr. Spanton, there 
 were 1119 deaths from hernia in a single year, of which 23.5 per cent, had 
 undergone operations for strangulation. The same author asserts that the 
 mortality after kelotomy, in eleven hospitals, is 41.8 per cent. 
 
 Division of the Stricture External to the Sac. — Respecting this method 
 the opinions of surgeons are at variance. All must agree that the less the 
 hernial sac and its contents are subjected to manual interference, the less 
 likely is severe inflammation, which is such a fruitful source of danger, to 
 arise. 
 
 It may be urged that as the bowel is not exposed to inspection, there 
 exists a great liability of returning, into the abdominal cavity some portion 
 of intestine already gangrenous, thereby giving rise to fatal results. This 
 objection is answered by the fact that such a condition can almost inva- 
 riably be recognized without opening the sac, and also that such a degree 
 of inflammation would have produced sufficient adhesions to prevent the 
 reduction of the tumor after simply dividing the tissues external to the 
 sac. And further, if this method is found insufficient, the division of the 
 stricture inside of the neck of the sac, or the haying open and displaying its 
 contents, are but additional steps in the same direction. It must be remem- 
 bered that there may be an omental as well as 'a peritoneal sac, as seen in. 
 Fig. 540. 
 
 In general, when there is reason to believe, from the character and 
 duration of the symptoms, that strangulation does not depend upon 
 
868 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 540. 
 
 adhesive inflammation, in fact, when taxis has been considered appli- 
 cable but has failed, the operation external to the sac is certainly justifi- 
 able, and when complete reduction 
 follows, all that could be gained 
 by any plan of treatment, has 
 been accomplished, and manual 
 injury of the peritoneum has been 
 avoided. 
 
 If, after dividing the edges 
 of the hernial opening, the re- 
 duction is still impossible, or if 
 something remains in the sac which 
 would raise a doubt as to the con- 
 dition of its contents, or when from 
 the severity or long continuance of 
 the strangulation, there is fecal 
 vomiting, a dark appearance and 
 leathery feel of the sac, with pros- 
 tration, indicating that gangrene 
 has already taken place, then it 
 should be freely laid open, and its 
 contents carefully examined and 
 judiciously dealt with. It is said 
 that Langenbeck operated for stran- 
 gulated hernia without opening the 
 sac, and lost but three cases in fifty- 
 nine operations. 
 
 Theilhaber* says that empty her- 
 nial sacs, especially if exudation 
 occur rapidly in them, give rise to 
 symptoms closely resembling stran- 
 gulation of the intestine, and gives 
 
 An " omental sac," from a case in which the stricture "&W0 Cases, 
 was relieved by operation, the omentum being divided Directions for the Performance Of 
 
 in order to reach the bowel; a, points to a dense fibrous tt„„„- i„ m „ riiA n«^« +■;«•« to. ~ 
 
 membrane, apparently a condensation of the different Herniotomy . — UIO. UperailOn. — 1 ne 
 
 fascise and neighboring areolar tissue; b, to the perito- -nafipnf "hpincr nnrlpr thp infhipnpp 
 
 neal sac ;c, the external surface ofthe omentum, which Pauent, Oemg Unaer Hie mnuence 
 
 is spread out over the interior of the whole of the her- 01 an ansesthetlC, With the bladder 
 
 teMcie C; d ' the w ° UDd made in theoperation; e ' the emptied and the hair shaved from 
 
 This preparation is from one of the cases referred to the parts, is placed, with shoulders 
 by Mr. Hewitt, in Med.-Chir. Trans., vol. xxvii., and is -,• -| ,-, • i -, \ a j • 
 
 in the Museum of St. George's Hospital.-HoLMES. Slightly raised SOld knees Hexed , in 
 
 a position similar to that assumed 
 during the taxis. An incision is made directly over the neck of the 
 sac, in inguinal hernia from the internal to below the external ring, in 
 the course of the inguinal canal ; while in femoral hernia, a vertical inci- 
 sion is made over and to the inner side of the crural ring. Divide the 
 coverings consecutively until the sac is reached, making free use of the 
 grooved director and scalpel handle when exposing the deeper structures. 
 Any important haemorrhage must be controlled by torsion or the liga- 
 ture. 
 
 It will not be possible to demonstrate the precise number of coverings of 
 the intestine, for if there has been considerable inflammation, the coats may 
 be almost indistinguishable, or additional layers may have been deposited. 
 
 * Abstract of Medical Science, vol. iv., No. viii. (Aertzliches Intelligenz-Blatt, 7, 1877). 
 
HERNIOTOMY. 869 
 
 The seat of the stricture is to be ascertained by passing the left index 
 finger into the upper extremity of the wound, and if it be found outside of 
 the sac, a director is passed beneath the obstruction, and with a hernia knife, 
 herniotome, or probe-pointed bistoury, the stricture is divided by a short 
 incision upward, this being more likely to avoid the epigastric artery. Care 
 should be taken to make the division as small as possible, just enough to 
 allow the return of the intestine without force. This being done, reduction 
 is carefully attempted, and if the bowel goes back readily, the object is ac- 
 complished. 
 
 But if this result does not follow, and any of the hernial contents remain 
 in the sac, then it must be opened freely, care being observed not to wound 
 the intestine. To avoid this make a small incision to admit the director, 
 and carrying it along close to the walls of the sac, divide them with a bis- 
 toury. Generally some fluid will escape, although in recent strangulation 
 the quantity may be small. The contents having been exposed, they should 
 be examined with care and gentleness. 
 
 Upon examination, the intestine may be much discolored, almost black 
 from congestion, or covered by the products of exudative inflammation, 
 yet if it be neither ruptured nor gangrenous, it should be restored to the 
 cavity of the abdomen. 
 
 Cases will be met, in which doubt exists as to the propriety of the above 
 procedure, and judgment and discrimination will be demanded to decide 
 the question. If a large amount of intestine be found to be injured, it will 
 be wiser to leave it, simply dividing the stricture. 
 
 Care should be taken in cutting the neck of the sac, lest the already in- 
 flamed and weakened bowel sustain further injury. 
 
 Having introduced the finger into the neck of the sac, a probe-pointed 
 bistoury is passed flatwise along the finger till underneath the constriction, 
 when by turning the edge of the knife upward, it is immediately divided. 
 An incision of one or two lines in length is generally sufficient. 
 
 This will be the best method of. treatment if the vitality of the bowel seems 
 destroyed beyond reasonable hope of recovery. To determine this, aid may 
 be given by the history of the case, the size of the tumor, duration of con- 
 striction, and the condition of the patient. 
 
 Greater danger of mortification exists when the hernia is small, recent, 
 and the strangulation has been protracted, than when opposite conditions 
 obtain. 
 
 If the ordinary phenomena of constricted hernia are succeeded by a 
 Hippocratic countenance, feeble wavering pulse, hiccough, and crackling 
 state of the tumor, with sudden cessation of pain, and great prostration 
 of the vital forces, it may be positively assumed that gangrene is pres- 
 ent. 
 
 When, however, the symptoms are less marked, the prognosis will be 
 assisted by recourse to the following measures : all constriction being re- 
 lieved, warm fomentations should be applied to the parts for ten or fifteen 
 minutes, in hope of restoring the circulation; but if at the end of that time 
 there is no change in the appearance of the tumor, if no blood issues on 
 puncturing the vessels, and if, superadded to these, the intestine is found 
 soft and flaccid, its sensibility lost, and its temperature decreased, the pres- 
 ence of mortification becomes a certainty. 
 
 Under these circumstances, the gangrenous gut may be resected or the sur- 
 geon may wait for the formation of an " artificial anus." If the surgeon pre- 
 fers the latter course, nothing remains but to support the patient, giving 
 care to the wound, in the hope that nature may be able to effect a sponta- 
 neous cure. No apprehension need be felt that the intestine will retract 
 
870 A SYSTEM OF SURGERY. 
 
 into the abdomen, for such strong adhesions have been formed at the neck 
 of the sac that such a result is for the time prevented. Later, this attempt 
 at retraction of the bowel is nature's method of perfecting a cure. 
 
 If the bowel be ruptured or perforation has taken place, the stricture 
 should be relieved at once, and resection performed. Should there be but a 
 small perforation, a delicate ligature may be carried around it, cutting the 
 ends close to the knot and leaving it at the orifice of the sac. 
 
 In all cases of epiplocele or entero-epiplocele, in which strangulation has 
 occurred, it must be remembered that the omentum cannot bear with 
 safety as much injury as the intestine, and when there is inflammation, 
 hypertrophy, or that loss of consistence which follows these two conditions, 
 the diseased portion should be removed with the knife, carefully ligating 
 all the vessels separately, as this tissue is quite vascular. Before perform- 
 ing this part of the operation the tumor should be closely examined, lest 
 it contain a knuckle of intestine concealed within its folds. There may 
 exist an omental sac, in which case care must be exercised ; the intestine 
 and omentum being returned separately, if reducible, with the precaution 
 that there remain no adhesions or bands at the neck which will prolong 
 the constriction. 
 
 The after-treatment is by no means unimportant. The patient is kept 
 quiet, and after the wound has been closed by sutures, a compress and 
 bandage are to be applied. All action of the bowels is to be prevented 
 by an opiate or suppository of morphia. Very little aliment should be 
 taken by the mouth ; but if the patient is very feeble he must be sup- 
 ported by a little brandy and water, or small lumps of ice may be freely 
 administered if there be thirst. Should there be high fever or symptoms 
 of peritonitis, they must be met by the appropriate remedies. 
 
 Enterectomy in Gangrenous Hernia.— As has been mentioned, it becomes 
 a matter for consideration what to do with the gangrenous gut after the 
 operation for strangulated hernia. For years the direction has been to 
 make an artificial anus by stitching the intestine, previously slit, to the 
 walls of the incision. The operation has generally been looked upon with 
 disfavor, not only on account of its mortality, but also because the wretched 
 condition in which it leaves the patient is, in many instances, worse than 
 death. 
 
 To remedy such evil, in 1727, Ramdohr successfully resected nearly two 
 feet of intestine. Among the first in this country to perform the operation, 
 was the late George D. Beebe, who resected four feet of intestine in a case 
 of umbilical hernia in a woman — the patient, though pregnant, recover- 
 ing. The establishment of communication between the cut intestines 
 was effected by means of clamps. Of late, the " circular resection and 
 suture of the intestines " has been performed about seventy times, and 
 of sixty-seven of these there were twenty-one cures which were perfect; 
 two imperfect, recovering with an artificial anus ; and forty-four deaths, 
 making a mortality of about 65.57 per cent. In removing a portion of the 
 intestine, the first consideration is to effectually occlude the gut, to prevent 
 effusion ; this may be done with a ligature, or with a pair of forceps having 
 the blades covered with an antiseptic gauze. Billroth and Czerny recom- 
 mend the fingers as the best medium of occlusion. The mesentery at- 
 tached to gangrenous intestine should be removed in a triangular piece, 
 and the vessels therein ligated. If the mesentery be not gangrenous it 
 may be ligated, although the former procedure is preferable. The greatest 
 caution is to be used during this part of the operation, to prevent the 
 separation of the mesentery any further than from that portion of the 
 bowel to be removed. If such an accident should happen, gangrene of the 
 
RADICAL CURE OF HERNIA. 871 
 
 edges of the wound will follow. The intestine is cut off at right angles 
 and the sutures inserted. The Czerny-Lembert suture is the one ap- 
 plicable to this condition. This suture is 
 made as follows : The needle is passed entirely FlG - 541 - 
 
 through the walls of the gut, about an eighth 
 of an inch from the margin of the cut, and 
 brought out on the opposite side. When the 
 entire circle of intestine is thus brought to- 
 gether, then the original Lembert suture, pass- 
 ing only through the serous coat of the bowel, 
 is made, and, when completed, the sutured in- 
 testine is returned into the abdominal cavity. 
 The first suture should be entered upon the mesenteric side of the gut. 
 The incisions should be made in sound intestine. 
 
 Radical Cure of Hernia. — In most of these so-called radical methods, the 
 patient is required to wear the truss, if not for life, for a considerable time, 
 so that these procedures are not as satisfactory as we are led to believe. 
 The operations of Gerdy, Wutzer, Woods, Chisholm, and Wells, are all 
 open to objection, that of the latter giving me the most satisfaction, until 
 the adoption of the more recent method. W r e must be careful, in studying 
 these, not to confound the operation of Dr. T. Wood, of Cincinnati, with 
 that of Professor John Wood, of London, although they are similar. 
 Dowell, of Texas, has an excellent method. Jamison, of Baltimore, fol- 
 lowed Dzondis' transplantation plan, and the "local irritation and com- 
 pression methods " of Pancoast, Velpeau, Armsby, and Riggs have had 
 their stanch supporters. The two operations which are at present engag- 
 ing the attention of the profession are : 1st, that known as the radical cure 
 by cutting off the sac, or the "open method," and the "radical cure by 
 Heaton's injection." 
 
 The Open Method has been a development of successive stages. The 
 ligature of the neck of the sac, and extirpation of its fundus, was first de- 
 scribed by Kiesel, of Germany, in 1876. The stitching together of the 
 edges of the ring was first performed by Professor Czerny, of Heidelberg, 
 in 1879. His method was to cut down upon the hernia, isolate the sac, 
 ligate its neck, cut away the fundus, return it within the abdomen, 
 and, finally, to stitch together the refreshened edges of the ring with cat- 
 gut. 
 
 Two years later Dr. Gross, of Philadelphia, adopted the plan as above, 
 with the modification of using silver wire in place of catgut for closing the 
 ring. With this alteration the method of Czerny has been freely used by 
 the surgeons of Liverpool with remarkable results. In all, one hundred 
 and twenty-five cases Have been operated upon without a single death. 
 Little is said about the recurrence .of the hernia. Of twenty-one operations 
 performed by Dr. Banks (which are included in the one hundred and 
 twenty-five), and in which sufficient time had elapsed to distinguish 
 successes from failures, fifteen were complete cures, four partial successes, 
 and two failures. Of twelve operated upon in the Northern Hospital, ten 
 were cured and two failed, making, for the entire thirty-three, a percentage 
 of failure of 24.2. 
 
 In 1883 Dr. Leisrink, of Hamburg, collated 390 cases. Of 202 opera- 
 tions upon reducible hernia, 187 recovered and 15 died ; of the former 20-J- 
 per cent, recovered. Of 188 operations for strangulated hernia, 155 recovered 
 and 33 died. Nothing is stated regarding relapses. 
 
 Combining the results of the Liverpool cases and those collated by Leis- 
 rink, we find that of 515 operations for reducible and strangulated hernia, 
 9.3 per cent, died, 2 per cent, of which may be ascribed to the strangulation, 
 
872 A SYSTEM OF SURGERY. 
 
 it being shown by Leisrink's statistics that the mortality in reducible cases 
 is about 7.4 per cent. 
 
 The operation as at present performed is applicable to all kinds of hernia, 
 reducible and irreducible, but should only be employed when the patient 
 is incapacitated, or his life made miserable by the rupture. 
 
 The operation should be made in the following manner : 
 
 The strictest antiseptic precautions should be taken, and the pubes, 
 scrotum, and the inner sides of the thighs shaven and carefully washed 
 with a bichloride solution, of one to one thousand. The first incision 
 should be full and free, that the operator be not cramped in his fur- 
 ther manipulation; and it is important that the surgeon should recog- 
 nize the sac when he reaches it, and not mistake other tissue for the 
 peritoneal covering. When the sac is found all the smaller bloodvessels 
 should be either tied or torsioned, and the sac drawn forward. The con- 
 tents of the bowel should be pushed back into the cavity of the abdomen 
 and kept there by the finger of an assistant ; then the sac should be freely 
 opened that the surgeon may ascertain beyond doubt that there is no 
 knuckle of the intestine nor fold of omentum contained. The sac must 
 then be drawn further out, ligated with a strong catgut ligature, and cut 
 off just anterior thereto. The stump of the gut may be stitched to 
 the pillars of the ring, or pins may be placed at right angles through 
 the stump, passing through the rings, which will prevent the retrac- 
 tion of the stump. The pillars of the ring may be stitched together, 
 which is readily effected by three or four sutures of silver wire, and 
 the wound closed in the usual manner. I have employed both catgut 
 and whale tendon ligatures for this purpose, and found them to answer 
 well. 
 
 My modification of this process is to encircle the base of the sac with 
 a piece of catgut ligature not drawn too tightly, to obstruct circulation, and 
 to twist around the remaining portion of the extruded peritoneum a piece 
 of catgut two feet in length by which an elastic plug is made. I then turn 
 this plug around, fitting its extremity into the abdominal ring, and hold it 
 in position by a suture passing through both pillars. Drainage-tubes are 
 inserted and the integument brought together. If the protrusion is an 
 epiplocele, I ligate the omentum close to the ring and cut off the protruded 
 portion, using the stump as before in the opening. 
 
 Heaton's Method of Radical Cure.— Dr. Heaton, of Boston* has devised 
 procedures for the radical cure of rupture, which deserve attention in this 
 place. He has two methods, which he denominates the " liquid " and 
 the " solid," in accordance with the character of the substance employed. 
 In the one it is solid and in the other liquid. He insists on one 
 point, and that is that but a slight degree of inflammation must be excited; 
 indeed, he denominates the process as " the method of tendinous irritation" 
 The irritant he employs in the " liquid method " is composed of half an 
 ounce of Thayer's fluid extract (prepared in vacuo) of Quercus alba, tritu- 
 rated, with the aid of gentle heat, with fourteen grains of the solid alco- 
 holic extract of Quercus alba, adding the sulphate of morphia in the pro- 
 portion of a grain to the ounce. These substances must be triturated for 
 a long time. The "solid method" differs, not in the operation, but merely 
 in the character of the substances, which are the same as above ; the solid 
 being mixed with the fluid extract of Quercus alba until a thick paste is 
 formed. The advantages of the latter over the former are, that a much 
 smaller amount is required to produce the irritation, and the paste can 
 
 * The Cure of Rupture, Reducible and Irreducible, also of Varicocele and Hydrocele, by 
 New Methods, by G-eorge Heaton, M.D., Boston. 
 
heaton's method of radical cure. 873 
 
 be smeared over the fibrous surfaces with less risk of producing inflam- 
 mation. 
 
 The instruments required are really hypodermic syringes (Fig. 542), the 
 cylinder being made of silver and the needle made of solid steel, bored. This 
 latter is considered an essential 
 
 point, as firmness and strength are fig. 542. 
 
 required to pierce the tissues. The 
 directions for performing the oper- 
 ation I give in Dr. Heaton's own n >sr**k*s&*w. 
 words: " The hernia and, if possi- ■■» 
 
 ble, the Sac, Should be returned into Heaton's Hernia Syringe. 
 
 the abdominal cavity, and the pa- 
 tient in the recumbent position. Invaginate the right forefinger in the 
 scrotum and find the external abdominal ring ; then with the left forefinger 
 press perpendicularly upon the integument directly over this ring, and use 
 sufficient force to, if possible, press the integument together with the finger, 
 directly into the ring, the left forefinger being at or in the ring, the sper- 
 matic cord and the sac, if in the way, are to be pushed to one side, so that 
 nothing may remain between the external pillar of the ring and the finger 
 except the integument and subjacent superficial fascia. Keeping the left 
 forefinger thus, take the instrument in the right hand and introduce its 
 freshly sharpened and polished beak quickly, penetrating the integument 
 and superficial fasciae, just passing but not grazing the external pillar, and 
 entering the canal at once. Then remove the left forefinger and gently in- 
 sinuate the beak further on, well into the canal, exercising the greatest care 
 not to impinge upon the spermatic cord, which is sensitive to the slightest 
 touch, or upon the fibrous walls of the canal Having satisfied him- 
 self that the beak of the instrument is in the canal, the surgeon then de- 
 posits about ten minims of the liquid irritant, emitting it drop by drop, and 
 
 spreading it as much as possible Particular care should be taken 
 
 that the intercolumnar or arciform fibres, and the inner edges of the external 
 ring are wet with the irritant. A well-fitting bandage, with a pad over the 
 ring, should be applied before the patient is allowed to get up, and it is 
 better to keep him quiet for some time in bed." 
 
 Dr. Warren, however, has lately improved the Heatonian method, not 
 only in regard to the material injected, but in the apparatus for throwing in 
 the fluid. He objects to the ordinary fl. ex. of Quercus because the solid* 
 portions of it are very liable to become impacted in the syringe, and when 
 ejected to be unequally distributed upon the fascia. 
 
 He also differs in the explanation of the method of cure. He believes 
 that the operation is successful, not because, as Dr. Heaton avers, " a tendi- 
 nous irritation " is produced, but because it produces a local inflammation 
 without suppuration. He gives, also some modifications of his original 
 formulae; thus.f 
 
 Formula A. — For infants and children, whether the herniae be accidental 
 or congenital : 
 
 R. Fl. ext. quercus albse, ^ij, reduced by distillation to gj ; alcohol (90 
 per cent.) 5ij ; ether sulph., 3j ; morph. sulph.,gr. ss. M. Sig. Inject 8-10 
 minims. 
 
 Formula B. — For old and long-standing hernise, whether congenital or ac- 
 quired: 
 
 R. Fl. ext. quercus albae, 3iv, reduced by distillation to 3j ; alcohol (90 
 
 * Medical Record, October 18th, 1879, p. 368. 
 f Glasgow Medical Journal, May, 1883, p. 339. 
 
874 
 
 A SYSTEM OF SURGERY. 
 
 per cent), SSiij ; ether sulph., 5ij 5 morph. sulph., gr. ij. M. Sig. Inject 
 10-25 minims. 
 
 Formula C. — Best in the majority of cases : 
 
 R. Fl. ext quercus albse, gvj, reduced by distillation to |ij ; alcohol (90 
 per cent), 3ss; ether sulph., 3ij ; morph. sulph., gr. iv; tine, veratri viridis, 
 3ij. M. Sig. Inject 15-20 minims in small and recent hernise ; but 25-50 
 minims in large or old hernise. 
 
 " This fluid will cause a marked reduction of pulse and temperature, 
 and it may be necessary to put a hot water bottle to the patient's feet. This 
 reduction may last as long as 48 hours, and gives a decided advantage in 
 obtaining a more decided local effect of the irritant." 
 
 Dr. Warren invented several instruments whereby the injection can be 
 made. The first (which I found so cumbersome that I soon laid it aside) 
 has been superseded by another, as seen in the cut (Fig. 543). De Garmo 
 
 Fig. 543. 
 
 Warren's Syringe. 
 
 has invented a good syringe for the same purpose, as seen in Fig. 544. 
 After the injection a truss must be worn, and Dr. Warren lays emphasis on 
 a device of his, known as the anatomical truss, the pad of which is made 
 of silver wire gauze, the object of the latter construction being to facilitate 
 
 Fig. 544. 
 
 DeGarmo's Syringe. 
 
 the application of medicated substances to the parts beneath should they 
 become irritated or inflamed. The truss has a large pad (as seen in Fig. 
 545) which has a tendency to bring the rings nearer together. The instru- 
 ment should be worn from three to five months. 
 
 I have used this method many times with a success which has surprised 
 me ; at other times with failure ; and again, at others, I have been disap- 
 pointed to find that after the removal of the ordinary truss which I have 
 used (I have not applied Warren's) the gut would reappear at the open- 
 ing of the ring, and, though not coming downwards as far as before the 
 operation, yet would cause sufficient inconvenience to require a second 
 injection. 
 
 My experience is that about half the operations succeed ; in my recent 
 treatments I have had recourse to two injections before allowing the patient 
 to leave his bed. The second, consisting of ten or fifteen minims, is given 
 on the fifth day. Lately, I use a hypodermic syringe with a little larger 
 point than usual, and have discarded all the instruments devised for this 
 special purpose. 
 
RADICAL CURE OF HERNIA. 875 
 
 In looking over some old medical and surgical literature I was surprised 
 to find that the celebrated Mr. Lizars employed a preparation of white oak 
 bark as an application for rupture, and that he spoke highly of its use. 
 
 Fig. 545. 
 
 Warren's Truss. 
 
 According to Dr. Schwalbe, who has written in favor of the method, 
 twenty injections are required to effect a cure, and the period of time 
 extends from two months to a year. Lately Mr. Keetley has operated upon 
 eleven cases, nine of which were cured, and two benefited. Mr. Keetley* 
 makes something of a cutting operation as well as the injection method. 
 The integument is incised down to the ring and a director passed under the 
 intercolumnar fascia ; upon the director the nozzle of the syringe is passed 
 and a concentrated solution of white oak bark is injected into the canal. 
 After this is thoroughly done, the pillars of the ring are drawn together by 
 two catgut sutures. 
 
 The following is Wood's description of his radical cure operations, of 
 which in 155 cases, there were but 2 deaths, 40 failures, and 113 cures : 
 " The patient being laid upon his back, with the shoulders well raised and 
 the knees bent, the pubes cleanly shaved, the rupture completely reduced 
 and chloroform administered, an oblique incision, about an inch long, is 
 made in the skin of the scrotum over the fundus of the hernial sac. A 
 small tenotomy knife is then carried flatwise over the margin of the inci- 
 sion, so as to separate the skin from the deeper coverings of the sac to the 
 extent of about an inch or rather more all round. The forefinger is then 
 passed into the wound, and the detached fascia and fundus of the sac in- 
 vaginated into the canal. The finger then feels for the lower border of the 
 internal oblique muscle, lifting it forwards to the surface. By this means 
 the outer edge of the conjoined tendon is felt to the inner side of the finger. 
 A stout semicircular needle, mounted in a strong handle, with a point flat- 
 tened antero-posteriorly, and with an eye in its point, is then carried care- 
 fully up to the point of the finger along its inner side, and made to transfix 
 the conjoined tendon and also the inner pillar of the external ring ; when 
 
 * British Medical Journal, September 19th, 1885. 
 
876 
 
 A SYSTEM OF STJRGEKY. 
 
 Fig. 546. 
 
 Wood's Operation.— Bryant. 
 
 the point is seen to raise the skin, the latter is drawn over toward the 
 mesian line, and the needle made to pierce it as far outward as possible. 
 A piece of stout copper wire, silvered, about two feet long, is then hooked 
 into the eye of the needle, drawn back with it into the scrotum, and then 
 
 detached. The finger is next placed behind the 
 outer pillar of the ring and made to raise that 
 and Poupart's ligament as much as possible 
 from the deeper structures. (Fig. 546.) The 
 needle is then passed along the outer side of 
 the finger and pushed through Poupart's liga- 
 ment, a little below the deep hernial opening 
 (the internal ring). The point is then directed 
 through the same skin-puncture already made, 
 the other end of the wire hooked on to it, drawn 
 back into the scrotal puncture, as before, and 
 then detached. Next, the sac, at the scrotal 
 incision, is pinched up between the finger and 
 thumb, and the cord slipped back from it, as in 
 taking up varicose veins. The needle is then 
 passed across behind the sac, entering and 
 emerging at the opposite ends of the scrotal 
 incision. The inner end of the wire is again 
 hooked in and drawn back across the sac ; both 
 ends of the wire are then drawn down until the 
 loop is near the surface of the groin above, and 
 are twisted together down into the incision, and cut off to a convenient 
 length. Traction is then made upon the loop ; this invaginates the sac and 
 scrotal fascia well up in the hernial canal. The loop of wire is finally 
 twisted down close into the upper puncture, and bent down to be joined to 
 the two ends, in a bow or arch, under which is placed a stout pad of lint. 
 The whole is held steady by a spica bandage. The wire is kept in from ten 
 to fourteen days, and even longer if the amount of consolidation is not 
 satisfactory. Very little suppuration usually follows, but after a few days 
 the parts can be felt thickened by adhesive deposit. The wire becomes 
 loosened by ulceration in its track until it can be untwisted and withdrawn 
 upwards. In this operation the hernial canal is closed along its whole 
 length, and an extended adherent surface is obtained to resist future pro- 
 trusion." 
 
 After this operation, as in others, the truss must be worn for a long time, 
 and always when lifting or straining. 
 
 For the radical cure of hernia, Langenbeck succeeded by dissecting up 
 as thick a flap of skin as possible, corresponding in width with the hernial 
 opening. In inguinal hernia, he begins at the external ring, and dissects 
 upwards and outwards for an inch and a half. He then makes room for 
 the flap, by introducing his finger into the inguinal canal, and forces the 
 flap into it without twisting, and finally closes the external wound over the 
 flap. For a femoral hernia, the flap is made from the fossa ovalis, and is 
 about one-half as long. The flap in umbilical hernia is made in any direc- 
 tion, except over the ligamentum teres. 
 
 Inguinal Hernia, Its Surgical Anatomy. — The surgical anatomy of inguinal 
 hernia is always a matter of consideration and study, and with careful dis- 
 section in a properly preserved or fresh cadaver the ordinary points may be 
 made out. I have, in some instances, been able to find all these cover- 
 ings in the cadaver in persons who have not suffered from hernia during 
 life, but my experience is that in those who have suffered from rupture 
 
THE ANATOMY OF INGUINAL HERNIA. 877 
 
 during life, there is always more or less alteration of structure (even when 
 there has been no strangulation) from the wearing of trusses, from an occa- 
 sional incarceration, or from the frequent manipulations necessarily per- 
 formed by the patient to restore or keep in position the refractory intestine 
 or omentum. The integument, fascia and peritoneum, and in the femoral, 
 the sheath of the femoral vessels are readily recognized, but the inter- 
 columnar and cremasteric fascia, the septum crurale, and cribriform fascia 
 cannot, in the majority of instances, be discovered. Where strangulation 
 exists these layers need scarcely be looked for. The necessary exuda- 
 tion consequent upon inflammation and strangulation destroys the rela- 
 tive position and even the appearance of the parts; the main object 
 of the surgeon in operating must be the recognition of the peritoneum. 
 These facts should be borne in mind by the inexperienced operator. Long 
 ago they were recognized, and in Pott's celebrated treatise * written over 
 110 years ago, I find these words which are worth recording: "However 
 incredible or strange it may seem, yet I am convinced that operations 
 have been performed by the information obtained from books only, without 
 any previous anatomical knowledge, any practice on dead bodies, and 
 hardly any, if any, opportunities of seeing any operations performed by 
 others on the living ; how grossly must such an operator be deceived, on 
 account of the rings, as they are usually but absurdly called, of the ab- 
 dominal muscles," etc. 
 
 I must, however, describe the actual dissections necessary for the proper 
 understanding of the anatomy of inguinal and femoral hernia, as these two 
 varieties are most frequently encountered by the surgeon and are those 
 which are often subjected to operation, and because once in a while it is 
 good for us to rub off the rust from our anatomy. 
 
 In studying the anatomy of this region assistance will be derived by 
 adopting certain " fixed points." 
 
 Of these points the umbilicus may be regarded as one, the symphysis 
 pubis another, and the anterior superior spinous process of the ilium a third. 
 Draw a line from the symphysis to the umbilicus, carry another from the 
 umbilicus to the superior spinous process of the ilium on each side, and 
 from these to the symphysis pubis. We now have two triangles with a 
 common base, while their apices correspond to the superior spines of the 
 ilia. These are the inguinal triangles. In the dissection of these points, 
 the incisions made will correspond to the common base of the triangles and 
 to the line drawn from the umbilicus to the superior spinous process of each 
 ilium. 
 
 The first covering is the integument, which is removed by reflecting it 
 downward. 
 
 The second covering is the superficial and deep fascia; the superficial 
 epigastric vessels and nerves being contained between the two layers of the 
 superficial fascia. 
 
 The third is formed by the intercolumnar fascia, which is a series of 
 curved tendinous fibres arching across the lower portion of the aponeurosis 
 of the external oblique muscle, from the outer third of Poupart's ligament, 
 closing the orifice of the external abdominal ring, and strengthening its 
 pillars by stretching from one to the other, and from this deriving its name, 
 — intercolumnar fascia. 
 
 The external abdominal ring is not round, but triangular in shape, and 
 any expectation of finding a round aperture will be disappointed. 
 
 * A Treatise on Ruptures, by Percival Pott. London, 1775, p. 232. 
 
878 A SYSTEM OF SURGERY. 
 
 In the recent state there is no opening, it heing closed, as before stated, by 
 the intercolumnar fascia ; otherwise hernial protrusions would be of more 
 frequent occurrence. 
 
 This ring is found in the aponeurosis of the external oblique, about an 
 inch or an inch and a quarter upward and outward from the crest of the 
 os pubis, lying above Poupart's ligament, and transmitting the spermatic 
 cord in the male, and the round ligament in the female. Poupart's ligament 
 is a reflection of the aponeurosis of the external oblique, from the anterior 
 superior spine of the ilium to the symphysis pubis. This is sometimes 
 called the crural arch. The external pillar of the external abdominal ring 
 is strengthened by a small triangular ligament, which extends from the 
 under surface of Poupart's ligament to the ilio-pectineal line, into which it 
 is inserted to the extent of one inch, and is called Gimbernat's ligament. 
 This may be the seat of stricture. 
 
 Having removed this fascia, immediately beneath is discovered the in- 
 ternal oblique muscle, the lower border of which gives the fourth covering, 
 the cremasteric fascia. The cremaster muscle consists of the lower fibres of 
 the internal oblique, taken away by the descent of the testes in the foetus. 
 These fibres are continued in loops upon the spermatic cord, and being held 
 together by dense areolar tissue, constitute the fascia of which we speak. It 
 has also received the name of tunica erythrodes. 
 
 The internal oblique muscle arises by fleshy fibres from the outer half of 
 Poupart's ligament, from the anterior two-thirds of the middle lip of the 
 crest of the ilium, and from the neighboring fascia. From these several 
 points of origin, the fibres diverge; the posterior ones ascend and are 
 inserted into the cartilages of the four lower ribs ; those from Poupart's 
 ligament pass downwards and inwards, join with the aponeurosis of the 
 transversalis in forming the conjoined tendon, and are inserted into the crest 
 of the os pubis and the pectineal line. 
 
 Those from the spine and crest of the ilium are directed forward, upward, 
 and inward, terminating in a broad aponeurosis : the upper three-fourths 
 divides and sends one portion in front, and the other behind the rectus 
 muscle, but unites again at its inner border to be inserted in the linea alba ; 
 while the lower fourth is continued forward unseparated in front of the rectus 
 to the linea alba, where it is also inserted. 
 
 When the muscle is removed, the transversalis is brought into view, but 
 this gives no covering to hernia, as the viscus passes beneath its lower 
 border. 
 
 Laying back the rectus, the transversalis fascia is reached. This is an 
 aponeurosis lying between the under surface of the transversalis muscle and 
 the peritoneum, and forming the fifth covering of the hernia by a funnel- 
 shaped process called the infundibuliform process of the transversalis fascia. 
 The internal abdominal ring is found in this fascia at a point about equi- 
 distant between the spine of the pubis and the anterior superior spine of the 
 ilium, and about a half inch above Poupart's ligament. 
 
 Its size differs in individuals, being larger in the male than in the female ; 
 it is of oval shape, and its oval extremities are directed upward and down- 
 ward. Above, it is bounded by the arched fibres of the transversalis, and 
 internally by the epigastric artery. 
 
 The inguinal or spermatic canal is about an inch and a half in length, is 
 directed upward and outward, placed parallel with and a little above Pou- 
 part's ligament, and extends from the internal to the external abdominal 
 ring. It transmits the spermatic cord in the male, and the round ligament 
 in the female. Immediately underlying the transversalis fascia, and form- 
 ing the sixth and last covering of hernia, is found the peritoneum, which 
 may be recognized by its white glassy appearance — and this forms the sac 
 
EPIGASTRIC ARTERY. 
 
 879 
 
 of the hernia. Between this and the gut is the subserous areolar tissue, 
 which by some is considered an additional investment of the intestine. 
 
 An oblique inguinal hernia passes through both rings, and through the 
 inguinal canal (Fig. 547) ; a direct inguinal hernia escapes through the 
 abdominal wall and the external ring (Fig. 548). The two varieties have 
 
 Fig. 547. 
 
 Fig. 548. 
 
 Guy's Hosp. Mus., 478 15 . Oblique Inguinal 
 Hernia. Bubonocele on right side, but pass- 
 ing through external ring on left.— Bryant. 
 
 Guy's Hosp. Mus., 480 20 . 
 guinal Hernia.— Bryant. 
 
 Direct In- 
 
 the same coverings, except that in the latter the conjoined tendon is substi- 
 tuted for the cremasteric fascia. 
 
 Epigastric Artery, its relation with the Internal Ring. — The study of the 
 relations of these vessels has been thoroughly made by M. Jules Cloquet * 
 from whose dissections these deductions are made. They may seem un- 
 important to the general practitioner, but may be of immense service to 
 the surgeon in case of emergency. The relations of the artery to the inner 
 ring are interesting and important. In general the epigastric artery passes 
 immediately upon the internal border of the internal abdominal ring, so 
 that the spermatic vessels on entering the canal appear at first sight to 
 wind around the artery. In some subjects the epigastric is situated four 
 or five lines to the inner side of this opening, and is not in contact with 
 the spermatic vessels at the point where they form a curve to enter the 
 inguinal canal. The situation of the umbilical artery varies considerably. 
 Converted into fibrous cord, it is, in some instances, situated immediately 
 on the inner side of the superior opening of the inguinal canal ; in others 
 some distance from it. We may, therefore, conclude: first, that the sper- 
 matic vessels are always sustained internally by the inner border of the 
 opening in the fascia transversalis ; secondly, that in most instances the 
 epigastric artery contributes to their support ; thirdly, that in some cases 
 the umbilical artery assists these two parts in maintaining the cord in its 
 situation. 
 
 Epigastric Artery, its relation with the Outer Ring. — The relations to the 
 outer ring should not be disregarded. Under ordinary circumstances the 
 epigastric is placed at the distance of about an inch from the outer 
 side of the external ring. There are, however, exceptions to this. When 
 the inguinal ring is of considerable length, its external angle, or rather 
 
 * Anatomical Description of the Parts concerned in Inguinal and Femoral Hernia, trans- 
 lated from the French of M. Jules Cloquet, with lithographic plates, etc., by Andrew Mel- 
 He McWhinnie, London, 1835. 
 
880 A SYSTEM OF SURGERY. 
 
 its summit, is situated a few lines from the epigastric artery. I will ob- 
 serve that the proximity of the external angle of the ring to the epigastric 
 artery is consequent, first, on the deviation of the vessel from its proper 
 course caused by an external inguinal hernia inclosed within the canal ; 
 secondly, by the elongation of this angle towards the epigastric artery 
 which retains its proper situation in relation to internal inguinal hernia ; 
 thirdly, these two parts in some cases appear to become opposite to each 
 other, which is observed in large external inguinal hernia where the obliquity 
 of the inguinal canal is destroyed. The epigastric artery is well known to 
 be situated on the outer side of the neck of the sac of internal inguinal 
 hernia. Before the artery reaches the rectus muscle, it forms the external 
 boundary of a triangular space, the base of which is formed by Poupart's 
 ligament, and the internal border by the rectus muscle. The extent of this 
 space is proportionate to the distance at which the epigastric artery is placed 
 from the symphysis pubis. Internal inguinal hernias occur in the lower 
 part of this triangular space, frequently near the tendon of the rectus ; it 
 rarely happens that the hernia is found on the outer side of the space, that 
 is, near the epigastric vessels. 
 
 Diagnosis between Inguinal Hernia and Other Diseases. — Abscesses can be 
 distinguished from inguinal hernia by the history of the case, the appear- 
 ance of the swelling, the absence of cough impulse, and the constitutional 
 symptoms indicating suppuration. It may be remembered that a psoas 
 or lumbar abscess may overlie a protruded intestine, and that the sjmip- 
 toms of both hernia and suppuration may be present. The hypodermic 
 needle will frequently settle this point. 
 
 Haematocele. — The peculiar heaviness of hematocele, with the absence 
 of cough impulse, will in many cases be sufficient to fix the diagnosis. If 
 other symptoms should be wanting, the history of a traumatism, the read}' 
 isolation of the cord from the swelling, the firmness of the tumor, and blood 
 following the puncture or filling the hypodermic cylinder will be sufficient 
 evidence that there is no hernia present. 
 
 Sarcocele is known by the history of the case, absence of cough impulse, 
 and the non-implication of the spermatic cord. 
 
 It will be seen from the above diagnostic marks that when the gut extends 
 into the scrotum we have the so-called scrotal hernia, which is nothing more 
 than an inguinal hernia, and that the differential diagnosis has been given 
 with this understanding. 
 
 A Bubo, from the sensation detected by the fingers, method of growth, and 
 its history, differs essentially from hernia ; but it must be recollected that 
 there may be an enlargement of the inguinal glands occurring at the same 
 time, with either femoral or inguinal protrusion. 
 
 In some cases a hernia or a bubo may coexist. It therefore behooves the 
 practitioner to bring all his knowledge to bear upon the diagnosis before an 
 attempt is made to operate. 
 
 Professor Metcalf, of the University Medical College, of New York, thus 
 writes : " Sometimes the most skilful and careful will be led into error by 
 deceptive appearances, and very often will the inexperienced be led astray. 
 How many would have been deceived, for example, in the following case : 
 A young gentleman consulted a friend of mine, giving the following his- 
 tory of his case : He had had inflammation of one of the inguinal glands, 
 for which his physician had used tincture of iodine externally. Suppu- 
 ration occurring in spite of this, an incision was made and the accumu- 
 lated pus discharged, but the abscess had again filled very rapidly, and his 
 physician having left the city, he wished my friend to relieve him. Upon 
 an examination of the spot indicated by the patient, it was found reddened 
 
HYDKOCELE OF THE HERNIAL SAC. 881 
 
 from the recent use of iodine, and a scarcely closed incision showed where 
 the pus had been discharged. Upon palpation the abscess seemed to have 
 again filled, but to the experienced touch of the examiner, into whose hands 
 he had fortunately fallen, a peculiar elastic softness was noticed which caused 
 him to pause, with his knife already in hand, and examine further. To his 
 surprise he found that a hernial protrusion had occurred just under the seat 
 of the abscess ! 
 
 " Had he entered this with his knife, death or a miserable infirmity would 
 have been the almost inevitable result. How many would have been de- 
 ceived by such a case ? " 
 
 The following is the differential diagnosis between inguinal hernia and 
 hydrocele : 
 
 HERNIA. HYDROCELE. 
 
 1. Hernia is almost invariably opaque, the 1. Hydrocele simulates hernia, but differs from 
 
 only exception being in case of a large it by being more or less translucent, 
 
 fold of intestine distended with gas and 
 covered by thin integument. 
 
 2. The tumor is always varying in size, and 2. The tumor is constant. 
 
 can generally be made to disappear by 
 pressure. 
 
 3. The cord can never be distinctly felt in 3. A part of the cord can be felt distinct 
 
 any part. from the tumor at its apex. 
 
 4. The tumor is enlarged by coughing or 4. Hydrocele, unless congenital, does not en- 
 
 exertion (cough impulse). large upon or feel the impulse of cough- 
 
 ing or exertion. 
 
 5. The testicle can be felt distinct and sepa- 5. The testicle can scarcely be felt, if at 
 
 rate from the tumor at the lower part of all. 
 
 the scrotum. 
 
 In hydrocele of the cord the tumor is circumscribed, leaving a portion of the 
 cord clearly to be felt above and below the tumor, and has most of the dis- 
 tinguishing signs of hydrocele. But when that portion of the cord within 
 the inguinal canal is the site of such serous effusion, the difficulty of diag- 
 nosis is great, for then the tumor may be caused to disappear on pressure 
 as in hernia. 
 
 Varicocele is diagnosed from hernia by the following signs : The swelling 
 is not reducible and has the feeling as of a bunch of earthworms. It simu- 
 lates hernia, because its size is reduced in the recumbent position as well as 
 by pressure, and the tumor returns upon assuming the upright posture, not- 
 withstanding the abdominal ring has been closed by pressure ; the latter 
 condition would not exist in hernia. 
 
 When the enlarged veins occupy the upper portion of the cord and the 
 inguinal canal, accompanied by an accumulation of serum, the diagnosis is 
 extremely difficult. 
 
 Enlargement of the veins of the cord frequently facilitates hernial pro- 
 trusion. 
 
 The testicle being late in its descent may be arrested either in the inguinal 
 canal or at the external abdominal ring, thus giving rise to a swelling which 
 presents appearances similar to those of rupture. The diagnosis may be 
 formed by the absence of the testicle from that side of the scrotum, and by 
 the peculiarly characteristic sickening sensation occasioned by pressure on 
 that organ. 
 
 In non-descent of the testicle, it may be lodged either within the in- 
 guinal canal or at one of its apertures ; this forms one of the predisposing 
 causes of hernia. 
 
 Hydrocele of the Hernial Sac. — This is a condition of hernia (hydrops 
 sacci herniosi) that has never, according to my experience, received the 
 attention it deserves. Very little notice is taken of the condition by writers, 
 
 56 
 
882 A SYSTEM OF SURGERY. 
 
 and in the majority of text-books it is ignored. The existence of fluid in 
 the sac of a hernia complicates the diagnosis, and must be differentiated 
 from simple hydrocele of the tunica vaginalis, for which it is often mis- 
 taken, and from that condition of dropsy of the cord high up, of which 
 mention has been made. This condition is the result of an exudation 
 from the sac, which has been caused by an inflammation of the neck 
 causing more or less adhesion and consequent occlusion, but not, neces- 
 sarily, strangulation ; the quantity of fluid varies from a few ounces to 
 three or even four quarts. Sometimes after a hernia has been cured the 
 sac remains oj)en, and may become a receptacle for quite a large amount 
 of ascetical fluid. To make a diagnosis between this affection and ordi- 
 nary hydrocele, the present or past existence of a hernial protrusion, to- 
 gether with its history, the changes it has undergone, the injury it has 
 sustained, and the varied conditions to which it has been subjected, will 
 generally be sufficient to point out the true nature of the case. In the 
 differentiation between this disorder and hydrocele of the cord, more diffi- 
 culty may be encountered, but it must be remembered that, in the " high 
 hydrocele," the fluid in the recumbent position has a tendency to gurgle 
 back into the abdominal cavity, whereas the occlusion of the sac in the 
 disease we are considering, prevents any especial change in the swelling 
 when the patient lies down. 
 
 There is another relation of the parts that has given rise to difficulty 
 in recognizing the trouble, and which it is important to remember, and 
 that is, an undescended testicle may lodge in the neck of a congenital 
 hernia ; such cases are described by Ball and Mayer, and, therefore, the 
 testicle should be carefully looked for in the scrotum, when a hydrocele of 
 this character is noted, and the absence of the gland should lead to a 
 recognition of the disorder. I may mention that hydrocele of the sac of 
 an acquired hernia is generally chronic and the hernia is irreducible, while 
 hydrocele of the sac in the " congenital form " of hernia is mostly acute, 
 and when, from some known cause, a congenital inguinal hernia sud- 
 denly with pain and heat enlarges, and the symptoms of strangulation 
 are absent, effusion into the sac takes place, and we have " hydrops sacci 
 hemiosi acutis." 
 
 Simultaneous Internal and External Hernia. — Probably this is the rarest 
 condition that can exist to obscure diagnosis. I am not aware of any other 
 case of its kind on record. It is unique in the literature of hernia, therefore 
 I give the record in full. 
 
 The patient was employed as a clerk in a trunk manufactory, and in 
 endeavoring to lift a portmanteau and place it upon a shelf higher than 
 his head, he suddenly felt something in the inguinal region " give way," 
 which was immediately followed by severe pain, sense of faintness, nausea, 
 and finally vomiting, and apparent collapse. Upon examining the parts 
 I found the left side of the scrotum enormously distended, and rapidly 
 turning that peculiar purplish-green hue which is characteristic of gan- 
 grene ; the patient was vomiting considerably from time to time, the sub- 
 stance ejected being ingesta, but neither looking nor smelling like fecal 
 matter; but the general condition of the patient pointed to strangulated 
 hernia. After a little manipulation I found it easy to return the gut into 
 the abdominal cavity, which had already been done once or twice by 
 Dr. E. T. Richardson. No sooner had the intestine been replaced, than, 
 upon any exertion of the body, coughing, or retching, it would again 
 protrude, to be as readily returned. Upon invaginating the scrotum 
 with my finger, what was my astonishment to feel the gut readily pass 
 into the abdomen, the two rings being open, and the canal shortened, as we 
 usually find from the dragging of an old rupture upon the parts. After 
 
OPERATION FOR STRANGULATED INGUINAL HERNIA. 883 
 
 the return of the bowel, the scrotum did not diminish much in size, 
 nor color, but the vomiting ceased, and the patient appeared, under the 
 use of mild and not often repeated stimulants, to revive from his lethargy. 
 Certainly the case was not one of ordinary strangulated hernia; indeed, 
 there was exactly the opposite condition, both rings being patulous and a 
 canal more open than usual. I concluded, to administer veratrum, and 
 watch results. The next night, a telegram summoned me, and, every 
 symptom appearing so aggravated, I determined to cut down upon the 
 canal and into the scrotum, and see if I could find any cause for the- 
 symptoms, for I thought, as I had seen before in one or two instances, a 
 small knuckle of gut might be turned up under Gimbernat's ligament, or 
 there might be a twist in the intestine within the canal, which, if the 
 bowel were pushed into the abdomen, the convolution not being undone, 
 the stricture would remain. After some delay in getting the proper lights 
 — it was 1 o'clock at night — and arranging them at a safe distance from 
 the ether, I cut down upon the canal, making an incision from the external 
 (superior) pillar of the lower ring to the fundus of the scrotum. At the 
 second incision, which penetrated the scrotal sac, there followed a large 
 gush of bloody serum, which for the moment startled me, fearing that I 
 had gone into the bowel. Continuing the dissection, I came upon the 
 intestine in the canal, which, save with a slight ecchymosis, appeared per- 
 fectly healthy, and was placed into the abdominal cavity, but, as I have 
 noted, was with difficulty retained there. Still continuing the dissection 
 higher, and exploring the cavity of the abdomen not only in search of 
 obstruction but for the testicle, I could find neither, and therefore closed 
 the wound as usual, and dressed it with calendula. The next day the 
 patient died with the usual symptoms of obstruction of the bowels, including 
 fecal vomiting. The case was a mystery to me, and therefore a post-mortem 
 was demanded, and obtained. I will pass over the usual rigor mortis, and 
 say that all the intestines appeared healthy on their superficial surface, and 
 the left testicle, rather larger than normal, was in its proper place. The 
 secret lay in the following : The right testicle, instead of passing as usual 
 through the rings and entering the scrotum, covered by its proper invest- 
 ment, had taken a directly opposite course ; instead of going downward and 
 forward, it had passed downward and backward, taking with it an acquired 
 pouch of peritoneum (in the same manner as the acquired hernia adapts to 
 itself its peritoneal covering), it had gone behind the border of the iliacus 
 internus, and there we found it, with rudimentary cord extending over the 
 roof of the bladder to the vesicula, and crammed in between it and its cov- 
 ering was a small knuckle of intestine, perfectly gangrenous, accounting for 
 every symptom save the bloody serum within the tunica vaginalis, which in 
 all probability was hydrocelic. 
 
 Operation for Strangulated Inguinal Hernia. — The patient having been 
 brought thoroughly under anaesthetic influence and the parts shaven, an 
 incision should be made from the external ring to the inferior extremity 
 of the swelling. This cut should be made by the operator pinching up 
 a fold of skin, lifting it from the intestine, and with a small sharp- 
 pointed curved bistoury, cutting from within outward. The director is 
 introduced into the wound, and the incision completed with a probe- 
 pointed bistoury. By this the superficial epigastric will, in the majority 
 of instances, be cut and must be secured. Each successive layer of 
 tissue must be raised with the forceps, nicked with the knife, and the 
 director used constantly. There may be six coverings, or there may be a 
 dozen. No matter how many, the same caution must be used, until the sac 
 is reached. 
 
 This is known by its slightly transparent hue ; its vessels, which may 
 
884 
 
 A SYSTEM OF SURGERY. 
 
 be seen ramifying on its surface, which is of a bluish color. The finger 
 should be introduced into the wound, and the endeavor made to discover 
 if the stricture be seated outside the sac; if this can be ascertained and 
 the surgeon assure himself that the intestine is in good condition, the 
 hernia knife, or a curved probe-pointed bistoury, wrapped with cotton 
 or silk to within a quarter of an inch of the point, should be introduced 
 flatwise, on the finger, insinuated beneath the stricture, and turned with 
 its edge upon the stricture, and with a sawing motion upward, the point 
 of strangulation divided. If there be the slightest doubt as to the con- 
 dition of the intestine, the sac must be incised after the manner of other 
 fasciae, and the gut exposed. Upon the division of the peritoneal cover- 
 ing, there will generally be a few drops of serum exude. The finger is 
 
 Fig. 549. 
 
 again introduced as a guide for the knife and the stricture divided as 
 above (see Fig. 549). If the omentum is either gangrenous or ulcerated, 
 parts of it may be removed. If the case be one of entero-epiplocele, 
 the intestine should be replaced first, the omentum afterward. 
 
 If the surgeon prefers the more modern operation, directions for which 
 are found on a preceding page, he may ligate the sac with catgut, cut off 
 the ligated portion, and secure the stump in the rings, drawing the pillars 
 together with silver sutures. 
 
 I have often found that adhesions have taken place. These may be broken 
 up by the finger, and the parts restored to their natural position. The wound 
 must be closed by silver sutures, and the patient given nux vom. 3d trit. 
 every half hour, for a considerable length of time. 
 
 By Mr. Ball, of Dublin, it is held that the best method, after isolating the 
 cord from the sac, is to grasp the latter high up with the clamp, and make 
 torsion until a decided sense of resistance is experienced. The neck of the 
 sac is firmly tied with an antiseptic ligature, and a salmon-gut is passed 
 through the pillars of the ring and the twisted sac to prevent it from 
 untwisting. The remainder of the operation is completed in the usual 
 manner. In reaching and separating the sac from the cord, the coverings 
 common to both are successively divided, so that nothing is twisted except 
 the thickened peritoneum and subperitoneal tissue. Dr. Ball considers 
 failure more common than generally supposed. In 34 cases collected by 
 
OVARIAN HEENIA. 885 
 
 Dr. Guenod, from the surgical hospital at Bale, relapses occurred in 12, and 
 as is shown by the Liverpool statistics, and by those collected by Leisrink, 
 the operation fails in about one case in five. More extended experience 
 and statistics are needed to definitely determine the exact utility of the 
 operation. 
 
 Dr. G, A. Hall* in comparing results of cutting operations for stran- 
 gulated and non-strangulated* inguinal hernia?, gives interesting figures 
 Non-strangulated hernia 213 cases; cured, 186; result not reported, 11 
 not cured, 13 ; died, 2 ; strangulated inguinal hernia 29 ; cured, 18 
 died, 11. 
 
 Congenital Inguinal Hernia in the Male. — This variety generally occurs 
 early in life, but the student must remember that the " congenital form " 
 may appear in the adult, and is often occasioned by late descent of the 
 testicle and imperfect closure of the inguinal rings. This hernia, should 
 be carefully returned at as early a day as possible, and nux vomica given 
 for a time, a well-adjusted pad being worn. Sometimes, in spite of the best- 
 directed efforts at reduction, strangulation occurs. In these cases the inter- 
 nal administration of medicine will often cure. (The student is referred to 
 the early parts of this chapter.) Sometimes, by raising the child by the 
 feet, or placing it upon an inclined plane, the facilities for reduction are 
 much increased. 
 
 Congenital Inguinal Hernia in Women. — The round ligament passes out 
 from the external ring, and is accompanied by a process of the peritoneum, 
 which in most cases is obliterated in adult life. Sometimes it remains open, 
 and forms the canal through which a hernia may protrude. 
 
 Ovarian Hernia is a peculiar variety of inguinal hernia, which demands 
 attention. As a testicle may be prevented from descending and fill the 
 abdominal ring, so occasionally an ovary may form a hernia which it is 
 difficult to recognize. When such does occur, it is generally of the con- 
 genital inguinal variety, although in some instances it may be acquired. 
 In the year 1878 Peuch constructed a table of 78 cases of the affection ; of 
 these, 12 were of doubtful origin, 47 congenital, and 19 acquired. 
 
 In most cases of ovarian hernia, the ovary alone is not found in the sac, 
 there being either a coil of intestine, the Fallopian tube, the uterus, the 
 vagina, and sometimes portions of the omentum associated with it. Eng- 
 lisch gives a table of 38 cases, in which the ovary alone was found in the sac, 
 and of these 27 were inguinal, 9 femoral, 1 ischiadic, and 1 obturator. In the 
 majority of the cases the affection was congenital. An ovarian hernia may 
 produce strangulation of the intestine, because as the ovary drops down it 
 leaves a cul-de-sac, into which a loop of intestine may pass, and the edge of 
 the pelvis and the side of the uterus form strong bands, which effectually 
 prevent the passage of fecal matter, but these hernia? are more frequently 
 incarcerated than strangulated. 
 
 It is stated by Hegar and Kaltenbach that when ovarian hernia is con- 
 genital, the ovary is immovable, while in the acquired form the ovary is 
 mobile and alone occupies the sac. 
 
 When such ruptures require operation, an incision should be made into 
 the sac and the ovary removed ; before it is cut off, the pedicle should 
 be not only securely tied, to prevent haemorrhage, but the stump should 
 be either stitched or secured by steel pins to the rings to prevent retraction 
 into the abdominal cavity, which would have a tendency to cause slipping 
 of the ligature, and if bleeding should occur, the stump would be accessible 
 to the operator for the application of a ligature. 
 
 Professor Andrea Ceccherelli relates the case of a woman thirty-eight 
 
 * Medical Advance, August, 1886, p. 146. 
 
886 A SYSTEM OF SURGERY. 
 
 years of age, who entered the hospital on account of a swelling which had 
 appeared the evening before in the right inguinal region simultaneously 
 with the menses. Examination showed a small tumor, a little larger than 
 a walnut, movable and but slightly painful on pressure. Herniotomy 
 being performed, the body was found to be an ovary. The organ was re- 
 turned with difficulty, but the patient made a good recovery and was dis- 
 charged at the expiration of a fortnight. Boinet has collected the statistics 
 of nine cases in which ablation of the ovary was practiced, with the cure of 
 eight. Dr. Ceccherelli advises oophorectomy in those cases of ovarian 
 hernia in which there are plain indications of disease in the organ at the 
 time of the operation. Such evidence of pathological change is present, 
 he says, only in exceptional cases, so that an endeavor should be made to 
 return the ovary intact into the abdominal cavity.* 
 
 Crural or Femoral Hernia. — Anatomy. — On the inner side of the thigh, be- 
 tween the sartorius and pectineus muscles, there is a slight depression, 
 known as the fossa ovalis or saphenous opening; this depression has no 
 well-defined inner border, but externally is bounded by the well-developed 
 edge of the fascia covering the sartorius muscle. 
 
 The floor of this fossa is formed by the pectineal fascia which invests the 
 pectineal muscle. 
 
 This aponeurosis, at the lower margin of the opening, becomes thicker, 
 turns inward, and is joined by the sartorial fascia, forming a lunated edge ; 
 over this, as is well known, the vena saphena major turns and joins the 
 great femoral vein. 
 
 Superiorly the sartorial fascia is connected with Poupart's ligament, or 
 with that reflection of it known as Gimbernat's ; thus forming a lunated 
 border, which receives the name of Hey's ligament. 
 
 The femoral vessels coming from the abdominal cavity, emerge beneath 
 Poupart's ligament, and consequently under Hey's ligament, being covered 
 by their sheath, which is formed by the fascia of the iliacus internus pos- 
 teriorly and the fascia transversalis anteriorly. 
 
 The sheath is loose, and by some writers is called the crural canal, and 
 that part of the canal found at the junction of the thigh with the abdomen 
 receives the name of the femoral ring. This so-called ring is filled with 
 loose tissue, which is called the septum crurale. 
 
 The anatomy of crural hernia is plain, but is oftentimes so clumsily 
 described in the books, that students are at a loss to understand the precise 
 relations of the parts. As the femoral vessels come from the cavity of 
 the abdomen to pass out upon the thigh, beneath Poupart's ligament, 
 a space is left between them and the pelvis, slightly guarded by loose 
 tissue, the septum crurale, which, when the intestine protrudes, is necessarily 
 pressed onward before it. Further, an opening in the upper part of the 
 thigh is formed where the superficial join the deeper-seated veins, and this 
 also is filled with a loose tissue — the cribriform fascia. It will be apparent 
 that the bowel, coming from the cavity of the abdomen along the course of 
 the femoral vessels, will protrude on the thigh at the opening where the 
 femoral vein is joined by the saphena major, as this point is but slightly 
 protected by fascia. 
 
 Proceeding from within outwards, the following would be the order of the 
 coverings of hernia in this region : First, the peritoneum ; secondly, the sep- 
 tum crurale, which covers the ring through which the intestine passes. The 
 gut then follows the crural canal, or, in other words, the sheath of the 
 femoral vessels, until it reaches the fossa ovalis, where it protrudes, pushing 
 before it the sheath of the femoral vessels, which constitutes the third covering. 
 
 * L'Union Me*dicale, October 20th, 1885. 
 
DIAGNOSIS OF FEMORAL HERNIA. 887 
 
 This coat carries with it the fascia which lies in the fossa ovalis, hence 
 we have as the fourth covering the cribriform fascia, which in turn forces 
 outward the fifth coating or superficial fascia, and with it comes lastly the 
 integument or sixth investment. 
 
 There is one point in the anatomy of crural hernia which deserves 
 attention, and that is the relations of the gut with the femoral vein, the 
 epigastric artery, the spermatic cord, and occasionally with the obturator 
 artery. 
 
 In femoral hernia the parts stand in the following order: On the out- 
 side the femoral vein, on the inside the spermatic cord, in front and near 
 the seat of stricture the epigastric, and in some instances the obturator 
 artery, the latter in about one case in four, being given off from the epi- 
 gastric artery. 
 
 In operating, the most important anatomical points are the relations of 
 the epigastric artery with the internal and external rings as well as with 
 the crural canal. 
 
 The Epigastric and Obturator Artery and their relations with the Crural 
 Canal. — According to M. Cloquet, after dissection of 250 subjects, the fol- 
 lowing results regarding the relations of these arteries have been determined : 
 
 Obturator Artery arising from . Males. Females. 
 
 1st. Hypogastric on both sides in 160 subjects, 87 73 
 
 2d. Epigastric on both sides in 56 subjects, 21 35 
 
 3d. Hypogastric on one side from the epigastric on the other side in 
 
 28 subjects, . 15 13 
 
 4th. The femoral in 6 subjects, 2 4 
 
 Total, 250 subjects, 125 125 
 
 The following is the relative proportion in which the obturator has or has 
 not a relation with the hernial sac, placing on one side the cases in which 
 the obturator arises from the epigastric or directly from the femoral, and 
 on the other, those arising from the hypogastric : 
 
 Obturator Artery arising from Males. Females. 
 
 The hypogastric in 348 subjects, 191 157 
 
 The epigastric or femoral in 152 subjects, 58 94 
 
 Total, 500 subjects, 249 251 
 
 From this calculation we find, First, that the cases in which the obtu- 
 rator takes it origin from the hypogastric are most numerous ; that their 
 proportion when compared with those in which it arises from epigastric or 
 femoral, is nearly as three to one ; secondly, that the obturator appears 
 to arise more frequently from the hypogastric in the male than in the 
 female. 
 
 Diagnosis of Femoral Hernia. — A femoral hernia may sometimes be mis- 
 taken for an inguinal ; the symptoms differential are as follows : In the 
 former the finger can be introduced into the inguinal canal. Poupart's 
 ligament can be made out even though the gut has ridden over it. An in- 
 guinal hernia lies inside of the spine of the pubis. 
 
 Sometimes a varix of the femoral vein, as it passes the saphenous opening, 
 simulates femoral hernia. 
 
 In such cases a careful examination is necessary to insure a correct diag- 
 nosis. 
 
 Place the patient on the back and reduce the protrusion. On assuming 
 
888 A SYSTEM OF SURGERY. 
 
 the erect position, if varix is present, the swelling immediately reappears 
 but if it be hernia, pressure will prevent its recurrence. 
 
 Psoas abscess may, in rare instances, be mistaken for femoral hernia. 
 
 The many presenting symptoms of spinal disease, the slowness and 
 variability of progress, the fluctuation, and the part at which the abscess 
 points, which, in the majority of cases, is outside of that at which hernia 
 protrudes, serve to form the distinctions necessary. 
 
 An enlarged gland has been mistaken for hernia by distinguished sur- 
 geons. Hamilton records one in which several days elapsed before the 
 diagnosis was made, the delay causing the death of the patient. Sir Astley 
 Cooper mentions two fatal cases. The absence of cough impulse, the solidity 
 of the tumor, the history, and the constitution of the patient, must be our 
 chief guides. 
 
 Operation for Femoral Hernia. — An incision should be made in the long 
 diameter of the swelling. The parts are raised upon the director as before 
 noted when treating of inguinal hernia. The seat of stricture is often at 
 Hey's ligament, and sometimes at Gimbernat's. The finger-nail or Little's 
 director is passed beneath the stricture ; the hernia knife, or the wrapped 
 probe-pointed bistoury is insinuated underneath the seat of stricture, and 
 the cutting edge turned upward, then with a slight sawing motion the stric- 
 ture is divided. The gut is carefully examined, and if there be any adhe- 
 sions they should be broken up, and the intestine returned. For further 
 information refer to the section on Kelotomy. 
 
 The same after-treatment is necessary as that recommended in inguinal 
 hernia. 
 
 Umbilical Hernia. — In this variety the intestine makes its way through the 
 umbilical ring in the foetus, or through a separation of the fibres of the linea 
 alba; in young persons we find it as congenital, or it may be found in 
 adults, especially in fat women. 
 
 The coverings of this form of hernia are very thin, and when the protru- 
 sion is large it may be of various shapes, pyriform, sessile, or pedunculated, 
 and contain omentum, portions of the large and small intestine, and indeed 
 the stomach. 
 
 Treatment. — In infants I have cured many of these with a well-adjusted 
 pad, in the centre of which a smaller or larger ball of ivory protruded. 
 Sometimes a piece of sheet lead, such as is found in tea-boxes, folded several 
 times, and held in situ with adhesive plaster and a broad band of stout mus- 
 lin, answers the purpose. 
 
 Dr. Bowers, of New York, devised a pad for the cure of congenital um- 
 bilical hernia, which is so easily constructed and is productive of such good 
 results, that he used no other for a number of years. 
 
 The following are the directions for its construction : 
 
 Take a piece of sheet lead, thick enough to retain its shape under mode- 
 rate pressure, about one and a half inches square, draw lines diagonally 
 across from corner to corner, and from the centre describe a circle within 
 the square. Then raise a little knob in the centre, and near each corner 
 where the circle cuts the diagonal lines, by placing these points directly 
 over a suitable hole in a board, and forcing the lead down by a blow on a 
 blunt rounded punch, taking care not to break the lead. Round the cor- 
 ners, straighten the square so that it will lie level, and it is ready for use. 
 The central knob may be a little the most prominent, and is to be placed 
 directly on the umbilicus, and secured by a compress and bandage. The 
 superiority of this pad consists in its permanently retaining its place with- 
 out slipping. 
 
 Dr. Wilcox has devised, an excellent truss for umbilical hernia, which is 
 seen in the figures (Figs. 550, 551). 
 
UMBILICAL HERNIA. 
 
 A consists of two circular plates of steel connected by four posts. Be- 
 tween the two plates is a stout steel wire running around through the posts. 
 The lower plate, which is the one nearest the skin, is perforated, and is 
 covered with perforated chamois skin. Upon the upper plate are four steel 
 spring catches. C is the pad, made of woven wire and also covered with 
 perforated chamois skin. The screw of C works in the centre piece of B 
 and has a loose attachment to the pad, so that when in position, and more 
 pressure is desired, it can be screwed down by the key D without rubbing 
 the skin of the patient. 
 
 The four arms of B are made to slip under the four catches in the upper 
 plate A. By means of the screw, the centre pad C can be made to project 
 
 Fig. 550. 
 
 Fig. 551. 
 
 from one-half to one inch below the lower plate of A. The whole apparatus 
 is fastened to the body by strips of adhesive plaster which are attached to 
 the wire between the upper and lower plates of A, and which radiate over 
 the abdomen as shown in Fig. 551. 
 
 The objects attained by the use of this apparatus are : 1st, the pain in 
 the back is obviated ; 2d, by use of the perforated lower plate of A and the 
 centre pad C, the air has constant access to the skin, preventing its charing ; 
 3d, by screwing down the centre pad C any amount of pressure desired can 
 be made ; and, 4th, when the patient lies down and the bowel is not so 
 likely to come out, the whole centre portion can be instantly removed by 
 giving a little twist sidewise on the arms of B, and the skin has a rest from 
 pressure as long as desired. 
 
 For the radical cure of this hernia several operations have been from time 
 to time proposed. 
 
 Mr. Barwell reported in the London Lancet several cases in which he per- 
 formed a radical cure, by pressing the gut back into its position, inserting 
 needles into the sac and twisting either wire or silk over them. 
 
 In the only cutting operation which I have been called upon to perform 
 for strangulated umbilical hernia, in a young infant, the patient died. 
 
 For the adult, an incision should be made over the bowel, the layers of 
 tissue be raised upon a director, and the stricture sought and liberated by 
 the smallest possible nick. The after-treatment is the same as in other 
 operations for hernia. It is not a matter of dispute that if the intestine 
 be gangrenous, several inches, and indeed even feet thereof, may be cut 
 away and the patient recover, as in the famous case of my friend, the late 
 
890 A SYSTEM OF SURGERY. 
 
 Dr. Beebe — vide Resection of the Gangrenous Gut in the former part of this 
 chapter. 
 
 The radical operation was performed as follows : The hernia being reduced, 
 the sac was caught by haemostatic forceps, ligated, cut off, and the stump 
 seared with Paquelin's cautery. Lister's dressing was applied. The child 
 was twenty hours old. The ligatures were removed on the eighth day, 
 and the cure was complete * 
 
 Obturator Hernia. — This variety is rare. In it the gut descends through 
 the obturator canal, the thyroid or obturator foramen. It occurs more 
 frequently in females than in males, and the protrusion is generally 
 small. The patients who suffer from it complain of pain along the course 
 of the obturator nerve, and from bowel affections in a greater or lesser 
 degree; sometimes there is cramp in the muscles of the affected limb. 
 In many cases there are complications which render the diagnosis difficult. 
 
 Treatment. — Taxis may sometimes be sufficient, together with the ad- 
 ministration of medicine, to relieve this affection ; should it not, an opera- 
 tion will be necessary. The incision should be made parallel with the 
 femoral artery and outside the femoral vein, beginning at the centre of 
 Poupart's ligament and extending about three inches and a half down- 
 ward. The fasciae are raised on the director and divided according to 
 directions already given. After this the fibres of the pectineus should be 
 divided in the line of the first incision, which will generally allow the 
 tumor to be felt. If it cannot yet be recognized, the fibres of the obturator 
 muscle must be separated. This will expose the protrusion. The stricture 
 must be felt for and divided in the same manner as directed for other 
 strangulations. 
 
 IscEiatic Hernia. — In an ischiatic hernia, the intestine forms a tumor be- 
 neath the large gluteal muscle. The neck of the sac is generally below the 
 pyriformis. The tumor is frequently reducible. The symptoms are those 
 of other henries. The operation consists of cutting down upon the sac and 
 enlarging its mouth. 
 
 Pudendal Hernia. — By the term pudendal hernia is understood the escape 
 of the gut into the labium pudendi. This may occur at an early age. It 
 forms a small and somewhat elastic tumor at the side of the vagina, the neck 
 of the sac lying between the vagina on the inside and the ramus of the 
 ischium on the outside. It may be diagnosed from inguinal hernia by its 
 location by the side of the ramus of the ischium, by its parallelism to the 
 axis of the vagina, and by the ability to feel the inguinal canal. 
 
 Treatment. — An appropriate bandage and pad. These hernise do not 
 become strangulated. 
 
 Diaphragmatic Hernia. — This variety of internal hernia is difficult to diag- 
 nose. By the best authorities it is, like other hernial protrusions, divided 
 into congenital and acquired. The left side of the diaphragm is more fre- 
 quently affected than the right, in the proportion of five to one. This can 
 readity be accounted for, not, as has been laid down by some authorities, 
 on account of the greater weakness of the left side of the diaphragm, but 
 because the right crus is firmer than the left, and because the larger 
 openings for the aorta and oesophagus are found more to the left side, and 
 because the large, firm, smooth convex surface of the liver lies close against 
 the right side of the diaphragm. As far as I can learn, excepting some 
 traumatic cases, there has not been one reported in which the contents of 
 the abdomen have passed through the opening for the inferior cava or the 
 aorta, the general site being through the fleshy portions of the muscle more 
 than through the tendinous ; indeed, the weakest points are, first, the tri- 
 
 * Medical Record, 1881, p. 376. 
 
DIAPHRAGMATIC HERNIA. 891 
 
 angular space immediately behind the sternum (sometimes called Larrey's 
 space), the oesophageal opening and the larger interstices between the mus- 
 cular bundles on the anterior border of the diaphragm. When the case is 
 traumatic any portion of the muscle may be ripped up, and to such an ex- 
 tent that almost the entire contents of the abdomen, save bladder and kid- 
 neys, pass into the thorax. In the non-traumatic variety the stomach and 
 small intestines frequently form the hernial protrusion. In the former the 
 edges of the opening are torn and ragged, and in the latter they are smooth 
 and callous; of course the traumatic cases are acute, and there may be 
 chronic diaphragmatic hernia. 
 
 The symptoms presented are those of compression of the lung, cyanosis, 
 great dyspnoea, and agonizing pain, which generally, in the acute cases, 
 causes death in a few hours ; besides this a notable inequality of expansion 
 is found in the chest walls. In the congenital variety these symptoms, 
 with nausea, vomiting, and a small pulse, may continue for years, may abate 
 and return when any disorder of the intestinal tract is noticed. 
 
 In a case reported by Drs. Galassi and Teneri* in which a woman died 
 with all the symptoms of strangulation of the bowels, and upon whom lapar- 
 otomy was performed without rinding the cause of the obstruction, a post- 
 mortem revealed the transverse colon in the left pleural cavity, the gut had 
 become twisted, thus causing the obstruction. The hernia was not sus- 
 pected during life, and was not revealed by the operation. The case is 
 instructive in several particulars, first, that a diaphragmatic hernia may 
 exist without discovery, even after abdominal and thoracic examination, 
 and that laparotomy sometimes fails to detect the true nature. It is diffi- 
 cult to understand, if the operation was conducted with ordinary care, how 
 the surgeon could avoid missing so large a mass as the transverse colon from 
 the abdominal cavity. 
 
 Dr. L. Harris f reports an instructive case of diaphragmatic hernia, in 
 which the left pleural cavity contained, besides the left lung, the stomach, 
 almost all the small intestines, the colon, and half the pancreas. The lung 
 was compressed and was eight inches in length, one to two inches in thick- 
 ness, and three inches in breadth, and was crowded into the anterior and 
 upper portion of the chest. The opening in the diaphragm was large 
 enough to admit the closed fist and all the usual vessels. 
 
 * American Journal of the Medical Sciences, January, 1886, p. 284. 
 f Medical Kecord, October 11th, 1884, p. 401. 
 
892 
 
 A SYSTEM OF SURGERY. 
 
 CHAPTER XLIV. 
 
 DISEASES OF THE RECTUM AND ANUS. 
 
 Examination — Imperforate Anus and Eectum — Foreign Bodies in the Eectum — 
 Prolapsus Ani — Hemorrhoids — Fistula in Ano — Tumors in the Eectum — 
 Stricture of the Eectum — Linear Eectotomy — Ulcers and Fissures of the 
 Anus — Excision of the Rectum— Carcinoma of the Eectum. 
 
 Examinations of the rectum were, until recent improvements both in 
 specula and light, unsatisfactory. The old-fashioned anal speculum of 
 glass, with the fenestrated side (Fig. 552) is painful in rotation and affords 
 
 Fig. 552. 
 
 Ordinary Anal Speculum. 
 
 imperfect views of the parts, even when assisted by Bodenhamer's Recto- 
 Colonic Endoscope (Fig. 553). 
 
 I have tried many specula and dilators, and give the preference to one 
 or two. That of Dr. E. M. Pratt, of Chicago, is superior in many ways 
 
 Fig. 553. 
 
 Bodenhamer's Recto-Colonic Endoscope. 
 
 (Fig. 554). It is easier to introduce on account of its bulbous extremities, 
 the latter keeping out of the way the folds of the rectum ; it is self-retaining, 
 and by partial closure can be revolved without pain. I have used this 
 instrument and can recommend it. Besides the speculum, Dr. Pratt has 
 
DISEASES OF THE EECTUM AND ANUS. 
 
 893 
 
 introduced a tenaculum (Fig. 555), a blunt rectal hook (Fig. 556), and a 
 pair of rectal scissors (Fig. 557). 
 
 The tenaculum is needed for seizing papillae or other morbid growths, 
 pendulous mucous membrane, etc. The small blunt hook is indispensable 
 in discovering and raising the rectal pockets. The scissors are constructed 
 so as to remove the hand of the operator from the field of vision. 
 
 Fig. 554. 
 
 CLOSED 
 
 Pratt's Rectal Speculum. 
 
 Slight study of these illustrations will explain their uses and advantages. 
 I have used with satisfaction a rectal speculum made after the fashion of a 
 
 Fig. 555. 
 
 SHARP a SMITH CHICASO 
 
 Pratt's Tenaculum. 
 
 Sims's, often indeed having employed a small size of the latter with excellent 
 results. Of course if the rectangular instruments are used, the patient must 
 be placed in Sims's or the knee-elbow posture. 
 
 Fig. 556. 
 
 SHARP & SMITH CHICAGO 
 
 Pratt's Blunt Hook. 
 
 The lithotomy position is the best — and the instrument, carefully oiled, 
 should be insinuated into the rectum, it having been previously thoroughly 
 
 Fig. 557. 
 
 SHARP? 
 
 SMI?? 
 
 c «'ca7T 
 
 Pratt's Scissors. 
 
 emptied, either by a full dose of castor oil or an enema. I have employed 
 the speculum of O'Neil, Fig. 558. 
 
894 A SYSTEM OF SURGERY. 
 
 A good deal has been written concerning the examination of the rec- 
 tum with the entire hand, as recommended by Simon. I have tried it, 
 sometimes having difficulty in passing my hand into the bowel, and 
 sometimes not encountering much obstruction. The sphincter, however, 
 always closes around the wrist, and the fingers are cramped in their move- 
 ments. The method is useful in recognizing tumors high up, and in 
 making pressure upon the iliacs. The surgeon must remember that hand- 
 rectal examination is likely to be unsatisfactory for two reasons : 1st. The 
 sense of sight cannot be used, the surgeon only being guided by a restricted 
 sense of touch ; and 2d. The process is by no means free from danger. 
 
 Fig. 558. 
 
 O'Neil's Rectum Speculum. 
 
 Danbridge and Conner* relate that they had examined the pelvis of a man 
 by Simon's method, for the purpose of confirming a diagnosis of psoas ab- 
 scess. The surgeons were gentle and went no higher than the iliac, but 
 the patient was seized with peritonitis and died in a short time. There 
 are other cases of this kind upon record. 
 
 The rectum is capable of great distension, and its mucous membrane, 
 like other portions of the intestinal tract, only to a greater degree, is 
 supplied with folds or rugse which are visible with a good speculum. 
 Often, indeed, too plainly, for they are liable to drop into the fenestrae 
 of the instrument, and not only impede the view, but prevent the specu- 
 lum from being rotated without pain. The lower fourth, the fibrous con- 
 nective tissue holding the mucous coat to the submuscular, is also loose, 
 which, of course, when the canal is empty, increases the number of mucous 
 folds. If we examine the locality below the internal sphincter (of which 
 and sphincter-ani-tertius of Hyrtl more will be said hereafter) a number 
 of semilunar valves, — some authors say five or six, and others more — with 
 their concavities looking toward the colon, can be found ; these " form an 
 irregular festooned line which surrounds the canal ; their folds, however, 
 are small, and have no tendency to obstruct the passage of fecal mat- 
 ters." f Of these Cloquet says : " The inner surface of the rectum is com- 
 monly smooth at its upper half, but in the lower there are observed some 
 parallel longitudinal wrinkles which are thicker near the anus and are 
 variable in length. These wrinkles, whose number varies from four to ten 
 or twelve, and which are called the columns of the rectum, are formed by the 
 mucous membrane and the layer of the subjacent cellular tissue. Between 
 these columns there are almost always to be found membranous semi-lunar folds, more 
 or less numerous, oblique or transverse, of which the floating-edge is directed from 
 
 * Medical Record, November 16th, 1878, No. 419. 
 
 f Textbook of Human Physiology, by Austin Flint, Jr., M.D., New York, 1882, p. 291. 
 
IMPEKFORATE ANUS AND RECTUM. 895 
 
 beloic upward toward the cavity of the intestine. These folds form a kind of lacunae 
 of which the bottom is narrow and directed downward." 
 
 Again, Kelsey says : * " Between the lower ends of the columnar recti, 
 little arches are stretched from one to the other forming pouches of skin 
 and mucous membrane. These are more developed in old people and may 
 retain small pieces of hardened faeces or foreign bodies in their cavities and 
 thus give rise to suppuration and abscess." There is a divided opinion 
 regarding the physiological action of these valves, and the part they 
 play in certain functions ascribed to the rectum-; indeed by some the 
 identity of these pouches with a portion of Hyrtl's sphincter is claimed. 
 When the nervous relations of the lower portion of the rectum including 
 the sphincters are more fully understood, it will be seen that it is not im- 
 possible that severe reflex nervous disturbances may result from irritation 
 at the lower end of the rectum. To how great an extent these may extend 
 we are unable to determine. 
 
 Imperforate Anus and Rectum. — There are several varieties of imperforate 
 rectum, all of which are more or less serious in character, and which often 
 terminate fatally, after the best-known means have been resorted to for 
 preserving life. 
 
 There are hundreds of children who die yearly from the malformation 
 in question ; how many of whom might have been saved by appropriate 
 treatment, it is impossible to say. 
 
 It is a question whether (if life may only be saved by the formation of 
 an artificial anus) it is not better to allow the sufferer to die rather than 
 drag on a miserable existence, with such a loathsome and disgusting afflic- 
 tion, " an artificial anus." 
 
 There are several classifications of this malformation : Mr. Holmes di- 
 vides the cases of imperforate rectum into two classes. The first embraces 
 those in which no anus exists (imperforate anus properly so called) ; the 
 second, those in which there exists an anal opening, which terminates in a 
 short cul-de-sac. These are again subdivided — 
 
 The former class (imperforate anus) into : 1. Membranous obstruction of 
 the anus. 2. Complete or partial absence of the rectum. 3. Communica- 
 tion of the rectum with the vagina in the female. 4. Communication with 
 the urinary tract in the male. 5. External communication or fistula. The 
 latter (imperforate rectum) may be subdivided : 1. Membranous obstruction. 
 2. Deficiency of the upper portion of the rectum. 
 
 Mr. Curling, who has given this subject a great deal of attention, makes a 
 more simple classification thus : 
 
 Those cases in which there is complete closure of the anus, the rectum 
 being either in part or entirely wanting. Second, those in which there 
 is nothing but a cid-de-sac, surrounding the anal opening; in the third va- 
 riety, there is no anus, but the rectum terminates in the bladder, vagina, or 
 urethra. 
 
 An imperforate anus, properly so called, is much sooner recognized 
 than an imperforate rectum, for the reason that the latter is not so easily 
 discovered, and the patient continues to suffer, the causes of indisposi- 
 tion not being rightly understood, and indeed, death may ensue with- 
 out either physician or attendants being aware of the true nature of the 
 malady. 
 
 It is from a knowledge of these facts that every child should be examined 
 on the second day after birth, if there has been no movement of the 
 bowels. In such an examination the practitioner should not be satisfied 
 
 * Diseases of the Kectum, p. 8. 
 
896 A SYSTEM OF SURGERY. 
 
 with the fact that the anus is open, but should institute an exploration with 
 his finger to ascertain as to the viability of the rectum. 
 
 In many of the cases of imperforate rectum, the intestines terminate in 
 a blind pouch, which may either be high up or low down, or connected 
 with the anal cul-de-sac itself. On this point, Mr. Bryant says : " It seems 
 possible from Curling's and MM. Goyrand and Friedberg's observations, 
 that such cases are caused by an obliteration of the bowel, which was 
 originally well formed, from some intra-uterine inflammatory action. Some 
 instances being recorded, when the muscular tissue of the intestine was 
 clearly traced." 
 
 When the anus is closed by membrane, the constipation, and the 
 "bulging" at the anus, show the nature of the malformation; a simple in- 
 cision generally suffices. If there be no bulging, and the anus is firmly 
 closed, then it is proper to make an exploratory incision, beginning at a point 
 where the centre of the anus should be, and carrying the knife backward 
 toward the sacrum. Forward incisions endanger the bladder, vagina, and 
 other important organs. 
 
 In cases of imperforate rectum, the following method may be successful, 
 if the gut can be reached ; the latter is the chief difficulty in the opera- 
 tion. 
 
 On the 3d of March, I was called by Dr. Richardson, of Williamsburgh, 
 to see a child, thirty-six hours old, who had an imperforate rectum. I 
 found an infant, healthy and plump-looking, with enormously distended 
 abdomen, the convolutions of the intestines being distinctly seen. The 
 child had passed urine once. A peculiar feature was that the parents 
 had had another child born with a similar malformation, who had been 
 operated upon, and died. They had, two weeks previously, lost two 
 children with measles, and were in an excited and despairing frame of 
 mind. 
 
 Upon inserting my finger into the anus, I felt a cid-de-sac, which fitted 
 over the end of the finger like a thimble. This I tore away, and pro- 
 ceeded to search for the gut. It was entirely beyond my reach, and the 
 finger moved about in vacancy. I divided the sphincter toward the 
 sacrum for half an inch ; and again introducing my finger, I could just 
 touch the intestine, but could not catch it sufficiently to draw it down. 
 By placing a small hook flat-wise on the forefinger of my right hand, 
 I pushed it through the anal orifice, and by using the left hand as a 
 manipulator, and the right as a guide, succeeded in hooking the intestine 
 and drawing it down. The amount of traction required to do this was 
 surprising. So soon as I had drawn the gut outside the anus, I passed 
 a needle, threaded with a double silk ligature, through it, and let it 
 retreat into the cavity of the abdomen. With a few strokes of the scalpel, 
 the margins of the anus were scarified. By making traction on the ligature, 
 the gut was brought into sight, and held outside the anal aperture by Dr. 
 Richardson until I had stitched it to the margins of the anus. So soon as 
 this was done, I cut off with a scissors the blind end of the intestine. The 
 amount of faeces that were discharged seemed incredible; several times 
 we were obliged to stop proceedings, on account of fseces issuing from the 
 punctures made by the hook and the needles. 
 
 The operation was successful. On the third day the anus had to be 
 dilated with the finger, and since then there has been no further trouble. 
 
 Foreign Bodies in the Rectum. — It is astonishing how many foreign sub- 
 stances, large and small, have been introduced within the rectum; bowls, 
 cups, bottles, pots, pencils, etc., have been removed from the lower bowel. 
 In some cases, the foreign body may come from within, having been 
 
PROLAPSUS AN I. 897 
 
 accidentally swallowed and thus passed into the alimentary canal. Pins, 
 fish bones, hair, bristles, etc., have been found within anal abscesses, and 
 have been impacted in the rectum. The first thing to be done is to care- 
 fully explore the rectum with the finger to ascertain not only the exact 
 location of the foreign body, but, if possible, its size and shape. The next step 
 is to place the patient thoroughly under anaesthetic influence, in order that 
 the sphincters may be relaxed ; the third to inject at least a pint of warm 
 olive oil into the bowel ; and then to use such forceps and scoops as may be 
 required. Fig. 559 shows forceps for this purpose. 
 
 Fig. 559. 
 
 G. T/£MANN-&-CO. 
 Forceps for Extracting bodies from the Rectum, 
 
 O 
 
 The best instrument, however, is a small pair of placenta forceps, those 
 of Loomis being preferable ; it may be necessary, and in some cases is both 
 practical and proper, to gradually introduce the hand into the rectum to 
 remove what has become impacted therein. 
 
 Prolapsus Ani. — A protrusion of a portion of the rectum, or of its internal 
 coat, from the anus, is denominated a prolapsus, or 'procidentia ani. In some 
 oases a considerable portion of the rectum protrudes. 
 
 The causes are such as tend to weaken the action of the muscles which 
 support the intestine, and violent exertions of the rectum in consequence 
 of certain irritations. The frequent use of cathartics, especially those 
 which contain aloes, the presence of ascarides in the lower portion of the 
 alimentary canal, habitual costiveness, and haemorrhoids, all occasionally 
 produce prolapsus ani. Cases are on record in which the affection was en- 
 gendered by the tenesmus attending dysentery. 
 
 In some instances, the intestine remains a considerable length of time un- 
 reduced without any ill effects, but more commonly it swells and inflames 
 speedily. 
 
 The protruded portion of the bowel is generally oblong in shape, of a 
 bright-red color — especially in recent cases — and covered with mucus. In 
 older cases, the color is purple, and it is difficult to ascertain where the 
 skin is merged into the mucous membrane ; sometimes ulceration takes 
 place. Often, especially in old cases, the bladder suffers, and complete 
 retention with violent pain results. The constitution suffers after the dis- 
 ease has existed for a time ; the patient is worn with the ]3rolonged suffering, 
 and suffers from severe dyspeptic .symptoms. 
 
 Treatment. — When called to a person suffering from an ordinary prolapsed 
 rectum, the surgeon should attempt reduction. This is accomplished by 
 grasping the displaced gut, having first smeared the protruded part with 
 fresh lard or simple cerate, and pressing upon it inwards and upwards. It 
 will slowly, or in some instances quickly, return to its natural position. 
 If a large portion has escaped, especially in women of advanced life, a 
 smooth towel folded cone-like, and well greased, must be placed against the 
 central and most dependent part, and pressure made firmly and steadily 
 upwards ; from time to time it may be necessary also to press inwards and 
 upwards upon the circumference of the intestine. If the surgeon be not 
 called until the protruded intestine is swollen and painful, an immediate 
 attempt at reduction may prove abortive ; therefore a dose of ignatia or mix 
 
898 
 
 A SYSTEM OF SUKGERY. 
 
 Fig. 560. 
 
 Anal Truss. 
 
 Fig. 561. 
 
 vomica should be administered, and the patient placed in a hot bath. These 
 medicines, possessing a powerful influence over the intestinal canal, will 
 probably relieve in a short time, when the bowel may be returned to its 
 normal position. The vapor of hot water retards rather than facilitates 
 
 reduction. This complaint is apt to recur ; to 
 prevent which the patient should be strictly 
 prohibited overloading the stomach, and the 
 diet should consist of the plainest aliment. 
 Dr. Physick succeeded in completely curing 
 some cases of prolapsus ani, by confining 
 his patients exclusively to a diet of rye mush 
 and sugar. 
 
 There have been many bandages and con- 
 trivances invented to prevent the recurrence 
 of prolapsus ani ; among the best is that seen 
 in Fig. 560 ; but they generally fail in accom- 
 plishing the desired end, which is more certainly attained by the adminis- 
 tration of appropriate medicines and rigid dietetic observances. 
 
 The principal medicaments are, ign., nux vom., mere, sulph., or ars., 
 calc, lye, rut., sepia. 
 
 For the particular symptoms indicating a choice of the above, the Materia 
 Medica must be consulted. 
 
 Another method, which is sometimes successful, especially in old cases, 
 is to draw dowm the rectum with a vulsellum forceps, include the prolapsed 
 
 portion in Smith's clamp (a cut of which is found 
 on page 901), and apply nitric acid, as recom- 
 mended in the treatment of haemorrhoids. 
 
 Haemorrhoids. — There is no disease which is 
 more frequently met w T ith by the surgeon than 
 haemorrhoids. The pain they engender is excru- 
 ciating, the constitutional symptoms various, and 
 their cure often difficult. Piles consist, not only 
 in an enlargement of the veins of the rectum, 
 but of the arterial twigs, together with more or 
 less infiltration into the surrounding structures. 
 They are divided into internal (those within the 
 sphincter), and external (those situated outside 
 and around the anus). The former are of more 
 frequent occurrence than the latter, and are more 
 serious. They generally begin w r ith frequent and 
 often profuse haemorrhage from the rectum after 
 stool, w T ith pains in the back and loins, and more 
 or less suffering during defecation. This condi- 
 tion may exist for a time without much incon- 
 venience. Then tenesmus becomes noticeable, 
 and increases, until with every action of the 
 bowels the piles protrude ; there is much haemor- 
 rhage and great pain. The abnormal growths 
 have to be returned, which increases the suffer- 
 ings. Sometimes during exercise, lifting, or strain- 
 ing, they pass beyond the sphincter, it contracts upon them, and agonizing 
 pain results. Fig. 561 represents old internal haemorrhoids as they appear 
 after defecation. There are generally three, four, or five distinct tumors ; 
 sometimes they are all sessile, sometimes pedunculated, and bleed easily. 
 Often after excesses these tumors inflame, and fever and severe constitu- 
 
 Old Internal Haemorrhoids. 
 
HAEMORRHOIDS. 899 
 
 tional symptoms result. External hemorrhoids at first merely consist of 
 enlarged bloodvessels ; gradually the parts around become infiltrated, and 
 the coats of the piles more or less thickened. When they are irritated, 
 they rapidly inflame, enlarge, the vessels composing them burst, their con- 
 tents become extravasated, and a series of changes ensue, which render the 
 haemorrhoids quite hard tumors surrounding the anus. Sometimes there 
 are many of these present, varying in size. Sometimes they are enormously 
 enlarged. The largest I have seen was the size of a coffee-cup, and it 
 with two others, each the size of a walnut, I removed successfully with the 
 6craseur. Dyspeptic persons suffering from liver disease, gourmands, hard 
 drinkers, and sedentary men, are all liable to haemorrhoids ; in many in- 
 stances there exists a haemorrhoidal diathesis, rendering the patient subject 
 to these tumors upon the slightest indiscretion. 
 
 Treatment. — In a disease so frequently encountered, the variety of medi- 
 caments, salves, and embrocations, which have been recommended, is legion ; 
 and combined medical and surgical treatment rarely fails if persevered in 
 to effect a cure. If a patient has internal piles, and they appear below the 
 verge of the anus at stool, the hot sitz bath, immediately after the evacua- 
 tion, will give relief, and enable the protruded parts to be returned. Many 
 persons having for years suffered with haemorrhoids, and taking cold baths 
 after an evacuation from the bowels, are relieved by the hot water. If there 
 is haemorrhage, apis mel. and hamamelis should be given. H. Strisower* 
 describes the case of a man which had resisted all treatment for profuse haem- 
 orrhoidal bleeding during six months, who was promptly cured by a clyster 
 containing five grains of ergotin in two ounces of glycerin. If severe pain 
 and dyspeptic symptoms are present, nux vom. and collinsonia canadensis 
 are useful. To allay the severe itching and inconvenience resulting from 
 an action of the bowels, a cerate of aesculus hippocastanum is useful, or the 
 applications mentioned further on in this chapter. 
 
 Hydrastis has proved efficient in haemorrhoids accompanied with fissures 
 and cracks about the anus. Three or four drops of the tincture, in half a 
 glassful of water, a tablespoonful taken every six hours, is of service. 
 
 Pond's extract of hamamelis permanently cured an aggravated case of 
 haemorrhoids ; it was taken internally and applied externally. 
 
 Dr. Von Holsbeck praises chelidonium as an excellent remedy for piles. 
 This medicine is in vogue with the inhabitants on the shores of the Seine, 
 and Dr. Von Holsbeck has used it extensively as decoction, tincture, or ex- 
 tract, prepared from the sun-dried root, gathered after the blossoming period. 
 Fumigations have been followed by amelioration of suffering which accom- 
 panies the complaint. 
 
 Without entering upon the symptomatology of the medicines which are 
 applicable in haemorrhoidal disease, I may say that nux vomica, collinsonia 
 can., and sulphur have produced in my hands the best results. I give a 
 drop of the tincture of nux vomica in a sherryglassful of water an hour 
 after each meal, and at bedtime, for a week. The next week, five-drop doses 
 of collinsonia are given in the same manner. These remedies are continued 
 for two months, with an occasional dose of sulph. 2* trit., five grains in the 
 morning, together with the baths already noticed. 
 
 If the haemorrhoids are attended with excessive colic, colocynth is an 
 excellent medicine. Sulphur may follow the administration of nux ; hepar 
 and bella. symptoms may be present. Other medicines are aesculus, capsi- 
 cum, calc. carb., china, mere, ipecac, and rhus tox. 
 
 * London Medical Record, February 15th, 1877. 
 
900 A SYSTEM OF SURGERY. 
 
 A case is recorded where aesculus glabra effected a cure ; Dr. R. Hughes 
 reports several cases in which sesculus hip. was successful ; Drs. C. H. 
 Lee, George Logan, E. M. Hale, A. A. Bancroft, T. C. Duncan, Cuthbert 
 and L. B. Wells, also verify the action of the medicine. Dr. Lippe men- 
 tions cactus grand. ; Dr. King chelone glabra • Drs. Hale, Carroll, Coe, E. P. 
 Fowler, Holcomb, Stewart, G. W. Barnes, and Jones recommend collinsonia 
 canadensis ; Dr. Burt speaks of dioscorea vil. ; Dr. Hale mentions erigeron 
 can. ; the virtues of hamamelis virg. are attested by Hering, Okie, Preston, 
 Burritt, Burt, and Hughes ; Hale cites several cases ; hydrastis is praised 
 by Dr. Brown ; Dr. Paine proves the homceopathicity of phytolacca decan- 
 dra ; and Talmage, of Brooklyn, records cases showing the virtues of podo- 
 phyllum* 
 
 Glycerin in two-drachm doses, given night and morning, is recommended 
 by Dr. D. Young as an efficacious palliative in internal haemorrhoids.! 
 
 Injection. — In most cases of internal haemorrhoids, when surgical treat- 
 ment is necessary (which often relieves the patient, and allows the medi- 
 cines a better opportunity for displaying their power), the best is the injec- 
 tion into the haemorrhoid of a mixture composed of equal parts of olive oil 
 and carbolic acid. The pile must be brought down as low as possible, and 
 
 Fig. 562. 
 
 Bodenhamer's Forceps for Ligature of Hemorrhoidal Tumor. 
 
 about eight to ten drops of the solution gradually thrown into it. If the 
 connective tissue is dense, it may be broken up with the end of the needle 
 before the piston is thrust home. An indication that the work is successful, 
 is the change of color of the haemorrhoid ; it becomes whitish. Only one 
 pile should be treated at a time, and the parts, well smeared with aesculus 
 cerate, should be returned into the rectum. I have cured the most obstinate 
 cases by this method. 
 
 Ligature. — In applying the ligature, the patient should sit for a time over 
 hot water, and use every effort to force without the verge of the anus, the 
 offending masses. They may be seized with a rectum polypus forceps, 
 or with that invented by Bodenhamer, Fig. 562, for that purpose. Having 
 a good stout round needle, with a sharp point and no cutting edge (threaded 
 with a double-waxed thread), pass it through the centre of the base of one 
 of the tumors, cut the thread off at the eye of the needle, and tie one side 
 around one portion of the haemorrhoid, and the other ends on the other 
 side. Having treated all the tumors in this manner, and allowing the ends 
 to remain, the parts are well smeared with hippocastanum or simple ce- 
 rate, and returned within the rectum. 
 
 * Vide Hale's New Kemedies, pp. 19, 159, 191, 250, 311, 319, 488, 500, 791, 826. 
 t American Journal of the Medical Sciences, April, 1878. 
 
FISTULA IN ANO. 901 
 
 Nitric Acid Treatment. — Where there have been profuse haemorrhages 
 from internal haemorrhoids, I have used the nitric acid treatment with 
 good results. Having drawn the haemorrhoids down, apply to them a 
 Smith's clamp, or the modification thereof by Mr. Stohlmann, which has 
 ivory plates fixed to the blades to prevent the action of the acid on the 
 steel (Fig. 563) ; this done, turn the screw tightly, and apply the acid 
 
 Fig. 563. 
 
 Smith's Hsemorrhoidal Clamp (ivory -plates). 
 
 thoroughly with a glass rod or a brush composed of glass threads, or a 
 piece of wood, and allow it to act for a considerable time. The clamp is 
 then removed, and cold water applied. This must be repeated every few 
 days until the growth is destroyed. 
 
 Ecraseur. — This is my favorite method of removing all internal haemor- 
 rhoids. The pile is brought well out, by a needle and thread, which is 
 passed through the tumor. By traction on the thread the haemorrhoid is 
 drawn out and kept out until the chain of the instrument bites. The thread 
 may then be removed, and the screw at the handle turned slowly. After 
 the haemorrhoid is cut through, a portion of the mucous membrane generally 
 is impacted between the chain and side of the instrument ; this may be 
 divided with scissors. Dr. Nott's rectilinear ecraseur is efficient in remov- 
 ing haemorrhoids. The galvano-cautery is another means of removal. It is 
 safe, and the results are successful. Those physicians who possess a battery 
 can have recourse to this method with confidence. 
 
 I have removed piles often with the ecraseur, and without any disastrous 
 result, excepting on one occasion, where a profuse haemorrhage followed, 
 which was arrested by pieces of ice inserted within the rectum ; in this 
 (the patient being a lady of great nervous sensibility) tetanus resulted, 
 from which she made a tedious recovery. There are cases upon record 
 where the use of the ecraseur has not been so free from after-results as in 
 my own. 
 
 Fistula in Ano. — When an abscess forms in the cellular membrane sur- 
 rounding the rectum, or about the verge of the anus, and leaves, after its 
 contents are discharged, one or mo're small openings communicating with 
 its cavity, the disease is denominated fistula in ano. Other appellations 
 have been employed, expressive of the particular situation of the fistulous 
 orifice and the extent of the disease. 
 
 If the fistula open upon the surface of the integument, it is called an 
 external fistula ; if it communicate with the rectum, and not with the integu- 
 ment, an internal fistula ; and if the sinus open internally through the rectum, 
 and externally through the skin, a complete fistula. 
 
 It will be seen that I have excluded the terms "blind internal fistula " 
 and "blind external fistula," because I have found the classification per- 
 plexing to the student — one has to stop and think which is the blind end. 
 
 The formation of a fistula in ano is often denoted by rigors, painful swell- 
 
902 A SYSTEM OF SURGERY. 
 
 ing about the ischium or perinaeum, difficulty of passing urine, and by irri- 
 tation in the rectum and neck of the bladder. During the progress of the 
 disease, the patient in many instances suffers extremely ; at other times, 
 the fistula forms almost without his being aware of its existence. Gener- 
 ally it communicates with the integument by a single opening, but occasion- 
 ally there are three or four. 
 
 In healthy constitutions the abscess does not differ from that in other 
 parts of the cellular tissue, but in consumptive and scrofulous subjects 
 the disease assumes a different character. The surface of the integu- 
 ment is covered with an erysipelatous inflammation, the constitutional 
 symptoms are well marked, the matter is discharged in small quantity, 
 and from a sloughy, ill-conditioned opening, or from a ragged, unhealthy 
 surface. 
 
 The causes of fistula in ano cannot be always ascertained. Sometimes 
 it arises from irritation about the rectum ; from local injury ; from the 
 lodgment of undigested articles of food taken into the stomach, and 
 passed through the intestine as far as the rectum (for example, small bones 
 of fish or fowls) ; severe and long-continued exercise, particularly on horse- 
 back, or haemorrhoids. 
 
 Medical Treatment. — When/the inflammation is er} T sipelatous, and spreads 
 rapidly, bell, or rhus may be prescribed. Silic. is an important medi- 
 cine, not only in the commencement but when the fistula is fully estab- 
 lished. In the former if the abscess has not discharged, and the cellular 
 membrane be found in a sloughy state, a free incision should be made 
 to permit the escape of the purulent secretion. If healthy action does not 
 display itself, ars. and china must be prescribed. 
 
 Merc, sulph., silic, hepar, or calc carb. must be exhibited, if cicatriza- 
 tion proceed imperfectly. If the constitution is impaired before opera- 
 tion, appropriate medicines must be administered, to eradicate any disease 
 that may be present. In cases where the fistula has not been subjected 
 to treatment, mere or silic. may be given. Hepar may be required 
 after mere, when the fistula is extensive; and phosph. after silic, where 
 there is complication with disease of the lungs. When the digestive 
 apparatus is impaired, calc carb., nux vom., mere, and silic will prove 
 valuable. 
 
 Caust. is important in cases of long standing, and in alternation with silic. 
 I have known a fistula in ano to be healed for a time. 
 
 Dr. Eggert, of Indianapolis, and Dr. Grasmuck, of Kansas, both report 
 cases cured by internal medication, the latter using sesculus cerate in 
 connection with nux vomica and sulphur. Dr. Scriven, of Dublin, related 
 to me a successfully treated case. As a general rule, surgical means must 
 be resorted to, although previous medication may do much toward render- 
 ing the operation successful. 
 
 Dr. Hute employs an ethereal solution of iodine as injection for the cure 
 of fistula. He states that patients are not obliged to keep their beds, and 
 has known several cures after one injection. 
 
 Surgical Treatment. — If, after a patient trial of the means above men- 
 tioned, the disease remain unchanged, recourse must be had to surgical 
 measures. I prefer the elastic ligature of Dittel. I have operated with it 
 many times with better results than with the knife, and have devised an 
 instrument for the better carrying of the ligature (Fig. 564). It can be used 
 for complete or incomplete fistulas, and may be explained thus : An 
 examination of the wood-cut shows two buttons (A and B), close to the 
 handle of the instrument. By pushing forward the button A, the blunt 
 end, as seen at F, opens. The elastic ligature is put upon the stretch, 
 
FISTULA IN ANO. 903 
 
 and, while thus drawn out, is slipped into the notch, and the button A 
 drawn back to its place, and the needle (if the case is one of complete 
 fistula) is ready for use. If this instrument is not at hand, the operator 
 may proceed as follows : 
 
 Having passed a director through the fistula, I introduce the finger of the 
 left hand into the rectum and draw the point of the instrument out at the 
 anus. It is then pushed over across to the opposite buttock. Having 
 a blunt probe threaded with the elastic, it is passed along the groove in 
 the director and the ligature drawn through. The director is withdrawn. 
 This leaves one end of the ligature hanging from the anus, the other from 
 the fistula. A round circlet of lead, made for the purpose, or a perforated 
 
 Fig. 564. 
 
 The Author's Elastic Ligature Carrier. 
 
 leaden ball, is slipped over the ends of the ligature, which are firmly 
 taken hold of with the thumb and finger of the left hand, and drawn out 
 until the thread is about half its ordinary thickness. A good-sized pair of 
 forceps with strong jaws is seized in the right hand and the clamp taken 
 hold of, but not squeezed, with the instrument. Holding the extended 
 elastic in the left hand and keeping it tense, the clamp is slid close up to 
 the fistula, and with a sudden and firm compression of the handles, the 
 jaws of the forceps are closed, thus pressing firmly together the malleable 
 lead and securely fastening the ligature, the ends of which are cut off. The 
 patient is not always confined to bed. By its elasticity the ligature cuts 
 itself out in from four to ten days, with the wound generally granulating 
 behind it. 
 
 When the knife is preferred, the operation may be performed in the fol- 
 lowing manner : The patient being placed upon his face and knees, the 
 pelvis elevated, with the thighs apart — or upon his back, with the thighs 
 separated and flexed upon the abdomen — the surgeon, oiling the fore- 
 finger of the left hand, introduces it up the rectum ; a narrow probe-pointed 
 scalpel or bistoury (Fig. 565) is passed up the fistula, until it comes in con- 
 tact with* the finger. If the intestine be not perforated by the disease, the 
 surgeon must make an opening into it with the point of the knife, and pass 
 it into the cavity of the intestine ;- the end of the finger is then firmly fixed 
 upon the probe point of the knife, and by drawing both outwards, the 
 sphincter muscle and all the intervening tissues are divided. 
 
 Another method is by passing a grooved director through the fistula, 
 against or into the intestine. Introduce into the bowel a smooth round 
 stick, resembling a rectum bougie, the size of the thumb; the stick having, 
 a groove on one side as wide as the finger. This being passed up and 
 held firmly by an assistant, the surgeon takes the director, already in- 
 troduced, and impinges its extremity firmly against the groove in the 
 stick. He now takes a sharp-pointed knife, and runs it forcibly down the 
 groove in the director, and when it comes in contact with the rectum 
 stick, cuts outwardly against this, and thus divides the fistula at one 
 sweep. This operation is performed in a shorter time than the one pre- 
 
904 
 
 A SYSTEM OF SURGERY. 
 
 viously mentioned, with much less pain to the patient, and greater con- 
 venience to the surgeon. 
 
 An operation which I have performed with success is that I believe 
 devised by Gross. Pass a grooved director (a strong one which will not 
 easily bend, and with a somewhat pointed extremity) into the fistula ; if 
 the canal is blind internally, make the internal opening b} T pressure with 
 the director. Having oiled the finger, pass it into the rectum until it 
 reaches the point of the director, hook the finger over the latter, and draw 
 
 Fig. 565. 
 
 Fig. 566. 
 
 Cooper's Knife. 
 
 the instrument outside the anus. So soon as the point of the director emerges 
 push it with the right hand, which has not left the handle of the instru- 
 ment, across on the opposite buttock. Then with a bistoury divide all the 
 structures upon the director (Fig. 566). The bowel then returns into the 
 cavity, and is dressed as below. 
 
 Many French surgeons, after dividing the fistula, dissect out its walls, 
 thus cutting out a tube of the indurated soft parts. 
 
 In whatever way the operation is performed, after the fistula is divided, 
 lint is to be pushed into the wound to insure its closing from the bottom by 
 granulations, which, as the healing process progresses, force the lint before 
 them. The patient must be kept at rest ; and, if there be any constitutional 
 excitement, it may be allayed by aconite and bella. in alternation, after 
 which silicea and sulphur may be exhibited to hasten granulation. 
 
 There is a point that should not be overlooked. When passing a probe 
 into the fistula the instrument should be carefully used, lest it perforate 
 the walls of the sinus, and pass into the cellular texture of the perinseum. 
 Deep cutting in this region may be productive of serious results-, and as 
 the cure does not call for such risk, it should never be encountered. The 
 service required of the knife is the division of the sphincter muscle ; and 
 to accomplish this object an incision an inch or an inch and a half in depth 
 is all-sufficient, and should never be exceeded. 
 
 There is another point of importance : when an abscess opens around 
 the verge of the anus, treat it at once as if it were a fistula, by dividing 
 the sphincter ; otherwise, a cure will not be effected. 
 
 Ligature. — When the internal orifice of the fistula is situated above the 
 internal sphincter, it is safer to use the ligature. Some surgeons prefer 
 this method. Its objection is the length of time required in cutting 
 itself out, which gives rise to more or less constitutional irritation. A 
 good way is to divide the upper portion of the fistula with the ligature 
 and then employ the knife. In passing the thread a flexible probe may 
 be used. It should be insinuated gradually into the sinuosities of the 
 
TUMORS WITHIN THE RECTUM. 905 
 
 canal until it impinges upon the finger within the rectum. It may be 
 
 brought out at the anus, as seen in Fig. 567, and the ligature, a good strong 
 
 cord, fastened to its end. The probe is 
 
 carefully withdrawn, guided by the fore- fig. 567. 
 
 finger of the left hand within the rectum. ^^^Bfttor 
 
 mass) over a small piece of flat cork. After .^j ^^^^^^^^K«lv)y? 
 
 Dr. Sawyer reports the case of a German ^^sa^ss^-^ I ~^|J 
 
 man thirty years of age, who from disease JJBIBlltellli 
 
 seemed very prostrate ; therefore he used a / -IMBM) 
 
 ligature drawn through a piece of cork, %J < <<r -"" : ' (j^ 
 
 which was to be tightened every day, at the 
 same time injecting dilute phosphoric acid 
 
 into the fistulous passage night and morning. He gave arsenicum three 
 times daily. In three weeks the fistula closed. 
 
 Forcible Dilatation of the Sphincter. — In the treatment of fistula in ano, 
 John Pattison, M.D., of London, has offered, as a substitute either for liga- 
 ture or the knife, a method of dilatation of the sphincter ani. The expan- 
 sion of the muscle is effected by placing both thumbs within the anus, and 
 drawing them forcibly outwards towards the tuberosities of the ischia ; and 
 thus paralyzing the sphincter by overstretching. This treatment has in 
 his hands been successful, all his cases, save one, having recovered. He 
 treats the sinuses by injections of hydrastis canadensis, to cleanse them ; 
 and afterwards packs with anhydrous sulphate of zinc. 
 
 Some of the cures reported by Dr. Pattison are remarkable, and the opera- 
 tions are so simple that they are worthy of trial. 
 
 Dr. Brownell tells of an Irish laborer, aged 39, admitted into Bellevue 
 Hospital, in which, after referring to Dr. Pattison 's mode of treating these 
 cases by suddenly paralyzing the sphincter ani, he gives his mode of accom- 
 plishing the same by inserting a sponge compress into the anus, which by 
 subsequent expansion exerts an equable steady pressure outwards, para- 
 lyzing the sphincter ; the man, with two or three causes for retarding pro- 
 gress, recovered. The doctor says a second case was cured in a few days, 
 and a third in seven. 
 
 George W. Bowen, M.D., reports five instances where he employed this 
 treatment successfully. He states that the bowels must be relaxed ; after 
 which the sinuses are injected with a solution of nitrate of silver; com- 
 pressed sponge or a fine sponge tent is then introduced into the fistula. 
 Dr. Bowen has found a week sufficient for this treatment. Thebaud's 
 dilator is probably the best instrument for forcible dilatation. 
 
 Dr. Brownell refers to a case cured by introducing a bivalve specu- 
 lum at the time of defecation, and washing the rectum before the with- 
 drawal of the speculum to avoid the necessity of confining the bowels, and 
 Dr. Sterling speaks highly of this method. 
 
 Tumors within the Rectum. — Various abnormal growths have been found 
 within the rectum, and according to their bulk or specific character, excite 
 more or less irritation, inflammation, or diarrhoea. There are cases on record* 
 of enormous tumors of the lower intestine, involving the whole circle of the 
 anus, and extending beyond it many inches. 
 
 Of these, polypus of the rectum is most frequent. The following example 
 will show the symptoms : 
 
 * Vide Mr. John Bell's Principles of Surgery, vol. iii., p. 188. 
 
906 
 
 A SYSTEM OF SURGERY. 
 
 A young woman twenty years of age, admitted into the Good Samaritan 
 Hospital, had never menstruated, was short of stature, and dwarfish in 
 appearance. She stated that eight years before she had suffered from a 
 red bleeding substance in the rectum, which had been removed, but 
 that similar growths had returned. She was pale and sickly though not 
 much emaciated, was troubled with a constant diarrhoea and more or 
 less tenesmus, and the passage of a good deal of blood. Upon external 
 examination nothing particular could be noted ; but upon desiring her to 
 attempt to expel the contents of the rectum, there would protrude several 
 elongated bodies, resembling earthworms in shape, but of a brilliant red 
 color. They presented a soft, vascular, shreddy appearance, bearing some 
 resemblance to sarcomatous growths. With the expulsion there was 
 always a yellow, fetid discharge. Upon examination of the faeces, they 
 were flattened, and there was flatulent distension of the bowels. Appre- 
 ciating the value of bromide of potassium in the removal of morbid 
 growths, I determined to try the medicine upon this patient and gave the 
 following prescription : 
 
 R. Potassii bromid., . . 3j. 
 
 Aquse font., ... * . ^vj. 
 
 M. ft. sol. S. A teaspoonful three times a day. 
 
 She continued the treatment from early in February until the middle of 
 May. She soon began to improve in health ; the diarrhoea ceased ; she 
 performed household duties in the hospital, and on the 13th of May, 
 though the fetid fluid was expelled, she was unable to protrude any polypi. 
 The remains of the growths could be felt, but otherwise the patient was in 
 good health. I had endeavored to draw down the polypi and ligate them, 
 but they were too friable, and broke away so easily that I gave up the 
 attempt. 
 
 Treatment. — The best medicines for such tumors are caust., conium, calc. 
 carb., lye, phos., sepia, sulph., and thuja; others may be employed accord- 
 ing to the presenting symptoms ; when these fail, resort may be had to an 
 operation. 
 
 If the tumor originate by a narrow pedicle, and admit of motion, it may 
 be pulled down by the forceps (Fig. 568), and a ligature applied to the neck. 
 
 Fig. 568. 
 
 Rectum Polypoid Torsion Forceps. 
 
 If the abnormal formation be large, it should be drawn down as low as 
 possible with the forceps, and several needles armed with ligatures passed 
 through its base, and their ends firmly tied; circulation thus being arrested, 
 sloughing will result. It is especially to these tumors that electrolysis is 
 applicable. 
 
 Stricture of the Rectum.— The rectum is sometimes the seat of stricture, 
 which may be either spasmodic or permanent: the former is caused by 
 
CARCINOMATOUS STRICTURE. 907 
 
 improper or unwholesome articles of food taken into the stomach, which 
 passing undigested through the alimentary canal, excite irritation, which 
 gives rise to the spasm. In the cases that have come under my observation 
 there has always been an actual deposit and permanent stricture of the 
 tube ; it is not until the calibre of the rectum has been materially circum- 
 scribed by the deposit that patients apply for relief. 
 
 Permanent Stricture generally originates from chronic inflammation of the 
 lining membrane of the intestine, causing thickening and contraction of the 
 part or deposit in the submucous cellular tissue. In these diseases there is 
 pain and difficulty in voiding faeces, which are passed in narrow flattened 
 fragments, or if fluid, are ejected with considerable force. The stricture 
 may be felt in some instances per anum, by the finger ; in others, when the 
 stricture is higher up, an instrument must be used. In examining a patient 
 care should be exercised, especially if the disease be high up in the rectum. 
 Instances are on record where fatal results, from perforation of the bowels, 
 have ensued. The digestive organs become impaired, dilatation takes place 
 above the seat of stricture, which may result in ulceration of the intestine. 
 In such cases the prognosis is unfavorable. 
 
 Carcinomatous Stricture. — This disease, which, in the majority of in- 
 stances, is of the epithelial variety, is often complicated with haemorrhoids. 
 Many physicians have treated cases as simple constipation when in reality 
 a stricture existed. Such instances have come under my notice; one in 
 particular, in which the stricture existed to such an extent that a small- 
 sized bougie could be introduced with difficulty. In this case the patient 
 vomited feces from time to time. I dilated the stricture at intervals with 
 graduated metallic bougies, and with arsenicum given by the attending 
 physician, was productive of happy results. On one occasion I believe life 
 to have been saved by the timely application of this medicine. 
 
 The following points will be useful in diagnosing between syphilitic con- 
 traction, carcinomatous and inflammatory stricture. 
 
 If the stricture be cancerous, we generally can detect, in and around it, 
 hard nodular masses, with here and there a softened and fluctuating spot. 
 In this there is an uneven deposit around the canal, and this deposit is 
 sessile. Together with these manifestations there is often discharge of 
 blood. 
 
 If the stricture be syphilitic, there is more or less ulceration from the anus 
 toward the constricted part of the gut, and upon investigating the case, 
 suspicious symptoms and appearances will generally be developed. In 
 this variety, there will be more or less discharge of mucus and bloody 
 matter. 
 
 If the stricture be inflammatory (and this is the most favorable for treat- 
 ment), the constriction will be annular, and some previous inflammation or 
 disease of the bowel will have been noticed. 
 
 Treatment. — In spasmodic stricture, nux vom. is the principal remedy, 
 and will often relieve the affection if the patient observe the strictest dietetic 
 rules. Arsenicum, bell., hyos., sulph ac, and verat. may be called for. 
 
 To ascertain the position of the stricture it is often necessary to explore 
 the rectum, which, when the seat of the disease is high, is sometimes diffi- 
 cult. In such cases the rectum exploring sound of Bodenhamer is a good 
 instrument (Fig. 570). 
 
 In permanent stricture, ars., bell., canth., colch., ignatia, nux vom., lye, 
 mere, sulph., may be indicated, and with the administration of the appro- 
 priate remedy, the bougie (Fig. 569) must be employed. The instrument 
 should be soft, and at first introduced once in three or four days, and al- 
 lowed to remain as long as the patient is able to bear it. After a time a 
 
908 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 569. 
 
 large-sized bougie should be introduced more frequently ; in some instances, 
 where there is great constriction, and the smaller-sized bougies cannot be 
 used with facility, it is necessary to divide the stric- 
 ture with a probe-pointed bistoury passed into the 
 intestine upon the forefinger. 
 
 Linear Rectotomy, anterior and posterior, may 
 be practiced when the stricture is within reach. 
 The patient being etherized, a small Sims's specu- 
 lum is introduced anteriorly. This, with traction, 
 will bring the stricture into view ; the forefinger 
 of the left hand should be used as a guide, and 
 passed into the rectum. On this a probe-pointed 
 
 Fig. 570. 
 
 \ G.TIEMANN-CO.N.Y. 
 
 Ft, 
 
 Bodenhamer's Rectum Exploring Sound. 
 
 bistoury should be pushed beyond the finger, and 
 the stricture, mucous membrane, and even a few 
 fibres of the muscular tissue, divided in a per- 
 pendicular line. The speculum is introduced to 
 bring the anterior portion of the rectum to view, 
 and the same method of incision practiced. The 
 haemorrhage will be profuse, and the operation 
 Rectum Bougies. must not be performed if there are internal haemor- 
 
 rhoids, otherwise disastrous bleeding might be the 
 consequence. Pieces of ice or, as practiced in a recent case, injections of 
 hot water will arrest the bleeding, when a fair-sized bougie (one that will 
 enter without much force) must be introduced and allowed to remain for 
 half an hour. 
 
 I cannot place too much stress upon the absolute necessity of caution 
 in these operations. After a day or two a bougie, somewhat larger, may be 
 entered, and by patience and gentleness the obstruction overcome. This 
 method was devised by Dr. Beane, of New York * 
 
 Other instruments have been employed for this purpose, as in Fig. 571. 
 Dr. Whitehead f has written an excellent article on stricture of the rec- 
 tum, and has devised an instrument for its dilatation. It consists of a bag, 
 as seen in the cut, Fig. 572, which, when collapsed, is easily introduced. 
 Either air or water may be injected, the pressure being thus easily regulated. 
 
 * American Journal of the Medical Sciences, April, 1878. 
 t American Journal of the Medical Sciences, January, 1871. 
 
ULCERS AND FISSURES OF THE ANUS. 
 
 909 
 
 Fig. 571. 
 
 Fig. 572. 
 
 Ulcers and Fissures of the Anus. — The verge of the anus and the mucous 
 coat of the bowels are often the seat of 
 fissures and small ulcers, which give rise 
 to intense pain, and after continuing for a 
 time, to severe constitutional disturbance. 
 Persons afflicted with dyspepsia are sub- 
 ject to this disorder. 
 
 The pain during defecation is excessive, 
 but in many cases the suffering does not 
 commence for fifteen or twenty minutes 
 after a movement of the bowels. The 
 stools are covered with blood and mucus, 
 the faeces flattened, constipation is present, 
 and, in fact, the patient is rendered miser- 
 able. It was said, I believe, by the late 
 Baker Brown, that sterility has been noted 
 as an accompaniment of this disease in 
 women, and that upon the cure of the fis- 
 sure, pregnancy resulted. 
 
 Treatment. — The medicines that relieve 
 are graphites and nitric ac. ; indeed, I 
 have known fissures that have resisted 
 other treatment for a considerable time, 
 yield to the action of these remedial agents, 
 especially the latter. 
 
 Dr. Perry* has written an article on this 
 subject, and the following are the results 
 of his experience : The chief medicines 
 for the affection are nit. ac. and ignatia ; 
 next in order are plumb., sulph., ars., 
 nat. mur., phos., and sepia ; lastly, caust., 
 sil., nux vom., thuja, tabac, gratio., and 
 mez. ; petrol, is also an important medi- 
 cine. 
 
 I have used, with success, to relieve the 
 pain after defecation, a cerate of sesculus 
 hippocastanum. Of late, I have found 
 surgical treatment the safest and 'most 
 speedy. The patient should be anaesthetized, as the pain of this apparently 
 trivial operation is excessive. Opening each fissure, divide thoroughly 
 the mucous membrane at its deepest point. To make sure of the thorough 
 division, pass the finger forcibly into the fissure, and break up any slight 
 adhesions that may remain. 'Gurdon Buck cured rhagades by dilatation, 
 either with the fingers, as directed in the treatment of fistula in ano, or 
 with Thebaud's instrument. I have successfully treated fissures in this 
 manner. If ulcers exist with the fissures, then the knife must be carried 
 across the ulcer. Erichsenf uses a suppository of 2 grains ext. bell., 2 
 grains acetate of lead, and 4 grains of tannin. 
 
 Dr. CreguyJ inserts charpie, soaked in a solution of chloral (1 to 50), 
 
 Whitehead's Elastic 
 Pressure Rectal Stric- 
 ture Dilator. 
 
 Rectum Dilator. 
 
 * Journal de la Soci&e Gallicane, quoted by British Journal of Homoeopathy, vol. viii., 
 p. 541. 
 
 f Science and Art of Surgery, vol. ii., p. 850, Philadelphia, 1885. 
 j Monthly Abstract of Medical Science, January, 1876. 
 
910 A SYSTEM OF SURGERY. 
 
 just within the anus daily, and reports complete cure of two cases within a 
 fortnight. 
 
 Itching of the anus is a troublesome and inconvenient affection. Fre- 
 quently it is an attendant upon verminous diseases, or in other cases it may 
 be purely idiopathic. In most instances it is attended with other symp- 
 toms, as burning and stinging, and is worse at night, and is difficult to 
 manage. 
 
 The following are the appropriate remedies, although internal treatment 
 rarely effects a cure: Alumina, capsicum, iod., terebinth.; after evacuation, 
 antim. tart., or strontia, antim. crud., colchicum, nit. ac, platina, kali carb., 
 plumb. A good local application is that of Creguy. 
 
 A favorite prescription with me is : 
 
 R. Acidi hydrocyan. dil., £ss. 
 
 Cretae preparat., 3J S8> 
 
 Cerat. cetacei, 3J 8S - 
 
 M. Ft. unguent. Apply at night. 
 
 Dr. T. G. Comstock has found the following serviceable: 
 
 R. Quiniae bisulph., £j. 
 
 Vaselini, ............ 3J. 
 
 M. Ft. unguent. Locally applied at night. 
 
 Carcinoma of the Rectum. — Some of the symptoms of cancer of the rec- 
 tum have been detailed, when speaking of certain forms of structure; in 
 all malignant diseases of this tube, there is more or less obstruction of 
 the canal. In the earlier stages, the affection is known by the peculiar, 
 hard, uneven (nodular) masses that are felt by the finger, or sometimes 
 seen with the speculum, situated from an inch to four inches beyond the 
 sphincter ani. The symptoms are pain during the efforts at defecation, 
 with occasional loss of blood, which becomes frequent and profuse as the 
 disease advances. The suffering lasts for some hours after stool, which is 
 accompanied with tenesmus. The faeces are altered in shape, being thin 
 and tapelike, and the patients become emaciated. After a time, a fetid and 
 acrid discharge escapes from the anus ; there is absolute constipation, and 
 an examination reveals a soft and pulpy degenerate tissue, which is reddish 
 or purplish, friable, and readily bleeding. The constitutional symptoms 
 are well marked, and the cancer cachexia is apparent. A portion or the 
 entire walls of the rectum may be involved, but as the disease advances, all 
 the surrounding tissues may be infiltrated and destroyed. I have known 
 instances where the entire sphincter and perinseum had been destroyed, 
 presenting a hideous and disgusting deformity. The cases that have come 
 under my care have generally been those of epithelioma. 
 
 Treatment. — In the early stages of the disease, the medicines are arseni- 
 cum, conium, hydrastis, both internally and externally, lachesis, and nitric 
 acid or thuja. 
 
 The best local application is electrolysis. I have known cases so far ad- 
 vanced that the patients were apparently beyond hope, in which the disease 
 was arrested by this method. If the surgeon, however, prefer it, the rectum 
 may be excised. 
 
 Excision of the Rectum. — Prof. Hyrtl, as well as Nelaton and Velpeau, 
 has asserted, that there is a peculiar band of muscular fibres above the 
 internal sphincter ani, which possesses sphincteric powers, and I was dis- 
 posed to believe that this sphincter ani tertius was the muscle that enabled 
 patients after the removal of the lower portions of the rectum to regain the 
 
EXCISION OF THE RECTUM. 911 
 
 control of the feces. Hyrtl writes : * u The older surgeons were astonished 
 after having divided the sphincter muscles in operations for fistulae, that no 
 involuntary discharges of the faeces followed. Paget found after removing 
 the lower end of the rectum from a patient, that he could retain his faeces 
 and flatus, and he explained this upon the hypothesis that a new sphincter 
 must have subsequently formed. Houston was not disinclined to believe 
 that the lower portion of the rectum, where a fold occurs as it passes through 
 the pelvic fascia, was surrounded with a development of circular fibres. 
 Lisfranc, who many times extirpated the terminal portion of the rectum, 
 noticed that such patients were not deprived of the power of holding back 
 their stools, and declared it as his opinion, that as a positive necessity a su- 
 perior sphincter must exist. Likewise every unprejudiced observer must 
 allow of the existence of such a muscle, for the reason that in prolapsus ani, 
 when both the external and internal sphincter are paralyzed, no involuntary 
 stools occur. 
 
 " In rupture of the perinseum and congenital opening of the rectum into 
 the vagina (cloaca) the same thing happens. Ricord cites a case of a woman, 
 aged 22, where the rectum opened into the vagina, yet the bowel acted regu- 
 larly, and, what is more remarkable, the husband after having been married 
 three years, had no conception of this abnormal condition in his wife. 
 
 " When the index finger is introduced into the rectum of a patient who 
 has had no action from the bowels for a few days, as a rule, just above the 
 anus, no faeces will be found, and yet the column of fasces would naturally 
 sink down to this point, if not held back by an opposing circular muscle. 
 Kohlrausch offered this view, which presupposes the existence of a third 
 sphincter, because he found upon dead subjects, as well as in patients, hard 
 scybala in the lower portion of the rectum ; but I take occasion to mention 
 that the existence of fasces in the rectum upon subjects, simply proves that 
 the sphincter tertius no longer acts, and the same thing in the living (in 
 patients) may be the result of diseased conditions, and which affords an 
 example of an exception to the rule. Enemata which are not introduced 
 high enough into the rectum, are liable to come away immediately ; on the 
 contrary, if the canula (extremity) of the syringe is pushed up sufficiently 
 high the injection will be retained a longer time. Dr. O'Beirn called atten- 
 tion to the fact that an elastic tube can be introduced quite a distance into 
 the rectum, before any flatus is given off, and then the discharge came sud- 
 denly. All these observations make it probable, a priori, that a certain dis- 
 tance above the internal sphincter ani, a third sphincter must exist. Nelaton 
 and Velpeau have demonstrated the existence of it, as a thickened band of 
 muscular fibres, four inches above the anus. The muscular development is 
 not always easy to find. To find it upon the cadaver, care should be taken 
 that the rectum is not forcibly distended with air. 
 
 " In order to demonstrate it well, the rectum should be cut upward longi- 
 tudinally, and stretched upon a board and the several layers carefully dis- 
 sected off, until the muscular layer is reached, when the sphincter tertius, 
 if present, will be seen as a broad bundle of thickly conglomerated muscular 
 fibres." 
 
 Dr. James R. Chadwick,f however, denies not only the existence of a 
 complete sphincter tertius, but claims for the bundles of muscular fibres so 
 called expulsory power, declaring that " Detrusor Feecium " is the appropriate 
 term for the fasiculi in question. He says : " On inflating recta, however, 
 
 * Handbuch der topographischen Anatomie, Von Joseph Hyrtl, Zwiter Band, p. 130-33. 
 Auflage, Wien, 1860. 
 
 f The Functions of the Anal Sphincters, so called, and the act of Defecation. Transactions 
 of the American Gynaecological Society, vol. ii., p. 43. 
 
912 A SYSTEM OF SURGERY. 
 
 in accordance with the directions given by him (Hyrtl), it is surprising to 
 find that no such annular constrictions appear. At the point of the rectum 
 designated by him is, nevertheless, observable a semi-circular constriction of 
 the rectum confined to its anterior wall; corresponding to this, but an inch 
 or more higher up, is always seen a second semi-circular constriction, affect- 
 ing the posterior wall only. The effect of these two semi-circular constric- 
 tions is to give the rectum the shape of the letter S" "If now a 
 
 mass of faeces be supposed to advance through the rectum, following the 
 sinuosities, it is evident that these bundles of fibres, when not in active con- 
 traction, would present scarcely any obstacle to its progress. It is further 
 noticeable that the partial constrictions of the canal, differ only in degree 
 from the constrictions visible in the higher segments, which give to the rec- 
 tum its characteristic sinuous appearance." 
 
 From the experiments made also by Goltz and Gowers as well as those of 
 Dr. Chad wick, it would appear also that the internal sphincter ani, instead of 
 obstructing, really materially assists in the expulsion of the fecal matter. 
 In other words the intermittent relaxation and tonic contraction of this 
 portion of the intestine point to distinct inhibitory action of the splanch- 
 nics and vagus — which control or perhaps constitute peristalsis. According 
 then to these views the external sphincter ani " is the only one of the 
 anal muscles which can properly assume the title of sphincter." 
 
 After making myself aware of these interesting points, I was for a time, 
 and indeed am in a measure now, at a loss to understand certain facts which 
 have been made apparent by my operations of extirpation of the rectum. 
 
 I hold that the external sphincter is per se a partial detrusor fsscium. I 
 know that when faeces are passing through the external outlet, the sphincter, 
 with partly automatic and partly involuntary power, propels the mass for- 
 wards, and sometimes with considerable force; and also from the many 
 times in which I have operated for fistula in ano with the knife, that after 
 complete division of the fistula, the patients, in most instances, have had 
 no trouble in retaining their faeces. 
 
 In operations about the anus with the elastic ligature, in some of which 
 the fistulae were very deep, the power of retaining excrement was not 
 materially interfered with. In two cases in which the ligatures cut them- 
 selves out, leaving their tracks entirely open, little difference in the power 
 of retention was noticed. Such facts go to prove Hyrtl 's idea of the action 
 of the sphincter ani tertius. On the other hand, it must be remembered, 
 that after operations for extirpation of the rectum, there is no control of 
 the fecal discharges for several weeks. They pass constantly without effort, 
 often without the knowledge of the patient. Would this be so if the third 
 sphincter possessed anything like obstructive powers ? 
 
 As a rule in all the recorded cases, and from careful observation, this fact 
 is apparent, that, in proportion as the wounds heal around the margin of 
 the anus, in that proportion does the power of controlling the faeces return. 
 I can scarcely account for this, by the increased power said to be obtained 
 by the circular fibres of the rectum, because they are composed of unstriped 
 muscular tissue, exactly similar to that of other portions of the intestinal 
 tract, and must therefore be, in a measure, under central control, and are a 
 part of the general peristaltic system. I therefore conclude, that the sphincter 
 ani, per se, is a muscle of mixed action. That alone, that is uncombined 
 with other muscular force, it may and does assist in expelling fecal masses, 
 that in conjunction with the surrounding muscles it becomes sphincteric, 
 and it is this connection with other sets of muscles that has much to do 
 with the production of the act sphincteric. All the so-called sphincters of 
 the body are in close connection with other muscles, which interlace fibres, 
 and the sphincter ani markedly so, cut through the sphincters on one side, 
 
EXCISION OF THE RECTUM. 913 
 
 and as a rule there is no difficulty in retaining the faeces. Cut off the 
 sphincters, take them out entirely, as in excisions, and just in the ratio as 
 the healing process connects the stump of the rectum with the surrounding 
 tissue, just in that proportion the sphincteric power returns. Still more 
 important is the nervous control of the parts. Dr. Chadwick, in the article 
 alluded to, quotes a remarkable case from Gowers. A man had a violent 
 fall upon the sacrum, apparently injuring the posterior roots of the sacral 
 nerves ; there was no muscular paralysis, excepting of the levator ani, the 
 sphincter ani and the sphincter vesicae, which were in a state of continuous 
 slightly varying contraction; a condition generally supposed to constitute 
 sphincteric power ; the incontinence of fasces ivas complete. 
 
 I know from the peculiar action of other muscles, especially those which 
 surround cavities and are inserted into others, that the fibres of the one act 
 upon the other in a peculiar manner. 
 
 For instance, in a state of health, the velum palati is composed of sym- 
 metrical muscles having a tendency to draw that septum upward and out- 
 ward. In the cleft state from the action of these muscles, we would most 
 naturally expect the cleft to widen during deglutition. The levator of each 
 side draws the fold upward ; the tensor directly outward, by the action of 
 its tendon around the trochlea ; the palato-glossus downward and forward, 
 and the palato-pharyngeus downward and backward. Yet the entire re- 
 verse of this is the case. The cleft shuts during deglutition, from the action 
 of the superior fibres of the constrictor. If this be so, why may not all the 
 muscles in the perinseum, and especially the levatores, which are in such 
 close connection, produce some such similar results ? These are but infer- 
 ences and are offered for consideration. 
 
 From these cases we may learn, that if Hyrtl's ideas regarding the sphinc- 
 ter tertius be true there would not be such complete inability to control the 
 fasces after these operations. 
 
 That Chadwick's explanations of the action of these bands are sustained. 
 
 That the full sphincteric power is maintained by the conjoined action of 
 a set of muscles. 
 
 That control is gained over the faeces in proportion as the cuts heal and 
 the nervous power is restored. 
 
 That in a majority of cases, after the operation a retraction of the gut will 
 take place. 
 
 That the water bag is not as efficient as the simple rectal tube, which ought 
 never to be dispensed with after complete excision, as the accumulation of 
 gases gives rise to great pain. 
 
 That excision of the rectum is more feasible in women than in men. 
 
 Lisfranc made this operation popular in 1826, and Prof. Schuh* in 1868, 
 operated successfully. Of late years, the performance has been revived, 
 with success. Volkmann gave it' new impetus, and it has been performed 
 many times with success, in this country. Dr. R. J. Levis,f of Philadel- 
 phia, Drs. Van Buren and Keyes, of New York,J Dr. L. A. Stimson,§ Dr.. 
 Briddon,|| and myself were among the first who advocated a renewal of 
 the process. The operation may be described as follows : After the usual 
 precaution of emptying the bowel, and preparing all antiseptic details, a 
 circular incision is carried around the anus, about three-quarters of an inch 
 from its margin ; a second cut is made in the median line from the circular 
 
 * Medical Record, N. Y., July 13th, 1878. 
 
 f Archives of Clinical Surgery, vol. i., p. 311, 1877. 
 
 X Medical Record, N. Y., Julv 13th, 1878. 
 
 I Loc. cit., October 19th, 1878. 
 
 || Archives of Clinical Surgery, vol. i., p. 313. 
 
 58 
 
914 A SYSTEM OF SURGERY. 
 
 one, back to the coccyx, and, if necessary, a forward one, in the perinseum ; 
 the rectum is drawn gradually down and dissected carefully out, or the 
 hand of the operator may be gradually insinuated into the hollow of the 
 sacrum, and the attachments of the gut loosened. The front portion of the 
 bowel must be removed with care, as the peritoneal fold on the anterior 
 face of the rectum is much lower than on the posterior portion of the gut. 
 Threads are now passed through the healthy portion of the intestine, which 
 is stitched carefully to the sides of the aperture and the cancerous portion 
 removed with the knife or scissors. As a necessary precaution, and also 
 as a guide, a good-sized bougie should be introduced into the bladder, and 
 held there during the operation. Volkmann, in one instance, to allow him- 
 self room, resected portions of the sacrum as high up as its promontory, 
 and in another removed a portion of the posterior wall of the vagina. If 
 the peritoneum is incised, the rent is immediately to be plugged with 
 sponges saturated with a solution of carbolic acid, and afterwards carefully 
 brought together with catgut sutures. If the entire circumference be not 
 involved, a portion may be taken away, and the lips of the wound united 
 by suture. In my cases* I have invariably found that the stitches holding 
 the rectal stump to the margins of the cut, tore out sooner or later, yet 
 withal excellent results followed. 
 
 CHAPTER XLV. 
 
 INJURIES AND DISEASES OF THE URINARY ORGANS. 
 
 Malformation — Exstrophy op the Bladder— Epispadias — Hypospadias — Her- 
 maphrodites— Calculous Nephralgia — Unstable (Floating) Kidneys — Ne- 
 phrpjctomy — Nephrotomy — Cystitis — Retention of Urine — ( Ischuria Vesi- 
 calis) — Tubercular Cystitis — Catheterism — Abscess and Fistula in the 
 Perineum — Laceration of the Urethra — Cystotomy — Foreign Bodies — 
 Stricture of the Urethra — Internal and External Urethrotomy — Calculi 
 — Stone in the Bladder — Various Methods of Lithotomy — Operations for 
 Lithotrity — Tumors of Bladder — Prostatitis. 
 
 Malformations. — Complete absence of the urinary bladder is rarely met 
 with, and if such were the case, the ureters would probably be found open- 
 ing somewhere on the surface of the body — perhaps around the umbilicus, 
 or into the rectum or vulva. 
 
 Cases have been known of double-bladder, in which a septum more or 
 less perfect has been found, stretching between the walls of the viscus and 
 dividing it into two cavities. 
 
 Exstrophy of the Bladder. — The variety of malformation which is more 
 frequently seen, but which is also of rare occurrence, is known as exstro- 
 phia, or inversion of the bladder. The term " inversion of the bladder," 
 does not convey a proper idea of that arrest of development which we 
 are to consider. When we say inversion of any hollow body, we do not 
 
 * Pamphlet on Excision of Kectum. 
 
EXSTROPHY OF THE BLADDER. 
 
 915 
 
 necessarily understand that its structure is deficient, but merely that it 
 has been turned inside out or upside down: whereas, in the cases that 
 I have seen, and the descriptions of all those I have read, there has 
 always been a complete deficiency in the anterior wall of the bladder and ab- 
 dominal wall. 
 
 In the majority of cases, the arrest of development appears to be first in 
 the abdominal walls, second in the symphysis pubis, and third in the struc- 
 tures beneath. 
 
 In the female, the deformity is often accompanied by an absence of the 
 clitoris, and in the male, by a fissure of the urethra, or "linear epispadias." 
 In the hypogastric region we find protruding the posterior wall of the 
 bladder, fiery red, with here and there a rudimentary trace of the mucous 
 coat, of a bluish color. The circumference of the organ is lost in the sur- 
 rounding integument, which has the appearance of a cicatrix, and is bluish. 
 The orifices of the ureters are found in the lower half of the organ. 
 
 The malformation is said to occur more frequently in males than in 
 females ; and the late Mr. Earle, of London, stated that, after a careful ex- 
 amination, he found sixty-eight cases upon record, of which sixty were in 
 males. Others have given the ratio as four to one. In twenty instances 
 by Mr. John Wood, but two were found in females. Agnew reports fifty- 
 three, of which but eight were females. I have had five cases of this de- 
 formity, and operated upon two; of these, four were males, the last a 
 female. 
 
 My first case came to me in St. Louis, in August, 1870. The patient 
 was twenty-four years of age and well developed; was over five feet in 
 
 Fig. 573. 
 
 a— -m 
 
 B— -£- 
 
 Author's Case of Exstrophy of the Bladder. 
 
 height and enjoyed moderately good health. There was a wide separation 
 of the pubic bones (about two inches), an entire absence of the umbilicus, 
 and the red and fiery mucous membrane of the trigonum vesicse protruded 
 through the abdominal deficiency (see Fig. 573, A). On the left side of the 
 bladder a slight nodule marked the opening of the ureter, into which a No. 6 
 bougie (English) could be passed. The penis was a little over an inch 
 and a half in length, and was completely epispadiac {vide Fig. 573, B), the 
 urethra being split open like a trough. By raising the bladder and depress- 
 ing the urethra, the veru montanum, and the openings of the ejaculatory 
 
916 A SYSTEM OF SURGERY. 
 
 ducts, were distinctly visible. There was also a rudimentary prostate. The 
 testicles were of good size and apparently perfect; the scrotum large and 
 full, and as the integument extended from the bag to the groins on either 
 side, it became so voluminous that it could readily be grasped. 
 
 Several methods of operating were considered and rejected, until finally 
 the following was performed on August 20th, 1870, at 12 m., in the pres- 
 ence of Drs. Franklin, Nibelung, Tirrell, Morrell, Goodman, Gundelach, 
 Campbell, Garrett, Read, and others. The lateral flaps were made of the 
 redundant groin-tissue, and drawn over the protruded viscus. The edges 
 of these were fastened in the median line, and the nodular mucous cir- 
 cumference was pared. The tissue was so loose that the flaps were ad- 
 justed without any stretching. A semi-lunar flap was dissected from the 
 abdomen above the bladder, turned down, and slid under the lateral flaps 
 and there secured. The operation lasted an hour and a quarter, and there 
 was haemorrhage from both superficial epigastrica, which were cut. 
 
 A severe cough, with mucous rales, appeared on the eighth day ; the ner- 
 vous system of the patient suffered materially, and on September 1st he 
 gradually sank and died without pain. The emaciation was so rapid and 
 complete that his friends scarcely could recognize him. On examining the 
 wound, I found the flaps had partially united in the upper part of the 
 median line, the lower portion of the wound was open, and the orifice of 
 the ureter clogged up with calcareous matter. The important and anom- 
 alous conditions found at the necropsy, which was made by Dr. J. S. Read, 
 were the entire absence of the right kidne} r , and the enormous size of the 
 left, which he thus described : " L} T ing in the left hypochondriac region, and 
 extending down into the left lumbar region, in immediate contact with the 
 abdominal walls, was found the left kidney, filling the left lumbar region so 
 completely as to leave no space for the descending colon and small intes- 
 tines. The peritoneum was greatly thickened, not only in the renal region, 
 but throughout the whole extent. The renal capsule was quite small — about 
 one-half the normal size — and of very loose texture. Tearing the kidney 
 away from its attachments, it was measured. The great circumference was 
 nineteen and three-fourths inches ; around the lower part, twelve and three- 
 fourths inches ; near upper end, nine and three-fourths inches. The ureter 
 was twelve inches long, slightly sacculated ; towards the lower end, just as it 
 was about to enter the vesical substance, it was much reduced in size ; the 
 walls of the ureter varied in thickness from one to three lines, the thickest 
 portion being above. This thickening extended to the pelvis of the kidney, 
 which was enlarged, the appearance being due to the increase in the thick- 
 ness of its walls. The pelvis of the kidney and the ureter were both filled 
 with calcareous matter, about the consistency of thin mortar, the mucous 
 membrane being finely dotted with minute calcareous particles, that were 
 with difficulty rubbed off. The kidney of the right side was entirely 
 absent ; not a vestige was there, nothing even rudimentary." 
 
 Dr. Gross believed the disease to be almost irremediable, and all things 
 considered, there is but a poor prospect for ultimate recovery. There has 
 been a successful operation reported by Mr. Simon, of London, who caused 
 the ureters to open into the rectum, which was done by introducing threads 
 from the ureters and carrying them to the rectum, and there allowing them 
 to remain until the passage was complete. The, patient narrowly escaped 
 with his life. Mr. Loyd's case, in which the communication was effected 
 by a suture, died on the third day. Mr. Sidney Jones, of St. Thomas's 
 Hospital, attempted a similar operation, his patient perishing of fatal peri- 
 tonitis, as did those of Mr. Johnson and Mr. Loyd. Mr. Holmes endeavored 
 to establish a communication between the bladder and rectum by clamping 
 
EXSTROPHY OF THE BLADDER. 917 
 
 that portion of the exstroverted bladder between the ureters until sloughing 
 and ulceration of the tissues were effected. 
 
 Dr. Levis, of Philadelphia, tried making a fistulous opening between the 
 bladder and the perinseum, by the passage of setons, and afterwards by 
 drawing a small bougie in the track of the silk ; this was effected. A 
 second operation for the purpose of covering the bladder-wall by turning 
 the scrotum upward and covering the penis and fixing it under a small 
 abdominal flap was attempted. The patient, however, died on the twelfth 
 day. 
 
 Covering the bladder by plastic operations, that is, taking the integu- 
 ment from the surrounding structure, is much more satisfactory, and has 
 been done a number of times. It was, I believe, first suggested by Roux 
 and Richards in 1853, and was performed by Dr. Pancoast, of the Jeffer- 
 son College, Philadelphia, in 1853, and by Dr. Avers, of Brooklyn. The 
 latter was more successful than the former. Afterwards Holmes and Wood, 
 of London, performed similar operations, the latter having practiced it seven- 
 teen times. 
 
 Dr. Ashhurst, of Philadelphia, has made three operations, two of which 
 were successful. Bryant, also, has been successful in covering the sensitive 
 bladder-wall by taking the flaps from the groin and the scrotum. 
 
 Maury's method is a modification of that of Roux. He makes a large 
 convex flap from the groin, perinseum, and scrotum, cuts a small hole 
 therein for the passage of the penis, turns this flap upward with the cuta- 
 neous side inward. A short flap of integument is then raised on the upper 
 and lateral portions of the exstrophy, and the first flap slid under it and 
 secured. 
 
 The results of these autoplastic operations are more encouraging than 
 those performed for diverting the course of the ureters or the establishment 
 of fistulous openings. Dr. Ashhurst has analyzed fifty-five cases, of which 
 forty-three recovered, four failed, and eight died. 
 
 The case which I have presented has some important peculiarities : 
 
 Fii'st. Entire absence of one ureter. 
 
 Second. Entire absence of one kidney, and the enormous size of its ureter 
 and renal pelvis ; and, 
 
 Third. In the wide and slit-like openings of the seminal ducts. 
 
 Case II. Is peculiar in that the parents supposed their child to be a girl, 
 and dressed " it " in that fashion. 
 
 The patient is about sixteen years of age, of light complexion and auburn 
 hair, having the expression of distress that belongs to those suffering long. 
 I must call her " she," for I have attended the case so long, and have always 
 seen the patient attired in petticoats and frocks, and never observed anything 
 bearing any resemblance to the male but a twisted and deformed epispadiac 
 rudimentary penis. The umbilicus is entirely absent. The pubic bones 
 are widely separated. The scrotum, when in the erect position, is very 
 large, and immense inguinal hernise are seen on either side (C, C, Fig. 574). 
 The odor urinx is almost intolerable, and the sensitiveness of the red and 
 exstroverted bladder (A, Fig. 574) is only equalled by that exhibited in 
 the rudimentary glans. The urethra is split open to the base of the blad- 
 der, and is about an inch and a half long. The penis (B, Fig. 574) has 
 two corpora cavernosa, and is capable of erection. I may state a fact un- 
 known to me before the first operation, which is that with the arrest of de- 
 velopment of other parts, I found entire deficiency of the recti. Nothing 
 but a moderately thick fascia, which became thinner and thinner as it ap- 
 proached the exstroverted bladder, covered the intestines. The patient was 
 weak, miserable and irritable, with a pulse always at 120 to 130, and a tem- 
 perature 101°. 
 
918 
 
 A SYSTEM OF SURGERY. 
 
 I performed two operations, the first somewhat similar to that I devised 
 for the case already recorded and which is almost identical with that 
 known as Wood's, which has recently been practiced by Ashhurst, of 
 Philadelphia, with success. I began by measuring the flaps and mark- 
 ing them on the abdominal wall. The first was taken from above the 
 bladder, of sufficient size to cover the exstro verted viscus as with a 
 lid (Fig. 574, D), the cutaneous surface being approximated with the 
 mucous coat of the bladder. In making this dissection, unaware of the 
 absence of muscular tissue beneath, I made an incision into the fascia, 
 and a portion of peritoneum protruded. This was brought together with 
 carbolized gut. The side flaps were made with their bases to the scro- 
 tum (Fig. 574, E, E) (to be nourished by the superficial external pudics 
 and superficial epigastrics), twisted over upon themselves, and united in 
 the median line with harelip pins and figure-of-eight sutures ; by this 
 means the angles F and F F in Fig. 574 were brought to B, as seen in Fig. 
 575. The angles of the raw surfaces were approximated and the patient 
 placed in a semi-recumbent position in bed. The wounds were dressed with 
 calendula, 
 
 Fig. 575. 
 
 Fig. 575 represents the appearance after the first operation : A the raw 
 surface left by superior flap, B the point of union of the lateral flaps secured 
 with hare-lip pins, C the rudimentary penis, D D the scrotum. The first 
 operation was successful thus far, viz., in the complete union of the flaps in 
 the median line ; but the contraction of the cicatrix above had a tendency 
 to draw them up so that the exstro verted bladder was but half covered (E, 
 
EPISPADIAS — HYPOSPADIAS. 919 
 
 Fig. 575). This operation was productive of much good, inasmuch as the 
 child could bear the weight of the dressings and bedclothes upon the flap, 
 which was almost impossible before. A change was noted in the disposi- 
 tion ; from being irritable, morose, and indeed sometimes almost savage, she 
 became so placid and cheerful that the change was noticed by every one 
 who was in attendance upon her. Before the flap-wounds had entirely 
 healed her condition was so much improved that I concluded to try a sec- 
 ond and more extended operation, utilizing the pendulous scrotum for flaps, 
 castrating the patient, and, if possible, curing the hernise. To that effect, 
 therefore, on January 19th, 1884, I removed a strip of the integument from 
 the lower border of the new flap, about three-quarters of an inch in width 
 (see dotted line E F in Fig. 575). I reduced the hernia on the left side, and 
 about two-thirds of the gut on the right, finding it impossible on that 
 side to return the whole tumor. Beginning then close to the body on the 
 left side, I split the entire scrotum to the body, making the incision on the 
 right side from G to G, and having pared a strip on the tegumental side 
 (vide the shaded space between the dotted line and the margin of the scro- 
 tum) so that the raw surface would come in contact with the denuded edge 
 of the new flap (dotted line E F) made by the previous operation, I turned 
 the anterior half of the scrotum upwards, and fastened it with pins and 
 sutures to the lower margin of the flap above, covering in entirely the rudi- 
 mentary penis, and leaving the raw surface of this scrotal flap (denuded of 
 the tunica vaginalis) exposed. I drew down the left testicle and cut it off, 
 having ligated the cord with catgut, proposing to do the same with the right 
 stone, but it could not be found on account of the hernia on that side being 
 only partially reducible. I, however, returned as much as possible into 
 the abdominal cavity. 
 
 The next step was to make the side flaps, which I took from each groin 
 and united to the median line over that portion of the bladder which could 
 be seen. I brought the posterior half of the scrotum upward and fixed it to 
 the remaining exposed surface of the already turned-up anterior wall. 
 
 These wounds healed kindly but slowly, having to skin-graft several of the 
 raw surfaces. Although I made an incision in the anterior scrotal wall as 
 it was turned up, and drew the penis through it, the organ was so un- 
 manageable that it slipped away from the opening. Knowing that Levis, 
 of Philadelphia, had turned the penis in with the anterior scrotal flap, this 
 did not give me much uneasiness ; but I found afterwards that I should have 
 amputated the penis, because the titillation of the skin caused erections of 
 the organ, which, pressing upward upon the newly forming connective tissue, 
 gradually separated a portion of the bands of adhesion and allowed a part 
 of the lower flap to fall downward. 
 
 It will be seen that both these cases were of the male sex. The third, 
 which I have under care, is a female. There is only a rudimentary vulva, 
 no clitoris, no pubic bones, and, I judge, no uterus. 
 
 Epispadias — Hypospadias. — In some cases the urethra terminates on the 
 upper portion of the penis, and sometimes from an arrest of development an 
 opening exists in the course of the canal on the lower side of the organ. To 
 the former condition the term epispadias is applied, to the latter hypospadias. 
 In both instances of exstrophy of the bladder which I have recorded, there 
 was complete hypospadias ; indeed, a simple groove covered with mucous 
 membrane existed on the upper part of the penis. As far as my knowl- 
 edge extends, the affection is beyond the reach of medical or surgical treat- 
 ment. In hypospadias, urethroplasty may be attempted. The first proceed- 
 ing is to open that portion of the urethra beyond the fissure, as from want 
 of use, in the majority of cases, it becomes obliterated. This must be con- 
 
920 A SYSTEM OF SURGERY. 
 
 ducted with great care, and be performed with a round blunt instrument 
 not much larger than a common probe. From experience in the sepa- 
 ration of occluded mucous surfaces, I am confident that greater success 
 follows carefully introduced blunt instruments than when the knife is em- 
 ployed. 
 
 So soon as the canal is opened, a catheter (silver) should be introduced 
 into the bladder, the edges of the fistula pared and approximated with 
 metallic sutures. Nelaton's method consisted of the above, together with a 
 dissection of the skin to relieve tension of flaps, underneath which a slip 
 of india-rubber was placed to prevent the surfaces being injured by the urine. 
 
 Auger's method, which is probably the best, is thus performed : 
 
 The first cut must be made about half an inch from the right margin of 
 the groove representing the urethra, from each end of this a transverse cut is 
 made to the urethral line and the flap dissected. A similar flap is to be 
 made on the left side, thus having two square leaves of integument hang- 
 ing by their urethral margins. The right flap is turned over (skin toward 
 the urethra) and secured by stitches thus placed : The needle is entered 
 through the base of the left flap piercing the skin first, and then through the 
 free edge of the right flap from the raw surface toward the skin. It must now 
 be made to catch the edge of the urethral groove on the left side and again 
 passed through the base of the left flap, the stitches must be tightened, 
 and can be removed through the skin surface, a like number of stitches 
 are then passed through the free margin of the left flap, by which it is, at- 
 tached to the skin of the penis at the outer edge of the raw surface, from 
 which the right flap was removed. The raw surfaces are thus brought into 
 apposition. As a rule, a small fistulous orifice remains, which may be 
 closed by a second operation. Care must be taken to keep the patient from 
 all excitement, especially sexual, for an erection may undo the entire opera- 
 tion. Such a case happened in the practice of Dr. Wilcox. Erection after 
 erection spoiled the surgeon's work in spite of the cold coil and many 
 sedatives. The doctor finally contrived an electric bell attached to the 
 penis ; as soon as the organ became turgid the bell rang violently. The ex- 
 pedient was a success. 
 
 Hermaphrodites. — Of all anomalies of form which the anatomist en- 
 counters, there is none so curious as the hermaphrodite. These compli- 
 cated deformities have been considered by different authors, arid are found 
 to arise from an arrest of development of the female organs of generation 
 and the formation of the male sexual system, or a part of it, in one indi- 
 vidual, and vice versa. 
 
 Such monstrosities have from time to time been described in medical lit- 
 erature ; but, according to Bischoff, Paget, and Miiller, many of the cases 
 cannot be considered as reliable. 
 
 The former of these authors has pointed out the reason for rejecting the 
 examples that have been described. He states that there are numerous 
 sources of error by which the judgment may be warped ; as, for example, 
 the great resemblance between the generative organs of the two sexes at 
 an early period, the uniform type in the development of both, the coalition 
 of the corpora Wolfnana, and the errors formerly prevalent as to the primi- 
 tive identity of both sexes. 
 
 The existence of testicles and of ovaries on the same side, in their normal 
 position, the development of the uterus, of the seminal vesicles, of the 
 prostate and Cowper's glands, have, strictly speaking, neither in man nor 
 in the higher order of animals, ever occurred. The case that I am about to 
 describe approximates nearer to true hermaphroditism than any on record, 
 there being both testicles (although concealed and abnormally placed), 
 
HERMAPHRODITES. 921 
 
 ovaries, more than rudimentary Fallopian tubes, uterus, vagina, penis, with 
 glans and prepuce, and scrotum. 
 
 Hermaphrodites have been thus classified : 
 
 I. Those which, being, as to the essential organs of generation (testicles 
 and ovaries), distinctly male or female, exhibit nevertheless some anomaly 
 of development — be it arrest, overgrowth (up to the masculine type), or 
 disproportion of some other kind — more or less typical of the opposite 
 sex. 
 
 a. " Hypospadias" in its highest grades, viz., on the one side a cleft 
 scrotum and the formation of a vagina-like sinus ; on the other side, as its 
 analogue, diminutive vagina, closure thereof into a raphe or suture, par- 
 tial or entire absence of this organ, with a clitoris developed into the sem- 
 blance of a penis hypospadiseus, or one completed, and channelled with a 
 urethra. 
 
 b. " Cryptorchism." Concealed testicles, in the one case ; in the other, its 
 parallel condition, descent of the ovaries into the greater labia pudendi, 
 now and then associated with the foregoing form. High grades of these 
 anomalies constitute the so-called transverse hermaphroditism, implying 
 external organs of the one, and internal of the other sex. The case of ex- 
 ternally female and internally male organs, is by far the more common, 
 because due to an arrest in the development of the male organs, whilst the 
 opposite case depends upon the ulterior development of the female organs 
 into the male type. 
 
 c. The occurrence in the male sex of a womblike organ. 
 
 These cases collectively constitute what is termed spurious hermaphro- 
 ditism. 
 
 II. " Lateral hermaphroditism." The presence of testicles and vas deferens, 
 with or without seminal vesicles on one side, and of ovarium and tube on 
 the other. 
 
 III. " True hermaphroditism" (hermaphroditism per excessum, androgynus, 
 coexistence of male and female organs on the same side). 
 
 From these remarks, it would appear that the case represented in the 
 woodcut is remarkable, in possessing the characteristics of all the dif- 
 ferent forms of hermaphroditism (with the exception of the lowest grade, 
 hypospadias) embraced in the above classification. By referring to the 
 drawing, it will be seen that it embraces a high grade of cryptochism, b, or 
 transverse hermaphroditism, viz., external organs of the one and internal 
 of the other sex. Also, c, the occurrence in the male sex not only of a 
 womblike organ, as mentioned in the classification, but of a well-developed 
 uterus and vagina. It comes, to a certain extent, under II, lateral hermaph- 
 roditism, and we find it nearly allied to III, hermaphroditism per excessum, or 
 the coexistence of the male and female organs on the same side, the last 
 being a condition of things which is positively denied by some authorities. 
 Gurlt and Meckel have recorded such cases ; but BischorY remarks in refer- 
 ence to them, " that not a single one offers conclusive evidence of the union 
 of the two main organs of generation, the testicle and the ovary, and that 
 the seeming dualism of the rest of the organs is explicable according to the 
 principles of arrest of development." 
 
 From these facts, the anomalies of form, size, and relation of the organs 
 represented in the cut, are certainly worthy of attentive examination. 
 
 The accompanying sketch (Fig. 576) I made from a cast. The model 
 was taken from the organs themselves shortly after death, and the arrange- 
 ment of i±ie parts is such as will best exhibit them in their connection. 
 The late Professor Brainerd was acquainted w r ith the individual during 
 life, and assured me that a regular menstrual discharge took place, the 
 fluid passing through the vagina into the urethra, and making its exit 
 
922 A SYSTEM OF SURGERY. 
 
 through the penis. By referring to the cut, it will be seen that the empty- 
 bladder, N N, with the uterus, K, have been, for their better exposure, 
 twisted upon their pedicle, which is the commencement of the urethra, 
 and that the rectum, F, has been flattened out. It is by such an arrange- 
 ment that the cast could be taken to show the entire parts in their con- 
 nection. The penis, A, is well developed, and has a prepuce and glans, 
 B. The scrotum and dartos, fully formed, are represented by C. The pubic 
 symphysis, D, has been sawn through ; the scrotal integument has been 
 allowed to remain, C, extending to the anus, E, showing the perinseum, P. 
 F is the rectum, empty and collapsed; G, the partial fimbriation of the 
 Fallopian tubes ; H, H, the ovaries ; I, I, testicles on each side, covered by 
 
 Fig. 576. 
 
 Hermaphrodite. 
 
 deflections of the peritoneum ; K, the uterus, well developed ; L, the os 
 tineas; M, the vagina, its wall divided to show its internal surface, with 
 rugae, etc., and the position of the cervix uteri ; N, the bladder (empty), upon 
 which is lying the uterus. 
 
 Through the kindness of Dr. John McE. Wetmore, I examined a remark- 
 able case. In this, the breasts were developed, there was a beard on the 
 face, and there was a well-developed penis with prepuce; a vagina of con- 
 siderable capacity, and apparently testicles in each enlarged labium, which 
 looked like a cleft scrotum. 
 
 The case of the German hermaphrodite who was exhibited throughout 
 the country is familiar to most medical men. 
 
 An interesting case of hermaphroditism in the male, the patient believing 
 itself to be a woman, and being married to a man, is recorded by W. E. 
 Wheelock, M.D.* 
 
 Calculous Nephralgia. — In this disease there is the passage of a calculus 
 down the ureter. Many of the symptoms are similar to those of nephritis, 
 with the exception of fever. The diagnosis is made by the suddenness of 
 the attack, the comparatively healthy condition of the urine, the absence 
 of fever already noted, and the instantaneous relief afforded, as the stone 
 passes into the bladder. The pain is of excruciating character, and shoots 
 down the loins into the scrotum ; there is vomiting and retraction of the 
 testicle. 
 
 * Medical Record, June 8th, 1878, 
 
UNSTABLE KIDNEYS. 923 
 
 Treatment. — I have never known though I have heard of cases relieved 
 by homoeopathic medication ; I have listened to long discussions in which 
 the enthusiastic have asserted, that in every case of nephritic colic, simple 
 and pure homoeopathic medicines, in attenuated doses, should be employed ; 
 but I must say, that the hot bath, hot fomentations to the part, and the 
 inhalation of chloroform, have been most serviceable in my hands. Morphia 
 must be used, either hypodermically or otherwise, in most cases, and has to 
 be given in full doses until the agony subsides. The suffering is occasioned 
 by a mechanical cause, and until it is removed the pain will continue. 
 
 Unstable Kidneys. — I have given this name to kidneys which are not fixed, 
 in order to mark the difference between the floating kidney and the movable 
 kidney. By the former is understood a kidney which has a mesentery, and 
 which moves within the cavity of the peritoneum, whereas the latter indi- 
 cates that the kidney is capable of restricted movement within its capsule 
 of fat, or in a sac made between the peritoneum and the abdominal wall. 
 The former is more rare than the latter, and there is always some difficulty 
 in making out the diagnosis. Mr. Lawson Tait is of opinion that the 
 " floating kidney " is a myth. In general terms, it may be said that the 
 degree of mobility indicates the different conditions. In a case of floating 
 kidney which I exhibited to the Medico-Chirurgical Society of New York, 
 the evidences of unstability were sufficiently obvious to convince the most 
 skeptical. 
 
 The patient was a young woman, aged twenty-three years. Her general 
 health was good, but she occasionally had severe shooting pains in the right 
 lumbar region, which were worse upon motion. When lying on her right 
 side, and rising suddenly and leaning a little forward, the members of the 
 society detected the kidne}^ (by its shape) in the right latero-lumbar region, 
 and sometimes also a little toward the front of the abdomen. This tumor 
 could be readily moved in all directions, and when the patient assumed the 
 recumbent position, the kidney immediately disappeared. I could not (and 
 according to my judgment, it must take a superlative " tactus eruditus" to 
 accomplish the feat) tell whether the kidney was attached by a pedicle, long 
 or short, as Henderson says can be done. Symptoms of dyspepsia, with 
 occasional diarrhoea, were present, and there was at times sudden stoppage 
 of the urine. The treatment I recommended was the wearing of a bandage. 
 According to Newman * who quotes Skorczewsky, out of 1422 patients, 32 
 females out of 1030, and 3 males out of 392, were affected with floating or 
 movable kidney. The reasons that females are more liable than males to be 
 afflicted, is supposed to be the congestions and pressure which are known 
 to result from menstruation, conception, gestation, and child-bearing. M. 
 Oser, of Vienna, quoted by Newman, " considers that pregnancy is one of 
 the most common causes of movable kidney, and states that among the 
 poor of Austria, 10 per cent, of the women who have borne children suffer 
 from it, and Professor Bartels, of Kiel, has found it frequent among working 
 women, but attributes it to the habit of wearing tight waist strings to hold 
 up heavy clothing." 
 
 The right kidney is more subject to displacement than the left, and 
 hydronephrosis is a frequent accompaniment of the affection. As might be 
 anticipated, the great vessels, from the constant traction upon them, are fre- 
 quently elongated, and from the twisting of the ureter as well as the vessels 
 the urine is prevented from passing into the bladder. In another case that 
 was under my care the bladder was affected sympathetically, and severe 
 urinary tenesmus was present. 
 
 This patient, who had borne three children, while feeling apparently 
 
 * New York Medical Abstract, January, 1884, p. 16. 
 
924 A SYSTEM OF SURGERY. 
 
 well, would be seized with great prostration and fainting, would pass into 
 a comatose state, accompanied with complete suppression of urine, at 
 which times a strong urinous odor could be perceived upon the breath. 
 This " fainting turn " would occur at irregular intervals, and last from 
 thirty minutes to three or four hours, and on one or two occasions collapse 
 and death were imminent. 
 
 Treatment. — It is important that the diagnosis, as to which kidney is 
 affected, be made, if any operation, either nephrorraphy or nephrotomy, is 
 to be performed, and in the section upon the latter, the directions are given 
 by which a somewhat definite conclusion may be arrived at. If the kidney 
 is movable, and can be felt and seen to change its position, the diagnosis is 
 not difficult, but if the case is one in which hydronephrosis or pyonephrosis 
 is present, the question which is the kidney to be operated upon, is the sine 
 qua non. 
 
 If the patient does not suffer inconvenience from movable kidney, the 
 best and only treatment is the application of a well-fitting elastic bandage, 
 which should be worn night and day. This will generally give the patient 
 relief. 
 
 The operation for fixing the kidney is as follows : 
 
 The patient is placed on the left side; an incision, about sixteen or 
 eighteen centimeters long, is made in the lumbar region along the external 
 border of the sacro-lumbar muscular mass, extending from the last inter- 
 costal space to the crest of the ilium. The surgeon must cut carefully 
 through the parietes, until the circumrenal fatty connective tissue is reached. 
 The kidney must be pushed up with the hand and kept in position, while 
 the operator, breaking through the fatty connective tissue, discovers the 
 convex border and the greater part of the posterior surface. The first 
 suture must be put in the convex border; the needle traversing the fibrous 
 capsule of the kidney. The circumrenal fatty connective tissue is then 
 raised and drawn into the wound, through the tissues directly under 
 the lower edge of the last rib, and again through the circumrenal con- 
 nective tissue. A second suture is applied on the posterior surface of the 
 kidney, and in the deep tissues of the posterior lip of the wound. A 
 third suture is placed in the same way in the anterior surface of the kidney, 
 at the convex border and the deep structures of the anterior margin of the 
 wound. With these three sutures the kidney is held in position. For 
 greater security, the circumrenal fatty connective tissue of the lower half of 
 the kidney may be united by four sutures to the tissues of the wound. 
 Catgut sutures are used. A large ckainage-tube is applied deeply, and a 
 small one superficially, and the wound sewed up with seven points of deep 
 sutures and twelve superficial. 
 
 Nephrectomy. — According to Weir* Simon first intentionally performed 
 nephrectomy in 1869, and since then the operation has been resorted to 152 
 times, about half the patients dying. Weir states, with good sense, " Nor 
 has the mortality decreased in the last fifty cases as might have been expected. 11 
 
 He then gives the following interesting summary : 
 
 Disease. Cases. Deaths. Mortality. 
 
 Wounds, 5 2 40 Percent. 
 
 Urinary fistula, 9 3f 33.32 " 
 
 Floating kidney, 16 6 37.5 " 
 
 Hydronephrosis, 21 12 57.14 " 
 
 Tumors, 32 22 68.75 " 
 
 Suppuration, 58 27 46.5 " 
 
 * Medical News, December 27th, 1884. 
 
 f Weir has two deaths, but is corrected by an editorial in Medical News, January 3d, 1885, 
 from which this table has been made. 
 
NEPHRECTOMY. 925 
 
 Thus making a mortality of about 50 per cent. 
 
 Gross * however, makes the death rate somewhat less, out of 233 cases 129 
 recovered, and 104 died, making a mortality of 44.63 per cent. Of these oper- 
 ations 111 were by the lumbar incision, and 120 by the abdominal, and 2 un- 
 certain. Of the first the percentage was 36.93 ; of the second, 50.83 per cent. 
 
 The diseases for which the operation should be performed are chiefly, 
 suppuration and hydronephrosis and various neoplasms. 
 
 The great point is to ascertain which kidney is affected, and whether there 
 are two kidneys. Instances are upon record where the operation has been 
 performed and one kidney found. These are rare. If the reader will refer 
 to the section of this Chapter on Exstrophy of the Bladder, he will find a 
 record of a remarkable case, in which but one kidney existed, which was 
 nineteen inches and a half in circumference. 
 
 It is said by Dr. Weir that such an anomalous condition need scarcely be 
 considered, as " the single kidney is found about once in five thousand 
 bodies." 
 
 In a case of tumor or of hydronephrosis (cystic disease) the affected kid- 
 ney can readily be ascertained, but it is difficult to discover which organ is 
 secreting the pus casts, and cellular elements after they have passed into the 
 bladder or through the urethra. Several methods have been devised for 
 this purpose, all of them save one being difficult and uncertain. 
 
 The idea has been, either by catheterization of the ureters, compression 
 with the hand in the rectum, or with the rectal rod of Davy, to temporarily 
 obliterate one ureter and to collect the urine and ascertain its character and 
 thereby judge which of the kidneys is diseased. The methods which pre- 
 sent the best chances of success are the introduction of the hand into the 
 rectum, the exploratory incision of Lange, or the method of Dr. Polk. The 
 hand may be allowed to compress the ureter for a time, to collect urine 
 enough for examination. Broad compression of the artery will generally 
 be sufficient to obstruct the ureter. 
 
 Dr. Polk proceeds as follows : 
 
 " The method I have to suggest is to compress the ureter. It is easier of 
 performance in the female than in the male, but I believe it can be accom- 
 plished in both. Take a large catheter, made of some substance like block- 
 tin, bend it to the shape of a Sims' sigmoid catheter, let the curve that 
 passes into the bladder be as decided as it can be made, and yet not so great 
 as to interfere with the ready passage of the instrument into the bladder. 
 Suppose it to be the right ureter you desire to close : 
 
 Introduce the instrument, then place the patient in the lithotomy posi- 
 tion. Now carry the fingers as far into the rectum as possible. Now place 
 the catheter so that its curve in the bladder hugs the right pelvic wall ; the 
 end of the curve will pass directly across the line of the right ureter. Now 
 press the fingers against the catheter, and the ureter will be sufficiently oc- 
 cluded to prevent all escape of urine. By means of the catheter in position 
 (it may be double) you thoroughly cleanse and empty the bladder. As 
 fresh urine flows in from the other ureter, it can be withdrawn and tested. 
 As urine from a sound kidney is secreted at about the rate of a minim in 
 four or five seconds, it will not require long-continued pressure to secure 
 the amount of urine necessary for satisfactor}' examination. In the female 
 the procedure is more certain of accomplishment than in the male, because 
 we can, in a measure, fix the base of the bladder by traction upon the an- 
 terior vaginal wall by means of a tenaculum hooked into it just below the 
 cervix, or, better, well to the right of the cervix on the lateral wall, the 
 traction being downward and to the patient's left."")" 
 
 * American Journal of the Medical Sciences, July, 1885, p. 79. 
 f New York Medical Abstract, vol. iv., No. 1, page 19. 
 
926 A SYSTEM OF SURGERY. 
 
 The Operation. — There are two methods of performing nephrectomy, one 
 through the abdomen, the other through the loin. For tumors of any 
 magnitude or hydronephrosis (when nephrotomy is not applicable), the 
 abdominal incision ought to be preferred, although, even in these cases, the 
 mortality is large. For the removal of smaller growths and pyonephrosis 
 the lumbar incision is best. 
 
 Abdominal Method. — There are two incisions by which the kidney can 
 be reached through the abdomen, one, when the tumor is large, being 
 made in the linea alba, about four inches below and three inches above the 
 umbilicus, the other as recommended by Langenbach in the linese semilu- 
 nares. The peritoneum then comes to view, and is carefully divided, and 
 the intestines turned over until the kidney is found, when the large vessels 
 forming the pedicle are exposed, if it be possible, they should, as recom- 
 mended by Agnew, be tied separately. In all masses of tissue in which 
 large bloodvessels ramify, it has been my custom before applying the 
 ligature, to put on some sort of a clamp, not so much for the arrest of 
 haemorrhage, but to keep the parts from slipping away when the ligatures 
 are being tightened. Even through the blades of a tightly-screwed clamp, I 
 have known just enough tissue escape to give rise to great haemorrhage. 
 After the vessels have been secured, and an additional ligature tied with 
 a Staffordshire knot has embraced the pedicle, then the operator may 
 enucleate the kidney from its capsule, if so desired, or cut away the 
 organ ; after this, he should cauterize the stump thoroughly with a Paque- 
 lin, or ordinary iron, then remove the clamp, still having hold, however, 
 of the stump with a pair of forceps as the clamp is unscrewed, to be sure 
 that there is no haemorrhage. The cavity may then be thoroughly washed 
 with bichloride solution 1 to 2500, and the wound brought together with 
 silver or catgut; all this must be done with the strictest antiseptic precau- 
 tions. 
 
 Lumbar Method. — In this the patient is placed on the sound side, three- 
 quarters or more face over, with the body somewhat bent. The incision 
 is made along the border of the quadratus lumborum, beginning below 
 the twelfth rib, three inches from the vertebrae, and carried almost or (if 
 occasion require) to the iliac crest. This cut includes integument and 
 cellulo-adipose tissue, and exposes the conjoined tendons or portions of 
 the internal oblique and transversalis muscles. These must be divided 
 upon a director, when the full border of the quadratus comes in view, 
 and, under this, the fat in which the kidney is embedded. This adipose 
 tissue is soft and may be separated easily with the finger, until the kidney 
 is seen. The organ may then be cut into or aspirated as may be deemed 
 proper, and an incision made in the capsule and the kidney removed, as in 
 the preceding method. It will be found sometimes difficult to clamp the 
 pedicle in this operation, but the ligature thrown about the vessels should 
 be strong and tied tightly. 
 
 Dr. Gross, says at the end of his elaborate paper, already referred to : 
 
 " From a careful analysis of all the facts pertaining to the surgery of the 
 kidney contained in this paper, based as it is upon a study of nearly four 
 hundred and fifty cases of different operations, I believe that I am justified 
 in formulating the following propositions for discussion : 
 
 " 1. That lumbar nephrectomy is a safer operation than abdominal ne- 
 phrectomy. 
 
 " 2. That primary extirpation of the kidney is indicated, first, in sarcoma 
 of adult subjects ; secondly, in benign neoplasm at any age ; thirdly, in the 
 early stages of tubercular disease ; fourthly, in rupture of the ureter ; and, 
 lastly, in urethral fistula. 
 
 " 3. That nephrectomy should not be resorted to until after the failure of 
 
NEPHROTOMY NEPHRORRAPHY. 927 
 
 other measures, first, in subcutaneous laceration of the kidney ; secondly, 
 in protrusion of the kidney through a wound in the loin ; thirdly, in re- 
 cent wounds of the kidney or the ureter, inflicted in the performance of 
 ovariotomy, hysterectomy, or other operations ; fourthly, in suppurative 
 lesions ; fifthly, in hydronephrosis and cysts ; sixthly, in calculus of an 
 otherwise healthy kidney ; and, finally, in painful floating kidney. 
 
 " 4. That nephrectomy is absolutely contraindicated, first, in sarcoma of 
 children ; secondly, in carcinoma at any age, unless, perhaps, the disease 
 can be diagnosticated and removed at an early stage ; and, thirdly, in the 
 advanced period of tubercular disease." 
 
 Dr. I. H-. McClelland, of Pittsburgh, published the account of an interest- 
 ing nephrectomy in November, 1880.* Mr. Christopher Heathf reports 
 also a nephrectomy for sarcoma of the kidney performed upon a young 
 child, the patient surviving eighteen hours. 
 
 Mr. F. B. Archer J gives an account of an abdominal nephrectomy per- 
 formed by himself on a widow, aged 50 years. The case was remarkable 
 because of the size of the cyst, which contained eighteen pints of fluid. 
 There was collapse, but the patient ultimately recovered. 
 
 Dr. John E. James and Dr. George A. Hall have successfully performed 
 this operation. 
 
 Nephrotomy — Nephrorraphy. — By this is understood an opening made in 
 the groin or in the abdomen according to the directions given for nephrec- 
 tomy, and either aspirating or opening the kidney for the evacuation of 
 water (hydronephrosis) or pus (pyonephrosis) or for fixing a movable 
 kidney. This operation should be done, if practicable, in preference to 
 nephrectomy, and should be tried before the performance of so serious a 
 procedure. 
 
 The incisions are made in a similar manner to those mentioned in 
 the last section, for the performance of lumbar nephrectomy ; when the 
 kidney is reached, the organ is to be pushed into the wound. The 
 surgeon must hold the kidney in the opening, and pass a stout needle, 
 threaded with a strong antiseptic catgut ligature, through the cortical 
 substance of the upper portion of the organ from its anterior to its 
 posterior aspect, about half an inch from its convex margin. A second 
 thread of similar calibre and preparation, must be passed through the lower 
 portion of the kidney in the same manner. The kidney must now be al- 
 lowed to slip back into its capsule of fat, and the cut surfaces of it (the 
 capsule) carefully stitched to the muscular tissue at the deep portion of 
 the wound. The kidney sutures must be passed through the muscle, cel- 
 lular tissue and skin, but not tied, a drainage tube must be inserted, and, 
 traction being made upon the ligatures passing through the kidney, it 
 is to be drawn into its place, filling the bottom of the wound. Then the 
 integument must be stitched together and the kidney sutures either clamped 
 or tied over a piece of bougie. 
 
 Prof. Franzatime performed nephrorraphy by fixing the floating kidney 
 to the wall of the lumbar region, according to the directions already given. 
 The operation was made through the abdominal incision, and the lapa- 
 rotomy and fixation together, only occupied one hour and thirty minutes. 
 It may be well to remark that the abdomen was opened for a suspected 
 tumor of the mesentery.§ 
 
 Dr. George A. Hall,|| of Chicago, made a successful nephrotomy in a case 
 of nephrolithiasis. 
 
 * Hahnernannian Monthly, November, 1880. 
 
 t British Medical Journal, July 15th, 1882. J London Lancet, July 1st, 1882. 
 
 \ Medical News, July 4th, 1885. \ Medical Investigator, May 15th, 1880. 
 
928 A SYSTEM OF SURGERY. x 
 
 Cystitis. — The urinary bladder may take on inflammation, to which the 
 names cystitis, inflammatio vesicas are given. The inflammation may attack 
 any of the coats, but generally affects the mucous one, and the secretion of 
 mucus, which in an acute form of the disease is diminished, in the chronic 
 stage becomes increased and altered, constituting the disease known as 
 catarrhus vesicas, dysuria, mucosa, catarrhal inflammation of the bladder. The 
 general symptoms are, acute pain, tension, and tumor in the region of the 
 bladder, with fever; pressure above the pubes causes pain and soreness, 
 and when made on the perinseum produces micturition, the urine being dis- 
 charged in small quantities and with suffering, or there is complete inability 
 to pass it; it is of a dark-red color and is frequently discolored with blood ; 
 there are also tenesmus and vomiting. The pains are burning, lancinating, 
 or throbbing, and extend to the perinseum, sometimes to the testicles and 
 upper part of the thighs. In some cases there is confirmed suppression, 
 with skin hot and dry, pulse frequent, hard, and full ; tongue whitish, thin, 
 red, and dry. Should the disease not be arrested, swelling in the hypogas- 
 tric region takes place, with increase of sensibility in the perinseum and 
 hypogastrium. If the neck of the bladder especially be affected, pain is felt 
 in the perinaeum, and there is complete retention of urine, or the patient has 
 dysuria (difficulty in passing urine), or strangury (issuing drop by drop). 
 In this condition the introduction of a bougie is painful. Tenesmus takes 
 place if the posterior part of the bladder be chiefly affected, in consequence 
 of its proximity to the rectum. If the inflammation be about the mouths 
 of the ureters, and extend along their course, complete retention takes place, 
 and there is more or less tenderness on pressing upon the hypogastrium. 
 The disease may terminate in resolution, suppuration, and as in other 
 inflamed mucous surfaces by the deposits of false membrane (Pseudo-mem- 
 branous Cystitis), gangrene, or induration and thickening of the coats of the 
 bladder. Resolution is known by the gradual disappearance of symptoms ; 
 suppuration if chills or rigors accompany the abatement of the pain and 
 fever, with deposit of a white matter in the urine. If suppuration take 
 place in the mucous membrane, or an abscess form between the coats of the 
 bladder, and the pus break into that viscus, it will be discharged with the 
 urine ; or it may open into the vagina or rectum, infiltrating cellular tissue of 
 the pelvis ; or it may burst into the peritoneum, labia pudendi, or scrotum. 
 
 In the majority of cases which have an unfavorable termination within 
 seven days, gangrene follows, which is known by the sudden subsidence of 
 pain, cold, clammy perspiration, cold extremities, prostration, confusion of 
 intellect, weak, frequent pulse, deathlike countenance, and hiccough. 
 
 The causes are, acrid substances irritating the bladder; injections of can- 
 tharides or turpentine thrown into the bladder ; metastasis of other diseases, 
 as rheumatism and gout; gonorrhoea; the introduction of a catheter or 
 bougie; suppressed sweat and haemorrhoids; injury in parturition, or by 
 the use of obstetrical instruments ; the application of cold to the feet or 
 lower portion of the abdomen; retained urine; external injuries in the 
 hypogastric region; retro verted womb; frequent use of stimulating drinks. 
 
 When complete suppression of urine exists and the inflammation is 
 high, the danger is imminent. 
 
 Treatment. — The medicines are, aeon., canth., equiset. hyem., nux, bell., 
 mere, scill., phosph., apis, sulph., lycop., sandalwood oil, uva ursi, copaiba, 
 cubebs, puis. With this treatment the bladder should be washed (see 
 further in this chapter), hot sitz baths taken in the chronic form of the 
 disease every night and morning, and in the acute every three or four hours 
 will give comfort to the patient. If there should be urinary tenesmus, 
 hyoscyamus in ten-drop doses, given in a small quantity of hot water and 
 repeated every four hours, has in my hands been more effectual than any 
 
CYSTITIS. 
 
 929 
 
 other medicine. In both the acute and chronic forms I have insisted upon 
 two things: one the complete abstinence from all — even the mildest — 
 stimulants, and the taking freely of demulcent drinks, especially a decoc- 
 tion of triticum repens or buchu, of which the patient should take at least 
 ten ounces daily. Small doses of the liquor potassa are frequently of signal 
 service. 
 
 In chronic cystitis I have been successful, especially in women, in dilating 
 the urethra. This is effected by the instruments constructed for the purpose. 
 In men a gradual dilatation may be made with sounds, followed by the use 
 of Sir Henry Thompson's dilator, and in women I have used Goodell's 
 cervix dilator with excellent results. If these means fail, then the surgeon 
 must consider the propriety of either a supra-pubic or vaginal opening. The 
 latter process of establishing a new outlet for the urine, thus allowing the 
 irritable parts complete rest, is gaining favor among specialists. 
 
 Washing out the bladder should be performed in all cases of cystitis whether 
 acute or chronic ; if the former, the water should be hot, in the latter it 
 
 Fig. 577. 
 
 should be tepid, and this no matter what substances are employed to medi- 
 cate the fluid. Irrigation is frequently done by the ordinarydouble catheter 
 (Fig. 577). 
 A more satisfactory instrument is that seen in Fig. 578, which is flexible. 
 
 Fig. 678. 
 
 Flexible Double Catheter. 
 
 The best apparatus is that devised by Dr. Keyes, and which I have 
 employed and recommended for years. Especially is this a useful instru- 
 ment in washing the bladder of those affected with enlarged prostate. Fig. 
 579 shows the apparatus with its description. 
 
 The simplicity of the instrument as figured is obvious. To the fountain- 
 syringe bag holding a pint, and a tube of variable length, so as to allow, if 
 desirable, considerable pressure by elevating the bag, is attached a two-way 
 stop-cock. Upon the tube is another stop-cock only useful when it is de- 
 sired, having thrown a medicated solution into the bladder, to retain it there 
 for a certain length of time without either allowing the bladder to become 
 over full, or its contents to escape. The nozzle of the stop-cock is very 
 large, and fits into the expanded conical mouth-piece. It fits so easily, that 
 
 69 
 
930 A SYSTEM OF SURGERY. 
 
 the most clumsy fingers can readily adjust it almost unaided by sight. 
 Upon this catheter is fitted a thin piece of rubber tubing, covering its upper 
 two-thirds, which allows the mouth-piece to be used with any metallic or 
 other hard catheter, and prevents leakage. The fine conical point is to be 
 
 Fig. 579. 
 
 Keyes's Bladder-washing Apparatus. 
 
 screwed into any soft catheter before introducing the latter. The other 
 branch of the two-way stop-cock is fitted into a short piece of rubber tubing 
 which conveys the urine and the washings into some convenient receptacle. 
 
 Other medicines are adapted to this disease, and especially to the more 
 chronic forms ; each case which presents itself for treatment having its own 
 peculiar symptoms, for which the materia medica must be consulted. 
 
 Tubercular Cystitis. — This disease manifests itself in three ways, and in 
 the majority of instances is secondary. 
 
 1. It may arise as secondary to tubercular nephritis ; 2. From tubercular 
 disease of the testicle ; 3. It may begin primarily in the bladder. 
 
 One of the first evidences is hematuria, the blood coming from the mu- 
 cous lining of the bladder; this symptom may continue for several years 
 before the more severe manifestations take place. After a time, pain is felt 
 in the region of the bladder, urination is increased in frequency, there is 
 much vesical tenesmus, and pus is found in the urine which is more or less 
 gelatinous in character. The pain may be diagnosed from that of calculus 
 by the fact that there is no relief in any position and that the suffering pre- 
 vents sleep. The position of the patient is often characteristic ; he lies with 
 his legs drawn up to relax the abdominal muscles and thus remove pressure 
 from the bladder. The prognosis is bad, because in the majority of instances 
 the kidneys become affected and the patient succumbs to uraemia. Relief 
 is obtained by washing out the bladder with an iodine solution and bella- 
 donna suppositories in the rectum. The medicines adapted internally are 
 thuja and boracic acid, together with the adjuvants of rest, absence of stimu- 
 lants, dilatation of the urethra, already mentioned in the treatment of ordi- 
 nary inflammation of the bladder. 
 
CATHETERISM IN THE MALE. 931 
 
 Cystitis in Women. — This disease is divided into acute and chronic, and the 
 inflammation may affect any of the investing coats of the bladder. It may 
 begin at the peritoneal coat and extend inward, or it may begin with the 
 mucous lining and extend outward. 
 
 There are many causes which develop this affection ; it arises from over- 
 distension of the bladder ; sometimes from the introduction of foreign sub- 
 stances into the vagina, as used by hysterical women in masturbating, and 
 sometimes from injuries. Peritoneal inflammation, gonorrhoea, vaginitis, 
 too frequent application of the catheter or the rough use of the instrument, 
 also produce the disease. The symptoms are so well marked that the diag- 
 nosis is easy. There are painful and frequent emissions of urine accom- 
 panied with tenesmus of the bladder ; there are pains in the peritoneum 
 which sometimes extend to the navel or even to the breast. The urine 
 contains, upon examination, mucus, blood, or pus. At first the secretion 
 is pale and the specific gravity low, becoming, after a time, high-colored. 
 After the symptoms have continued for a length of time the inflammation 
 may extend by continuity of surface along the ureters to the kidneys and 
 secondary nephritis result. 
 
 Treatment. — Besides the remedies mentioned, rest is an important factor, 
 and a diet consisting of large quantities of skimmed milk may be em- 
 ployed. When the tenesmus is excessive the tincture of hyoscyamus in 
 five- to ten-drop doses, given in hot water, will be found useful. The blad- 
 der must be carefully washed with a solution of boracic acid and warm 
 water, twenty grains to the ounce. Rapid dilatation of the urethra is also 
 effective, and can be employed without danger every other day. The in- 
 strument which I have employed for this purpose is Goodell's dilator for 
 the cervix uteri. The other medicines for the treatment of cystitis in 
 women do not vary materially from those used for inflammation of the 
 bladder in men. 
 
 Retention of Urine (Ischuria Vesicalis). — This affection differs from sup- 
 pression of urine. In the latter the kidneys do not perform their usual 
 function, while in ischuria, the urine is secreted and passes into the bladder, 
 but cannot be ejected. There is more or less pain in the bladder, which, 
 from distension, is perceptible above the pubes ; there is urgent desire to 
 void the urine, with pain and nausea, and but few drops are emitted. The 
 disease is generally amenable to treatment, but in some cases it is of intract- 
 able character. 
 
 Treatment. — The medicines for this complaint are, aeon., cann., canth., 
 dulc, mere, nux vom., op., puis., stram. Others may be required in par- 
 ticular cases. An empirically applied medicine, but one which relieves 
 spasmodic retention of urine frequently in a short time, is buchu. The 
 powerful action that this plant is known to exercise upon the urinary appa- 
 ratus, should lead to its complete proving upon the healthy individual. 
 
 The method of preparing it for administration is as follows : Place in a 
 large-sized tumbler, or other vessel, a small handful of the leaves and pour 
 thereon scalding water ; allow this to remain until it becomes cold ; of this 
 infusion administer a dessertspoonful every quarter or half hour, until the 
 patient is relieved. This mode of administration may be useful to the prac- 
 titioner in urgent and peculiar cases, when other means have failed. When 
 the patient is suffering intense pain from distension of the bladder, the 
 catheter should be immediately used. 
 
 Catheterism in the Male. — Every physician and surgeon is called upon to 
 pass the catheter into the bladder of man. 
 
 Those who have often essayed the operation are aware of the difficulties 
 that attend its performance, and those who are seldom called upon are fre- 
 
922 A SYSTEM OF SURGERY. 
 
 quently, after repeated and unsuccessful trial, obliged to abandon the task, 
 or hand the case over to more experienced manipulators. 
 
 There is scarcely an operation which requires more dexterity and knowl- 
 edge, more gentleness and steadiness, than the simple procedure of the in- 
 troduction of a catheter, or, as it is technically termed, catheterism. 
 
 A bungler may often pass an instrument through a healthy urethra and 
 reach the bladder, while, on the other hand, experienced and renowned 
 surgeons have been foiled in the attempt. I very well recollect, while I was 
 a student, waiting in the amphitheatre of the old Pennsylvania Hospital 
 for over an hour while two gentlemen of acknowledged surgical ability were 
 endeavoring to relieve a patient of a bladder full of urine. I have heard 
 the illustrious Mutter state to his attentive class that the most important 
 operation which the general practitioner was called upon to perform was 
 undoubtedly catheterism. 
 
 Surgical Anatomy of the Deep Urethra. — If we draw a line across the 
 perinseum from one tuber ischii to the other, we form the base of two tri- 
 angles, the upper one having an apex at the pubic arch, and being termed 
 the urethro-perineal, the other having its point at the coccyx, and being 
 designated the perineo-anal triangle. It is the upper of these spaces that 
 we propose to consider, as bearing upon the point we have in view. The 
 line aforesaid from the tuberosities of the ischia would pass above the verge 
 of the anus, and must therefore be some distance below the transverse 
 perineal muscles. The sides are very nearly equal, and measure from three 
 inches to three inches and a quarter. In the centre of this triangle, and 
 dividing it into two halves, passes the raphe 7 of the perinseum, which is of 
 considerable importance in a surgical point of view, but of little consequence 
 anatomically. 
 
 Underneath the skin, which is counted as the first covering of the parts, 
 and which is thin, elastic, and very movable, — indeed to such a degree as 
 to render it not easily divisible without being put upon the stretch and 
 firmty held by the finger and thumb, — we have the second layer, which is 
 a cellulo-adipose structure, varying considerably in thickness ; this fascia 
 does not lie in contact with the pelvic bones, but is continuous with a similar 
 structure upon the thighs and scrotum. After we remove this layer we 
 come upon the true superficial fascia of the perinseum, which is attached in 
 a peculiar manner, an appreciation of which serves to explain the course 
 taken by the urine in extravasation, either from rupture of the urethra or 
 after surgical operations in the peringeum. To the outer border of the pubic 
 and ischiatic bones it is firmly attached, and also to the triangular ligament, 
 of which I desire to speak more particularly hereafter, whereas in front it 
 is continuous with the dartos of the scrotum. Therefore in cases of urinary 
 infiltration, unless this fascia is ruptured, the renal secretion cannot gravi- 
 tate either downward or backward, as would be supposed, but passes for- 
 ward into the scrotum and upward into the groin. Dr. Buck, of the New 
 York Hospital, demonstrated by careful dissections that this fascia also 
 envelops the perineal muscles, the spongy structure of the urethra, and the 
 corpora cavernosa penis. 
 
 Underneath the superficial fascia we come upon the fourth layer of the 
 perinseum, which is composed of Jive muscles, two in pairs and one single 
 muscle, which, together with the anterior portion of the sphincter ani, are 
 connected at a point called the central tendon. The transverse muscles are 
 situate in front of the anus, are irregular and somewhat triangular in shape, 
 arise from the inner side of the tuber ischii, and are inserted into the already 
 mentioned central tendon. 
 
 The erectors also arise from the tuberosities of the ischium, and are in- 
 serted into the cavernous body of the penis ; while the accelerator muscle, 
 
SURGICAL ANATOMY OF THE DEEP URETHRA. 933 
 
 with a bipenniform arrangement of the fibres, surrounds the bulb of the 
 urethra and is inserted into the triangular ligament and into the cavernous 
 body of the penis. I have passed hastily over these muscles, which are 
 possessed of great interest, that we may come to the structure which we 
 wish to consider, viz., the triangular ligament. Before proceeding to describe 
 it, let me premise that it is called by many names, each anatomist and sur- 
 geon giving it what he deems its most appropriate signification, which often 
 leads to considerable confusion. Thus it is called the deep perineal fascia, 
 Cowper's ligament, the recto-urethral aponeurosis, and the ischio-pubic 
 fascia. It would be far better to designate it by the term triangular ligament 
 of the urethra, which would abundantly suffice for all practical purposes. 
 
 The triangular ligament then closes up a greater part of the space between 
 the pubic and ischiatic bones, excepting superiorly or immediately under 
 the arch of the pubis, which space is filled by an expansion of fibrous tissue 
 called the subpubic ligament. It is attached to the inner border of the pubic 
 and ischial bones, and extends from the ligament above — the subpubic — to 
 the rectum and anal aponeurosis. It is composed of two layers, an anterior 
 and a posterior ; the former, which is comparatively dense, is prolonged 
 forward around the urethra, while the latter is connected with the fibrous 
 investment of the prostate gland. It contains foramina, superiorly for the 
 passage of the dorsal veins of the penis, and about an inch below the pubic 
 symphysis and directly opposite the raphe of the perinseum, an opening of 
 considerable size for the passage of the membranous portion of the urethra. 
 
 The urethra, being movable along the most of its extent, becomes fixed and 
 stationary after it passes the triangular ligament, making therefore a fixed 
 curve, which varies but little, excepting in disease of the prostate gland. 
 Besides this triangular fascia, the suspensory ligament of the penis and the 
 anterior true ligaments of the urinary bladder assist in keeping the urethra 
 in situ, and necessarily^ the curve at this point of the canal. It is at this 
 point that, from the wrong direction of the curve of catheters, which are 
 often constructed merely as the fancy of the cutler may dictate, or some ill- 
 defined conception on the part of the surgeon, often great difficulty in the 
 introduction of the catheter is experienced. Having in mind the ligaments 
 already mentioned ; by finding the distance from the pubic symphysis to 
 the opening in the triangular ligament, we can discover the lowest portion 
 of the curve which the urethra makes as it passes beneath the subpubic arch. 
 This point Sir Henry Thompson has found, by careful and oft-repeated 
 measurements, to be distant from the pubic symphysis from seven-eighths 
 of an inch to one inch and one-eighth, the variations not exceeding one- 
 quarter of an inch, thus explaining why the urethral curve varies so little. 
 Dr. Van Buren thus wrote : " By these firm attachments the curve of the 
 urethra is maintained in a fixed relation to the symphysis pubis, a relation 
 which is unchangeable except by disease or injury to the parts. By taking 
 its centre from the surface of a vertical section through the symphysis, the 
 mathematical elements of the curve can be readily determined. It consti- 
 tutes three-tenths of a circle, three inches and a quarter in diameter." 
 
 Or, as Sir Henry Thompson says, the subpubic curve may be considered 
 as an arc of a circle, three and three-quarters inches in diameter, thus 
 making a circle described by a radius of one and five-eighths of an inch in 
 length, the chord of whose arc is two and three-quarters inches. 
 
 Fig. 580 shows a catheter and sound bent according to measurement. 
 A B, the arc of a circle, three and three-fourths inches in diameter, having 
 a radius of one and five-eighths inches ; A B E, a catheter, corresponding 
 to this curve; F B E, a sound, with same curve, though shorter; CBD, 
 Benique's sound, following same curve, though with a larger arc of circle. 
 
 I would have it understood that these remarks apply to simple stricture, 
 
934 
 
 A SYSTEM OF SURGERY. 
 
 or the passage of the catheter in retention of urine. It is a different matter 
 in treating cases of enlarged prostate, because in this disease the prostatic 
 portion of the urethra may be double its natural size, because the increased 
 thickness in the diameter of it may be so great as to form a projection into 
 the canal, and therefore the entrance into the bladder may be pushed so far 
 backward, as to occupy a position almost behind the symphysis pubis. In 
 such cases the catheter must be at least four to six inches longer than usual, 
 have a greater curve, and be somewhat elevated at the point, or otherwise 
 represent more of the arc of a complete circle. 
 
 Fig. 580. 
 
 It is always better to have a good-sized catheter, with a curve corre- 
 sponding to the measurements to which attention has been called, if we 
 wish to remove many difficulties in the performance of the delicate opera- 
 tion of catheterism. 
 
 Catheters and bougies are made of various sizes, but according to a regular 
 scale. The Nos. 10 to 16 of the English scale are most frequently called for 
 in general practice, although every physician should have eight or ten 
 
CATHETERISM IN THE MALE. 
 
 935 
 
 catheters on hand. Fig. 581 shows Parker's compound catheter, a useful 
 
 and convenient instrument. 
 
 Fig. 581. 
 
 Parker's Compound Catheter and Caustic-holder. 
 
 The French scale is much used, and by some preferred, because there are 
 smaller, more regular intervals between each number. Thus No. 1 is one 
 
 Fig. 582. 
 
 French and English Catheter Gauge compared. 
 
 The 
 
 Fig. 583. 
 
 millimeter in circumference, No. 2 is two millimeters, and so on to 30 
 diagram shows the comparison between the 
 sizes of the instruments (Fig. 582). 
 
 In introducing the catheter, the patient 
 may be placed in the horizontal or in the 
 upright position, the former being that pre- 
 ferred. The head should rest upon a pillow, 
 and the thighs be slightly bent upon the 
 abdomen. The catheter (of the proper size 
 and curve), well oiled, should be held with 
 the thumb and forefinger of the right hand, 
 while the surgeon, on the left side of the 
 patient, takes the glans penis between his 
 thumb and finger, retracting the prepuce 
 and allowing the orifice to gape. The in- 
 strument is entered with gentle pressure of 
 the. right hand, and the penis drawn up 
 almost on a line with the abdomen, with 
 the left, the object is to put the movable 
 portions of the urethra on the stretch, and 
 to draw out the folds of the mucous lining 
 (see Fig. 583). The catheter is carried along 
 the canal until it reaches the arch of the 
 pubis, at which point, as has been shown, the urethra perforates the tri 
 
 Catheterism. 
 
936 
 
 A SYSTEM OF SURGERY. 
 
 angular ligament. When the instrument reaches this point, it should be 
 brought parallel with the linea alba. Then, still drawing the penis well up 
 on the catheter, compressing it with finger and thumb of left hand, the han- 
 dle should be depressed, or, in other words, made to describe a part of a 
 circle, of which the straight portion of the catheter is the radius, and it will, 
 with a little additional pressure, glide into the bladder. 
 
 Dr. Squire, of Elmira, New York, devised a " vertebrated catheter," espe- 
 cially for prostatic enlargement. Its curve is formed of sections, as seen in 
 the figure, and it is designed for passing tortuous canals. So soon as it 
 enters the viscus, by turning the screw at the handle the sections are 
 tightened. This improvement has again been somewhat modified by 
 Dr. Caro, of New York (Fig. 584). 
 
 Fig. 584. 
 
 'ORLMAHN PfARRE 9 CO. 
 
 a 
 
 Caro's Modification of Squire's Vertebrated Catheter, a, Is a regulating screw, by which the links can 
 be made firm or slack to any degree, b. Is a stopcock, with nozzle for the escape of urine, as indicated 
 by the dart. Whenever the two buttons (c) stand parallel, the stopcock is then open for the evacuation 
 of urine ; but when the nozzle of the stopcock is turned up, or to either side, the escape of urine is 
 entirely prevented. 
 
 The best ordinary instrument that can be used for entering the bladder 
 is the soft rubber catheter, Fig. 585 ; it has the advantage of having the 
 edges of the eye sunken. With this catheter a patient may readily be 
 taught to relieve himself, as no danger can result from its application. 
 
 Fig. 585. 
 
 
 Tiemann's Soft Rubber Catheter. 
 
 In some cases, however, especially of enlarged prostate, the difficulties of 
 entering the bladder seem almost insurmountable ; none but those who 
 have had experience in these matters can appreciate the patience, gentle- 
 
 FlG. 586. 
 
 -U.^-WM-M-VrVA^-^-AM-W^Wf^ ^ 
 
 G. TIE to 'AM d CO 
 
 Otis's Prostatic Guide. A, Small rod. b, Spiral riband to accommodate itself to the urethra. 
 
 ness, tact, delicacy, and perseverance that are required. Dr. F. N. Otis has 
 invented an ingenious instrument, Fig. 586, for the purpose of aiding the 
 introduction of the soft rubber catheter in cases of enlarged prostate. 
 
ABSCESS AND FISTULA IN PERINEO. 937 
 
 Figs. 587 and 588 represent the elbow catheter of Mercier, which is said 
 to be useful. 
 
 If all these means fail, or if there be much difficulty in the introduction 
 of instruments, the aspirator may be used without fear. The capillary 
 punctures heal readily, and the operation may be repeated without danger. 
 It is a question whether, after a careful trial of the catheter, the surgeon 
 
 Fig. 587. Fig. 588. 
 
 Mercier's Elbowed Catheter. Mercier's Double-Elbowed Catheter. 
 
 should not resort immediately to aspiration, rather than continue his 
 efforts with other instruments, thereby necessarily bruising or injuring the 
 parts, and running the risk of making false passages. 
 
 Catheterism in the Female. — The following is the method of passing the 
 female catheter : 
 
 The forefinger of the left hand should be introduced between the nym- 
 phse, and passed down to the urethral orifice, which is known by a depres- 
 sion, with an elevation on its vaginal aspect. The catheter should be taken 
 in the right hand, and introduced along the finger which is at the urethral 
 orifice, into which it should be inserted, and thence it easily passes within 
 the bladder. 
 
 Abscess and Fistula in Perineo. — Urinary fistulse, or perineal fistulas, may 
 arise from a variety of causes, one of the most frequent of which is abscess 
 in the perinseum. Wounds, bruises, tight strictures, etc., give rise to this 
 distressing complaint. We must remember the manner in which the 
 perinseum is bound down ; that the deep layer of the superficial fascia is 
 firmly attached on each side to the rami of the pubes and ischia, and that 
 it curves behind the transverse muscles of the perinseum to join the lower 
 margin of the triangular ligament, or deep perineal fascia. It will then 
 be understood why we should endeavor to assist nature in making an outlet 
 for discharges at as early a moment as possible after we have detected the 
 symptoms of a urinary abscess. The constitutional symptoms are often 
 more troublesome than the local. The shivering, nausea, febrile paroxysms, 
 and the furred tongue, are well marked ; and, in connection with these — 
 especially if the patient has been afflicted with tight stricture — there is 
 heaviness in the loins, and uneasy sensation in the neck of the bladder, 
 with the stream of urine rapidly diminishing in size, and a slight puffiness 
 about the parts. In proportion as a stricture increases, the urethra at the 
 diseased part is diminished, while that portion of the canal immediately 
 behind the obstruction is enlarged by the continued propulsion of the- 
 urine. The irritation thereby induced, engenders the inflammatory process, 
 which terminates in ulceration ; an opening is formed through the urethra, 
 and communicates with the cellular membrane surrounding it ; the presence 
 of the urine excites additional irritation ; suppuration results, the pus is 
 discharged, and there remains a fistulous opening, through which the urine 
 constantly dribbles. 
 
 Fistula in the perinseum may sometimes proceed from rupture of the ure- 
 thra ; then the urine is instantly diffused into the loose cellular membrane 
 of the perinseum and scrotum, where it occasions much distension, and 
 excites inflammation so intense, that in a few hours gangrene and sloughing 
 of the scrotum may take place, leaving the testicles and urethra bare, and 
 endangering life. 
 
938 A SYSTEM OF SURGERY. 
 
 There is seldom more than one fistulous opening communicating imme- 
 diately with the urethra, but from it numerous sinuses extend in various 
 directions ; and in cases of long standing it is not unusual to find the cellu- 
 lar membrane of the scrotum, and all the other parts through which the 
 urine meanders, condensed and converted into indurated tumors, upon the 
 surface of which may be found innumerable small holes, that discharge 
 offensive urine and pus, rendering the patient disagreeable to himself and 
 his neighbors. 
 
 Treatment. — When a fistula in perineo depends upon a stricture of the 
 urethra, the first care must be to get rid of the obstruction, by means to be 
 mentioned farther on; after which the appropriate medicines should be 
 administered. Among these are, ars., calc, carb. an., silic, and sulph. By 
 such means it will be found that as soon as a natural outlet is established 
 the sinuses heal. The safe practice in perineal abscess is to incise the 
 perinseum in the raphe down through the triangular ligament. This cut may 
 be from an inch to an inch and a half in depth. Even if the pus does not 
 escape, the incision relieves the tension and establishes an opening through 
 tissues which, from their unyielding nature, form such a barrier to the 
 exit of pus that infiltration of the surrounding tissues would be the inevitable 
 result. If the perineal incision be not resorted to at an early day, a ure- 
 thral communication is formed, and we have a true urinary fistula, through 
 which, at every act of micturition, more or less urine escapes. These peri- 
 neal fistulse are divided into the simple and the indicated, scrotal and ante- 
 scrotal, the terms explaining themselves. Of these, the latter are most 
 difficult to heal on account of the small quantity of tissue surrounding the 
 urethra. 
 
 In speaking of the treatment, Sir Henry Thompson, in his Sixth Lecture, 
 published in the Lancet, says : " It was sometimes attempted to cure such 
 fistula? by tying in a gum catheter for weeks or even for months ; but this 
 always fails, and for this reason, that urine always finds its way from the 
 bladder by the side of the catheter, along the urethra, and so into the fistula, 
 by the force of capillary attraction, and thus the object supposed to be attain- 
 able, in reality never was and never could be accomplished. The practical 
 surgeon soon discovers that tying in an instrument never insures the transit 
 of all the urine through it ; some will always pass by the side and defeat 
 your purpose. 1 ' 
 
 If the fistula is small, the application of tincture of cantharides to the 
 opening sometimes produces a good result. The patient's urine must be 
 drawn off twice or thrice during the day with an elastic catheter. Free in- 
 cisions may be made to the bottom of the fistulse or nearly so, and the parts 
 washed with carbolic acid water. Galvanism has been tried, and with good 
 results. 
 
 In the ante-scrotal variety, plastic operations may be devised and are 
 sometimes successful. As a rule the treatment is unsatisfactory. 
 
 Laceration of the Urethra. — This untoward accident is generally occasioned 
 by falls, kicks, or bruises in the perinseum ; whenever it occurs it always 
 requires immediate and decisive means for its relief. The symptoms are 
 (besides the immediate pain and sensation of sickness) those that belong 
 to extravasation of the urine. The scrotum becoming infiltrated and cede- 
 matous, no water being passed through the urethra, vesical tenesmus and 
 excessive pain, spasm of the bladder accompany the accident. In some 
 cases, when the rent has extended far back, the urine is discharged per 
 rectum. 
 
 The treatment must be prompt. So soon as the first appearance of infil- 
 tration is present, the surgeon should lay open the scrotum or the perinseum 
 to allow of drainage and endeavor to pass a catheter into the bladder, which, 
 
CYSTOTOMY — PARACENTESIS VESICAE. 
 
 939 
 
 if the entrance is accomplished, should be allowed to remain in the viscus. 
 In the majority of instances, however, the introduction of the instrument is 
 prevented by the swelling around the laceration, or by the catheter passing 
 into the rent. If free outlet has been given to the urine, by the requisite 
 incision, much suffering and danger is prevented. In many instances, as 
 the wounds heal, extensive sloughing of the scrotum takes place, which 
 must be treated on general principles, antiseptics being used to rectify the 
 odor, which is intensely fetid. 
 
 Though lacerations of the urethra are always serious and the prognosis 
 doubtful, yet in young persons it is astonishing how these most serious acci- 
 dents are followed by recovery. 
 
 Cystotomy—Paracentesis Vesicae. — Occasionally cases happen which re- 
 quire paracentesis of the bladder. These are generally caused by stricture, 
 traumatic or other, chronic enlargement of the prostate gland, and chronic 
 
 Fig. 589. 
 
 Rectum Trocar. 
 
 cystitis. Cystotomy for the latter disease is comparatively recent, but 
 from the reports of its success, it should be tried should the case appear 
 to resist all other methods of treatment. Dr. E. F. Ingals* states that as 
 
 Fig. 590. 
 
 Cystotomy through the Rectum. 
 
 long ago as 1866, Prof. Powell, of Rush Medical College, resorted to the 
 operation for obstinate cystitis, and considers it as one of the legitimate 
 operations in surgery, and not a dernier ressort. 
 
 * Medical Kecord, December 2d, 1872, p. 549. 
 
940 A SYSTEM OF SURGERY. 
 
 There are several methods of performing cystotomy. The perforation 
 may be made either through the rectum, through the perinseum, or above 
 the pubis. 
 
 The patient is placed on his back and the limbs drawn up. 
 
 The surgeon introduces the forefinger of the left hand, well oiled, into 
 the rectum, and determines the situation of the prostate gland and the 
 trigone vesica?. Keeping the ball of the finger in the position aforesaid, a 
 long curved trocar (Fig. 589), the point withdrawn within the canula, is 
 passed into the rectum upon the finger already introduced, and pressed 
 firmly upon the bladder from half to an inch above the prostate gland ; the 
 point of the trocar is then thrust into the bladder, and the instrument with- 
 drawn, leaving the canula within the bladder. In some cases, a tube may 
 be allowed to remain, but usually this is not necessary. Fig. 590 represents 
 the operation. 
 
 Cystotomy through the perinseum is the same operation as perineal section, 
 which will be considered further on. 
 
 Cystotomy through the hypogastrium is performed as follows : An incision is 
 made just above the symphysis pubis, between the recti and pyramidales 
 muscles ; the bladder is thus brought to view, and the trocar and canula 
 are used as before. An instrument having a side opening connected with 
 india-rubber tubing is better than the ordinary trocar. For more minute 
 directions the student is referred to the article on supra-pubic lithotomy in 
 this chapter. These operations, however, unless performed with some other 
 especial purpose than relieving the bladder, are all superseded by the 
 aspirator. The puncture should be made above the symphysis pubis, the 
 needle looking downward and backward. The operation may be repeated 
 often without danger. I have performed it without hesitation twice a day 
 for ten days, and not a single untoward symptom presented. 
 
 Foreign Bodies in the Urethra. — A stone may have escaped from the 
 bladder and become lodged in the urethra, or by some accident, a foreign 
 substance may have found its way into the canal. In such cases the irri- 
 tability of that organ must be allayed by the administration of aeon., 
 canth., scill., or calc. carb., nux vom., opium, puis., kali carb., and the 
 patient should be made to drink freely of decoction of buchu, or water- 
 melon seed. When the desire to urinate comes on, it should be restrained 
 as long as possible; when it becomes very great the patient should lie 
 on the belly, grasp the penis and draw it outward and downward, and 
 then with a sudden forced tenesmus endeavor to propel the urine forward. 
 If this plan does not succeed a small and delicate forceps (Fig. 591) should 
 
 Fig. 591. 
 
 Urethral Forceps. 
 
 be introduced into the urethra. A better instrument, and one which can 
 be procured easily for an emergency, can be made as follows : Take a 
 flexible catheter, about No. 9 of the English scale, and cut off its end, in 
 order to convert it into a hollow tube ; insert into this a loop of silver wire. 
 Then having it well oiled, introduce the instrument until the end touches 
 the foreign material, when the wire is pushed down and twisted a little, in 
 order to make it encircle the foreign substance in the manner familiar to all 
 in withdrawing a cork which has fallen within the body of a bottle. If this 
 does not remove the obstruction, the effort may be made to push it into the 
 
STRICTURE OF THE URETHRA. 941 
 
 bladder and then perform one of the operations described for lithotomy, or 
 to resort to external perineal urethrotomy. 
 
 Stricture of the Urethra. — Stricture may be denned, " An abnormal con- 
 traction of some part of the urethral canal." Sir Charles Bell, however, 
 regarding the normal condition of the urethra to be that of approximation, 
 defines it as a canal that has lost the power of dilating. These constrictions 
 have been regarded as of two kinds, 'permanent and transitory, the former 
 being due to organic deposit about the walls of the urethra, the latter to the 
 spasmodic action of the muscular fibres ; the latter may be cured by the in- 
 ternal administration of medicine alone. The permanent is that to which 
 the greatest importance is attached. John Hunter classifies strictures as 
 the permanent, spasmodic, and inflammatory, while Thompson makes use of 
 the terms linear, annular, irregular, or tortuous. By linear stricture we un- 
 derstand, an obstruction of the canal by a membranous diaphragm ; by the 
 annular, that in which the contracted part is thicker than the linear ; whilst 
 the irregular include such varieties as cannot be classified under either of 
 the above heads. Dr. Otis contends that " a true stricture always and of 
 necessity surrounds the urethra." Independent strictures may be found in 
 the same urethra. Hunter records six. Leroy D'Etiolles mentions a case 
 of eleven. Seldom do we find the tube entirely obstructed. 
 
 The urethra may be long or short, according to provocation ; it may be 
 bent like the italic ^, with the external meatus looking downwards, or, with 
 a single curve, it may point directly upward. It passes from the neck of 
 the bladder to the end of the penis, and, generally, is nine inches in length 
 and is divided into four portions. First, the prostatic, which passes through 
 the prostate gland, about twelve to eighteen lines in length. Second, the 
 membranous, ten to twelve lines. Third, the bulbous, which occupies an inch 
 of its extent ; and fourth, the spongy, which is four to four and one-half 
 inches in length. 
 
 A man with a small penis may have a large urethra, and the tube may 
 be of small calibre in an organ of good size. This is peculiar, but never- 
 theless true. This is in direct opposition to the opinion published by Dr. 
 Otis, who contends that there always exists a constant relation between the 
 size of the flaccid penis and the capacity of the urethra, but experiment will 
 prove the truth of my assertion. 
 
 The urethra is subject, during its whole extent, to these abnormal con- 
 tractions, but some portions of it seem to specially favor its location. John 
 Hunter says the bulbous portion is most liable. Sir E. Home writes: 
 " Next to the bulbous portion, the most frequent place is four and one-half 
 inches from the orifice of the glans." Says Mr. Liston : " Stricture is found 
 most frequently about four inches from the meatus." Mr. Shaw, in more 
 than one hundred dissections, has never found a stricture posterior to the 
 ligament of the bulb. Vidal observed stricture to be most frequent at the 
 junction of the membranous and bulbous parts. However much they differ 
 in other respects, anatomists generally agree in assigning the most frequent 
 point to be at the subpubic curvature. 
 
 Mr. A. Pearce Gould* in reply to " Why is organic stricture most com- 
 mon in the bulbous portion of the urethra," speaks thus: 
 
 The causes of stricture in this part of the urethra, are two : injury and 
 chronic urethritis. 
 
 1. Traumatic Stricture. — The commonest stricture-producing injuries are 
 falls astride beams, or kicks. Sometimes the cause is a punctured wound, 
 or the urethra may be lacerated. 
 
 2. Stricture from Chronic Urethritis, which almost invariably begins at the 
 
 * Braithwaite's Eetrospect of Pract. Med. and Surgery, July, 1878, Part 77. 
 
942 A SYSTEM OF SURGEEY. 
 
 meatus externus, spreading towards the bladder, is more common in the 
 penile urethra, yet the induration resulting from it is most commonly found 
 at the bulb. This seeming paradox has been thus explained by Sir H. 
 Thompson : " It is the prolonged existence of subacute inflammation .... 
 which is to be regarded as the cause of that deposit, in and beneath the 
 mucous membrane, which, by its subsequent contraction, so commonly 
 produces stricture." M. Gu6rin explains it by the greater size and vascu- 
 larity of the corpus spongiosum at the bulb than further forwards, leading 
 to increased plastic effusion. Injections to be useful must be frequent and 
 efficient, as they secure cleanliness and free the canal from secretions. It 
 is remarkable that stricture is said to occur more frequently in hot than in 
 cold climates — may not this depend on less frequent micturition, and more 
 concentrated irritating urine in the former ? 
 
 From all these authorities Dr. Otis* differs materially. He states that out 
 of 258 strictures, 52 were in the first quarter inch of the urethra, 63 in the 
 following inch ; 48 from 11 to 21 ; 48 from 21 to 31 ; 19 from 31 to 41 ; 14 
 from 41 to 51 ; 8 from 51 to 61 ; 6 from 61 to 71. It must be borne in mind, 
 however, that Dr. Otis's method of examination is by very large sounds, 
 and that thereby inequalities of surface unnoticed by the ordinary instru- 
 ments would be designated. 
 
 The earliest symptom premonitory of this affection, is a constant desire 
 to urinate, often causing great pain; uneasiness is also experienced along 
 the canal. As the disease progresses there is a slight discharge of urine, 
 not unfrequently containing mucous shreds. The presence of long-lasting 
 " gleet " should alone arouse the suspicions of the watchful surgeon as to 
 the probable existence of stricture. Then the discharge of urine is no longer 
 subject to the will ; there is a sense of heat and soreness of the parts about 
 the bladder, pain during coitus, and retention of urine, followed by engorge- 
 ment. At this stage we have a condition simulating incontinence, the urine 
 dribbling away drop by drop. 
 
 The changes effected by stricture will be apparent in the whole genito- 
 urinary apparatus. Sacculi of the bladder are frequent ; some have been 
 found capable of holding from two to three ounces. Nor is this dilatation 
 limited to the bladder alone ; cases are on record of its extending through 
 the ureters to the pelvis and calices of the kidneys ; especially do we find 
 it in the urethra just posterior to the stricture, and often of sufficient size 
 to admit the passage of a man's finger. Constant contact of the walls of 
 the urethra with urine will often result in ulceration of that membrane. 
 Abscess and fistula form from urinary infiltration, and extravasation of 
 urine takes place from breaking down of the urethra, consequent upon pro- 
 longed retention. 
 
 Treatment. — The spasmodic variety of stricture is amenable to treatment ; 
 applications of hot water, the warm sitz bath, and injections of warm oil 
 often relieve the patient in a short space. Of the latter injection I can 
 speak with much confidence. I have relieved patients by this method when 
 the catheter has been tried in vain for hours. My plan is to have four to 
 six ounces of olive oil heated, and slowly inject into the urethra, by means 
 of a two-ounce syringe, a quantity of the lubricating fluid. If this does 
 not relieve the patient in itself, it much facilitates the passage of the bougie 
 or catheter. 
 
 Aconite is useful for the inflammatory symptoms, belladonna for frequent 
 urging and tendency to congestion, cantharides for priapism and discharge 
 of blood, and camphor when the urine is very acrid. 
 
 Other medicines are, agaricus, clematis, iodine, kali, iod., acid, nitric, 
 
 * Stricture of the Urethra, its Kadical Cure, by Fessenden N. Otis, M.D. New York, 1875. 
 
STRICTURE OF THE URETHRA. 943 
 
 stramonium, digitalis, nitrate of silver, opium, eupatorium purpureum, and 
 thuja. 
 
 Dr. Bagley* reported a case of a man aged thirty-nine, attacked with 
 cystitis. All efforts to empty the bladder by use of the catheter had been 
 ineffectual, although attempted by a number of surgeons. The patient 
 called on Dr. Bagley, stating he had stone in the bladder, and was troubled 
 with incontinence of urine. On examination, a false passage from the 
 urethra, an enlargement and induration of the prostate, a stricture of the 
 membranous portion, and constant dribbling of urine were found. There 
 was capability of performing the generative act, but not ejaculation of 
 semen, it passing back into the bladder on account of stricture. The false 
 passage was irritated with a roughened bougie, and then adhesion secured 
 by pressure ; the stricture was readily relieved by use of bougies. Mer- 
 curius iodatus acted on the prostate promptly, discussing the chronic in- 
 flammation and induration. Eupatorium purpureum restored the nervous 
 
 Fig. 592. 
 
 tone and energy of the bladder and relieved the irritation at its neck, re- 
 storing also integrity of the mucous surface from the kidneys to the glans. 
 The patient could again void urine and ejaculate semen. 
 
 The first great point, in the treatment of stricture, is to understand the 
 normal calibre of the urethra we are to treat. That this can be accurately 
 determined by the circumference of the flaccid penis, a point which is de- 
 clared by Otis to be demonstrable, and as stoutly denied by Sands and 
 others, must at present be left an open question. The difficulty in deter- 
 mining the point, must be that the urethra is, in its natural condition, en- 
 tirely closed, and because it can be enormously distended by instruments 
 is no reason whv its overdistension should be considered as its normal size. 
 
 The vagina is expanded and not ruptured by the passage of the foetus, and 
 yet its normal capacity could not be said to be that of its distensibility. 
 Following a law of nature, the size of the urethra may be said to be that 
 of the volume of the ordinary stream of water that passes through it, and 
 that the passage of very large instruments is not necessary for the perma- 
 nent cure of stricture. 
 
 To find the locality of the stricture, the bougie a boule, or the metallic 
 bulbous sounds, Fig. 592, are fair instruments ; they are not, however, so 
 
 * American Homoeopathic Observer, Detroit, July, 1867, p. 280. 
 
944 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 594. 
 
 good as the urethra-meter, Fig. 593, of Otis. The dial indicates in milli- 
 meters the amount of expansion at the bulb. It is introduced closed, and 
 having passed it carefully down to the membranous portion of the urethra, 
 the screw in the handle is turned until a sensation of fulness is experienced ; 
 it is then withdrawn. As it reaches the narrowed part of the canal it will 
 meet with opposition. The screw must be again turned until the instru- 
 ment can be withdrawn. The hand on the dial will mark the size of the 
 stricture. 
 
 Dr. Otis has also invented an endoscopic tube for the urethra. (Fig. 
 594.) It is six inches in length, and from No. 17 to No. 19 of the English 
 scale. By this instrument a partial view may be obtained of the canal. 
 It is used also to repress haemorrhage. 
 
 In the treatment of organic stricture the main consideration is the res- 
 toration of the canal to its normal calibre, and its maintenance in that con- 
 dition. To accomplish this, introduce from day to day, bou- 
 gies of increasing diameter, until the contraction is overcome, 
 or forcibly separate the adhesions at once. 
 
 I am in favor of the treatment of stricture by dilatation, and 
 from it I have obtained excellent results, and though from time 
 to time instruments must be used, the same objection, either 
 in a greater or lesser degree, holds good with other methods. 
 Incisions have to be repeated in some cases a number of times. 
 The value of ascertaining where the stricture is located, its 
 measurement, and the internal urethrotomy treatment, are 
 points for the proper explanation of which credit must be 
 given to Dr. Otis, of New York, and whether or not we agree 
 with him in reference to his theory of gleet, or his ideas 
 regarding the slitting of the meatus, we must allow that his 
 accurate observations, careful experiments, and manly defence 
 of his doctrines have opened a new field of inquiry and ex- 
 perimentation. 
 
 In adopting the method by gradual dilatation, bougies may 
 be used of wax, plaster, softened ivory, gum-elastic, whalebone, 
 or metal. The treatment of a complicated case requires care, 
 patience, and skill. It may be days before we introduce the 
 slenderest instrument, and in such, the " guides " of Dr. Gou- 
 ley (Fig. 595) should be used. The twisted bougies of Leroy 
 D'Etiolles, which are made of whalebone or gum-elastic, are 
 useful to discover the smallest cavities and tortuous canals. 
 The English filiform bougie (Fig. 596) is also used. It is well 
 to remember that false passages' may exist, which often mislead 
 in the endeavor to pass instruments, particularly when ex- 
 ploring. 
 
 The best method, after having selected a proper bougie, is 
 to place the patient in a standing position, grasp the glans 
 penis with the ring and little finger of the left hand, and, by 
 gentle traction, place the penis in a horizontal position; then, 
 having smeared the instrument with oil, and holding the bou- 
 gie as a pen, gently introduce it by a slight rotary motion un- 
 til it reaches the stricture, when a sensation will be communi- 
 cated to the hand, which should be a warning to proceed with 
 increased gentleness. There are several obstacles which may 
 impede the course of a bougie ; it may become entangled in 
 one of the lacunas, or in an accidental fold of the urethra. A 
 small and soft instrument may bend when pressed against the lower por- 
 tion of the canal, or its onward course may be arrested by a spasmodic 
 
 Otis's Hard Rub 
 ber Endoscope 
 
STRICTURE OF THE URETHRA. 
 
 945 
 
 Fig. 595. 
 
 (spasmodic stricture) contraction. It is always the better plan to com- 
 mence with small and soft bougies, for the stricture may be old, narrow and 
 tortuous, and additional suffering and danger be avoided. 
 
 Some surgeons recommend a fine catgut bougie ; others a 
 gum catheter, curved and without wire. There is some 
 disadvantage in using these pliable instruments, because, 
 on pressure being exerted, they yield easily ; but a skilful 
 hand can readily distinguish between the bending of the 
 bougie and the narrowing of the canal. If a soft instrument 
 cannot be introduced, recourse must be had to a metallic 
 one. Frequently the obstacle preventing the passage of 
 the bougie arises from the vital action of the part, but this 
 may be overcome by steady pressure, using care, as it passes down the 
 urethra, that nothing is lacerated. We can tell whether the bougie has en- 
 tered the stricture by endeavoring to withdraw the instrument. If it has 
 passed the contraction there will be a resisting force. 
 
 Many surgeons object to the term " dilatation," as applied to strictures. 
 It is argued, and justly, that, if a stricture were merely a muscular contrac- 
 
 ? / 
 
 Fig. 596. 
 
 tion, the term would be correct, but this is not the case, for organic changes 
 have taken place. The passage of the instrument modifies the vital proper- 
 ties of the canal, while the pressure which it exercises on the newly-organ- 
 ized parts, induces a tendency to absorption, and gives a stimulus which 
 enables nature to complete the cure. 
 
 The effect of the bougie, or, as it has been well termed,. the " vital action," 
 is visible from the commencement of the treatment. Haemorrhage is often 
 present, and there is always a slight discharge. Whatever be the kind of 
 instrument employed, experience has demonstrated that, with certain ex- 
 ceptions, the so-called dilatation is the safest and most effectual method 
 for relieving the distressing symptoms which attend stricture of the ure- 
 thra. The mode of dilatation is not to be disregarded. It may be con- 
 ducted on different principles : it may be temporary or permanent ; or 
 gradual or rapid. The size of the instrument, whether it be a plastic bougie 
 or metallic sound, must be regulated by the presumed diameter of the 
 
 Fig. 597. 
 
 contraction; and after having been selected and introduced in the manner 
 described, it must be allowed to remain for a certain time, and withdrawn 
 at stated intervals. The object is to effect a regular and progressive dila- 
 tation of the strictured part, without inflicting injury on the tissues or ex- 
 citing severe irritation in the urethra. On the first introduction of the 
 instrument it ought not to remain more than a few minutes. If it has been 
 tolerated, it may be repeated on the following day, and so on : but the best 
 
 60 
 
946 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 598. 
 
 practice is to introduce the bougie every third day at first, and then gradu- 
 ally shorten the intervals, at the same time increasing the size of the instru- 
 ment. All this must be regulated by the effect 
 produced upon the stream of urine, which indi- 
 cates the progress of improvement. Though dila- 
 tation is the safest and most certain, it is never- 
 theless a tedious method; and hence many sur- 
 geons have attempted to procure the same result 
 in a more speedy manner. This is done by first 
 introducing a bougie of small calibre, quickly 
 withdrawing it, and then passing others of larger 
 size, until the patient complains of uneasiness or 
 pain. The same operation is repeated every day 
 or two, larger instruments being gradually em- 
 ployed. By the adoption of this method obstinate 
 strictures have been cured in five or six days. 
 Permanent dilatation, as its name implies, is effected 
 by leaving the instrument permanently in the 
 bladder. The treatment should commence by 
 
 (using a metallic bougie, which should be allowed 
 to remain in the urethra from twenty -four to forty- 
 eight hours, and then withdrawn. Temporary di- 
 latation is the method most frequently employed, 
 because it is the safest and best. Rapid and forci- 
 ble dilatation may be attempted when the stricture 
 yields readily, or when it is a matter of moment 
 to the patient to be speedily relieved. Indeed, 
 some surgeons prefer this method to any other, 
 and in the worst forms of stricture it has been 
 effectual in my hands. Several instruments are 
 used for the purpose. Among the best is that of 
 Sir Henry Thompson (Fig. 597), and Holt's (Fig. 
 598) as modified by Bumstead. In the latter the 
 " guide" is first introduced , and upon this the closed 
 instrument is passed into the stricture. The screw 
 is turned, which separates the sides of the dilator; 
 into this the solid rod is driven home. As a general 
 rule, no untoward results follow the apparently 
 summary proceeding. Dr. Thebaud's stricture- 
 dilator works with a screw in the handle, as does 
 Sir Henry Thompson's (Fig. 597), the difference 
 being that in the former the jaws separate by the 
 motion of the thumbscrew, while in the latter the 
 expansion takes place higher up in the body of the 
 instrument. In the treatment of permanent stric- 
 ture, any disorder of the general health or of the 
 genital organs must be corrected by the adminis- 
 tration of appropriate medicines, after which dila- 
 I // tation must be employed. Subcutaneous division 
 
 \ ^^^ of the stricture by means of a delicate tenotome 
 
 has proved successful in the hands of Dr. C. H. 
 Mastin * who resorts to it when neither catheter 
 nor guide can be made to traverse the urethra. 
 External Urethrotomy. — In obstinate cases of rupture of the urethra and 
 
 il 
 
 Holt's Dilator, Bumstead's 
 Modification. 
 
 * Medical News, September, 1886. 
 
URETHROTOMY. 947 
 
 extravasation of urine, or in impassable and traumatic stricture, the oper- 
 ation of opening the urethra from the perinseum is necessary. This has received 
 the sanction of many eminent surgeons, and is growing in repute. Prof. 
 Syme stated that perineal urethrotomy was the only safe and sure means for 
 the radical cure of traumatic or impervious stricture. Prof. Van Buren says 
 the same ; and in a lecture styled " Then and Now," in which the great 
 improvements in medicine and surgery are noted, the late Prof. Gross gives 
 the same idea. 
 
 The patient should be placed in a position similar to that for lithotomy, 
 a director passed into the stricture, the left forefinger introduced into the 
 rectum in order to feel for the urethra and serve as a guide to the incisions. 
 A straight bistoury is plunged into the perinseum to the depth of an inch, 
 and carried backward on the director until the stricture is divided. An- 
 other method is as follows : The perinseum having been shaved, a capillary 
 probe-pointed whalebone bougie is introduced into the urethra. If the 
 guide in passing catches in the lacunae of the canal, it must be withdrawn 
 and again introduced until it enters the bladder. A No. 8 grooved metallic 
 sound is then introduced by passing through its eye the free end of the 
 guide. The instrument is known as Gouley's staff and director, a descrip- 
 tion of which is seen further on. An assistant takes charge of the staff and 
 guide, while the surgeon, after an examination per rectum, makes a free in- 
 cision in the median line of the perinseum, which extends from the base of 
 the scrotum to within half an inch of the anus. This, however, only involves 
 the skin and superficial fascia. By dissection the urethra is brought in 
 view, and the canal opened on the groove of the staff. The edges of the 
 urethral incision are kept apart by loops of silk. After withdrawing the 
 sound, the stricture and about half an inch of the urethra are divided with 
 
 Fig. 599. 
 
 a modified canalicula knife (Fig. 599). By passing a catheter into the blad- 
 der it will be known that the stricture is divided. 
 
 Internal Urethrotomy. — All operations for internal urethrotomy may be per- 
 formed in one or two ways ; either the stricture is divided from the vesical 
 side, or that nearest the meatus, the former being by far the best. Many 
 modifications have been made and plans proposed for dividing the obstruc- 
 tion within the urethra, but they consist of essentially the same steps. A con- 
 ducting rod or bougie is passed into the bladder, and upon this as a guide 
 the knife is carried, dividing the stricture. In some of the instruments a 
 blade is concealed in a canal, as.proposed by Civiale, which being made to 
 pass the obstruction, the blade is released by a spring and cuts into the 
 stricture from the vesical side, then the instrument is withdrawn. Fig. 600 
 shows Bumstead's modification of Maisonneuve's stricture-cutter. Char- 
 riere's instrument combines both methods. 
 
 The following is a description of Prof. Gouley's catheter and its use in 
 stricture (Fig. 601). The catheter is three millimeters in diameter. A 
 groove on its convex side extends four inches, and is bridged over in its 
 last twelfth of an inch, to form a canal for the reception of a delicate whale- 
 bone guide. The catheter eye is on the concave side, about three-fourths 
 of an inch from its point, and is kept close to a well-fitting stylet. Its curve 
 is equal to one-fifth of the circumference of a circle three inches and a 
 quarter in diameter. 
 
 The manner of using is as follows : With a small syringe the urethra is to 
 
948 
 
 A SYSTEM OF SURGERY. 
 
 be filled with olive oil, and an attempt made to introduce a probe-pointed 
 whalebone guide, half a millimeter in diameter, and the length of an ordi- 
 nary bougie, the point of which may be made temporarily spiral by immer- 
 sion in boiling water, then twisting around a small staff, and suddenly cool- 
 ing it. If its point becomes engaged in a lacuna, it is to be withdrawn a 
 little, and carried onward with a rotating movement. If it enter a false 
 
 Fig. 600. 
 
 Fig. 601. 
 
 Maisonneuve's Stricture-Cutter. 
 
 Gouley's Staff and Guide. 
 
 passage, it is to be retained in situ with the left hand, while another is passed 
 by its side. If this second guide makes its way into the false passage, it is 
 to be treated precisely as the first, and the operation repeated till one be 
 made to pass the obstruction and enter the bladder. Sometimes five or six 
 guides are thus caught before the false passage is filled and the natural 
 
INTEENAL UEETHEOTOMY. 
 
 949 
 
 Fig. 602. 
 
 route discovered. As soon as the bladder is entered, which is known by the 
 instrument being easily moved in and out, the outer ones are to be with- 
 drawn, the free end of the retained guide passed through the canal at the 
 end of the catheter, and this instrument carried down the urethra until its 
 point reaches the stricture. Generally with slight pressure in the right di- 
 rection, the catheter may be made to enter the stricture and finally pass into 
 the bladder. The guide may be kept in position after the withdrawal of the 
 catheter, and dilatation carried on by the successive introduction of the 
 instruments already mentioned. 
 
 Dr. Otis, who is a strong advocate for internal urethrotomy, believing 
 in the largest expansion of the urethra and the thorough division of all 
 stricture, to effect a permanent cure, thus writes : " To 
 warrant the reasonable expectation of cure, the stric- 
 ture must be completely divided at some one point, and 
 this cannot be with certainty accomplished without a 
 knowledge of the normal urethral calibre. The normal 
 calibre once ascertained by means of the urethrameter, 
 or by measurement of the flaccid penis, the method by 
 which the sundering of the stricture at some one point is 
 accomplished, may vary and rest in the judgment of the 
 operator. If dilatation or divulsion be selected as the 
 medium through which to effect this result, the pro- 
 cedure must be carried far enough to completely rupture 
 every fibre of the contraction ; if division, every fibre must 
 be completely severed, or subsequent recontraction is 
 certain. Neither divulsion alone, nor simple urethrot- 
 omy, is capable of effecting this with any certainty. 
 It requires a combination of these two methods to 
 accomplish the desired result." To effect this purpose 
 he has devised several instruments (Fig. 602), which 
 combine the properties of thoroughly expanding and 
 then dividing the stricture. Of his ordinary dilating 
 urethrotome, he says : " It should measure 18f when 
 closed, and be capable of expansion to 45. It is curved 
 so as to pass readily through the curved portion of the 
 urethra when this is necessary. It is thus well adapted 
 for the division of deep strictures. The blade is guarded 
 at the top like that of M. Maisonneuve's, for the purpose 
 of avoiding incision of the healthy portions of the canal 
 in introduction ; in the same way it limits the incision 
 on withdrawal. This instrument is introduced closed, 
 and without the knife, unless the stricture is very large. 
 The knife is then carried down, the screw at the handle 
 turned until the hand on the dial indicates two or three 
 millimeters beyond the previously determined normal 
 calibre of the canal, and the blade is drawn through the 
 stricture or strictures. The instrument is then closed to 
 25f and withdrawn. Partial closure prevents pinching 
 the mucous membrane. The results are ascertained by examination with 
 the full-sized bulbous sound. If a trace of stricture is left, the operation 
 should at once be repeated, either using a wider blade or dilating two or 
 three more millimeters. In very resilient strictures, two or more attempts 
 are sometimes unavoidable before complete sundering of the strictures is 
 effected, nothing short of which can produce permanent beneficial results. 
 
 " The guarded blades of this instrument should not project more than 
 four millimeters, nor less than three, above the shaft ; and the guard should 
 
950 
 
 A SYSTEM OF SURGERY. 
 
 not exceed 1 m. in breadth, as more than this will hold behind the stricture 
 and prevent easy division. In case of very dense and resilient stricture, a 
 perfectly plain blade may be used, always in such event turning the instru- 
 ment down as soon as the blade has passed through the stricture." 
 He then gives us the following table : 
 
 * OTIS'S TABLE. 
 
 Time after operation. 
 
 3 years 
 
 2% years.. 
 \y 2 year. .. 
 13 months 
 
 1 year 
 
 10 months 
 
 9 " 
 
 8 " 
 
 7 " 
 
 6 " 
 
 No. 
 
 No. of 
 
 of cases. 
 
 strictures. 
 
 1 
 
 4 
 
 1 
 
 7 
 
 2 
 
 8 
 
 3 
 
 14 
 
 4 
 
 7 
 
 1 
 
 2 
 
 1 
 
 1 
 
 1 
 
 1 
 
 2 
 
 10 
 
 7 
 
 21 
 
 Time after operation. 
 
 5 months 
 4 " 
 3 " 
 
 l H " 
 
 1 month. 
 3 weeks.., 
 
 2 " ... 
 
 No. 
 of cases. 
 
 37 
 
 No. of 
 strictures. 
 
 128 
 
 In thirty-one cases none of the strictures had recontracted. In six cases 
 most of them had been absorbed, while some remained. 
 
 RESULTS. 
 
 CASES. 
 
 Cures. Re-examined. No recontraction, 31 
 
 Cure. Patient perfectly well when .last heard from. No re-examination, . 52 
 Perfect relief for a long time. Keturn of symptoms. Re-examination. 
 
 Stricture found to have recontracted, 4 
 
 Perfect relief for a length of time. Return of symptoms. No re-exami- 
 nation, 5 
 
 Relief of most symptoms. Some remaining. Patient still under treatment, 4 
 
 Partial relief, 3 
 
 Result not known, 1 
 
 Dr. Thomas R. Brown* gives the following summary of varied profes- 
 sional views in regard to the treatment of stricture, and they are important 
 as embodying the experience of eminent gentlemen. 
 
 In answer to the question proposed by Dr. Brown : " What is your opinion 
 as to there being such a condition as spasmodic urethral stricture?" the re- 
 plies were about equal in number. In answer to the question, " What means 
 of relief should be employed when renal disease is detected ?" the majority 
 preferred gradual, continuous dilatation or divulsion, rather condemning 
 operative procedure except when clearly necessary. The after-introduction 
 of the sound, they thought, could not for an indefinite period be dispensed 
 with in cases treated by the ordinary method ; while as to the relation of 
 the size of the urethra and the flaccid penis, the majority, having no expe- 
 rience, had no answer. The views of all the respondents were that close 
 strictures of the penile urethra should be treated by internal section, and all 
 the rest by gradual dilatation or divulsion. 
 
 Electrolysis is one of the best methods of treating urethral stricture. The 
 rationale of its application can be found on pages 58-61. 
 
 In stricture of the urethra the result desired is its absorption, and except 
 in old, hard, cartilaginous formations, all cauterizing effects must be sedu- 
 lously avoided. The modus operandi is to introduce into the urethra an 
 electrode, about a size larger than the stricture will admit (insulated to the 
 tip) down to the stricture. The electrode in this case must be soaped, not 
 
 * The Medical Record, October 12th, 1878, No. 414. 
 
URINARY DEPOSITS AND URINARY CALCULI. 951 
 
 oiled (oil being a non-conductor), for the purpose of lubrication, and to 
 facilitate its introduction. This electrode is to be attached to the negative 
 pole of the battery. The circuit is completed by the broad sponge rheo- 
 phore, moistened with salt and water, and either held in the hand of the 
 patient or placed upon some convenient part. The patient may be operated 
 upon either standing or lying, as is most convenient. As regards the amount 
 of current to be used, the first point is here, as elsewhere, to use as little as 
 will produce the desired effect, and that is best judged by consulting the sen- 
 sation of the patient. We must avoid the production of pain. As soon as 
 the patient feels the current, the intensity is sufficient, and should not be 
 increased beyond this point. I prefer the use of some modification of 
 Daniell's elements, and perhaps I may state as an average, that a current 
 from six to twenty of these cells is all that is needed. Keeping the elec- 
 trode pressed in contact with the stricture, but not forced, in a few minutes 
 it slips through with facility. If a second stricture is present, it must be 
 treated in the same way. This completes the operation, which may be 
 repeated as many times as necessary at intervals of a few days. It will be 
 noticed that I have laid stress upon the use of the negative pole. This is 
 quite necessary, as the use of the positive easily produces an eschar, which 
 heals by contraction, and thus, instead of curing a stricture, will actually 
 cause one. 
 
 Dr. Robert Newmann* gives the following tabulated statement of one 
 hundred cases treated in this manner without a relapse : 
 
 " These one hundred patients had one hundred and eighty-nine strictures 
 together, which were situated in all parts of the urethra, from close to the 
 meatus to within eight inches from the meatus. The exact location of these 
 strictures was as follows : 
 
 " Eight strictures were found at one inch or less from the meatus. 
 
 " Twelve strictures were found from one to two inches from the meatus. 
 
 " Thirty-one strictures were found from two to three inches from the 
 meatus. 
 
 " Twenty-five strictures were found from three to four inches from the 
 meatus. 
 
 " Forty-two strictures were from four to five inches from the meatus. 
 
 " Thirty-seven strictures were from five to six inches from the meatus. 
 
 " Twenty-four strictures were from six to seven inches from the meatus. 
 
 " Ten strictures were from eight to nine inches from the meatus. 
 
 "Seances. — From one to ten operations, in some cases even more, were 
 necessary for a cure, from which one may draw the conclusion that the 
 average number of stances was five to six for each case. 
 
 " Time. — The treatment in each case averaged two to three months. Long 
 intervals between the seances, and weak currents, are rules to which I still ad- 
 here, and which I cannot impress too strongly upon operators, as most 
 important points in these operations." 
 
 Urinary Deposits and Urinary Calculi. — Urinary calculi may be found in 
 the kidney, in the bladder, or in the passages leading from these organs, 
 but in all cases they give rise to symptoms of grave import. 
 
 To arrive at a proper understanding of this subject it will be necessary 
 to consider the appearances of urine in health, and also its deviations from 
 that condition. It is known that the ingredients of the urine are modified by 
 the diet, the time of day, and the habits of the individual. In health, urine 
 is of clear amber color, gives an acid reaction, and has a specific gravitv of 
 1020 to 1030. In 1000 parts, 954.81 are water and 45.19 solid matters.^ For 
 analysis, it is best to obtain a quantity passed shortly after the midday 
 
 * Reprint from the New England Medical Monthly, June, 1885. 
 
952 
 
 A SYSTEM OF SURGERY. 
 
 meal. When the urine contains any ingredient in excess, there is reason 
 to suspect some important change in the system. If there is excess of any 
 of the constituents, a deposit takes place, which, if not easily soluble, as the 
 salts of lime and magnesia, and also uric acid, a nucleus is afforded for the 
 formation of a calculus. 
 
 Urinary deposits may be classed under two heads, organic and inorganic. 
 Of the former are urea, which is found in the proportion of from 15 to 35 
 parts in 1000 parts of urine ; and uric acid, which exists only in very small 
 quantities — one-half or one grain in 1000 grains of urine. 
 
 The inorganic deposits are saline, consisting of sulphuric, phosphoric, and 
 hydrochloric acids, combined with bases of potash and soda; and mineral, 
 comprising phosphoric and sometimes carbonic acid in combination with 
 lime, magnesia, and occasionally alumina ; silica is sometimes found. Of 
 these ingredients, the phosphates are most often deposited. 
 
 For the sake of distinction, the deposits are called " sediments " when 
 consisting of amorphous matter ; when they are composed of small crys- 
 tals, they receive the name of " gravel ; " and when these by concretion 
 form larger masses, they are known as " calculi " or " stones " — being de- 
 nominated " renal " or " vesical," according as they are located in the pelvis 
 of the kidney or in the bladder. Other deposits take place, such as blood, 
 
 Fig. 603. 
 
 Fig. 604. 
 
 Epithelium from Urinary Passages. 
 Bryant. 
 
 Spermatozoa and Vaginal Epithelium. 
 Bryant. 
 
 pus, mucus, epithelium (Fig. 603), spermatozoa (Fig. 604), fatty matter, etc., 
 the presence of which is determined by chemical tests or the microscope. 
 
 We find renal casts, which are sometimes " waxy," at others " oily," some- 
 times " granular," and " epithelial." (Fig. 605.) 
 
 Uric acid deposits (Fig. 606) are common, appearing in variously formed 
 crystals of a yellow or yellowish-red color, generally rhomboid, with the 
 angles rounded, or lozenge-shaped. By aggregation these crystals may form 
 gravel, and finally result in calculus. They are soluble in soda or potash, 
 but not in the mineral acids. Urates of ammonia are common (Fig. 607), 
 but rarely result in calculus. The ammoniacal odor will be apparent by 
 the application- of heat. The presence of uric acid may be detected in a 
 deposit by treating it with nitric acid, and applying heat until the mass is a 
 dry powder. Add a drop of ammonia and a bright-violet color will be pro- 
 duced. 
 
 The oxalate of lime, which is the origin of the mulberry calculus, usually is 
 of a dark-brown color, and the crystals are either octahedral or dumb-bell- 
 
PHOSPHATIC DEPOSITS. 
 
 953 
 
 shaped bodies (Fig. 608). The diathesis which specially favors this deposit, 
 is found in persons suffering from nervous exhaustion and impaired diges- 
 tion. 
 
 The oxalates are not soluble in alkalies, but the mineral acids will dissolve 
 them without effervescence. If they are subjected to the heat of a blowpipe, 
 
 Fig. 605. 
 
 Fig. 606. 
 
 QUyCas&t 
 
 CrouwUr 
 Caut& 
 
 and the white ash which remains be placed upon moist red litmus-paper, 
 an intense blue color will result. 
 
 Phosphatic Deposits. — These are of two varieties, the alkaline and the earthy. 
 The former include phosphate of soda, the acid phosphate of soda, and the 
 phosphates of soda and ammonia, and seldom form concretions. 
 
 Fig. 607. 
 
 Fig. WZ. 
 
 The earthy phosphates comprise: 1. The ammonio-magnesian phosphates 
 (the triple phosphates'), which appear as beautiful, colorless, transparent 
 crystals, forming an iridescent pellicle on the surface of the urine. They 
 are supposed to arise from a decomposition of urea ; are soluble in acetic 
 acid, but not by heat. 
 
 2. The phosphate of lime and the phosphate of magnesia, which occur gen- 
 erally in the form of a white amorphous deposit, sometimes assume a crys- 
 talline form. If it exists in solution, or is precipitated by heat, it may be 
 
954 A SYSTEM OF SURGERY. 
 
 mistaken for albumen ; and when it forms the greater part of a deposit, may- 
 be erroneously called pus or purulent mucus ; especially as it is most fre- 
 quently found in alkaline urine mixed with pus or mucus. These phos- 
 phates are insoluble by heat, but soluble in acetic and the mineral acids. 
 
 According to Sir Henry Thompson, who has experimented on this sub- 
 ject, an atonic bladder may retain urine unexpelled for a long time, without 
 undergoing decomposition. When, however, crystals are developed, " the 
 urea is broken up and ammonia is formed. The phosphates of lime and 
 magnesia decompose, their earthy bases being precipitated, and from these 
 actions are produced the ammoniaco-magnesian or triple phosphate, as well 
 as some bibasic salts." Pus also will be formed, and the plastic inflam- 
 matory exudation being mixed with these phosphates is with difficulty 
 expelled. Thus portions remain and form a nidus for the formation of 
 calculus. 
 
 Sir Henry arrives at the following important conclusions : 
 
 1. That in its healthy condition the bladder rarely if ever retains, but on 
 the contrary expels all phosphatic deposits. 
 
 2. That when the bladder is not healthy, but affected by chronic inflam- 
 mation, provided it is not considerable or very prolonged in duration, the 
 power of expulsion is still almost as great as in the healthy organ. 
 
 3. That there is a diseased condition of the inner coat of the bladder, in 
 which the ability to expel phosphatic deposits is almost lost, and in which 
 the formation of concretions — and, if these are neglected, of stone — is certain 
 to occur* 
 
 The mixed or fusible phosphates, which are a combination of the two 
 already described, and frequently form the crust of calculi, are made up of 
 urates or oxalates, or have their nuclei in some foreign body introduced into 
 the bladder. At other times the stone may consist entirely of phosphates 
 and may reach a considerable size. They are not soluble in alkalies, readily 
 in acids, and by the blowpipe maybe fused into a hard enamel. There are 
 also deposits known as uric oxides, also called xanthic oxides or xanthin; cystic 
 oxides or cystin ; carbonate of lime calculus; fibrinous calculus ; tyrosin ; haematin 
 and urostealith, which are all pseudo-deposits, and for a description of which 
 the reader is referred to the many works on urine and its deposits. It may 
 be said in review, that the urates alone are dissolved by heat ; potash renders 
 soluble all except the phosphates and the oxalate of lime; while uric acid only 
 is insoluble in hydrochloric acid. 
 
 When any of these organic substances combine, or when they attach 
 themselves to some organic matter or foreign body, they form a calculus. 
 These may arise as follows : 
 
 • 1. A precipitation of the salts may take place in the secreting cells of the 
 kidneys, as occurs naturally in the kidneys of reptiles and birds. 
 
 2. A precipitation of some of the ingredients of the urine may take place 
 in the bladder, in consequence of stagnation of its contents. 
 
 3. The presence of anything which acts as a foreign body in the bladder 
 causes decomposition of urine, leading to abundant precipitation. 
 
 Urinary Calculi may be divided into three classes, viz. : Those formed of 
 uric acid and the urates ; together with the oxalates ; those derived from 
 the phosphates ; and, lastly, those exceptional concretions already men- 
 tioned under urinary deposits. 
 
 The uric acid calculus is found most frequently. It usually originates in 
 the kidney, is carried into the bladder, and there becomes an oval-shaped 
 stone of a yellowish or yellowish-brown color. It is generally composed of 
 
 * Medical Record, April, 1878, p. 270. 
 
TREATMENT FOR URINARY DEPOSITS. 955 
 
 layers, which are crystalline and fibrous, the fibres radiating from a centre. 
 It is often found in gouty subjects, associated with acid urine. 
 
 The urate of ammonia calculus is rarely seen, and generally occurs in chil- 
 dren. It is ovoid, smooth, and not above an inch in diameter. Its color is 
 characteristic, being grayish or clay-tinted, sometimes like pipe-clay, or has 
 an earthy appearance. 
 
 The oxalate of lime forms the mulberry calculus, which after the uric acid 
 stone is the most frequent form. The surface presents a tubercular, angu- 
 lar or spinous appearance, being rarely smooth. In color it varies from 
 brown to almost black, from which it derives its name. A section shows an 
 imperfectly lamellated structure with waving lines, simulating the knotted 
 heart of oak. These stones are said to produce less irritation than the 
 smooth varieties, perhaps because they are more stationary. 
 
 The phosphate of lime calculus is generally found combined with other 
 salts. Those of renal origin are of a pale brown color, with a smooth pol- 
 ished surface, and contain considerable animal matter. The variety which 
 begins in the bladder, and is most frequent, resembles irregular pieces of 
 mortar, or is a granular powder covered by mucus, and is often termed 
 " bone-earth calculus." 
 
 The triple phosphate calculus, or ammoniaco-magnesian phosphate, is 
 uncommon. It has been seen a few times with some foreign body as its 
 nucleus. 
 
 The fusible or mixed calculus is the most common of the phosphatic con- 
 cretions. It is found of large size and of different shapes, often moulding 
 itself to the form of the place in which it rests. It is of a whitish gray or 
 dull yellow color and more friable than any other, sometimes resembling 
 moist chalk. 
 
 The character of the urine will sometimes give a correct idea of the 
 nature of the calculus. If it be acid, the stone probably is uric acid or 
 oxalate of lime, or a combination of both. If the urine is fixed alkaline, the 
 deposition probably consists of earthy phosphate or the carbonate of lime. 
 
 Frequency. — In regard to the frequency of calculus in the two sexes, it is said 
 to be found twenty times in men to one in women. This probably is due 
 to the fact that in the female the urethra is much shorter and more dilata- 
 ble than in the male, and permits the natural discharge of these concretions 
 while they are yet small. 
 
 Treatment. — The medical treatment for the different urinary deposits can 
 scarcely be laid down here, inasmuch as they are so numerous, and are but 
 symptoms of other diseases, which require constitutional treatment. When 
 a calculus has formed of any size, the only means of relief is one of the 
 operations about to be recorded. For the smaller varieties, the best medi- 
 cines that I know of, are scilla, nitric acid in full doses, phosph. acid, car- 
 bonate of lithia, and Poland or Gettysburg water. From the latter I have 
 received unmistakable results; in one instance nearly two hundred calculi, 
 varying in size from a shot to a large pea, were passed in a space of two 
 months, while the patient drank this water. A coincidence was observed, 
 in the fact that these calculi were dissolved after being immersed in this 
 water, while they withstood the action of hydrochloric acid. The following 
 medicines may be found serviceable according to their symptoms : apis, 
 can. sat., canth., alnus rubra, digital., chimaphila, erigeron, caust., eupato- 
 rium purpureum. Speaking of the latter, Rafinesque says that it is a spe- 
 cific among the country people, who give it the name of " gravel root." 
 
 Galium aperinum and the fluid extract of hydrangea are also extolled by 
 the eclectics, among whom are Beach, Scudder, and Smith. 
 
 My experience (being generally called to see these cases after the calculi 
 have formed) is, that those medicines which I have first named will give 
 
956 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 609. 
 
 more favorable results than any others. According to Dr. Coe, corydalis 
 formosa is a good medicine in this affection. 
 
 Stone in the Bladder.— Although the physical signs of stone (chiefly elicited 
 by " sounding ") are the real means by which we can unhesitatingly give a 
 correct diagnosis, yet there are certain subjective symptoms which always 
 lead to. the suspicion that a calculus may exist, and these are often so well 
 denned, that the presumptive evidence is in favor of the presence of stone 
 in the bladder. Among these we find pain, which, however, varies greatly 
 in different patients. It generally occurs in paroxysms, especially in the 
 early stages ; after a time, however, it becomes more constant, and the 
 patients, especially children, lie on their bellies or draw at the prepuce. 
 Together with the pain there is frequent desire to urinate and often urinary 
 tenesmus. During micturition, the stream is suddenly arrested by the stone 
 falling toward the neck of the bladder. There is hematuria, coldness of 
 the glans penis and aching in the testicles ; there is in some cases severe 
 priapism. 
 
 The symptoms of stone vary in severity according to its size and rough- 
 ness, the state of the urine, and the condition of the bladder, whether 
 healthy or inflamed. The manifestations may be slight for years; indeed, 
 a little pain and bloody urine when micturating after exercise, may be 
 
 the only inconvenience experienced. After a 
 time the bladder suffers as it does from any 
 other irritation; the urine deposits a slight 
 cloud of mucus ; the bladder becomes more 
 irritable, and finally inflames ; the urine be- 
 comes alkaline, loaded with viscid mucus 
 and with the triple phosphates and phos- 
 phate of lime; the strength fails, and, after 
 years of suffering, the patient sinks. Sir B. 
 Brodie remarks, " That if the prostate be- 
 comes enlarged, the sufferings from stone are 
 mitigated ; because it is prevented from fall- 
 ing on the neck of the bladder." 
 
 Sounding for Stone.— To perform this por- 
 tion of the operation, upon which alone the 
 diagnosis of the case is to be made out, one 
 should possess a thorough knowledge of the 
 anatomy of the urethra and the curves that 
 it makes in different parts of the canal, other- 
 wise not only will the patient be subjected to 
 much additional pain, but dangerous results 
 may follow the improper management of the 
 instrument. 
 
 To sound a person properly the bladder 
 should contain urine, or should have fluid 
 injected therein. The instrument must pos- 
 sess a proper shape, the curve being the arc 
 of a circle described by a radius of II inches. 
 It should be constructed of solid steel, highly 
 polished, with a broad, flat and rather thin 
 handle, that any impression made at one 
 extremity may be distinctly appreciated at 
 the other, while that portion which enters 
 the bladder should be of larger calibre than that which remains in the 
 urethra. Fig. 609 shows Van Buren's Sound, and Fig. 610 that of Benique. 
 Grasp the penis in the left hand and retract the prepuce ; put the organ 
 
 Van Buren's Sound or Bougie. 
 
SOUNDING FOE STONE. 
 
 957 
 
 upon the stretch and direct its extremity at about an angle of forty-five 
 degrees from the body. 
 
 Taking the sound, well oiled, between the thumb and forefinger of the 
 right hand, held close to the body of the patient, introduce its point into 
 the meatus urinarius, and allow it to glide along the urethra until the curve 
 reaches the perinseum ; then holding the sound and penis in the left hand, 
 gradually depress them or turn them toward the feet of the patient, whereby 
 the point of the instrument is raised, and then with gentle pressure of tbe 
 right hand cause the curve to pass over the bulb of the urethra, and into 
 the bladder. 
 
 This is not " sounding " properly so called : it is merely the introduction 
 of the sound ; the more delicate portion of the proceeding remains to be 
 accomplished. The sound must now be held lightly, and must be moved 
 about in all portions of the bladder until the peculiar click is heard or felt. 
 
 Fig. 610. 
 
 o. TIEMAHN & CO 
 
 Benique'sf Sound. 
 
 Fig. 611. 
 
 As soon as the operator has satisfied himself that the steel instrument has 
 touched the stone, he should pass it to other professional friends, that it 
 may be demonstrated beyond the possibility of a doubt that the calculus 
 is present. This rule should always be followed, nor should the opera- 
 tion be commenced until several surgeons have detected the offending mate- 
 rial. 
 
 Sometimes the stone cannot be found ; in such cases by introducing a 
 finger into the rectum, and pressing the lower part of the bladder upwards, 
 the calculus may be made to touch the sound. When these means proved 
 unsuccessful, Dr. Physick, whose experience in lithotomy was extensive, 
 was in the habit of placing the 
 patient nearly upon his head, by 
 which position the stone was dis- 
 lodged from the fundus of the 
 bladder and thrown against the 
 sound. 
 
 In sounding, care must be taken 
 lest the student mistake a stone 
 in the urethra or prostate gland 
 for a calculus within the bladder. 
 
 It will, therefore, be seen that- 
 this operation is difficult and deli- 
 cate ; and when men who have 
 devoted their attention to the con- 
 sideration of stone in the bladder 
 say of " sounding," " that to per- 
 form it well requires great tact in 
 the use of instruments, a perfect 
 knowledge of the anatomy of the 
 urinary apparatus, and a degree 
 of experience which multiplied 
 observation can alone supply," and that " the want of success in the opera- 
 tion is not confined exclusively to the young, the ignorant, or the unskilful, 
 but that men of most consummate dexterity have occasionally failed in 
 
 Position of the patienf for Lithotomy (Cheselden's 
 Operation). 
 
958 A SYSTEM OF SURGERY. 
 
 detecting a stone where stone really existed ; " the procedure must be 
 looked upon as all-important in the operation. 
 
 The Preparation of the Patient. — Having had the bowels evacuated by a 
 full dose of castor oil, which serves the double purpose of relieving the 
 bowels and inducing thereafter constipation, he must be brought to the edge 
 of the bed, over which an oil cloth or india-rubber blanket has been laid, 
 and the wrists and ankles are to be firmly secured as seen in Fig. 611, or 
 ".the leg braces " of Comstock or Peters applied. An assistant must stand 
 on either side, and with his hands upon the knees of the patient, must 
 separate the thighs as widely as possible. 
 
 Anaesthesia should now be complete, and an instrument resembling in 
 shape a catheter, constructed of solid steel, with a groove a little to the left 
 side, with a rounded extremity, and which is called a staff, Fig. 612, must 
 be passed into the bladder, drawn up against the pubes and placed in the 
 hand of a steady assistant. Gross says : " A poor staff-holder is a great 
 curse," and so he is, for a change in the direction of this instrument, its 
 depression in a sidewise position, may not only embarrass the operator, 
 but may cause the death of the patient, by a division of wrong structures. 
 
 Lateral Lithotomy. — Having now all things prepared, the patient anaes- 
 thetized and well secured, the staff-holder steady, and the staff in position, 
 sponges, etc., at hand, the instruments beside him in convenient position, 
 and a good light falling upon the perinaeum (which, if the patient be an 
 adult, must be carefully shaved) and thoroughly disinfected, the surgeon 
 seats himself in front of the patient, takes an ordinary scalpel in his right 
 hand, and with the thumb and forefinger of the left, puts the skin upon 
 the stretch, and enters the point of the knife on the left side of the peri- 
 naeum about an inch and a half above the margin of the anus, and carries 
 it downward and outward to a little distance below the tuber ischii of the 
 left side (Fig. 611, page 957, shows line of this incision). In a child there 
 is not much subcellular tissue, and therefore not a very deep incision is 
 required, but in some instances, where the patient is fat, this cut must be 
 fully an inch in depth. There is an important point to be remembered in 
 this part of the operation, viz., the incision from the external surface of the 
 perinaeum to the point where the knife enters the groove in the staff, must 
 
 Fig. 612. 
 
 G.TIEMANN & CO 
 
 Lithotomy Staff. 
 
 be either conical or triangular, with the apex at the membranous portion of 
 the urethra, a little in.front of the prostate gland ; by bearing this in mind 
 it will be perceived that the nearer we approach the staff the less extended 
 will be the incisions. Placing the index finger in the upper angle of the 
 wound, the transverse muscles and triangular ligament are successively 
 divided until the staff is clearly felt within the canal at its membranous 
 portion. Keeping the finger in the wound, and with the nail for a guide, 
 
LATERAL LITHOTOMY. 
 
 959 
 
 introduce the point of the scalpel into the urethra, and then withdrawing 
 it, substitute for it a knife which has a long blade, a long handle, and a 
 short cutting edge, with a buttonlike extremity which fits into the groove 
 
 Fig. 618. 
 
 Lithotomy Forceps. 
 
 Fig. 614. 
 
 in the staff. At this stage it is well to pause a moment, and have the staff 
 drawn up under the pubes and ascertain if it is in the proper position, and 
 finding it in place, push forward the knife; it readily enters the bladder, 
 which is indicated by the gush of urine which generally follows. 
 
 Let me impress upon the student the direction in which the knife is to 
 be pushed. It should be carried straight along into the bladder, keeping 
 the probe-point well into the groove, care being 
 taken not to elevate the hand or allow the 
 blade of the knife to look downwards, for if this 
 be done it will slip from the groove in the staff 
 and be plunged into the rectum instead of the 
 bladder, and the operation spoiled. Another 
 caution is necessary, lest too much of the pros- 
 tate be cut ; the knife must be withdrawn as 
 soon as there has been an opening made into 
 the bladder, and the forefinger of the right 
 hand gradually inserted to enlarge the open- 
 ing. 
 
 Frequently the stone can be felt at the open- 
 ing of the bladder, and by introducing a pair 
 of forceps with broad serrated jaws (Fig. 613) 
 the stone can be removed with the assistance of 
 the finger (Fig. 614). If it be impossible, from 
 the size of the offending mass, to accomplish its 
 removal, the wound must be carefully enlarged 
 to its utmost extent. If still the calculus can- 
 not be withdrawn, it must be broken in pieces 
 with a crusher (Fig. 615). The bladder must 
 now be thoroughly washed out with carbolized water by means of a good- 
 sized syringe, and the finger again introduced to ascertain if other calculi be 
 present. If there be none, release the patient from his bands, place him in 
 bed on his left side, with an india-rubber cloth covered with absorbent cotton 
 under the buttocks to catch the urine, and the operation is complete. I 
 employ neither compress, straps, bandage, nor catheter. To enlarge the in- 
 ternal opening and facilitate the passage of the crusher or forceps, without 
 further entanglement of tissues, an instrument has been devised, as seen in 
 Fig. 616. 
 
 Key's Operation. — Lateral lithotomy was modified by Aston Key, of Guy's 
 Hospital ; he used a staff nearly straight, instead of the ordinary curved 
 
 Removal of the Stone in Lateral 
 Lithotomy. 
 
960 
 
 A SYSTEM OF SURGERY. 
 
 director of Fergusson. When the groove in the staff has been exposed, 
 " the point of the knife being kept steadily against the groove, the operator 
 with the left hand takes the handle of the director and depresses it to an 
 angle of 65° or 70°, at the* same time keeping the right hand fixed. Next, 
 
 Fig. 615. 
 
 Stone-crushing Forceps. 
 
 by moving both hands simultaneously, the groove of the director, with the 
 edge of the knife, are turned obliquely toward the left side, and the knife 
 has now the correct bearing for the section of the prostate ; which may be 
 accomplished by carrying the knife slowly forward in an exact line with 
 the director." 
 
 Besides these methods of procedure, other operations have been adopted 
 by eminent surgeons, as improvements. 
 
 Allarton's Operation. — The median section is an ancient method, also known 
 
 Fig. 616. 
 
 Guide for the Forceps through the Perineal Opening. 
 
 as the Marian or Italian operation. It either adopts the plan of making 
 a vertical incision through the prostate, as practiced by Vacca, or follows 
 the method revived by Allarton, in which only the apex of the gland is 
 incised. 
 
 In this the common grooved staff is passed into the bladder, and its 
 handle intrusted to an assistant. The surgeon introduces his finger into the 
 
 Fig. 617. 
 
 Little's Director. 
 
 rectum as far as the apex of the gland, and there retains it as a guide to the 
 next part of the proceeding, which consists in entering a long straight bis- 
 toury with its edge uppermost, about a half inch in front of the anus, in the 
 median line ; cutting down to the membranous portion of the urethra until 
 
BILATERAL SECTION. 
 
 961 
 
 the groove in the staff is reached, and pressing it toward the bladder for 
 about half an inch ; then carrying the incision upward, the membranous 
 portion of the urethra is freely divided, and the soft tissue of the perinseum, 
 A long ball-pointed probe, or, what is better, the director of Dr. Little (Fig. 
 617), is now carried through the groove into the bladder, and the staff is re- 
 moved. By passing the finger along this probe into the bladder the orifice 
 is dilated ; it also serves as a guide to the forceps in seizing and removing 
 the stone. 
 
 In cases where the calculus is of small size this method may be success- 
 fully employed ; but in general, experience has failed to give much support 
 to this mode of operation. 
 
 Bilateral Section. — Dupuytren recommended a bilateral incision through 
 the prostate gland, making a semilunar cut transversely through the peri- 
 naeum. He considered this a superior method for the removal of large cal- 
 culi, but the operation now finds few advocates. The first incision having 
 reached the staff, a double-bladed curved lithotome is pushed close along 
 its convexity into the bladder. The blades are now opened transversely, 
 
 Fig. 618. 
 
 Wood's Lithotomy Staff and Knife. 
 
 and by withdrawing the instrument, the neck of the bladder and the pros- 
 tate gland are divided. The late Dr. James R. Wood was partial to the 
 bilateral section, and to facilitate the operation devised a bisector, with fixed 
 open blades, as seen in Fig. 618. 
 
 Civiale's Medio-bilateral Operation differed from the above only in that the 
 first incision was made in the median line. 
 
 Buchanan's Operation. — In this a staff bent at right angles three inches 
 from its point, with a deep lateral groove and a posterior opening, is intro- 
 duced into the bladder, and, guided by the finger in the rectum, its angle is 
 made to correspond to the apex of the prostate gland. With the finger still 
 retained in the rectum and the staff in the hands of an assistant, the peri- 
 nseum is entered by a long straight bistoury held horizontally, with the edge 
 turned to the left, directly opposite the angle of the staff. When it enters 
 the groove it is pushed toward the bladder until it reaches the stop at the 
 end of the staff. On withdrawing the knife, a curved incision is made 
 through the soft tissues to the left of the rectum, about li inch in length. 
 The cut can be made with a lithotome cache (Fig. 619). The author claims 
 several advantages over the ordinary method, viz. : The prostate gland is 
 reached more easily and rapidly, the membranous portion of the urethra is 
 avoided, all bloodvessels of any importance are out of danger, there is less 
 liability of the rectum being injured, and not so much risk of deep-seated 
 urinary infiltration. 
 
 Recto-vesical Lithotomy, or lithotomy through the rectum, was at one time 
 frequently resorted to, but at present has fallen into disuse, so that it 
 
 61 
 
962 
 
 A SYSTEM OF SURGERY. 
 
 has been omitted from some modern works on surgery. The grooved curved 
 staff being in position, a straight bistoury laid flat on the palmar surface of 
 the finger is carried into the rectum about one inch. With the other hand, 
 the edge is turned up and the knife thrust through the wall of the rectum 
 
 until it reaches the groove of the 
 staff, when by withdrawing it, the 
 rectum, external sphincter, and sur- 
 rounding tissues are divided about 
 one inch in the median line. Insert 
 the left index into the wound, guid- 
 ing the knife, with its edge turned 
 downward, to the groove, and then 
 push the instrument forward into 
 the bladder, making the incision to 
 correspond to the supposed size of 
 the stone. The finger is now car- 
 ried into the bladder, the sound 
 withdrawn, the forceps introduced, 
 and the stone extracted. 
 
 The important objections to this 
 operation are the danger of wound- 
 ing the peritoneum and vesiculae 
 seminaJes, the subsequent infiltra- 
 tion of urine, or recto-vesical fistula. 
 The Suprapubic or High Opera- 
 tion, Epicystotomy, Hypogastric Sec- 
 tion.— This operation was first per- 
 formed by Pierre Franco, who, in 
 1561,!according to Belmas* and Vel- 
 peau,f and in 1560, according to 
 Heister,J operated successfully upon a boy. Hypogastric section gained 
 favor for a time, Cheselden, Proby, Grcenvelt, and others lauding it highly. 
 It fell into disrepute for a time, until the French surgeons, notably Sou- 
 berbeille, brought it into notice. Soon it lapsed into oblivion again, to be 
 resurrected, attacked, and defended, until to-day its merits are being dis- 
 cussed by the greatest men of the age. Elsewhere,§ as well as in the last 
 edition of this work, I have expressed the opinion that it is the best method 
 of cutting for stone. The following description, with some modifications, I 
 have taken from my work on this subject. 
 
 It makes little difference whether the incision be made with a bistoury 
 or scalpel, whether it goes from above downward or below upward, whether 
 the bladder be held up with a tenaculum, or a hooked finger, or a loop of 
 catgut, provided it be held up. A surgeon will have his favorite instru- 
 ments, which, in his hands, have been best adapted for making the appro- 
 priate incisions. Several days before the operation, if the urine has been 
 putrid, or there has been atony of the bladder, that viscus should be washed 
 out carefully with a saturated aqueous solution of the biborate of soda, and 
 the best apparatus for the purpose is that of Dr. Keyes. 
 
 The injection of the bladder and rectum before the operation is begun, is 
 an important feature in the performance. According to Fehleisen the rec- 
 tum should hold more fluid than the bladder — 14 or 15 ounces in the former 
 and 10 or 12 in the latter. In my last operation I used a good-sized colpeu- 
 
 Application of the Lithotome Cache. 
 
 * Traite de la Cystotomie Suspubenne. Paris, 1827. 
 
 X Institutiones Chirurgicse, torn, ii., p. 927. 
 
 | Suprapubic Lithotomy, 4to, p. 99. Boericke & Tafel, 1882. 
 
 f Velpeau, Operative Surgery. 
 
THE STJPKAPUBIC OR HIGH OPERATION. 963 
 
 rynter, introduced well up in the rectum, to the tube of which a stopcock 
 was attached ; they should be distended as much as possible to elevate the 
 peritoneum. The sonde-a-dard is not an essential ; a catheter or ordinary 
 sound will mark the point where the bladder incision should terminate 
 if begun at the pelvis, or where it should be begun if it terminates at the 
 pubes. It, however, gives a sure guide to a free, bold, and smooth incision 
 into the bladder, and should be used if practicable. Besides this, in the 
 modification which I have devised, it prevents the frequent passage of in- 
 struments through the urethra, which, in some cases, is not desirable. 
 
 Every instrument must be " listered," every particle of the bedclothing, 
 the clothing, atmosphere, and apparatus, should be prepared with care ; 
 then, 
 
 (1.) Place the patient in a comfortable position, supine, on a table of 
 proper height, and administer the ansesthetic. 
 
 (2.) The patient being etherized, a small rubber bag is rolled up in the 
 shape of the letter V, upside down (\), and gently pushed into the rectum, 
 care being taken to have it clear of the sphincter. It is then slowly filled 
 with water, the surgeon using his judgment as to the amount, about 12 to 
 14 ounces being required. The bladder is in its turn filled until its promi- 
 nence over the pubis is both seen and felt. The distension of the bladder 
 is not as important as that of the rectum, but in either case force must be 
 used. 
 
 (3.) Introduce the sonde-a-dard (Fig. 620) without the stilet, and inject 
 the bladder (with stopcock B open) with a solution of calendula 1 : 100, at a 
 
 Fig. 620. 
 
 The Author's Sonde-&-dard. 
 
 temperature of 100°. So soon as the slightest resistance to the passage of 
 liquid is observed, draw the plug from the mouth of the flange C, and, as 
 the water passes out, inject more until the bladder is thoroughly cleaned. 
 
 (4.) Insert the plug D firmly into its place, and inject the bladder with 
 as much as it will hold, and, having done this, turn the stopcock to retain 
 the water. It will be seen that the sonde may be used not only as a 
 searcher for the stone, but for injecting and washing out the bladder, and 
 that if it be made the proper size, equal to a No. 16 English bougie, there 
 will be little, if any, water escape by its side. By using one instrument a 
 great advantage is gained, especially in cases of sensitive urethra?, where 
 
964 A SYSTEM OF SURGERY. 
 
 the frequent introduction and withdrawal of tubes may greatly complicate 
 the case. The instrument used to inject is the ordinary rubber 12-ounce 
 syringe fitted with a stopcock. 
 
 (5.) The surgeon, with a scalpel, makes an incision from a point about 
 two inches and a half above the linea alba, down to the top of the pubis, 
 and about half an inch over the top of the pubic arch, almost to the root of 
 the penis. This extension of incision is of importance, for it gives room to 
 manipulate instruments, and in persons in whom there is much adipose 
 tissue, this latter part of the cut assists materially in widening the mouth 
 of the pit. While making this cut, by holding a small sponge with the 
 middle, ring, and little fingers (after the manner in which an apothecary 
 holds the cork of a vial which he is decanting into another bottle), and 
 rendering the integument tense with the thumb and finger of the same 
 hand, the surgeon may do his own sponging, and keep the cut clean as he 
 goes through the tissues. 
 
 (6.) When the linea alba is reached, the parts are examined to see if there 
 be any bleeding points ; if there are, the vessels may be twisted, or small 
 catch forceps, as recommended by Spencer Wells, may be applied, or Vidal's 
 forceps employed. The lips of the wound may be more widely separated 
 by pushing them apart with the fingers. 
 
 (7.) The tendinous expansion must be snipped above the pubes, a di- 
 rector inserted, and the abdomen opened from below upwards for at least 
 two inches. I generally do this with the scissors, although a knife with a 
 probe point, or a sharp-pointed curved bistoury, will do as well. This 
 brings the fat, which is usually found above the fundus of the bladder, in 
 view, and, as in my first case it gave me much perplexity on account of 
 its quantity, it is well to remember that it is often found of considerable 
 thickness. If the cut is extended higher towards the umbilicus, the peri- 
 toneum is exposed, but, as a rule, this is not necessary. 
 
 (8.) At this stage the handle of the sonde-a-dard must gradually be de- 
 pressed between the legs of the patient, to bring its beak at the fundus of 
 the bladder, just below the point of attachment of the peritoneum ; thus 
 the surgeon has a guide to this important point in the anatomy of the 
 operation. 
 
 (9.) The assistant holding the instrument as above, the surgeon takes a 
 round curved needle, threaded with strong carbolized catgut, passes it 
 through the bladder- wall, and draws it through, ties a knot in the catgut, 
 making a loop of about an inch and a half, cuts off the needle, and places 
 the loop over the bent finger of an assistant, or fenestrated catch-forceps 
 may be used. 
 
 (10.) The stopcock (B) of the sonde is turned, and a portion of the fluid 
 allowed to escape. This is done to prevent any water flowing into the 
 cavity of the abdomen, as the stilet is passed through the bladder. 
 
 (11.) The stilet (C) is pushed into the canula and passed directly 
 through the bladder. 
 
 Fig. 621. 
 
 (12.) The sharp point of a pair of scissors, or the point of a curved 
 bistoury, or the curved probe-pointed aponeurotome (Fig. 621) (I prefer 
 the former), is introduced into the groove of the stilet, and the incision 
 enlarged to obtain a fair opening into the bladder. The stilet is then 
 
THE SUPRAPUBIC OR HIGH OPERATION. 965 
 
 withdrawn into the sonde, which is removed from the bladder, that organ 
 being kept up, by the loop of gut on the finger of the assistant. 
 
 (13.) The ringer is gently introduced into the bladder, the stone or stones 
 are at once perceived, and in the majority of instances the fingers are the 
 instruments which remove the calculi. When the concretions are large, or 
 the patient very fat, as in my first case, forceps must be employed, and 
 used with the utmost gentleness, until the calculus is grasped and removed. 
 
 (14.) Search must be made to ascertain that the bladder is entirely free 
 from stones, and then the bladder wound must be sewn up. 
 
 (15.) In sewing the bladder (whether indeed it should be sewn or not, has 
 been a matter of discussion), care should be used, and fine needles threaded 
 with catgut employed. In my cases, and in those of Dr. Doughty, in every 
 instance, the bladder-wound was closed with carbolized sutures of catgut. 
 To do this effectually, a fine piece of the gut should be threaded upon a 
 small-sized curved needle, and a small knot tied at the end ; beginning at 
 the top of the wound, just below the point of suspension of the bladder by 
 the loop of catgut already mentioned, a glover's or continued suture should 
 be carried the length of the wound, a reverse stitch taken, and the needle 
 cut away. Gunther does not apply any stitches, but Starr sews the walls 
 of the abdomen and the bladder-wound with a peculiar stitch, which in- 
 cludes both the bladder and the walls of the abdomen. He says of it : "I 
 passed a silver suture down through the walls of the abdomen into the 
 cavity of the bladder, included a part of this, and brought the wire back 
 through the bladder and abdominal wall on the same side, then I carried 
 it across the incision, passed it down through the abdominal wall and blad- 
 der on this side, included a segment here, and brought it out as before, and 
 just opposite where it had first entered the tissues ; now when the ends of 
 the suture were drawn upon, the sides of the wound were approximated, 
 but the edges of the incision in the bladder were inverted and their outer 
 surfaces brought into contact, while the mucous surfaces were turned in- 
 ward, thus promoting union."* 
 
 (16.) After the bladder- wound has been sewn (that is, if it be not included 
 with the abdominal walls after the manner of Dr. Starr), a sponge-holder 
 containing antiseptic absorbent cotton must be gently pressed within the 
 wound to remove all clots and moisture, but sufficient force must not be 
 used to separate any of the paravesical connective tissue. 
 
 (17.) The loop of catgut must be drawn to the top of the wound, where 
 it generally remains, and held there while the tegumentary cut is closed. 
 In my last case, instead of using the catgut loop, I held the bladder with 
 a pair of forceps with a spring-catch on the handles and broad fenestrated 
 blades. 
 
 (18.) In sewing the abdominal wound, either one of two methods will be 
 found serviceable : a large-sized round needle should be threaded with 
 waxed-silk, which should be cut to leave ends about four inches long; 
 these should be sewn together with fine thread, or be spliced to make a 
 loop. This method, which I have used for many years, is better than tying 
 the half knot. The loop must again be waxed ; upon this the silver wire, 
 No. 26, must be bent, and squeezed together with a pair of forceps. By 
 this means the flexibility of the silk allows the needle to be inserted and 
 withdrawn through the abdominal walls without kinking the wire. The 
 best of all needle-holders, especially where the tissues are thick, is that 
 known as the Russian (page 35). 
 
 The needle is introduced half an inch from the margin of the cut at 
 the upper angle of the wound, passed through the entire thickness of the 
 
 * American Journal of the Medical Sciences, July, 1877, p. 113. 
 
966 A SYSTEM OF SUKGERY. 
 
 abdominal wall, and drawn through ; again it is grasped by the needle- 
 holder, inserted in the opposite side under the tissues, and brought out at 
 the integument at a point opposite to where it has been entered on the other 
 margin of the cut. The wire is drawn gently through and cut to leave 
 about an inch and a half projecting from each side of the incision. These 
 two ends are taken in charge by an assistant, who turns them over on the 
 abdomen towards the head of the patient. A second suture is introduced 
 in like manner a quarter of an inch from the first, and so on ; the lips of 
 the wound are brought in proximity, leaving, however, about half an inch 
 at the lower angle for the admission of the drainage-tube. 
 
 The second method for the introduction of the wires is to take a needle 
 with an eye in its point (page 40), thread it with waxed silk about four 
 inches long, introduce it from within outward, and when the eye with the 
 thread in it appears at the integument, draw it (the thread) forward with 
 a small tenaculum, until the loop is sufficiently large to hook upon it the 
 wire, which is bent over the thread. The needle is withdrawn, the operator 
 taking care to hold in his grasp, with the handle of the instrument, the 
 distal extremity of the silk. The operation is repeated in a similar manner 
 on the opposite side. As each wire is introduced, the assistant turns the 
 ends upward, as in the first instance, and holds them out of the way until 
 a sufficient number are introduced. 
 
 (19.) Before the parts are approximated, the surface is washed with an 
 antiseptic solution, and again the sponge-holder, charged w T ith fresh anti- 
 septic cotton, is used to remove any blood that may have oozed from the 
 needle puncture. 
 
 (20.) A small-sized glass drainage-tube, having a flange, to which is 
 attached a piece of new india-rubber tubing, is inserted into the lower angle 
 of the wound, and the wires twisted with the usual instrument. A new 
 cork must be placed in the drainage-tube, and the india-rubber tube carried 
 over the thigh into a vessel containing carbolized water, on the floor, or 
 upon a stool by the edge of the bed. A narrow strip of plaster must then 
 be laid along one side of the wound and the ends of the wire bent over the 
 point of a tenaculum. Over the whole wound a covering of marine lint 
 should be placed, and secured by carbolized india-rubber plaster. The 
 loop of catgut must be lowered a little, and fastened by placing a bit of 
 bougie through the loop transversely over the incision, and holding the 
 bougie in the abdomen by adhesive strips. I use this as an additional 
 preventive for extravasation; the idea being to keep the bladder-walls some- 
 what apart, thus making a deeper trough for the accumulation of urine. 
 Whether this has accomplished its purpose I cannot say, for I have been 
 careful to keep the bladder empty by the presence of the catheter, or its 
 frequent application. Dr. Doughty has invented an ingenious, and, in 
 his hand, satisfactory apparatus to prevent excoriation from overflowing 
 urine, which should be applied as the urine shows itself at the abdominal 
 opening. It consists (Fig. 622) of a glass bell similar to a nipple-shield, 
 which, for illustration, we divide as follows: A, bell; B, flange ; C, rest. At 
 the junction of A and B is an aperture for the passage of the drainage- 
 tube. This must fit snugly, and be of sufficient length to pass from a bottle, 
 between the thighs, over the scrotum by the side of the penis, through the 
 aperture of the bell, and well into the wound. The end of the drainage- 
 tube in the bottle must be lower than the bladder, that it may act as a 
 siphon. The tube must have openings at intervals, in that part of it within 
 the wound, and one at its upper side within the bell where it has passed the 
 aperture. Let the pubes be shaved, the drainage-tube introduced, and the 
 wound, unless there has been primary union, brought together with adhe- 
 sive strips (as applied to an ordinary indolent ulcer), leaving the lower inch 
 
THE SUPRAPUBIC OR HIGH OPERATION. 
 
 967 
 
 of it exposed. In applying the instrument, let the centre of the bell cor- 
 respond with the lower extremity of the incision, to admit of easy intro- 
 duction into the wound. To secure it, let a strip of adhesive plaster, six 
 inches in length by one inch in width, with a semicircular piece cut from 
 one edge in the middle to receive the bell, be 
 applied across the wound and over the flange. 
 Next let a piece of roller bandage be passed 
 under the patient, and the ends brought up over 
 the thighs above the great trochanters, leaving 
 the space across the abdomen for the attachment 
 (by pinning or sewing) of a piece of elastic 
 i to f of an inch in width, and without tension 
 raise the elastic from its centre to the rest C. 
 The roller bandage and the elastic being prop- 
 erly adjusted, no urine can escape on the person, 
 nor can any suffering be experienced by the 
 patient; therefore skill and precision in the 
 application of the apparatus is indispensable. 
 If the pubes be unequally impressed by the 
 entire flange, so that pain results from too severe 
 pressure, the application is a failure. The reasons 
 and the remedies are obvious. If the failure is 
 due to the roller bandage (causing tipping of the 
 bell, and so unequal pressure of the flange), 
 it must be newly adjusted by removing it, either 
 a trifle higher or lower ; if the fault is due to 
 the elastic, its tension must be increased or di- 
 minished. Stoppage of the tube, external to the 
 bell, will be readily detected by the rising of the 
 urine within it (the bell), and can be relieved by 
 aspiration, by means of a small penis syringe. 
 If the obstruction is in the part within the wound, 
 the whole apparatus must be removed, for reasons readily appreciable. 
 
 It is a question with some surgeons regarding drainage. Dr. Stimson 
 says that Dr. Keyes recommended drainage per rectum ; others draw the 
 water every few hours, as recommended by Dulles. I have seen excellent 
 results from fixing a Nelaton flexible catheter in the bladder, only remov- 
 ing it sufficiently to cleanse it, recollecting that so soon as its bladder-end 
 shows a tendency to becoming rough, a new one must be substituted. 
 
 (21.) The position the patient assumes makes but little difference, but for 
 the first few days the recumbent is that most desired, because it is more 
 comfortable. As far as the renewal of the old practice of turning the 
 patient on the face, as lately practiced by Trendelenberg, I should think 
 it both undesirable and tiresome, and above all, the position would be 
 likely to force the urine from the wound, simply by attraction of gravita- 
 tion, a circumstance which is much to be deprecated in the after-treatment 
 of the operation. 
 
 After-Treatment.— The chief danger in " the high operation " for stone, 
 consists in the liability to urinary infiltration, and, perhaps, phlegmonous 
 inflammation of the paravesical tissues. The wounding of the peritoneum 
 need not occur, excepting in cases in which the enormous size of a cal- 
 culus necessitates a corresponding wound in the bladder, and in such it 
 would be preferable to crush the stone and remove it by fragments ; that 
 is, if it can be broken. 
 
 The evil results of urinary extravasation can be much reduced by the 
 methods I have lately practiced. The morning after the operation the 
 
968 A SYSTEM OF SURGERY. 
 
 patient should be dressed as follows: All the bandages should be removed 
 and the parts carefully washed and dried, then a coating of flexible collo- 
 dion should be placed over the wound and around it, for the distance of 
 three or four inches on each side, and down on the inside of the thighs. 
 The drainage-tube should be removed ; if glass, it must be cleansed and 
 allowed to lie in a solution of carbolic acid 1 : 60 until it is wanted ; if 
 india-rubber, it is to be burned and a new one employed. A flexible Nela- 
 ton catheter, with a countersunk eye, is to be attached to the tube of a 
 fountain-syringe, and carbolized water 1 : 200, at a temperature of 100°, is 
 allowed to run into the wound; this should be continued until a quart 
 of the solution has been so used. The dresser, taking his probe, wraps 
 the end of it with borated cotton, introduces it to the depth of the in- 
 cision, and wipes out the wound ; he then removes the cotton, reapplies 
 another piece, uses it in a like manner, and so on until the whole cavity 
 is dry. This may take half an hour or even more. The catheter is re- 
 moved from the bladder, washed and carbolized, and is ready for readjust- 
 ment. 
 
 The surface of the abdomen must be covered with a large wad of borated 
 absorbent cotton, and a muslin binder applied over it, and fastened with 
 safety-pins. 
 
 The catheter for the first few days must be permanently retained in the 
 bladder, which is accomplished as follows : Take six or eight hooks, such as 
 are used in fastening ladies' dresses (hooks and eyes), secure three of them 
 just below the glans penis, by wrapping around the organ a strap of india- 
 rubber salicylated adhesive plaster, apply a corresponding number to the 
 flexible catheter at a point about an inch from the meatus ; the catheter is 
 inserted, and by slipping over the corresponding hooks small india-rubber 
 bands, which, from their elasticity, will allow sufficient expansion of the 
 penis, when it has a tendency to erect, or at least enlarge, the instrument 
 will be comfortably kept in position. After the first week, the permanent 
 use of the catheter should be dispensed with, and the urine drawn every 
 two or three hours. 
 
 Dangers. — As to the relative danger attending these several methods of 
 operation, it may be stated as follows : 
 
 In 1827 cases, of all ages, in the various metropolitan and provincial 
 hospitals, upon whom the lateral operation was performed, the ratio of mor- 
 tality was about one to eight. 
 
 The recto-vesical operations show the proportion of fatal cases to be about 
 one in five and one-fourth. 
 
 In suprapubic lithotomy a death ratio has been found of one in four. This 
 is hardly a fair estimate, because of the character of the cases which have 
 heretofore been subjected to the suprapubic. According to Dulles * the 
 mortality is shown to be 1 in 10 in the table he collected for ten years, and 
 from the tables in my work the true mortality is about the same.' 
 
 Under twelve years of age the lateral operation is said to be the safest and 
 most successful. After that age the various modes of procedure have been 
 instituted, hoping to diminish the mortality, but the results thus far are by 
 no means flattering. 
 
 The causes of death, after the operation of lithotomy, may be briefly stated 
 — 1. Disease of the kidneys, which is generally present if the calculus has 
 existed a long time ; indeed, if the source of irritation remain in the blad- 
 der, death will probably result from the cause above mentioned ; and where 
 there exists any serious lesions of the kidneys, the operation is much less 
 
 * Suprapubic Lithotomy, by C. W. Dulles, M.D. American Journal of the Medical 
 Sciences, April, 1878. 
 
STONE IN THE FEMALE BLADDEK. 969 
 
 likely to prove successful. 2. Deaths from shock, so called, are undoubtedly 
 often dependent on the same condition. 3. Hemorrhage may be one of the 
 causes, but is rare. 4. Pelvic cellulitis is a common cause of mortality in 
 adults, and generally arises from urinary infiltration. 5. Peritonitis is less 
 common. 6. Cystitis has sometimes given rise to fatal results. Other causes 
 are phlebitis, pyelitis, and uraemia. 
 
 Stone in the Female Bladder. — It is probable that calculi are formed in the 
 kidneys of the female as often as in the male, but having once passed into 
 the bladder, the anatomical relations of the urethra to that organ are such 
 as to render the escape of small concretions comparatively easy. No pros- 
 tate gland obstructs the passage, the urethral canal is short, straight, and 
 largely dilatable, so that calculi of nearly an inch in diameter have, by nat- 
 ural efforts, been expelled with little pain. 
 
 The above reasons will explain why vesical calculi in the female so rarely 
 require surgical interference. 
 
 The symptoms are similar to those already detailed as occurring in the 
 male ; but the special ones are bearing-down pains, pains in the urethra, and 
 incontinence of urine, and these may so simulate the symptoms of uterine 
 disease that a correct diagnosis can only be attained by a vaginal examina- 
 tion and the use of the sound. Sometimes nature adopts a method for the 
 removal of stone, in which ulceration of the bladder takes place, and the 
 mass is discharged into the vagina, leaving a vesico-vaginal fistula, an acci- 
 dent much to be deplored. 
 
 Urinary calculi in the female are more easily removed than in the male, 
 as the operation generally consists of dilatation of the urethra, followed by 
 extraction ; or of lithotrity. By the former process, stones three-fourths of 
 an inch in diameter may be removed from children, while from adults, cal- 
 culi one-fourth to one-half inch larger in diameter may be extracted with 
 safety. 
 
 There are two methods of dilatation, — the slow, performed gradually by 
 means of tents, bougies, or dilators, until the urethra is sufficiently en- 
 larged to introduce the forceps ; and the rapid, which is accomplished while 
 the patient is under chloroform, by the use of the urethral dilator, and the 
 whole operation completed at one sitting. 
 
 The first method is more liable to be followed by incontinence of urine 
 than the second. If the stone prove too large to be removed by these 
 means, it should be broken up by the lithotrite, and the pieces extracted, 
 which may be done with little danger. If the bladder is so much diseased 
 as to render lithotrity impracticable, an incision must be made through the 
 septum of the vagina into the bladder — avoiding the urethra — by means of 
 a director passed into it, which will serve as a guide. The wound is to be 
 closed by sutures, as in vesico-vaginal fistula. Experience has taught that 
 any incision into the neck of the female bladder is reprehensible, as it is 
 liable to be followed by incontinence of urine. 
 
 The suprapubic operation is by far the better method of removing stones 
 from the female bladder when a cutting operation is necessary. 
 
 Other foreign bodies are found in the bladders of both males and females, 
 and their extraction will be effected by the same general means as those for 
 the extraction of stone. 
 
 Lithotrity. — As early as 1626, the idea of crushing stones within the blad- 
 der and passing the fragments through the urethra, was conceived by 
 Santorio, an Italian, and one Ciucci, of the same nationality, projected a 
 similar method of dealing with urinary calculi. But to Civiale must be 
 awarded priority in conceiving the idea and accomplishing the result. His 
 instrument, as first constructed, consisted of a straight canula, containing 
 three claws and a drill, with the claws concealed; the instrument was passed 
 
970 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 
 
 into the bladder, the claws opened, the stone seized, and the drill put in 
 motion, until the stone was broken. Civiale, however, soon modified his 
 apparatus, and finally produced an instrument as seen in 
 Fig. 623, and which I used some years ago, with fair results. 
 In 1824, the London cutler, Mr. Weiss, devised and con- 
 structed a lithotrite with two blades bent at a right angle 
 with the shaft, one working upon the other, by a set screw 
 in the handle, and since that period all lithotrites have been 
 modifications of that principle. 
 
 It is scarcely necessary, except as matters of historical in- 
 terest, to allude to the old operations of lithotripsy. 
 
 The instrument of Heurteleup consisted of two blades, 
 which were made to slide one upon the other. It was intro- 
 duced into the bladder as a simple sound or catheter, and the 
 blades were afterwards expanded, for grasping the stone. In 
 its original form, the male blade was struck with a hammer ; 
 later, however, the crushing force was exerted by means of a 
 peculiarly adapted screw. The extremities of the instrument 
 were fitted with teeth, for the retention of the stone after it 
 had been grasped, and fenestras, or perforations, to allow the 
 escape of the powdered stone or sand. 
 
 Previous to the operation, the urethra was dilated, and 
 the urine retained in order that the bladder might not be in 
 a collapsed condition, and thus endanger its coats being 
 caught by the instrument. 
 
 The patient was laid on a convenient bed or table, with 
 the pelvis elevated in such manner as to throw the stone 
 into the fundus of the bladder. The instrument, having 
 been oiled and warmed, was introduced, and, after encoun- 
 tering the stone and fairly grasping it — an operation which 
 required skilful manipulation — the calculus was crushed by 
 slowly and gradually turning the screw. 
 
 The methods of Thompson and others were similar to that 
 of Civiale, except that the instruments were better adapted 
 for crushing the stone ; Fig. 624 shows the entire lithotrite 
 of Sir Henry Thompson ; Fig. 625 represents the handle ; 
 and Fig. 626 the jaws. 
 
 In these operations as much of the stone was crushed as 
 the skill and dexterity of the surgeon could accomplish in 
 a few moments, and the debris removed either immediately 
 through the urethra or a catheter, or allowed to remain 
 some time in the bladder that the sharp ends of the frag- 
 ments might be worn off. 
 
 There can be no doubt (notwithstanding the usual oppo- 
 sition offered by the characteristic spirit of our transatlantic 
 brethren) that Bigelow's American Method of Lithotrity, or 
 Litholapaxy, as it is denominated by its author, has taken 
 the place of all the older proceedings for crushing stone in 
 the bladder, has reduced a prolonged series of suffering sittings to a single 
 painless operation, and has demonstrated beyond cavil, the toleration of 
 the bladder and urethra for very large surgical instruments. 
 
 Of course the single seance, the large instruments, and the washing 
 bottle, when first introduced, were critically scrutinized, for the old teaching 
 was small instruments — the smaller the better, — from two to six sittings and 
 two or three minutes at a sitting. If a stone was thought to require more 
 than this, the patient was subjected to lithotomy. In reviewing the opera- 
 
 Civiale's Litho- 
 triptor, modified 
 after Weiss. 
 
LITHOTRITY. 
 
 971 
 
 tion, Sir Henry Thompson thought the instruments too big and the time 
 of the operation too long ; but only so short a time ago as 1882 he wrote in 
 the Lancet :* " In order to remove two or three hundred grains of calculous 
 material from the bladder — many calculi weigh less than a hundred grains, 
 
 Fig 
 
 G. TIEMANN. CO.N. Y. 
 
 Thompson's Lithotrite. 
 
 while all ought to be found before they attain that weight — it is wholly un- 
 necessary, I will even say that it is unwarrantable, to introduce lithotrites 
 and evacuators with the diameter of No. 18 or 20 English scale into the 
 bladder." But soon the experiences of Trevan,f Van Buren,J Keyes,§ 
 
 Fig. 625. 
 
 C.TIEMANN-CU. 
 Handle of Thompson's Lithotrite. 
 
 Sands,|| Otis,^[ and other distinguished surgeons removed these objections, 
 the operation was accepted, and they have proven that, not only is the 
 operation adapted for most cases of stone, but that it may be accomplished 
 with success in spite of serious constitutional disorders. Mr. W. F. Trevan, 
 
 Fig. 626. 
 
 G.TIEMANN-CO. 
 Jaws of Thompson's Lithotrite. 
 
 F.R.C.S., prefaces the publication of some cases of lithotrity by these 
 words : " The cases I relate prove what Bigelow's operation can accomplish 
 even when the presence of stone is complicated by the existence of grave 
 constitutional disease. The calculi were, I believe, the largest single ones 
 ever removed, in this country, from the bladder at one sitting. One of the 
 patients was suffering from diabetes, the other from paralysis. Youngest, 
 fifty-six, eldest, seventy-seven."** 
 
 * London Lancet, Mav, 1881. 
 
 f Medical Record, March 22d, 1879. 
 
 % American Journal of the Medical Sciences. 
 
 I Medical Kecord, March 22d, 1879. 
 
 || American Journal of the Medical Sciences, January, 1880. 
 
 I Medical Record, November 3d, 1883. 
 
 * London Lancet, May, 1881. 
 
972 
 
 A SYSTEM OF SURGERY. 
 
 Specialists in this department have proved the value of the operation and 
 accorded the credit to Bigelow. On this point Dr. Otis says, in his remarks 
 regarding the fact that other surgeons besides himself 
 had crushed stones at a single sitting before Bigelow : 
 
 " I am sure that many surgeons have experiences, prac- 
 tically equivalent to the foregoing, antedating the opera- 
 tion of litholapaxy by many years. And thus I claim 
 that Professor Bigelow did not discover the tolerance of 
 the human bladder to prolonged instrumental inter- 
 ference. He did much more — he utilized the knowledge 
 which he in common with other surgeons possessed. He 
 had the inspiration to conceive of its value as a factor in 
 a great life-saving operation. He seized the demonstration 
 of an average urethral calibre of 32 mm. in circumference. 
 He joined it with his knowledge of the toleration of the 
 bladder to legitimate surgical procedures, and litholapaxy 
 was born. He had the courage, the surgical knowledge, 
 the skill, the inventive mechanical genius, and the perse- 
 verance to carry it, vi et armis, to a successful maturity, 
 thus finally achieving one of the most brilliant surgical triumphs 
 of modern times."* 
 
 There is a point here worthy of mention regarding the 
 gentleman who has just been quoted in according to 
 Dr. Bigelow his meed of praise — I refer to Dr. Otis. That 
 however surgeons may differ from him regarding the rela- 
 tive size of the urethra with the circumference of the 
 penis, to him unquestionably belongs the credit of demon- 
 strating the extreme toleration of the urethra, for instru- 
 ments at least 22 mm. in circumference, which fact, no 
 doubt, assisted Dr. Bigelow in the construction of his 
 evacuating tubes, the proper calibre of which is an essen- 
 tial feature in successful litholapaxy. 
 
 For the satisfactory performance of this operation, it is 
 requisite, first that the lithotrite should be of sufficient 
 size and strength, and that the blades, being opened and 
 closed so frequently within the bladder, do not become 
 clogged with the debris ; and second, that the evacuator 
 should have sufficient power, that the evacuating tubes 
 — as before remarked — should be of sufficient size, and 
 that as little air as possible be allowed to enter the blad- 
 der. To accomplish these results, endless modifications 
 of the lithotrite and washing-bottle have been devised. 
 
 Dr. Bigelow's instrument, Fig. 627, works with a round 
 handle, a, which can set the jaws by a turn of the wrist, 
 and a circular grooved hand-piece, 6, to force the blades 
 together ; c represents the handle proper ; d the shank ; 
 e the male blade with large triangular notches, the better to grind the stone, 
 and to allow the escape of a portion of the debris laterally, and furnished 
 with an additional projection at the heel to fit into the slot in the female 
 blade/. The female blade should be very smooth and the floor nearly level 
 with its rim. 
 
 Dr. Bigelow has made other modifications of his instrument both in the 
 handle and blades, which will readily be seen by referring to the cuts. 
 
 * Medical Eecord, November 3d, 1883. 
 
LITHOTRITY. 
 
 973 
 
 The lithotrite which I now use is the one modified by Dr. Keyes ; it has 
 the fenestrated blade with the male blade angular and with a flat heel, the 
 
 Fig. 628. 
 
 Bigelow's Lithotrite. 
 
 female blade being smooth, tapering, and curved with serrated sides. Fig. 
 629 shows the lithotrite ; the strong shaft, 2, on which are the measurements 
 
 Fig. 629. 
 
 Keyes' Lithotrite. 
 
 to register the size of the stone ; f, the screw ; m, handles for locking ; d, the 
 female curved and serrated blade ; p, the male blade, grooved and notched 
 for completion of the crushing. 
 
974 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 630 represents the modifications of Keyes' instrument, with the groove 
 in the male blade, and the arrangement of the female blade. 
 
 I have used Keyes' first instrument many times and have found it satis- 
 factory, occasionally inclined to clog and once in a while catching in the 
 walls of the bladder — more, perhaps, because, as Dr. Keyes, in the early 
 
 Fig. 630. 
 
 Jaws of Keyes' Lithotrite. 
 
 days of the operation, himself wrote : " There is no royal road to lithola- 
 paxy," than from fault in the lithotrite. The objections urged against the 
 fenestrated instruments are chiefly, that as the crushing process goes on, 
 sharp splinters are forced against the bladder-wall, and thus become sources 
 of serious irritation ; and that the process is delayed, because the same 
 fragments are liable to be caught again, and thus delay the operation. 
 
 Fig. 631. 
 
 Jaws of Fenestrated Lithotrite. 
 
 Each surgeon has his preference and can do the best work with that instru- 
 ment with which he is most familiar. Fig. 631 shows the jaws of fenestrated 
 lithotrites. 
 
 So much for the crushing apparatus ; the next step is the evacuation of 
 the debris. In one of his earlier articles upon litholapaxy, Dr. Bigelow laid 
 down axioms regarding the washing apparatus which are still true. He 
 stated then* it is essential that the shape of the tubes and the shape of the 
 
 * American Journal of the Medical Sciences, January, 1878. 
 
LITHOTRITY. 
 
 975 
 
 receiving extremities of the tubes, their large capacity, the assemblage of 
 
 Fig. 632. 
 
 Sir Philip Crampton's Evacuator. 
 
 fragments around their ends, the immediate recognition of these fragments, 
 
 Fig. 633. 
 
 Mr. Clover's First Evacuator. 
 
 are conditions for the successful withdrawal of the debris. As Weiss, the 
 
 Fig. 634. 
 
 Fig. 635. 
 
 / 
 
 Stand for Bigelow's Evacuating Apparatus. 
 
 Bigelow*s Evacuating Apparatus. 
 
 instrument-maker, arranged a model upon which most of the lithotrites 
 
976 
 
 A SYSTEM OF SURGEHY. 
 
 have been made, so Clover invented an aspirator which was a modification 
 of Sir Philip Crampton's. Fig. 632 shows the original instrument, and Fig. 
 
 Fig. 636. 
 
 Sir Henry Thompson's Original Evacuator. 
 
 633 Mr. Clover's modification. So late as January, 1882, Sir Henry Thomp- 
 son* states that " the instrument of Clover is still a useful one." Bigelow's 
 
 Fig. 637. 
 
 Sir Henry Thompson's latest Evacuator, modified by Weiss. 
 
 original washing-bottle is the only one I have employed, though I have 
 been present onseveral occasions where the modifications have been used*, 
 
 * London Lancet, January, 1882. 
 
LITHOTRITY. 
 
 977 
 
 and I am of opinion that up to this time the old will bear comparison with 
 any of the newer models, because it is much more simple ; sometimes, it is 
 true, a bit of stone may be returned into the tube, and perhaps some air be 
 forced into the bladder, but this is liable to occur with any of the bottles. 
 
 Fig. 638. 
 
 Bigelow's Evacuator. 
 
 As a rule, I have had better success with the straight than the curved tube. 
 Fig. 634 shows the original apparatus of Bigelow ; Fig. 635 its stand. 
 
 Sir Henry Thompson's original evacuator, Fig. 636, was on the same 
 principle as that of Bigelow. He says of it, that it should be light, easily 
 
 Fig. 639. 
 
 Walker's Washing Bottle. 
 
 grasped with one hand, A, have its opening at the top for filling, F, regu- 
 lated by the screw, H, the catheter, B, should be attached to its lower part, 
 E, governed by the screw, D, and that its trap should be at the bottom, G. 
 
 This instrument I have never seen used, but it was said to be open to 
 several objections, mainly that the fragments mounted again into the reser- 
 voir. Later Mr. Weiss modified the apparatus by putting the trap forward, 
 Fig. 637, which I should consider a great improvement. 
 
 It were useless to endeavor to portray the various modifications of Prof. 
 Bigelow's washing apparatus. Fig. 638 represents the most recent, which 
 
 62 
 
978 A SYSTEM OF SURGERY. 
 
 is perhaps the best, making the route to and from the bladder short, and 
 being easily filled, refilled and readily worked. 
 
 It has an elastic bulb, glass receiver, and stopcocks. Below there is a 
 metal brace between the collar of the glass receiver and that of the catheter 
 to steady the latter. Within the bulb, and open at the end, is a tube 
 strainer to prevent the return of debris. The bulb forms a concentric handle 
 to the catheter. 
 
 The efforts that have been made to produce an evacuator which shall 
 combine efficiency with lightness have resulted in many good contrivances ; 
 of these, that by Prof. H. C. Walker* appears to be one of the best. The 
 cut will explain itself, and further description may be found in the journal 
 referred to. 
 
 Dr. F. N. Otisf has invented and modified probably the most easily 
 worked and efficient aspirator, of which he says : 
 
 " The instrument may be filled, preparatory to using, by means of an or- 
 dinary Davidson's syringe attached to the stop-cock. The readiest and best 
 way of filling the instrument, is to plunge the evacuating end into a vessel 
 of water, of a temperature of 98°, and by one or two firm compressions of 
 the rubber bulb, the filling is complete, and the evacuator is ready for use. 
 If, during the operation, it is found desirable to introduce additional water 
 into the bladder, this is done with great ease, by attaching the discharge 
 pipe of the Davidson's syringe to the stop-cock (at L), while the supply end 
 is immersed in a vessel (preferably a large glass graduate), filled with water 
 
 Fig. 640. 
 
 G 'TIEMANN&C0. 
 Otis's Evacuator. 
 
 of a proper temperature. The easy attachment and detachment of the 
 Davidson's syringe, allows any desired amount of fluid to be introduced 
 into the bladder without delay or inconvenience." 
 
 With this understanding of the instruments, a few explicit directions for 
 performing the operation is all that will be necessary. 
 
 I should advise those who undertake litholapaxy for the first time, to 
 make experiments with the lithotrite, in order to gain experience in using 
 the instrument. The method by which I instructed myself, was by taking 
 the fresh bladder of an ox, putting therein a few pieces of coal cinder and 
 fixing at the neck of the bladder a flat cork of about two inches in diam- 
 eter, with a hole in the centre of sufficient size to admit the lithotrite. The 
 bladder was then partially filled with water and the lithotripter applied, 
 
 * Medical News, January 10th, 1885. 
 
 f A Simplified Evacuator, etc., Pamphlet, February 4th, 1885. 
 
LITHOTEITY. 979 
 
 In performing the operation on the patient, he may be etherized or not 
 according to his desire, the sensitiveness of his urethra, or the magnitude 
 and hardness of the stone. Some who have a canal of large calibre and 
 been accustomed to the use of the sound and catheter, prefer to be operated 
 upon without anaesthesia, but I prefer in all cases the use of an anaesthetic, 
 save when there is a suspicion of kidney disease, and then it should be 
 prohibited entirely. The bladder should be washed with tepid water, either 
 through a large soft catheter, 18-English, or one of the washing apparatuses 
 already depicted. 
 
 In the majority of instances, the surgeon will find it good practice to di- 
 vide the mouth of the urethra with the urethrotome. Of course this addi- 
 tional operation need not be made if the meatus is of sufficient size to readily 
 admit the lithotrite. 
 
 The bladder must be filled with warm water, generally from eight to ten 
 ounces. This must be gradually done, for sometimes the sensitive bladder 
 reacts slowly, and its walls are so thickened that its capacity is much dimin- 
 ished. The operator, standing on the side of the patient most convenient, 
 takes the penis in his left hand, separates the meatus by pressure with the 
 forefinger and thumb, and enters the point of the lithotrite, held in the 
 right hand, within the urethra until its point reaches the fossa navicularis. 
 The penis being steadied by the left hand, the handle of the lithotrite is 
 made to ascend the arc of a circle, by raising the handle ; after it has been 
 a little elevated the lithotrite, in many instances from its own weight, and 
 in all instances where there is no stricture, with gentle pressure, drops down 
 to the triangular ligament. By drawing the penis upward upon the shank 
 of the lithotrite, with the left hand, while at the same time the right hand 
 finishes the arc of the circle, by depressing the handle between the legs of 
 the patient the closed jaws enter the bladder. 
 
 During these manipulations, in most instances, there are spasmodic gushes 
 of water through the urethra, and I am in the habit of tying a broad tape 
 around the root of the penis to prevent the escape of all the fluid. Some- 
 times the beak of the lithotrite touches the stone immediately it enters the 
 bladder, in others it does not; then the lithotrite must be slowly turned to 
 the right side, sometimes to the left, sometimes to the base, in search of the 
 
 Fig. 641. Fig. 642. 
 
 Lithotrite Grasping the Stone. Eye of Evacuating Tube. 
 
 calculus. When the stone is found, the blades are opened, not too slowly, 
 but with steadiness, and it falls (sometimes at once) into the jaws of the 
 lithotrite. 
 
 This manoeuvre may have to be done many times before the stone is 
 grasped. When the jaws are fixed upon the calculus, the instrument should 
 be rotated each way to see that the mucous membrane is not caught in 
 the blades, and, if free, the blades should be turned directly upward as 
 seen in Fig. 641 ; the catch fixed, the screw turned, and the stone broken. 
 
980 A SYSTEM OF SUEGERY. 
 
 This crushing should be performed several times without the withdrawal of 
 the lithotrite, the surgeon being careful every time that the bladder walls 
 are not entangled in the jaws of the instrument. When the operator is sat- 
 isfied that there is sufficient debris made (and it must be borne in mind, 
 that the detritus may, after a time, prevent the further crushing of larger 
 fragments), the lithotrite is to be withdrawn, and the washing bottle, with 
 its reservoir filled, brought by the side of the patient, or placed upon the 
 abdomen. The evacuating catheter with its large eye, Fig. 642, is introduced 
 into the bladder and affixed to its tube, the stopcocks arranged as already 
 described, and the pressure made upon the bulb. This pressure ought also 
 to be steady, not too sudden, and the bulb allowed to slowly expand. The 
 bits of calculus fall into the trap and the bulb fills again with the recurrent 
 water. This operation is to be repeated until there appears to be no more 
 debris. The bladder is filled again with water, the lithotrite put in action, 
 and the process of crushing and evacuating continued until the operator is 
 certain that nothing remains behind. The bladder then should be carefully 
 washed with warm calendula and water, 1 to 4 or 6, the patient put to bed 
 with warm bottles at the feet, and aconite administered every half hour for 
 a few hours, to allay any urinary irritation. If bladder tenesmus should be 
 present, I have found tinct. hyoscyami in 8 to 10 drop doses, given every ' 
 hour or two, productive of much relief. If the urine be acid a drink of 
 potash water, made palatable, may be given. 
 
 There is in some cases a secondary cystitis set up, after the third or fourth 
 day, which demands attention, and which should be checked at its onset, 
 lest it become chronic. This condition is especially controllable by the 
 equisetum and sandal wood oil. 
 
 The conclusions of Dr. Bigelow regarding his operation as first given 
 remain essentially the same, though the instruments have undergone vari- 
 ous modifications. I give them as authority on this subject, in his own 
 words. 
 
 " 1. The calculus, although not necessarily pulverized, is crushed as 
 rapidly and completely as is practicable. The dust and fragments are im- 
 mediately evacuated, and a serious source of irritation is thus removed. 
 
 " 2. This can be generally effected in a single operation. 
 
 " 3. The operation — performed of course under ether — may be, if neces- 
 sary, of one or two hours' duration, or even longer. 
 
 " 4. The method applies to larger stones than have been hitherto consid- 
 ered to lie within the province of the lithotrites. It also applies to small 
 stones, nuclei, phosphatic deposits, and foreign substances. 
 
 " 5. Evacuation is best accomplished by a large tube, preferably straight, 
 with a distal orifice, the extremity of which is shaped to facilitate its intro- 
 duction, and, during suction, to repel the bladder wall — and by an elastic 
 exhausting bulb, which acts partly as a siphon. Below the latter is a glass 
 receptacle for debris. 
 
 " 6. The best size for the tube is the largest the urethra will admit. 
 
 " 7. Such a tube is usually introduced with facility, if passed vertically 
 as far as it will go toward the anus before changing its direction, and after- 
 ward directed almost horizontally, and passed by rotation through the tri- 
 angular ligament. The first part of this rule applies also to the introduction 
 of a lithotrite, and even a curved catheter. A free injection of oil is impor- 
 tant. 
 
 " 8. A small meatus should be enlarged, or a stricture divulsed, to allow 
 the passage of a large tube. 
 
 " 9. If the bladder be not small, a large and powerful lithotrite is always 
 better than a small one. 
 
 " 10. That this may have room for action, the escaping water should be 
 
LITHOLAPAXY IN CHILDREN. 981 
 
 replaced occasionally, through a tube inserted a few inches into the urethra 
 by the side of the lithotrite. But the bladder should not be over-distended. 
 
 " 11. To save time, and also to prevent undue dilatation of the vesical 
 neck, a non-impacting lithotrite is desirable. The jaws of a non-fenestrated 
 instrument will not impact, if the male blade is furnished with alternate 
 triangular notches by which the debris is discharged laterally, and also with 
 a long thin spur at the heel fitted to a corresponding slot in the female blade, 
 — provided the floor of the female blade, especially at the heel, be made 
 nearly on a level with its rim. To repel the bladder, the female blade 
 should be longer and a little wider than is usual. It should have also low 
 sides easily accessible to fragments, — relying for strength less upon these 
 than upon a central ridge below the heel. In the male blade of such a 
 lithotrite the apices of the triangle should be a little blunted. Lastly, a non- 
 fenestrated female blade protects the floor of the bladder, during a long sit- 
 ting. A fenestrated instrument directs sharp splinters against it. The latter 
 also delays the process of disintegration, by delivering through its opening 
 the same fragments many times. 
 
 " 12. In locking and unlocking a lithotrite repeatedly in a long operation, 
 it takes less time and is easier to turn the right wrist, as in my instrument, 
 than to displace the thumb of either hand in search of a button or lever, 
 as in previous instruments." 
 
 Sir Henry Thompson* says that, after lithotrity, the appearance of muco- 
 purulent matter in the urine indicates cystitis from irritation of the bladder 
 by the remaining fragments, and advises further crushing without delay. 
 He points out the necessity of drawing the residual urine by means of the 
 catheter as soon as the slightest inability to evacuate the bladder, even to 
 the extent of a drachm or two, comes on after lithotrity. In this way alone 
 can the formation of subsequent phosphatic calculi be prevented. When 
 the urine becomes ammoniacal and the earthy phosphates are deposited, he 
 washes out the bladder with weak nitric acid. He has found one admirable 
 remedy for that low chronic cystitis, associated with the production of phos- 
 phatic calculi, viz., the injection every other day of a solution of silver nitrate, 
 one-half grain to four or six ounces of distilled water. 
 
 The results of litholapaxy are very favorable, the mortality being a little 
 over five per cent. : Freyer having 76 cases, with 3 deaths ; Sir Henry 
 Thompson 194 cases, and 10 deaths ; Von Dittle 80 cases, with 5 deaths. 
 
 Litholapaxy in Children. — It has been generally considered that children 
 under fifteen must always be subjected to the cutting operations for stone, 
 and the suprapubic method has been so successfully employed in such 
 patients, that other methods need not be tried. Of late, however, litho- 
 lapaxy has been successfully employed in children, especially by Surgeon- 
 major Keegan, of Indore. He reports f the successful use of the lithotrite 
 in twenty-three cases. The lithotrites were small, being equal in calibre to 
 Nos. 5, 6, 7, and 8 of the English scale. The diameter of the evacuatory 
 tube was equal to the English No. 9. 
 
 The ages of the patients varied very much, the youngest being only 
 twenty months, the eldest twelve years ; five of them were five years old, and 
 three of them were aged eight. The largest stone weighed two hundred 
 and forty grains, while seven grairfs was the heft of the smallest. The aver- 
 age time consumed in the operation was about thirty-nine minutes, the 
 shortest time being four minutes, the longest about seventy. In seven cases 
 the evacuator was not used, the stones being thoroughly pulverized, the 
 debris being passed per vias naturales. 
 
 * Monthly Abstract of Medical Sciences, October, 1876 ; Lancet, January 8th, 1876. 
 f India Medical Gazette, May, 1884. 
 
982 A SYSTEM OF SURGERY. 
 
 Tumors of the Bladder. — These neoplasms are difficult to diagnose, espe- 
 cially as to their clinical characters. They may be either malignant, semi- 
 malignant, or non-malignant, and are often obstinate as to treatment and 
 fatal as to their results. They occur generally after adult life, although 
 they have occasionally been discovered in the young ; in character they are 
 generally fibrous, myxomatous, villous, papillomatous, or carcinomatous — 
 perhaps, in the majority of instances, the latter being the case. If there be 
 much haemorrhage and little cachexia, the inference would be that the 
 growth was innocent, especially if the haematuria was a late symptom ; if, 
 on the contrary, pain was an early symptom, and the haemorrhage a sec- 
 ondary appearance, with cachexia and heredity, then the malignancy of 
 the tumor could be pronounced with some degree of certainty. In some 
 instances, calculi and growths have been found at the same time, giving 
 rise to the supposition that the irritation of the former may produce the 
 latter. In a late case, wherein the patient had every symptom of stone, 
 with profuse haemorrhages, I sounded the patient twice, once when he was 
 thoroughly anaesthetized, and though I could find readily enough a soft, 
 villous, nay, even trabeculated growth, could discover no calculus ; yet in 
 a few weeks after, a couple of calculi were voided per urethram,. Looking 
 at the formation of the bladder, with its muscular, mucous, and epithelial 
 coats, it will be perceived that there can be no valid reason why tumors 
 of all varieties may not arise within it, that is, if there be any truth in the 
 blasto-dermic theory. The epithelia may develop into epithelioma, or the 
 gland-structure into carcinoma, while the ordinary growths of the connec- 
 tive-tissue series may arise from the muscular walls and its connective 
 tissue. These would include fibromata, myxomata, sarcomata, etc. 
 
 These tumors arise probably from the chorionic villi of the bladder, and 
 are necessarily (if we recollect the origin of this structure from the alantois) 
 very well supplied with bloodvessels. This variety are generally small, are 
 often pedunculated, though I have seen them sessile ; they are reddish in 
 color, though sometimes purplish, resembling a mass of placenta. 
 
 The microscope, however, is the most valuable assistant in diagnosing 
 these tumors. The history of these cases of bladder-tumors is well described 
 by Sir Henry Thompson* " They come," he says, " first under the care of 
 a physician for haematuria, then pain follows, a surgeon is called, the sound 
 used, and no stone found ; another surgeon is called, and the operation is 
 repeated with the same result. The haemorrhage is then supposed to be 
 renal, and the patient is allowed to die slowly from chronic haematuria." 
 
 Treatment. — In the early part of the disease, the medicines which have 
 already been given for the treatment of chronic cystitis may be employed 
 (aeon., hyos., canth., cann., mere, nux vom., equisetum, etc.). Infusions of 
 uva-ursi, pareira brava, buchu, and alchemilla, the latter having often a 
 salutary effect, may be used, together with the hot sitz-bath, twice during 
 the day. I have also employed the triticum repens, in the proportion of an 
 ounce of the root and stems to a pint of water, a half a tumblerful being 
 taken three times a day. The " back water " must be removed and the 
 viscus washed out, as already noted. If all medical means fail, then first 
 make the diagnosis certain, and an operation is justifiable. If the patient 
 appear perishing before the eyes of the surgeon, an exploratory incision 
 may be made. Sir Henry Thompson frankly states that he has opened 
 twenty-seven bladders and has found but twelve tumors, and I note this 
 fact that the down-sinking heart of the surgeon performing his first cyst- 
 otomy may be relieved if no tumor or stone be found. It may be neces- 
 sary in some cases to perform a second operation. As usually performed, 
 
 * British Medical Journal, June 16th, 1883. 
 
TUM0E3 OF THE BLADDEK. 
 
 983 
 
 the patient is placed in the lithotomy position, and the lateral or median 
 cut made, and the director (Fig. 643) inserted. Then the operation is 
 completed as follows : " Insert the forefinger first through the urethral 
 incision, and make a complete examination of the interior of the blad- 
 der, so as to feel familiar with the exact position and size of any tumor 
 
 Fig. 643. 
 
 Sir Henry Thompson's Director for Digital Exploration. 
 
 present. Then quietly withdraw the finger and insert the forceps, as seen 
 in Fig. 644, guided only by the knowledge he has acquired, and make a 
 decided nip with it with little or no traction ; withdraw the forceps, re- 
 insert the finger, and remove, if necessary, with the finger-nail anything 
 
 Fig. 644. 
 
 Forceps for removing growths in bladder, with separation of the blades to avoid nipping 
 the neck of the bladder. 
 
 that the forceps left incompletely divided. It is often best to leave the 
 detached pieces of the tumor in the bladder for the moment and remove 
 them all at the end of the operation by the lithotomy scoop." Care must 
 be taken to hold up the bladder wall by means of a ball probe alongside 
 
984 A SYSTEM OF SURGERY. 
 
 the forceps, otherwise the depressed bladder may be mistaken for a tumor, 
 and as in one case the wall gave way after the operation from bruising with 
 the forceps ; this accident is to be deplored. I have given the manner of 
 performing this operation in the words of its distinguished author, but it 
 would be under very peculiar circumstances that I should ever resort to its 
 performance, when there remained the supra-pubic method of opening the 
 bladder, seeing the growth, removing it in toto, either by the scoop, the for- 
 ceps, or the ligature, and washing the viscus readily and perfectly twice 
 a day. 
 
 Tumors in the Female Bladder. — Growths of the same character as those 
 affecting the male bladder are found in the female, the symptoms being 
 haemorrhage and pain. The existence of the growth is somewhat difficult 
 to diagnose, and the exploration of the bladder with the finger and the 
 endoscope can alone be relied upon. As a rule, the catheter and the sound 
 are of little use. The plan is first to gradually dilate the urethra with a 
 urethral or two-bladed uterine dilator, and finally insert the finger. The 
 scoop, or the wire of an ecraseur may then be inserted and the growth 
 scooped or scraped away. If this method is not successful, that of Simon, 
 which consists of making a T-shaped opening into the bladder through 
 the vagina, and thus exposing the cavity, may be performed, or if the 
 growth be large, suprapubic cystotomy may be employed. 
 
 Acute and Chronic Prostatitis. — The prostate gland is liable to inflam- 
 mation, which is always serious in character because of the difficulty in 
 management, and because of the close intimacy which exists between it and 
 the surrounding structures. It is a difficult thing to define exactly or dis- 
 sect minutely the prostate so that we may actually detect its boundaries. 
 It appears to submerge itself into the surrounding structures, and can only 
 with difficulty be separated from them. The gland receives its name from 
 " standing before " the neck of the bladder, and thus forming or blending 
 with the structure. For these reasons an acute attack of prostatitis per se is 
 a rare disorder, but its inflammation from an extension of disease from 
 bladder, urethra, or rectum is not so uncommon. 
 
 The causes of the affection are extension of urethral inflammation, strict- 
 ures of the urethra, particularly those of old standing, which are tight and 
 contracted, cystitis, calculi in the bladder, wounds or bruises in the peri- 
 naeum, long-continued and drastic purgative medicines; diseases of the 
 rectum, as haemorrhoids, fissures, etc., constant straining at stool, and some- 
 times violent horseback exercise. 
 
 The symptoms are pain, weight, and fulness in the perinaeum, weight and 
 heaviness in the loins, a fulness in the rectum, pressing at the cervix vesicae. 
 These pains are particularly aggravated by straining at stool and by pass- 
 ing water. The attempt to introduce the catheter gives great pain to the 
 patient. With these symptoms there is fever, thirst, and more or less vas- 
 cular excitement throughout the system. If the finger is introduced into the 
 rectum, the gland is found hardened and enlarged, the anterior wall of the 
 rectum is also indurated, and together with these, there is a constant desire 
 to go to stool, with pains extending down the thighs and along the penis. 
 
 If these symptoms be not subdued, the inflammatory process may end in 
 suppuration, thus producing abscess of the prostate. Such a condition may 
 be feared, if the inflammation has not yielded to the appropriate treatment, 
 and the difficulty of micturition and defecation either continue or increase 
 in severity. The usual symptoms of the formation of pus are then noticed, 
 and fluctuation may be perceived in the perinaeum or in the rectum. There 
 is a variety of abscess known as periprostatic, in which suppuration takes 
 place external to 'the gland. Such abscesses are not as troublesome or 
 dangerous as those previously named. 
 
PROSTATITIS. 985 
 
 An abscess of the prostate may discharge itself into the urethra or the 
 rectum, the former being generally the locality at which the pus finds exit. 
 
 The chief trouble in this disease is the long-continued suppuration which 
 generally follows the acute abscess, and this continues for such a length of 
 time, that the entire gland is destroyed ; then the bladder and other organs 
 sympathize, until finally emaciation, hectic, and death 'result. 
 
 If entire resolution does not take place, and the more violent inflam- 
 matory symptoms subside, then there remain those symptoms which point 
 to chronic inflammation of the prostate. These are weight and fulness in the 
 perineum, extending to the anus ; pain in passing water, with diminished 
 power in propelling the stream ; the urine is cloudy ; a gleety discharge often 
 exists ; there is pain in coitus and defecation, and sometimes spermatorrhoea. 
 
 Treatment. — It is scarcely necessary to repeat what has been so often 
 mentioned throughout the volume, viz., the indications of aconite and bel- 
 ladonna for the feverish conditions belonging to the commencement of all 
 inflammations. Besides these, cannabis, mere, prot., pulsatilla, and thuja 
 are medicines that may be called for ; and hepar, silic, and sulphur, with 
 calendula for abscess. 
 
 For the chronic inflammation, the medicines which are best are thuja, 
 kali hydriod., calc. carb., conium mac, pulsatilla, and sulph. A useful 
 application to the perinseum I have found to be a compress saturated with 
 the tincture of cantharides. 
 
 Dr. T. G. Comstock, of St. Louis, speaks highly of the spircea ulmaria in 
 the treatment of prostatitis. He has employed it in both acute and chronic 
 cases, and regards it " in a measure specific."* 
 
 Dr. M. 0. Terry ,f of Utica, N. Y., thus writes : 
 
 u My success in the treatment of chronic inflammation and in hyper- 
 trophy of the prostate, was not satisfactory until I had tested the efficacy of 
 the muriate of ammonia. I generally prescribe it in the following formula : 
 
 "R. Ammonii chloridi, SEss. 
 
 Syr. Aurantii cort., £iv. 
 
 Sig. One teaspoonful taken in water three times a day." 
 
 Dr. Terry quotes M. Fischer, of Dresden (1821), as recommending it, and 
 states that several German practitioners have spoken highly of its value. 
 
 Dr. Magendie, of Paris, believed that muriate of ammonia had a decided 
 effect in reducing the hypertrophied gland. Dr. Gross says : u The treat- 
 ment of hypertrophy of the gland seldom fulfils the expectation of the sur- 
 geon," but he mentions hydrochlorate of ammonia incidentally. 
 
 Dr. Terry, in conjunction with Drs. Hill and Laird, of Utica, reports ten 
 cases, representing various forms of prostatic disorders, but especially hyper- 
 trophy of old men, speedily cured. 
 
 Hypertrophy of the Prostate. — This serious affection, which is encountered 
 among the aged, and receives the name senile hypertrophy of the prostate, 
 has been denominated u the common inheritance of mankind." Although 
 many old people pass away without suffering from it, Mr. Thompson states : 
 " I have never seen or heard of a true example of it before the age of fifty- 
 four years." 
 
 The tissues constituting the enlargement are : " First, unstriped muscular 
 fibres and the connective tissue are always associated ; they form at least 
 three-fourths of the prostate body. Second, interspersed among this struc- 
 ture are numerous branching glandular tubes and their accompanying 
 ducts." 
 
 * Personal letter to the author. 
 
 f Transactions of the Homoeopathic Medical Society of the State of New York, 1883. 
 
986 A SYSTEM OF SURGERY. 
 
 The first symptom of the disease is merely a diminution in the force of 
 the urinary stream, which may exist without giving inconvenience or ex- 
 citing particular attention. After a time, however, the desire to urinate 
 increases, but the patient feels less ability to accomplish the act. During 
 these periods there is a sense of weight, heaviness, and dull pain in the 
 perineum. There exists a degree of irritation about the rectum, which 
 may increase to such a degree that faeces pass with the efforts to urinate. 
 The fasces are flattened, and hemorrhoidal tumors result. Then inflamma- 
 tion of the neck of the bladder develops, which adds to the discomfort and 
 uneasiness of the patient. As the hypertrophy increases, the urethral canal 
 becomes more and more closed, and consequently micturition more incom- 
 plete, while urinary tenesmus is also aggravated. At this stage, inconti- 
 nence of urine takes place during the night. 
 
 While these symptoms are gradually developing, the constitutional symp- 
 toms are more and more marked ; there are frequent attacks of fever, sweats, 
 emaciation from loss of sleep, constant urinary irritation; and paroxysms 
 of complete retention occur, which are distressing in character. 
 
 The obstruction thus offered to the natural outlet for the renal secretion, 
 combined with the irritation of the urinary apparatus, are sufficient to 
 cause changes in the chemical characters of the urine. There is a large 
 amount of glairy and slimy matter deposited; the chemical reaction is 
 alkaline, the odor is fetid or ammoniacal, and the color often altered by the 
 admixture of blood. 
 
 From these changes it is not surprising that after a time, calcareous for- 
 mations take place, which, of course, add materially to the suffering. In 
 such cases there is constant and often agonizing pain at the neck of the 
 bladder, and at the end of the penis, with purulent or bloody discharges. 
 If, in addition to these symptoms, portions of the calculus can be detected 
 in the urine, the diagnosis may be made; otherwise, in the absence of the 
 last symptom, the true nature of the affection may not be readily discov- 
 ered. 
 
 Assistance may be rendered in making a diagnosis, when senile enlarge- 
 ment of the prostate is apprehended, by physical examination. The fore- 
 finger of the left hand should be introduced within the rectum, and the size, 
 position and relations of the prostate ascertained ; by passing a catheter 
 into the bladder and (keeping the left forefinger still in the rectum) moving 
 it gradually and gently from side to side, the dimensions and relations 
 may be determined. If the ordinary catheter does not pass through the 
 increased length of the gland, the prostatic catheter must be used. This 
 is from two to four inches longer, and possesses a larger curve than the 
 ordinary instrument. If, in its introduction, the handle appears to turn to 
 one side or to the other, the enlargement may be expected to be found on 
 that side toward which the handle is deflected. Sometimes a sound with a 
 short curve may be used as an explorer. 
 
 Treatment. — The urine, if possible, must all be removed from the bladder several 
 times a day. This may be accomplished either by the prostatic catheter, 
 or by the use of Squire's vertebrated prostatic catheter, a cut and de- 
 scription of which are found in the first part of this chapter. By a little in- 
 struction, patients soon learn how to manage the instrument, and after a 
 time become dexterous in its application. I have known several who could 
 surpass their professional attendant in the introduction of the catheter. 
 
 The medical treatment is professedly weak. The medicines which have 
 effect are mercury, the iodide of potash, iodine, Pulsatilla, calc. carb., thuja, 
 and sulphur. Long-continued treatment with medicines will often produce 
 amelioration, the main secret, however, being the continuous use of the 
 drug. The muriate of ammonia, as recommended by Dr. Terry, in the pre- 
 
ORCHITIS. 987 
 
 vious pages, with faradization within the rectum, together with baths, etc., 
 can all be tried, and sometimes give great relief. 
 
 Galvano-Cautery. — The use of this instrument in this affection is at present 
 attracting considerable attention. Dr. Robert Newman thus describes his 
 method : * The instrument consists of a smooth metal catheter with a fenes- 
 trum at the end of the curve in which is placed a platinum wire. In the 
 interior of the instrument is the mechanism for treatment. The catheter 
 is introduced into the urethra so that the fenestrum is held against the 
 enlarged prostate, which is then instantaneously cauterized. The catheter 
 is equal to No. 18, French scale. The instrument must be regulated by a 
 fixed potential, and can be so adjusted that failure is impossible. These 
 applications are repeated at short intervals until the cure is effected by 
 shrinkage of tissue. The objections are said to be, that after the operation 
 has been performed several times, a cicatrix forms which increases the 
 denseness of the gland. The advantages consist in the absence of pain and 
 haemorrhage, and in that patients are not detained from their business by 
 the treatment. 
 
 Dr. Lippe f has given the indications for the following medicines : Thuja, 
 Pulsatilla, digitalis, cyclamen, selenium, causticum, lycopodium, secale, 
 copaiba, zinc, agnus castus, alumina, hepar, apis, and sulphuric acid. The 
 student may refer, for further information, to the article, or to Raue's Path- 
 ology. 
 
 CHAPTER XLVL 
 DISEASES OF THE MALE GENITAL ORGANS. 
 
 Malformations — Acute and Chronic Orchitis — Fungoid Growths of the Testicle 
 — Cystic Disease— Carcinoma — Castration — Carcinoma of the Scrotum — Hy- 
 drocele— H jem atocele — Varicocele — Eleph anti a sis Scroti — Amputation of 
 the Scrotum — Phimosis — Paraphimosis — Epithelioma Penis — Amputation of 
 the Penis — Spermatorrhoea. 
 
 Malformations. — There may be a failure in the development of the testi- 
 cle, or in the formation of either of its parts. It is well known that the 
 body of the testicle is produced, in foetal life, in front and independent of 
 the Wolffian body, and that the . epididymis comes apparently from the 
 lower part of that body itself. Either of these may be absent in imper- 
 fect development of the testes. The vas deferens is sometimes wanting, 
 although the virile power may be unimpaired, the person being necessarily 
 sterile. 
 
 When speaking of the diagnosis of hernia, mention was made of the re- 
 tained testicle, which retardation, according to Sir Astley Cooper, takes place 
 in one out of five infants. 
 
 Orchitis. — Inflammation of the testicle proper is denominated orchitis; 
 epididymitis being the term used when the epididymis is involved. Often 
 both testicle and epididymis are implicated, and the cause is generally a 
 
 * Paper read before the American Medical Association, St. Louis, 1886. 
 f American Homoeopathic Keview, vol. iii., p. 150. 
 
988 A SYSTEM OF STJEGEBY. 
 
 badly managed gonorrhoea — a sudden suppression of the discharge, either 
 from cold or strongly astringent injections. The pain is severe, the parts 
 enlarge, are redder than usual, the rugse of the scrotum are lost, and there is 
 exquisite sensitiveness to both touch and pressure. High fever, and often 
 delirium, accompany the disease. The urethral discharge abates, but the 
 patient may be troubled with nocturnal emissions. 
 
 Pain in the back and loins, sometimes extending down the thighs and 
 into the perinseum, is often present, and the attacks are frequently accom- 
 panied with nausea and vomiting. 
 
 Abscess of the Testicle. — If the inflammatory process be not arrested it 
 passes on to the suppurative stage, and abscess of the testicle results. If such 
 condition takes place the fever increases, the pulsation, redness, and pain 
 are deep-seated, and shiverings are present. Touch — even the pressure of 
 the bedclothes — is insupportable, and the pus when formed is mostly ill- 
 conditioned. Fluctuation appears at different points, and the abscess dis- 
 charges at several places. 
 
 I have noticed a particular feature in cases — especially neglected ones — 
 of suppuration of the testicle, and that is the apparent unwillingness of the 
 openings to heal, through which the pus has been discharged. Very often 
 through these openings a fungous growth protrudes, of which more will be 
 mentioned in the following portions of this chapter. 
 
 Treatment. — It is astonishing how rapidly the proper medicines, if admin- 
 istered early in this affection, arrest the disease. I use neither ice-bags, 
 hot fomentations, nor any applications save a compress wet with water laid 
 over the part, and begin the treatment with aconite, which I administer 
 always in a low potency, even a few drops of the mother tincture in water. 
 Belladonna is excellent in plethoric persons, with tendency to delirium, 
 and congestion to the head and face. 
 
 Gelsemium is a superior medicine when the disease arises from a sup- 
 pressed gonorrhoeal discharge, from exposure to sudden cold or wet, when 
 there are also indications of biliary disorder and congestion. 
 
 After the inflammatory symptoms have in a measure subsided, clematis 
 erecta is an admirable medicine, especially if the epididymis is particu- 
 larly involved, and there appears to be a tendency to assume a chronic 
 form. 
 
 Pulsatilla is applicable to mild and rather delicate men, when the gland 
 is more involved than the surrounding structure, when the pain shoots down 
 the back, or into the thigh, and changes place, with but little or no thirst 
 during the fever. 
 
 Mercurius after the inflammatory symptoms have subsided, and there 
 appears to be a tendency to the formation of pus, with shiverings and per- 
 spiration. The gland is hard and sensitive, but not in such a degree as would 
 indicate clematis, which is a reliable medicine for the disease. 
 
 Hepar is called for in abscess of the testicle. When the pus has formed 
 the fluid should be evacuated with a simple puncture, and the wound 
 closed with a piece of adhesive plaster. After the evacuation of pus, silicea 
 and phosphorus are generally sufficient to complete the cure. The patient 
 must wear a suspensory bandage, and must keep the recumbent posture. 
 During the treatment if there be priapism or burning during the act of mic- 
 turition, cantharides or cannabis are necessary as intercurrent medicines. 
 
 Dr. Ludlam speaks of hamamelis, Dr. Hale* of phytolacca dec. and Pul- 
 satilla nut., and Dr. Osgood of veratrum viride, in the treatment of this dis- 
 ease. 
 
 * Hale's New Kemedies, vide pp. 509, 792, 866, and 1059. 
 
CHEONIC OKCHITIS. 989 
 
 Chronic Orchitis. — Chronic inflammation of the testicle, or, as it is termed by 
 some, sarcocele, may result from acute orchitis imperfectly resolved, or trie 
 action may be chronic from the commencement. It may be either primary 
 or secondary, that is, it may occur as an independent affection, or as a 
 concomitant result of gonorrhoea ; it not unfrequently results from disease 
 of the urethra, and in some instances may be traced to syphilis. The tume- 
 faction extends from the epididymis, which is usually the primary seat of 
 the disorder, and gradually involves the whole testicle, which presents the 
 appearance of an inelastic, uniform tumor, which is oval, and seldom ex- 
 ceeds two or three times the bulk of the healthy gland. The accompany- 
 ing uneasiness is slight, is more severe at night than during the day, and, as 
 the disease advances, the characteristic sensibility of the organ to pressure 
 is lost. Occasionally the disease, in its later stages, is accompanied with a 
 degree of effusion within the tunica vaginalis, constituting what is termed 
 hydrosarcocele. Upon examination more or less yellow solid lymph is found 
 interspersed throughout the substance of the testicle, extending into the vas 
 deferens, and, according to Mr. Curling, deposited in the tubuli seminiferi. 
 By the smoothness and uniformity of the swelling, its gradual progress, and 
 the absence of glandular enlargement, the affection may be distinguished 
 from malignant disease. 
 
 Treatment. — Rest and a recumbent posture are necessary in the first in- 
 stance, and in the milder forms, or at its commencement, resolution may 
 be effected by the following medicines : aurum, clematis, lycopodium, agnus 
 castus, graphites, rhododendron, and sulphur. 
 
 When the disease has a syphilitic origin, a careful investigation, and a 
 knowledge of the character of the syphilitic affection from its commence- 
 ment, are required. Calc. carb., carbo veg., aurum, kali carb., lycopodium, 
 spongia, mere, sol., acid, nit., clematis, mezereum, etc., may be required. 
 Graphites, lycopodium, oleander, and belladonna are recommended if the 
 disease is complicated with a scrofulous condition, chronic eruptions, or 
 glandular enlargements. 
 
 Where the tumor, in an advanced stage, gives evidence of the superven- 
 tion of a malignant condition, arsenicum, clematis, diadema, carbo veg., and 
 thuja, may arrest the progress of the 
 
 disorder, though in the majority, the ^ 645 - 
 
 use of the knife can scarcely be 
 avoided. 
 
 In chronic cases, especially in syph- 
 ilitic patients, I have succeeded by 
 the internal administration of the 
 iodide of potassium, five grains three 
 times a day. Strapping the testicle 
 with adhesive plaster sometimes is 
 necessary; in all, the suspensory strapping the Testicie.-BBYANT. 
 
 bandage must be used. 
 
 Bryant says : " To strap a testicle requires some skill. The -patient should 
 be made to stand against the edge of a table and separate his legs. The 
 surgeon should then with his left hand grasp the organ from behind, and 
 press it down to the bottom of the scrotal sac, making the scrotum tense 
 over its surface, the thumb and index finger of his left hand holding its 
 neck. A piece of elastic strapping, spread on leather half an inch or more 
 wide, is next to be wound around the neck of the tumor once, twice, or 
 even thrice, to hold it in position, for if this point be not attended to, all 
 the subsequent steps will be useless." (Fig. 645.) 
 
 This process requires some time, to save which, and insure equal com- 
 pression, Dr. A. L. Carroll has devised an excellent compression. ( Vide Fig. 
 
990 A SYSTEM OF SURGERY. 
 
 646.) It is constructed of ordinary web, with a strip of flexible metal to 
 isolate and control the gland. Fig. 647 represents Holmes's orchitis com- 
 pressor. 
 
 The following remarks of Professor Thiry, in a lecture on a well-marked 
 case of acute blenorrhagic orchitis, deserve consideration. He says : Al- 
 though there must be some pain occasioned by the application of the 
 bandage, compression should not be lost sight of; in fact, it is of more benefit 
 in acute than in chronic cases. The orchitis will often subside with rapid- 
 ity in proportion to its acuteness. By applying the compressive bandage 
 success may be made certain if we remember the objects in view: 
 
 1. Benumbing the local, the general sensibility becomes less, as seen just 
 after the application ; 
 
 2. Diminishing the afflux of blood into the affected organ by compressing 
 the vascular parietes — the arterial afflux being in proportion to the intensity 
 of the pain ; 
 
 3. Repelling the venous blood and the products of exudation ; and 
 
 4. The immobilization of the testes, and their safety from injury. 
 Compression of the testis by the starch bandage was applied, and brought 
 
 to bear on the cord by means of graduated compresses. Though the patient 
 suffered much, he at once became calm, and expressed himself free from 
 
 Fig. 646. Fig. 647. 
 
 Carroll's and Holmes's Orchitis Compressors. 
 
 pain. A pill had been previously prescribed, composed of a small quantity 
 of bromide of potassium and opium, every three hours, to aid the anaes- 
 thetic effect of the bandage. 
 
 Of all the trials of various modes of treatment, he has invariably come 
 to the conclusion that compression is the most simple, expeditious, and 
 efficacious procedure. 
 
 Fungoid Growths of the Testicle. — Fungoid growths from the testicle after 
 chronic orchitis are not uncommon, and are often troublesome to manage. 
 They are of two varieties, the benign and malignant. This distinction, how- 
 ever, was unknown to the older writers, who believed that every growth 
 presenting the well-known objective symptoms of fungoid tumors, was 
 of malignant character. The benign has received the names of hernia testis 
 and granular swelling. The symptoms which render the diagnosis more 
 certain are : in the malignant disease there is frequent haemorrhage, and 
 liability to bleed upon slight irritation. This condition is rarely noticed 
 in the benign growth. In the latter the protruding mass presents a granu- 
 
CYSTIC OR ADENOID DISEASE OF THE TESTICLE. 991 
 
 lating appearance, while in the former it is soft and spongy. In the benign 
 the color is paler than in the malignant, the growth is more consistent, and 
 pressure on the tumor causes that peculiar sickening sensation which 
 attends the compression of the healthy testicle, while in the other variety 
 no such sensation is experienced. To make the diagnosis certain, the 
 microscope should be employed. 
 
 The following may illustrate the course and history of a fungus, when 
 proceeding, as it often does, from chronic orchitis. The patient, a young 
 man, was a conductor on a sleeping car. He fell astride a large iron bar, 
 causing a severe contusion of the right testicle. The pain was intense, the 
 swelling enormous, the testicle hard and extremely sensitive; there was 
 weight and dragging in the loins ; the spermatic cord was tumefied ; and 
 all the symptoms of severe acute orchitis followed. The patient was treated 
 secundum artem, and after a considerable period, a sensation of fluctuation 
 being apparent, the scrotum was lanced. In a short time a fungoid-looking 
 substance, presenting an ashy or yellowish-white appearance, protruded 
 from the opening. 
 
 The whole tissue of the scrotum was much thickened and indurated, the 
 color of the integument being purplish. The epididymis was pushed up- 
 ward, and the cord much thickened. Castration radically cured him. 
 
 Treatment. — If mercurius, thuja, phosph., or those medicines already 
 mentioned for the treatment of acute and chronic orchitis, are not avail- 
 able, one of two operations may be selected. The one proposed by Mr. 
 Syme, of Edinburgh, consists in carefully loosening the fungoid testicle from 
 the scrotum, pressing it within the cavity and stitching the walls over the 
 growth, thus producing a certain amount of steady pressure. " The surface 
 of the fungus," says Mr. Syme, " being coated with granulations becomes 
 incrusted with effused lymph, and in order to facilitate the healing process, 
 the hard ring of skin through which the fungus protrudes must be also 
 removed." 
 
 The other operation is castration, which must be performed in the malig- 
 nant disease. The methods of operation are noticed on the next page of 
 this chapter. 
 
 Cystic or Adenoid Disease of the Testicle. — This is a rare affection, and the 
 growth is so insidious and slow that, in its early stages, it gives rise to 
 scarcely any inconvenience to the patient. The tumor is oval in shape, 
 somewhat elastic, and can be handled without much pain. The swelling 
 is smooth in the majority of instances, but in others it may be lobulated 
 or slightly irregular. Generally at its upper portion, there may be fluctua- 
 tion, which may resemble hydrocele of the cord. 
 
 The usual symptoms of weight, heaviness, and dragging are experienced 
 in the groin, and there is aching numbness of the part. 
 
 The chief trouble is the correct diagnosis of the case. Distinguished 
 surgeons have been misled, and Sir Astley Cooper confesses to have seve- 
 ral times plunged a lancet into a tumor of the scrotum expecting fluid 
 to pass, when nothing but blood flowed from the wound. The disease 
 may be diagnosed from hydrocele by the following symptoms : In hydro- 
 cele we have translucency. In cystic disease none. In hydrocele the 
 tumor is pyriform. In cystic disease the tumor is oval. In hydrocele 
 pressure on the part usually occupied by the testicle produces no pain. In 
 cystic disease there is slight pain, but as a rule, the swellings are painless. 
 
 Hydrocele is occasionally double ; cystic disease is always single. 
 
 Treatment. — The remedy is complete removal. Upon examination of the 
 testicle after removal, it will be found enlarged and situated within the 
 tumor ; it is somewhat harder than natural, and here and there a cyst con- 
 taining a small quantity of straw-colored fluid is found. 
 
992 A SYSTEM OF SURGERY. 
 
 Carcinoma of the Testicle. — The testicle is affected with medullary cancer, 
 as well as scirrhus. According to recent authority we find that the majority 
 of cancerous affections attacking the testes are of the soft, encephaloid or 
 fungoid variety. (For the differential diagnosis the student must refer to 
 the preceding page.) There are two especial forms of cancer — one being 
 the tuberous, the other the infiltrating. In the substance of the glands 
 cysts are generated, which become filled with blood-stained glairy fluid, 
 containing cancer-cells in profusion. The swelling is tense, firm, and 
 elastic ; some parts of it being firm, others presenting appearances of fluc- 
 tuation. The peculiar feeling, known by some as ■ * testicular sensation," 
 is soon lost, and the parts growing rapidly acquire large bulk. The pain 
 is not great, although sometimes a sharp snooting one is felt ; the veins are 
 full and enlarged. The infiltrating form may be complicated with cancer 
 in other portions of the body, and is characterized by smoothness and infil- 
 tration. 
 
 Treatment. — By referring to the Chapter upon Cancer, those medicines 
 will be found which are adapted to the treatment of the disease. Conium 
 mac, phosph., the protoiodide of mercury, iodine, the iodide of potash, 
 arsen., iodide of arsenic, hydrastis, phytolacca, Scutellaria, may be of ser- 
 vice, but, as a general rule, time is lost by internal medication, and operative 
 measures must be employed. 
 
 Castration. — This operation is demanded in several varieties of affections 
 of the testicle, sometimes by men in the full enjoyment of their health and 
 faculties. I was once requested to castrate a young and healthy man (a 
 patient of Dr. J. F. Talmage, of Brooklyn), who desired to preserve his 
 voice as a falsetto in an opera troupe. It is needless to say that the request 
 came from the patient himself, who preferred to be a eunuch with a good 
 voice than a man with procreative powers. I declined to perform the oper- 
 ation. 
 
 The following methods may be resorted to: The scrotum and groin 
 having been carefully shaved, and the patient placed in a recumbent posi- 
 tion, the surgeon grasps the tumor behind in order to render the skin tense. 
 An incision is made from the external abdominal ring, reaching to the 
 bottom of the scrotum ; or the scrotum may be gathered into a fold by the 
 fingers, and transfixed at its base, when a suitable incision will be made by 
 cutting directly outwards. The cord, having been exposed, is separated 
 from the surrounding textures, and intrusted to the firm grasp of an assist- 
 ant to prevent retraction within the abdominal aperture when divided ; the 
 bistoury is carried behind the cord, which is cut across, and the operator 
 seizing its lower portion draws it forward, and proceeds to dissect out the 
 testicle — a dissection rendered comparatively painless and bloodless, by 
 early section of the cord. The arteries should be tied, and the wound kept 
 open until the bleeding has ceased ; the lower portion, seldom healing other- 
 wise than by granulation, need not be closely approximated. Care should 
 be taken during the operation not to wound the septum, and thus expose 
 the sound testicle. 
 
 The operation also may be performed by first separating the testicle from 
 its integuments, before dividing the cord ; all fear of irrepressible haemor- 
 rhage by retraction of the vessels may be avoided, by dissecting up their 
 cremaster envelope for a considerable distance towards the abdominal ring, 
 and passing a ligature around them before severing the cord. Where, how- 
 ever, there is but a small portion of the cord to be found, where there may 
 be tedious dissection required to separate the diseased tissues from the 
 healthy, and where the walls of the scrotum are much distended, then the 
 dangers are more apparent, and an operation which, under most circum- 
 
HYDROCELE. 993 
 
 stances, is simple, becomes one which may not only prove embarrassing to 
 the operator, but fatal to the patient. For instance, where the cord is short, 
 and has to be divided close to the ring, a retraction may take place, which 
 renders the condition alarming. " In a case which came under the obser- 
 vation of Sir. A. Cooper," says Mr. Curling, " the bleeding from the vessels 
 of the retracted cord was so profuse that the operator was convinced that 
 he had wounded the iliac artery, and unfortunately proceeded to place a 
 ligature on that vessel. The patient died the day after the separation of the 
 ligature. The iliac artery, though not wounded, had been tied securely 
 enough ; but the vessels of the cord, the source of the haemorrhage, had been 
 neglected." The same author records two instances which came under the 
 observation of Mr. Benjamin Bell, in which two patients died from haemor- 
 rhage from retraction of the cord, before the vessels could be secured. Sec- 
 ondary haemorrhage is a serious complication, which is apt to occur after 
 the operation, chiefly from the vessels of the scrotum. 
 
 Taking these circumstances into consideration, I prefer a mode of opera- 
 tion which I have not seen anywhere recorded, and which may be recom- 
 mended for the ease with which it may be performed, and the safety of its 
 results. Having placed the patient under the influence of an anaesthetic, 
 take the cord between the thumb and finger of the left hand, just at its exit 
 from the external abdominal ring ; having rendered the integument tense 
 by firm pressure, enter an acupressure pin at right angles with the cord, 
 and having depressed the head, bring out the point on the opposite side. 
 To make it still safer, another pin may be placed about half an inch below ; 
 over these draw two slight rings of india-rubber. Make an incision upon 
 the tumor and dissect out the gland. Divide the cord with a single stroke 
 of the knife, and neither will a drop of blood exude, nor a particle of retraction 
 take place. Thus, by pins properly applied, two serious difficulties are re- 
 moved. The acupressure prevents the haemorrhage from all the vessels of 
 the cord, and does not allow it to retract. 
 
 Hydrocele. — The tunica vaginalis testis secretes, in its natural state, a 
 limpid fluid, which lubricates its internal surface and that of the tunica 
 albuginea; and whenever this fluid, from any cause, is secreted in undue 
 proportion, it distends the tunica vaginalis, giving rise to a tumor of the 
 scrotum, which is termed hydrocele. 
 
 It is probable that the accumulation is the result of excited action in 
 the parts, for its origin is frequently attributable to externalinjury, followed 
 by swelling, which after a time subsides, leaving some enlargement of the 
 testicle, or of the more superficial tissues, and succeeded by the gradual 
 appearance of the disease. It is also caused by inflammation of the testes, 
 and is frequently combined with stricture of the urethra, or local irritation 
 along its course. Dr. Physick succeeded in curing a case by dilating the 
 stricture with a bougie. 
 
 Congenital Hydrocele. — When the communication between the cavity of 
 the abdomen and the tunica vaginalis is not closed as it should be at 
 the usual period, the fluid descends from the cavity of the abdomen into 
 the cavity of the tunic, forming what is denominated a congenital hydro- 
 cele. 
 
 This affection is sometimes conjoined with sarcocele, or chronic enlarge- 
 ment; when it is termed hydro-sarcocele. It is important to distinguish 
 between these two diseases. In sarcocele, the tumor is oval and flattened ; 
 it may attain a considerable size, without ascending so near to the ex- 
 ternal abdominal ring as does a large hydrocele. In sarcocele there is a 
 space between the tumor and the abdominal ring, whereas there is none in 
 a large hydrocele. The tumor may be known by its weight and opacity. 
 In hydrocele the swelling commences at the bottom, and is confined to one 
 
 63 
 
994 
 
 A SYSTEM OF SURGERY. 
 
 side. At first the tumor is flaccid, and the testicle may readily be distin- 
 guished ; but as it increases, it becomes firm and incompressible, and the 
 testicle can scarcely be felt. The swelling assumes a pyriform shape, the 
 corrugations of the scrotum disappear, and the raphe is displaced to the 
 opposite side ; there is little or no pain or inflammation, and no alteration 
 of color. When inflammation, however, precedes this disease, there is 
 pain, swelling, and hardness. The swelling is translucent, and, on placing 
 a lighted candle on one side of the scrotum, the light can be discerned 
 through it. In some cases the tunica vaginalis becomes thicker and harder, 
 the fluid is opaque and dark-colored, thereby obstructing the passage of the 
 rays of light. 
 
 Encysted Hydrocele of the Cord. — Sometimes an accumulation of fluid 
 takes place in the tunica vaginalis of the spermatic cord, forming an encysted 
 hydrocele of the cord. This variety occurs more frequently in children 
 than in adults. The fluid is thin, clear, and contained in a distinct cyst, of 
 a smooth, shining, serous appearance ; this cyst may be either an unoblit- 
 erated portion of the congenital spermatic structure, or composed of thick- 
 ened and condensed cellular tissue, strengthened exteriorly by the expan- 
 sion of the cremaster muscle. This variety may be confounded with hernia, 
 from which it is necessary to distinguish it. In hydrocele of the cord the 
 accumulation takes place gradually, unattended with pain, and is always 
 below the external abdominal ring. When the patient coughs, there is no 
 impulse communicated to the finger, and the tumor is not capable of being 
 returned into the cavity of the abdomen ; whilst in hernia, the swelling 
 takes place suddenly, attended with pain ; and a peculiar impetus is com- 
 municated to the tumor when the patient coughs, and it may generally be 
 returned by pressure into the abdomen. It sometimes happens that both 
 these affections coexist in the same individual, and in such cases the diag- 
 nosis is difficult. 
 
 If, in the withdrawal of the fluid with the hypodermic needle, it is found 
 to be whitish, the diagnosis of spermatozoa in a cyst may be arrived at, and 
 spermatozoa may be said to be pathognomonic of encysted hydrocele of 
 the cord, although in some instances the disease may exist without them. 
 
 Diffuse Hydrocele of the Cord. — Accumulations occur in the meshes of 
 the cellular tissue of the cord ; the cells expand and form receptacles 
 
 for the fluid ; these vary from the 
 size of a pea to that of an almond. 
 We then have the affection known as 
 " diffuse hydrocele of the cord" (Fig. 
 648). In this disease the swelling is 
 uniform, has a defined shape, grows 
 slowly, and is productive of little pain. 
 By careful manipulation the swelling 
 may be separated from the vaginal 
 tunic. 
 
 Of itself, hydrocele is not a dangerous 
 disease. Persons may have it for years, 
 and be free from pain ; but, if the swell- 
 ing increase to a great size, pains in the 
 spermatic cord and renal region are ex- 
 perienced. On account of the enormous 
 size of the effusion, the penis becomes 
 much retracted, and sexual intercourse 
 is rendered impossible. The discharge 
 of urine may be interfered with, and the emission of semen is likewise im- 
 peded. 
 
 Fl(i. 648. 
 
 Diffuse Hydrocele of the Cord. 
 
HYDROCELE. 995 
 
 The diagnostic symptoms may be arranged as follows : Increase of the 
 tumor from below upwards. Fluctuation, or want of solidity. Translucency. 
 Lightness as compared to solid growth. Sickening sensation experienced 
 when pressure is made in the region of the testicle. Smoothness of sur- 
 face. Absence of cough-impulse. Absence of pain. The history of the 
 case. 
 
 By examining these symptoms, we find that separately they are equivocal 
 in complicated or old cases. 
 
 In such, how must we proceed? 
 
 First. By a careful comparison of the tout ensemble. 
 
 Second. Especially by the use of the exploring needle or aspirator. 
 
 Third. If the diagnosis be obscure, -by carefully cutting down upon the 
 sac with a scalpel, instead of puncturing with a trocar. 
 
 There are peculiar cases, in which the symptoms may be rendered more 
 obscure by the formation of one or more partitions in the sac, forming 
 multilocular hydrocele. This may give rise to unevenness of surface, and 
 may perplex the surgeon during an operation, in which the ordinary trocar 
 or acupuncture-needle is only thrust into one of the compartments. In 
 such there is a flow of serum and suddenly a stoppage of the fluid, and but 
 a partial diminution in the size of the sac. These cases are rare. 
 
 The Quantity of Fluid. — Sometimes the quantity of fluid is so great that 
 the records appear almost incredible; yet, when it is remembered how 
 much serum may collect in those cavities of the body, the walls of which 
 are extensible, we will not be astonished at the quantity that may accumu- 
 late in the scrotum. Who does not recollect the famous epitaph recorded 
 by Watson of Dame Gregory Page, who in sixty-seven months, was tapped 
 sixty-six times, and had taken from her two hundred and forty gallons of 
 water ? 
 
 Gibbon, the historian, is said to have had removed from his scrotum six 
 quarts of water. In the tables of hydrocele prepared by Dr. Duyat, at 
 Calcutta, the quantity of serum varied from ten to one hundred ounces. 
 
 Analysis of the Fluid. — The following analysis of the fluid, made by 
 Dr. Bostock, of 100 parts, of the specific gravity of 1024, were found to 
 contain : 
 
 Water, 91.25 
 
 Albumen, 6.85 
 
 Uncoagulable matter, . . 1.1 
 
 Salt, 8 
 
 100.00 
 
 The fluid, as has been mentioned, in old cases, is of a thickish, dark 
 color, and may contain cartilage and osseous deposit. Albuminous sedi- 
 ment is present. 
 
 Treatment. — Hydrocele may be divided into medical and surgical, and 
 the latter into palliative and radical. 
 
 Let it be remarked that hydrocele, especially in infants and young chil- 
 dren, often disappears spontaneously ; and, indeed, in adults, such cures 
 have been recorded. Mr. Pott describes two cases of confirmed hydrocele, 
 which disappeared without any treatment. 
 
 The small accumulations that are often noticed in very young children 
 need no treatment, except, perhaps, a suspensory bandage, which latter, in 
 the majority of instances, is rendered unnecessary, because a certain degree 
 of pressure is exerted by the diaper. 
 
996 A SYSTEM OF SURGERY. 
 
 Humphrey* records a case cured by pulsatilla, in which there was swell- 
 ing of the scrotum on one side, and of the left spermatic cord ; also, a suc- 
 cessful one, in which arnica was externally applied, and conium internally, 
 together with sulphur, nux vomica, puis., and graph. 
 
 Dr. Black f gives an interesting account of hydrocele successfully treated 
 by medicines, and records, especially, the action of graphites in the dis- 
 order. 
 
 Hastings]; records a remarkable cure of hydrocele by rhododendron. 
 
 Ozanam § cites a number of cases, where he employed rhododendron. A 
 boy, aged H years, suffered from hydrocele; rhodo. internally and locally 
 administered, and compresses saturated with a solution of the same medi- 
 cine, removed the difficulty in one month. After ten days' treatment a 
 marked diminution was observed. 
 
 " A boy six years of age had had two attacks of hydrocele, the first about 
 two years ago. This patient was cured with rhodo. in one month. A 
 year and a half after, he had another attack, caused by a long ride upon 
 a donkey. The parents did not call for advice until three months after the 
 attack ; rhodo. internally and locally produced a speedy cure." 
 
 In several cases of long standing, one of forty years' duration, the im- 
 provement was more tardy, yet the enlargement was reduced to half its 
 former size. 
 
 Ozanam's observations led him to the conclusion that rhodo. not alone 
 manifests positive action upon the tunics of the testicles in the male, but 
 also upon the ovaries of the female, and, perhaps, also upon the fibrous and 
 muscular tissues of these organs. 
 
 Raue|| says : " Those hydroceles which are dependent upon a general hy- 
 dremic state of the blood, must be treated with reference to this whole gen- 
 eral state and its symptoms. Hydrocele in consequence of a blow, requires 
 arnica and pulsatilla ; those of unknown causes, aurum, graphites, iod., 
 psoricum, rhodo., silic." 
 
 The medicines which have proved most effectual in my hands are calc. 
 carb., conium, dig., dulc, graphites, iodium, mere, sol., puis., rhod., sil., 
 sulph. 
 
 The palliative treatment of hydrocele consists in evacuating the sac either 
 by the aspirator or the trocar ; while the radical cure is effected by exciting 
 inflammation in the sac after the withdrawal of the fluid, thus preventing 
 its return. 
 
 Some persons, especially those in the upper walks of life, prefer the pal- 
 liative treatment; but, if the patient be healthy, it is always better to per- 
 suade him to have the operation thoroughly performed, to prevent further 
 accumulation in the tunica vaginalis. There are circumstances where only 
 palliative treatment is required. 
 
 Treatment by Acupuncture. — The method of acupuncturing is simple, and, 
 if properly performed, causes so little suffering, that I prefer it where mere 
 palliation is required. 
 
 The needles, which should be of different sizes, are very sharp ; one of 
 these is set in a handle by means of a small thumbscrew ; its point is 
 applied to the most dependent portion of the tumor ; the handle is twirled 
 rapidly between the thumb and fingers, gentle pressure being exerted at the 
 same time. The sac must be punctured in several places. 
 
 * Humphrey's Ruoff, p. 121. 
 
 t British Journal of Homoeopathy, vol. iii., p. 525. 
 
 t B. J. M., vol. xviii., p. 351. 
 
 | Bulletin de la Soc. Med., April 15th, 1869. 
 
 || Kane's Pathology, p. 402. 
 
HYDROCELE. 
 
 997 
 
 Fig. 649. 
 
 Dr. Lanyin, in the London Lancet, speaking of the palliative treatment, 
 states that he has met with several cases where the introduction of a com- 
 mon needle of large size has invariably caused the removal of the fluid, 
 after an interval of twenty-four hours. 
 
 The Palliative Treatment by the Trocar. — When this is employed, a round 
 trocar and canula are to be used. The patient is placed in the erect pos- 
 ture, with the thighs separated; the 
 surgeon takes the scrotum and posterior 
 part of the tumor in his left hand, ren- 
 dering it tense and prominent in front ; 
 the instrument is entered at the lower 
 and anterior part of the tumor, pass- 
 ing obliquely upwards and backwards 
 (see Fig. 649), so as to avoid wounding 
 the testicle, yet at the same time taking 
 care that the obliquity is not such as 
 endangers separation of the coverings 
 of the sac, and non-entrance into the sac 
 itself. 
 
 The trocar being withdrawn, the ca- 
 nula remains, and the fluid is allowed 
 to pass. 
 
 The Hypodermic Injection of 10 drops 
 of compound tincture of iodine into 
 the hydrocele, without any attempt to 
 draw off the fluid, should always be 
 tried first. In some instances one in- 
 jection cures, in others several are neces- 
 sary, and again the relief is but tempo- 
 rary. I have cured some patients, but 
 
 by far the greater number have only been relieved. The operation is so 
 simple, and so free from pain or danger, that it may be tried before more 
 severe measures are resorted to. 
 
 The Radical Methods of Cure are the withdrawal of the fluid, and estab- 
 lishing adhesion within the scrotum. This is accomplished in a variety of 
 ways. 
 
 Mr. Miller speaks of the radical cure being effected by injections ; and 
 remarks, " that the operations of seton, caustic, and incision, are fallen into 
 complete disrepute." It is to this latter statement I must dissent. 
 
 There are cases in which injection treatment has failed ; indeed, this 
 method is not resorted to by surgeons of considerable experience and skill. 
 
 John Mason Warren,* after an extended term of years at the Massachu- 
 setts General Hospital, speaking of injections, says: " This treatment is, at 
 best, very uncertain." 
 
 Dr. Grossf prefers the seton, on account of its simplicity, its freedom from 
 danger, and its never-failing certainty. He describes the method of oper- 
 ating (which will be mentioned towards the close of this section), and refers 
 to incision as consisting of simply opening the tunica vaginalis with the 
 knife, and dressing the wound with lint, or irritating substances. 
 
 Simple incision has cured hydrocele. Mr. Cooper has related several 
 instances of the kind, and Mr. Cook states that, after such operations the 
 whole fibrous tunic was thrown off by the sloughing process. 
 
 Tapping the Scrotum. 
 
 * Surgical Observations, p. 251. 
 f Gross, Surgery, vol. ii., p. 946. 
 
998 A SYSTEM OF SURGERY. 
 
 A case is related by Paul F. Eve * in which a large hydrocele was cured 
 by a stab inflicted with a bayonet. 
 
 Erichsen,f speaking of the caustic treatment by injections of iodine as 
 that commonly employed, says: "when the injection fails, the seton will, 
 I think, be found to be the most certain means of accomplishing our 
 object." 
 
 The injection treatment is most common, and, in ordinary cases, is suc- 
 cessful. 
 
 The operation is simple: the surgeon ascertains, first, the position of the 
 testicle ; avoiding it, he inserts a trocar and evacuates the fluid. Through 
 the canula he injects the tincture of iodine, which in some cases may be 
 allowed to remain, and in others, to escape from the scrotum after a few 
 minutes. Some surgeons use the dilute tincture of iodine, and others the 
 pure article; my preference is for the compound tincture of iodine in small 
 quantities. It should be retained in the tunica vaginalis. 
 
 Dr. Bellingham is averse to the employment of the ordinary preparations, 
 and prefers the following : 
 
 K. Iodidi potass., ^ij. 
 
 Aquae dest., ^ss. 
 
 Adde, 
 
 Tinct. iod., ^iv. 
 
 He states that, in using this formula, there need be no fear if the injection 
 does not return, as it will be taken up by the absorbents. 
 
 It would be useless to give, in detail, successfully treated cases of ordinary 
 hydrocele of the tunica vaginalis with iodine injections. Every practitioner 
 has either used the treatment, or known of cures being accomplished 
 by it. 
 
 Professor Syme stated that he used the tincture of iodine alone, and with- 
 out a single case of failure, either in private or public practice. The quan- 
 tity he employed was about one teaspoonful. 
 
 Bransby Cooper employed the iodine injections in about thirty cases, 
 and in all, the cure was effected. He stated that the compound tincture 
 must be used, in preference to the ordinary preparation. He injected 5ij 
 of a mixture composed of one part tr. iod. comp. to three of water, and 
 allowed it to remain. 
 
 The injection treatment fails sometimes, oftener, perhaps, than is sup- 
 posed, especially in those obscure and difficult cases already considered ; 
 then recourse must be had to other methods. 
 
 The proportion in which iodine injections fail has been variously esti- 
 mated. Mr. Martin affirms that in India the failures scarcely amount to 
 one per centum. Velpeau calculates them at about three per cent., and 
 Mr. Erichsen says : " I have, during the last few years, seen a considerable 
 number of cases of hydrocele of the tunica vaginalis, both in hospital and 
 private practice, in which a radical cure has not been effected, although the 
 iodine injections had been had recourse to by some of the most careful 
 and skilful surgeons of the day." In such he prefers the seton, which is 
 introduced by a large needle, and the fluid allowed to drain away through 
 the puncture, or the method recommended by Mr. Green, and lauded and 
 practiced by the late Dr. Gross. 
 
 Dr. Keyes, of New York, prefers the injection of pure carbolic acid into 
 the sac, the quantity being a drachm, and speaks highly of his success. 
 
 * Remarkable Cases in Surgery, p. 371. 
 
 f Science and Art of Surgery, vol. ii., p. 1110. 1885. 
 
HYDROCELE. 999 
 
 Dr. Keyes uses a glass syringe holding 100 minims. The needle is intro- 
 duced, the cyst emptied, the point unscrewed from the barrel and allowed 
 to remain in the cyst, the syringe is then filled with pure carbolic acid deli- 
 quesced with a little glycerine, and from thirty to sixty minims thrown into 
 the sac* 
 
 Treatment by Seton. — Having drawn off the fluid through the canula, 
 insert the trocar again, and push it up until its point emerges from the 
 upper part of the scrotum. Having withdrawn the trocar, pass through 
 the canula either a probe or long needle, armed with a ligature, which is 
 drawn out at the upper orifice made by the reintroduction of the trocar ; 
 this done, remove the canula and make fast the ligature, which is allowed 
 to remain until suppuration is established. 
 
 The Treatment by Incision. — This treatment was employed by John 
 Hunter. He opened the scrotum, allowed the fluid to escape, and then 
 sprinkled flour on the surface of the tunica vaginalis, to excite inflamma- 
 tion. Pott repudiates such proceeding, because of the frequency of slough- 
 ing. Where there is difficulty in diagnosis, or where other methods have 
 failed, incision may be practiced. Chelius prefers incision, because com- 
 plications are more readily made out, and existing intestinal rupture can be 
 properly treated ; whereas, he is of opinion that the injections, especially of 
 iodine, act violently on the testicles, or the fluid may be poured into the 
 cellular tissue, which has been known to produce mortification and death, 
 and also, because the disease is likely to return. It is singular that the 
 objections urged here are said to be provocative of cure by other surgeons; 
 thus Mr. Stanley, F.R.S., recommends the fluid to be evacuated into the cellular 
 tissue of the scrotum, and records cases where the fluid was absorbed in forty- 
 eight hours. 
 
 German surgeons prefer treatment by incision. In one of my cases the 
 injection method with compound tincture of 
 iodine had been tried, and the fluid had re- FlG - 65 °- 
 
 accumulated. I made an incision into the sac, 
 and having introduced a grooved director, 
 opened the scrotum about an inch and a 
 half; into the cavity were passed strips of 
 lint, until the scrotum was packed. This 
 dressing was allowed to remain three days, 
 when it was removed, and others applied. 
 The pain was severe, but the cure complete. 
 
 Some surgeons, after the opening is made, 
 sprinkle the parts with mercurial powder. 
 Mr. Lloyd, of St. Bartholomew's, introduces 
 into the sac, finely levigated, the powder of 
 hydrarg. nitr. oxidum, and has employed it 
 with complete success. 
 
 Treatment by Incision and Removal of a 
 Portion of the Vaginal Tunic-Having placed Treatment by v ^S.° f the Tumca 
 the patient in the usual position, the walls 
 
 of the scrotum are divided with a scalpel, and a fold of the tunica vagi- 
 nalis taken up with the forceps, and a portion thereof cut away. (See Fig. 
 650). The wound may then be closed with carbolized gut sutures. 
 
 Treatment by Electrolysis. — Two acupuncture-needles are introduced, the 
 one in the upper, the other in the lower part of the tumor, and the free 
 extremities of the needles are connected with the poles of the induction 
 
 * Medical Eecord, February 20th, 1886. 
 
1000 A SYSTEM OF SURGERY. 
 
 machine. Care should be taken that the points of the needles project into 
 the fluid, and the current passed through them should be mild, and grad- 
 ually increased until the patient complains of pain. The operation should 
 continue twenty minutes. At first, the scrotum appears puffed, but soon 
 diminishes in size. Cases are known in which hydrocele has diappeared 
 in twenty-four hours after one application of the battery. 
 
 In conclusion, I may allude to the treatment by alcoholic fomentation, as 
 introduced by M. Pleindoux, who has been successful in several instances, 
 and which was accidentally introduced to his notice. A wine merchant 
 of Nismes had been affected for a length of time with a considerable hydro- 
 cele of the left side of the scrotum, and, for private reasons, desired the 
 palliative treatment. A puncture was made, and more than a pint of water 
 drawn off. Nine months after, a second puncture was made to evacuate the 
 fluid ; it then occurred to the patient to envelop the scrotum with a large 
 compress, steeped in alcohol at 30°. The application was renewed every 
 evening, and was kept in place by a suspensory bandage. The first effect 
 was great contraction of the scrotum. These fomentations were continued 
 forty days, and the patient was completely freed from his hydrocele, which 
 had not returned in eighteen months. 
 
 Hematocele. — By this term is understood an accumulation of blood in one 
 of three localities, — the areolar tissue of the scrotum, the areolar tissue of the 
 cord, or the tunica vaginalis. It may be of spontaneous occurrence, or the 
 consequence of external injury. 
 
 When it attacks the scrotum it is the result of a bruise or oblique wound ; 
 the scrotum becomes swollen, and assumes a blackish hue, like urinous 
 infiltration ; the swelling has a doughy feel, and at one or more points, 
 where the cells are broken down and blood has collected, fluctuation is per- 
 ceived more or less distinctly. Hematocele of the cord arises from the 
 giving way of a spermatic vein, from external injury, or great bodily ex- 
 ertion, when extravasation into the areolar tissue will result, forming a 
 tense, discolored tumor. Hematocele of the tunica vaginalis is the most 
 common variety ; and to it, in strict accuracy, the term may be limited. 
 The blood is extravasated into the cavity of the tunica ; it may be associated 
 with hydrocele, from a wound of the testicle in tapping, by a blow or 
 other external injury, or by the spontaneous giving way of a bloodvessel. 
 A hydrocele maybe converted into hematocele, the diagnostic marks of 
 hydrocele thereby being lost. The tumor suddenly increases in size, and 
 is the seat of pain; and when handled is found heavier and less fluctu- 
 ating than before. The blood, if in small quantity, becomes diffused in the 
 serous fluid ; when copious, a portion coagulates, and assumes the fibrinous 
 arrangement. This, acting as a foreign substance, may excite inflamma- 
 tory action ; and suppuration may take place, with increase of swelling and 
 pain. 
 
 Treatment. — When the accompanying inflammation assumes a high grade, 
 aconite should be administered ; when it results from contusion, or other 
 mechanical injury, arnica or conium should be given and applied to the 
 affected parts as a lotion ; pulsatilla may avail in such cases ; and nux vom., 
 rhus, sulph., or zinc, may be found efficient. The use of the knife is not 
 necessary unless suppuration has occurred. When extravasation super- 
 venes on hydrocele, and the medicines prove unavailing, simple tapping is 
 to be employed. To inject then, would be productive of evil rather than 
 good. The fluid is allowed to collect again, and tapping is repeated, and 
 when, after several withdrawals, the fluid is found to be of the same char- 
 acter as in simple hydrocele, then injection may be resorted to with safety, 
 and with probability of success — provided the testicle be sound. In con- 
 
VARICOCELE. 1001 
 
 firmed cases, and especially when suppuration is threatened, the only means 
 for a radical cure is free incision ; laying the cavity open, turning out the 
 coagula, and obtaining closure of the wound by granulation; care being 
 taken to avoid wounding the testicle. 
 
 Varicocele. — Varicocele, circocele, or spermatocele, expresses a varicose condi- 
 tion of the veins of the scrotum or spermatic cord. Usually the latter is 
 affected. It commonly commences close to the testes, and extends upwards 
 towards the abdominal ring. It is caused by obstruction to the return of 
 blood, the dependent nature of the part predisposing to the affection. 
 Laborious ancl constant exercise in the upright position, constipation, cor- 
 pulence, the wearing of tight belts, trusses, tumors, or whatever affects the 
 upward flow of blood, give rise to the disease. It is more frequently ob- 
 served on the left than on the right side, in consequence of the spermatic 
 vein of that side having a longer and more tortuous course, and having 
 to support a greater column of blood, and by its being more liable to com- 
 pression, by accumulation of fecal matter in the sigmoid flexure of the 
 colon. The affection is chiefly met with amongst young, vigorous, un- 
 married men, who have led exemplary lives. The whole of the cord ap- 
 pears to consist of knotty and tortuous veins, which feel like a bundle or 
 congeries of earthworms twisted upon each other ; it is sensitive to the touch, 
 creates a feeling of weight in the scrotum and loins, and often a degree of 
 numbness in the thighs. It may be distinguished from hernia in the fol- 
 lowing manner: After the patient has been placed in a recumbent posture, 
 and the swelling reduced by compression of the scrotum, the fingers are 
 pressed on the upper part of the abdominal ring, and the patient is directed 
 to rise ; if it be circocele, the swelling will reappear in increased size, from 
 the obstruction offered by the pressure to the return of blood ; but if hernia 
 be present, the recurrence of the tumor cannot take place so long as the 
 pressure is continued. 
 
 Treatment. — The radical cure of this affection by means of medicine is 
 attended with difficulty, and in many instances palliative relief is all that 
 can be obtained. Pulsatilla and hamamelis are useful medicines ; the 
 treatment may be commenced with puis., and the testes should be sup- 
 ported by means of a suspensory bandage, or bag truss, made of silk net- 
 work. When the affection has been occasioned by a blow or other external 
 injury, or by pressure from the pad of a truss, arnica should be applied in 
 the form of a lotion. As a constant application, hamamelis, one part of the 
 tincture to three of water, is excellent as a palliative, while the same medi- 
 cine administered internally has relieved the pain and dragging of the cord. 
 When the symptoms do not yield to medicines, and the tumor is large and 
 painful, and there is danger of the testicle becoming atrophied in conse- 
 quence of the pressure, the varicose veins should be obliterated. Several 
 processes have been adopted (none of them, however, being free from dan- 
 ger) for this purpose. 
 
 It must be recollected that the cord is composed of the spermatic arteries, 
 which arise directly from the aorta ; of the veins, which constitute the pam- 
 piniform plexus, coming from the back of the testes ; and of the vas def- 
 erens, which is the excretory duct of the testicle and a continuation of the 
 epididymis. The obliteration by pressure, suture, injection, or otherwise, 
 of either the artery or the excretory duct, is equivalent to castration, and — 
 setting aside the danger of phlebitis, which is of itself a disease of great 
 danger and liable to occur in any operation of the kind — the proceeding is 
 one which requires, not only a correct knowledge of the anatomy of the 
 parts, but delicate manipulation. 
 
 It was the elder Delpech, who had obtained an enviable position among 
 
1002 A SYSTEM OF SURGERY. 
 
 the first surgeons of the world, who operated upon both sides, and unfortu- 
 nately included in the ligature the spermatic arteries ; atrophy of the testicles 
 occurred ; the mind of the patient brooded over the terrible mishap, and 
 his brain, crazed with sorrow and mortification, thirsted for revenge. He 
 waylaid Delpech, and rushing upon him as he left his carriage, stabbed him 
 to the heart. 
 
 There are many methods of treating this disease. 
 
 1st. Compression. Breschet's method, consisting of applying to the en- 
 larged veins two iron clamps, the jaws of which were tightened with thumb- 
 screws. Curling uses a peculiar variety of truss. 2d. By Suture, as employed 
 
 by Velpeau and others. 3d. By Ligature, 
 FlG - 651 - as recommended by Reynaud of Turin, 
 
 Gagnebe, Ricord, and others. 4th. By Roll- 
 ing up the veins of the spermatic cord, as per- 
 formed by Vidal. Dr. Packard, of Phila- 
 delphia, employs a double wire loop (Fig. 
 651). 
 
 Dr. Gross passed a needle behind the 
 veins, and applied a figure-of eight suture (Fig. 652), but stated that after 
 losing one of his patients with phlebitis, he resorted to subcutaneous liga- 
 tion. 
 
 A simple method is as follows : 
 
 The patient should rise early, take a light breakfast, leave off the suspen- 
 sory bandage, and use as much exercise as possible. By these means the 
 veins are enlarged for the operation. He should be seated upon the edge 
 of a chair, and, with the forefinger and thumb of the left hand, the palmar 
 surface being toward the anterior part of the scrotum, the vas deferens and the 
 spermatic artery are searched for. Those accustomed to anatomical manip- 
 ulations are aware that the vas deferens ascends behind, and may be distin- 
 guished from the surrounding structures by its fibrous feel, or somewhat 
 cartilaginous hardness. So soon as the duct is found, the ball of the index 
 finger of the hand aforesaid is pressed between it and the veins, thereby 
 making it lay against the nail or posterior surface of the finger, by which it 
 can be pressed against the pubic bones ; the artery is also felt by its pulsa- 
 tion, and held aside with the thumb, thereby having nothing between the 
 finger and thumb of the left hand but the bundle of veins. This is an import- 
 ant step in the operation. The patient can be placed under the anaesthetic 
 agent, while the veins are held by the surgeon. It is better to defer the ad- 
 ministration of ether, because the patient can materially assist the surgeon 
 by describing the sensations which are experienced when pressure is made 
 upon the excretory duct of the testicle. Taking a strong piece of carbolized 
 ovariotomy silk, and doubling it, the loop is passed through the eye of a 
 large needle similar to that used by sailmakers, which is with the right 
 hand introduced in front of the thumb of the left hand, and made to pass 
 behind the veins and to emerge in front of the index ringer, which holds 
 behind it the vas deferens. The ligature must be drawn through and the 
 needle removed, and again inserted in the same opening, but this time 
 directed in front of the veins and behind the skin of the scrotum. The 
 point is then brought out at the same opening from which the loop pro- 
 jects. By this means a double ligature is behind the veins, and the needle 
 in front of them, where it is allowed to remain. The loop is then brought 
 over the point of the needle, and by making traction on the ends of the 
 ligature at the point of entrance, and tying them firmly over the shank 
 of the needle, and again over a piece of cork, the veins are thoroughly 
 compressed. To prevent irritation resulting from the point of the needle, 
 
AMPUTATION OF THE REDUNDANT SCROTUM. 1003 
 
 it should be covered with a small cork. On the fifth day the knot is to 
 be tightened, and on the eleventh day the whole may be removed. 
 
 This method is safe. In the first place, but two punctures are made in 
 the scrotum ; in the second, should any of the important structures become 
 entangled in the ligature, by withdrawing the needle the whole apparatus 
 is removed. This is the method recommended and employed by the late 
 Dr. Pancoast, of Philadelphia, and from its simplicity and safety should 
 be borne in mind by the surgeon. I have employed a needle set in a handle 
 with the eye in its point. By this means a single loop of cord may be drawn 
 through instead of a double one. 
 
 The injection of the persulphate of iron has been used with success. The 
 solution should be weak and small in quantity. It may consist of from 
 two to five drops of the following solution. 
 
 R . Ferri persulpk. (liquor), gtt. x. 
 
 Aquae font., . gtt. xxx. 
 
 The superficial veins are the first to be injected, and afterwards the 
 deeper seated ones. A clot appears after the injection, which ulcerates and 
 obliterates the veins. 
 
 In double varicocele, by operating on one side, sometimes the disease 
 disappears. 
 
 Dr. Clark's Method. — In a Report on the Progress of Surgery, made to the 
 St. Louis Medical Society, and afterwards published in pamphlet, Dr. Clark 
 thus describes his operation : " It consists in excising a portion of the re- 
 dundant scrotum, by taking up a fold of it between the blades of a forceps, 
 or with Ricord's fenestrated forceps for phimosis, and thus exposing the 
 cord with its vessels, so that they can be manipulated separately, and the 
 veins be distinguished from both the artery and the vas deferens. This 
 part of the operation was originally proposed by Sir Astley Cooper, who, 
 after excising a portion of the scrotum, brought the wound together by 
 sutures, relying upon this procedure to effect a cure. I, however, after a 
 fold of the scrotum has been removed, and the vessels of the cord exposed, 
 so that the vas deferens can be isolated, pass a needle around with a wire 
 ligature beneath the cord, excluding the vas deferens and including all the 
 other contents of the cord. The needle is then disarmed, removed, and 
 the two ends of the wire passed through a small tube about two inches in 
 length, and wound over a cylinder fixed at the other end of the tube, so as 
 to grasp the vessels as the ecraseur does, and compress them sufficiently to 
 arrest their circulation, and induce their complete obliteration. 
 
 " After the lapse of thirty-six or forty-eight hours, the ' ecraseur ' is re- 
 moved and the wound closed by the ordinary interrupted suture or needles, 
 the former being preferable. The operation is comparatively devoid of ail 
 danger, as any excessive inflammatory action may be controlled at once, 
 by cutting the wire and withdrawing the ecraseur." 
 
 * Amputation of the Redundant Scrotum. — Dr. M. H. Henry* read an inter- 
 esting paper before the New York Academy of Medicine, on the subject of 
 amputation of the redundant scrotum for the cure of varicocele, which pro- 
 cess I have now repeated some twenty-seven times with success. In this 
 operation care and attention to details are necessary. After the usual shaving 
 and antiseptic washings, the scrotum is to be expanded with both hands, 
 the testicles thrust up to the rings, and the clamp (Fig. 653) fitted to the ex- 
 
 * Medical Record, May 28th, 1886. 
 
1004 
 
 A SYSTEM OF SURGERY. 
 
 panded scrotal wall. The curves of the clamp will be found to sufficiently 
 correspond with the curve of the raphe to embrace the bag from the root 
 of the penis to the anus. Care must be taken not to place the clamp too 
 
 Fig. 653. 
 
 Henry's Clamp. 
 
 far up in front, or the cut will remove the skin from the under side of the 
 penis, which should be pulled up over the abdomen out of the way. In 
 screwing down the clamp the operator must make sure that both screws are 
 turned evenly, and that the blades fit accurately ; otherwise, so great is the 
 contractility of the dartos, that upon incising the redundancy the lips of 
 the wound may be drawn through the clamp. The shears (Fig. 654), are 
 
 Fig. 654. 
 
 Henry's Shears. 
 
 then applied, and the extra blade of the clamp removed. The entire wound 
 should be overhanded, or closed with the "bagging-stitch;" the stitches 
 made with whale-tendon carbolized, and about one-eighth of an inch apart. 
 These ought to be drawn tightly. Then the clamp is to be removed and 
 the whole track of the wound carefully looked after. If there is a single 
 oozing point, a couple of extra stitches will arrest the bleeding. The entire 
 scrotum is to be powdered with iodoform and covered with sublimated 
 cotton, enclosed in borated gauze, held in position by an antiseptic band- 
 age. I have been successful with Dr. Henry's method, but it requires 
 some experience in its performance. I have had a poorty fitting clamp 
 allow the scrotum to slip awa}^ ; severe haemorrhage in one case from not 
 sufficiently attending to the sutures, and great extravasation and clots in 
 the tunica vaginalis in another. I have had pins cut out and clamps cut in, 
 when I employed them for closing the wound ; but lately, with proper 
 stitching and care, the parts have required but one dressing. 
 
 Keyes's Method.* — After having the scrotum washed with a -j-^Vo" solution 
 of corrosive mercury, a few drops of a four per cent, solution of cocaine are 
 injected at the site of puncture. The patient is made to stand, and the vas 
 deferens and artery separated in the manner already described. A needle set 
 in a handle and threaded either with catgut or whale tendon (the latter being 
 preferable), is thrust through the scrotum from before backward, leaving 
 the veins on its outer side (toward the thigh). A tenaculum catches the 
 loop on the posterior face of the scrotum and pulls out one end of the 
 
 * Medical Kecord, February 26th, 1886. 
 
AMPUTATION OF THE REDUNDANT SCROTUM. 1005 
 
 thread. The needle is carefully drawn back through the posterior puncture 
 and into the scrotum, but not through the anterior puncture. The veins are 
 freed from the fingers of the left hand and find their natural position. Thus 
 far the thread is on the inner side of the veins, with its end extending 
 through the posterior puncture, and the needle, still threaded, sticking in 
 the anterior puncture. By gentle manipulation the needle is passed under 
 the integument of the scrotum, external to the veins, and its point brought 
 out at the same hole through which the single strand is protruding. A 
 tenaculum is employed as before, and the loop drawn out. The single 
 thread is then passed through the loop and the whole drawn through. The 
 needle is removed, and the ends of the ligature tied in three knots. 
 
 In a more recent paper,* Dr. Keyes has modified his needle by placing 
 two eyes at its end a short distance apart. 
 
 The front eye is to carry the ligature, and the loop passes through the other 
 eye, and is held tense on one of the steel buttons at the handle. Dr. Keyes 
 now uses silk instead of gut, thoroughly cleansed and made antiseptic. 
 
 Ogston's Method.f — After disinfection, the left half of the scrotum is, by 
 the usual manoeuvre, seized three-quarters of an inch above the testicle, 
 between the forefinger and thumb of the left hand, and its contents allowed 
 to slip back and escape until the cord-like vas deferens slips out of grasp. 
 At this point the finger and thumb squeezes the skin of the two sides of the 
 scrotum together, to withdraw the veins from the vas deferens, and a threaded 
 needle is thrust through the scrotum at this spot. A handled needle, with 
 a large eye at its point, is threaded with the strongest surgeon's silk, disin- 
 fected either by having been boiled in five per cent, carbolic solution, or by 
 Kocher's method of twenty-four hours soaking in German oil of juniper, 
 the thread being afterwards kept in absolute alcohol. The needle should 
 be disinfected. In thrusting the needle through the scrotum, care must be 
 taken to avoid the tubular sebaceous scrotal glands from which hairs 
 emerge. They are always full of bacteria and their disinfection is impos- 
 sible. The needle is unthreaded and withdrawn, leaving the thread in its 
 track. The skin of the front of the scrotum must be seized by the left 
 forefinger and thumb and drawn forwards in a fold between them until 
 the punctures from which the thread emerged are drawn forward over the 
 dilated veins to the base of the folds. They are there squeezed together and 
 steadied by the finger and thumb, and the needle, this time without any 
 thread, is once more passed through the scrotum, entering and emerging by 
 the same points as before. The end of the thread emerging beside the 
 needle-point, is threaded into its eye and the needle withdrawn, carrying 
 the thread with it, so that both ends of the thread emerged by the same 
 point, where the needle was first entered. The needle having been detached 
 the long ends of the thread are tied by a surgical knot and tightened upon 
 the veins and tissues they embrace with the utmost strength. A triple 
 knot is made, the ends of the silk are cut off short, and the knot permitted 
 to sink into the depth of the scrotum. The puckerings inward of the 
 needle apertures, due to the first and second needle-tracks, sometimes do 
 not quite coincide in the subcutaneous tissues, and can be freed by pulling 
 the skin outwards at these spots until the included fibres give way and 
 allow the skin to fall into its natural position, entirely unconnected with 
 the knot. 
 
 Another exactly similar procedure is made an inch (or two finger 
 breadths, as the case requires) higher up the veins, and the operation is 
 then complete. 
 
 * Medical Kecord, September 18th, 1886. 
 f Annals of Surgery, August, 1886. 
 
1006 A SYSTEM OF SURGERY. 
 
 The scrotum should be disinfected, surrounded by a sheet of salicylic 
 wool, and the patient laid in bed with the testes elevated. 
 
 Carcinoma of the Scrotum. — This disease is, in the generality of instances, 
 of the epithelial variety, and is formidable in its nature. It is called also 
 chimney-sweepers' cancer. It is not common, but is intractable in its nature. 
 A small excrescence forms at the base of the scrotum, which soon degen- 
 erates into a malignant ulcer, which extends rapidly, consuming the neigh- 
 boring integument, and involving the testicle and other subjacent parts. 
 The induration often extends along the spermatic cord, and the lymphatics 
 participate in the diseased action at an early period. The discharge is acrid, 
 sanious, and possessed of much fetor ; sometimes fungi protrude, but more 
 commonly the surface is excavated and smooth. Not unfrequently the skin 
 surrounding the ulcer is studded, to a considerable extent, with numerous 
 clusters of warts of an unhealthy and angry aspect. The general health is 
 soon undermined, and the disease advances from bad to worse, with the 
 usual certainty and rapidity of malignant action. 
 
 "Other people besides chimney-sweepers," says Pott; "have cancers of 
 the same part ; and so have others, besides lead- workers, the Poictou colic 
 and the consequent paralysis ; but it is, nevertheless, a disease to which 
 they are peculiarly liable, and so are chimney-sweepers to the cancer of the 
 scrotum and testicles." 
 
 It cannot be determined why a cancerous growth should arise in one 
 locality rather than in another, but there appears to be conclusive evidence 
 that the habitual handling of certain substances and direct violence are 
 much concerned in the development of cancer in particular regions. Mr. 
 Lawrence operated on a chimney-sweeper, who presented cancerous forma- 
 tion anterior to the concha of the left ear. This patient appeared especially 
 obnoxious to the action of soot, for previously a genuine chimney-sweepers' 
 cancer had been removed from the scrotum ; but it is probable that when 
 the disease reappeared on the ear it was caused by the same substance, for 
 the patient was in the habit, whilst engaged in his trade, of carrying bags 
 of soot on his left shoulder, and it is likely that the ear on that side was 
 often covered with the substance; thus the growth of the tumor may be 
 accounted for* 
 
 Treatment. — Arsenicum appears to be serviceable in this affection, when 
 there is inflammation and swelling of the scrotum, and the ulcer is painful 
 in the morning, with burning in the circumference, and uneasiness when 
 the part becomes cold; when the ulcerative process consumes the adjoin- 
 ing structures, and the constitution of the patient is in a debilitated and 
 impoverished condition. It would seem that this medicine, together with 
 carbo veg., is especially indicated by the habits and mode of life of that 
 class of persons who are liable to the affection. The latter medicine should 
 be administered when the parts surrounding the ulcer are bluish or purple, 
 or when there are pressure and tension around the sore, which emits a cor- 
 rosive humor. 
 
 Thuja, secale, china, lachesis, rhus tox., clem, erect., hell., iod., mur. ac, 
 mere, corr. sub., may also prove serviceable. 
 
 If the disease appears to be spreading, complete excision should be prac- 
 ticed. In this operation every bleeding orifice should be secured with fine 
 ligatures, or secondary haemorrhage will result. 
 
 Elephantiasis Scroti. — The student, for a description and cut of this for- 
 midable disease, is referred to page 419. In that chapter will be found a 
 reference to the hydrocotyle asiatica in the treatment. 
 
 Hamilton! gives an interesting account of Dr. Thebaud's case — that of 
 
 * London Lancet, November, 1850, p. 488. 
 f Principles and Practice of Surgery, p. 884. 
 
AMPUTATION OF THE SCROTUM. 1007 
 
 Isaac Newton — as seen in Fig. 207 of this volume. During the operation, 
 " nearly one hundred vessels, most of which were large and open-mouthed 
 veins, were tied. His recovery was complete." 
 
 In describing this operation, I have given the rules of Dr. Allen Webb, 
 a Calcutta surgeon. 
 
 Amputation of the Scrotum. — Before the surgeon begins this operation, he 
 will by examination ascertain : 1st. If there be hernia (best recognized by 
 percussion if the tumor be large) ; 2d. If the glans penis be drawn near the 
 external opening ; 3d. If there have been abscesses in the perinseum, drag- 
 ging down the fascia ; 4th. Whether or not hydrocele exists ; 5th. The 
 situation of the testicles ; 6th. The consistence of the tumor and skin ; 7th. 
 If the patient is completely under the influence of the anaesthetic. While 
 the operator is being satisfied on these points, the assistants, of whom there 
 should be at least six, arrange the instruments, prepare the patient, and 
 take their respective positions as follows : The first assistant provides the 
 instruments for immediate use : bistouri-cache, double-edged catling, guarded 
 with a nodule of -wax, one small Liston knife, and one long knife of same 
 pattern, a strong-handled scalpel, six forceps, six tenacula, many sponges, 
 ligatures, chloroform, brandy and ammonia, bandages and split cloth, tow 
 and lint ; also a hospital cot, folded blanket, oilcloth, and pans of sand and 
 water. Having placed the patient on the cot or table, he administers the 
 anaesthetic, at the same time sees that the pubis is shaved. The second and 
 third assistants separate the patient's legs, and having extended them, place 
 them upon stools on a level with the trunk, which lies with the nates pro- 
 jecting over the edge of the table. The business of the fourth assistant will 
 be to support the tumor, moving it as required, and managing it throughout 
 the operation ; he stands at the right of the patient. If the tumor is large, 
 two assistants may support it on a cloth placed beneath. 
 
 The fifth and sixth assistant, standing at the patient's hips, keep the 
 sponges wrung out for immediate compression. The surgeon should be 
 assured that each assistant is in his place, and fully competent to perforin 
 the part allotted to him, and that all the instruments are ready at his hand. 
 He now seats himself on a low chair between the patient's legs, and directs 
 the fourth assistant to raise and reverse the tumor that it may be drained ; 
 he then endeavors to feel with the left index finger the reflexion of the pre- 
 puce from the penis ; if found, the tumor is depressed at the same time that 
 the knife (guarded by wax at the end), aided by the weight of the tumor, 
 is thrust through the point of reflexion till it cuts itself out, and the penis 
 is fairly exposed up to its root on its dorsum. The fifth assistant now, 
 keeping apart the edges of the incision, clears it with a sponge, and then 
 grasps the penis firmly, raises it from the attachments and preserves the 
 urethra from the knife. The surgeon then severs the fraenum and attach- 
 ments of the under surface of the penis already drawn up. The fourth 
 assistant now raises the tumor, rendering the integument lax, so that the 
 operator may pinch it up over the right spermatic cord, and by thrusting 
 the knife under the raised skin, cuts it through horizontally on a line with 
 the root of the penis. 
 
 The surgeon follows this by another incision bold and deep, from top to 
 bottom of the tumor in the course of the cord — going less deep if any por- 
 tion of the cord appear — as far as the testicle. If hydrocele exists, it will 
 probably be opened and reveal the testicle at the back part of the sac. The 
 fifth assistant instantly thrusts both thumbs into the incision, grasps the 
 mass and compresses the vessels. Using his knuckles as a fulcrum, he turns 
 out the bottom of the incision, revealing the attachment of the testicle and 
 presenting it to the action of the knife. He lifts the testicle with a firm 
 grasp up to the abdomen, and holding it there by the left hand, thrusts a 
 
1008 A SYSTEM OF SURGERY. 
 
 sponge into the cavity with his right, compressing the vessels at the neck of 
 the tumor. The testicle and cord being lifted they are rapidly dissected 
 upwards toward the abdominal ring. The surgeon next proceeds with the 
 left side, by pinching up the skin and cutting it through as with the right 
 testicle. He cleaves the tumor by a firm and deep incision from top to 
 bottom as before, and exposes the left testicle. If a large hydrocele pre- 
 sents, it is opened, and the testicles and cord are dissected from the mass, 
 carrying them upward. The sixth assistant immediately thrusts in both 
 thumbs and turns out the testicle, with his fingers placed behind the tumor ; 
 lifts the testicle, carries it up to the abdomen, and holds it there with his 
 left hand, while with the right he presses a sponge on the vessels at the neck 
 of the tumor. The fourth assistant now draws the tumor toward the oper- 
 ator, rendering it tense like an apron spread out, if it is small, or if very 
 large, supporting it upon his arm. Taking care that the penis and testes 
 are well drawn up out of harm's way, the surgeon with a long catling 
 divides the remaining attachments of the tumor close to the perineal 
 fascia. 
 
 The assistants now proceed to draw out and ligate all vessels of any im- 
 portance, keeping them compressed with sponges, and exposing but one at 
 a time. They will also raise the patient's legs at right angles to the trunk, 
 and administer restoratives if necessary. At the same time the operator 
 examines the testes, castrates if they are diseased, cuts away portions of 
 the hydrocelic sac if it be abundant, and removes any diseased blubber 
 which may remain. 
 
 As soon as these details have been properly attended to, the dressing 
 of the wound will be accomplished by the first assistant securing a T 
 bandage around the abdomen, and bringing the split-tails of it between the 
 legs. 
 
 At the same time the operator fixes each testicle at the root of the penis 
 where he intends them to adhere, until the bandage is brought up by which 
 they are secured, while the assistant applies strips of oiled lint over the 
 wound, and over that some teased tow, to support the testicles and prevent 
 them from slipping down from the fingers of the operator. Over this are 
 brought the tails of the bandage, which cross under the penis, and are 
 carried on either side and secured to the horizontal band. A water-dressing 
 will be found serviceable, and the surgeon, having ordered the patient to be 
 carefully watched in case of supervening haemorrhage, can now leave the 
 wound until the discharge renders dressing necessary. 
 
 Dr. D. W. Osgood, surgeon to the Medical Missionary Hospital, Foochow, 
 China* after remarking that about three-fourths of the patients treated at 
 Foochow had the disease located in the legs, and the remainder in the 
 scrotum, gives a description of his method of operating. This consisted : 
 1st. In the elevation of the scrotum for an hour or more before the opera- 
 tion. 2d. The use of Fayrer's tourniquet, which was of prime impor- 
 tance in the suppression of haemorrhage. 3d. Dissecting up lateral flaps, 
 which should not include any of the diseased skin. 4th. Dissecting out the 
 penis and testicles. 5th. Holding the genitals well out of the way, and 
 removing the scrotum by a few well-directed strokes of the scalpel. 6th. 
 Arresting the haemorrhage by pressing upon the wound and by ligating or 
 twisting the arteries. When hydrocele existed the sac was opened with a 
 free incision. In some cases the spermatic cords were much elongated, but 
 they retracted soon after the operation, and in a few days the testicles were 
 drawn up close to the inguinal ring. The parts were usually covered with 
 granulations in two or three weeks, after which time skin-grafting was ad- 
 
 * Medical Record, April 8th, 1876. 
 
PHIMOSIS. 1009 
 
 vantageously resorted to. The writer appends a table of fifty cases of ele- 
 phantiasis scroti, operated upon in Southern China, all of which recovered. 
 Thirty-three of these were known to have had ague ; about one-half had 
 hydrocele, which was frequently connected with atrophy of the testicle. 
 The average age of the patients was 38 years, and the duration of the dis- 
 ease eight years and a half. 
 
 Phimosis. — Phimosis signifies a preternatural constriction of the edge of 
 the prepuce in front of the orifice of the urethra. The prepuce occupies its 
 natural relative situation, but difficulty is experienced in uncovering the 
 glans, and frequently is impossible. 
 
 There are two varieties of this affection, the natural or congenital, and the 
 preternatural or acquired. The former exists at birth; the latter may occur 
 at any period, and is frequently the result of an acute inflammatory pro- 
 cess following external injury ; the cicatrization of an ulcer or wound; or 
 is sympathetic with gonorrhoea, balanitis, or venereal sore. 
 
 Congenital phimosis is not an uncommon affection, and will be found 
 in two or three varieties. Sometimes, though rarely, the prepuce is imper- 
 forate, and consequently the urine, not being emitted, collects between the 
 glans and prepuce, forming a bag or tumor. 
 
 Another variety is that in which an opening exists at the extremity of 
 the prepuce, which is not sufficiently large to allow the urine to escape with 
 the same rapidity as it issues from the urethra ; consequently it collects 
 under the prepuce, and distending the latter, is forced off gradually in a 
 fine stream and to a distance. If the disease continues for several years, 
 pus, and even calculi, may collect, keeping up a constant irritation. 
 
 In the majority of instances, there is no impediment to the flow of 
 urine, and no extraordinary elongation of the prepuce, yet it is so con- 
 tracted at its orifice as to prevent the exposure of the glans. A whitish 
 sebaceous matter collects in quantity between the glans and prepuce, ex- 
 citing irritation ; and inflammation ensuing, adhesion takes place between 
 the glans and prepuce, only to be relieved by dissection. 
 
 In after-life the preputial contraction may have the same effect as a tight 
 stricture of the urethra ; causing irritability of the genito-urinary system, 
 organic change, stricture of the urethra, alteration of the coats of the blad- 
 der, dilatation of the urethra, and finally renal disease. Should the patient 
 have escaped these dangers, ulceration is apt to take place at the contracted 
 part ; or a cancerous condition may ensue, which, involving the glans and 
 body of the penis, demands amputation ; for in nine cases out of twelve in 
 which Mr. Hey* had occasion to amputate the penis for cancerous disease, 
 the patients were affected with natural phimosis. 
 
 Preternatural or acquired phimosis may be either acute or chronic. In 
 the acute variety the areolar tissue becomes infiltrated with serum ; the 
 swelling thus caused prevents the glans from being uncovered in the usual 
 way, and secretion accumulating, aggravates the disorder. The chronic 
 form may result from gradual increase of original malformation, or may be 
 occasioned by the cicatrization of a wound or ulcer. 
 
 The neuroses which are developed by this disorder are numerous. They 
 are all affections of the nervous system, and vary from ordinary sleepless- 
 ness and nervous jactitations, to complete incoordination of movements and 
 loss of equilibriating power. Sometimes the affections simulate hip disease, 
 sometimes locomotor ataxia is present. A typical case, as exhibiting to 
 what degree these symptoms may be present, was reported by E. P. Hurd, 
 M.D.f " A lad of seven years had for several months been losing strength, 
 
 * Practical Observations in Surgery. 
 
 f Boston Medical and Surgical Journal, January 18th, 1877. 
 
 64 
 
1010 A SYSTEM OF SURGERY. 
 
 appetite, and flesh, was restless and nervous. Locomotor ataxia was 
 a marked symptom : he could not coordinate his members in any act ; 
 could not walk across the room without staggering and pitching headlong. 
 The same want of coordination was manifested when he attempted to 
 feed himself. It seemed impossible for the will to guide the hand to the 
 mouth. Intellect not disturbed, only the hebetude before mentioned was 
 marked. Responded to questions in monosyllables, and speech was not 
 distinct. Pupils dilated ; at times an outward and slightly upward squint 
 of both eyeballs, from paresis, as was supposed, of the third pair of nerves. 
 Marked dulness of hearing. No febrile heat ; pulse normal. No pain. 
 Could not elicit from him whether he experienced any abnormal sensations 
 on attempting to put his feet to the floor, or whether the tactile or mus- 
 cular sense was perverted. Hyperesthesia of general surface. Shortly after 
 coming under treatment, had a fit of epileptiform type. There was no con- 
 stipation or difficulty of micturition. 
 
 "For upwards of a week he was treated with sedatives to quiet the 
 excessive nervous irritability manifested during the night, with only par- 
 tial benefit. One day the patient lay naked in his mother's arms, when a 
 glance revealed phimosis, the prepuce was greatly elongated, strangulating 
 the glans, and the urinary punctum was minute. Circumcision was per- 
 formed, and from that time steady improvement set in." Dr. John Thomp- 
 son, of Albany* reported a case of epileptiform convulsions produced by 
 phimosis, and I have relieved intense nervousness, jactitations, and vomit- 
 ing by circumcision. 
 
 An interesting monograph on the reflex neuroses of phimosis, by Dr. T. 
 G. Comstock, of St. Louis, will repay perusal. 
 
 Treatment. — When the inflammation has been produced by friction, or 
 other mechanical cause, arnica should be employed both internally and as 
 a lotion. If the inflammatory action be violent, aconite is advisable. If 
 no beneficial effect appears to result from the use of the latter remedy, 
 calencl., rhus, or puis, may be administered. When the affection is accom- 
 panied with suppuration, mere, caps., or hepar may alleviate; and when 
 induration of the affected part and surrounding integument supervenes, 
 sepia and sulphur are appropriate medicines. When gangrene threatens, 
 or has commenced, particularly if the disease is associated with gonorrhoea, 
 ars. is recommended.f When young children are affected, aeon., mere, 
 calc, and sulph. are suitable. When this difficulty arises from syphilitic 
 causes, the remedies are, mere, sol., rhus t., thuja, cinnab., sulph., viola trie, 
 and kali hydriod. Balanorrhoea generally accompanies this variety of 
 phimosis ; some authors state this to be always the case ; and when the 
 above-mentioned remedies are insufficient, it may be necessary to make 
 incisions into the prepuce, and allow the secreted pus to escape. J 
 
 The congenital and chronic variety of acquired phimosis, can seldom be 
 relieved without an operation. 
 
 When natural phimosis existing at birth is complete, an immediate opera- 
 tion is required ; generally puncture with an ordinary lancet in the promi- 
 nent portion of the tumor, will be sufficient, as the stream of urine will 
 prevent the closure of the wound. 
 
 When the orifice of the prepuce is not entirely closed, but merely con- 
 tracted, a simple method is that recommended by Mr. Liston ;§ which con- 
 
 * New York Medical Journal, July, 1875. 
 
 f For an interesting account of several cases of this nature, effectually treated by arseni- 
 cum, vide British Journal of Homoeopathy, vol. iv., p. 265. 
 X Gollmann's Diseases of Urinary and Sexual Organs, p. 64. 
 | Elements of Surgery, p. 410. 
 
TREATMENT OF PHIMOSIS. 1011 
 
 sists in passing a grooved director, open at the end and well oiled, under 
 the prepuce, alongside of the frsenum, taking care that it is not passed into 
 the urethra. A sharp-pointed knife is slid along the groove, and emerges 
 at its extremity, when with one sweep the prepuce is divided. If the edge 
 of the prepuce is thickened, it should be seized between the blades of the 
 forceps, and shaved off. Several fine sutures will be necessary to prevent 
 the separation of the integument and mucous membrane, that they may 
 unite by adhesion. 
 
 In phimosis the stricture is caused by contraction and rigidity of the 
 internal membrane of the prepuce, the external portion consisting of cel- 
 lular tissue and skin, remaining generally sufficiently loose and yielding. 
 Hence the constriction may be relieved by dividing the internal lamina. 
 This may be effected, where the phimosis is not complete and rigid, by 
 drawing back the external portion of the prepuce as far as practicable, 
 until the tense ring of the inner prepuce, which forms the stricture, is ex- 
 posed, and dividing the latter with a bistoury or a pair of scissors, at one 
 or more points, sufficiently to permit of the free motion of the prepuce over 
 the glans. 
 
 Another operation is that of Cullerier. It is applicable to those cases in 
 which the integuments appear to be not condensed or indurated, but in 
 which the stricture is due to the more unyielding mucous membrane. The 
 instrument employed is a pair of small straight scissors, of which one of 
 the blades is terminated by a button, like a probe-pointed bistoury. This 
 is passed between the glans and prepuce, while the sharp-pointed blade is 
 thrust into the substance of the prepuce, being separated from the other by 
 the mucous membrane ; the latter is then divided a sufficient length to allow 
 the prepuce to be drawn back.* 
 
 The operation which I prefer is as follows : Make the first incision as that 
 directed by Mr. Liston, and then with the scissors trim the mucous mem- 
 brane and integument around to the frsenum prseputii, unite the mucous 
 and integumentary surfaces ; or, having drawn the integument well forward 
 with a pair of " bull-dog " forceps, it is given to an assistant. With a pair 
 of narrow-bladed forceps, held at right angles with the first, the prepuce is 
 grasped transversely. With a sweep of the knife or scissors all the part 
 anterior to the forceps held transversely is divided ; both pairs of forceps 
 are removed, and it will be found that scarcely any of the mucous surface 
 has been cut through ; this must be lifted up with the forceps and trimmed 
 with the scissors, after which the sutures are applied. 
 
 Some surgeons prefer introducing the stitches first, and forceps with 
 fenestrated blades (Vidal's) have been invented for that purpose. The pre- 
 puce is drawn out, the fenestrated blades (held perpendicularly to the penis) 
 grasp the prepuce (Fig. 655), the ligatures are passed through the open- 
 ings in the blades, two being sufficient ; the prepuce is removed, and through 
 the preputial orifice the threads are drawn forward and cut, thus making 
 four ligatures, which, being tied, unite the mucous and integumentary 
 surfaces (Fig. 656). 
 
 Dr. Hutchinson, of the Brooklyn City Hospital, has devised a pair of 
 forceps " for rupturing the mucous membrane in accidental phimosis " (Fig. 
 657). The doctor says : " The operation consists in introducing the blades 
 of the forceps closed, through the preputial opening and along the dorsum 
 of the glans penis as far as the corona. They are then suddenly expanded, 
 and withdrawn fully dilated. The prepuce can at once be retracted behind 
 the corona glandis, when it will be found that the mucous membrane has 
 
 * South's Chelius, vol. ii. 
 
1012 
 
 A SYSTEM OF SUEGERY. 
 
 been split at the seat of stricture, the skin being uninjured unless the 
 phimosis has been produced by a cicatrix at the preputial orifice, which 
 existed in one of my cases, and was ruptured. The patient is now directed 
 to retract the prepuce behind the glans several times a day, especially 
 during micturition, both in order to prevent the contact of urine with the 
 wound, and also the too rapid union of the ruptured edges, which would re- 
 
 FlG. 655. 
 
 FIG. 656. 
 
 Dividing the Prepuce. 
 
 Ligatures in Position. 
 
 produce the disease. The patient should be cautioned not to leave the 
 foreskin retracted behind the glans, for swelling might occur to such a 
 degree as to cause paraphimosis. This indeed happened in one case at the 
 Brooklyn City Hospital, which was operated upon by house surgeon H. T. 
 Pierce. The prepuce was drawn forward by the usual manipulations, aided 
 by ether spray thrown upon the glans by Richardson's atomizer, to diminish 
 
 Fig. 657. 
 
 Hutchinson's Prepuce Dilator. 
 
 the size of the organ. This operation should not be practiced when chan- 
 croids are present, for fear of inoculation, nor until sufficient time has elapsed 
 for the phimosis to disappear spontaneously. 
 
 " The above operation has now been repeated nine times by myself and 
 house surgeon H. T. Pierce with the most satisfactory results. It will be 
 found, I think, to possess the following advantages over the methods of treat- 
 ment ordinarily practiced : 
 
 " 1st. It is preferable to circumcision, or slitting up the prepuce, because 
 it is simpler, is done more quickly, and there is no haemorrhage requiring 
 
PARAPHIMOSIS. 1013 
 
 the use of haemostatic agents. But when the prepuce is much diseased, 
 circumcision should be preferred. 
 
 " 2d. It is better than simple dilatation by means of Thompson's urethral 
 dilator, as suggested by Mr. Erichsen, because the contraction is less likely 
 to recur after rupture than after dilatation. 
 
 " 3d. It is preferable to simple division of the mucous layer of the pre- 
 puce, which is done by thrusting one blade of a sharp pair of scissors 
 between the layers of the prepuce, while the other is carried along the dor- 
 sum of the glans penis, so as to divide the mucous membrane to the corona 
 glandis, because there is less danger of a reproduction of the disease after a 
 rupture than after an incised wound." 
 
 Paraphimosis. — Paraphimosis is the reverse of phimosis — the prepuce 
 becoming retracted behind the corona glandis, leaving the glans uncovered ; 
 the body of the organ is constricted by the tight preputial orifice, and gives 
 rise to unpleasant and sometimes dangerous consequences. The superficial 
 areolar tissue becomes swollen on either side of the stricture, the glans being 
 involved in the tumefaction, and an acute inflammatory process is estab- 
 lished under adverse circumstances, the strangulated parts being obviously 
 ill-provided with the power of resistance or control. 
 
 The disease may be either congenital or acquired, though the latter is 
 more common. It may be the result of a retraction of the prepuce, when 
 the patient had previously been affected with phimosis ; but it generally 
 proceeds from inflammation, induced by a syphilitic or gonorrhoea! disease. 
 In some instances the swelling and constriction are so great that mortifica- 
 tion ensues, and the glans, or even the whole penis, may be lost ; this, how- 
 ever, must be considered a rare termination. In neglected cases, ulceration 
 of the body of the penis may take place, perforating the urethra, and pro- 
 ducing urinary fistula. 
 
 Treatment. — In recent cases, before the swelling has attained any consid- 
 erable size, reduction is practicable. The patient having been placed in a 
 suitable position, and the parts well oiled, the surgeon grasps the glans with 
 the fingers of the right hand and makes pressure thereon, at the same time 
 pushing it steadily from him ; with the fingers of the left hand he draws 
 forward the constricting portion — the object being to push the glans, when 
 diminished by pressure, through the narrow preputial orifice. If it should 
 fail, and there be no marked urgency, the penis should be placed in an erect 
 position and a stream of cold water poured on it. This may have a happy 
 effect in diminishing the bulk 
 
 of the formerly turgid part, and FlG - 658 - 
 
 it may be replaced within the 
 prepuce without much diffi- 
 culty. 
 
 For many of the symptoms 
 connected with paraphimosis, 
 aconite, cannabis, sabina, and 
 mercurius are the appropriate 
 medicines ; but should these 
 fail, resort must be had to an 
 operation. 
 
 The tumefied parts are to be 
 separated by the fingers, and 
 
 the Strictured band CUt through Method of making Incision in Paraphimosis— Bbyant. 
 
 with the sharp point of a knife, 
 
 when the prepuce should be drawn forward so as to occupy its normal 
 position : this operation is recommended by Mr. Hunter. That of Richter 
 consists in raising a fold of the skin, and cutting through it ; a director is 
 
1014 A SYSTEM OF SURGERY. 
 
 pushed beneath the stricture, and the latter is divided by a sharp bistoury. 
 (Fig. 658.) 
 
 Epithelioma of the Penis. — Cancer of the penis is generally of the epithe- 
 lial, and rarely of the encephaloid variety. The disease commences with 
 the appearance of a small watery excrescence or pimple on the prepuce or 
 glans. It often occurs in old persons, and may be traced to the irritation 
 consequent upon phimosis, commencing b} 7- ulceration at the preputial 
 orifice, and thence extending to the body of the penis. The glans becomes 
 hardened and enlarged, ulcers of an irritable appearance penetrate it, the 
 lymphatics on the dorsum of the penis become swollen and indurated, the 
 glands of the groin are involved, and the discharge from the sore is fetid 
 and irritating. The disease follows the ordinary course of cancer. 
 
 Treatment. — Medicines which have been mentioned for cancer in other 
 parts of the body, may be used ; in a majority of instances amputation is 
 the only resort ; and this is not always successful, as the disease reappears 
 in the stump, or exhibits itself in the inguinal glands. 
 
 Amputation of the Penis. — Ricord's method of amputating is good, being 
 calculated to obviate the difficulty attendant upon the operation — namely, 
 tendency to contraction in the orifice of the urethra. 
 
 The penis is put upon the. stretch b}^ the left hand, and removed with one 
 cut, care being taken to leave sufficient integument to cover the corpora 
 cavernosa ; the surgeon, seizing the mucous membrane of the urethra by 
 means of forceps, with a pair of scissors makes four slight incisions, to 
 form four equal flaps ; then using a fine needle armed with a silk ligature, 
 he unites each flap of membrane to the skin by a suture. The wound heals 
 by the first intention, adhesions form between the skin and mucous mem- 
 brane (these textures becoming continuous), and the cicatrix contracting, 
 tends to open the, urethra. When micturition is difficult of accomplish- 
 ment, in consequence of the shortness of the penis, the inconvenience may 
 be obviated by allowing the patient to urinate through a funnel-shaped 
 canula. 
 
 During the operation fine ligatures are required. If the penis has to be 
 amputated close to the body, a stout cord or wire may be passed through 
 the base of the organ to draw it downward in cases of retraction and sec- 
 ondary haemorrhage. 
 
 Many surgeons use the ecraseur or the galvano-cautery, and thus prevent 
 danger of haemorrhage. The integument may first be divided to form a 
 track for the chain of the instrument. 
 
 Spermatorrhoea. — The symptoms of this affection are well known. It is 
 a mistake to suppose, because a young person in all the vigor of man- 
 hood has an occasional nocturnal emission, that the disease exists. It is a 
 question whether certain emissions of semen without copulation are not 
 necessary to the preservation of virility. This fact is not sufficiently under- 
 stood, and young persons having had an emission or two become alarmed, 
 apply to the physician, and are " put through " a disastrous surgical and 
 medical treatment. Cases of spermatorrhoea are occasioned by masturba- 
 tion, and this must be controlled by the will and proper medication. 
 
 The symptoms are emissions of semen, at night or towards morning, 
 gradually increasing, until they recur with great frequency. 
 
 The patient does not feel the loss at first, but, as the pollutions increase, 
 there is depression of the mental powers, ringing in the ears, loss of strength, 
 emaciation, and great bodily disturbance, dyspepsia, constipation or diar- 
 rhoea, and flatulence, until the mind itself shows symptoms of decay. 
 
 Treatment. — Some years since I frequently made use of the instrument 
 of Lallemand, and cauterized the seminal ducts. I have never known an 
 instance of its curing, or even benefiting the patient, while I have known 
 
EXAMINATION OF THE UTERUS. 1015 
 
 it to produce bad results from tampering with a sensitive urethra. I have 
 also tried the perineal pad, perhaps with benefit. 
 
 With gelseminum, platina, agnus castus, and nux vom., together with 
 cold sitz-baths, proper exercise and ventilation, I have cured many cases. 
 Patient and persevering application of the means will accomplish the de- 
 sired end. 
 
 Kafka* remarks that nux vomica takes high rank in the treatment of 
 onanism and pollutions. Its characteristics are ; nervous erethism all over, 
 and especially in the sexual sphere ; frequent pollutions, with lascivious 
 dreams ; sleeplessness in the forepart of the night, and sleep with pollutions 
 toward morning ; ejaculation of semen from the slightest cause without 
 erection, and coldness and weakness of the lower extremities after it : hypo- 
 chondriasis, dyspepsia, and constipation. 
 
 Nux vom. or calcarea will be indicated, especially for pressing pains in 
 the head, neck, and back, after the pollutions ; lassitude and weakness in 
 the lower extremities. 
 
 Dr. Lilienthal recommends sulphur, mere, staphisagria, phosphorus and 
 phosphoric acid, acidum sulphuricum, anacardium, bufo, cobaltum, dios- 
 corea, eryngium aquaticum, gelseminum, graphites, iris versicolor, hama- 
 melis virg., kali brom., lycopodium, naja tripudians, natrum mur., nuphar 
 lutea, selenium, sepia, thuja, ustilago maidis, zincum oxidatum. 
 
 Circumcision ought to be performed early if there is a redundant or con- 
 tracted prepuce. 
 
 CHAPTER XLVII. 
 INJURIES AND DISEASES OF THE FEMALE GENITAL ORGANS. 
 
 Examination of Uterus— Carcinoma — Scirrhus — Epithelioma, Vegetating and 
 Ulcerating — Amputation of the Cervix — Uterine Tumors — Fibro-Myomata 
 — Vaginal Removal, and Laparotomy — Hysterectomy — Vaginal Extirpation 
 of the Uterus— Oophorectomy — Laceration of the Perineum — Vaginismus — 
 Elephantiasis of the Labia. 
 
 It is not to be expected, in a work on General Surgery, that much space 
 can be devoted to gynaecology : that department already covers so wide a 
 field, that a series of volumes can scarcely contain all that is known con- 
 cerning the varied diseases of the uterus and appendages. 
 
 There are, however, some diseases and operations that fall within the 
 province of every physician, and to these allusion may be made. These 
 are tumors of various kinds, including ovarian cysts and ovariotomy; 
 oophorectomy, cancer of the uterus, vaginismus, fistulas, lacerated peri- 
 nseum, cervix, and atresia vaginas. 
 
 Examination of the Uterus. — Position is a matter of import in the exami- 
 nation of a patient, and may vary with the kinds of instruments to be em- 
 ployed, and the operations to be performed. 
 
 If the examination be made by touch, the patient should recline on her 
 
 * Horn. Therapie, i., 942. 
 
1016 
 
 A SYSTEM OF SURGERY. 
 
 back, with the hips elevated and the head resting on a single pillow. She 
 should be close to the edge of the bed (the right side, if the surgeon is to 
 use his right hand, and vice versa), and the sheet and coverlet should fall 
 over the side of the couch to prevent any exposure of person, when the 
 hand is introduced. If the patient is to be examined with her clothing on, 
 the covering should be placed over the lower parts of the body. The knees 
 should be slightly raised, and the operator, sitting on a chair facing the 
 patient, having lubricated the fore-finger of his right hand with oil, glycerin, 
 or soap, raises the covering slightly with his left hand, and introduces the 
 
 Fig. 659. 
 
 <3,77£/VWVA/&Co. 
 Fergusson's Speculum. 
 
 oiled finger into the vagina at the posterior fourchette. If the speculum be 
 used, the patient should face the light; the thighs be flexed on the abdo- 
 men, and the legs on the thighs, and the knees separated. A sheet should 
 be thrown over the lower portion of the person, and each end of the linen 
 wrapped around the legs, as the thighs are open. By such a manoeuvre 
 carefully performed, there need be no exposure. A great variety of specula 
 have been and are now being introduced to the profession. The old- 
 fashioned one of Fergusson (Fig. 659) is preferred by some operators. It 
 
 is made of glass, coated with india-rubber 
 fig. 660. on the outside, and lined with quicksilver. 
 
 Most of the specula are more or less modi- 
 fications of the instrument of Dr. Sims,* 
 and to him belongs the credit of allow- 
 ing atmospheric air, to enter the vagina 
 and dilate the canal. Fig. 660 shows the 
 speculum which now receives the name of 
 the inventor. The patient for the intro- 
 duction of this instrument must lie in a 
 semiprone position. The right thigh must 
 be flexed, so that the right knee will be 
 above the left, and the left arm must be 
 drawn well behind the patient, that the 
 left side of the thorax will come closely in 
 contact with the couch. When the specu- 
 lum is introduced, it must be drawn up 
 well to put the perinseum on the stretch ; 
 provided the posterior wall of the vagina 
 is to be viewed, it may be drawn under the 
 Sims's speculum. pubes, its position being reversed if the 
 
 vagino-rectal septum is to be brought under 
 observation. Fig. 661 represents Nott's speculum open. It is self-retain- 
 ing, and has two short arms, which depress the anterior wall of the vagina. 
 
 Silver Sutures in Surgery. 
 
CARCINOMA OF THE UTERUS. 
 
 1017 
 
 Dr. William 0. McDonald's modification of Sims' speculum, one flange 
 being much shorter and broader than the other, is now used almost entirely 
 
 Fig 
 
 Nott's Speculum. 
 
 at the Hahnemann Hospital. Its advantages are additional expansion of 
 the posterior vaginal wall, and the increased facility with which any ma- 
 nipulation of the cervix can be accomplished. Comstock's " Gynepod " is 
 seen further on in this section. 
 
 Uterine probes and sounds (Fig. 662) are necessary in ascertaining the 
 internal condition of the uterus. 
 
 Fig. 662. 
 
 Uterine Probes and Sounds. 
 
 Carcinoma of the Uterus. — The uterus is frequently the seat of carcinoma, 
 but there are other diseases which may simulate one or other of the varieties 
 of cancer and render the diagnosis difficult. Venereal ulcerations, polypus, 
 and even prolapsus, have been mistaken for carcinoma, and have been 
 treated accordingly, the error not being discovered until the disease was 
 too far advanced to admit of successful treatment of any kind. A minute 
 examination and inquiry must, therefore, be instituted, and the microscope 
 employed in the examination of the discharges, before venturing to offer 
 any decided opinion concerning the character or termination of the affec- 
 tion. 
 
 Scirrhus of the Uterus. — In scirrhus, the cervix and mouth of the uterus 
 become heavier than usual; there is likewise inequality of surface with 
 hardness. The organ appears situated lower down in the vagina than natu- 
 ral. There is pain during coitus, and the lancinations which are experi- 
 enced are often severe. As ulceration progresses, pain is experienced when 
 touching the part ; ulcers appear with spongy bottoms and callous edges, 
 and frequently fungi sprout from the surface of the wound. In most cases 
 the vagina participates, losing its natural rugosity and becoming contracted, 
 nodulated, and finally the whole cavity of the matrix becomes filled with 
 
1018 A SYSTEM OF SURGERY. 
 
 degenerate tissue, with frequent bleedings and offensive discharges. Some- 
 times the bladder, at others the rectum, is perforated by the ulceration. 
 
 Epithelioma. — In the incipent stages of epithelioma, the disease is fre- 
 quently mistaken for irregularity of the menstrual function ; for leucorrhcea 
 or chronic metritis. The first symptoms are cessation or too frequent return 
 of the menses, irregular discharges of blood in place of the eatamenia, to- 
 gether with fluor albus. The patient complains of a sensation of heaviness 
 or drawing within the pelvis, and pressing towards the external organs, 
 being aggravated or excited by various circumstances, such as lifting, 
 fatigue, etc. Upon examination, the vaginal portion of the uterus is found 
 to be preternaturally indurated, bleeding readily, of irregular consistence, 
 swollen, misshaped, tuberculous, and sensitive to pressure ; the lips of the 
 os uteri are interstitially infiltrated, indented, and elevated, and the orifice is 
 distended. The pains become violent, particularly at night, and are press- 
 ing, stitching, shooting, and burning, not only in the pelvis, but extending 
 into the lumbar region and along the thighs, with swelling and tension of 
 the inguinal glands ; frequently there is a continual burning pain in the 
 lower part of the pelvis, accompanied with shooting pains in the uterus. A 
 pungent acrid ichor, of a reddish-brown or claret color, exhaling a deleterious 
 effluvium, is discharged from the vagina, excoriating the surrounding in- 
 tegument, and giving rise to painful itching of the external organs. Copious 
 discharges of blood, containing coagulated and fibrinous substances, are fre- 
 quent, and sometimes cause great exhaustion. The cancer has now changed 
 to an open, irregular ulcer, which is readily recognized by the touch. The 
 neck of the uterus feels rugged, and is studded with soft, readily-bleeding 
 excrescences, which are narrow at their base, as though a ligature had been 
 placed around them ; these fill up the whole vagina, the walls of which are 
 indurated or disorganized, conveying to the finger the sensation as of a 
 hard, contracted ring. As the disease advances, the symptoms of the cancer- 
 ous dyscrasia become more apparent ; the skin is of a pale straw color ; the 
 features exhibit an expression of suffering ; the digestive functions are im- 
 paired ; sleep is almost impossible, the patient emaciates, and hectic fever 
 supervenes. The affection frequently occurs between the ages of forty and 
 fifty, and as it proceeds it may partake of one of the two varieties, — vege- 
 tating or ulcerating. 
 
 Vegetating Epithelioma. — This affection was formerly called " cancroid," 
 but belongs to the cancer family, differing chiefly from other forms in the 
 depth of parenchymatous involvement. The name epithelioma was given 
 to it in 1852, by Hannover. 
 
 The cauliflower or strawberry-shaped excrescence of the os tineas is seated 
 generally on one of its lips, or in some instances proceeds from the whole 
 circumference. This fungus grows from a broad base, is soft, of a bright 
 flesh-color, presents a granular or straAvberry-shaped surface, and to the 
 touch conveys somewhat the same sensation as that of the uterine surface 
 of a placenta, It is formed of large papillae with a central stroma covered 
 with epithelium, which grows in nests. The ulceration is superficial, the 
 walls and floor of which are infiltrated with round cells. This disease has 
 been considered as a local affection, and progresses slowly, the latter feature 
 serving as one of the diagnostic marks between it and cancer. There is 
 another variety of epithelioma, which ulcerates instead of propagating a 
 fungus. To this the term ulcerating epithelioma is given. 
 
 Ulcerating Epithelioma was formerly called phagedenic uterine ulcer ; this 
 is preceded by a pseudo-plastic formation, or infiltration of the surrounding 
 textures. The uterus around the ulcer may be almost in a normal condi- 
 tion, but in the generality of instances the sore is surrounded by a diseased 
 mass, which is soft and yellow, or of a reddish-brown color. If the un- 
 
EPITHELIOMA OF THE UTERUS. 1019 
 
 healthy action be not arrested, the destruction may extend to the wall of 
 the uterus, to the vagina, rectum, and perinseum. 
 
 Treatment. — When the disease is established, the physician can do little 
 else than palliate the sufferings of the patient, though in the incipient 
 stages benefit may be had from treatment. In the later stages the uterus 
 feels like a hard body lying above the pubic bones, and presents the follow- 
 ing symptoms, which correspond to belladonna. Pressing and fulness of 
 the inner parts, rendering it difficult for the patient to stand, accompanied 
 with pain in the sacral region. Likewise when a sanguineous ichor is dis- 
 charged from the uterus, either continually or at intervals. Platina is indi- 
 cated by spasmodic, or pressing colicky pains, accompanied with a dis- 
 charge of thick, viscid, venous blood, especially if the patient previously 
 suffered with profuse menstruation. If constipation, nervousness, and a 
 long-lasting, though regularly occurring discharge of acrid blood, with burn- 
 ing, smarting, and itching be present, nux vom. should be administered. 
 The debility which supervenes in consequence of the pain and loss of blood, 
 is relieved by china, Arsenic, sepia, creasote, iodine, conium, and thuja 
 may be used with advantage. 
 
 The treatment which has given me most satisfaction is the early applica- 
 tion of Marsden & McLement's paste (vide page 183) and the hypodermic 
 use of Declat's nascent phenic acid — 60 to 80 minims being injected into 
 the skin of the abdomen or upper portions of the thigh every night and 
 morning. In addition to this a granule of arsenic, 1-100 of a grain, should 
 be given after dinner. The paste is to be applied upon cotton, through a 
 cylindrical speculum, and the wad pressed firmly upon the cervix. It 
 should be allowed to remain three hours, be then withdrawn, and the parts 
 carefully syringed with hot water. The application may have to be re- 
 peated six or eight times. 
 
 Dr. Wahle, of Rome, Italy, prescribed graphites for the following symp- 
 toms: The vagina hot and painful; swelling of the lymphatic vessels and 
 mucous glands, some of which are of the size of a filbert ; the cervix uteri 
 hard and swollen, and on its left side three large and painful tubercles of 
 various sizes, each consisting of several smaller ones, which threaten to 
 change to a bleeding excrescence ; upon rising a sensation as of great 
 weight is experienced deep in the abdomen ; with increase of pain, debility 
 and tremor of the lower extremities ; the sufferings are most acute shortly 
 before and during the period of menstruation; the discharged blood is 
 black, coagulated, and emits a disagreeable odor ; a sensation of heaviness 
 is experienced in the abdomen, with violent lancinations in the uterus, ex- 
 tending down the thighs, somewhat resembling the passage of an electric 
 current; the pains are burning and lancinating; little appetite, constipa- 
 tion, frequent chilliness, without .subsequent heat and sweat; the patient is 
 sad, anxious, and sometimes desperate ; complexion livid ; pulse frequent 
 and rather hard. 
 
 ' It is necessary that injections of disinfecting substances be made use of, 
 and for this I employ Piatt's chlorides or Labarraque's solution. The 
 reader may refer to Disinfectants for information on this subject. 
 
 It may be considered necessary, under certain circumstances, to extir- 
 pate the cervix uteri or the entire uterus, which subjects will be treated 
 in this chapter. 
 
 Amputation of the Cervix.— Prof. Osiander, of Gottingen, was the first to 
 conceive and execute excision of the cervix uteri, and his example was fol- 
 lowed by Dupuytren and other distinguished surgeons. The first operation 
 was performed by Osiander in 1801, on a widow, whose vagina was filled by 
 a vascular fetid fungus from the orifice of the womb, as large as a child's 
 
1020 
 
 A SYSTEM OF SURGERY. 
 
 head. By means of Smellie's forceps the fungus was brought down low in 
 the vagina, but being accidentally broken, haemorrhage ensued ; undis- 
 mayed, the operator determined to proceed, and immediately pushed a 
 number of crooked needles, armed with strong ligatures, through the bot- 
 tom of the vagina and body of the uterus, until they emerged at the inner 
 orifice. These ligatures served to draw down the uterus, and retain it in 
 the vagina near the external orifice. The surgeon then introduced a strong 
 bistoury above the scirrhous portion, and divided the womb completely in 
 a horizontal direction. The haemorrhage, though profuse for an instant, 
 was speedily suppressed, and the patient recovered in three or four weeks. 
 Osiander afterwards performed eight similar operations upon different pa- 
 tients, all of whom recovered. 
 
 Dupuytren operated eight times ; but, instead of employing the ligatures 
 and bistoury recommended by Osiander, he drew down the uterus with 
 forceps, and divided it above the scirrhus by knives and scissors. This pro- 
 cedure is recommended at the present time. 
 
 The operations of to-day may be made either with scissors and knives, 
 with the ecraseur, or b}^ the galvano-caustic wire. 
 
 The patient should be placed in the position of Sims — see p. 1016 — and 
 
 Fig. 663. 
 
 Scissors Curved on the Flat. 
 
 the cervix divided bilaterally ; the lips are then seized, drawn downward, 
 and removed with the scissors ; these should be curved on the flat, as seen 
 in Fig. 663, or have long handles, with the cutting edge at right angles 
 (Fig. 664). Sims, after the amputation, drew down the mucous membrane 
 
 Fig. 664. 
 
 Long Uterine Scissors. 
 
 and stitched it over the raw surface. If the ecraseur be used, the chain is 
 applied as high up as possible, and the screw worked slowly. By referring 
 to page 259 et sequentes, the student will understand the method of using the 
 instrument. If the galvano-caustic is used, the wire instead of the chain is 
 
 Fig. 665. 
 
 G. TIE MANN & CO. 
 
 Electro-cautery Sling and Platina Wire. 
 
 applied. Fig. 665 represents the looped platina wire and the sling for its 
 application. This method is the safest of the three, and I have had satis- 
 faction in witnessing its thoroughness and efficiency in numerous cases. 
 
UTERINE TUMORS. 1021 
 
 Uterine Tumors — Fibroids— Fibro-Myomata — Myomata. — There is a dis- 
 crepancy among writers concerning tumors of the uterus. They are called 
 fibroid, fibro-cystic, and polypoid. Some classify them according to their 
 seat, others according to the texture of the parenchyma. Virchow denomi- 
 nates them myoma, to which term Billroth objects, and declares that myo- 
 fibroma should be the name, because there is a mixture of fibrous and mus- 
 cular substances. The latter is the term generally in use. 
 
 A fibroid tumor consists chiefly of connective tissue and unstriped mus- 
 cular fibres, It is probable that the preponderance of the latter element 
 caused Virchow to classify these tumors as myoma. The connective tissue 
 is hard and firm in the majority of cases, in others it is loose, but in 
 either case generally formed in concentric layers. 
 
 Rokitansky makes three varieties of fibroid tumors of the uterus. 
 
 The first variety is distinguishable : 
 
 1st. By its smallness. 
 
 2d. By its spherical shape. 
 
 3d. By its density. 
 
 4th. By its hardness. 
 
 5th. By its poverty of vessels. 
 
 This latter is common in married women. 
 
 The second variety, which is the true fibro-cystic tumor, is distinguished : 
 
 1st. By a concentric arrangement of fibres, which is more discernible 
 before their immersion in spirits. 
 
 2d. By an accumulation of softer tissue in the interstices, and their re- 
 semblance either to a coarse-grained salivary gland or to a soft mammary 
 gland. 
 
 3d. By a peculiar soft, doughy, elastic " feel," and the fluctuation of the 
 fluid in the cysts. 
 
 4th. By a somewhat rounded and nodulated exterior. It is this variety 
 that attains the largest size. 
 
 These tumors become more cystic as they advance in age, and the best 
 explanation of the transformation is that of Coe,* who has given a great 
 deal of study to the subject. In his sixth conclusion he states : " such cysts 
 probably arise from the so-called ' geodes ' or gelatinous patches," and in 
 his eighth conclusion he affirms : " The geodes are probably dilated lymph 
 spaces, which expand by reason of the accumulated fluid in their interior, 
 a condition due to a general stasis." 
 
 The third variety, or true fibroid polypus fibro-cystic, is distinguished : 
 
 1st. By its distinctly lobulated surface. 
 
 2d. Its expansion of fibres, making, 
 
 3d. Internal cavities of considerable size. 
 
 4th. Its flattened shape. 
 
 5th. Its close adherence to the uterine parenchyma. 
 
 6th. Its great vascularity. 
 
 7th. Its congested and reddened appearance. 
 
 By bearing in mind these peculiar characteristic appearances, it will not 
 be a difficult matter to diagnose the variety of uterine tumor that may be 
 encountered by the physician. 
 
 The most common classification of the present day of these tumors is into 
 submucous, subperitoneal, and interstitial, according to their seat and the manner 
 of their development. M. Malgaigne f makes five divisions of the polypus : 
 1st. The vascular. 2d. The cellulo-vascular. 3d. The polypus from hyper- 
 trophy. 4th. The moliform. 5th. The fibrous polypus. 
 
 * American Journal of Obstetrics, 1882, p. 877. 
 f Colombat, " On Females," p. 390. 
 
1022 A SYSTEM OF STJRGEKY. 
 
 Colombat appears to divide them into pedunculated and non-pedunculated, 
 the former being the true polypus, the latter the fibroid tumor. Other phy- 
 sicians recognize the glandular, the cellular, and the fibrous polypus. Thomas 
 defines uterine polypus " as a tumor covered by the mucous membrane of 
 the uterus and attached to that organ by a pedicle or stem " (p. 508). It is 
 a well-known fact that submucous fibroids become pedicellated ; they would 
 then be classified as polypi. Fibroid is as good a term for these growths as 
 can be applied. But the best and most simple classification is that of 
 Rokitansky, of which I have condensed the main features. With refer- 
 ence to the frequency of their appearance, we quote a single passage from 
 Colombat : 
 
 " The fibrous tumors, properly so called, that are developed under the 
 same influences as those that produce the pedicellated sort (polypi), are far 
 more frequent than the latter. Boyle estimates that in one-fifth the number 
 of women beyond thirty -five years of age, he met with samples of one or 
 more fibrous tumors. Patal found a still larger proportion, since in twenty 
 wombs he examined in 1770 there were thirteen exhibiting the fibrous ex- 
 crescence. Lastly, according to Dupuytren, there are but few specimens of 
 the womb in aged women that are unaffected with tumors." 
 
 These statistics are somewhat modified by Dr. Orrum, who, in 1002 post- 
 mortem examinations for six years, found but 53 individuals who showed 
 the appearances of fibroids. Under 20 none were discovered ; after 40 they 
 occurred in 12 per cent, of the bodies examined.* 
 
 A fibro-myoma of the uterus may attain considerable size before any 
 special symptoms are noted. I had under treatment a lady, who for two 
 years had projecting from the os uteri a fibroid tumor of the second variety, 
 which gave little inconvenience excepting by the occasional discharge, which 
 was mucous and bloody in character. In general, the patient experiences 
 a sense of weight and fulness about the uterus, often accompanied with 
 frequent desire to urinate, which disagreeable sensations are aggravated at 
 the menstrual period. In many cases a reflex nervous action upon the 
 stomach causes constant nausea. The discharges are not always bloody, 
 although the haemorrhage may be so exhausting as to endanger life. ' Were 
 it not for the bleeding and constant anaemia and exhaustion following every 
 menstrual period, a patient might pass through life with but little disturb- 
 ance, for it is an acknowledged fact that the organs of the human body, 
 and the uterus in particular, tolerate these growths with remarkable facility ; 
 indeed, they may last for years, and the only unpleasant symptoms be those 
 of pressure. On the other hand, as already stated, the distressing and alarm- 
 ing haemorrhages often bring the patient to the verge of the grave. 
 
 When the growth is subperitoneal, it can generally be recognized by the 
 eye and by palpation ; when submucoid, the uterine sound gives evidence 
 of the neoplasm ; and when the interstitial growths are present, the fre- 
 quent and prolonged haemorrhages, if they are not pathognomonic, are 
 sufficient to place the surgeon on his guard. It must be remembered, in 
 making a diagnosis, that large fibro-cysts (second variety)t may exist with- 
 out haemorrhage, and that women of full habit, of complaining and hys- 
 terical temperaments, while passing through the climacteric, suffer from 
 profuse bleeding, at irregular (often very short) intervals. The abdomen, 
 in such persons, often enlarges, and the abdominal muscles, from hysteri- 
 cal contractions, become irregularly rigid. I have known a myo-fibroma 
 coexist with a distinct carcinoma. 
 
 I repeat, that the presence of profuse and protracted haemorrhage de- 
 
 * Howitz, Gynaecological and Obstetrical Transactions, vol. ii., 1878, No. 1. 
 f Vide Good ell, Am. Journ. of Obstet., vol. xiii., p. 146. 
 
UTERINE TUMORS. 1023 
 
 mands immediate and thorough examination with the sound, and by pal- 
 pation, both single and bimanual, and that such examinations should be 
 often instituted. 
 
 It may be difficult to diagnose between fibro-myoma and distension of 
 the Fallopian tubes. I, therefore, give the following differential diagnosis 
 between these two diseases, taken from Dr. P. Horrocks' article in the British 
 Medical Journal:* 
 
 "1. Fibro-myomata are usually accompanied by menorrhagia, and disten- 
 sions of the tube are not. 2. Fibro-myomata, especially when intramural, 
 cause uterine enlargement ; while in distension of the Fallopian tube the 
 uterus is not enlarged, or only slightly, unless complicated by some other 
 condition. 3. Fibro-myomata are usually painless, except that there is 
 often dysmenorrhcea, and, if large, a bearing-down pain, or sense of weight: 
 while in distension of the tube the pain is constant throughout the inter- 
 menstrual period, aching in character, and aggravated by the menstrual 
 period. 4. Nutrition is not much affected in fibro-myomata, while it is in 
 distension of the tube, especially when the distension is caused by pus ; 
 hence, wasting or loss of flesh is a valuable distinction. 5. The temperature 
 is normal in fibro-myomata, raised more or less according to nature and 
 amount in distensions of the tube. 6. Fibro-myomata, when intramural, 
 move much more rigidly with the uterus than distensions of the Fallopian 
 tube. 7. Fibro-myomata are much less painful, on pressure, than distensions 
 of the tube. 8. Fibro-myomata are usually much firmer in consistence 
 than distensions of the tube. 9. Intermenstrual discharges, usually yellow, 
 are much commoner in distension of the Fallopian tube than in fibro- 
 myomata. 10. The position and direction of the uterine cavity is much 
 more affected by fibro-myomata than by distensions of the tube. 11. Fibro- 
 myomata are usually more or less spherical, distensions of the Fallopian 
 tube cylindrical. 12. Aspiration yields serum or pus in hydrosalpinx or 
 pyosalpinx, and blood in fibro-myomata and hematosalpinx. 13. Disten- 
 sions of the Fallopian tube are accompanied by pelvic inflammation much 
 more frequently than fibro-myomata." 
 
 Treatment. — The question arises, Can such tumors be removed by the 
 administration of internal medicine? From my experience I would say 
 that in the earlier stages of the disease, when the outgrowths are small, it 
 may be possible to remove them by the exhibition of drugs. In the ma- 
 jority of cases, it is an absolute waste of time to attempt to remove the 
 larger growths by any other means than operative procedure. 
 
 The muriate of ammonia is highly spoken of in the treatment of the fibro- 
 cystic form of tumor. Dr. Minorf records a case, in which the muriate was 
 given in from three to six-grain doses, three times a day, dissolved in a 
 large quantity of water. The patient was kept under the treatment ten 
 months, "at the end of that time' the tumor was decreased to such small 
 dimensions that it could only be detected with difficulty. . . . She is now 
 apparently restored to perfect health." 
 
 Dr. John H. Thompson furnishes me the following : 
 
 Mrs. G. W. M., age 42 ; married ; has had four children ; the youngest, 
 seven years ago. 
 
 May 19th. Has been treated for a tumor by several physicians, without 
 deriving any benefit. On examination, a subperitoneal fibroid discovered 
 in the left hypogastric region, about the size of a small orange. 
 
 B . Ammon. mur., gr. v ter die in aqua q. s. f. haustus. 
 
 July 22d. Patient returned, complaining of tenderness of left ovary ; ex- 
 
 * Medical Kecord, July 3d, 1886. 
 f The Medical Union. 
 
1024 A SYSTEM OF SURGERY. 
 
 amination failed to detect any trace of a tumor. Several examinations, 
 made to October, show no reappearance. 
 
 Dr. Kidd* states that, though sabina, ferrum mur., and secale may be 
 homoeopathic to the symptoms produced by these tumors, " yet that their 
 use is only palliative, and in no way curative to the disease." He relates 
 four cases, one of which is reported as successful, the others not at all so. 
 Dr. Sampsonf reports in like manner. That the proper administration of 
 medicine will alleviate the symptoms produced by such abnormal forma- 
 tions there can be no doubt. For the expulsion, or to cause the resorption 
 of the submucous tumors, calc. c, kali hydriod., mere. corr. sub., and silic. 
 may be tried ; but if after their employment for a number of weeks no 
 diminution in the size of the growth is discovered, the sooner it is removed 
 by mechanical means the better. For the haemorrhages which supervene 
 I have been better satisfied with the action of secale and ferrum in low 
 potencies than with any other remedies ; ham., virg., cinnamon, crocus, 
 and sabina have been employed ; but the two first mentioned are generally 
 efficacious. The topical application of the preparations of iron, particularly 
 the perchloride and persulphate, are serviceable. It is well known that the 
 third variety of fibroid tumors, according to Rokitansky,J viz., the fibrous 
 polypus, is frequently spontaneously expelled. Quite a number of cases 
 are upon record, but those in which the growth returned are not so numer- 
 ous. While we are disposed to believe in the action of medicines admin- 
 istered to arrest haemorrhage, alleviate concomitant symptoms, and to assist 
 in the expulsion of the foreign body, we must remember that patients have 
 been relieved by nature, and recovered without the use of any medication. 
 Dr. Meigs relates a case of this kind in his edition of Colombat, and most 
 surgeons are familiar with them. 
 
 Removal Through the Vagina. — The best instrument for the eradication 
 of polypi is the ecraseur ; care must be taken to place the chain as high up 
 as possible, and, to prevent undue haemorrhage, to turn the screw very 
 
 slowly, frequently allowing it to remain at rest for a moment or two during 
 the course of the operation. There have been invented a great variety of 
 canula, knot-tyers, polypi forceps, etc., for the strangulation of the base or 
 pedicle of uterine tumors ; the 6craseur does away with all these. 
 
 There is often considerable difficulty in passing the wire around the 
 pedicle of the tumor ; in such, a canula, or the instrument of Van Buren 
 (Fig. 666), should be used: r represents a growth to be removed, t t are 
 two hollow tubes through which the wire is slipped; and thus, holding one 
 in each hand, and with the use of the hook, u, the wire is readily manipu- 
 
 * British Journal of Homoeopathy ; Fibroid Tumors of the Uterus, No. lxxix., p« 52. 
 t United States Journal of Homoeopathy, No. vi., p. 255. 
 X Pathological Anatomy, vol. ii., p. 211. 
 
UTERINE TUMORS. 
 
 1025 
 
 lated. The two cylinders are then passed into the ecraseur. 
 tightened, and the instrument gradually screwed up. 
 
 The screw is 
 
 Fig. 667. 
 
 G.T1EMANN &CO. 
 Braxton Hicks's Wire Ecraseur. 
 
 Fig. 667 represents Hicks's wire rope ecraseur, with three wire leaders, 
 and Fig. 668 exhibits the instrument of Emmet. 
 
 Many authors have recommended the gradual strangulation of the poly- 
 pus by tightening the ligature each day ; but if the ligature is used, we 
 
 Fig. 668. 
 
 Emmet's Ecraseur. 
 
 agree with Mr. Brown* that it is better to draw the thread or the wire 
 closely around the pedicle, and divide it with a sharp curved bistoury. 
 
 Enucleation. — If the tumor is of the submucous variety, enucleation 
 should be performed, as directed by Dr. Thomas :f " The cervix should be 
 fully dilated with tents or freely incised in two or three places, as practiced 
 by Dupuytren, Amussat, and Baker Brown. After checking haemorrhage, 
 if any be created by incision (should this have been resorted to), the vagina 
 being dilated by Sims's speculum, and the tumor held firmly by toothed 
 forceps, an incision is made over its surface and through its capsule. This 
 may be either straight or crucial. Thomas's scoop may then be introduced 
 and the mass gouged away. In some instances profuse haemorrhage follows, 
 but in others, and I think in the majority, though there is considerable 
 bleeding, it is readily checked by hot water and styptics. If the mass be 
 removed, all clots should be washed out of the uterus by a stream of water, 
 and the patient quieted by a full dose of opium. 
 
 "Sometimes a middle course may be followed with advantage: the os 
 being dilated or incised, a long crucial incision is made over the presenting 
 part of the tumor, and the lips of the capsule separated by the finger, in the 
 hope that the body of the tumor may present through this species of os and 
 be expelled by uterine effort. 1 ' 
 
 I have had a fair share of these cases, both pedunculated and sessile, and 
 as yet have not found any covered with a capsule. Dr. Emmet says : " It 
 is my conviction that fibroids become pedunculated only when influenced 
 by the force of gravitation, which causes uterine contraction. / do not 
 
 * On Some Diseases of Women Admitting Surgical Treatment. 
 f A Practical Treatise on Diseases of Women, page 498, 
 
 65 
 
1026 A SYSTEM OF SURGERY. 
 
 believe they have a capsule proper, the only capsule being the mucous mem- 
 brane of the uterus, covering their projection ; the only line of demarcation 
 between them and the uterine wall, being the difference in the density of 
 the respective tissues." 
 
 The author states, that by traction alone these tumors may be brought 
 without the cavity of the womb, and that he discovered the fact fourteen 
 years ago. He remarks, that when the tumor is larger than a pigeon's egg^ 
 the best method is to control haemorrhage, and assist the uterus in forcing 
 the tumor into the cavity, and remove the same by traction. After the 
 thorough removal of the debris, the application of Churchill's tincture of 
 iodine is said to act beneficially. There is no mention of any internal 
 treatment, and I must acknowledge that, excepting for arrest of haemor- 
 rhage, medicines are of no avail, and surgical treatment is the only reliable 
 cure. Large doses of ergot have a' tendency to force the intra-uterine 
 tumors into the vagina, and Dr. 0. Stroinski, of Chicago * in speaking of 
 the treatment of intra-mural uterine tumors, states that continued intra- 
 uterine injections of dilute subsulphate or sesquichloride of iron, will cause 
 the errowth to be forced into the uterine cavit} T , from which it may be more 
 readily extracted. 
 
 Hypodermic Injection of Ergot. — The cases suitable for these injections are 
 intra-mural tumors accompanied with profuse haemorrhages. The fibroid 
 polypus is not at all affected by this treatment so far as my experience leads, 
 excepting as it may be expelled from the cavity of the uterus into the 
 vagina by its use. It has been advocated strongly by Hildebrant, who uses 
 the following: Aqueous extract of er^ot, forty-six grains; glycerin and dis- 
 tilled water, each two- drachms.f The preparation which I have made is 
 the following : 
 
 R. Extra cti ergotae aquosse (Squibb), . grs. 200 
 
 Aquffi, m. 250 
 
 Stir, filter, and add 
 Aquam, ad "l 300 
 
 In this each minim represents six grains of powdered ergot. I also em- 
 ploy Squibb 's solid extract, so reduced that each minim represents four 
 grains of the powdered substance. 
 
 The action of ergot appears to depend upon the contractility of the mus- 
 cular tissue, and therefore those tumors partaking of the nature of myomata, 
 are especially adapted for the use of the secale. If the muscular fibrillae 
 have not undergone fatty degeneration, or been broken up by the appear- 
 ance of other growths, we may have a reasonable hope of success. 
 
 I cannot agree with Schroeder that the injections are painful ; in my 
 cases, excepting in one or two instances, the pain passed away soon after 
 the injection. Sometimes suppuration, which often follows the use of the 
 hypodermic syringe, has been set up, but no bad results have followed. On 
 one or two occasions, when I have injected through the abdominal parietes, 
 some symptoms of peritonitis have developed, which were speedily arrested 
 by aconite or belladonna. In several cases a chill has followed the injec- 
 tion, and in one alarming symptoms of collapse followed. Latterly, I have 
 inserted the needle into the side of the buttock, a process, I think, also 
 recommended by Hildebrant. 
 
 I can count about one-third cured ; in all alleviation of bad symptoms, 
 and in the majority a diminution of the tumor. I have had cases under 
 
 * Medical Kecord, July 19th, 1886. 
 
 f Ziemssen, Diseases of Female Sexual Organs, p. 250. 
 
UTERINE TUMORS. 1027 
 
 treatment for years, taking an injection every week, or once in ten days, 
 according to circumstances, and always ceasing during the menstrual pe- 
 riod. 
 
 The secale was administered both by the mouth and hypodermic syringe, 
 the latter being sometimes inserted into the cervix, or indeed into the tumor 
 itself. The substance used was Squibb's solid extract, reduced with water, 
 so that each minim of the solution contained about four grains of ergot in 
 powder. Internally, a gelatin-coated pill of five grains was administered 
 twice or three times during twenty-four hours. 
 
 In these cases we have not only the wonderful emmenagogue properties 
 of the spurred rye fully developed, but also its haemostatic powers brought 
 into play. The question may be mooted, as to whether this method of 
 treatment would not assist " the traction method," as recommended by 
 Dr. Emmet, and whether the physiological action of the drug itself would 
 not allay many of the disagreeable and alarming symptoms of pain, haemor- 
 rhage, and contractions, during the progress of the manipulations. 
 
 Dr. J. H. Thompson has been successful in many cases of uterine fibroids. 
 
 Dr. William H. Byford * in a resume of 101 cases of fibrous tumors 
 treated by ergot and reported by various observers, reports twenty-two 
 cured, thirty-nine diminished in size with removal of disagreeable symp- 
 toms and haemorrhage, nineteen benefited without diminution in size, and 
 twenty-one unaffected. In twenty-one of these cases the treatment was 
 suspended. He presents the following general conclusions : 
 
 1. Ergot may cause the tumor to be gradually disintegrated and absorbed 
 without any disagreeable symptoms. 
 
 2. Ergot may so interrupt nutrition as to produce rapid destruction, with 
 consequent decomposition within the capsule, and later expulsion of the 
 semi-putrid mass, accompanied by inflammation of the uterus and toxaemia 
 more or less grave. 
 
 3. It may cause the tumor inclosed in its capsule to be totally or par- 
 tially expelled from the cavity of the uterus, with more or less inversion of 
 the organ. 
 
 He calls attention to the fact that ergot may have a cumulative action, 
 and recites how in one case, after two months' persistent use of the drug 
 without any observed effect, " terrific uterine contractions " set in with 
 " explosive suddenness." 
 
 Dr. Byford concludes that " ergot, in the treatment of fibrous tumors of 
 the uterus, is a prompt and powerful agent, not to be recklessly used with- 
 out great danger ;" and that u the circumstances under which its adminis- 
 tration will be safe and effective " have not yet been determined. 
 
 M. Delore made injections into the tissues of the uterus itself. He em- 
 ployed one part of ergotin to two of distilled water, using a speculum and 
 piercing the cervix uteri. In these patients he observed phenomena of 
 different kinds: chills, trembling, bilious vomiting, fainting, troubles of 
 vision, diarrhoea, pain in the kidneys, thighs, legs, abdomen, or head. 
 In two cases he has seen abscesses produced. The cases had all been 
 relieved ; the haemorrhages had been arrested ; in fine, the results had been 
 encouraging. 
 
 M. Duplay has employed the method several times, and, while he has not 
 obtained curative effects, has obtained satisfactory results as to the relief 
 given. He has never seen any accidents. 
 
 M. Terrier has made a number of injections into the skin of the ab- 
 domen without accident; frequently they were made by the husbands of 
 
 * Month. Abs. Med. Science, May, 1876; American Medical Association, 1875. 
 
1028 A SYSTEM OF SURGERY. 
 
 the patients; in these cases the injections had been made not into the sub- 
 cutaneous cellular tissue, but in the skin itself, and were followed by small 
 foci of sloughing. The treatment had given good results in haemorrhages, 
 but in one case there was violent contraction of the uterus, and the metror- 
 rhagia was augmented. Probably the most satisfactory method of treating 
 fibro-myomata is the removal of the ovaries and tubes. The method of 
 operating will be detailed in the section on oophorectomy. 
 
 The Removal of the Tumor by Laparotomy. — In this operation, which can 
 be accomplished with good results, two methods may be employed : the 
 one being the removal of the pedunculated tumor per se, the other the re- 
 moval of the tumor with portions of the uterus attached. 
 
 The abdominal cavity is to be opened as usual (see Ovariotomy, Sutur- 
 ing Intestines, Hysterectomy, etc.), and, if possible, the tumor should be 
 raised and pushed through the incision ; if the neoplasm is larger, a long 
 cut is required, particularly if the tumor is solid. If the size of the growth 
 can be diminished, either by puncturing the cysts or cutting away parts 
 of the tumor, it may be done, but it is better to get it in its entirety through 
 the abdominal wall. Even after this is accomplished it is sometimes neces- 
 sary to gouge out portions of the growth to get access to the pedicle. 
 
 If portions of the womb are taken away, and the patient not have passed 
 her climateric, the ovaries and tubes ought to be removed also, else fatal 
 haemorrhage might occur, and cases of abdominal conception have been 
 recorded, from neglect of this precaution. 
 
 The treatment of the stump should be extra-peritoneal in all cases. The 
 method of performing this important portion of the operation will be de- 
 scribed when treating of supra-vaginal hysterectomy. 
 
 Hysterectomy. — The removal of the uterus and its appendages is an oper- 
 ation of magnitude and danger, but is justifiable in certain cases of myo- 
 fibromata of the womb, but whether it can be considered useful in malignant 
 disease of the organ, is a question which has not yet been decided. 
 
 The certainty of recurrence of cancer and the severity of the operation, 
 render its performance doubtful. Many surgeons, therefore, wholly con- 
 demn hysterectomy for malignant disease. My opinion is, from the great 
 mortality that attends it, the operation ought not to be undertaken. 
 
 Dr. A. Reeves Jackson,* in an admirable paper on this subject, declares 
 that " extirpation of the cancerous uterus does not lessen suffering, and it 
 shortens the aggregate of life," and that " other methods of treatment less 
 dangerous than extirpation of the uterus are equally or even more useful." 
 He bases his opinion on the fact that diagnoses of carcinoma cannot be 
 made out early enough to insure a non-return after extirpation ; and that 
 even if the operation be performed there is no reasonable hope of a radical 
 cure, and the operator neither ameliorates suffering " except in those whom 
 it kills." 
 
 Dr. Paul F. Mundef takes different ground, showing that the results are 
 more favorable than ordinary operations for the removal of the cancerous 
 cervix. He says, " that 39.2 per cent, of the cases in which the operation 
 was performed at a sufficiently early period to permit the incisions to be 
 carried through still healthy parametrium, remained free from recurrence 
 two years after the operation," and, " compared with the results reported 
 by Paeolik, of 25 per cent, after the removal of the cancerous cervix only, 
 and of Schroeder of 21.8 per cent, after different methods of operation," the 
 average can scarcely be considered unfavorable. These arguments, it must 
 be said, were chiefly concerning the vaginal extirpation of the womb. 
 
 * Gynaecological Transactions, 1883, p. 173. 
 f Gynaecological Transactions, vol. ix., 1884. 
 
HYSTERECTOMY. 1029 
 
 Hysterectomy is performed in two ways, one being known as the " vaginal 
 extirpation," the other as laparo-hysterectomy. 
 
 Laparo-Hysterectomy. — The patient should be thoroughly etherized, placed 
 upon the table, and a large pillow laid under the nates, to allow the intes- 
 tines to gravitate toward the diaphragm. The incision is commenced 
 just below the umbilicus, and extends downward upon the pubic bones. 
 The peritoneum should be opened, and as the omentum and intestines pro- 
 trude, they should not be drawn out, as first recommended by Freund (who 
 now has a netting to inclose them), but held within the cavity with soft 
 flannels, wrung out of hot water. The fundus of the uterus now comes in 
 view just about on a level with the pubic symphysis. Hanks 's hooks can 
 be used to draw up the organ, which should be steadied and elevated by an 
 assistant, with his fingers in the rectum. The right broad ligament may 
 then be drawn forward, and the upper two-thirds of it ligated in two sec- 
 tions, and divided close to the uterus. The left ligament is to be treated 
 in like manner. Haemorrhage on both sides may occur which requires 
 ligatures. After bleeding has ceased the finger is placed in the vagina and 
 carried over the anterior lip of the cervix, kept as a guide, firmly pressed 
 upon the cervico-vaginal junction. A sharp-pointed knife is then passed 
 through the mucous membrane. Into this opening, and keeping close to 
 the cervix, a Stohlmann's hysterotome is passed, the blades opened and 
 withdrawn, thus making a clean cut in front of the cervix. A similar 
 method is adopted posteriorly, the hysterotome being entered at the centre 
 of Douglas's pouch ; thus, the anterior and posterior junctions of the 
 vagina are cleanly divided, leaving the lateral connections containing the 
 uterine arteries intact. These incisions are made as close to the body of the 
 uterus as possible, to avoid inclosing the ureters when the ligatures are 
 applied. Simple as this procedure is to write, it is by no means so facile in 
 its accomplishment generally, on account of the enlarged cervix, which 
 projects into the vagina, as a champagne cork does into the neck of the 
 bottle, tightly constricted at the mouth, but expanding in the neck. In 
 attempting to puncture the cul-de-sac posteriorly, care should be taken 
 not to pass the instrument through instead of behind the cancerous mass. 
 Passing the finger of the left hand into the anterior opening in front of 
 the cervix, the right hand should be introduced through the abdominal 
 wound, and the bladder separated from the uterus. This is accomplished 
 partly with the fingers and partly with a blunt-pointed scissors curved on 
 the flat. 
 
 This is said to be easy of accomplishment. I do not find it so. The 
 rectum should be separated in like manner, the uterus being drawn forward 
 by an assistant. A ligature must be carried on the right side through the 
 openings made anteriorly and posteriorly, and, drawing the bladder away, 
 tied tightly; this lower segment'of the broad ligament must be cut through. 
 The mass is now so movable that it can be drawn far out of the pelvis, and 
 a ligature applied to the lower segment of the left broad ligament, which is 
 cut through and the uterus removed with a few applications of the scissors. 
 All the ligatures should be left with long ends, drawn through the vaginal 
 opening, which is left open for drainage. In considering the different 
 methods adopted in securing the uterine arteries, I give preference to the 
 one already described, for unless the needle, after it has been passed in front 
 of the broad ligament and threaded, is brought down and re-introduced at 
 its point of entrance (a difficult manoeuvre), the result will not be attained. 
 Freund has modified his method of late on account of this difficulty. The 
 abdomen is to be carefully cleansed, and the wound closed with silver 
 sutures, including the peritoneum. 
 
 I give below the method used by Freund in ligating the broad ligament, 
 
1030 
 
 A SYSTEM OF SURGERY. 
 
 illustrating the same vertical section through base of right broad ligament 
 to show the position of the ligatures in Freund's extirpation of the uterus. 
 The posterior aspect of the broad ligament is to the right. A, Fallopian 
 tube ; B, ovarian ligament ; C, round ligament. A Peaslee's needle, threaded 
 with a loop of silk, is carried behind the ovarian ligament, B, and the loop 
 held in place while the needle is brought back. One end of this thread, b, 
 is passed through the margin of broad ligament, c ; the lower loop, d, is 
 
 Fig. 669. 
 
 passed behind the round ligament, C, and cut off at e. The loop, a, is cut, 
 and the ends being drawn tightly, the ovarian artery is entirely occluded. 
 The loop, dj when tied, controls the pampiniform plexus. The ligature, 
 e,/, g, is passed from the vagina and made to pass the lateral fornix at e, 
 and to emerge behind it, leaving e the free end. The needle is slid along 
 and the thread passed through the lateral fornix, K, on the opposite side. 
 The end, g, is then passed through the round ligament. The two ends of 
 this thread being tied, the uterine artery is occluded. 
 
 Vaginal Extirpation of the Uterus. — The uterus must be drawn carefully 
 down to the vulva and the cervix separated from the bladder partly with 
 the knife and scissors together with the aid of the fingers. The entire cervix 
 must be liberated all around, and Douglas's pouch cut into. Two fingers 
 of the left hand are carefully introduced into the cut, passed over the fundus 
 into the space between the bladder and the uterus (vesico-uterine pouch). 
 
 The fingers being held in this position, they are felt for with the fingers 
 of the right hand within the cut already made in the front of the cervix. 
 The surgeon now withdraws the right hand, and, with the scissors or knife, 
 cuts carefully upon the fingers of the left until the peritoneum is thoroughly 
 divided. These incisions free the uterus both in front and behind. 
 
 The womb must then be retroflexed and forced through the cut in the 
 posterior fornix. If this can be executed with the hand it is better so to do, 
 if not, a forceps may be used. 
 
 A Peaslee's needle, armed with very stout, waxed, antiseptic silk, is passed 
 through the centre of the broad ligament, cut, and the ligature tied above 
 and below. It is often advisable to use Thomas's large clamp temporarily 
 while applying these ligatures, and to remove it afterwards before tying 
 them. This is done to both ligaments, and as a matter of security a bit of 
 india rubber ligature may be clasped around the stumps. The uterus can 
 
SUPRA- VAGINAL HYSTERECTOMY. 
 
 1031 
 
 then be readily removed. The stumps must be brought into the roof 
 of the vagina and both pedicles secured by a strong ligature passing first 
 through the cut surface of the posterior fornix, then through the pedicles 
 and, finally, through the anterior fornix. It will be seen that when the 
 ends of such a suture are brought together, the wound in the roof of the 
 vagina is also closed, a drainage tube should be passed between the stumps 
 into the peritoneal cavity, the vagina packed (around the drainage tube) 
 with antiseptic cotton, which must be removed as soon as any odor is man- 
 ifested, and the parts washed with a solution of the bichloride of mercury 
 1 to 3000. It is said that by this method the mortality is 27 per cent. 
 
 Supra-vaginal Hysterectomy. — This operation is resorted to for the re- 
 moval of fibroid tumors, especially the intramural, and in my hands has 
 been so successful that I can recommend it, even in cases in which the 
 patients are exhausted from profuse haemorrhage, and are suffering from 
 
 Fig. 670. 
 
 Wilcox's Pins. 
 
 aggravated pressure symptoms. The surface of the abdomen is washed 
 with a bichloride solution 1 to 2000, and an etherial solution of iodoform 
 is poured over the belly below the umbilicus. The incision is made in 
 accordance with the size of the tumor. It is better to begin the cut just 
 below the umbilicus and extend it to the pubis; if necessary, it may be 
 enlarged toward the sternum. The peritoneum is divided, and the tumor 
 exposed. If there are many adhesions, they are tied with catgut and 
 
 Fig. 671. 
 
 Tait's Clamp. 
 
 divided. The hand is insinuated into the cavity behind the tumor and 
 the mass lifted forward. If the tumor be large the ovaries and tubes are 
 drawn upward close to its sides and the broad ligaments may all be in- 
 cluded in the clamp. Two large steel pins, devised by Dr. Wilcox, are 
 then thrust diagonally through the pedicle and a stout elastic ligature, 
 stretched sufficiently to reduce it to half its calibre, is twisted six or eight 
 times around the pedicle below the pins. The ligature is secured by means 
 of a leaden clamp, and for the sake of security a second one may be em- 
 ployed. I have used the clamp of Lawson Tait, Fig. 671, and have had 
 excellent success with Dr. Thomas's large instrument, Fig. 672. 
 
 In some cases I have employed the clamp and the ligature combined, with 
 
1032 A SYSTEM OF SURGERY. 
 
 surprising results. The uterus is cut away ; of course the stump remains 
 outside the abdomen and is powdered with iodoform. The cavity is 
 cleansed by means of sponges on holders, and the wound dressed after the 
 manner described in the Chapter on Ovariotomy. If the operation is care- 
 fully performed, the dressings need not be removed for eighteen or twenty 
 days. 
 
 Martin's operations for the removal of the uterus are peculiar. He treats 
 the pedicle by the intra-peritoneal method. The tumor is lifted up and the 
 elastic ligature applied as low down as possible. Deep lateral ligatures are 
 
 Fig. 672. 
 
 Thomas's Clamp. 
 
 applied to the uterine arteries. The tumor is turned out and the uterus 
 split to within a short distance of the cervix. The two sides are cut ob- 
 liquely in such manner as to make a funnel of the cervix, which can thus 
 be more readily scraped. The pedicle is then dropped into the abdomen. 
 If bleeding occurs the pelvis is packed with sponges, until the operation is 
 completed, when the separate points are tied.* 
 
 Oophorectomy. — This method may be either called " Battey's," when the 
 ovaries are removed, or "Tait's," when the procedure includes the exsection 
 of both ovaries and tubes for disease. 
 
 In the year 1823, James Blundell, of London, suggested the operation 
 as pointed out by Aveling, and in 1865, Dr. Battey, of Georgia, conceived 
 the idea of producing an artificial menopause by double ovariotomy. In 
 1872 Hegar operated with fatal results. A month later, in the same year, 
 Mr. Lawson Tait performed the operation, but the patient died shortly 
 after, and there was no publication made of the case. Seventeen days after 
 Mr. Tait's failure, Battey was successful at Rome, Georgia ; two years after, 
 he again cured two cases following closely the one on the other. Since 
 then the operation has been frequently performed with varying success. 
 
 The removal of both ovaries has been variously christened. It has been 
 called normal ovariotomy in contra-distinction to the usual term ovariotomy, 
 as belonging to the diseased condition of these organs ; or oophorectomy, 
 which is approved by some but rejected by others, on account of its being 
 used as a synonym for ordinary ovariotomy by Peaslee. It has been desig- 
 
 * Medical News, September 11th, 1886. 
 
OOPHOEECTOMY. 1033 
 
 nated " spaying," " the castration of women," and finally, at the suggestion 
 of the late Dr. J. Marion Sims, has received the name of Battey's operation, 
 which I think is the appellation by which it will hereafter be known. 
 
 It is well to determine what are the conditions that justify the operation ; 
 what is the best method of removing the ovaries ; what are the results and 
 what the objections to the procedure. 
 
 It must be remembered that the operation is not to remove diseased 
 ovaries, although in many cases these organs are found so to be, the object 
 being to prevent the function of ovulation, or establish an artificial meno- 
 pause, and by so doing to arrest and cure the many complex and painful 
 maladies dependent on that process. 
 
 At the last meeting of the International Medical Congress, Dr. Battey thus 
 spoke: "No safer rule can be laid down to-day than is embodied in the 
 three questions : Is this a grave disease ? Is it incurable by any of the re- 
 sources of art short of the change of life ? Is it curable by the change of 
 life? If all of these questions can be answered affirmatively the case is a 
 proper one, but if not, the operation is not to be thought of." 
 
 The following disorders are enumerated as those which demand the re- 
 moval of the ovaries * : 1. Congenital disease of the uterus, with functional 
 activity of the ovaries resulting in fatal heart disease by reason of a men- 
 strual molimen, unrelieved by a menstrual flux. 2. Where there is an 
 occlusion of the entire genital tract, as a sequence of labor where restoration 
 of the outlet has been found impossible. 3. Cases of menstromania, where 
 all other remedies have failed. 4. Ovarian epilepsy in which the convulsive 
 action is evidently due to a disease of the ovaries, or to some abnormal 
 condition of ovular action. 5. Certain forms of chronic inflammation of the 
 ovaries, attendant upon severe pains, and nerve disturbances, at the men- 
 strual period. 6. Amenorrhcea with grave disturbances of the nervous 
 system, unrelieved by the menstrual function or by medical treatment. 7. 
 Hernia of the ovaries into the inguinal canal, or into the labia, disabling 
 the woman by excessive sensitiveness to pain and suffering. 8. Large sub- 
 mucous and interstitial fibroids, accompanied by dangerous haemorrhages. 
 9. Certain incurable flexions of the uterus, attended with grave consequences 
 requiring relief. 10. Deformities of the pelvis endangering a necessity for 
 the Caesarian section. 
 
 Dr. Thomas Savage, of Birmingham, England, records thirty cases, ten of 
 which were protracted and painful ovary-prolapses, and four of myomata ; 
 and for these two especial conditions he thinks the operation applicable. 
 
 Dr. Sutherland has arranged a table of the history of over five hundred 
 inmates of the Wakefield Lunatic Asylum, and says " that in epileptic in- 
 sanity the fits are generally increased in number, and that the patient fre- 
 quently becomes excited at the catamenial period ; that in mania, exacer- 
 bations of excitement usually occur at the menstrual period, and that a 
 state of intense excitement is almost continuous in patients suffering from 
 metrorrhagia, and also that Esquirol and Morel have estimated the derange- 
 ments of menstruation as the source of origin of one-sixth of the cases of 
 insanity due to physical causes. In such cases as these the operation should 
 always be considered, indeed Dr. Goodell advocates the removal of the ovaries 
 in all insane women.f 
 
 There are two methods employed for the removal of the ovaries, one by 
 abdominal incision, the other through the vagina. At first some distin- 
 guished gynaecologists in this country gave preference to the latter method, 
 but later experience has proven, that in the majority of cases incision through 
 
 * Transactions of the American Gynaecological Society, Vol. x., 1881. 
 f The American Journal of Obstetrics, October, 1881, p. 923. 
 
1034 A SYSTEM OF SURGERY. 
 
 the abdominal walls is the better. The vaginal removal, however, is always 
 to be considered when the ovaries are prolapsed, can readily be felt through 
 the canal, and appear to be movable. In one case in which I resorted to 
 this method, great difficulty was experienced in drawing down the left ovary, 
 as it appeared to be surrounded by dense fibrinous connection with the 
 periuterine connective tissue, as well as to the broad ligaments which were 
 themselves hard and inelastic. The operation through the vagina is as fol- 
 lows : The patient may be placed on the left side, or in the lithotomy posi- 
 tion ; the latter, I believe, being preferred by Dr. Goodell, the former by 
 Drs. Emmet and Sims. At all events the perinseum must be retracted 
 and the cervix caught by a stout tenaculum and drawn down to the outlet. 
 The Douglas' cul-de-sac is then snipped with the scissors, making a sufficient 
 opening to admit the finger which is introduced and hooked over the ovary 
 to hold it steadily, a pair of forceps with concealed hooks is made to grasp 
 the ovary which is drawn through the incision. The pedicle is ligated with 
 a double silk ligature, and the organ removed with the scissors. The stump 
 is then returned into the abdominal cavity, and a suture or two applied. 
 In some cases the stitch is not necessary. 
 
 The abdominal section, now most in vogue, will probably supersede the 
 former. In this operation the incision is made in the median line, four or 
 five inches in length ; the hand inserted and the ovary found. This is not 
 easy of accomplishment. In several instances I have been obliged to lift 
 myomatous tumors without the cavity to find a compressed and shrivelled 
 ovary pressed behind the growth. When the organ is not bound in the pelvis 
 by adhesions, the finger and thumb can readily grasp and withdraw it into 
 the incision. If, on the other hand, it is firmly impacted in the pelvis, the 
 adhesions are to be separated with the finger and scissors, until it is suffi- 
 ciently free to allow the ligature to be passed around it. It is then readily 
 removed. 
 
 With reference to the selection of the method of " spaying," I agree with 
 Dr. Sims, who wrote : "Asa rule operate by abdominal section, because if 
 the ovaries are bound down by adhesions, it is possible to remove them 
 entire, whereas by the vaginal incision it is impossible. 
 
 " If we are sure that there has been no pelvic inflammation, no cellulitis, 
 no hematocele, no adhesions of the ovaries to the neighboring parts, then 
 the operation may be made by the vagina, but not otherwise."* 
 
 The results of this operation are thus far very encouraging, but that it 
 is one which could be much abused, is a foregone conclusion. It has been 
 argued by some, that it may open the door to an increased immorality, by 
 depriving woman of the power of conception, but I can scarcely believe 
 this will be the case, for two reasons : first, because a woman would scarcely 
 be sufficiently a slave to her passions to undergo such a critical operation, 
 and second, because I have confidence enough in the profession to believe 
 that no one will resort to it, without having duly weighed all the circum- 
 stances by which the patient is surrounded, and the character and kind of 
 suffering to which she has been subjected. 
 
 It might be supposed that the removal of the ovaries always arrested 
 menstruation, but this is not the case. In Mr. Tait's article, published 
 in the American Journal of the Medical Sciences, for January, 1882, and in 
 which he gives a record of thirty-one operations, he states distinctly that 
 the removal of the ovaries alone is not always effectual in arresting 
 menstruation, while the exsection of the uterine appendages is found to be so. 
 
 Dr. Goodell,f in his excellent treatise, gives two tables, one of twenty- 
 
 * British Medical Journal, December, 1877, quoted by Emmet, p. 756. 
 f Lessons in Gynaecology, p. 340. 
 
LACERATED PERINEUM. 
 
 1035 
 
 six cases, in which both ovaries were removed, with the following results 
 bearing upon the return of the menses. In nine cases the menstrual flux 
 continued uninterruptedly after the operation, and in the balance it was ir- 
 regular. In some there was an amenorrhceal period of six months, and a 
 return of the discharge for the six following months, while in others the 
 flow appeared at intervals of from three to seven months, and again in 
 others, small quantities of the fluid were irregularly noticed. In his second 
 table we find thirty-one cases in which the removal of both ovaries during 
 menstrual life was followed by an arrest of the flux. In eighteen of these 
 there was no menstruation whatsoever, in several there appeared a sangui- 
 neous discharge. In a few there was a metro-staxis, which soon ceased, 
 and in one there was a white discharge, which soon disappeared. 
 
 In the discussion upon this subject, at the International Medical Con- 
 gress, Mr. Tait gave the following analysis of seventy cases : 
 
 First: Those Operated upon for Pain. 
 
 Recurrent hematocele 
 
 Abscess of the ovary 
 
 Hvdro-salpinx 
 
 Pyo-salpinx 
 
 Chronic ovaritis 
 
 Cirrhosis of the ovaries 
 
 Second : Cases Operated on for Haemorrhage. 
 
 Hydro-sal pinx 
 
 Chronic ovaritis 
 
 Small cystic ovaries 
 
 Myoma 
 
 Third : Cases Operated on for Reflex Symptoms. 
 
 Menstrual epilepsy 
 
 Deformity 
 
 Total. 
 
 11 
 
 1 
 2 
 5 
 
 26 
 
 Incomplete 
 operation. 
 
 Deaths. 
 
 Lacerated Perinaeum. — This accident, which is well known to all ac- 
 coucheurs, and which often produces much misery, is occasioned either 
 by traumatic lesion, instrumental delivery, pressure of tumors, or parturi- 
 tion, by far the greater number of cases being caused by the latter. If the 
 rupture is incomplete, the inconvenience may be borne ; if, however, both 
 sphincters are torn through, there is perhaps no affection which renders 
 life more miserable. Displacements of the uterus and vagina, incontinence 
 of flatus and fasces, prolapsus of the rectum, and inflammation of the 
 uterus itself are often engendered by this troublesome accident. The patient 
 is unable to perform her usual duties, cannot go out for fear, and becomes 
 disgusting to herself and to all around her. The operations which have 
 been devised for the relief of this accident are sometimes successful and 
 sometimes the reverse; the great difficulty being in bringing into apposition 
 the torn muscular fibre. On this subject Dr. Emmet (than whom there is 
 no better authority) says :* " In a large number of cases not a fibre of the 
 
 * Medical Record, March loth, 1873, p. 121. 
 
1036 
 
 A SYSTEM OF SURGERY. 
 
 muscle is united, although the perinseum may have been restored and the 
 laceration through the recto-vaginal septum closed by the operation. To 
 unravel the cause of failure, and to devise means of obviating it, has occu- 
 pied my attention for years. To appreciate so simple an explanation has 
 cost me more thought than any other point in the whole field of the branch 
 of surgery to which I have devoted myself." 
 
 Time of Operating. — A good deal has been said and written about the 
 proper period of operating. The majority of surgeons are of opinion that 
 the operation should be immediate. In those cases in which I have per- 
 formed it at that time, the results have been favorable. If, however, this is 
 not done, the interference must be deferred until the parts have cicatrized, 
 and the patient regains her ordinary strength, that is, if she is not nursing. 
 If she nourishes her own child, operative measures must be deferred until 
 
 Fig. 673. 
 
 Comstock's Modification of Fritsch's Leg Brace. 
 
 the offspring can be safely weaned. The welfare of the child would appear 
 to demand such procrastination. 
 
 The employment of the leg braces of Fritsch as improved by Dr. T. G. 
 Comstock, of St. Louis, much facilitates the performance of the operation. 
 Fig. 673 represents the apparatus. Peters has also an excellent leg brace, 
 Fig. 674, which I have used with satisfaction. 
 
 The operation of Baker Brown, which is often quoted, and in the per- 
 formance of which he and others, as well as myself, have been successful, 
 is not as delicate as others to be mentioned. There is too much cutting 
 about it. In this method the patient is placed on the table and fully 
 etherized ; the fissure is rendered tense by an assistant, and with a bistoury 
 the surgeon removes all the cicatricial tissue on either side ; after this the 
 sphincter ani (external) is divided. The directions are to cut the muscle 
 on both sides about a quarter of an inch in front of its attachments to the 
 coccyx, by two incisions carried outward and backward. These are made 
 
LACERATED PERINEUM. 
 
 1037 
 
 by a blunt-pointed instrument, which is introduced into the rectum (guided 
 by the forefinger of the left hand), and carried an inch within the gut; by 
 drawing out the knife a cut an inch or thereabouts is made, extending 
 outward from the anus, between the coccyx and the tuberosity of the 
 ischium. 
 
 When the cutting has been accomplished, which, however, many operators 
 consider unnecessary, the sutures are introduced as follows : With the fore- 
 finger and thumb of the left hand, the left edge of the fissure is taken up r 
 
 Fig. 674. 
 
 Leg Separator, for Perineal Operations (Emmet's and Peters'). 
 
 a needle threaded with a double cord is inserted one inch from the refreshed 
 margin, and its point being directed downward and inward is made to 
 emerge at the bottom of the pared margin of the fissure. It is then inserted 
 at a point opposite on the denuded surface and brought out an inch there- 
 from through the integument. This suture is passed at the upper end of 
 the fissure. A second suture is made as before, going as deep as the sep- 
 tum, and a third is entered at a low angle of the cleft. The ordinary method 
 of making the quilled suture is then practiced, pieces of bougie answer- 
 ing the purpose, and the cleft is thus approximated. Several silver-wire 
 sutures are passed into the integument, and the operation is completed. 
 The bowels are to be constipated with opium, a grain being given night and 
 morning for a day or two, and after that a grain once in twenty-four hours. 
 The patient should be put to bed, and a light and unstimulating diet or- 
 dered, the urine carefully drawn with the catheter twice a day, and the 
 knees tied together. The deep sutures are removed from the third to the 
 sixth day, and on the eighth or tenth the superficial ones may be taken out. 
 The operations which I formerly performed with considerable success, are 
 now known as the old operation of Dr. Emmet. I use for such curved 
 scissors, with fine points, and clawed forceps for raising the mucous surface. 
 It is only necessary to denude the fissure of its mucous covering. Having 
 placed the patient in position, and having the fissure put on the stretch on 
 both sides, the cicatricial lines can generally be discovered marking out the 
 triangles. Just on the outside of these, and going only through the mucous 
 
1038 
 
 A SYSTEM OF SURGERY. 
 
 surface, I mark off the triangles. Taking up one of the angles (the upper 
 and outer), with a pair of delicate forceps, with the curved scissors I snip 
 away the membrane. In many instances I succeeded in removing the part 
 entire. This generally happens on the left edge of the fissure ; were I 
 ambidextrous I am quite certain that both could be easily removed entire. 
 Taking then a round needle threaded with a long piece of silk, and having 
 the forefinger of my left hand well in the rectum, with the ball of the finger 
 I press up the septum, and pass the needle about an eighth of an inch above 
 and a quarter of an inch to one side of the anus and carry it through all 
 the tissues up to the septum (which it may have been necessary also to 
 refresh) ; I then turn it and bring it down on the other side of the fissure 
 and out at a point equidistant from the anus at which it was entered. The 
 next suture is passed about the eighth of an inch above, its terminus being 
 the septum ; it is brought out like the first ; the third and a fourth if neces- 
 sary are introduced in like manner. It will be seen, that, when the ends 
 of these sutures are twisted, the raw surfaces come in contact entire, not 
 
 r 
 
 being pierced with the sutures, the sides of the wire (as it were) holding 
 together the cleft. The patient's bowels are to be confined with opium, as 
 above ; the catheter used twice a day, and the same after-treatment as before 
 adopted. 
 
 The following is Dr. Emmet's description of the rationale of his opera- 
 tion. The paper was read before the State Medical Society, on February 
 4th, 1873. 
 
 " The success of the operation is due to the point at which the first suture 
 
 Fig. 676. 
 
 Fig. 677. 
 
 is introduced in relation to the edges of the divided muscle. If the first 
 suture be entered on the line and a little outside of A B, Fig. 675, at the 
 point which would seem most appropriate, but a small portion of the mus- 
 cle could be approximated, as shown in Fig. 676, and incontinence to some 
 extent must be the consequence. 
 
LACERATED PERINEUM. 1039 
 
 " Introduce the suture, however, at some distance behind the muscle, 
 toward the coccyx, at the points C D, Fig. 675, and we see at a glance, by- 
 Fig. 677, that on securing the suture the divided edges of the sphincter 
 must be turned up and brought in perfect apposition." 
 
 Since the above was written, Dr. Emmet has modified his procedure. I 
 have, therefore, omitted the minute details of the former method and sub- 
 stituted his last operation.* 
 
 Perineorraphy — Emmet's Method. — The new method of Emmet is as fol- 
 lows, and is probably the best. It must, however, be somewhat modified by 
 the condition of the laceration, the extent of the rectocele and other points 
 which vary considerably in certain cases, especially with reference to the 
 extent of paring the sulci. I have made some drawings which I think will 
 explain the method of performing this operation. 
 
 The patient is placed in the lithotomy position, the leg brace (gynapod) 
 if at hand is applied. 
 
 The parts are shaven and thoroughly cleansed with soap and warm water. 
 
 The operator should have on a shallow tray at his side Emmet's scissors, 
 right and left (but with handles not too long, and made to work easily on 
 
 Fig. 678. 
 
 their pivots), at least four uterine tenacula ; two small-sized and narrow- 
 bladed scalpels ; half a dozen artery compressors ; a pair of long, slender 
 catch forceps ; half a dozen needles, round, slightly curved at the point, 
 strong in the shaft, threaded with silk and silver wire or whale tendon (the 
 former being preferable) ; several sponges set in sponge-holders ; sponges, 
 etc. Seating himself at the foot of the table and introducing the forefinger 
 of his left hand, bulb uppermost, into the rectum, he presses up the crest 
 of the rectocele, a, Fig. 678, and with a tenaculum in his right hand enters 
 
 * Transactions of the American Gynaecological Society, vol. viii., p. 206, 1884. 
 
1040 
 
 A SYSTEM OF SURGERY. 
 
 its point at a ; this is given to an assistant, who slightly puts the parts on 
 the stretch. A second tenaculum is then entered at the lowest caruncle, 
 Fig. 678, b, and a third at the posterior commissure of the vagina, Fig. 678, c. 
 The ringer in the rectum is now to be removed, and point a is to be drawn 
 upward, point b outwards, point c downward, thus putting the entire tri- 
 angle upon the stretch. With a pair of scissors, as preferred by most opera- 
 tors, or with a small scalpel,, which I always use, I mark out the triangle to 
 be denuded, drawing first the line from a to c, then from a to b, and finally 
 from b around the laceration to c. This cut is only down to the subjacent 
 tissues, and, if the mucous membrane is entirely cut through, the gaps 
 made by the retraction mark distinctly the triangle of mucous membrane 
 to be removed. Taking up the angle at b, a strip of mucous surface is 
 removed from around b to a, and so on the whole surface may be denuded. 
 If the knife be used, after a little experience the mucous triangle may be 
 taken off entire. 
 
 The parts are then irrigated with a weak, hot antiseptic solution, and all 
 bleeding arrested. The tenacula may then be removed, and the denuded 
 
 Fig. 679. 
 
 surface will present somewhat the appearances presented in Fig 679. The 
 needle, threaded and held in a stout needle-holder, is introduced high up 
 in the vagina just below point a, Fig. 679, and so the stitches are severally 
 passed, as seen in the cut. A similar proceeding is adopted on the other 
 side, and the sutures are all twisted. This will bring the points of the cres- 
 cent in apposition, and consequently lift up the sides af the perinseurn. 
 Sometimes, while these sutures are being tightened, I take a pair of haemo- 
 static forceps and, catching the point b (formerly the crest of the rectocele), 
 let the instrument hang ; by its weight it draws downward the ununited 
 part of the flap. The method of bringing together the apex of the flap is 
 seen in Fig. 680. The needle is entered at the side of the labium b, carried 
 through the crest of the rectocele, turned and brought out at b'. The su- 
 
LACERATED PERINiEUM. 
 
 1041 
 
 perficial wires are then placed as seen in e e', //', and g (f, and twisted not 
 too tightly together. 
 
 Fig. 680. 
 
 The late Prof. John T. Hodgen, of St. Louis, devised an excellent opera- 
 tion for the closure of complete lacerations, which has given me satisfaction 
 when other methods have failed. He says : 
 
 " An incision is carried through the centre of the lower border of the 
 
 Fig. 681. 
 
 C C, transverse line through the centre of the septum. B B, first incision. B D and B D, lateral 
 incisions carried from B B forward to D, the muco-cutaneous junction. 
 
 imperfect septum, between the rectum and vagina, splitting it in the middle. 
 The two ends of this incision are about one and a half inches from the 
 median line, and about half an inch anterior to a transverse line drawn 
 
 66 
 
1042 
 
 A SYSTEM OF SURGERY. 
 
 through the centre of the septum. This incision is about one-third of an 
 inch deep at its central point, with its lateral portions passing into the sub- 
 cutaneous areolar tissue. Other incisions of equal depth and about an inch 
 and a half long are carried from the ends of the first incision forward and 
 toward the median line, until they reach the muco-cutaneous junction of 
 the labia majora. (Fig. 681.) 
 
 " These thick, triangular flaps being dissected from their posterior lateral 
 angle, but left attached along the inner or muco-cutaneous border, are now 
 drawn forward over the vulva by their free angles, with the cutaneous sur- 
 faces toward the vagina and the cut surface externally. The borders which 
 correspond to the line of the posterior or first incision are thus approxi- 
 mated and held by interrupted sutures, beginning at the anus, made by 
 passing a fine needle armed with silk through, first from the cutaneous to 
 the cut surface, and then the other flap from cut to cutaneous surface, so 
 that when tied the knot shall be on the cutaneous side of the flaps. This 
 suture should, be repeated every quarter of an inch until the free angles are 
 reached. 
 
 " The usual deep sutures of silver wire are now placed, entering for the 
 first one at a point on the buttock about an inch beyond the cut surface, 
 and nearly opposite the outer posterior angle, and, traversing deeply the 
 septum between the rectum and vagina, it emerges at a point (on the oppo- 
 site buttock) corresponding to that of entrance. 
 
 " The second suture is placed about half an inch anterior to the first, and 
 enters about an inch from the margin of the cut surface, and, traversing the 
 tissues, emerges from the cut surface near the attached line of the flap, and 
 
 Fig. 682. 
 
 E is at the free margins of the skin flaps ; E A is a line of junction, hy interrupted sutures, of margins 
 of flaps taken from incision B B. The dotted lines represent the portions of the wire which are buried 
 in the tissues, and the black and white portions are external to the tissues. 
 
 passing across external to the flaps re-enters at a corresponding point near 
 the attached line of the other flap, traversing the tissues of this side to 
 emerge through the skin an inch from margin of cut surface, and half an 
 inch anterior to similar point in first suture. A third, and if necessary a 
 fourth suture may be used anterior to those above described, being placed 
 about half an inch apart. (Fig. 682.) 
 
 " The thighs are now brought together, pushing the flaps of loose skin 
 forward toward the vagina, and holding them in apposition by tightening 
 and twisting the wire. It will be seen that the flaps, which are usually cut 
 off, are made to serve a double purpose. They double the extent of the 
 surfaces approximated, which increases the strength of the new perinseum, 
 
VESICOVAGINAL FISTULA. 1043 
 
 and their cutaneous surfaces are continuous with the vagina, thus furnish- 
 ing an apron which prevents the vaginal discharge and urine from flowing 
 into the cut. 
 
 " In these two points consist the advantages claimed for the modified 
 operation. 
 
 " The margins of the flaps, which correspond to the outer borders of the 
 denuded surfaces, are without sutures, leaving thus an opening for the dis- 
 charge of pus from any part of the denuded surfaces which may not unite 
 by first intention, and preventing the formation of openings for the dis- 
 charge of pus along the line of the sutures." 
 
 Vesico-Vaginal Fistula. — By the above term is understood a commu-. 
 nication established between the vagina and bladder or urethra in the 
 female. 
 
 The symptoms are unmistakable. There is a constant discharge of urine 
 through the vagina, which the patient is unable to control ; the parts be- 
 come inflamed and excoriated, the thighs being much irritated. There 
 is that constant odor of heated urine which is familiar to all, and disgusting 
 to the patient. 
 
 In olden times these fistulse were considered incurable, but at present the 
 majority are amenable to surgical aid. The causes are chiefly inflammation 
 and sloughing of the parts occasioned by the pressure of the head of the 
 foetus; sometimes the forceps have made the rent, sometimes a lithotomy 
 wound produces it. A sensitive vagina and a large hard pessary are also 
 favorable for the formation of vesico-vaginal fistula. 
 
 It was formerly supposed that these accidents were occasioned by instru- 
 mental delivery, but the reverse is found to be true. Dr. Sims says : " From 
 a careful analysis and from my own experience, I am well satisfied that for 
 one case thus produced their (the forceps') judicious application has pre- 
 vented it fifty times." 
 
 These fistulse appear in many parts of the vagina, and are often compli- 
 cated. In one case there was a complete closure of the upper part of the 
 vagina, thus shutting up the os uteri ; a complete extroversion of the blad- 
 der, which protruded like a large red cherry through the vulva, This patient 
 menstruated vicariously through the rectum. In another case, with com- 
 plete destruction of the urethra, there was prolapse of the bladder, and also 
 a recto- vaginal opening. 
 
 These fistulse may be confined to the urethra, the neck or the base of the 
 
 Fig. 683. 
 
 Emmet's Curved Scissors. 
 
 bladder, with its body or the cervix uteri. Many complications often exist, 
 which space will not allow us to mention. The student may refer to the 
 works of Thomas, Sims, and especially to the brochure on the subject by T. 
 Addis Emmet, 
 
 Sims's and Emmet's Operation. — The patient having been placed in what 
 is known as Sims's position, a Sims's speculum is introduced, the perinseum 
 drawn back and the fistula brought into view; the edge is raised with a 
 fine tenaculum with a long handle, and the parts either pared away with 
 
1044 
 
 A SYSTEM OF SURGERY. 
 
 scissors bent at right angles, or those of Dr. Emmet, which are made rights 
 and lefts (Fig. 683), or with one of Sims's straight knives (Fig. 684), or, if 
 the parts require, a knife with a right-angled blade, as seen in Fig. 685. 
 
 Fig. 684. 
 
 S.-IISJIAUAI-CC 
 
 Sims's Straight Knife. 
 
 During this portion of the operation, the sponge, held in an applicator, a 
 sponge-holder, or with long uterine forceps (Fig. 686), should be in frequent 
 use. 
 
 A good deal of time is required to refresh the edges, and the operator 
 must continue until every portion of the fistula is denuded. Simpson 
 
 Fig. 685. 
 Ftp. 
 
 S.T/£MA.VN &■ CO. 
 
 Sims's Curved Knife. 
 
 says, " Enter the point of your knife into the vaginal mucous membrane 
 at'some distance from the fistula; then transfix with your knife the edges 
 of the fistula to the extent you intend to remove it, and bringing it out at 
 
 Fig. 686. 
 
 T/EMANN- 
 
 Uterine Forceps. 
 
 the vesical border, carry it right and left fairly around the opening, so as if 
 possible to bring out a complete circle of tissue." 
 
 The needles threaded with silk, to which annealed silver wire may be 
 attached, must be fixed in the forceps. The needles used are short, and 
 are held with Russian needle forceps, or the modification as seen on pages 
 35 and 248. 
 
 The passage of the suture is a matter of great importance. The operator 
 should select that part of the fistula most difficult to reach, and enter the 
 
 Fig. 687. 
 
 Fig. 688. 
 
 Passage of Thread. 
 
 Sims's Self-retaining Catheter. 
 
 needle from a quarter to half an inch from the pared edge, and bring it out 
 just anterior to the mucous membrane of the bladder. As its point emerges 
 it is encircled with a small blunt hook, which presses the tissues around it, 
 so that it may be caught with a seizing forceps and drawn through. The 
 needle is then taken with the forceps, its point entered in the refreshed 
 margin opposite that where it passed out and near the mucous vesical sur- 
 
VES ICO- VAGINAL FISTULA. 
 
 1045 
 
 face, and made to emerge about half an inch from the pared edge of the 
 fistula on the vaginal side (Fig. 687). The tenaculum must be used during 
 this operation, to render the parts tense for the better passage of the needle. 
 As the thread comes through, to prevent the tissues from tearing, the fork 
 must be gently employed. When the silk is drawn through, the wire follows, 
 and suture No 1 is ready for twisting, which, however, is not done until a 
 sufficient number of sutures are passed. So soon as they are all entered 
 and brought out, the ends of the wire of the first suture are seized by the 
 forceps, the spoon is slipped up to the tissues and the wire twisted, as seen 
 in Fig. 106, page 249. The sutures having been all twisted, their ends are 
 clipped with the scissors, the bladder syringed, and Sims's self-retaining 
 catheter (Fig. 688) inserted in the bladder. A small cup should be placed 
 between the limbs to catch the urine, and the patient ordered a light and 
 nutritious diet. 
 
 The sutures may be allowed to remain from ten to fourteen days, and in 
 certain cases even longer. 
 
 Care is required in the removal of the sutures, as the wire has a tendency 
 to become imbedded in the tissues. It may be accomplished by raising 
 gently with the forceps the twisted ends of the sutures and inserting the 
 
 Fig. fi«9. 
 
 Bozeman's Chair. 
 
 sharp end of a small pair of scissors beneath the loop as it is drawn up, 
 and severing the wire. The forceps may be used with a slight rotary 
 motion, which twists out the wire without traction on the parts. 
 
 Fig. 690. 
 
 Fig. 691. 
 
 tuiu««-<o. 
 
 Bozeman's Button. 
 
 Passage of Wires. 
 
 In the earlier days, Dr. Sims recommended clamps and perforated shot. 
 These I used with good results, and am not sure whether the method of 
 fastening by perforated shot is not accomplished with more facility than 
 the twisting of the wires. 
 
1046 
 
 A SYSTEM OF SURGERY. 
 
 Fig. 692. 
 
 Dr. Bozeman's operation has met with high favor. Hamilton, in his work, 
 says, the " distinctive characters of Bozeman's operation are : the button suture, 
 the position of the patient, and the self-retaining speculum" 
 
 Dr. Bozeman first removes all obstructions from the vagina, in the 
 shape of bands and adhesions ; this is done by division and dilatation, 
 and, to prevent contraction, bags made of oiled silk, and stuffed with 
 sponge, are inserted into the vagina. So soon as this is effected, the patient 
 is placed in the knee-chest position, or in Bozeman's chair (Fig. 689), and 
 his self-retaining speculum applied. 
 
 The paring of the edges of the fistula is accomplished after the manner 
 already described, and the next step is the insertion of the needles. Fig. 
 692 shows Bozeman's needle-holder, which is com- 
 posed of a flexible canula, which holds the needle at the 
 required angle. The dotted lines show angles at which 
 the needles may be set. The needle is entered about 
 one-third to one-quarter of an inch "from the pared 
 surface, passed along the tissues of the septum, and is 
 made to emerge just below the vesical mucous mem- 
 brane, where it is caught upon a blunt hook, seized by 
 the forceps and drawn through Thus transfix- 
 ing of the mucous membrane is avoided." Fig. 691 
 shows bevelled tissues and threads in situ. The wires 
 are adjusted by passing them through an instrument 
 with an eye at its extremity, and the button pushed 
 up to the cut surfaces. The button is made of lead, 
 is one-twentieth of an inch thick and five-eighths of 
 an inch in width, and must be cut of length and width 
 to fit the part, and perforated in order to admit the 
 wires. The holes should be about one-third of an inch 
 apart. Fig. 690 shows the button. It must be moulded 
 or arched, which is conveniently done by the plate- 
 bending forceps of Dr. Bozeman. By this bending or 
 arching of the button, the lips or edges of the fistula 
 are prevented from being strained, while at the same 
 time they are supported. The ends of each wire having 
 been brought together, they are passed through the 
 button, as seen in Fig. 693, which is pushed up to its 
 place, as seen in Fig. 694 ; then perforated shot (Xo. 3 
 being the best size) are placed upon the wires, as seen 
 in Fig. 695, and slipped up and adjusted by an instru- 
 ment (Fig. 696) ; then with a pair of strong forceps, 
 made somewhat after the fashion of bullet-moulds, the 
 shots are compressed. The ends of the wires are cut 
 off an eighth of an inch from the button and turned 
 down. For complicated cases other forms of buttons 
 
 ■ are used. 
 
 Dr. W. T. White* relates the spontaneous cure of 
 vesico- vaginal fistula. 
 The woman had been delivered by instruments six 
 weeks previous to seeing her— urine escaping from some 
 false passage soon after the operation. A fistula near 
 the cervix on the left side was found. About ten days 
 subsequent to menstruation, it was noticed that urine had ceased to escape, 
 and it was discovered that the vesico-vaginal fistula was completely closed. 
 
 Bozeman's Needle- 
 holder. 
 
 * Medical Record, January 25th, 1879, No. 429. 
 
VAGINISMUS. 
 
 1047 
 
 Vaginismus. — This disease, which a few years ago was little understood 
 and imperfectly described, has found but small space in surgical literature. 
 Women of nervous temperament, of an emotional nature, are most likely 
 to suffer from this affection, and it will be generally observed that with it 
 are associated symptoms of spinal irritation. It consists of an involuntary 
 spasmodic contraction of the ostium vaginae, attended with such hyper- 
 sensitiveness of the vulva and outer extremity of the vagina, that the 
 slightest contact may produce great pain, and marital intercourse be ren- 
 dered impossible. There exists in most women the voluntary power of 
 contracting portions of the vagina when excited during coition, and there 
 
 Fig. 694. 
 
 Application of Buttons and Clamps. 
 
 can be no reason why such muscles may not suffer from spasm. Cases are 
 upon record, where this contraction has been so powerful, that the penis 
 has been retained within the vagina, notwithstanding the most forcible 
 
 JlP^Sss 
 
 Fig. 696. 
 
 G. TIEMANN ic CO. 
 
 efforts to effect its withdrawal. A case is recorded by Dr. E. G. Davis* in 
 which, before an amorous couple could be separated, chloroform had to be 
 administered. In some instances, the sphincter ani is also implicated, and 
 severe suffering is experienced in the region of the anus. 
 
 A single case will serve to present the characteristics of the affection, and 
 the treatment necessary for its cure : A young lady who had been married 
 about eight months, of a naturally strong constitution, was brought to me 
 by her mother, who detailed the following symptoms : 
 
 Shortly after her marriage, a peevish and fretful state of the nervous 
 system was manifested, accompanied by loss of appetite and nausea; 
 as these conditions were attributed to the new relations of life into which 
 she had entered, no particular treatment was instituted for their relief. 
 Constipation followed with such complete anorexia that medical aid was 
 summoned, and the usual routine of cathartics and tonics administered, 
 with no effect, save an aggravation of nearly all the symptoms. Emacia- 
 tion and excessive nervous irritability followed, together with anaemia and 
 great prostration, which the exhibition of cod-liver oil, wines, and other 
 tonics, in conjunction with travelling, failed to relieve. Upon a careful ex- 
 amination of all the symptoms arising since her marriage, I was led to sus- 
 
 Medical News, Philadelphia, December 13th, 1884. 
 
1048 A SYSTEM OF SURGERY. 
 
 pect that these manifestations were due to reflex nervous action, arising 
 from an irritable sexual system. 
 
 On further inquiry I learned that the menses had appeared regularly, 
 and although somewhat less in quantity, still presented a natural appear- 
 ance. An examination per vaginam was suggested, and upon attempting 
 to introduce my finger into the vagina I found the orifice closed to such a 
 degree, and the patient suffered such excruciating pain, that the attempt 
 was abandoned. 
 
 Thinking this remarkable sensitiveness might be due to the presence of 
 one of those painful tubercles that sometimes are found at the orifice of the 
 urethra, I proceeded to use the speculum; but although no such excres- 
 cence existed, it was impossible to introduce the instrument on account of 
 the severe pain. Her husband informed me that any attempt at sexual 
 intercourse caused her such agony and produced such extreme nervous 
 excitement that hours would elapse before she would become calm. I was 
 satisfied that the patient before me was suffering from vaginismus, the de- 
 scription and treatment of which had about that time been published by 
 Dr. J. Marion Sims.* It is proper to say, that, although this disease was 
 first presented to the profession by Dr. Sims, it was Dr. Tyler Smith, of 
 London, who is said to have suggested the idea; and, according to Debrand,t 
 it was Huguier, in 1834, who described the spasmodic condition of the 
 sphincter vaginse. 
 
 The method employed by Dr. Sims places the patient on her back ; the 
 index and middle finger of the left hand are passed into the vagina, sepa- 
 rating the labia laterally, opening the canal as widely as possible and drawing 
 the fourchette very tense ; then with a common scalpel make an incision 
 through the vaginal tissue, a little to the right side, bring it from above 
 downward and terminating at the perineal raphe, making one side of a V ; 
 then insert the knife on the left side and cut obliquely toward the first in- 
 cision, so as to join it at the raphe ; then follow the raphe itself until the 
 incision resembles the letter Y- The amount of haemorrhage is generally 
 unimportant and will be readily controlled by the pressure of a glass di- 
 lator, which may be introduced immediately or twenty -fours after the 
 operation, where, by an appropriate bandage, it is kept in situ for two hours 
 in the morning, and two or three hours in the evening, according to the 
 tolerance of the patient. 
 
 By this treatment I effected a perfect cure in my patient, and she has 
 since become a mother. 
 
 Dr. E. Clark, of Portland, Me.,| one of the oldest and most valued expo- 
 nents of our school in that State, relates a perfectly successful cure similar 
 to the above, by the same operation. 
 
 Ludlam, speaking of this subject in his Diseases of Women, says : " Unless 
 there is some special reason why the cure should be speedy, it is best to try 
 the milder means," before resorting to the knife. 
 
 One of the plans recommended to overcome this spasm of the vagina is 
 the gradual dilatation of the canal by bougies. These should be annointed 
 with oil or a preparation of extract of belladonna, one part to six parts of 
 lard or simple cerate. The process will be necessarily tedious, but a per- 
 sistent use of these instruments, from a few minutes to an hour or two 
 each day, with the administration of the remedy which seems indicated 
 by the general condition of the patient, will often be rewarded by a per- 
 manent cure. 
 
 * American Medical Times, May 31st, 1862. 
 
 f Medical News, November 29th", 1884. 
 
 t New England Medical Gazette, August, 1873. 
 
ATEESIA VAGIXJE — ELEEHAXTIASIS. 1049 
 
 Incidental or transient attacks of vaginismus may be relieved by the 
 application of a mixture, consisting of chloroform one drachm, and olive 
 oil and glycerin each one ounce. If the spasm is severe, the mixture may 
 be thrown into the rectum, and treatment instituted most likely to remove 
 the cause on which the paroxysms depend. 
 
 Atresia Vaginae. — This closure of the canal may be either congenital or 
 acquired, being often of the former variety. The nurse or mother discovers 
 the fact. In such cases there is generally sufficient space for the passage of 
 the urine. Sometimes the entire canal is occluded from ulceration in early 
 life, and sometimes from imperforate hymen. The great difficulty in these 
 cases is the diagnostication of the presence of the uterus ; and this is the 
 more difficult because sexual instinct may be present when the womb is 
 absent. It depends more upon the ovaries than the uterus. In such cases 
 the most careful examination must be made per rectum and over the abdo- 
 men. If a tumor be found at the latter point, it may be assumed that it is 
 formed of menstrual accumulation. 
 
 I have had fifteen cases of this affection, five congenital ; two I saw 
 and operated upon with Dr. Skiles, of Brooklyn ; one aggravated case, a 
 patient of Dr. Mandeville, of Newark. Several others came under my ob- 
 servation in Missouri, and a most remarkable one I saw with Dr. Clark, 
 of Troy. 
 
 Treatment. — Place the patient on the back, secure the legs with the 
 gynapod, or other contrivance, thoroughly vaseline the parts, and as I be- 
 lieve that mucous surfaces separate better by gently breaking up adhesions 
 with the finger and blunt instruments, with here and there a touch of the 
 knife to sever a fibrous or cartilaginous band, than when the knife is em- 
 ployed exclusively, such means must be employed ; moreover, union by 
 the first intention is not nearly so likely to result. A catheter in the bladder, 
 held by an assistant, the forefinger of the left hand in the rectum, to guide 
 and draw away the parts, and the forefinger of the right hand in the vagina, 
 worked steadily and carefully, now and then using the knife to free strong 
 adhesions, will be productive of better results than the use of cutting in- 
 struments. 
 
 The main trouble is the prevention of a recurrence of the contractions ; 
 therefore glass plugs, or those made of hard rubber, must be constantly 
 worn, and the operation repeated if only a partial success occurs. 
 
 Elephantiasis of the Labia. — The disease is classed by most authors (Til- 
 bury Fox,* Rayer,f and others) as one of the hypertrophies of the same 
 genus as ichthyosis, keloid, and fibroma, and by Paget as cutaneous out- 
 groicths, which appears but another name for the same pathological state. 
 He says : " The best examples of cutaneous outgrowths, of which, as I have 
 said, a second division of the fibro-cellular outgrowths is composed, are 
 those which occur in the scrotum, prepuce, labia, clitoris and its prepuce, 
 and, not unfrequently, in the lower limb. These, which reach their maxi- 
 mum of growth in the huge elephantiasis scroti of the tropical countries, con- 
 sist mainly of overgrown fibro-cellular tissue, which, mingled with elastic 
 tissue and more or less fat, imitate, in general structure, the outer, compact 
 la} r er of the cutis. Their tissue is always closely woven and very tough and 
 elastic ; in some cases it is compressible and succulent, and it yields on sec- 
 tion a large quantity of serous-looking fluid." He speaks also of the great 
 enlargement of the veins, which he noticed in a specimen under examina- 
 tion. I have given this brief quotation from Paget, because it covers exactly 
 the appearances of the tumor after removal, which is accomplished only after 
 a prolonged and very bloody operation. 
 
 * Skin Diseases, p. 331. f Treatise on Diseases of the Skin, p. 401. 
 
1050 A SYSTEM OF SURGERY. 
 
 It is said that inflammation of the lymphatics constitutes the first stage 
 in this affection. These being arrested in their function, the lymph re- 
 mains to be appropriated by the tissues, thus rendering them hyper- 
 trophic. Another of the chief peculiarities is the enlargement of all the 
 veins and the extremely patulous condition of their mouths, together with 
 an enlargement of both arterial and venous capillaries. The bleeding is 
 always profuse and often dangerous when these tumors are removed, and 
 no one can read over Allan Webb's description of the amputation of the 
 scrotum for elephantiasis arabum without seeing at once the great danger 
 to be apprehended from haemorrhage. 
 
 Cases of elephantiasis scroti, and of " tropical big leg," or " Barbadoes 
 leg," are frequently encountered, and scattered throughout the medical 
 journals can be found the records of numerous cases. But although in 
 many works the fact is mentioned that this form of hypertrophy can and 
 does affect the labia, I can find but very meagre records of such an 
 affection. 
 
 Thomas, in his Diseases of Women, merely says : " Elephantiasis of the 
 labia differs in nothing from that of other parts. The affection is very rare. 
 Kiwisch records one case, in which both labia increased in size to equal the 
 head of a man, and to fall nearly to the knees. The parts affected by it are 
 the labia majora and minora and the clitoris."* I find a case reported 
 in an old number of Ranking, by Dr. 0. Ferrall, to the Dublin Pathological 
 Society, in which a species of cellular pendulous tumor, seven inches in 
 circumference, was removed from the left labium. The haemorrhage was 
 profuse. Dr. Eve, in his Remarkable Cases in Surgery, records a case of " ex- 
 cision of the external labia pudendi for sarcoma." This, no doubt, was 
 similar to those now known as elephantiasis ; indeed, the disease has been 
 called, especially by Mr. Abernethy, "vascular sarcoma." After relating 
 the history of the patient, the surgeon (Simeon Bullen, Esq., of London), 
 thus writes : " On removing the left labium, the discharge of blood was so 
 rapid and profuse, and the vessels so numerous, that before I could succeed 
 in securing them, fainting had taken place, and the effect on the system 
 was so alarming that I was obliged to postpone for many days the opera- 
 tion for removing the other, which was attended with similar loss of blood. 
 The substance of each tumor was composed of adipose and fleshy tissue, 
 numerously supplied with bloodvessels." 
 
 Many works on Surgery do not mention this variety of hypertrophy 
 as affecting the vulva, although they give descriptions of the disease as 
 found in the leg and scrotum. Velpeau records the case of a girl, whose 
 left labium was affected with an enlargement (hypertrophia). Bryant 
 merely alludes to the fact of a case coming under his observation, and 
 Holmes gives about a page to the consideration of the disorder — I mean as 
 affecting the parts in question, for he has further on in the same volume an 
 extended article on the subject of elephantiasis arabum, in which is given 
 a table of one hundred cases, in which not one is recorded as affecting 
 the labia. 
 
 Treatment. — I do not know of any other medicines for this disease, than 
 those noted on page 419, and with regard to the methods of operating, I 
 shall give a case of my own, in which the right labium measured one foot 
 in length, and twenty inches in circumference. 
 
 On February 7th, 1875, the patient, Mrs. X., was sent to the hospital by 
 
 * At the college clinic, in 1874, I removed an hypertrophied clitoris, measuring in length 
 five and a half inches, and in breadth nearly three inches. The operation was performed 
 with the ecraseur of Chassaignac. 
 
ELEPHANTIASIS OF THE LABIA. 1051 
 
 Dr. Wetmore for operation. Continuous with the right labium, there ap- 
 peared a huge, fleshy mass, dark in color, sparsely covered with hair, ru- 
 gous on the surface, with here and there a deep fissure. From the elastic 
 nature of the tissues, and the infiltration of serum in some parts, there ap- 
 peared to be distinct fluctuation, which, inded, I have even known in cer- 
 tain varieties of fatty outgrowths. The doctor explored the tumor with a 
 trocar, passing the instrument into the growth " up to the handle ; " a pro- 
 fuse stream of blood flowed through the canula. This operation was re- 
 peated a second time with like result. When she came into the hospital, 
 aspiration was resorted to, and about a tablespoonful of serum was with- 
 drawn. A second puncture yielded no result. This serum, as I discovered 
 afterward, found its bed between the meshes of the tissue, for the tumor 
 was solid throughout, but when cut into, quite an amount of serum would 
 immediately trickle away, though there was, apparently, no break in the 
 substance of the tumor, tipon careful measurement, the growth was found 
 to be twelve inches in length, and over twenty inches in circumference, 
 globular in shape, and almost painless when handled. 
 
 The patient had been unable to move about for a long period, nor could 
 she retain her urine, the weight of the mass keeping the meatus continually 
 open. 
 
 After due consultation, it was deemed advisable to attempt the removal 
 of the mass. The best method of so doing was a question. To apply 
 properly Esmarch's bandage to a globular tumor, is no easy matter ; and as 
 it is necessary, in using the elastic, to have each turn properly overlap the 
 other, to drive all the blood back, I relinquished the idea, fearing the band- 
 age might slip at a critical moment, 
 
 I did not think the ecraseur safe, where such profuse haemorrhage was to 
 be apprehended; and although the heated wire presented some points for 
 consideration, I finally adopted, as a preventive, Erichsen's double thread, 
 as used for naevus. This was applied. Taking a stout needle, it was 
 threaded with a strong hempen cord, about four feet in length ; one-half 
 of this cord was blackened and allowed to dry ; then, having raised the 
 tumor, the needle was passed upward through the pedicle (which was over 
 six inches in length), and brought out on the upper side, and the thread 
 drawn almost through. The needle was turned, entered on the upper side 
 about half an inch from its place of exit, and drawn through on the lower 
 side of the tumor, leaving a loop. This method of stitching was continued, 
 until the whole pedicle was traversed. The pedicle was nothing more than 
 the margin of the labium. The white loops were all cut at the top, and the 
 black ones at the bottom ; the white ends of the thread tied tightly together 
 above, and the black ones below. Not satisfied with this, and for a more 
 thorough protection against sudden and exhausting haemorrhage, a second 
 row of similar stitches was placed half an inch lower down. Having now 
 the tumor held up, in order to take off all strain on the threads, with a large 
 scalpel, I rapidly severed the growth. The bleeding, as the knife went 
 through, and for a moment after, was terrific; the blood shot up in a stream 
 which caused an exclamation from the bystanders. A good deal was 
 venous, and had been held in the tumor by the superimposed ligatures. 
 After this a steady flow with jets and spurts kept up. Thirty-two vessels 
 were ligated, and, after having covered the wound with styptic cotton, placed 
 over this a wad of tenax, and firmly applied a T-bandage, the patient was put 
 to bed. The next morning she had scarcely begun to rally from the terrible 
 shock of the operation, when, upon examination, I found she was bleeding 
 again. The blood had soaked through the bandages and into the bed. All 
 the dressings were removed, and eleven more ligatures applied. This 
 effectually checked the haemorrhage. The patient reacted very slowly, had 
 
1052 A SYSTEM OF SURGERY. 
 
 constant nausea for several days, and could retain nothing on her stomach. 
 Nutritive anemas were given her, but she sank and died on the 23d day of 
 February. 
 
 " Urethral Excrescences ; Caruncles of the Urethra ; Vascular Tumors of the 
 Urethra." — Patients who suffer from this affection have various urinary 
 troubles, such as strangury and dysuria, with hypersensitiveness of the 
 nervous system, which are especially noticeable during the menopause. 
 There then appear, either within or around the urethra, these so-called 
 caruncles. Most physicians have seen these exquisitely painful growths, 
 rendering the patient miserable and nervous all the time, and giving acute 
 agony during micturition or coition. They are generally solitary, but I have 
 now under treatment a case in which there are three distinct lobules to one 
 peduncle. 
 
 These " urethral haemorrhoids," as they are frequently called, from resem- 
 blance to the vascular piles, are, as far as I have seen, situated on the lower 
 border or floor of the urethra. 
 
 Treatment. — In the treatment of these painful tumors, I have never found 
 internal medication of any avail so far as removal was concerned ; but the 
 surgical treatment has been followed by the best results. I draw down the 
 tumor, pass a fine needle, armed with a strong but fine double thread, deep 
 down into the base of the growth (for, be it remembered, although these 
 growths appear superficial, they often extend quite deeply into the tissues), 
 and then, having ligated the tumor, cut it off outside th£ ligature, and apply 
 either chromic acid, the acid nitrate of mercury, or the actual cautery to the 
 pedicle. J. H. Woodbury* recommends highly the eucalyptus globulus. 
 " With it," he says, " I have been able to cure the patients." Cures have 
 been produced by the use of the eucalyptus, without a resort to any surgi- 
 cal means. He applies a glycerole of the drug to the parts, and adrainsters 
 internally the first decimal trituration. 
 
 CHAPTER XLVIII.f 
 
 LACERATIONS OF THE CERVIX UTERI. 
 
 The first mention regarding this most important lesion, was made by 
 Dr. James Henry Bennett, of London. In 1862 Dr. T. Addis Emmet acci- 
 dentally recognized its importance, and originated the operation for its 
 relief which has been styled by different authors " Emmet's operation," 
 " Hystero-trachelorraphy," " Trachelorraphy," and "Tracheoplasty." In 
 1869 Dr. Emmet described the operation in a paper on " Lacerations of 
 the Cervix Uteri," read before the Medical Society of the County of New 
 York. In 1871 he read a second paper before the same societ)' upon the 
 
 * New England Medical Gazette, June, 1876. 
 
 f This chapter was prepared by Dr. F. S. Fulton, late house-surgeon to the Hahnemann 
 Hospital, New York. 
 
LACERATIONS OF THE CERVIX UTERI. 1053 
 
 subject. This paper received a wide circulation, being translated by Dr. 
 M. Vogel, and published in Berlin in 1875. To Dr. Emmet belongs the 
 honor of introducing to the medical profession an operation which has 
 probably done more to relieve the sufferings of women than any surgical 
 procedure known to gynaecology. 
 
 This lesion is apt to occur in primiparse, whose cervical tissues yield 
 with difficulty to the dilating force of the head and amniotic fluid. In 
 multiparas the os naturally is patulous ; while in those who have not borne 
 children, the inelasticity of the tissues resists the dilating force of the ute- 
 rine contents during the latter months of gestation, and remains tightly 
 drawn together until just preceding delivery, greatly favoring laceration. 
 
 Dr. Emmet's statistics show that in his cases slow and tedious labor has 
 been more frequently the cause, 20 per cent, being due to this cause alone. 
 But, although contrary to the present evidence, he says he fully believes 
 that more extended investigation will prove that rapid and difficult de- 
 livery is more often responsible. Careless and needless instrumentation 
 is another productive cause. Application of the obstetric forceps within 
 or above the superior straits, is an operation attended with danger, even 
 in the hands of experienced obstetricians, and should be avoided whenever 
 possible. 
 
 Dr. T. A. Reamy, of Cincinnati, considers ergot, and the use of the fingers 
 in hastily dilating the cervix, as of greater injury in the production of 
 lacerations than are the forceps ; and Dr. McDonald, in the New York Ob- 
 stetrical Journal, says that " meddlesome application of obstetrical fingers 
 in hurrying dilatation of a slow cervix, or in forcibly pushing the neck over 
 the occiput during a pain, is the most frequent cause of cervical lacerations." 
 It is also a fact not always recognized, that abortion, even at an early 
 period, is capable of producing a serious lesion of this character. Dr. 
 Emmet says that in every case where criminal abortion is acknowledged 
 or can be proven, laceration has resulted. 
 
 Regarding the frequency of laceration of the cervix, Dr. Munde says that 
 out of 2500 parous women, he found that 25 per cent, suffered from this 
 lesion, and 50 per cent, of these were serious enough to demand operative 
 treatment, making, according to his statistics, only about 12£ per cent, of 
 all parous women requiring this operation. I have but little doubt that, 
 as the operation assumes more and more its rightful place in surgery, and 
 through more perfect knowledge the evil results of this lesion become better 
 known, and its detection more frequent, this estimate will not be found too 
 large. 
 
 As a consequence of laceration, cellulitis is most apt to be established, 
 entirely suppressing, at times, the secretion of milk. It is claimed by Emmet 
 that you can, not infrequently, ascertain at which delivery the laceration 
 occurred, by finding out after which the mother had been unable to nurse 
 her child. 
 
 The cervix implicated in the laceration undergoes cystic hyperplasia, by 
 which the parts are rendered prominent, boggy, and soft, as is indicated in 
 Fig. 697. Nature endeavors to repair the damage and to again restore the 
 normal outline of the cervix by filling in the bottom of the cleft with a 
 large amount of cicatricial tissue, which is hard, and, at times, almost horny 
 in consistency. For this reason, unless careful examination be made, an 
 extensive laceration may be overlooked. It is this cicatrix which, by pres- 
 sure upon the nerves of the cervix, causes so much reflex nervous disturb- 
 ance. Great cystic degeneration and hyperplasia result, which may at 
 times be so excessive as to be mistaken by even the best gynaecologists for 
 a malignant neoplasm. Fig. 698 well represents this simulation of carci- 
 noma. 
 
1054 
 
 A SYSTEM OF SURGERY, 
 
 Kegarding the tendency of these new formations to appear at the site of 
 old lacerations, there can be but little doubt. 
 
 Any portion of the cervix is liable to rupture during delivery. The lac- 
 eration may be unilateral, bilateral, anterior, posterior, stellate, or internal. 
 
 Fig. 697. 
 
 Fig. 698. 
 
 Posterior and Bilateral Laceration, with 
 Cystic Hyperplasia.— (MundE.) 
 
 Cystic and Papillary Hyperplasia, Simulating 
 Epithelioma — (Munde.) 
 
 When unilateral, it involves only one side of the cervical tissue, which is 
 usually the left. Emmet's statistics for the cases in which it is recorded as 
 to what form of laceration existed, show the following results : 
 
 Right side,. 15 7 per cent. 
 
 Left side, 40.7 
 
 Bilateral 39.5 " 
 
 Posterior, 4.0 
 
 From the large number of cases, however, in which it is not stated as- to 
 the variety of laceration, I cannot regard these results as correct, as in other 
 statistics, as well as in my hospital experience, I found a much greater pro- 
 portion of bilateral than recorded here. 
 
 Dr. T. A. Reamy, of Cincinnati, in an article which appeared in the New 
 York Medical Record, of May 10th, 1884, reported 223 cases of laceration, 
 with the following results : 
 
 Bilateral, 170 
 
 Unilateral, 30' 
 
 Stellate, 16 
 
 Posterior, .5 
 
 Anterior, 2 
 
 Extending into the cervico-vaginal junction, ... . 15 
 
 With perineal laceration also, . 167 
 
 Anal sphincter damaged, 15 
 
 Recto-vaginal septum opened, 7 
 
 Perineorrhaphy subsequently in, 50 
 
 I believe that these statistics would more nearly represent the ratio exist- 
 ing between the different forms of laceration. 
 
 Fig. 699 represents a right unilateral laceration. (All the cervix cuts 
 represent the appearance with the patient in Sims's position upon the left 
 side.) According to the depth of the lacerations, they are arbitrarily clas- 
 
LACERATIONS OF THE CERVIX UTERI. 
 
 1055 
 
 sified as those of the first, second, and third degree ; the first being merely 
 a nick in the mucous membrane ; the second a tear through the superficial 
 
 Fig. 699. 
 
 Fig. 700. 
 
 Right Unilateral Laceration of the 
 Cervix.— (Munde. ) 
 
 Bilateral Laceration of Cervix — Second 
 Degree.— (Munde.) 
 
 muscular fibre ; and the third extending to or beyond the cervico-vaginal 
 junction. Figs. 700 and 701 show the second and third degree of bilateral 
 laceration. 
 
 The stellate laceration, as shown in Fig. 702, is one in which the rents 
 extend into the cervical tissue from the os uteri as a centre, it being not in- 
 
 Fig. 701. 
 
 Bilateral Laceration of Cervix— Third Degree. The two tenacula show the direction of 
 approximation of the everted lips.— (Munde.) 
 
 frequent to find as many as four or five different tears. These clefts can be 
 discovered radiating in all directions from the os, some filled entirely 
 with cicatricial tissue, others gaping, with exuberant granulations covering 
 some of the everted surfaces, and hard nodosities disfiguring others ; and 
 all, to a greater or less extent, covered with erosions, from which is con- 
 stantly poured a thick yellow or pearly leucorrhcea, which in time pro- 
 duces a profound condition of anaemia. The os is patulous, the lips everted, 
 and the whole cervix and uterine body hyperplastic and low down upon 
 the floor of the pelvis. The average length of time in which symptoms be- 
 come so distressing as to drive the sufferer to the physician for relief is 
 about five years. 
 
 It is not infrequent, however, for the patient to feel the bad effects of the 
 
1056 A SYSTEM OF SURGERY. 
 
 laceration from the time she leaves her bed until she submits to the opera- 
 tion. In others, aside from the malaise from which they suffer, they may 
 notice no inconvenience for several years, except the tendency to abort. 
 After a time, symptoms begin to manifest themselves. The patient will 
 be unable to undertake her usual amount of work or exercise. Slight exer- 
 tion brings with it an amount of fatigue. Shaking and trembling for hours 
 follows a walk of comparatively short distance. There is a dragging weight 
 in the pelvis, and oftentimes a severe bearing down drives the patient nearly 
 frantic. As the uterus becomes heavy from its condition of hyperplasia and 
 subinvolution, the natural tendency is for it to become retroverted, in which 
 
 Fig 
 
 Stellate Laceration of Cervix.— (Mund£.) 
 
 case the heavy and enlarged fundus is thrown over against the sacrum and 
 rectum, causing the dull dragging backache, with not infrequently tender- 
 ness on the sacral or lumber portion of the spine. It also produces a con- 
 dition of partial stenosis of the rectum, obstructing the passage of the ex- 
 crement and inducing an obstinate form of constipation. Both from the 
 mechanical pressure upon the sacral nerves and the nervous disturbance 
 produced by the laceration itself, there are developed all forms of neuralgia, 
 and neuralgic pains in the limbs, more generally extending from the small 
 of the back through the pelvic structures and downwards over the anterior 
 surface of the thighs, sometimes reaching to the calf of the leg, but more 
 generally stopping at the knee. The spine is the seat of a dull dragging 
 pain, or at times sharp neuralgic darts. 
 
 The spine gives out easily on effort, seems scarcely to have strength 
 enough to sustain the weight of the body, and if required to do so for any 
 length of time, fails utterly, not infrequently prostrating the patient for 
 days. The ovarian and hypogastric regions are usually more or less sensi- 
 tive to pressure, and the seat of sharp darting pains frequently extending 
 across the abdomen ; or of a dull aching distress which is just as annoying. 
 At other times a persistent form of sciatica is developed which resists all 
 kinds of medical treatment. 
 
 As a consequence of the laceration, cellulitis is usually developed, which 
 is evidenced, if it occurs early, by the stoppage of the milk, fever, great 
 pain, tenderness, and strong disinclination to move, on account of the pain 
 occasioned. When the cellulitis results in bands of adhesion being formed, 
 binding the uterus backward, as is most common, or laterally, it produces 
 a displacement with its entire coterie of symptoms, which is most intrac- 
 table. 
 
 Every variety of menstrual disturbance known to women is produced by 
 this lesion. In 17.80 per cent, of the cases recorded by Emmet, menstrua- 
 
LACERATIONS OF THE CERVIX UTERI. 1057 
 
 tion remained unchanged as at puberty ; 44.74 per cent, had their flow 
 either lessened or increased, or made irregular as to quantity without al- 
 teration in the length of time of menstruation. In 82.17 per cent, the men- 
 struation was altered as to quantity, the flow being increased, lessened or 
 irregular; and of these, 62.8 per cent, had their menstruation increased. 
 
 When the laceration first occurs, before the plugs of cicatricial tissue are 
 deposited in the angles of the cleft, the woman is apt to be unusually pro- 
 ductive, one impregnation following another with great rapidity, only to be 
 aborted about the second or third month. This condition is especially 
 liable to supervene after a large stellate laceration. The reason of this is 
 plain when the large patulous os, the softness of the cervical tissues, and 
 the great facility which is afforded the spermatozoa, to enter the uterine 
 cavity, are considered. This habit to abort generally persists till the cleft 
 is filled with hardened tissue, and a heavy, thick, oftentimes, acrid leucor- 
 rhcea is developed, which occludes the passage, when impregnations usually 
 cease, and absolute sterility follows. Most distressing reflex nervous dis- 
 turbances arise, as, for example, persistent headache usually in the occiput, 
 of a dull, heavy character, as if the patient had been struck with a club in 
 that locality. The sufferer is exceedingly nervous and irritable, oftentimes 
 semi-hysterical or melancholic, fears she is going crazy or about to die. 
 
 The diagnosis of a laceration must be reached by means of both the finger 
 and the eye. Neither alone is quite sufficient. When the finger is intro- 
 duced it will generally find- the uterus prolapsed, retroverted, and in a con- 
 dition of subinvolution. The finger will detect the patulous os, the cleft 
 angles of the laceration studded with little cysts presenting as hard nodular 
 bodies above the cervical mucous membrane. The finger will also be able 
 to detect the abrasion of the mucous membrane by the absence of the soft 
 smooth feel of the healthy cervix. There will be usually more or less 
 tenderness from existing cellulitis. The variety of the laceration is fre- 
 quently detected by feeling the different clefts, or the hard stringy bands of 
 cicatricial tissue which have filled them. 
 
 In the use of the speculum, there is a great deal of choice. If the tubular 
 one is used, the vaginal tissues are frequently pushed forcibly back, some- 
 times carrying with them the posterior lip of the cervix, so that the appear- 
 ance through the speculum is of a raw ulcerating surface. The natural 
 ectropium is greatly increased, and no true idea can be gained of the pro- 
 portionate amount of laceration and healthy tissue. The bivalvular specu- 
 lum is much better and affords a truer view ; but even here the natural 
 eversion of the parts is greatly increased, and it is usually very difficult, if 
 not impossible, to successfully approximate in order to determine the 
 amount of laceration. The Sims' removes the difficult} 7 . With the patient 
 in Sims's position, the vagina ballooned out, and the perinseum retracted, 
 there is nothing which offers any traction upon the cervical flap. It pre- 
 sents itself to the eye exactly as it is. 
 
 Having completed the diagnosis, the next question is when to operate, as 
 statistics show that only about 50 per cent, of the cases of laceration require 
 surgical treatment. If there is simply a slight laceration, without marked 
 eversion of the lips, a slight amount of cicatricial tissue in the clefts, with 
 a healthy mucous membrane, even if there be nervous symptoms and a 
 certain degree of anaemia, there is no indication for an operation ; and, if 
 one were performed, it would probably be disappointing in its results. 
 When, however, there is marked ectropium, more or less extensive erosions, 
 deposit of cicatricial tissue in the cleft, cysts of the cervix, leucorrhcea with 
 menstrual disturbances, anaemia, and reflex nervous trouble appearing as 
 sciatica, ovaralgia, cephalalgia, neuralgia of various forms in different parts 
 of the body, or some obscure neuroses for which no assignable cause can be 
 
 67 
 
1058 
 
 A SYSTEM OF SURGERY. 
 
 found aside from that furnished by a well-marked laceration with the above 
 distinctive marks, the probability is that an operation will be followed by 
 brilliant results. No doubt exists of its being indicated in these cases. 
 A marked degree of cellulitis or peritonitis is a contra-indication, unless 
 the surgeon is satisfied that it is originated and perpetuated by the lacera- 
 tion itself. An operation immediately after delivery would not be advisable 
 on account of the softness, distension, and partial obliteration of the cer- 
 vical tissues, rendering satisfactory coaptation well-nigh impossible, and 
 endangering subsequent union. 
 
 All gynaecologists consider preparatory treatment necessary. When there 
 is the usual condition of subinvolution, hyperplasia, ectropium, cystic de- 
 generation, erosion, leucorrhcea, and cellulitis with attendant pain and sore- 
 ness on manipulation, hot-water douches night and morning, giving each 
 time about a gallon of water as hot as can be endured, should be given. 
 There is probably no agent which is of greater therapeutic value in treat- 
 ment of uterine and pelvic inflammations than hot water used in large 
 quantities. Its astringent action on the bloodvessels and tissues of the 
 pelvis is great, so much so, that when a douche has been properly given, 
 the vaginal walls will be found thrown into additional rugae, narrowing 
 the canal perceptibly, and reducing the size of the large congested cervix. 
 The proper method of giving a douche is to place the patient in bed or on 
 a douche-board, with the hips elevated sufficiently to retain a large amount 
 of water in the vagina. The Davidson syringe should be used in place of 
 the customary fountain bag, as there is a certain mechanical effect to be 
 derived from the interrupted current of the former. Some patients cannot 
 tolerate the pain which the more forcible jets of water occasion. If there 
 be any cysts upon the cervix, they should be punctured, and their contents 
 evacuated. It is not necessary to carefully select each cyst, but with a 
 scarificator (Fig. 703) the cervix may be punctured over the entire surface. 
 
 Fig. 703. 
 
 *SH£ 
 
 ».TJ£M/iai-LU. 
 
 Buttle's Scarificator. 
 
 This will empty the cysts, and relieve the congestion by allowing some of 
 the additional blood to escape. After this the entire cervix, and, if there 
 is much tenderness or congestion over the vaginal walls, they also should 
 be painted with Churchill's iodine. Care should be exercised to introduce 
 the iodine into any large cyst which may be punctured, to obliterate it. 
 The iodine will check the bleeding and reduce the congestion. If, as is 
 usually the case, extensive erosions are present, iodine may still be used 
 or one of the following solutions : 
 
 R. Glycerinae, . 
 Hydrastis (Fl. ext 
 
 R. Glycerinae, . 
 Iodini (Churchill'i 
 
 R. Aquae, . 
 
 Acidi Nitrici, 
 
 R. Glyc, . . 
 Alum., . 
 
 R. Give, . 
 
 Acidi Tannici, 
 
 Or any creamy mixture of iodoform and pure carbolic acid. One of the 
 
 33- 
 
 IV 
 
 a- 
 
LACERATIONS OF THE CERVIX UTERI. 
 
 1059 
 
 most satisfactory medicaments for local application is ominico, diluted 
 about one-half, and applied as a douche night and morning. It is not neces- 
 sary to use a large quantity, but enough to thoroughly wash the cervix. 
 The peroxide of hydrogen, 15 volumes, diluted about 18 to 8 with water, 
 makes a cleansing and stimulating application. 
 
 In the New York Medical Journal, of October 10th, 1885, Dr. B. Brown, of 
 Alexandria, Va., claims that by the use of the graduated solution of argentum 
 nitricum, many cases, even of severe laceration, may be successfully cured. 
 He first employs a solution of 
 
 R 
 
 Arg. Nit. (cryst.), 
 Aquee dest., . 
 
 • AS- 
 
 Which he applies to the cervix and canal as far as the os internum. This 
 he uses only in simple fissures of the cervix without deep laceration or 
 ectropium. In deeper clefts, 
 
 R. Arg. Nit. (cryst.), 
 Aquae dest., . 
 
 ^ijss. 
 
 With this he washes the entire surface until a uniform white coating, con- 
 sisting of albuminate of silver, is formed over the entire abraded surface of 
 the cervix. This answers a double purpose of preventing septic infection 
 and stimulating the formation of healthy tissue. 
 
 After all applications to the uterine cervix, it is advisable to insert a tam- 
 pon soaked in glycerin, or glycerin and alum, or in the glycerin, calendula, 
 and tannic acid solution. These tampons should remain for about twenty- 
 four hours. 
 
 The room in which an operation for laceration of the cervix is performed 
 must be scrupulously clean, and should, every little while, be disinfected 
 
 Fig. 704. 
 
 Dawson's Sims's Speculum. 
 
 by the use of carbolic acid, sulphur, thymol, listerine, or some other dis- 
 infectant. It is not necessary to adopt all the antiseptic precautions that 
 are necessary in an abdominal section. As an operating speculum, Dr. 
 McDonald's modification of Sims's is one of the best. Dr. Dawson has 
 modified Sims's speculum by placing the blades on hinges for easy trans- 
 portation. (Fig. 704.) 
 
 Various needle-handles are used, such as Emmet's, Russian, Sims's, etc., 
 all of which can be found in the chapter on Minor Surgery and Wounds. 
 
 Skene's Needle-holder. 
 
 Skene has devised a holder for which he claims the special advantage of 
 being able to better grasp and draw the needle through the cervical tissue. 
 
1060 
 
 A SYSTEM OF SURGERY. 
 
 (Fig. 705.) For all purposes our preference is for the Russian forceps, as 
 they grasp the needle firmly and are simple in construction. Three pairs 
 of scissors are necessary, unless some of the more modern revolving scissors 
 are used. Those needed are Emmet's scissors, straight, curved on the right, 
 curved on the left, and curved on the flat. 
 
 If knives are used, and many operators are partial to them, on the 
 ground that the deeper angles can be more easily reached and tissue divided 
 
 Fig. 706. 
 
 
 Bozeman's Scalpels. 
 
 more accurately ; three, attached to long handles, will be necessary (Fig. 
 706 ) ; one straight, and two curved at the junction of the shaft and blade, 
 
 Fig. 707. 
 
 Emmet's Tenacula. 
 
 so as to allow cutting either to the right or left. Dr. Helmuth clings to the 
 use of the knife, claiming for it far greater rapidity and nicety of operating. 
 
 Skene's Double Tenaculum. 
 
 Two small Emmet's tenacula (Fig. 707) will be needed to raise the tissue 
 as it is dissected away. 
 
 A double tenaculum is often found serviceable for drawing down the 
 cervix towards the vulval orifice. Fig. 708 is one devised by Dr. Skene. 
 Generally no artery forceps are necessary. If the circular artery be cut, it 
 can be secured by passing a thread of cutgut or whale tendon beneath it, 
 and ligating through the tissues. If a tenaculum is not required, a pair of 
 strong-bladed tissue forceps, with a serviceable catch, may be used. The 
 style of needle varies with the operator. The majority of surgeons use 
 either Emmet's (Fig. 709) or Sims's (Fig. 710). I prefer Emmet's latest 
 needles, which are slightly curved at the point, and have three rather dull 
 
LACERATIONS OF THE CERVIX UTERI. 
 
 1061 
 
 cutting edges. Dr. Helmuth prefers, and generally uses, the large heavy Hel- 
 muth needles, for the sake of greater rapidity and ease of placing the sutures. 
 
 Fig. 709. 
 
 Fig. 710. 
 
 •oa ■* wwwm-s 
 
 Emmet's Needles. 
 
 Sims's Needles. 
 
 Dr. Van de Warker, of Syracuse, has devised a needle especially designed 
 to overcome the difficulty of passing small or large needles through a very 
 tough cervix, retracted, as it sometimes is, high up the pelvis. (Fig. 711.) 
 
 Fig. 711. 
 
 Van de Warker's Needle. 
 
 These may be found useful, but, under most circumstances, no device is 
 equal to the ordinary needle, placed at a proper angle in a serviceable pair 
 of needle-holders. With these either a counter-pressure hook (Fig. 712) 
 or Emmet's blunt hook will be required. 
 
 Fig. 712. 
 
 gX^TffFMgflN^ 
 
 Hanks's Counter-pressure Hook. 
 
 According to the preference of the operator, silver wire, whale tendon, silk 
 or. catgut will be needed. Each of these materials has its special advocates. 
 The greater number of operators prefer wire. Dr. Skene uses silk and 
 claims excellent results. Dr. Helmuth and some other surgeons use whale 
 tendon almost exclusively. I believe that silver wire possesses great ad- 
 vantages over the others. Dr. Sims first introduced silver wire, and it is 
 now used extensively by many gynaecologists, among whom are Emmet, 
 Hunter, and Munde\ 
 
 On the night preceding the day of operating, the patient is given a ca- 
 thartic sufficiently strong to insure a free movement of the bowels. About 
 half an hour before the operation, the patient should receive a hot, copious, 
 vaginal douche, also an enema if the bowels are not thoroughly evacuated. 
 Some system of irrigation should be at hand by which a douche of hydrarg. 
 bichlor. 1 to 2000 can be thrown into the vagina just before and at the com- 
 
1062 A SYSTEM OF SURGERY. 
 
 pletion of the operation. Large irrigating bottles are the best. A fountain 
 syringe containing the solution will answer all purposes. The patient is 
 placed upon her back, anaesthetized, after which she is turned upon her left 
 side and placed in Sims's position, well down upon the table, the pillow 
 removed to facilitate respiration, and towels and rubber sheeting placed 
 under the buttocks and about the clothing to avoid soiling. Three assist- 
 ants will be needed, one to give ether, one to hold the speculum and retract 
 the buttocks, and one to manage the sponges and assist the operator. 
 
 After the speculum, which should be warmed and well oiled, has been 
 introduced, and the douche of hydrarg. bichlor. given, the cervix should 
 be seized with a tenaculum and drawn carefully down toward the vaginal 
 orifice. Care must be exercised not to exert too great traction, especially 
 when old cellulitic bands of adhesion remain. The cervix can be drawn to 
 within an inch of the vulva without danger. It should be retained in situ 
 either by a double tenaculum or by a double thread passed through the an- 
 terior lip, beyond the reach of the surfaces to be denuded. The tenaculum 
 or double thread may be given to the assistant who holds the speculum. 
 The lips are then brought together by tenacula, in order to ascertain the 
 amount of surface to be denuded. The mucous membrane, which is to form 
 the cervical canal, is mapped out with the eye, and should be slightly wedge- 
 shaped, the broadest portion being at the extremity which is to form the os. 
 
 Fig. 713. 
 
 Surfaces denuded in Bilateral Trachelorraphy. Undenuded Strip for Cervical Canal in the 
 
 centre.— (Mtjnd£. ) 
 
 The mucous membrane which is to be cut away is hooked up with a 
 tenaculum and removed with the scissors or knife. In a bilateral lacera- 
 tion, it is well to denude the lower cleft first, to avoid the blood from an 
 upper raw surface running over the portion upon which the operator is 
 working; merely the mucous membrane and cicatricial tissue should be re- 
 moved. The tissue in the angles of the cleft must be entirely cut away. It 
 is advisable to continue the denudations well out upon the vaginal surface, 
 to avoid subsequent puckering of the tissues. Fig. 713 represents the area 
 of denudation, and the strip of mucous membrane left to form the cervical 
 canal. 
 
 All the hardened tissue in the cleft must be dissected away, until the 
 healthy muscular substance is reached and the lips can be easily approxi- 
 mated. The extent of cicatricial tissue can be determined by* the hard, 
 gristly, resisting sensation imparted to the hand by the scissors on cutting, 
 and by the fingers and nail which easily distinguish its nodular, hard, 
 resisting character, from the soft yielding nature of the healthy cervical 
 tissue. Unless this entire tissue is dissected out, the reflex neurosis and 
 general mal-nutrition will probably not be benefited. It is a matter the 
 importance of which cannot be overestimated. If, in making a deep dis- 
 section, the circular artery is cut, it can be secured, as has been previously 
 indicated. 
 
LACERATIONS OF THE CERVIX UTERI. 1063 
 
 The opposite side is now denuded precisely as the first, leaving between 
 them two symmetrical strips of mucous membrane, one on the posterior 
 and one on the anterior lip, to form the cervical canal. Where the anterior 
 lip is greatly hypertrophied, the whole lip may be denuded and the excess 
 of tissue cut away, trusting to the mucous membrane left upon the posterior 
 lip to insure the patency of the cervical canal. Any cysts remaining at 
 the time of operation must be remove/1. If the laceration be stellate, with 
 an enlarged cervical canal remaining, a V-shaped piece must be removed, 
 including any hardened tissue. This may be done on either side and the 
 whole treated* as a bilateral laceration. If this is not practicable, the cervix 
 must be freely laid open, the diseased portions dissected, the canal nar- 
 rowed to its healthy calibre, and treated as bilateral laceration. A less 
 radical course will be of no service. All unilateral lacerations are treated 
 as above, it being necessary, however, to denude only one side. 
 
 Everything is now ready for the sutures. If whale tendon, silk, or cat- 
 gut are to be used, they can be threaded directly into the needle. If wire, 
 for which I have a preference, the needles must be first threaded with double 
 linen thread about fifteen inches long, the ends being drawn through the eye 
 three or four inches, leaving the loop into which subsequently to hook the 
 wire. Six or eight needles may be threaded, leaving the threads in the cervix 
 until all the sutures have been placed, or only one needle may be used. This 
 necessitates the placing of the wire as the sutures are introduced. I prefer the 
 former method, as it assists the proper coaptation of the parts and the easy 
 introduction of the stitches. The needle is now grasped with the forceps, the 
 cervix steadied with a counter-pressure hook; and, introducing the needle 
 at the outer angle, about one-quarter of an inch from the denuded surface, 
 it is passed through the two lips. This can usually be done at the outer 
 angles when the lips are not thick. Toward the cervical canal, especially if 
 the lips be hypertrophied and hardened, it will be necessary to introduce the 
 needles from without to the bottom of the denuded cleft, withdraw them, 
 and reinsert them at the same point through the opposite lip, care being 
 taken that they be reintroduced at a point exactly corresponding to the place 
 of withdrawal. If catgut, silk, or whalebone be used, they can be drawn 
 through, cut off at convenient length, handed to the assistant in charge of 
 the speculum to hold, and, after the introduction of all, tied. If wire be 
 employed the silk threads are left in situ until all the needles are introduced. 
 The operator must see that the strips of mucous membrane, which are to 
 form the cervical canal, are in exact apposition. The wire, bent over at the 
 end, the loop being squeezed down as flat as possible, to facilitate its pas- 
 sage through the cervical tissue, is hooked into the loop of thread first in- 
 troduced and drawn by a quick movement of the wrist through the tissue. 
 It is then cut off at a convenient length, the ends merely twisted together 
 and handed to an assistant to hold until all be placed. Fig. 714 illustrates 
 the sutures in situ, together with the triangular appearance of the denuded 
 flaps. 
 
 When all the sutures are in, those nearest the cervical canal are drawn 
 down, unlooped at their extremity, carefully drawn over the cervix and line 
 of incision, twisted once with the hands, the ends straightened out and 
 grasped with the wire twister. The shield is then placed over the wire and 
 the sutures twisted sufficiently to hold the parts in easy apposition, but 
 without enough force to, in any way, strangulate the tissues. 
 
 The wire is then bent over a tenaculum in the direction of the cervical 
 canal, so as to lie close to the cervix, and cutoff, leaving about three-eighths 
 of an inch to be grasped when it is later removed. All the sutures are to 
 be treated in the same way. When they are all twisted, properly bent, and 
 cut away, a probe is introduced into the uterine cavity, to ascertain if the 
 
1064 A SYSTEM OF SURGERY. 
 
 canal is pervious. The uterus is then replaced and rather strongly ante- 
 verted, the cervix and vagina douched with the bichloride solution, the 
 parts cleansed, all soiled linen removed, and the patient placed in bed. 
 
 Fig. 714. 
 
 Appearance of Raw Surfaces and Introduction of Sutures in Wedge-shaped Excision in Lacerated 
 
 Cervix.— (Mund&) 
 
 The after treatment is in most cases simple, consisting mainly of douches 
 of hot water, to which may be added carbolic acid making a strength of 
 about 1 to 100, or boracic acid. These douches are to be given as soon as 
 the discharge commences, and may be administered as often as two or three 
 times a day. If the patient can pass urine unaided, it is best to let her do 
 so ; if she cannot, it must be drawn every six or eight hours, according to 
 her individual requirements. She should not leave her bed until the stitches 
 are removed, which can usually be done on the seventh or eighth day. No 
 harm, however, results from their remaining in situ for a much longer time. 
 If secondary haemorrhage should occur*, which is not common, it can be 
 controlled by injections of hot water, or hot water to which has been added 
 some astringent, as alum, tannic acid or iodine ; or a tampon, soaked in 
 glycerine and covered over with powdered alum, can be placed against the 
 cervix. 
 
 Cellulitis and peritonitis, should they arise, are best controlled by in- 
 ternal medication, to which may be added the liberal use of hot water as a 
 douche, or in the form of the coil, or applied to the abdomen by means of 
 flannel wrung out in it and laid upon the hypogastric region and covered 
 first with oiled silk and then with three or four thicknesses of dry flannel. 
 These must be changed as often as they become cold. 
 
 If the case progresses favorably, the stitches are to be removed on the 
 seventh or eighth day. If perineorraphy has been performed at the same 
 time as trachelorraphy, the perineal stitches had best be removed about the 
 tenth day, and the cervical sutures allowed to remain three or four weeks 
 longer. No harm will occur from the presence of the stitches in the cervix. 
 In removing the stitches, the twisted end of the wire is grasped with a pair 
 of long dressing forceps and the sutures cut with the scissors or preferably 
 with a wire-cutter having a hook-like projection at its end, which can be 
 inserted into the loop. It is necessary to exercise care not to cut the twisted 
 portion of the wire just above the loop, which is exceedingly easy to do, 
 and causes great difficulty in subsequently finding the loop. If it be lost, 
 it is best not to irritate the parts too greatly by searching for it, but to allow 
 
LACERATIONS OF THE CERVIX UTERI. 1065 
 
 it to remain until the cervix is somewhat reduced in size, when it can be 
 more readily found. 
 
 If, on attempting to remove the stitches, the operator finds that union has 
 not taken place, or still worse, that sloughing has occurred, he must freshen 
 the surfaces with a probe, knife, or scissors, tighten the wire a trifle, if 
 necessary, and allow it to remain quiet another week. If the parts have 
 sloughed badly, so that there is no prospect of union, the stitches must be 
 removed and the parts healed by the argentum nitricum solution, in strength 
 of from 20 to 40 grains to the ounce. 
 
 The benefit to be derived from trachelorraphy is not always measured by 
 the perfection of the union of the parts. If the cicatricial tissue be removed 
 from the angles of the cleft and the parts healed without its redevelopment, 
 the same good results usually follow. Nature smoothes down the project- 
 ing lips, fills up the gap, and transforms sometimes apparent failure into a 
 fair success. 
 
 The beneficial results of trachelorraphy do not always immediately follow 
 the operation. In certain cases, even of long standing, the tormenting head- 
 ache or backache will disappear as if by magic as soon as the patient re- 
 covers from the influence of the anaesthetic, and she will obtain the most 
 refreshing sleep which has visited her for years. As a rule, however, there 
 is gradual improvement, which must be measured by months ; and it is not 
 unusual for a year and a half or two years to elapse before the patient 
 realizes the full benefit of the operation. 
 
 Not infrequently, as the result of the mental excitement and the mechani- 
 cal irritation of the parts, menstruation will appear. This ordinarily causes 
 no disturbance, nor does it seem to exercise any prejudicial effect upon the 
 healing process. It is well to omit the douches during the catamenia. 
 
 Trachelorraphy is an operation remarkably free from surgical danger. 
 A few fatal cases are reported, but it is unusual for the operation to imperil 
 more than the immediate comfort of the individual. Failure to unite occurs 
 in about eight per cent, of cases. 
 
 After the operation, the uterus gradually returns to its normal size, the 
 subinvolution and hyperplasia disappear, the cervix gradually resumes 
 its conicity, and becomes covered with healthy mucous membrane. The 
 endometritis and endotrachelitis, with their accompanying leucorrhcea, 
 usually subside in from a few weeks to several months, and the menstrual 
 flow becomes more free from pain, and gradually approaches its normal 
 standard. 
 
 Dr. Van de Warker, in the American Journal of Obstetrics and Gynaecology, 
 for July, 1883, gives the result of thirty-one cases of trachelorraphy, as 
 follows : 
 
 Uterine displacement unchanged- in 16 
 
 Uterine displacement removed in ........ 11 
 
 Uterine catarrh unchanged in 10 
 
 Uterine catarrh removed in 11 
 
 Subjective neuroses unchanged in 3 
 
 Subjective neuroses improved or removed in 16 
 
 Nutrition improved in . . 18 
 
 Nutrition unchanged in 5 
 
 When the cervix is properly healed, there appears to be no more danger 
 of a laceration at a subsequent pregnancy than existed prior to the opera- 
 tion. 
 
 Drs. Goodell, Hunter, Skene, Lee, Emmet, and many others, have re- 
 ported, through the medical journals, numerous cases of pregnancy follow- 
 ing trachelorraphy with no impairment oi* the natural continuity of the 
 
1066 A SYSTEM OF SURGERY. 
 
 cervix. The subsequent history of the operation shows that laceration is 
 no more apt to occur, cseteris paribus, than in one whose cervix has never 
 been torn. 
 
 The effect of the operation upon sterility, which I cannot consider at any 
 length, is uniformly good, except in those cases where for various reasons, 
 such as the establishment of the menopause, the after effects of severe in- 
 flammatory action, the advanced age of the patient which predisposes 
 towards a failure to become .pregnant, the patient is rendered incapable of 
 impregnation. 
 
 In the New York Medical Journal, of July, 1883, Dr. B. F. Baer reported 
 six impregnations following out of what he regarded as a possible eight. It 
 needs, however, great exclusive ability and propensity to justify this pro- 
 portion. In the following number, Drs. Githens, Lee, Montgomery, and 
 Goodell, reported numerous cases of pregnancy following the operation. 
 Dr. Emmet remarks that the effect of trachelorraphy upon sterility is good 
 providing the pelvic organs have not been too greatly injured by inflam- 
 mation ; that, after preparatory treatment, pregnancies are of very common 
 occurrence without subsequent laceration. Under favorable circumstances 
 there can be no doubt that trachelorraphy, properly performed, exercises a 
 very beneficent action upon the sterility, as well as upon the symptoms, 
 local and reflex, dependent upon a severe laceration of the cervix. 
 
 CHAPTER XLIX. 
 
 OVARIAN TUMORS. 
 
 Formation — Varieties— Formation of Colloid — Of Dermoid— Fibrous and Fibro- 
 cystic — Diagnosis— Pseudocyesis — Pregnancy — Parovarian Cysts— Encysted 
 Dropsy of the Peritoneum — Ascites — Microscopical Examination of the 
 Fluid — Albuminoid — Malignant Disease— Treatment— The Performance of 
 Ovariotomy and Subsequent Management. 
 
 If it be true that each ovary contains 300,000 Graafian vesicles, the 
 healthy function and anatomical peculiarities of which tend toward the 
 production of cystic formations, it can readily be seen why certain morbid 
 processes can induce a hypertrophic degeneration of some of the component 
 parts of these vesicles and their surrounding stroma, and that cystic for- 
 mations should result so frequently. Indeed, it has been well said by Mr. 
 Tait * " The function of the ovary is one of cyst-formation from its earliest 
 existence to its latest, and in its pathology we need not go far away from 
 its physiology." 
 
 Of course the majority of this immense number of Graafian vesicles are 
 either atrophied, or lie latent in the ovary, and comparatively few of them 
 develop and rupture, although this process is said to be going on in the 
 body from the time of birth. It is affirmed that ovisacs are being con- 
 stantly ruptured before puberty, the ovum being thrown into the peritoneal 
 cavity, where it perishes. The sac then fills with blood, a portion of which 
 also enters the abdomen, and there gives rise to little disturbance, being 
 rapidly absorbed, or if a large extravasation be poured out, may produce 
 and explain certain varieties of haematocele. From this it may be said that 
 the first and simplest variety of ovarian cystoma arises from the dropsical 
 
 * Diseases of the Ovaries, p. 140. 
 
OVAKIAN TUMORS. 1067 
 
 enlargement of the Graafian vesicle, and we can understand the rationale 
 of the appearance of these tumors in the very young subject. Dr. T. G. 
 Thomas* describes a case where, a month after birth, a tumor was developed 
 in the iliac fossa, about as large as a hen's egg. The child lived in an ex- 
 hausted condition until it was three years and five months old, and then 
 died. Post-mortem examination revealed an ovarian cyst filling the ab- 
 domen. The probability is that this tumor was a parovarian cyst, for Dr. 
 Thomas states that " the Fallopian tube and ovary " were upon one side 
 of the tumor. Dr. Basil, of Bonn, and Mr. Folker, of Hanley,t have per- 
 formed ovariotomy, the first upon a child of two, the second upon a patient 
 aged three years. Mr. Mills has operated upon a child of eight years, and 
 in a contribution to the Medical News % it is related that Dr. Rcemer actually 
 performed ovariotomy upon a baby eighteen months old, the patient 
 making a good recovery. From these facts it seems proper to deduce the 
 opinion that many cases of ovarian cystomata are to be traced to the succes- 
 sive enlargement of the Graafian vesicle until it finally becomes a patho- 
 logical cyst. Indeed, up to the year 1848, the origin of all ovarian cysts was 
 supposed to lie in these hodies,§ and even now, there is reason to believe 
 that they alone give rise, either through one or another pathological -pro- 
 cess in the development of the vesicle, to C} T stic tumors. 
 
 Dr. Emmet,|| as late as 1879, quotes Schroeder as follows: u They (the 
 cysts) occur singly, or the whole ovary becomes, through a repetition of the 
 same process in numerous Graafian vesicles, converted into a tolerably large 
 tumor, which presents, on section, a multilocular cystic appearance." 
 
 Thomas 1 quotes Rokitansky : " They are undoubtedly formed from the 
 Graafian follicles, and it appears that an inflammatory process is particu- 
 larly liable to give the first impulse to this metamorphosis. They are prob- 
 ably, however, as often new formations from the beginning." 
 
 Thus, Courty, also quoted by Thomas : "Ina word, these cysts are drop- 
 sies, simple or complicated, of the Graafian follicles." 
 
 Rokitansky is of opinion that ovarian cystoma may arise from a corpus 
 luteum, which Emmet substantiates, he having seen a cyst of the corpus 
 luteum in the ovary of a woman who had died of a haemorrhage during 
 miscarriage.** 
 
 Virchow at first, afterward Forrester, Rindfleisch, Maywig and others, 
 have apparently demonstrated, that the proliferating cystoma'ta have their 
 origin in a colloid degeneration of the stroma of the ovary ; that epithelium 
 is not found in the smaller cysts, it only being developed in the larger and 
 older formations. This doctrine appears to be at variance with that of de 
 Sinety and Melassez, Wills, Fox, Klob, Waldeyer, and others, who contend 
 that the earlier cysts are developed by a dilatation of Pfliiger's ducts, 
 through the medium of the germinal epithelium. 
 
 The ovary is composed of a cortical portion known as the germinal epithe- 
 lium formed of cells rather columnar in arrangement, with granular nuclei, 
 and an internal stroma also composed of epithelial cells in columns, be- 
 tween which latter a vascular stroma of spindle-shaped cells is found ; in 
 this tissue are small tubuli known as Pfliiger's ducts. These lie chiefly 
 at the base of the ovary, and it is said that through the pathological de- 
 velopment of these germinal epithelia, ovarian cysts have their origin. 
 
 * American Journal of Obstetrics, 18S0, p. 110. 
 f Vide Tait's Diseases of the Ovaries, p. 135 ; also Medical Record. 
 X March 15th, 1884, p. 135. 
 | American Journal of Obstetrics, 1880, p. 2. 
 || Principles and Practice of Gynaecology, p. 760. 
 f Diseases of Women, p. 648. 
 ** Loc. cit, p. 760. 
 
1068 A SYSTEM OF SUEGERY. 
 
 These " ovular chains " of Pfliiger are, according to Heintzman * nothing 
 more than prolongations of the germinal epithelia "in the shape of tubules 
 and solid strings, which at first are connected, holding in their centres 
 large rows of nucleated epithelia." As these ducts, however, are considered 
 as foetal structures, which are removed with advancing age, one of two 
 facts must be deduced, either that certain ovarian cystomas begin their 
 development during the embryonic existence, or that the tubes, in many 
 instances, remain in adult life. 
 
 Tait, on the other hand, differs materially in his opinion regarding these 
 ducts, saying that if they (Pfluger's ducts) are found they are but the re- 
 mains of the Wolffian structures, and that he has never seen them " lined 
 with epithelium," and he does " not believe them capable of undergoing 
 cystic degeneration." An argument in favor of the development of cystoma 
 from these tubes might be found in the appearance of cystoma ovarii in 
 many young children. 
 
 Still another method of development has been advanced by Noeggerath.f 
 His idea is, that a certain number of cystic tumors of the ovary (adenoma 
 eylindro-cellulare) arise from diseased bloodvessels of the gland. The in- 
 tima of the vessel first becomes diseased and its lining membrane is de- 
 stroyed, then the intima itself is broken up by migrating cells accumulat- 
 ing about it, leaving tubules. He states further, " I have no longer any 
 doubt, having seen all the stages of development from the beginning of the 
 alteration to the very last determination, that a great deal of what has been 
 described hitherto as corpora ablicantia and lutea are nothing but degen- 
 erated bloodvessels, "J and again at the end of his paper he says, " I, there- 
 fore, conclude that in a certain number of instances, the epithelial tubes 
 found in ovaries as precursors of ovarian cysts do not derive their origin 
 from the germinative epithelium, but from the tissues composing the capil- 
 lary bloodvessels." 
 
 Here we have three different opinions, all possessing weight from the 
 character of those who have promulgated and developed them. 
 
 The defenders and originators of the idea that the " proliferous cyst," 
 " myxoid epithelial cyst," "gelatinous or colloid cyst," arises essentially from 
 the distension and degeneration of the Graafian vesicles, are met by those 
 espousing the origin of the formations to be originally in the enlargement 
 of the tubes of Pfliiger — with the remarkable fact that none of the cysts are 
 found to contain ovules or proligerous disks, and as Cornil and Ranvier say,§ 
 neither is there found any trace of ovisacs or Graafian follicles, the ovary 
 being completely transformed into cysts analogous to those we have de- 
 scribed. Therefore, the hypothesis of a formation of the cysts by the dis- 
 tension of pre-existing Graafian vesicles cannot be accepted. 
 
 Mr. Tait, however, in his decided manner explains the non-appearance 
 of ova. He says, " I am quite strengthened by my later researches, as 
 well as by those before referred to, in the views I advanced eight years ago 
 to the effect that ovarian cystomata are the result of follicular dropsy only," 
 and he goes on to state that in all his cases save two which he calls mul- 
 tiple cystomata, he has failed to see anything like ova in any cysts of any 
 tumors he has examined. He further explains this absence of ova as follows : 
 " The aim and object of this cyst formation (healthy function of the ovary) 
 is the production, maturation and discharge of the ovum. But if the ovum 
 
 * Microscopical Morphology, p. 826. 
 
 f Am. Jour, of Obstet., 1880, p. 1 ; Diseases of the bloodvessels of the ovary and their 
 relations to ovarian cysts. 
 J Am. Jour. Obs., 1880, p. 9. 
 \ Manual of Pathological Histology, p. 681. 
 
OVARIAN TUMORS. 1069 
 
 be not formed, or if it be produced only in a rudimental extent, may it not 
 happen that the cyst will not be ruptured, but go on aimlessly expanding?" 
 
 There appears to be a great deal of common as well as of scientific sense 
 in these remarks of Mr. Tait. The tumors of which he speaks are those 
 which grow with rapidity, and may frequently take on malignant degenera- 
 tion, whereas those neoplasms which he denominates "multiple cystomata" 
 or " Rokitansky's tumors," are of much smaller size, are rather rare in their 
 occurrence, and within the cysts, ova are found ; in this variety also both 
 ovaries are affected. 
 
 From this hasty sketch we perceive that ovarian cj^stomata may arise from 
 the following conditions : 
 
 1. Follicular distension of the Graafian vesicles. 2. Degeneration of the 
 corpora lutea. 3. From colloid degeneration of ovarian stroma. 4. From 
 the ovarian bloodvessels. 5. From the ducts of Pfliiger. (Enclosed germ 
 epithelium.) 6. From a retrograde metamorphosis of the Graafian vesicles 
 and stroma (malignant formation). 
 
 With all these theoretical explanations of the formation of ovarian tumors 
 one is likely to "confound the categories," as logicians say, and to get the 
 matter much entangled. The tumors may all be classed generically as 
 adenoma, because they arise from and absorb a gland ; and I can see no 
 reason for classifying a dropsically enlarged Graafian vesicle in one category, 
 and the other varieties of formation as cystomata. There appears no very 
 potent theory to oppose the proposition by Mr. Tait, that ovarian cystomata 
 develop from Graafian follicles only, and this is the more plausible when 
 we remember the powers of development residing in the area germinativa, 
 and that in the centre of the Graafian vesicle there is a cavity containing 
 albumen. These tumors, with all their high-sounding names, divisions, 
 classifications, and microscopic revelations, are all epithelial in their begin- 
 ning, nothing more, nothing less. We may say, for instance, that certain 
 forms of these neoplasms originate in the glandular parenchyma. So they 
 do, but what generates the glandular parenchyma but the epithelium ? We 
 say that certain of these tumors arise from Pfliiger's ducts ; this may be also 
 true, but what are these ducts but a division and transformation of epithe- 
 lium ? We may state again that ovarian cystomata arise from the Graafian 
 follicle, but what are the follicles derived from save Pfliiger's ducts, which 
 arise from modifications of epithelium ? 
 
 We know one thing, that in whatever manner these growths arise, after 
 they are mature they present varied appearances, and may be classified with 
 more certainty, thus : 
 
 The simple dropsy of the Graafian vesicles. 
 
 The myxomata embracing the two most noteworthy species. 
 
 (A.) Glandular cysts (cystoma ovarii proliferum glandulare). 
 
 (B.) Papillary cysts (cystoma' ovarii proliferum papillare). 
 
 Dermoid cysts. 
 
 Cancerous cysts (cystoma maligna). 
 
 Strictly speaking, there is no such thing as what is familiarly known 
 as a unilocular cyst of the ovary. De Sinety and Melassez say, " among 
 all the cysts we have examined, we have not found one which was truly 
 unilocular; all those sent to us as such, presented truly a large principal 
 cyst, but on examining them with care, we have always found other cystic 
 cavities, sometimes small enough, it is true, to pass unperceived on a first 
 examination." Tait says,* regarding this appearance : " This conclusion 
 I can entirely substantiate." He then gives a lucid explanation of the 
 appearances.f "The formation," he says, "of a compound cystic tumor 
 
 * Diseases of the Ovaries, p. 136. f Tait, Diseases of the Ovaries, p. 138. 
 
1070 A SYSTEM OF STJRGEKY. 
 
 in the ovary, whether it be of the multiple variety or of the less complete 
 kind of which I am about to speak, may be very well illustrated by blowing 
 soap-bubbles in a basin. If the fluid be not viscid enough to enable the 
 cells to retain their form, then the normal condition of the ovary is repre- 
 sented, its cells bursting and disappearing. Let us suppose that the cell- 
 growth is constantly going on, and that some alteration occurs in the state 
 of matters which prevents the cell-walls bursting ; the fluid in the basin is 
 so viscid that the cells do not break, and bubble after bubble is formed, some 
 larger, some smaller, until a large multicystic tumor is the result. The 
 actual appearance of the cystic ovary may be very well imitated in the 
 basin of soap-lees. A large cyst can be made with little ones crowding into 
 it, looking like its offspring, and the walls between two or three may be 
 broken down, making one larger multilocular — the remains of the interven- 
 ing walls not being left in the instance of the soap-bubbles. 
 
 1 Dropsy of the Graafian Vesicles. — The physiological performance of the 
 follicle is to develop and burst ; if, however, this metamorphosis does not 
 take place, a retention cyst is formed, and as several of these coalesce the 
 cell-walls may disappear, allowing the secretion to remain, and thus account 
 for the production of the cyst. 
 
 Cystoma Proliferum Glandulare. — In this a new formation takes place 
 within the walls of the sac, originally arising (according to Waldeyer) from 
 imperfectly formed Graafian follicles ; in other words, Pfliiger's ducts. The 
 outlets of these glands are obstructed, the cyst enlarges by proliferation, 
 each new group pouring out new cells to develop new formations, the pro- 
 cess continuing until an innumerable number of cysts are produced. I 
 have observed several such cases, one especially in which the operation was 
 performed at the New York Surgical Hospital, while Dr. Dillow was the 
 house surgeon, the count was made up to 118 cysts, and was then discon- 
 tinued. These were of the larger size, but there were innumerable dimin- 
 utive cysts scattered all over the cyst- wall, and budding out as the soap- 
 bubbles already described.* 
 
 The Cystoma Proliferum Papillare differs from the foregoing in that, in 
 this variety, the connective tissue proliferation exceeds that of the adeno- 
 matous. The connective tissue becomes hypertrophied from excessive 
 nourishment, the epithelia are pushed forward into the cyst, and thus 
 a papillary growth is produced. In some instances the pressure of the 
 hypertrophied epithelia is too great for the cyst- wall and it ruptures. I 
 have frequently met these dendritic processes scattered irregularly over the 
 cyst-wall, sometimes in patches and sometimes covering the entire surface. 
 But I had two remarkable cases of complete papilloma of both ovaries, 
 which were removed by me at the Hahnemann Hospital. 
 
 A similar condition to that described is found in the testicle, the an- 
 alogue of the ovary, arising from a proliferation of the epithelia from the 
 tubuli semeniferi, and probably produced in the same manner. This 
 fungoid growth has been mistaken for encephaloid or vegetating epithe- 
 lioma, but is perfectly bland and receives the name of " benign fungus." 
 
 Formation of Colloid. — Colloid material is nearly allied to protein sub- 
 stances, and mainly consists in the albuminous transformation of tissues 
 varying much in consistency, sometimes being about the density of egg 
 albumen and again presenting an almost solid appearance. These altered 
 albuminates contain sometimes a certain proportion of mucin, a substance 
 insoluble in acetic acid and soluble in alkalies, although as a rule this latter 
 ingredient is absent in the colloid of ovarian cystoma. These myxomatous 
 products arise not so much from a true metamorphosis of tissue, as from a 
 
 * New England Medical Gazette, July, 1877. 
 
OVAEIAN TTJMOES. 1071 
 
 modified secretion from or transformation of epithelial elements. In the 
 young cyst the colloid material is more dense than in the larger and older 
 ones, the fact being explained by some* as resulting "in a slow digestion 
 of these crude substances " by the prolonged and constant action of the 
 heat of the body. 
 
 It must be remembered that there is both an innocent and a malig- 
 nant colloid material found in these cysts and which it is important to 
 understand. I believe that a broad line cannot be drawn between the two, 
 as myxomatous or mucoid formations are composed generally of imper- 
 fectly formed cells which, instead of proceeding to a perfect and mature 
 development, assume a retrograde metamorphosis, resembling in many 
 respects the appearances presented by cancerous structures. This is proven 
 by the fact that after an apparently successful ovariotomy, carcinomatous 
 formations may speedily destroy life. I have had occasion to observe this 
 in several cases. In one infiltration and cachexia commenced before the 
 abdominal wound had entirely cicatrized, in another there was a large 
 ascitical accumulation, the patient returned home apparently cured, but in 
 eleven months reentered the hospital with well-developed cancer of the 
 omentum with large colloid accumulation. She was aged forty-seven, and 
 had given birth to one child. According to Dr. Beyer, whose paperf 
 Heintzman gives in full, colloid cancer is not to be classed as a separate 
 species, but as arising from secondary changes in the encephaloid or medul- 
 lary cancer. He says: "In the same manner as cancer elements arise 
 from medullary elements, so may fully developed epithelia under certain 
 unknown conditions retrogress" to medullary elements. Whenever this 
 occurs, medullary corpuscles are transformed into a reticulum, containing 
 a jelly-like, homogeneous basis-substance, with interspersed remnants of 
 epithelia." 
 
 And again Pepper says| : " Colloid cancer is built upon the same struc- 
 tural type as scirrhus and encephaloid. It bears a close resemblance to the 
 
 latter in its clinical features, being rapid in growth and quickly fatal 
 
 The consistence of these tumors is subject to wide variations, but for the 
 most part they are very soft, sometimes diffluent. When springing from 
 the ovaries they may be mistaken for simple cystic formations The de- 
 generation commences in the cells ; first a drop appears in the protoplasm, 
 and as it enlarges the nucleus is thrust to the margin. Finally nuclei and 
 cell capsules disappear, the change advances from the centre to the peri- 
 phery, and the outside cells, prior to their destruction, become compressed 
 and elongated and occupy a concentric position. The stroma undergoes a 
 similar alteration, it softens and liquefies, so that the contiguous alveoli run 
 together forming festooned cavities." 
 
 The Formation of Dermoid Cysts. — There have been many theories propa- 
 gated regarding the origin of dermoid cysts, some indeed at the present day 
 regarding them as fcetal remains (foetus in foetu), or ovarian pregnancy. 
 These conclusions have been proved erroneous. The argument against 
 such hypotheses is the appearance of bone, hair, teeth, lime, etc., in other 
 portions of the body and in both sexes. The majority of the profession 
 appear to agree as to the congenital origin of these cysts. Waldeyer's views 
 are generally accepted, although founded on no very recent experiments. 
 He is of opinion that these tumors arise from the epithelial cells of the 
 ovary, each of which is capable of becoming an ovular cell, and by some 
 morbid process to proceed to incomplete embryonic development. 
 
 * Peaslee, Ovarian Tumors, p. 33. 
 
 f Medical Gazette, New York, April, 1880 ; Microscopical Morphology, p. 551. 
 
 X Elements of Surgical Pathology, London, p, 482. 
 
1072 A SYSTEM OF SURGERY. 
 
 " Now it may very well be assumed that the epithelial cells of the ovary, 
 in conformity with their significance of undeveloped ovular cells, furnish 
 in their multiplication or division, and by budding, other products, and in 
 fact such as are further advanced in the direction of an incomplete em- 
 bryonic development than they themselves are."* 
 
 Tait supposes that during the developmental period of life a stimulus is 
 given to a Graafian vesicle with its ovum, which, if it were not disturbed, 
 might in time be carried into the uterus and there impregnated. On the 
 contrary, if it remain in the ovisac and there " share alike with the rest of 
 the economy in developmental activity, there could be only one result, and 
 that would be the formation, in an incomplete degree, of those structures 
 which it would evolve in perfection under more formidable conditions. "t 
 
 I think the best solution of the question is that of the invagination of the 
 blastodermic membrane, the external layer of which develops the organs of 
 animal life. If, therefore, there should be an enclosure of any part of this 
 membrane within any organ of the body, these epidermal formations would 
 readily be produced. 
 
 In this variety, the wall is thickened, and consists of two layers. I have 
 seen a cyst that could be separated into six laminse. The older the cyst- 
 wall becomes, the more are these concentric layers of deposit arranged 
 within it. 
 
 There are fat-globules and masses of fat on this layer, which may be mis- 
 taken when opening the cavity for the appendices epiploicse of the omentum. 
 
 The inner layer is skin, in which some observers have found not only the 
 ordinary sebaceous glands, but also hair-follicles and sweat-glands. This 
 skin presents the anatomical formation of the derma, and has often the 
 papillary body and the chorium well developed. The contents of the cysts 
 are various, — hair, bones of various and peculiar conformation, teeth, fatty 
 or cheesy (vernix caseosa) matters, lime, and cholesterin crystals. 
 
 I have seen several such tumors. One, in a patient aged twenty-seven 
 years, weighed in all forty-three pounds, twenty pounds of which were 
 contained in one large cyst, opening into which was a smaller one twelve 
 inches in circumference, filled with sebaceous matter, hair, and lime ; in 
 another cyst were dark hair, bones, and teeth, and in one sac was a bone 
 resembling the superior maxilla, containing perfectly formed teeth, with 
 various other pieces of curiously formed bones. 
 
 In another case there was some doubt as to the true nature of the tumor, 
 but it proved to be a dermoid cyst, containing fourteen pounds of sebaceous 
 material, first coming out like bullets, and then having to be scooped out 
 with the hands. The substance was actually packed together, and was inter- 
 mixed with a quantity of long, dark hair. 
 
 My last case of the kind was in June, 1886. There were seventy-six bits 
 of bone, with hair, lime, and much colloid material in the cysts. 
 
 Parovarian Cysts. — It is necessary to say a few words regarding these, 
 which have generally been called cysts of the broad ligament. They are 
 peculiar both in diagnosis and treatment. 
 
 As the testicle has an accessory — the epididymis, so has the ovary — the 
 parovarium, which is the remains of foetal life, tubular in structure, and 
 coming from the upper and outer surface of the ovary. It is also called the 
 paraoorphoron. These bodies are really portions of corpora Wolffiana, 
 which are tubular structures and are the primordial kidneys. When the 
 kidney is formed some of these tubules remain undeveloped, and are con- 
 nected with the ovary, as already noted, and are lined with epithelium. 
 
 * Emmet, Gynaecology, p. 767. 
 
 f Tait, Diseases of the Ovaries, p. ISO. 
 
OVARIAN TUMORS. 1073 
 
 These tubules vary in their number, from three to forty, always having 
 csecal extremities, and generally showing a larger duct, known as that of 
 Rosenmiiller. It is from the lining membrane of these tubes that the 
 cyst-formation develops. The duct of Rosenmiiller can also be traced with 
 clearness. 
 
 Fibrous and Fibro-Cystic Tumors of the Ovary. — These neoplasms are of 
 rare occurrence, and are generally small (about the size of a cocoanut), 
 although they sometimes attain great magnitude. They are difficult, espe- 
 cially when they have become cystic, to diagnose from the true ovarian 
 cystoma, and operators have frequently been led, by the similarity of 
 appearances in the two varieties of tumor, to mistake one for the other. It 
 has been doubted whether the ovary ever develops a true fibroma, the idea 
 being that the majority of such neoplasms have their origin in the uterine 
 tissue. I think there can be no doubt regarding the existence of fibroma of 
 the ovary. The solid fibroid by its deterioration may become cystic. I 
 was called to Corning, New York, by Dr. Bryan, to operate upon an ab- 
 dominal tumor. The abdomen was conical, fluctuation was perfect on the 
 left side, but a solid tumor, smooth and elastic, extended above the umbilicus. 
 The usual incision was made, and a white, shining, fibrous mass presented. 
 There were no adhesions anteriorly, and upon introducing the hand, the 
 uterus could be felt, but posteriorly the growth was everywhere adherent, 
 it appeared perfectly immovable ; upon introducing the hand into the left 
 lumbar region the fluctuating part of the mass could be detected, but I 
 could not bring it sufficiently up to the line of incision to introduce the 
 trocar. I therefore deferred the tapping until a future occasion, and closed 
 the wound. The patient recovered rapidly. Shortly after Dr. Bryan wrote 
 me, " The fibrous portion of the tumor has diminished, the cystic has in- 
 creased ;" and in a letter a year later, stated that he aspirated the patient, 
 removing about thirteen pints of fluid, and that he could find no signs of 
 the hard fibrous tumor. 
 
 The best explanation of the transformation of the solid to the liquid 
 tumor is made by Coe * who has given a great deal of study to the subject. 
 In his sixth conclusion he states, " such cysts probably arise from the so- 
 called ' geodes ' 01 gelatinous patches," and in his eighth conclusion he 
 affirms : " The geodes are probably dilated lymph spaces, which expand by 
 reason of the accumulated fluid in their interior, a condition due to a gen- 
 eral stasis." 
 
 The original fibrous tumor (solid) develops from the stroma of the ovary 
 itself, and its rareness may be accounted for by the fact, that the ovary is 
 for the most part cystic in body and in function. 
 
 Diagnosis. — In some instances this is easy and in others it is difficult. 
 The latter fact is verified by the experience of those who have had extended 
 opportunities for observation. Mr. Taitf thus writes, u I have more than 
 once opened an abdomen under the complete belief that I should find an 
 ovarian tumor, but have found only masses of cancer with an abundant 
 ascitic effusion;" and again he refers to a case thus, "I diagnosed a parova- 
 rian cyst, and in a few days I opened the abdomen to remove it; I found, 
 however, that it was not a cyst of the broad ligament, but a dropsical dis- 
 tension of the lesser cavity of the peritoneum, due to the occlusion of the 
 communicating cavity by peritonitis." 
 
 I believe, if all the mistakes which have been made were to be recorded, 
 an interesting volume could be written. It would profit both the surgeon 
 
 * Am. Journal Obstetrics, 1882, p. 877. 
 f Diseases of the Ovaries, p. 218. 
 
 68 
 
1074 A SYSTEM OF SURGERY. 
 
 and the patient. Dr. Atlee refers to such cases, and on one occasion diag- 
 nosed a swelling of the abdomen as an ovarian cyst, and appointed a day 
 for the operation. • Shortly after, the birth of a healthy infant prevented 
 the necessity of further interference. Goodell says:* "Once an enormously 
 distended bag of water broke, just as a deservedly eminent British sur- 
 geon had rolled up his sleeves, and was about to wheel his patient into 
 an amphitheatre, crowded with spectators to witness an ovariotomy ; and 
 a surgeon, of whom Great Britain can well be proud, drove a trocar into 
 the shoulder of a foetus under the idea that he was tapping one of these 
 cysts, "f 
 
 I was sent for to give an opinion in the case of a lady said to be preg- 
 nant, and who had passed a month beyond her time. The nurse was at 
 hand, the baby basket was furnished, the cord and scissors were arranged 
 in their proper places, and a bureau full of clothes awaited the arrival of 
 the stranger. The foetal heart was said to have been distinctly heard by a 
 professor and another medical man of repute, and the family were anxious 
 for the expected event. The introduction of the aspirating needle proved 
 the fallacy of their expectations, and the removal of a tumor of forty 
 pounds dispelled the illusion. 
 
 The characteristics for diagnosis are : 
 
 1. Prominence of the abdomen, it being conical in shape; lower ribs 
 bulging. 
 
 2. Not much change in the shape of the belly when changing position. 
 
 3. Clear sound on percussion around flanks and high up on the tumor. 
 Often the line of the cyst may be made out by this alone. 
 
 4. No bulging or fluid between recti muscles when the patient rises from 
 the dorsal decubitis. 
 
 5. As the patient turns from the side to the back, there is but slight flat- 
 tening of the abdomen. 
 
 6. Enlargement of the abdominal veins. 
 
 7. Pulsations of the aorta generally felt through the abdominal walls. 
 
 8. Decided fluctuation all over the cyst, modified in some portions, espe- 
 cially in multilocular cysts. 
 
 9. Fluctuation more distinct in the recumbent position than in the erect 
 (the contrary the case in ascites). 
 
 10. The fades ovariana well marked in most cases, with emaciation about 
 neck and shoulders. 
 
 11. The fluid contains the ovarian granules CDrysdale's corpuscles). 
 
 12. Fluid generally contains much albumen, though it does not coagulate 
 spontaneously. 
 
 13. The uterus is, in most cases, found behind the c) r st. 
 
 Tumors presenting these symptoms will be found to be true ovarian, 
 either monocystic or polycystic, the latter being generally made out by the 
 uneven surface of the abdomen. 
 
 Pseudocyesis. — There is a condition known as phantom tumor (pseudo- 
 cyesis). I have seen two cases, one in the practice of Professor Burdick, 
 the other in that of Professor Danforth. I examined both of these patients, 
 and in both there was certainly a bewildering resemblance to abdominal 
 tumors. The abdomen was large and firm, and presented dulness on per- 
 cussion in certain areas while resonance was distinctly noted in others ; 
 there was also that peculiar gurgling sound that leads one to the conclusion 
 that the tumor is of the phantom variety. Complete anaesthesia rendered 
 both the abdomens flat, with considerable relaxation of tissue. 
 
 * Lessons in Gynecology, p. 352. 
 
 f For further information refer to Thomas, pp. 655, 657, also to Emmet, p. 776. 
 
OVAKIAN TUMORS. 
 
 1075 
 
 Sterile women are more frequently affected with the disorder than the 
 fruitful, and those suffering from it are generally hysterical and neur- 
 asthenic, crave sympathy, and invariably grieve because offspring is denied 
 them. 
 
 Pregnancy. — Difficulty in diagnosis is sometimes experienced by the prac- 
 titioner in cases of young unmarried women, whose abdomen has suddenly 
 enlarged after suppression of the menses. Such a case was brought me in 
 June, 1883. The patient was twenty-two years of age, had been living in 
 a malarial region, her menses had ceased, she had experienced some sore- 
 ness of the breasts, had failed in general health, and had steadily enlarged 
 in the abdomen. Her sister suffered great anxiety concerning her, not 
 knowing whether pregnancy existed. Upon examination I found the ab- 
 domen conical, with dulness over its entire surface, no fluctuation percepti- 
 ble, and the introduction of the aspirating needle drew no fluid. Knowing 
 that, in such cases, the physician must be skeptical to the last (for women 
 have stoutly denied their pregnancy with the head of the child protruding- 
 through the vulva), I questioned her closely, but she declared her innocence 
 in such positive terms, that I was fain to believe her. However, I did not 
 introduce the sound, and proposed an exploratory operation. She readily 
 consented, and though she was suffering from malarial fever, with a pulse 
 of 120 and temperature of 102°, yet she was failing so rapidly that I operated 
 at once, removing a cyst weighing thirty-five pounds. An excellent rule in 
 such cases (I mean those occurring in young unmarried women, in whom 
 the menses have disappeared and the abdomen has steadily and symmetri- 
 cally enlarged) is to delay a few months, listening from time to time for 
 the foetal heart, and keeping such watch upon the patient as may facilitate 
 diagnosis. 
 
 When we find a tumor arising from the pelvis, it will be advisable to in- 
 quire if it may not be a gravid uterus, and by assuming such to be the case 
 until it is proved to the contrary, the mistake of attempting ovariotomy on 
 a pregnant woman will be avoided. 
 
 I give here the differential diagnosis from Penslee. 
 
 NORMAL PREGNANCY, FIVE AND A HALF 
 MONTHS OR MORE. 
 
 Enlargement sudden and rapid ; symmetrical 
 or slightly inclined to the right side. 
 
 Features natural, healthy. 
 
 Superficial veins of abdomen not enlarged. 
 (Edema in ankles not uncommon after 
 seven months. 
 
 Chest not conical. 
 
 Fluctuation indistinct, unless there is much 
 
 liquor amnii. 
 Menstruation arrested. 
 Vaginal touch detects softening and apparent 
 
 shortening of the cervix and enlargement 
 
 of the uterus. 
 Ballottement feels impulse of foetus. 
 Foetal heart-sounds heard. 
 Foetal movements felt. 
 Enlargement of mammae. 
 
 OVARIAN CYST, SECOND OR THIRD 
 STAGE. 
 
 Enlargement gradual ; not symmetrical till 
 the third stage. 
 
 Features emaciated, anxious. 
 
 Veins are enlarged ; oedema in late stages ; 
 in exceptional cases one to two years after 
 commencement. 
 
 Chest conical, when there is great disten- 
 sion. 
 
 Fluctuation very distinct, especially in mono- 
 cysts. 
 
 Menstruation does not cease till third stage. 
 
 No such change apparent, but uterus gener- 
 ally displaced behind the cyst. 
 
 Ballottement reveals nothing. 
 No sound of foetal heart. 
 No motion of foetus. 
 Occurs but exceptionally. 
 
 Parovarian Cysts are diagnosed from ovarian cysts by the character of the 
 fluid. It is clear and limpid, like spring-water. It is, however, wrong to 
 lay down as a rule that this fluid contains no albumen ; in certain cases 
 it does, and in large quantities. Another characteristic of this fluid is its 
 
1076 A SYSTEM OF SURGERY. 
 
 power of resisting decomposition. I have known it remain a week or ten 
 days without showing signs of degeneration. Here the microscope aids the 
 diagnosis. By referring to Dr. Atlee's work, it will be found that on several 
 occasions an ovarian tumor was diagnosed by skilful physicians, when a 
 cyst of the broad ligament was found. In most cases, a first or second 
 tapping will be sufficient to cure. These tumors generally occur in young 
 females, and if a pregnancy exist may be cured by this alone. 
 
 Dr. Terillan, after giving some important information regarding parova- 
 rian cysts, arrives at the following conclusions :* 
 
 1. Parovarian cysts, the fluid contents of which are limpid, not stringy 
 and devoid of paralbumen, return after complete evacuation of their con- 
 tents. 
 
 2. This return, though usually slow, and possibly occurring after an in- 
 terval of three or four years or more, may occur within a few months. 
 
 3. The interval of time between tapping and the return of the fluid is 
 such as to simulate complete cure, and has proved a source of error. 
 
 4. It is difficult to say in what proportion of cases the tumor returns, but 
 it is more often the rule than the exception. 
 
 5. There are some well established cases, though few, in which a complete 
 cure has been obtained after one or more tappings. 
 
 6. Ought tapping, therefore, always be practiced in supposed cases of par- 
 ovarian cysts? 
 
 7. Removal, complete or incomplete, is indicated after relapse ; the results 
 are good, being below fifteen per cent. 
 
 8. Removal is preferable to the injection of iodine. 
 
 Encysted Dropsy of the Peritoneum. — In the majority of cases of chronic 
 pelvo-peritonitis, whether or not occasioned by tuberculosis, an effusion 
 takes place in the lower space ; of this I have seen an interesting case, asso- 
 ciated with hard cancer of the uterus. The fluid collected in the cul-de-sac 
 of Douglas was evacuated readily by a small trocar, and the next night 
 the patient died. This is contrary to the experience of Brickell,t but I 
 am persuaded that in pelvic effusions, unaccompanied by cancerous or 
 tuberculous disease, the result of the withdrawal of the fluid is satisfactory. 
 
 PeasleeJ says of encysted dropsy: "This is an extremely rare patholog- 
 ical condition ;" in his carefully prepared chapter on differential diagnosis, 
 many symptoms are laid down, which I believe to be inaccurate. 
 
 Ziemssen§ lays stress on the " sensitiveness" that presents, although he 
 grants that it may be " exceedingly slight, or altogether wanting." He says, 
 also, "In cancer of the peritoneum and omentum, the cancerous nodules 
 may sometimes be felt in the exudation surrounding them, yet these very 
 cases bear an extraordinary resemblance to irregular multilocular ovarian 
 cysts, which lie in a copious ascites." And again he says: " If, through 
 the diagnostic points already given, it has been ascertained that the collec- 
 tion of fluid in the abdomen is encysted, the presumption is in favor of 
 its being an ovarian cyst, since other forms of encysted fluid are much less 
 common." 
 
 Dr. Routh || records three cases of this peculiar condition, which were diag- 
 nosed by the surgeons to the Samaritan Hospital as ovarian cystoma. In 
 one of these, Mr. Wells diagnosed an extra-ovarian cyst. All were tapped, and 
 all died. 
 
 * American Journal of the Medical Sciences, April, 1886. 
 
 f Ibid., April, 1877, p. 358. 
 
 % Ovarian Tumors, p. 1-^5. 
 
 I Vol. x., p. 385. 
 
 || Obstetrical Journal of Great Britain, April, 1874. 
 
OVARIAN TUMORS. 
 
 1077 
 
 He thus finishes his paper : "These three cases, although all unfortunate, 
 illustrate this point in practice, that where you have adhesions of the colon, 
 and especially if the induration is more marked on the one side than the other, it 
 is extremely difficult, if not absolutely impossible, to diagnose the pseudo- 
 cyst from a real ovarian or extra-ovarian cyst." 
 
 Morgagni* also recognizes this variety of dropsy. He says : " But others 
 (dropsies) are of a different kind, as that described by the celebrated An- 
 hoinius ; an almost incredible quantity of fluid being confined between the 
 peritoneum and the omentum, which had become very hard, in a woman whose 
 face, considering her emaciated state of body, was of a pretty good color, 
 and whose feet were free from swelling." 
 
 Atlee'sf 15th, 16th, and 17th cases were instances of a similar character. 
 
 If the nodules can be felt through the abdominal walls, the fluid floating 
 over them, the surgeon may be upon his guard, but no clear diagnosis can 
 be made without the withdrawal of the fluid and subjecting it to the micro- 
 scope. 
 
 Accumulations of fat beneath the skin of the abdomen, which are often 
 found in women between the ages of thirty and forty years, have sometimes 
 been mistaken for pregnancy, and also for tumors of the ovary. But as the 
 signs of ovarian tumor are absent, such a mistake would not be readily 
 excused. 
 
 Ascites. — I give from Peaslee the differential diagnosis between ascites 
 and ovarian cysts. 
 
 ASCITES. 
 
 History shows previous ill health, as dis- 
 ease of the liver, lungs, heart, or kidneys. 
 
 Enlargement comparatively rapid. 
 
 Face full, puffy, leaden hue. 
 
 Patient lying on the back, the abdomen is 
 flattened in front, but symmetrical. 
 
 Patient on side, the sides are flattened. 
 
 Patient rising suddenly from the back, the 
 fluid bulges between and to the sides of 
 the recti muscles. 
 
 In sitting posture, lower part of abdomen 
 bulges, 
 
 Skin of abdomen smooth, tense, and shining. 
 
 (Edema of extremities in all cases, and at . 
 
 last of abdomen also. 
 There is no bulging of the floating ribs. 
 
 Navel prominent and thinned. 
 
 Fluctuation decided and clear; diffused 
 through the abdomen, but avoids highest 
 parts in all positions, and always has a hy- 
 drostatic level. 
 
 More distinct in erect position. 
 
 Percussion gives a clear sound at highest 
 portions of abdomen in all positions ; is 
 dull elsewhere, and changes with the posi- 
 tion. 
 
 Aortic pulsation not felt through abdominal 
 walls. 
 
 Fluctuation immediately felt through vagina 
 or rectum. 
 
 OVARIAN CYST. 
 
 The patient has previously enjoyed good 
 
 health. 
 Gradual enlargement. 
 Peculiar emaciation of face. 
 The tumor is not generally symmetrical, is 
 
 prominent in front. 
 Patient on side, no change. 
 Patient rising in same manner, may cause 
 
 some bulging, if not adherent. 
 
 In sitting, there is little, if any change in 
 
 abdomen. 
 Skin of abdomen appears natural or only 
 
 thinned. 
 (Edema only in exceptional cases. 
 
 The chest is conical from bulging of the 
 false ribs. 
 
 Navel not thinned. 
 
 Fluctuation less clear and decided, limited 
 by the cyst, and may remain at the highest 
 points ; has no hydrostatic level. 
 
 More distinct in recumbent position. 
 
 Clearness on percussion only at parts not 
 corresponding to the cyst, and in both 
 flanks. Dulness over cyst in all positions. 
 
 Aortic pulsations transmitted through the 
 
 cyst to abdominal walls. 
 Fluctuation not so clear, or may not exist in 
 case of polycyst. 
 
 * Essay on Diseases of the Belly, vol. iii., book iii., p. 350. 
 f Ovarian Tumors, pp. 72-78. 
 
1078 A SYSTEM OF SURGERY. 
 
 ASCITES. OVARIAN CYST. 
 
 Uterus normal in size, mobility, and posi- Uterus generally displaced behind the cyst. 
 
 tion; sometimes prolapsed. 
 Fluid light-straw color, contains albumin Fluid darker shade; abounds in albumin 
 
 and amoeboid corpuscles ; coagulates or colloid matter, but contains no amoe- 
 
 spontaneously. boid corpuscles ; never coagulates sponta- 
 
 neously. 
 Ansemia comes on early. Ansemia appears late. 
 
 Hydragogues and diuretics produce tempo- This treatment produces little if any effect. 
 
 rary relief. 
 Exceptions to the above rules are rare ; but Exceptions. — There may be a tympanitic 
 
 occasionally, if there be a very large de- resonance if the cyst communicates with 
 
 posit of fluid, even the highest point of the intestine. 
 
 the abdominal cavity will present dulness 
 
 when the patient lies on the back. Or the 
 
 intestines may be glued down by adhesions, 
 
 in which case deep percussion may bring 
 
 tympanitic sounds. 
 One or both flanks may give a clear sound, One or both flanks may be dull from faeces 
 
 from gas in the colon. in the colon. 
 
 Iii addition to the above, the presence of ovarian granules and columnar 
 epithelium in the fluid from a cystoma, their absence in ascites; while in the 
 latter are found amoeboid lymph capsules, the diagnosis can be made. 
 
 Withdrawal of a Portion of the Fluid.— Enough has been said regarding 
 the difficulties which surround the diagnosis of some forms of abdominal 
 tumors, to show that it requires experience and care to arrive at a correct 
 conclusion regarding them. A patient is brought to the surgeon with 
 an enlarged abdomen ; thin face, with peculiar expression ; emaciated, es- 
 pecially about the neck ; dulness on percussion over the anterior parietes 
 of the tumor, with resonance of the flanks; conical abdomen in all posi- 
 tions, with enlarged abdominal superficial veins ; an absence of cardiac or 
 hepatic disease ; a smooth surface, without nodules or hardness ; and the 
 inference would be that an ovarian tumor was present. Is it ovarian or 
 parovarian ? Is it an encysted cfropsy of the peritoneum, or is it a colloid 
 cancer of the ovary ? Or does a cancerous condition exist in conjunction 
 with an ovarian cystoma ? The best aid to diagnosis in these cases is 
 chemical and microscopical examination of the contents of the tumor. To 
 obtain the fluid, it must necessarily be drawn from the abdomen, and 
 although I am aware that some high in authority have expressed them- 
 selves averse to the use of abdominal puncture, I have never seen any bad 
 results follow the method I have adopted. I employ a syringe capable of 
 holding about eighty minims, with a needle four inches in length. The 
 quantity thus taken is sufficient for microscopical purposes, the puncture 
 and pain are nothing, and I have performed this little operation in my 
 consulting-room, and sent the patient immediately either to the hospital 
 or her own home, and never have known evil consequence. The adhesions 
 from so small a puncture are of little import, and the slight modicum of 
 risk appears a trivial offset to the unfortunate results that might ensue from 
 an error in diagnosis. In this I differ from Dr. Garrigues.* There is no 
 more danger of the remaining fluid leaking into the peritoneal cavity, if the 
 puncture is made with the hypodermic needle, than there would be from the 
 diagnostic puncture of the needle into the bladder, the pericardium, or the 
 pleura, and if a small quantity did so exude, it would produce no effect 
 save slight local irritation, as the peritoneum is tolerant of these fluids. 
 
 Microscopic Examination. — While I decry the evacuation of the sac, by 
 tapping (if a subsequent operation is to be performed), as being prejudicial 
 
 * Am. Journ. Obstetrics, 1882, p. 679. 
 
OVARIAN TUMORS. 
 
 1079 
 
 in many ways, I am so firm in my belief regarding the aid to diagnosis 
 exhibited by the microscope, that I should consider myself derelict in my 
 duty, if I performed ovariotomy without subjecting the fluid to careful 
 examination.* I am not a microscopist, though I have somewhat versed 
 myself in the appearances presented by these fluids ; all my recent examina- 
 tions have been made, with one or two exceptions, by Dr. Dillow. 
 
 I am a believer in the appearance of what are known as " Drysdale's 
 corpuscles " as being diagnostic^of ovarian cystoma. I am bound to em- 
 phasize this, as it is in accordance with my experience. In the only 
 two cases wherein I have made an error in the diagnosis, and which have 
 heretofore been stated as being encysted dropsy of the peritoneum, the 
 examiners wrote in their reports in one case that the acetic acid test had 
 not been applied, and in the other, the appearance of the granule was rather 
 doubtful, and there were only few in the field. 
 
 I am aware of the discussions which have taken place regarding this 
 granular cell. I know that it has been stated that Drysdale's corpuscle is 
 
 Fig. 715. 
 
 0. Ovarian granules (Drysdale's corpuscles). 
 
 1. Inflammatory corpuscles. 
 B. Blood-globules. 
 
 P. Pus-corpuscles. 
 0. Oil-globules. 
 
 not a cell, " but the nucleus of an epithelial cell in a state of fatty degenera- 
 tion,'^ and that the peculiar corpuscle had been discovered by Lebert, in 
 1846, and that these bodies, large and small, were also described by Dr. 
 Bennett in 1852, and that they were frequently found in cysts in other parts 
 of the body, Dr. Dillow having lately seen perfectly formed ones in the 
 fluid from a mammary cyst and also from other tumors. It is also affirmed 
 that Dr. Drysdale himself has made a serious mistake in the diagnosis of a 
 cyst not ovarian. 
 
 These points in the discussion Dr. Drysdale denies. He declares! that 
 the bodies described are original with him, neither Bennett nor Lebert hav- 
 ing noticed them, and that they are true cells. He states that inexperienced 
 
 * Both Drs. Atlee and Drysdale, and others of large experience, can corroborate this fact. 
 Am. Journal Obstetrics, 1881, p. 956. 
 f Am. Journ. Obstet., 1882, p. 681. 
 t Ibid. 
 
1080 
 
 A SYSTEM OF SURGERY. 
 
 observers may mistake the pyoid cell of Lebert and the large cell of Bennett 
 for his corpuscle, and he states positively that his test of acetic acid and 
 ether will solve the problem. He writes, u The test which I recommend to 
 distinguish the ovarian from Gluge's or Bennett's cells, is ether. If a small 
 quantity of ovarian fluid be put upon a slide, and a few drops of ether 
 added, and mingled with it by means of a tubular pipette, and the cover 
 at once put on, the result will be that the pus-cells will be dissolved and 
 the ovarian granule be made apparent." "• 
 
 Fig. 716. 
 
 Microscopical Appearances Presented in Ovarian Fluid. 
 a. Cells with granular appearance, and frequently with plainly distinguishable fat-globules— Drys- 
 dale's corpuscles, b. Cholesterin crystals, c. Leucocytes, d. Fat-globules, e. Colloid concretions. /. 
 Detritus in cysts which have repeatedly been punctured, g. Ciliated cells, h. Pavement epithelium. 
 i. Red blood-corpuscles. 
 
 Figs. 715 and 716 show the different appearances of bodies found in 
 ovarian fluids. 
 
 If the fluid, as it comes into the syringe, is colored brown, inky, or 
 mahogany-color, and is rather difficult to be evacuated through the tube 
 by the piston, and when it is removed is sticky, the tumor is ovarian. If, 
 however, the fluid is amber colored, clear and limpid or bloody, then the 
 surgeon must be upon his guard; he may have ascites, either general or 
 peritoneal, a parovarian cyst, or a cancerous condition to look after. If 
 nothing comes from the introduction of the needle, and yet the dulness on 
 percussion and undoubted fluctuation are present, the chances will be that 
 
OVAKIAN TUMORS. 1081 
 
 the contents of the cyst is colloid too thick to be drawn through so small 
 an aperture, and other means should be resorted to, even if it may be 
 necessary to make the exploratory incision. 
 
 A few drops of the fluid thus drawn should be placed in very clean 
 drachm vials for microscopic examination, and the balance into a small 
 test-tube to secure the process of coagulation. If the fluid be ovarian, 
 there is no spontaneous coagulation, as a rule, or if there be anj^ it is 
 very slight, but upon the application of heat it rapidly coagulates ; if the 
 fluid be ascitical after a day, spontaneous coagulation results ; and if in 
 addition, the microscope shows, as pointed out by Garrigues, flat endo- 
 thelium and amoeboid lymph-corpuscles, the diagnosis may be said to be 
 certain. The twenty-fourth conclusion of Garrigues is essential to re- 
 member. He thus writes: "The most important element in regard to 
 diagnosis are columnar epithelial cells, seen in side view. Their presence 
 excludes all other tumors than those of the ovary, Fallopian tube, or broad 
 ligament." According to Noeggerath, " if ciliated epithelium is found, it 
 (the cyst) is probably parovarian, while if the epithelium is simply col- 
 umnar, it is more likely from an ovarian cyst." * 
 
 For those who desire to enter fully into the chemistry of these fluids 
 I would refer them to Hart and Barbour,f or to Ziemssen,| where Eich- 
 wald's experiemts are fully described. As a rule, the fluid drawn from 
 a parovarian cyst is clear and limpid as spring water, contains no cell ele- 
 ments, and is slightly saline. I think, however, that this character so much 
 relied upon, viz., limpidity, is only characteristic of comparatively young 
 parovarian cysts, and that as they increase in age, or have been frequently 
 tapped, the color is likely to vary. On February 20th, 1874, having a 
 patient in whom I was much interested, I sent her to Doctor Atlee, of 
 Philadelphia, to confirm the diagnosis I had made of " cyst of the broad 
 ligament," as it was called in those days. After examination he confirmed 
 the diagnosis, and I tapped her. The fluid was perfectly clear and limpid. 
 She was pregnant then, and now has a fine boy nearly ten years of age. 
 During this period I have tapped her four times, and on each occasion the 
 fluid has changed its character; first, yellow, the second, brown, the third 
 of an inky character, the fourth of a yellow hue. 
 
 On December 19th, 1880, a patient was sent to me by T. F. Allen, whom 
 I aspirated and drew off the characteristic limpid fluid destitute of cell 
 elements. About a year after I again evacuated the contents which were 
 chocolate-colored. Neither of these patients would submit to any other 
 operation. 
 
 Albuminoids in the Fluid. — A word more is necessary regarding the pres- 
 ence of the albuminoids found in these cysts. According to Waldeyer 
 both paralbumin and metalbumin, especially the latter, are always found 
 in ovarian tumors, which is also a valuable aid in discriminating between 
 these neoplasms and ascites. Scherer's test is said to be unreliable, and it 
 gives me pleasure to insert a new method of testing for paralbumin in 
 ovarian cysts by Dr. Clifford Mitchell, of Chicago. § He says: 
 
 " The method I have devised for detecting paralbumin is much more 
 simple and convenient than any test which involves boiling. Scherer found 
 that paralbumin was coagulated by nitric acid and that the coagulum dis- 
 solved in strong acetic acid. My method is based on this fact, and is as fol- 
 
 * American Journal of Obstetrics, 1881, p. 678. 
 f Manual of Gynaecology, vol.i., p. 213. 
 X Cyclopaedia of Practical Medicine, vol. x., p. 368. 
 $ American Homceopathist, vol. x., p. 99. 
 
1082 A SYSTEM OF SURGEKY. 
 
 lows : Pour a fluid drachm of the ovarian fluid into a test-tube of small 
 diameter (preferably not over one-half inch), then allow one or two drops 
 of nitric acid to trickle slowly down the side of the test-tube into the ova- 
 rian fluid. The acid slowly sinks through the fluid, coagulating the paral- 
 bumin as it goes, forming a well-defined clot. The tube may be shaken gentty 
 to accelerate the separation of this clot. When it has well settled to the 
 bottom of the mixture, carefully pour off the supernatant fluid, and the clot 
 remains. Now pour in some strong (glacial) acetic acid, filling the tube 
 half full ; the clot rises to the top of the acetic acid, and on placing the 
 thumb over the mouth of the test-tube and shaking well, the clot is wholly 
 or at least very perceptibly dissolved by the acid. The advantages of this 
 method are that it does away wholly with boiling, and that it can be per- 
 formed with a very small amount of ovarian fluid. Care must be taken not 
 to use too much nitric acid or to form too large a clot, or some difficulty 
 may be encountered in dissolving it with acetic acid. Moreover, only acetic 
 acid having a specific gravity of 1065 at least, must be used. Commercial 
 acid, having a specific gravity of about 1045 on the urinometer scale, failed 
 to dissolve the clot. A slight turbidity remaining after shaking with the acetic 
 acid is of no significance, being due probably to proteids not soluble in this 
 acid.^ 
 
 Malignant Disease. — The diagnosis of malignant disease of the ovary is 
 quite difficult. The main features are increased and increasing sensitive- 
 ness of the abdomen over a rather small tumor, continued pain and general 
 emaciation, a cancerous genealogy, and especially a rapid increase in asciti- 
 cal fluid. The microscopical appearance presented by the fluid accumu- 
 lating around cancers of the ovary, has been the subject of especial study, 
 notably by Mr. Foulis, of Edinburgh, and is of the greatest importance in 
 the formation of a diagnosis. The fluid should be sent to a specialist for 
 examination. 
 
 Tuberculosis of the peritoneum is often accompanied with increased peri- 
 toneal exudation, but the unevenness of the abdominal walls will assist 
 materially in the formation of the diagnosis. In some instances, however, 
 the " knotty feel " is not present, and then the microscope or the exploratory 
 incision must tell the story. 
 
 Exploratory Incision. — Notwithstanding all that experience has thrown 
 upon the diagnosis of ovarian cysts, there are yet cases so complicated 
 that it is necessary to make an incision in the abdominal walls to discover 
 the real nature of the disorder. There need be no hesitation in adding 
 thereby to our acquaintance with the case, and any conscientious prac- 
 titioner who has exhausted his means of diagnosis, should perform the 
 operation. 
 
 The incision should be cautiously made in the linea alba, and the peri- 
 toneum carefully dealt with. Then if there be too many adhesions, with- 
 out any attempt to break them up if they are very dense on the anterior 
 face of the tumor, or if the tumor be any other than ovarian, the surgeon 
 must decide what course to take. In encysted dropsy of the peritoneum such 
 a proceeding is, it appears to me, absolutely necessary. In certain forms 
 of cystic disease, and often in fibro-cystic tumors accompanied with ascites, 
 the procedure is called for. This method is by no means free from danger. 
 Wills reports four and Baker Brown three fatal cases. I have lost two, and 
 am aware of several other deaths. 
 
 Treatment of Ovarian Cysts. — There are cases of ovarian cysts which may 
 be amenable to internal medication, and I have no doubt that if some 
 cases were so treated ovariotomy might be dispensed with. I give the 
 record of a number of such with the authorities from which they come. I 
 
TREATMENT OF OVARIAN CYSTS. 1083 
 
 cite at least two undoubted ovarian cysts which were cured, one by apis 
 mel. and arsen. ; the second by tapping, and the after-administration of 
 proper medicines. Dr. Black* gives a remarkable cure with small doses of 
 bromide of potassium. 
 
 Dr. Neidhardt reports a case in which iodine and hepar in the first, third, 
 and sixth dilution, together with a sponge saturated with iodine water in- 
 troduced into the vagina, was productive of happy results. Dr. Neidhardt 
 regards ignat., graph., apis and platina as appropriate medicines,f and gives 
 the following indications : 
 
 Ignatia for spasmodic pain in both ovaries, with contracted sensation at 
 stomach. 
 
 Graphites — swelling of both ovaries as if they were in motion ; pain on 
 stooping and pressure ; enlargement caused by sexual excess. 
 
 Apis mel. in the more acute form, pain increased by stooping and walk- 
 ing, pressure on the bladder, frequent micturition. 
 
 Platina — enlargement of ovaries ; catamenial discharge coagulated and 
 thick. 
 
 Arsen., calc. carb., canth., china, iod. and lycop. are other medicines. 
 
 It is probable that many cases of ovarian tumor which are reported as 
 cured were parovarian cysts, which in many instances cannot be diagnosed 
 from cystoma without a microscopic analysis of the fluid. The tumors 
 are amenable to tapping and medicine. Vreith J does not remove them with 
 the knife on this account. 
 
 Dr. D. A. Baldwin, of Englewood, was successful in the treatment of a 
 case after several tappings. At the first he drew five and a half gallons ; at 
 the second, four and a half gallons ; at the third, three and a half gallons ; 
 at the fourth, three and a half gallons ; making in all seventeen gallons of 
 fluid. The medicine was iodine in the third decimal solution given three 
 or four times a day. 
 
 In Dr. Peaslee's work we have a notice of cures by several remedial 
 agents ; two by Mr. Craig, by the administration of a saturated solution of 
 chlorate of potassa, a tablespoonful three times a day ; two cases by Prof. 
 Courty, of Montpelier, with the oxide of gold, in doses varying from -£% to f 
 of a grain ; a case by Dr. J. Millar, with the bromide of potassium, five 
 grains three times a day, increasing the dose to fifteen grains ; Dr. Miller, 
 of Chicago, three cases with bromide and iodide of potassium in alterna- 
 tion. 
 
 Dr. Peaslee employed with success the chlorate of potassa ; the dose being 
 half an ounce of the saturated solution three times a day. 
 
 Palliative Treatment consists in paracentesis abdominis. This should be 
 effected with a large aspirating needle, and may be done often, though the 
 operation is by no means free from danger. After the evacuation of the 
 fluid, properly administered medicines may be of service toward effecting 
 a cure. The trocar may be inserted at the linea alba, or if the tumor be 
 polycystic, the operator may select the linea semilunaris or other points in 
 the abdominal parietes. 
 
 Other Curative Measures. — Tapping the sac and pressure, effected by means 
 of compresses securely fastened with broad adhesive straps, so placed as to 
 embrace the spine, " meeting and crossing in front and extending from the 
 vertebral articulation of the eighth rib to the sacrum," and secured by a 
 broad flannel band, are recommended by Dr. J. Baker Brown. 
 
 Tapping and the injection of iodine has cured, but appears only applicable 
 
 * British Journal of Homoeopathy, January, 1869. 
 
 f North American Journal of Homoeopathy, 1864, p. 17. 
 
 X N. Y. Medical Journal, August 21st, 1886, p. 208. 
 
1084 A SYSTEM OF SURGERY. 
 
 to the monocystic tumor, as it would be a difficult matter to inject all the 
 compartments of a polycyst ; although several cases reported as the latter 
 were cured. The following is the formula of Boinet : 
 
 Distilled water, 100 parts, ^iij and &j. 
 
 Tine, iodine, 100 parts, . . * ,^iij and gj. 
 
 Iod. of potassium, 4 or 5 parts, 3J ^° 3Ji' 
 
 Or tannic acid, 1 to 2 parts, grs. xv. to xxx. 
 
 For the injection, a large trocar and canula is used, and the cyst is tapped 
 in the ordinary manner. When most of the fluid is drawn off, a good-sized 
 gum-elastic catheter, with several holes on either side, near the end, is passed 
 through the canula to the bottom of the sac. The above quantity is injected 
 and allowed to remain from five to ten minutes. The catheter may then be 
 withdrawn. 
 
 Electrolysis.— Dr. Danforth, of Chicago, and Dr. Franklin, of Ann Arbor, 
 and Dr. Murphey, of New Orleans, have reported cures of ovarian cysts by 
 electrolysis. This method is simple and effective, and is rapidly gaining 
 favor; though I have seen it tried in several instances, it has never been 
 productive of permanent good, and in two cases a sharp peritonitis fol- 
 lowed the application of the needles. In a cyst of the broad ligament oper- 
 ated upon by Dr. Butler, the tumor almost entirely disappeared, but soon 
 after refilled. As yet, experience has not satisfactorily demonstrated the 
 value of this method in the treatment of ovarian tumors. 
 
 The Performance of Ovariotomy. — Before proceeding to details there is a 
 point upon which I ought to dwell for a moment, and that is the priority of 
 claim for the performance of ovariotomy, and to express the national pride 
 that every one of us must entertain in pronouncing Ephraim McDowell, of 
 Danville, Kentucky, the father of ovariotomy, not of American ovariotomy, 
 but of ovariotomy the world over, and especially of ovariotomy in Great 
 Britain. I am urged to this decisive declaration because the endeavor 
 has been made in England to deprive ilmerica of the honor which belongs 
 to it. 
 
 Dr. Ephraim McDowell was a student of John Bell, the anatomist of 
 Edinburgh, who suggested and defended the removal of the ovaries for 
 ovarian dropsy. Mr. McDowell espoused the idea of his preceptor, and in 
 December, 1809, performed his first operation, which must have been a 
 colloid cyst. In 1813 the second ovariotomy was made, and in May, 1816, 
 his third, all of which were successful. In 1818 he prepared a report of 
 these cases, and with justifiable pride sent a copy to his former preceptor. 
 Mr. Bell was absent from London, and Mr. Lizars, having charge of his 
 (Bell's) practice and correspondence, kept the record of Dr. McDowell's 
 cases for seven years before bringing them to light, and when he did, they 
 appeared as an appendix to a paper recording a case of his own, which 
 proved to be not one of ovariotomy, as it had been diagnosed, but a simple 
 accumulation of fat. With these well-known facts published time and 
 again, no less a surgeon than the celebrated Mr. Christopher Heath, F.R.C.S., 
 thus spoke to his class :* " Although ovariotomy was first performed by Dr. 
 McDowell, of Kentucky, who was a pupil of John Bell,f the operation of 
 modern times has been entirely of British cultivation. Mr. Lizars, of Edin- 
 burgh, was the first to attempt ovariotomy in this country, and by the 
 long incision, i.e., from the umbilicus to the pubes; his example was fol- 
 
 * British Medical Journal, June 16th, 1877. 
 
 f Of course the credit should, therefore, in the lecturer's estimation, be given to Mr. Bell, 
 the Scotchman. 
 
OVARIOTOMY. 1085 
 
 lowed by a few other surgeons and from time to time a success was ob- 
 tained." 
 
 The facts are these : Mr. Lizars perhaps would never have attempted the 
 operation but for the seven years' study of Dr. McDowell's cases, and 
 it appears that when he did he actually mistook a mass of fat for an ova- 
 rian tumor, examination revealing two healthy ovaries. In addition to this 
 rather humiliating mistake, in 1825, Mr. Lizars again attempted ovari- 
 otomy, but in two cases was unable to remove the tumors, and in the 
 third mistook a subperitoneal uterine fibroid for a cystoma ovarii ; indeed, 
 such disastrous results followed "the father of ovariotomy in Great Britain" 
 that the operation was not repeated for twenty years in Scotland* These 
 facts are well known to every gynaecologist, and, though of interest to the 
 general practitioner, would not have been mentioned had it not been that 
 the effort has been again made in England, to give priority in the perform- 
 ance of ovariotomy to a certain Robert Houston, of Glasgow. In Mr. 
 Lawson Tait's latest work the endeavor of the author to procure for Great 
 Britain the precedence in the performance of this operation is overdrawn. 
 The operation described as an ovariotomy was performed in August, 1701, 
 and is as follows : 
 
 " I found this tumor grown to so monstrous a bulk, that it engrossed the 
 whole left side from the umbilicus to the pubes, and stretched the abdomi- 
 nal muscles to a great degree. It drew toward a point. From being obliged 
 to lie continually on her back, she was grievously excoriated, which added 
 much to her sufferings, which, together with a want of rest and- appetite, 
 had greatly emaciated her. 
 
 11 The operation of puncturing the abdomen being proposed, she con- 
 sented ; accordingly with an imposthume lancet I laid open about an inch, 
 but finding nothing issue I enlarged it two inches, and even then nothing 
 came forth but a little thin, yellowish serum, so I ventured to lay it open 
 about two inches more. I was not a little startled after so large an aperture 
 to find only a glutinous substance bung up this orifice. The difficulty was 
 how to remove it; I tried my probe and endeavored with my ringers, but it 
 was all in vain ; it was so slippery that it eluded every touch and the 
 strongest hold I could take. 
 
 " I wanted in this place everything necessary, but bethought of a very 
 odd instrument, yet as good as the best in its consequences, because it 
 answered the end proposed. I took a strong fir-splinter, such as the poor 
 in that country use to burn instead of candles ; I wrapped about the end 
 of this splinter some loose lint, and thrust it into the wound, and by turn- 
 ing and winding it I drew out above two yards in length of a substance 
 thicker than jelly, or rather like glue fresh made and hung out to dry ; its 
 breadth was above ten inches ; this was followed \>y nine full quarts of such 
 matter as is met with in steatomatous and atheromatous tumors, with 
 several hydatids, of various sizes, containing a yellowish serum, with several 
 large pieces of membrane, which seemed to be parts of a distended ovary. 
 I then squeezed out all I could, and stitched up the wound in three places almost 
 equi-distant."\ 
 
 Can this be called an ovariotomy? Mr. Tait's reasoning is most pecu- 
 liar; he says: "Although he (Houston) does not describe his division of 
 the pedicle, or his having tied it, it is almost certain that he did both. He 
 certainly must have seen and divided the pedicle, for he describes the disease 
 as being of the left ovary, therefore he saw the pedicle." How the latter 
 
 * Peaslee, Ovarian Tumors, p. 270. 
 
 f I have placed these words in italics to show that there is no mention made of a pedicle. 
 
1086 A SYSTEM OF SURGERY. 
 
 conclusion could be deduced from the former expression appears to me 
 incredible. The disease was of the left ovary, " therefore he saw the pedi- 
 cle." Mr. Tait further continues : " Perhaps he tore it and it did not need 
 tying. That he performed a complete ovariotomy is certain, from his hav- 
 ing noticed secondary cysts, as well as from the recovery of his patient, and 
 from the fact that she lived thirteen years afterward in perfect health." 
 From a careful reading, we may make deductions antagonistic to those of 
 Mr. Tait, and may positively say that Houston did not perform a complete 
 ovariotomy. It is not at all likely that a man like Houston, without previ- 
 ous experience, or the example of others, could have turned out a cyst, 
 ligated its pedicle and cut it off, without accurately describing the entire 
 operation. The precise manner in which the former steps of the operator 
 are detailed forbids the idea, that so important a feature as ligating the pedi- 
 cle and completely removing the sac, should be entirely overlooked. These 
 deductions of Mr. Tait appear wholly without foundation, and cannot be 
 allowed to stand in opposition to the complete performances of ovariotomy 
 as furnished by Dr. Ephraim McDowell. It has been suggested by Dr. R. S. 
 Sutton of Pittsburgh* that Dr. Houston, without knowing, enucleated the 
 cyst and directed no further attention to the pedicle. Peaslee simply says : 
 " Dr. Houston did not perform ovariotomy .f The fact appears to me to be 
 that Dr. Houston cut down upon a colloid multilocular cyst, drew out its 
 contents, with the rude instrument he describes, perhaps ruptured other 
 cyst-walls within the mother cysts and dragged forth the torn-out particles; 
 that he sewed up the abdominal wall, and left a small tent in the lower 
 angle of the wound — ' only this and nothing more.' With the under- 
 standing of all these circumstances, it must be apparent to every one 
 that Dr. McDowell holds priority of claim in the performance of this opera- 
 tion, and we must still dignify him with the title of < the Father of Ovari- 
 otomy.' " 
 
 Every one who has performed a number of ovariotomies has some varia- 
 tion in method, and, although the object to be attained, i.e., the removal of 
 the tumor, is, of course, the ultimatum, there are different ways of arriving 
 at it. Believing, as I do, that the atmosphere, in some undefined and unex- 
 plained way, exerts an influence over the reactive power of a patient about 
 to be subjected to ovariotomy, I select a perfectly bright and clear day for 
 the operation, and in appointing a time for its performance state that if the 
 day fixed be cloudy, or rainy, the operation will be postponed. This state- 
 ment mollifies, in a measure, the disappointment which naturally would 
 result from the change of time. Before the operation, if it be in the hospital, 
 the ovariotomy room (an apartment about eighteen feet square, containing 
 two beds and a chair, perfectly plain walls, destitute of ornament, pictures, 
 or carpet) receives a thorough scrubbing, the walls are wiped down, and 
 the windows opened to the sun for two days. The bed-clothing, mat- 
 tresses, pillows, etc., are then aired, sunned, and brought into the room. 
 If in a private house, the carpet is taken up, the furniture removed and 
 the floors scrubbed. A kettle containing carbolic acid solution 1-20 is 
 placed upon a small furnace, and the steam allowed to pass into the cham- 
 ber for an entire day, and on the morning of the operation the windows 
 are again opened to the sun and air. The sponges (which have been first 
 allowed to soak in a strong soda solution, afterwards washed and immersed 
 for a few hours in dilute hydrochloric acid, and then placed in jars contain- 
 
 * A paper read at the mpeting of the American Gynecological Society, held at Boston, 1882. 
 f Peaslee, Ovarian Tumors, p. 227. 
 
OVAEIOTOMY. 1087 
 
 ing a small quantity of carbolic acid, 1-60) are taken from the jars and 
 placed in a basin and exposed to the sun. The night before, the instru- 
 ments, which I count myself, are placed in an earthenware pan containing 
 carbolized oil 1 to 20, and the rubber coil and india rubber sheeting also 
 washed off with carbolized solution. 
 
 In the morning, the instruments are removed from the oil, wiped carefully 
 and placed in shallow pans containing carbolized w 7 ater 1 to 60. A list is 
 made of every instrument and placed upon the w^all, and the sponges (gen- 
 erally one dozen, nine small, and three large and flat) are put into a basin 
 holding a solution of bichloride of mercury 1-2000. The douche is hung 
 up ready for use, and the thermometer suspended in a convenient place. 
 The hypodermic syringe is charged with brand} T , and the ether cone, pre- 
 pared of an ordinary tow 7 el folded over newspaper and covered with an 
 india-rubber cloth, is arranged beside the ether can. The carbolic steam is 
 allowed to permeate the atmosphere of the room, and no one allowed to 
 enter until near the time of the operation. No spray is used ; it makes the 
 parts too cold. In an adjoining room, however, a steam spray apparatus is 
 kept continually at work, and those who are to be present are requested 
 by a written placard to disinfect their clothing before coming into the apart- 
 ment. 
 
 I always perform the operation at half past two o'clock in the afternoon, and 
 at two o'clock the patient (having a small cup of beef-tea at eleven) receives 
 a hypodermic injection containing one-sixth grain morphia and one one- 
 hundredth of a grain of atropia. In about half an hour the medication is 
 complete, the patient has slight dizziness, and a healthy flush upon the 
 face ; she is then brought into the operating room, and placed upon the 
 table and the ether administered. This mixed method of anaesthesia has 
 many advantages; much less ether is required to produce insensibility, and 
 the capillary circulation is increased, not only throughout the operation, 
 but for some time after. By this means also the coldness and collapse 
 which often follow prolonged ovariotomies are scarcely perceptible, and 
 the vomiting is less; often the patient slumbers tranquilly for one or two 
 hours after she has been put to bed, w r hich I regard as a great advantage. 
 Before the anaesthesia is quite complete, the abdomen is washed carefully 
 with warm water and corrosive sublimate solution 2 o 1 ooj an( ^ dried. The 
 low r er limbs are covered with blankets, the upper garments are tucked 
 well up and shielded by india-rubber cloth. All the assistants wash their 
 hands in soap and water and take their positions — that one in charge of the 
 ether at the head of the table (which is on india-rubber wheels), the oper- 
 ator on the right side, the first assistant on the left, and next to him the 
 second assistant, who hands the instruments, and behind and a little to the 
 left of the latter are stationed the nurses, who do nothing but clean sponges, 
 which are beside them in two basins. Just before the incision is com- 
 menced, I go to the list of instruments hung upon the wall, and call out 
 the names of them in order, the chief assistant answering to the call. The 
 nurse then counts the sponges, and the operation is proceeded with. The 
 incision is made as usual, and the skin-vessels caught by catch forceps 
 (Koeberle's), the fascia is exposed and easily recognized, is caught and 
 nicked and incised upon a director, or if the operator has experience, he 
 may cut through it with the knife. The peritoneum is easily recogniza- 
 ble by its rather bluish color, and membranous appearance, but sometimes 
 it is very much thickened, and may be mistaken for the sac. I always 
 divide this membrane upon the director with a pair of scissors, and am 
 very particular to incise it carefully and sharply ; often there may be the 
 escape of ascitical fluid, or, perhaps, of some colloid material, and the sac 
 is brought into view. Anterior adhesions are now recognized by the passage 
 
1088 
 
 A SYSTEM OF SURGERY. 
 
 of a steel sound all over the parietes of the tumor; if there be many, they 
 should not be ruptured with the instrument, but dealt with afterward. 
 
 There are cases in which the peritoneum is not so easily recognized, espe- 
 cially where a prolonged chronic peritonitis has been present, materially 
 thickening and transforming the membrane, or, what is still worse, causing 
 it to adhere to the cyst wall ; nothing but cautiously cutting down upon 
 
 Fig. 717. 
 
 Fig. 718. 
 
 Wilcox's Forceps. 
 
 Spencer Well's Ovariotomy Trocar. 
 
 the presenting mass will decide the matter. I recollect a case in which 
 such a complication existed, and I actually had separated a portion of the 
 abdominal peritoneum before I discovered the mistake. 
 
 I may state here, that after each instrument is used, it is not laid upon 
 the table, but handed back to the second assistant, who wipes it and replaces 
 it in the pan. This is the rule, and by following it there is not an accumu- 
 
OVARIOTOMY. 1089 
 
 lation of bloody instruments lying around or upon the patient, and when 
 it is necessary to employ the same instrument a second or third time, it 
 comes to the operator's hand perfectly clean and carbolized. 
 
 I now take a Wilcox's forceps (Fig. 717) and give it to an assistant and 
 introduce the trocar; immediately the cyst wall begins to relax from the 
 escape of fluid it is grasped with the forceps and held firmly ; the patient is 
 rolled three-quarter face over the edge of the table and the trocar with- 
 drawn. I then take a knife or scissors and make a cut several inches long 
 in the cyst, thus rapidly evacuating its contents, and allowing room for my 
 hand to enter the cavity and rupture the child cysts through the parent 
 wall. As a rule, I use the trocar very little, and have always found diffi- 
 culty in catching the wall of the sac with the hooks on Wells's trocar. 
 (Fig. 718.) Dr. Lungren, of Toledo, has devised a modification of this 
 instrument, in which the hooks slide up upon the canula and are fixed 
 by a set screw, which greatly enhances the value of the instrument. Occa- 
 sionally the bladder is carried up hy the tumor, or the urachus is much 
 dilated, and these may be punctured by the trocar. Dr. Thomas and Dr. 
 Noeggerath have each had one case of the kind, and I also have met 
 with a most interesting one which has been reported elsewhere. The lady 
 was brought to me by Dr. C. A. Bacon, and was operated upon in the 
 Hahnemann Hospital. Dr. Emmet* also reports a remarkable instance in 
 which the stomach and transverse colon were spread out over the surface 
 of the tumor. In rolling the patient over some care must be exercised 
 to keep the tumor well out, for I have read somewhere, that during this 
 manoeuvre, the uterus and intestines forced their way into the opening, and 
 the former was punctured to the depth of half an inch by the trocar. As 
 the sac is being emptied the assistant draws it still further out to prevent 
 the escape of intestines, and the patient is then turned supine again, and 
 the adhesions treated. Each adhesion is tied with carbolized gut and then 
 cut away, and if the attachments are broad, they are clamped with an 
 instrument made for the purpose (of which I have two sizes). A needle 
 armed with a double thread is passed through the centre, the loop is cut, 
 and the ends tied on both sides. During this process, which takes con- 
 siderable time, the flannels which are laid over the omentum are constantly 
 changed, being wrung out in hot water, and gently laid over the parts. 
 When the pedicle is reached I formerly applied the clamp, then ligated it 
 (the pedicle) in two or more portions, cut it off and applied the Paquelin 
 cautery at a dull heat and then removed the clamp. Lately, however, I use 
 the Staffordshire knot, which is made easily, and can be tied very securely, 
 and is not likely to slip. The knot is made by taking a Peaslee's needle, 
 threaded with ovariotomy silk, made completely of silk fibre and very 
 strong, and passing it through the centre of the pedicle ; the loop is drawn 
 through and the needle withdrawn, the loop is then passed over the tumor 
 and the right hand free end of the silk is passed through the loop, the two 
 free ends of the ligature are then tied tightly in a surgeon's knot, particu- 
 larly if the pedicle is broad, and consequently a good deal of tissue, neces- 
 sarily included ; security is of paramount importance. I have often found, 
 particularly if the tumor be colloid, that my fingers and the silk become 
 so lubricated, that sufficient traction is sometimes difficult, even after the 
 ends are carefully wiped ; towels or napkins are cumbrous, and often in the 
 way; I therefore have devised a pair of "pullers," which answer my pur- 
 pose. I place the free ends of the ligature within the blades, clamp them 
 together, rotate the instrument several times upon itself, winding the thread 
 
 * Am. Journ. Obstet. 
 69 
 
1090 A SYSTEM OF SUKGERY. 
 
 around several times, and thus a powerful purchase can be exerted. When 
 the knot is secured I give the ends in charge of the first assistant, and cut 
 off the tumor, and sear the stump thoroughly with the Paquelin cautery. 
 This clone, I allow the stump to fall partially back into the abdominal 
 cavity, but keep it in hand by the ends of the ligature. The abdomen is 
 now thoroughly cleaned with large and small sponges, the latter being fixed 
 on holders, and if there has been much escape of fluid or blood into the 
 cavity, carbolized water 1-100, at a temperature of 100°, is allowed to run 
 from the douche into the abdomen, until it passes away clear. The in- 
 testines are all again thoroughly cleansed, and not until the sponges 
 withdrawn are dry and clean is the wound closed. Before doing this, how- 
 ever, the pedicle is drawn to the surface, examined, and if clean and dry, 
 the ends of the knots are cut close and the stump allowed to find its way 
 to its position. The omentum is carefully arranged, and a large flat 
 hot sponge is placed over it and the sewing begun. If I have reason to 
 believe there will be much exudation, a glass drainage-tube, thoroughly 
 clean and carbolized, is placed in a Douglas's pouch. The needle-holder I 
 use is the large-sized Russian (vide pages 35 and 248) forceps ; the needles 
 stout round ones, with a good-sized eye and a slightly curved bayonet 
 point. The loops of silk are spliced into the needles, and the silver wire 
 bent upon the loop. The sutures are placed about the eighth of an inch 
 apart, and pass through the peritoneum in each side of the cut; when the 
 deep wires are all in, I place my two forefingers in the centre of the inci- 
 sion and hook the two middle wires, one on each finger ; one finger draws 
 the sutures toward the upper, the other finger draws the sutures to the lower 
 angle of the wound, and the flat sponge is withdrawn through the opening 
 thus made. It is amazing to see in some cases how much blood has escaped 
 from the needle punctures and has been received by the sponge. Before 
 twisting the wires, the sponges are again counted, and the instruments also, 
 and if they are " all right " the wires are fastened. A few superficial sutures 
 of silk are sometimes required. A piece of salicylated india-rubber plaster 
 is laid along the margin of the cut, and the ends of the twisted wire 
 bent down upon it (the plaster). Another strip of the plaster is laid over 
 the wire, and thus irritation is effectually prevented. The patient is made 
 dry and clean, and the soiled materials removed. Over the track of the 
 wound is laid a small strip of marine lint finely shredded, over this a 
 large layer of cotton, which is enveloped in gauze, both having been pre- 
 viously rendered antiseptic by the bichloride of mercury 1 : 2500. Over 
 this an additional gauze is laid, and then a bandage, or, rather, a piece of 
 jxrepared linen. This is kept in position by broad adhesive straps, three 
 or four on each side, which are pinned with safety pins to the cloth. The 
 patient is put to bed, warm bottles to the feet, and every article that has 
 been used immediately removed from the room. If there are stains on 
 the floor, it is cleaned with soap and water and wiped with a solution of 
 carbolic acid 1-20. If the pulse has flagged during the operation, one, two, 
 or more hypodermics of whiskey are given. 
 
 Since I have been using the mixed method of anaesthesia, I have found 
 that the patients sleep from one to three hours after the operation, a 
 condition which I rarely met with when I used the simple ether narcosis. 
 Of late I have had less occasion to employ morphine in the after treat- 
 ment, for I have found that hypericum often relieves the immediate 
 pain ; I do not, however, fail to use the opium if the suffering and restless- 
 ness are severe, giving five to eight minims of Magendie's Solution. Ice 
 is allowed, though in small quantities, and if the patient vomits and is 
 cold veratrum alb. is given. If there be much distension of the abdomen 
 with flatus, the best medicine is the chlorate of potash. It is remarkable 
 
OVARIOTOMY. 1091 
 
 what an effect this drug will produce. As a rule, when a quantity of flatus 
 passes by the anus, the patient will make a good recovery. At all events 
 it is a signum salutis. When the temperature rises to 101° the cold coil is 
 put on and kept for several hours, and rarely fails to produce a decline in 
 heat line. The diet on the second day is well-made cold rice water given 
 every three hours, in small quantities ; after the third day the patient is 
 put upon peptonized milk. This milk is prepared as follows : a powder, 
 composed of five grains of Fairchild's ex. pancreatis and twenty grains 
 bicarb, of soda, is dissolved in a gill of water and poured into a clean wine 
 bottle, which is filled with a pint of milk. The bottle is placed in hot 
 water for an hour, then removed and kept in a cool place. This is a won- 
 derful preparation, and I have used it so frequently and in so many sur- 
 gical and medical diseases, that I recommend it. 
 
 If the patient is doing well the dressing is not removed for a week. 
 
 The cork, however, is taken from the drainage tube on the second morn- 
 ing and a small piece of absorbent cotton introduced ; if it come back wet 
 and bloody, the tube is cleansed with the douche until the water runs clear, 
 and then it is wiped out. Serum in the drainage tube is of little conse- 
 quence except it be present in large quantities. If I find nothing but simple 
 serosity for two days, the tube is removed. If suppuration takes place the 
 abdomen must be cleansed at least once a day with warm water, not with 
 carbolized water (too much carbolic acid is worse than none all), and the 
 parts and dressings kept remarkably clean. I do not allow my patients to 
 see any one save the doctor and the nurse for two weeks after the opera- 
 tion. The stitches, most of them, are removed on the ninth to the twelfth 
 day, according to circumstances, and before the patient sits up a body 
 bandage is put on, which she is enjoined to wear for at least two months 
 after she gets about. The washing of the abdominal cavity may be con- 
 tinued as long as there are any evidences of suppuration. Death occurs 
 from shock — from a few hours to a couple of days after the operation — or 
 peritonitis from the second to the ninth, or septicaemia, from the seventh to 
 the thirtieth, or even later. Dr. Ludlam* calls attention to a condition 
 of auto-infection which may exist in old cases in which the idea of long 
 postponement of operation has been held, and thus not only is there a drain 
 of the vital fluids into the cysts, but the blood becomes cumulatively septic, 
 thereby materially affecting the chances of recovery. Dr. Ludlam con- 
 cludes his article with the following postulates : 
 
 " 1. That the absorption of a part of the cyst contents prior to the opera- 
 tion is a not infrequent cause of fatality in ovariotomy. 
 
 " 2. That this condition is incident to old tumors, to compound cysts, 
 and to cases that have been tapped. 
 
 " 3. That this insidious, pre-operative form of sepsis is most likely to de- 
 clare itself through an irritable state of the gastro-alimentary mucous mem- 
 brane, with repeated attacks of vomiting and purging, and to be confirmed 
 at post-mortem by gastric or enteric ulceration. 
 
 "4. That if the patient is predisposed to renal or hepatic disease, the 
 kidneys or the liver may be the seat of serious lesions of function or of struc- 
 ture, which really depend upon this auto-infection. 
 
 " 5. That the cardiac degeneration and involvement which are incident to 
 this form of abdominal growths, as shown by Dr. Fenwick,f may be ascribed 
 to a pernicious anaemia that is of septic origin, and which has its source in 
 
 * The Clinique, July, 1886. 
 
 f On Intra-abdominal Tumors as a Cause of Cardiac Degeneration. The British Gynae- 
 cological Journal for May, 1886, p. 72. 
 
1092 A. SYSTEM OF SURGERY. 
 
 absorption through and from the disintegrating tissues of the walls and 
 partitions of the cyst, and not alone in the size and pressure of the sac. 
 
 " 6. That, when this septic infection has existed temporarily before the 
 operation was made, the risk of its continuance and recurrence is very great, 
 and the danger from it is due to the dyscrasia which it had insidiously de- 
 veloped. 
 
 " 7. That these facts present a new and powerful argument for the early 
 performance of ovariotomy, and indirectly explain the increasing exemption 
 from fatal consequences." 
 
INDEX. 
 
 Abdomen, injuries and diseases of, 832 
 
 wounds of, 832 
 Abdominal aneurism, 461 
 
 hernia, 857 
 
 varieties of, 857 
 
 parietes, abscess of, 836 
 
 viscera, wounds of, 832 
 Abscess, 113 
 
 of the abdominal parietes, 836 
 
 acute, 115 
 
 of the antrum highmorianum, 777* 
 
 in bone, 512 
 
 chronic, sinuous, 512 
 
 cold, 115 
 
 consecutive, 388. 
 
 dangers of, 115 
 
 diffuse, 115 
 
 hepatic, 841 
 
 hyperdistension with carbolic acid, 118 
 
 opening of, 116 
 
 of the parotid gland, 793 
 
 in the perinseum, 937 
 
 perityphlitic, 850 
 
 pointing of, 114 
 
 post-pharyngeal, 774 
 
 of the prostate gland, 984 
 
 psoas or lumbar, 691 
 
 residual, 115 
 
 of the testicle, 988 
 
 of the tongue, 750 
 Absorption of pus, 123 
 
 ulcerative, 129 
 Acetabulum, fracture of, 568 
 Acromion process, fracture of, 565 
 Active haemorrhage, 316 
 
 hyperemia, 91 
 Actual cautery in haemorrhage, 322 
 Acupressure, 329 
 
 methods of, 333 
 
 vs. ligature, table of, 331 
 Acupuncture, treatment of hydrocele, 996 
 Acute mortification, 142 
 Adenitis, 233 
 Adenoma, 165 
 Adhesion, 100 
 Adhesive plaster, 251 
 Air in veins, 483 
 Albuminuria in hernia, 860 
 Allarton's operation of lithotomy, 960. 
 Alopecia from syphilis, 237 
 Alveolar cancer, 178 
 Amputation, 352 
 
 bony tumors requiring, 356 
 
 of the cervix uteri, 1020 
 
 compound fractures requiring, 353 
 
 conical stump after, 392 
 
 Amputation, contused and lacerated wounds 
 requiring, 3^4 
 definition of, 352 
 diseases of joints requiring, 355 
 gangrene and mortification requiring, 354 
 immediate, 3"3 
 intermediate, 353 
 instruments for, 357 
 methods of, 358 
 mortality in, 360 
 neuralgia of the stump after, 391 
 other causes for, 356 
 primary, 353 
 
 protrusion of bones after, 392 
 question of, in wounds, 289-354 
 retraction of flaps, 392 
 secondary, 353 
 special, 365 
 of the breast, 832 
 
 cervix uteri, 1020 
 lower extremities, 365 
 at the ankle, lateral plantar flat, 378 
 PirogoflT's method, 378 
 Syme's method, 376 
 hip, 365 
 
 anterior and posterior flap, 367 
 lateral flap, 367 
 knee, 372 
 
 Carden's method, 374 
 circular, 374 
 leg, circular method, 376 
 flap method, 375 
 mixed method, 376 
 Teale's method, 376 
 sub-astragaloid, 380 
 through the tarsus, Chopart's method, 379 
 
 tarso-metatarsal articulation, 380 
 of the thigh, 369 
 
 anterior and posterior flap, 370 
 circular, 370 
 
 combination method, 370 
 lateral flap, 370 
 rectangular flap (Teale's), 371 
 through the condyles (Stokes), 
 371 
 toes, 381 
 penis, 1014 
 scrotum, 1007 
 tongue, 764 
 upper extremities, 382 
 
 arm, circular method, 384 
 
 flap method, 384 
 at the elbow, 386 
 of the fingers, 388 
 
 metacarpo-phalangeal, 
 388 
 
1094 
 
 INDEX. 
 
 Amputation of the index finger, 389 
 
 forearm, circular method, 385 
 flap method, 385 
 Teale's method, 386 
 through the metacarpus, 389 
 at the shoulder, 382 
 of the thumb, carpo-metacarpal, 390 
 
 in wounds, 289 
 
 at the wrist, 387 
 Amygdalitis, 767 
 Anaesthesia, 70 
 
 death from, 79 
 
 discovery of, 71 
 
 local, 81 
 
 mixed, 78 
 
 primary anaesthesia, 79 
 
 sickness of, 79 
 Anaesthetic ether for local application, 84 
 
 mixtures for small operations, 85 
 Anatomy, microscopic, of cancer, 173 
 
 surgical, of the vessels, 463 
 Anchylosis, 615 
 
 of the inferior maxilla, 786 
 
 spurious, 615 
 Aneurism, 438 
 
 abdominal, 461 
 
 by anastomosis, 441 
 
 of the aorta, 456 
 
 arm, forearm, or hand, 460 
 arteria innominata, 457 
 
 arterio-venons, 441 
 
 of the axillary artery, 460 
 
 in bone, 533 
 
 of the carotid artery, 458 
 
 catgut ligature in, 454 
 
 causes of, 443 
 
 cirsoid, 441 
 
 classification of, 439 
 
 compression in, 446 
 
 deformity in, 442 
 
 diagnosis of, 444 
 
 diffuse, 440 
 
 by dilatation, 440 
 
 dissecting, 440 
 
 electrolysis in, 453 
 
 external, 439 
 
 false, 439 
 
 femoral, 461 
 
 fusiform, 440 
 
 galvano-puncture in, 453 
 
 general treatment of, 444 
 
 hernial, 439 
 
 inguinal, 439, 461 
 
 injection into, 452 
 
 internal, 439 
 
 introduction of foreign materials into 
 sac, 456 
 
 of the leg or foot, 463 
 
 limited, 440 
 
 manipulation in, 448 
 
 medical treatment of, 445 
 
 oedema in, 442 
 
 old operation for, 449 
 
 pedunculated, 440 
 
 popliteal, 462 
 
 pulsation in, 442 
 
 rapid method of treating, 489 
 
 Aneurism, rest in the treatment of, 444 
 by rupture, 440 
 shape, 442 
 sounds in, 442 
 sphacelus after ligation, 455 
 special, 456 
 
 spontaneous cure of, 443 
 of the subclavian artery, 459 
 symptoms of, 441 
 treatment by compression, 446 
 Esmarch's bandage, 449 
 galvano-puncture, 453 
 injection into the sac, 452 
 ligature, 453 
 manipulation, 448 
 medical, 445 
 placing foreign material into the 
 
 sac, 456 
 rapid method of, 449 
 rest, 444 
 true, 439 
 Aneurismal varix, 441 
 Angeioma, 155 
 Angina maligna, 772 
 
 pharyngea, 772 
 Angular curvature of the spine, 686 
 Ankle, amputations at, 376 
 dislocation of, 667 
 excision of, 709 
 weak, 639 
 Anthrax, 401 
 
 treatment of, 402 
 Antiseptic dressing of wounds, Lister's, 295 
 ligature, 338 
 method in gangrene, 147 
 Antiseptics, 61-66 
 
 and disinfectants in Surgery, 61 
 Antrum highmorianum, abscess of, 777 
 tumors of, 779 
 
 removal of, 779 
 Anus, artificial, 836 
 
 formation of, 848 
 fissures of, 909 
 fistula of, 901 
 prolapse of, 891 
 pruritus of, 910 
 and rectum, diseases of, 892 
 imperforate, 895 
 Aorta, aneurism of, 456 
 Apncea from drowning, 825 
 
 hanging, 826 
 Apparatus, movo-amobile of Suetin, 542 
 Arm, amputation of, 384 
 
 forearm or hand, aneurism of, 460 
 Arsenic in cancer, 190 
 Arterial haemorrhage, 316 
 Arteries, calcification or ossification of, 437 
 injuries and diseases of, 436 
 ligation of, 463 
 Arterio-venous aneurism, 441 
 Arteritis, adhesive, 436 
 
 diffuse, 436 
 Artery forceps, 36 
 Arthritis, chronic, rheumatic, 621 
 Arthropyosis, 609 
 Articles for dressing, 40 
 Articular cartilages, ulceration of, 612 
 
INDEX. 
 
 1095 
 
 Artificial anus, 836 
 
 formation of, 848 
 haemostatics, 319 
 ischaemia, 339 
 respiration, 825 
 Ascites, 844 
 Aspirator, the, 52 
 
 Aspiration of intestine in strangulated hernij 
 864 > 
 of pericardium, 824 
 of thorax, 821 
 Astragalus, dislocation of, 670 
 
 excision of, 708 
 Atheroma, 437 
 Atresia vaginae, 1049 
 Atrophy of bone, 528 
 muscular, 430 
 
 progressive, 430 
 reflex. 431 
 Autoplasty, 395 
 
 Axillary artery, aneurism of, 460 
 ligature of, 470 
 surgical anatomy of, 470 
 
 Balanitis, 215 
 Ball, minie, 272 
 Bandage, the, 44 
 Bandages, India-rubber, 45 
 
 pi aster-of- Paris, 46 
 
 starch, 542 
 Barton's fracture, 575 
 Battery for galvanic cautery, 57 
 Bed-sores, 423 
 Bending of bones, 544 
 Bismuth subnitrate in wounds, 311 
 Bistouries, 37 
 Black cancer, 178 
 
 phagedena, 146 
 Bladder, exstrophy of, 914 
 
 female, stone in, 969 
 
 inflammation of, 928 
 catarrhal, 928 
 
 paracentesis of, 939 
 
 stone in, 956 
 
 tumors in, 982 
 Blenorrhagia, external, 215 
 Blood, buffy coat of, 93 
 
 changes of, in inflammation, 93 
 
 effusion of, in inflammation, 93 
 
 transfusion of, 346 
 Boil, 399 
 
 Bones, abscess in, 512 
 sinuous, 512 
 
 atrophy of, 528 
 
 bending of, 544 
 
 cancer in, 531 
 
 cracked, 549 
 
 cvsts in, 530 
 
 death of, 519 
 
 excision of, 693 
 
 flexion or bending of, 544 
 
 fractured, non-union of, 545 
 
 hypertrophy of, 528 
 
 inflammation of, 511 
 
 injuries and diseases of, 507 
 
 non-union of, 545 
 
 Bones, protrusion of, after amputation, 392 
 
 resection of, 698 
 
 sclerosis in, 512 
 
 suppuration in, 512 
 
 syphilis in, 517 
 
 tumors in, 528 
 innocent, 528 
 pulsating, 533 
 
 ulceration of, 515 
 scrofulous, 517 
 Bony tumors, 162 
 
 requiring amputation, 356 
 Bowels, intussusception of, 846 
 
 obstruction of, 846 
 Bozeman's operation for vesico-vaginal fistula, 
 
 1046 
 Brachial artery, ligature of, 472 
 
 surgical anatomy of, 472 
 Brain, compression of, 723 
 
 concussion of, 722 
 Breast, amputation of, 832 
 Broad ligament, serous cyst of, 1072 
 Bromide of ethyl, 78 
 Bromine as a disinfectant, 63 
 Bronchocele, 794 
 Bronchotomy, 807 
 Brood-cells, 173 
 
 Bubo, comparison of, in infectious and non- 
 infectious chancre, 230 
 
 indurated, symptomatic of chancre, 228 
 
 non-svphilitic, 233 
 
 syphilitic, 233 
 Buchanan's operation of lithotomy, 961 
 Buck's extension in fracture, 590 
 Buffy coat of blood, 93 
 Bunion, 431 
 Burns and scalds, 406 
 
 cicatrices after, 410 
 
 classification of, 407 
 
 treatment of, 408 
 Bursae, injuries and diseases of, 427 
 
 synovial, 195 
 Bursitis, 431 
 
 treatment of, 432 
 
 Calcis, caries of, 706 
 
 excision of, 706 
 Calculi fellei seu biliarii, 838 
 
 salivary, 766, 794 
 
 urinary, 951, 954 
 
 in veins, 484 
 Calculous nephralgia, 922 
 Calendula as a dressing, 112, 311 
 Cancellated exostosis, 529 
 Cancer, 171 
 
 alveolar, 178 
 
 arsenic as a prophylactic in, 190 
 
 black, 178 
 
 in bone, 531 
 
 cell, 173 
 
 chimney sweeper's, 1000 
 
 colloid, 178 
 
 encephaloid, 175 
 
 enucleation of, 183, 186 
 
 epithelial, 177 
 
 gelatiniform, 178 
 
1096 
 
 INDEX. 
 
 Cancer, gum. 178 
 
 hard, 174 
 
 hydrastis in, 181 
 
 hypodermic injection in, 186 
 
 juice, 173 
 
 lapis albus in, 185 
 
 of mamma?, 829 
 
 medullary, 175 
 
 melanotic, 178 
 
 mode of death in, 174 
 
 osteoid, 179 
 
 pigmental degeneration of, 178 
 
 of the rectum, 910 
 
 removal of, by the knife, 189 
 
 of the scrotum, 1006 
 testicles, 992 
 
 treatment of, 180 
 
 by Marsden and MacLimont, 183 
 
 of the uterus, 1018 
 
 varieties of, 171 
 
 villous, 180 
 Capillaries, diseases of, 484 
 Capillary tumors, 484 
 Carbolic acid, 6Q 
 Carbuncle, 401 
 Carcinoma, 171 
 
 melanodes, 178 
 Carden's amputation at the knee, 374 
 Caries, 515 
 
 of the calcis, 706 
 
 causes of, 517 
 
 dry, 519 
 
 varieties of, 517 
 Carotid artery, aneurism of, 458 
 
 common, ligature above the omo-hvoid, 
 465 
 below the omo-hyoid, 466 
 surgical anatomy of, 464 
 
 external, ligature of, 467 
 Carpus, dislocation upon radius and ulna, 
 
 677 
 Cartilages loose in joints, 631 
 Caruncles of the urethra, 1052 
 Castration, 992 
 Catheterism in the female, 937 
 
 male, 931 
 Catheters, 933 
 Causes of inflammation, 104 
 Cautery, the actual, 322 
 Cells, cancer, 173 
 
 granulation, 102 
 
 wandering, 90 
 Cellular tissue, diseases and injuries of, 396 
 Cerebral localization, 725 
 Cervix uteri, amputation of, 1020 
 Chancre, 228 
 
 differential diagnosis of, 229 
 
 soft, 221 
 
 treatment of, 230 
 Chancroid, 221 
 
 character of, 221 
 
 definition of, 222 
 
 phagedenic, 223 
 
 seat of, 223 
 
 treatment of, 224 
 
 of the urethra, 224 
 Charpie, 41 
 
 Cheiloplasty, 739 
 Chemical constituents of pus, 110 
 Chest, injuries and diseases of, 879 
 Chilblain, 405 
 
 Chimney-sweeper's cancer, 1006 
 Chlorides, Piatt's, 65 
 Chlorine as a disinfectant, 64 
 Chloroform, 76 
 
 method of administering, 77 
 
 symptoms of danger, 77 
 Cholecystotomy, 839 
 Chondroid tumors, 157, 159 
 Chondroma, 159 
 
 Chopart's amputation through the tarsus, 379 
 Chordee, 208 
 Chorion, cysts of, 199 
 Chronic rheumatic arthritis, 621 
 Cicatrices, 410 
 Cicatrization, 102 
 Circocele, 1001 
 Circumclusion, 334 
 Cirsoid aneurism, 441 
 Civiale's operation for stone, 961 
 Clap, 208 
 Clark's splint, 593 
 Clavicle, dislocation of, 650 
 
 excision of, 705 
 
 fracture of, 558 
 Cleanliness in surgery, 33 
 Cleft palate, 751 
 
 spine, 682 
 Cloacae, 529 
 Club-foot, 633 
 
 hollow, 639 
 Cocaine as an anaesthetic, 85 
 Coffee as a disinfectant, 63 
 Cold abscess, 115 
 Cold, effects of, 404 
 Colles's fracture, 574 
 Colloid cancer, 178, 1070 
 
 cysts, 195 
 Colotomy, 848 
 Compact exostosis, 529 
 
 Compound fractures requiring amputation, 353 
 Compresses, 42 
 Compression in aneurism, 446 
 
 of the brain, 723 
 
 in haemorrhage, 324 
 
 permanent, in haemorrhage, 324 
 
 temporary, in haemorrhage, 325 
 Concussion of the brain, 722 
 
 of the nerves, 494 
 spine, 681 
 Condylomatous venereal disease, 220 
 Congenital cutaneous cysts, 194 
 
 hernia, 858 
 
 hydrocele, 993 
 
 syphilis, 243 
 Congestion, local, 91 
 Connective tissue, 90 
 tumors, 165 
 Consecutive abscess, 1 25 
 Constitutional symptoms of syphilis, 234 
 Continued suture, 250 
 Contraction of the palmar fascia, 435 
 Contused wounds, 256 
 
 requiring amputation, 354 
 
INDEX. 
 
 1097 
 
 Contusions, 256 
 Contusion of the spine, 681 
 Coracoid process, fracture of, 565 
 Coronoid process, fracture of, 580 
 Corpuscles, exudation, 90 
 
 migration, 90 
 
 pus, 109 
 
 white blood, 90 
 Costal cartilages, fracture of, 557 
 Cotton as a dressing, 41 
 Cough impulse in hernia, 860 
 Coxo-femoral dislocations, 656 
 Cracked bones, 549 
 Crassamentum, 93 
 Creasote as a disinfectant, 6Q 
 Crepitus in fracture, 535 
 Cruor, 93 
 Crural hernia, 886 
 Cryptorchism, 921 
 Cut-throat, 789 
 Cylindroma, 159 
 Cynanche tonsillaris, 767 
 Cystic or adenoid disease of testicles, 991 
 
 osteoma, 530 
 
 tumors, classification of, 190 
 of the jaws, 780 
 of the lip, 751 
 Cystitis, 928 
 
 tubercular, 930 
 
 in women, 931 
 Cysto-sarcoma, 196 
 
 Cystotomy through the hypogastrium, 940 
 perinseum, 940 
 rectum, 939 
 Cysts in bones, 194, 530 
 
 of chorion, 199 
 
 colloid, 195, 1070 
 
 compound proliferous, 196 
 
 congenital cutaneous, 194 
 
 dermoid, of ovary, 1071 
 
 with mixed contents, 201 
 
 from expansion, 193 
 
 exudation, 194 
 
 independent, 194 
 
 mucous, 193 
 
 ovarian, 199, 1060 
 
 parovarian, 1072 
 
 pultaceous, 192 
 
 retention, 199 
 
 sanguineous, 194 
 
 sebaceous, 199 
 
 serous, 191 
 
 of broad ligament, 1072 
 of orbit, 194 
 
 svnovial, 195 
 
 thyroid, 194 
 
 Dangers of wounds, 246 
 Death of bone, 519 
 
 mode of, in cancer, 174 
 Degeneration of tissue, 109 
 Delitescence, 99 
 Demarcation, line of, 141 
 Dendritic vegetation, 180 
 Dentigerous cysts, 780 
 
 Derbyshire neck, 794 
 Desmoid tumors, 157 
 Diaphragmatic hernia, 890 
 Diathesis, hemorrhagic, 316 
 Differential diagnosis between concussion and 
 compression of brain, 724 
 encephaloid and scirrhus, 176 
 endostitis and periostitis, 509 
 inguinal hernia and other dis- 
 eases, 880, 887 
 intracapsular and extracapsular 
 
 fractures of the femur, 585 
 ovarian cyst and ascites, 1077 
 pregnancy, 1075 
 Diffuse abscess, 115 
 aneurism, 440 
 hydrocele of the cord, 994 
 Dilatation of sphincter ani in treatment of 
 
 fistula, 905 
 Directors, 34 
 Direct transfusion, 348 
 Disarticulation of the toes, 382 
 Diseases of the anus and rectum, 892 
 capillaries, 484 
 gall-bladder, 838 
 glands of the neck, 792 
 hip-joint, 623 
 lymphatics, 503 
 sacro-iliac synchondrosis, 645 
 tongue, 759 
 venereal, 205 
 Diseases and injuries of the abdomen, 832 
 arteries, 436 
 bones, 507 
 genital organs, female, 1016 
 
 male, 987 
 head, 718 
 jaw, 777 
 joints, 608 
 
 mouth and throat, 739 
 muscles, tendons, and bursse, 
 
 427 
 neck, 789 
 nose, 729 
 
 skin and cellular tissues, 396 
 spine, 681 
 thorax, 819 
 
 urinary organs, male, 914 
 veins, 479 
 Disinfectants, 61 
 
 and antiseptics in surgery, 61 
 Dislocations, 648 
 
 Dislocation, after treatment of, 680 
 of the astragalus, 670 
 extension and counter-extension in, 649 
 general diagnosis of, 648 
 
 treatment of, 649 
 lower extremities, 656 
 at the ankle, 667 
 
 lower end of tibia backward, 669 
 forward, 669 
 inward, 668 
 outward, 668 
 of the foot, 667 
 at the hip, 656 
 
 head of femur downward into 
 foramen ovale, 663 
 
1098 
 
 INDEX. 
 
 Dislocation at the head of femur forward upon 
 the pubes, 664 
 upward and backward on 
 dorsum of ilium, 
 658 
 into sciatic notch, 
 662 
 knee, 666 
 
 head of fibula back ward, 667 
 tibia backward, 666 
 forward, 666 
 inward, 667 
 outward, 667 
 of the patella, 665 
 lower jaw, 652 
 manipulation in, 649 
 of muscles and tendons, 429 
 of the pelvic bones, 653 
 pubis, 653 
 ribs, 655 
 upper extremities, 671 
 carpal bones, 678 
 carpus upon radius and ulna, 677 
 clavicle, 650 
 at the elbow, 675 
 
 radius backward, 677 
 forward, 677 
 and ulna backward, 676 
 
 backward and outward, 676 
 backward a 
 ulna backward, 677 
 of the fingers, 678 
 
 metacarpal bones, 678 
 at the shoulder, 671 
 
 head of humerus, backward, 674 
 downward, 671 
 forward, 674 
 of the thumb, 680 
 
 ulna from the radius, 678 
 varieties of, 648 
 of the vertebrae, 656 
 Dissecting aneurism, 440 
 
 forceps, 35 
 Dissection wounds, 285 
 Dittel's elastic ligature, 345 
 Divulsion of the pylorus, 854 
 Doigt £t ressort, 644 
 Dorsalis pedis artery, ligature of, 479 
 
 surgical anatomy of, 479 
 Drainage tubes, 43 
 Dressing of wounds, articles for, 40 
 methods of, 246 
 rules for, 44 
 Dropsy, encysted, of the peritoneum, 1076 
 Drowning, apnoea from, 825 
 Dry caries, 519 
 
 mortification, 143 
 suture, 250 
 Dupuytren's contraction, 435 
 
 Earth as a disinfectant, 62 
 
 in treatment of ulcers, 140 
 Ecraseur, the, in relation to haemorrhage, 328 
 
 treatment of haemorrhoids, 901 
 Effusion of blood in inflammation, 93 
 Elastic ligature, Dittel's, 345 
 
 Elbow-joint, amputation at, 386 
 
 dislocations at, 675 
 
 excision of, 700 
 Electric light, 57 
 Electrolysis, 58 
 
 in aneurism, 453 
 
 in cysts, 200 
 Elephantiasis Arabum, 419 
 
 Graecorum, 420 
 
 of the labia, 1049 
 
 of the scrotum, 419, 1006 
 Elongation of the uvula, 775 
 Embolism, 437 
 Emphysema, 821 
 Empresma hepatitis, 837 
 Emprosthotonos, 491 
 Empyema, 820 
 Encephaloid cancer, 175 
 Enchondroma, 159 
 Encysted hernia infantilis, 858 
 
 hydrocele of the cord, 994 
 Endodontics, 759 
 
 Endostitis and periostitis, differential diag- 
 nosis between, 509 
 Enterectomy, 834, 854 
 
 in hernia, 870 
 Enucleation of cancer, 183, 186 
 
 of uterine tumors, 1026 
 Epicystotomy, 962 
 Epididymitis, 987 
 
 Epilepsy, reflex, nerve-stretching in, 496 
 Epispadias, 919 
 Epistaxis, 730 
 Epithelioma, 177 
 
 of the lip, 748 
 penis, 1014 
 
 ulcerating, of the uterus, 1019 
 
 vegetating, of the uterus, 1019 
 Epulis, 157, 780 
 Equinia, 287 
 Erectile tumors, 484 
 Erysipelas, 396 
 
 bullosum, 396 
 
 contagion of, 397 
 
 hospital, 397 
 
 phlegmonous, 396 
 Escape of white blood-corpuscles, 92 
 Esmarch's bandage in treatment of aneurism, 
 449 
 
 method of artificial ischaemia, 339 
 Ether, 71 
 
 anaesthetic for local application, 84 
 
 inhalers for, 74 
 Etherization by rectal method, 75 
 Examination of the rectum, 770 
 Exanthemata syphilitica, 235 
 Excisions of the bones and joints, 698 
 Excision of ankle-joint, 709 
 
 of astragalus, 708 
 
 of bones of hand, 698 
 forearm, 700 
 leg, 714 
 
 of clavicle, 705 
 
 of elbow-joint, 700 
 
 of hip-joint, 715 
 
 of humerus in its continuity, 703 
 
 of joint between os calcis and astragalus, 708 
 
index. 
 
 1099 
 
 Excision of knee-joint, 710 
 of lower jaw, 784 
 
 entire, 785 
 of olecranon process, 700 
 of os calcis, 706 
 of rectum, 910 
 of ribs, 706 
 of scapula, 705 
 of shoulder joint, 703 
 of toes, 710 
 of upper jaw, 781 
 of veins, 483 
 of wrist, 699 
 Exostosis, 162,528 
 
 cancellated, 162, 528 
 eburnous, 529 
 medullary, 529 
 periosteal, 529 
 subungual, 426 
 varieties of, 528 
 Exstrophy of the bladder, 914 
 External aneurism, 439 
 
 urethrotomy, 946 
 Extirpation of the larynx, 818 
 parotid gland, 793 
 spleen, 854 
 Extracapsular fracture of neck of femur, 
 
 585 
 Extravasation, 316 
 
 Extremities, lower, amputations of, 363 
 dislocations of, 656 
 fractures of, 584 
 upper, amputations of, 382 
 dislocations of, 671 
 fractures of, 570 
 Exudation corpuscles, 90 
 
 Facial artery, ligature of, 467 
 
 surgical anatomy of, 467 
 Facial neuralgia, 501 
 False anchylosis, 615 
 aneurism, 439 
 joint from dislocations, 650 
 fracture, 545 
 Farcy, 287 
 
 treatment of, 288 
 Fatty tumors, 156 
 
 removal of, 156 
 Femoral aneurism, 461 
 traumatic, 462 
 treatment of, 462 
 artery, ligature of, 476 
 
 surgical anatomy of, 476 
 hernia, 886 
 
 diagnosis of, 887 
 strangulated, operation for, 888 
 Femur, fractures of, 584 
 Fever, hectic, 128 
 
 and inflammation, 98 
 inflammatory, 98 
 surgical, 120 
 syphilitic, 235 
 traumatic, 120 
 Fibro-calcareous tumor, 157 
 cellular tumor, 157 
 cvstic tumor, 157 
 
 Fibro-cystic tumor of ovary, 1073 
 
 plastic tumor, 168 
 Fibroid or fibroma of the uterus, 1021 
 Fibrous polypi, 157 
 
 tumors, 157 
 Fibula, dislocation of, 667 
 
 fracture of, 603 
 
 Figure-of-eight suture, 248 
 
 Fingers, amputation of, 388 
 
 Fingers, amputation of, 389 
 
 dislocation of, 678 
 
 metacarpo-phalangeal amputation of, 388 
 Fissures of the anus, 909 
 Fistula, 119 
 in ano, 901 
 lymphatic, 506 
 in perinseum, 937 
 salivary, 767 
 vesico-vaginal, 1043 
 Flaps retracted after amputation, 392 
 Flat foot, 646 
 Flexion or bending of the bones, 544 
 
 forced, in haemorrhage, 323 
 Floating kidney, 923 
 Fluctuation, 111 
 Foot, dislocation of, 670 
 backward, 669 
 forward, 669 
 inward, 668 
 outward, 667 
 or leg, aneurism of, 463 
 fractures of, 607 
 Forceps, 35 
 
 perforating ulcer, 426 
 Forearm, amputation of, 385 
 
 arm, or hand, aneurism of, 460 
 excision of, 700 
 fractures of, 573 
 both bones, 582 
 Foreign bodies in the larynx and trachea, 806 
 in the nose, 729 
 oesophagus, 800 
 rectum, 896 
 urethra, 940 
 Fractures, 534 
 causes of, 535 
 comminuted, 534 
 compound, 534, 607 
 crepitus in, 535 
 divisions of, 534 
 examination of patient in, 536 
 general consideration of, 534 
 green-stick, 545 
 impacted, 534 
 incomplete, 549 
 
 diagnosis of, 549 
 of the head and face, 549 
 hyoid bone, 551 
 inferior maxilla, 551 
 malar bones, 550 
 nasal bones, 549 
 skull,719 
 
 superior maxilla, 550 
 lower extremities, 584 
 femur, 584 
 neck of femur, 584 
 extracapsular, of femur, 585 
 
1100 
 
 INDEX. 
 
 Fractures, lower extremities, impacted, 586 
 intracapsular, 584 
 shaft of femur in lower third, 589 
 in middle third, 589 
 in upper third, 588 
 fibula (Pott's), 603 
 foot, 607 
 
 leg, both bones, 604 
 patella, 598 
 pelvis, 566 
 tibia, 602 
 medical treatment in, 543 
 mobility in, 536 
 mode of repair in, 537 
 simple, 534 
 splints for, 539 
 
 plaster-of-Paris, 540 
 symptoms of, 535 
 
 transverse, 535 
 of the trunk, 555 
 acetabulum, 568 
 clavicle, 558 
 
 acromial extremity, 559 
 costal cartilages, 557 
 os innominatum, 566 
 ribs, 557 
 scapula, 561 
 
 at acromion process, 565 
 at coracoid process, 565 
 at neck, 566 
 sternum, 557 
 vertebrae, 555 
 of the upper extremities, 570 
 forearm, 573 
 hand, 583 
 humerus, 570 
 
 at base of condyles, 571 
 
 at head and anatomical neck, 
 
 572 
 in the shaft, 570 
 at surgical neck, 572 
 through the tubercles, 572 
 phalanges, 583 
 
 radius at lower end (Barton's), 575 
 at lower end (Colles's), 574 
 at neck, 573 
 through shaft, 574 
 and ulna, 582 
 ulna, 579 
 
 at coronoid process, 580 
 at olecranon process, 580 
 Frsenum linguae, malformation of, 765 
 Fragilitas ossium, 527 
 Fumigation, nitrous, 65 
 Fungoid degeneration of joints, 613 
 
 growths of the testicle, 990 
 Fungus haematodes, 175 
 
 melanodes, 178 
 Furunculus, 399 
 Fusiform aneurism, 440 
 
 Gall-bladder, diseases of, 838 
 Gall-stones, 838 
 Galvano-cautery battery, 57 
 
 moxa, 56 
 Galvano-puncture, 56 
 
 Galvano-puncture in aneurism, 453 
 Ganglion, 432 
 diffuse, 432 
 treatment of, 433 
 Gangrene, 141 
 
 divisions of, 142 
 
 hospital, 145 
 
 and mortification requiring amputation, 
 
 354 
 of the parotid gland, 793 
 senile, 143 
 Gangrenous pharyngitis, 772 
 Gastrotomy, 852 
 Gelatiniform cancer, 178 
 Gelatinous sarcoma, 158 
 
 Genital organs, female, injuries and diseases 
 of, 1016 
 male, diseases of, 987 
 
 malformation of, 987 
 Genuthrotomy, 615 
 Genu-valgum, 640 
 
 subcutaneous osteotomy for, 640 
 Giant-celled sarcoma, 168 
 Gingivitis, 758 
 Glanders. 287 
 
 treatment, 288 
 Glandular tumors, 165 
 Gleet, 210 
 Glioma, 171 
 Globules, pus, 109 
 Glossitis, 759 
 Glottis, intubation of, 811 
 oedema of, 776 
 spasm of, 775 
 Glover's suture, 250 
 Goitre, 794 
 Gonalgia, 644 
 Gonorrhoea, 208 
 
 praeputialis, 215 
 
 treatment, 215 
 sicca, 209 
 spurious, 215 
 treatment of, 210 
 in women, 215 
 Gonorrhceal ophthalmia, 218 
 
 rheumatism, 217 
 Grafting skin in ulcers, 136 
 Granulation, 102 
 Granulations, gray, 202 
 
 healthy, 102 
 Gravel, 951 
 
 Gray pultaceous phagedaena, 146 
 Greenstick fracture, 544 
 Growths, morbid, on the skin, 422 
 Gum-boil, 759 
 Gum cancer, 178 
 Gummatous products in svphilis, stage of, 
 
 236 
 Gunshot wounds, 270 
 
 delusions concerning, 278 
 diagnosis of, 281 
 foreign bodies in, 279 
 of scalp, 719 
 shock of, 276 
 surgical prognosis of, 281 
 treatment of, 282 
 varieties of, 278 
 
INDEX. 
 
 1101 
 
 Hematocele, 1000 . 
 Hematoma, 194 
 Hemophilia, 316 
 Hemorrhage, 315 
 
 active, 316 
 
 acupressure in, 329 
 
 arterial, 316 
 
 cautery in, 322 
 
 compression in, 324 
 
 definition of, 316 
 
 elastic ligature in, 345 
 
 Esmarch's method of arresting, 339 
 
 forced flexion in, 323 
 
 intermediary, 316 
 
 internal, 316 
 
 internal medication, 319 
 
 ligature in, 336 
 
 method of arresting, 317 
 
 nasal, 730 
 
 other methods of arresting, 335 
 
 passive, 316 
 
 percutaneous ligature in, 335 
 
 primary, 316 
 
 secondary, 316 
 
 styptics in, 320 
 
 torsion in, 327 
 
 venous, 316 
 Hemorrhagic diathesis, 316 
 Hemorrhoids, 898 
 
 treatment by ecraseur, 901 
 by injection, 900 
 by ligation, 900 
 by nitric acid, 901 
 Hemostatics, 317 
 
 artificial, 319 
 
 natural, 317 
 Hand, arm, or forearm, aneurism of, 460 
 
 excision of, 698 
 
 fracture of, 583 
 Hanging, apnoea from, 826 
 Hare-lip, 739 
 
 double, 747 
 Head and face, special fractures of, 549 
 
 injuries and diseases of, 718 
 Healing of wounds, 245, 251 
 Healthy granulations, 102 
 
 ulcer, 131 
 Heat as a disinfectant, 63 
 
 in inflammation, 95 
 Hectic fever, 128 
 Hepatic abscess, 841 
 Hepatitis, 837 
 Hermaphroditism, 920 
 Hernia, 856 
 
 abdominal, 857 
 
 albuminuria in, 860 
 
 coffee in, 862 
 
 congenital, 858 
 
 cough impulse, 860 
 
 crural or femoral, 886 
 anatomy of, 886 
 diagnosis of, 887 
 
 diaphragmatic, 890 
 
 enterectomy, 870 
 
 epigastric artery in crural, 887 
 in inguinal, 879 
 
 frequency, 856 
 
 Hernia, funicular, 858 
 incarcerated, 860 
 infantile, encysted, 858 
 inguinal, congenital, in the female, 885 
 
 in the male, 876 
 interstitial, 858 
 irreducible, 859 
 ischiatic, 890 
 medical treatment of, 861 
 nomenclature, 856 
 
 oblique inguinal, operation for strangula- 
 tion of, 883 
 obturator, 890 
 ovarian, 885 
 pudendal, 890 
 radical cure of, 871 
 
 Heaton's method, 872 
 open method, 871 
 Wood's method, 875 
 reducible, 858 
 
 reduction by puncture of intestine, 864 
 by rubber bandage, 865 
 by taxis, 862 
 simultaneous, 882 
 strangulated, 860 
 traction in taxis, 864 
 trusses for, 865 
 umbilical, 888 
 varieties of, 857 
 Hernial aneurism, 439 
 Herniotomy, 867 
 
 division of stricture external to sac, 
 867 
 Heteroplasty, 395 
 
 Heurteleup's operation of lithotrity, 970 
 High operation for stone, 962 
 Hip-joint, amputations at, 365 
 disease, 623 
 dislocations of, 656 
 excision of, 715 
 iliac dislocation, 658 
 pubic dislocation, 664 
 sciatic dislocation, 662 
 thyroid dislocation, 663 
 History of syphilis, 205 
 Hodgens' splint, 592 
 Hodgkin's disease, 505 
 Horny tumors, 164 
 Hospital gangrene, 145 
 Housemaid's knee, 431 
 
 Humerus, dislocation of head backward, 674 
 downward, 671 
 forward, 674 
 partial, 675 
 excision of, 703 
 fractures of, 570 
 fracture at base of condyles, 571 
 
 of head and anatomical neck, 572 
 of the shaft, 570 
 
 surgical neck, 572 
 Humid gangrene, 142 
 Hydatid tumors, 199 
 Hvdramvl as an anesthetic, 85 
 Hydrocele, 993 
 
 congenital, 993 
 diffused, of the cord, 994 
 encysted, of the cord, 994 
 
1102 
 
 IXDEX. 
 
 Hydrocele, medical treatment of, 995 
 palliative treatment, 997 
 radical method of cure, 997 
 treatment by acupuncture, 996 
 by faradization, 999 
 by hypodermic injection, 997 
 by excision of tunica vaginalis, 999 
 by incision, 999 
 by injection, 997 
 by seton, 999 
 Hydrogen peroxide in wounds, 310 
 Hydrophobia, 261 
 symptomatic, 269 
 treatment of, 267 
 Hydrops articuli, 609 
 Hvdrosarcocele, 993 
 Hydrothorax, 820 
 Hygroma of the neck, 193 
 Hyoid bone, fracture of, 551 
 Hyperemia, 91 
 Hypertrophic lupus, 414 
 Hypertrophy of the prostate gland, 985 
 
 tongue, 761 
 Hypodermic medication, 50 
 Hypogastric lithotomy, 962 
 Hypospadias, 921 
 Hysterectomv, 1028 
 laparo, 1029 
 supra-vaginal, 1031 
 vaginal, 1030 
 Hysterical joints, 644 
 
 Ichorrhaemia, 121 
 
 Iliac artery, common, surgical anatomy of, 474 
 ligature of, 474 
 external, surgical anatomy of, 475 
 
 ligature of, 475 
 internal, ligature of, 475 
 Iliac dislocation of the femur, 658 
 Immediate union, 101 
 Impacted fracture of neck of femur, 586 
 Imperforate anus and rectum, 895 
 Incarcerated hernia, 860 
 Incised wounds, 252 
 Incisions, methods of making, 49 
 Incomplete fracture, 549 
 Index finger, amputation of, 389 
 India-rubber suture, 250 
 Indirect transfusion, 347 
 Indolent ulcer, 132 
 Infantile hernia, 858 
 
 syphilis, 243 
 Infarctions, 124 
 Infection, systemic, 121 
 Infiltration, cedematous, 92 
 
 purulent, 115 
 Inflammation, 86 
 
 of the arteries, 436 
 bones, 511 
 bladder, 928 
 liver, 837 
 prostate gland, 984 
 results of, 104 
 symptoms of, 95 
 theories of, 91-93 
 treatment of, 105 
 
 Inflammation, varieties of, 103 
 
 of the veins, 480 
 Inflammatory fever, 98 
 gangrene, 141 
 new formations, 100 
 Ingrowing toe-nail, 424 
 Inguinal aneurism, 461 
 hernia, 876 
 
 anatomy of, 877 
 congenital, in the male, 885 
 
 in the female, 885 
 diagnosis of, 880 
 epigastric artery in, 879 
 oblique operation for strangulation 
 of, 883 
 Inhibitory nerves, 89 
 Injection of haemorrhoids, 900 
 Injuries and diseases of the abdomen, 832 
 arteries, 436 
 bones, 507 
 head, 718 
 
 female genital organs, 1016 
 jaws, 777 
 joints, 608 
 larynx, 806 
 
 male urinary organs, 914 
 mouth and throat, 739 
 muscles, tendons, and bursse, 427 
 neck, 789 
 nose, 729 
 
 skin and cellular tissue, 396 
 spine, 681 
 thorax, 819 
 veins, 479 
 and operations, nervous system after, 488 
 Innocent tumors, 153 
 Innominata, fracture of, 566 
 Innominate artery, aneurism of, 457 
 ligature of, 470 
 surgical anatomy of, 470 
 Insect wounds, 259 
 Instruments for excision of bones, 694 
 
 used in minor surgery, 34 
 Intention, first, healing by, 101 
 Internal aneurism, 439 
 haemorrhage, 316 
 malignant pustule, 421 
 medication in haemorrhage, 319 
 urethrotomy, 947 
 Interrupted suture, 247 
 Intestines, suturing the, 834 
 Intracapsular fracture of neck of femur, 584 
 Introduction of tubes into the oesophagus, 801 
 Intubation of the larynx, 811 
 Intussusception, 846 
 Involucrum in necrosis, 520 
 Iodine as a disinfectant, 63 
 Iodoform in wounds, 309 
 Iritis, syphilitic, 239 
 Irreducible hernia, 859 
 Irritable ulcer, 132 
 Ischsemia, artificial, Esmarch's method of, 
 
 339 
 Ischiatic dislocation of hip-joint, 662 
 
 hernia, 890 
 Ischuria vesicalis, 931 
 Ivory exostosis, 529 
 
INDEX. 
 
 1103 
 
 Jaw, lower, anchyloses, 786 
 Jaws, cystic tumors of, 780 
 
 dislocation of lower, 652 
 
 excision, lower, 784 
 
 injuries and diseases of, 777 
 
 necrosis of, 781 
 
 phosphorus necrosis of, 781 
 Joints, diseases of, requiring amputation, 355 
 
 excisions of, 693 
 
 false, 545 
 
 fungoid degeneration of, 613 
 
 hip disease, 623 
 
 hysterical, 634 
 
 injuries and diseases of, 6U8 
 
 loose cartilages in, 630 
 
 wounds of, 608 
 Juice, cancer, 171 
 
 Keloid, 420 
 
 treatment of, 421 
 Kelotomy, 867 
 
 Kev's operation of lithotomy, 959 
 Kidney, floating, 923 
 King's evil, 201 
 Knee, amputation at, 372 
 
 chronic contraction of, 614 
 
 dislocations at, 666 
 
 excision of, 740 
 
 housemaid's, 431 
 
 mixed amputations at (Garden's), 374 
 Knives, 37 
 Knock-knee, 640 
 Kyphosis, 691 
 
 Labia, elephantiasis, 1049 
 Labium leporinum, 739 
 Lacerated perinaeum, 1036 
 
 wounds, 257 
 Laceration of the urethra, 938 
 Laparo-hysterectomy, 1030 
 Laryngitis, syphilitic, 240, 806 
 Laryngoscopy, 813 
 Laryngotomy, 807 
 Laryngo-tracheotomy, 810 
 Larynx, adenoid growths in, 815 
 
 diseases of, 806 
 
 extirpation of, 818 
 
 intubation of, 811 
 
 neoplasms in, 815 
 
 polypi in, 815 
 
 syphilis of, 240 
 
 tumors in, 815 
 
 warty growths in, 815 
 
 and trachea, foreign bodies in, 806 
 surgical affections of, 806 
 Lateral lithotomy, 958 
 Laudable pus, 109 
 Leg, amputations of, 375 
 
 dislocations of, 666 
 
 excision of, 714 
 
 fracture of both bones, 604 
 
 or foot, aneurism of, 463 
 Lepra tuberculeuse d'Alibert, 420 
 Leucocytes, 90 
 
 Levis's metallic splints, 540 
 Ligation of arteries, 463 
 of haemorrhoids, 900 
 percutaneous, in haemorrhage, 335 
 Ligature, antiseptic, 338 
 in aneurism, 453 
 Dittel's elastic, 345 
 in fistula in ano, 904 
 in haemorrhage, 336 
 in naevi, 486 
 silk-worm gut, 39 
 thread, 39 
 whale tendon, 39 
 of the anterior tibial artery, 477 
 arteria innominata, 471 
 axillary artery, 470 
 brachial artery, 472 
 common carotid, above the omo- 
 hyoid, 465 
 below the omo-hyoid, 466 
 dorsalis pedis artery, 479 
 external carotid artery, 467 
 
 iliac artery, 475 
 facial artery, 467 
 femoral artery, 476 
 iliac artery, 474 
 internal iliac artery, 475 
 lingual artery, 467 
 popliteal artery, 477 
 posterior tibial artery, 477 
 radial artery, 472 
 subclavian artery, 468 
 superficial palmar arch, 474 
 superior thyroid artery, 471 
 ulnar artery, 473 
 Light, electric, 57 
 Limited aneurism, 440 
 Line of demarcation, 141 
 
 separation, 141 
 Linear rectotomy, 908 
 Lingual artery, iigature of, 467 
 
 surgical anatomy of, 467 
 Lint, 40 
 Lip, cysts of, 751 
 
 enlargement of mucous glands of, 749 
 epithelioma of, 748 
 lower, restoration of, 750 
 upper, restoration of, 747 
 Lipoma nasi, 731 
 Lipomata, 157 
 
 Lister's antiseptic dressing of wounds, 295 
 Litholapaxy, 970 
 
 in children, 981 
 Lithotomy, 957 
 
 Allarton's operation, 960 
 bilateral section, 961 
 Buchanan's operation, 961 
 Civiale's operation, 961 
 dangers of, 968 
 Key's operation, 959 
 lateral, 958 
 
 preparation of the patient for, 958 
 recto-vesical operation, 961 
 suprapubic or hypogastric operation, 962 
 Lithotrity, 969 
 
 American method of, 970 
 Heurteleup's method, 970 
 
1104 
 
 INDEX. 
 
 Little's artery forceps, 36 
 Liver, abscess of, 841 
 
 inflammation of, 837 
 
 melanosis of, 837 
 Local anaesthesia, 81 
 
 mixtures for, 85 
 Localization, cerebral, 725 
 Lock-jaw, 491 
 
 Loose cartilages in joints, 630 
 Lordosis, 691 
 
 Lower extremities, amputation of, 365 
 Lower jaw, dislocation of, 652 
 excision of, 735 
 fracture of, 551 
 Lumbar abscess, 691 
 Lupus erythematodes, 416 
 
 exedens, 414 
 
 hypertrophic, 414 
 
 microscopical appearances in, 415 
 
 non-exedens, 414 
 Luxations, 604 
 Lymphadenoma, 505 
 Lymphangitis, 504 
 
 mammary, 826 
 Lymphatic fistula, 506 
 Lymphatics, diseases of, 503 
 
 thrombosis of, 504 
 Lymphoma, 505 
 Lympho-sarcoma, 505 
 
 Maculae syphilitica?, 235 
 
 Maggots in wounds, 288 
 
 Malacosteon, 524 
 
 Malar bones, fracture of, 550 
 
 Malformation of the frsenum linguae, 765 
 
 nose, 729 
 Malformations of the male genital organs, 987 
 
 urinary organs, 914 
 Malignant pustule, 421 
 internal, 421 
 tumors, 171 
 
 of the parotid gland, 793 
 Mammae, amputation of, 832 
 benign tumors of, 831 
 cancer of, 829 
 lymphangitis of, 826 
 Marine lint, 40 
 Mastitis, 826 
 
 Maxilla, inferior, anchylosis of, 786 
 dislocation of, 652 
 excision of, 784 
 entire, 785 
 fracture of, 551 
 superior, excision of, 781 
 fracture of, 550 
 Maxillary artery, external, ligature of, 467 
 
 surgical anatomy of, 467 
 Medication, hypodermic, 50 
 in hernia, 861 
 interna], in haemorrhage, 319 
 Melanosis, 178 
 
 of the liver, 837 
 Mercurial fumigation, in syphilis, 242 
 Mercury bichloride in wounds, 310 
 Metacarpus, amputation through, 389 
 
 Metastasis of tumors, 151 
 Methylene, bichloride of, 81 
 Microscopic anatomy of cancer, 173 
 Migration corpuscles, 90 
 
 theory of Cohnheim, 91 
 Milk, transfusion of, 350 
 Miner's elbow, 431 
 Minor surgery, 33 
 
 articles for dressing, 40 
 instruments, 34 
 Mode of death in cancer, 174 
 Moist mortification, 142 
 Mollities ossium, 524 
 Morbid growths on skin, 422 
 Morbus coxae senilis, 621 
 
 coxarius, 623 
 
 excision of hip in, 630 
 Mortality in amputations, 360 
 Mortification, 142 
 
 amputation in, 354 
 
 dry, 143 
 
 moist, 142 
 Mouth, injuries and diseases of, 739 
 Moxa, galvanic, 56 
 Mucous cysts, 195 
 
 tumors, 157 
 Mumps, 792 
 Muscles, dislocations of, 429 
 
 injuries and diseases of, 427 
 
 and tendons, ruptures of, 429 
 treatment of, 429 
 Muscular atrophy, 430 
 
 progressive, 430 
 reflex, 431 
 Myeloid tumors, 168 
 Myomata of the uterus, 1021 
 Myxoma, 57 
 
 Naevus, 484 
 
 Nail, ingrowing toe, 424 
 
 Nasal bones, fractures of, 549 
 
 polypus, 732 
 Naso-pharyngeal polypus, 734 
 Natural haemostatics, 317 
 Neck, cystic tumors of, 794 
 
 Derbyshire, 794 
 
 diseases of the glands, 792 
 
 injuries and diseases of, 789 
 Neck of femur, extracapsular fracture of, 585 
 impacted fracture of, 586 
 intracapsular fracture of, 584 
 
 of scapula, fracture of, 566 
 Necrosis, 519 
 
 causes of, 521 
 
 of the jaw bones, 781 
 
 operative measures in, 523 
 
 periosteal, 520 
 
 peripheral, 520 
 
 of the skull, 510 
 Needles, 40, 246 
 Needle forceps, 35 
 Neoplasms, 150 
 
 laryngeal, 815 
 Nephralgia, calculous, 922 
 Nephrectomy, 924 
 
INDEX. 
 
 1105 
 
 Nephrorraphy, 927 
 Nephrotomy, 927 
 Nerves, concussion of, 494 
 
 inhibitory, 89 
 
 stretching of, 495 
 
 wounds of, 495 
 Nerve suture. 499 
 
 secondary, 500 
 
 vaso-motor, 89 
 Nervous system after injuries and operations, 
 
 488 
 Neuralgia, 501 
 
 false, 502 
 
 nerve-stretching in, 495 
 
 of the stump, 391 
 Neurectomy, 503 
 Neuroma, 154 
 Neuromatous tumors, 154 
 Neurotomy, 503 
 
 New formations, inflammatory, 100 
 Nitrous fumigation, 65 
 
 oxide, 81 
 Nodes, 509 
 Noli-me-tangere, 414 
 Nomenclature of hernia, 856 
 Nose, foreign bodies in, 729 
 
 haemorrhage from, 730 
 
 hypertrophy of, 730 
 
 injuries and diseases of, 729 
 
 lipoma of, 731 
 
 malformations of, 729 
 
 polypus of, 731 
 
 ulceration of, 731 
 
 Obstruction of the bowels, 846 
 Obturator hernia, 890 
 (Edema glottidis, 776 
 (Edematous infiltration, 92 
 Oesophagitis, 797 
 (Esophagotomy, 802 
 (Esophagus, foreign bodies in, 800 
 
 inflammation of, 797 
 
 introduction of tubes into, 801 
 
 rupture of, 796 
 
 stricture of, 797 
 
 electrolysis in, 800 
 Olecranon fracture, 580 
 Onychia, 425 
 Oophorectomy, 1032 
 Ophthalmia, gonorrhoea^ 219 
 Opisthotonos, 491 
 Orchitis, 987 
 
 chronic, 989 
 Os calcis, excision of, 706 
 
 innominatum, fracture of, 566 
 Ossium fragilitas, 527 
 Osteitis, 511 
 
 causes of, 511 
 
 symptoms of, 511 
 
 rarefying osteitis, 530 
 Osteo-chondroma, 159 
 Osteo-cystoma, 530 
 Osteoid cancer, 531 
 
 tumors, 528 
 Osteoma, 162 
 Osteo-malacia, 524 
 
 Osteo-malacia, and rickets, artificial produc- 
 tion of, 526 
 Osteo-myelitis, 513 
 
 idiopathic, symmetrical, 514 
 treatment of, 514 
 Osteo-plastic amputation (PirogofFs), 378 
 operation for removal of tumors from 
 antrum highmorianum, 779 
 Osteo-sarcoma, 531 
 
 benign, 159 
 Osteotomy, subcutaneous, 526, 620, 640 
 
 supra-condyloid, 641 
 Ovarian fluid, examination of, 1078 
 peculiarities of, 1081 
 hernia, 885 
 tumors, 1066 
 
 diagnosis of, 1073 
 electrolysis in, 1084 
 formation of, 1067 
 medical treatment of, 1082 
 palliative treatment of, 1083 
 tapping and injection of, 1083 
 and pressure of, 1083 
 Ovariotomy, 1084 
 
 treatment of pedicle, 1089 
 washing out abdominal cavity, 1091 
 Ovary, colloid cysts, 1070 
 dermoid cysts of, 1071 
 fibro-cysts of, 1073 
 Ozsena, 731 
 
 syphilitica, 731 
 Ozone as a disinfectant, 63 
 
 Pain in inflammation, 95 
 Painful subcutaneous tumor, 154 
 Palate, cleft, 751 
 
 Palmar arch, superficial, ligature of, 474 
 surgical anatomy of, 474 
 
 fascia, contraction of, 435 
 Paper as a dressing, 48 
 Papilloma, 164 
 Papulae syphilitica?, 236 
 Paracentesis abdominis, 845 
 
 vesicae, 939 
 Paraphimosis, 1013 
 Paronychia, 411 
 
 treatment of, 412 
 Parotid gland, abscess of, 793 
 
 diseases and injuries of its duct, 
 
 793 
 extirpation of, 795 
 gangrene of, 793 
 malignant tumors of, 793 
 Parotitis, 792 
 Parovarian cysts, 1072 
 Parulis, 759 
 
 Passive haemorrhage, 316 
 Patella, dislocation of, 665 
 
 fracture of, 598 
 
 wiring the, 602 
 Pedunculated aneurism, 440 
 Pelvis, dislocation of, 653 
 
 fractures of, 566 
 Penis, amputation of, 1014 
 
 epithelioma of, 1014 
 Percutaneous ligation in haemorrhage, 335 
 
 70 
 
1106 
 
 INDEX. 
 
 Perforating ulcer of the foot, 426 
 Periangioma, 436 
 Pericardium, aspiration of, 824 
 Perinseum, abscess and fistula in, 937 
 
 lacerated, 1035 
 Perineorraphy, 1035 
 
 Bozeman's method, 1046 
 
 Emmet's, 1039 
 
 Hodgen's, 1041 
 
 Sims's, 1043 
 Periodontitis, 758 
 Periosteal exostosis, 529 
 Periostitis, 508 
 
 constitutional symptoms of, 508 
 
 and endostitis, differential diagnosis be- 
 tween, 509 
 
 treatment of, 510 
 
 secondary, 509 
 Peritoneal transfusion, 351 
 Peritoneum, encvsted dropsy of, 1076 
 Perityphlitis, 850 
 Perityphlitic abscess, 850 
 Pernio, 405 
 Pes cavus, 639 
 
 valgus, 646 
 Phagedena, black, 146 
 
 gray, 146 
 
 sloughing, 145 
 Phagedenic chancroid, 223 
 
 diphtheritic, 223 
 Phalanges, fracture of, 583 
 Pharyngitis, 772 
 
 gangrenous, 772 
 Phimosis, 1009 
 Phlebitis, acute, 480 
 
 chronic, 481 
 Phlebolith.es, 484 _ 
 Phlegmonous erysipelas, 396 
 Phosphatic deposits in urine, 953 
 Piles, 900 
 
 Pirogoff's operation at ankle, 378 
 Plaster, adhesive, 251 
 Plaster-of-Paris bandages, 46 
 
 splints, 540 
 Plasters, 42 
 Plastic operations, method of, 394 
 
 surgery, 392 
 Pleurosthotonos, 491 
 Pleurotomy, 823 
 Pneumocele, 819 
 Poisoned wounds, 259 
 Poisoning with rhus tox., 399 
 Polvpus, fibrous, 157 
 
 * fibro-cellular, 158, 732 
 
 nasi, 733 
 
 naso-pharyngeal, 734 
 soft, 157 
 uteri, 1022 
 Popliteal aneurism, 462 
 artery, ligature of, 477 
 
 surgical anatomy of, 477 
 Post-pharyngeal abscess, 774 
 Pott's disease, 686 
 Pott's fracture of fibula, 603 
 Pressure in abscess, 119 
 Primary haemorrhage, 316 
 Probes," 34 
 
 Process of inflammation, 89 
 
 scabbing, 102 
 Progressive muscular atrophy, 430 
 Prolapsus ani, 891 
 Prosopalgia, 502 
 Prostate gland, abscess of, 984 
 
 senile hypertrophy of, 985 
 is, acu 
 Prothesis, 395 
 Pruritus ani, 910 
 Pseudo-arthrosis, 545 
 Psoas abscess, 691 
 Pubic dislocation of femur, 664 
 Pubis, dislocation of, 653 
 Pudendal hernia, 890 
 Pulsating malignant tumors, 533 
 
 tumors in bone, 533 
 Pultaceous cysts, 192 
 Punctured wounds, 255 
 Purulent infiltration, 115 
 Pus basin, 49 
 
 chemical constituents of, 110 
 
 corpuscles, 109 
 Pustule, malignant, 421 
 
 general or internal, 421 
 treatment of, 422 
 
 syphilitic, 236 
 Pyemia, 123 
 
 tables of cases, 125 
 Pylorectomy, 853 
 Pylorus, divulsion of, 854 
 
 Question of amputation in wounds, 289, 354 
 Quilled suture, 250 
 Quinsy, 767 
 
 Rabid animals, wounds of, 261 
 Rabies canina, 261 
 in the dog, 262 
 Rachitis, 524 
 Radial artery, ligature of, 472 
 
 surgical anatomy of, 472 
 Radical cure of hernia, 871 
 
 Heaton's method, 872 
 open method, 871 
 Wood's method, 875 
 Radius, dislocation of head backwards, 677 
 forwards, 677 
 fracture of the neck of, 573 
 shaft, 574 
 Railway concussion, 681 
 
 spine, 681 
 Ranula, 766 
 
 Rectal method of etherization, 75 
 Rectotomy, linear, 908 
 Recto-vesical lithotomy, 961 
 Rectum and anus, diseases of, 892 
 examination of, 892 
 cancer of, 910 
 excision of, 910 
 foreign bodies in, 896 
 imperforate, 895 
 prolapsus of, 897 
 stricture of, 906 
 tumors within, 905 
 
INDEX. 
 
 1L07 
 
 Recurrent tumors, 165 
 
 Redness in inflammation, 97 
 
 Reducible hernia, 858 
 
 Reflex muscular atrophy, 431 
 
 Repair, 100 
 
 Resection of bones, in continuity, 698 
 
 of the pylorus, 853 
 Residual abscess, 115 
 Resolution, 99 
 Respiration, artificial, 825 
 Retention of urine, 931 
 Retracted flaps after amputation, 372 
 Retroclusion (acupressure), 334 
 Rheumatic arthritis, 621 
 Rheumatism, gonorrhceal, 217 
 Rhinoplasty, 737 
 Rhinoscopy, 770 
 Rhus tox., poisoning with, 399 
 Ribs, dislocation of, 655 
 
 excision of, 706 
 
 fracture of, 557 
 Rickets, 524 
 Roller bandage, 44 
 
 Rotary, lateral curvature of spine, 6S4 
 Rules for dressing, 44 
 Rupture, 856 
 
 of muscles and tendons, 429 
 
 of the oesophagus, 796 
 
 Sacro-iliac disease, 645 
 
 dislocation, 654 
 Saddle-back, 691 
 Salines, transfusion of, 351 
 Salivary calculus, 766, 794 
 
 fistula, 767 
 Sanguineous cysts, 194 
 Sarcoma, 149 
 
 alveolar, 171 
 
 cysto, 196 
 
 gelatinous, 158 
 
 giant-celled, 168 
 
 lytnpho, 505 
 
 round-celled, 171 
 
 spindle-celled, 165 
 Scabbing process, 102 
 Scalds and burns, 406 
 Scalp, gunshot wounds of, 719 
 
 wounds of, 718 
 Scalpels, 37 
 Scapula, excision of, 705 
 
 fractures of, 561 
 Sciatic dislocation of the femur, 662 
 Scirrhus, 174 
 
 of mammae, 830 
 Scissors, 34 
 Sclerosis in bone, 512 
 Scoliosis, 684 
 Scrofula, 201 
 
 in bone, 517 
 Scrofulous pus, 110 
 
 ulcer, 203 
 Scrotum, amputation' of, 1007 
 
 carcinoma of. 1006 
 
 elephantiasis of, 419, 1006 
 Sebaceous cysts, 199 
 Secondary haemorrhage, 316 
 
 Semi-malignant tumors, 165 
 Senile gangrene, 143 
 Separation, line of, 141 
 
 at sacro-iliac symphysis, 654 
 Septicaemia, 121 
 Sequestrum in necrosis, 520 
 Serous cysts, 191 
 
 congenital, 194 
 Shaft of femur, fracture of, 588 
 Shock, 488 
 
 secondary, 489 
 
 symptoms of, 490 
 
 temperature during, 489 
 Shoulder-joint, amputation at, 382 
 
 dislocation of, 671 
 
 excision of, 703 
 Simple ulcer, 131 
 
 Sims's and Emmet's operation for vesicovagi- 
 nal fistula, 1043 
 Sinus, 119 
 Skin-grafting, 136 
 Skin, injuries and diseases of, 396 
 
 morbid growths upon, 422 
 Skull, fracture of, 719 
 
 with depression, 719 
 Slough, 131 
 Sloughing, 131 
 
 phagedena, 145 
 
 ulcer, 145 
 Smith's anterior splint, 592 
 Smoke as a disinfectant, 62 
 Snakes, venemous, wounds of, 260 
 Soft chancre, 221 
 Sounding for stone, 956 
 Spasms of the glottis, 775 
 Special fractures of the head and face, 549 
 Specific pus, 110 
 Spermatocele, 1001 
 Spermatorrhoea, 1015 
 Sphacelus, 141 
 Spina bifida, 682 
 Spindle-celled sarcoma, 165 
 Spine, angular curvature of, 686 
 
 cleft, 682 
 
 concussion of, 681 
 
 injuries and diseases of, 681 
 
 rotarv, lateral curvature of, 684 
 Splay foot, 646 
 Spleen, extirpation of, 854 
 Splints, 539 
 
 plaster-of-Paris, 540 
 Spondylitis, 686 
 Sponge grafting, 138 
 Sprains, 433 
 Spurious talipes, 639 
 Squamae, syphilitic, 236 
 
 Stage of gummatous products in syphilis, 236 
 Staphylorraphy, 751 
 Starch bandage, 542 
 Stasis, 91 
 Steatomata, 157 
 
 Steno's duct, diseases and injuries of, 793 
 Sternum, fracture of, 557 
 Stone in the bladder, 956 
 
 sounding for, 956 
 female bladder,. 969 
 Strangulated hernia, 860 
 
1108 
 
 INDEX. 
 
 Strapping of ulcers, 134 
 Straps and plasters, 42, 251 
 Stricture of the oesophagus, 797 
 rectum, 906 
 urethra, 941 
 Struma, 201 
 Strumous synovitis, 613 
 Stump, neuralgia of, after amputation, 391 
 Styptics, 320^ 
 
 Subastragaloid amputation, 380 
 Subclavian artery, aneurism of, 459 
 ligature of, 468 
 surgical anatomy of, 468, 469 
 Subclavicular dislocation of humerus, 671 
 Subcoracoid dislocation of humerus, 674 
 Subcutaneous osteotomy, 526, 020, 640 
 
 painful tumor, 154 
 Subglenoid dislocation of humerus, 671 
 Submaxillary gland, diseases of, 794 
 Subspinous dislocation of humerus, 674 
 Subungual exostosis, 426 
 Superior maxilla, fracture of, 550 
 Suppuration, 109 
 
 in bone, 512 
 Supra-pubic lithotomy, 962 
 Supra-vaginal hysterectomy, 1032 
 Surgery, minor, 33 
 
 plastic, 392 
 
 of special regions and tissues, 396 
 Surgical affections of trachea and larynx, 806 
 
 anatomy of vessels, and methods of ope- 
 rating, 463 
 neck, 464 
 
 fever, 121 
 Sutures, 246 
 
 continued, 250 
 
 dry, 250 
 
 figure-of-eight, 248 
 
 glover's, 250 
 
 india-rubber, 250 
 
 interrupted, 247 
 
 nerve, 499 
 
 quilled, 250 
 
 silk, 38 
 
 silkworm-gut, 39 
 
 twisted, 248 
 
 whale tendon, 39 
 Suturing the intestines, 834 
 Swelling in inflammation, 96 
 Sycosis, 220 
 
 treatment of, 220 
 
 Hahnemanni, 237 
 Syme's operation at ankle-joint, 376 
 Synostosis, 615 
 Svnovial cvsts, 195 
 Synovitis, 609 
 
 strumous, 613 
 Syphilis, 205, 226 
 
 in bone, 237, 517 
 
 congenital, 243 
 
 treatment of, 244 
 
 constitutional symptoms of, 234 
 treatment, 238 
 
 history of, 205 
 
 infantile, 243 
 fvphilitic alopecia, 237 
 
 bubo, 233 
 
 Svphilitic exanthemata, 235 
 
 fever, 235 
 
 iritis, 239 
 
 treatment of, 240 
 
 laryngitis, 240, 806 
 
 maculse, 235 
 
 ozsena, 731 
 
 papulse, 236 
 
 pustules, 236 
 
 squamse, 236 
 
 tubercles, 236 
 Syphilization, 241 
 Systemic infection, 121 
 
 Talipes, 633 
 
 calcaneus, 634 
 
 equino-varus, 634 
 
 equinus, 634 
 
 spurious, 639 
 
 tenotomy in, 637 
 
 valgus, 634 
 
 varus, 634 
 Tapping the abdomen, 845 
 Tarso-metatarsal articulation, amputation 
 
 through, 380 
 Tarsus, Chopart's amputation through, 379 
 Taxis, 862 
 Telangiectasis, 485 
 Tendinous tumors, 157 
 Tendons, ham-string, division of, 614 
 
 injuries and diseases of, 427 
 
 and muscles, dislocation of, 429 
 rupture of, 429 
 Tenotomv, 637 
 Tents, 48 
 
 Terminations of inflammation, 99 
 Testicle, abscess of, 988 
 
 cancer of, 992 
 
 chronic inflammation of, 989 
 
 cystic or adenoid disease of, 991 
 
 fungoid growths of, 990 
 
 inflammation of, 987 
 Tetanus, 491 
 
 causes of, 491 
 
 nerve-stretching in, 494 
 Thecitis, 427 
 
 Theories of inflammation, 88, 91, 93 
 Thermo-cautery, 55 
 
 for tracheotomy, 811 
 Thigh, amputations of, 370 
 
 fractures of, 584 
 Thoracentesis, 822 
 Thoracis, gradual drainage, 822 
 Thorax, aspiration of, 821 
 
 injuries and diseases of, 819 
 Thread, ligature, 39 
 Throat, injuries and diseases of, 789 
 Throbbing in inflammation, 97 
 Thrombosis, 479 
 Thumb, amputation of, 390 
 
 dislocation of, 680 
 Thymol as a disinfectant, 69 
 Thyroid artery, superior, ligature of, 471 
 surgical anatomy of, 471 
 
 cysts, 194 
 
 dislocation of femur, 663 
 
IXDEX. 
 
 L109 
 
 Tibia, dislocation of head, backward, Q6Q 
 forward, 666 
 inward, 667 
 outward, 667 
 lower end, backward, 669 
 forward, 669 
 inward, 667 
 outward, 668 
 
 fractures of, 602 
 Tibial artery, anterior, ligature of, 477 
 surgical anatomy of, 477 
 posterior, ligature of, 477 
 
 surgical anatomy of, 477 
 Tic douloureux, 502 
 Tissue, connective, 90 
 
 changes in inflammation, 92 
 
 degeneration of, 109 
 
 metamorphosis, Strieker, 93 
 Toes, amputation of, 381 
 
 dislocation of, 670 
 
 excision of, 710 
 Toe-nail, ingrowing, 424 
 
 treatment of, 424 
 Tongue, abscess of, 759 
 
 amputation of, 762 
 
 diseases of, 759 
 
 entire removal of, 764 
 
 hypertrophy of, 761 
 
 partial amputation of, 764 
 
 tumors of, 760 
 Tonsillitis, 767 
 
 Tonsils, chronic hypertrophy of, 768 
 Tooth wounds, 285 
 
 treatment of, 285 
 Torsion in haemorrhage, 327 
 Torsoclusion (acupressure), 334 
 Torticollis, 790 
 Trachea and larynx, foreign bodies in, 806 
 
 surgical affections of, 806 
 Trachelorraphy, 1062 
 Tracheotomy, 807 
 
 with thermo-cautery, 811 
 Transfusion, 346 
 
 direct, 348 
 
 indirect, 347 
 
 of milk, 350 
 
 peritoneal, 351 
 
 of salines, 351 
 Traumatic fever, 120 
 
 gangrene, 142 
 
 tetanus, 491 
 Trephine, application of, 724 
 Trigger finger, 644 
 Trismus,491 
 
 treatment of, 492 
 True aneurism, 439 
 Trunk, fractures of, 555 
 Trusses, 865 
 Tubercle, syphilitic, 236 
 
 varieties of, 202 
 Tuberculosis, 201, 203 
 Tumors, 147 
 
 adenomatous, 165 
 
 in the antrum highmorianum, 777 
 
 in the bladder, 982 
 
 in bone, 528 
 
 bony, 162 
 
 Tumors, cancerous, 171 
 
 carcinomatous, 171 
 
 cartilaginous, 159 
 
 chondroid, 159 
 
 classification of, 148 
 
 color, 151 
 
 condylomatous, 237 
 
 cystic, 190 
 
 desmoid, 157 
 
 differential diagnosis between innocent 
 and malignant, 151 
 
 enchondromatous, 159 
 
 epitheliomatous, 177 
 
 erectile, 484 
 
 fatty, 156 
 
 fibro-calcareous, 157 
 
 fibro-cel hilar, 157 
 
 fibro-cystic, 190 
 
 fibrous, 157 
 
 fleshy, 157 
 
 forms of, 151 
 
 glandular, 165 
 
 growth, 152 
 
 histological formation, 152 
 
 homologous, 148 
 
 horny, 164 
 
 hydatid, 199 
 
 innocent, 153 
 
 lymphomatous, 162 
 
 malignant, 171 
 
 melanotic, 178 
 
 metastasis of, 151 
 
 mobilitv, 151 
 
 myeloid, 168 
 
 myomatous, 154 
 
 myxomatous, 157 
 
 neuromatous, 154 
 
 osseous, 162 
 
 ovarian, 1066 
 
 papillomatous, 164 
 
 parotid, 793 
 
 pulsating, malignant, 533 
 
 in the rectum, 905 
 
 recurrent, 165 
 
 sarcomatous, 165 
 
 schirrous, 174 
 
 semi-malignant, 165 
 
 size of, 151 
 
 subcutaneous, 154 
 
 tendinous, 157 
 
 of the tongue, 760 
 
 of the uterus, 1021 
 
 vascular, 155 
 
 volume of, 151 
 Turf as a dressing, 310 
 Turgescence, vital, 91 
 Twisted suture, 248 
 
 Ulatrophia, 759 
 Ulceration, 129 
 
 of the articular cartilages, 612 
 
 of bone, 515, 517 
 
 of the nose, 731 
 Ulcerative absorption, 130 
 Ulcers, 131 
 
 classification of, 131 
 
1110 
 
 IXDEX. 
 
 Ulcers, indolent, 132 
 irritable, 132 
 
 perforating, of the foot, 426 
 phagedenic, 130 
 rodent, 414 
 scrofulous, 203 
 serpiginous, 414 
 simple, 131 
 sloughing, 131, 145 
 specific, 131 
 varicose, 133 
 Ulna, dislocation backward, 677 
 of from the radius, 678 
 fractures of, 579 
 
 coronoid process, 580 
 olecranon process, 580 
 Ulnar artery, ligature of, 473 
 surgical anatomy of, 473 
 Umbilical hernia. 888 
 Upper extremities, amputation of, 382 
 fracture of, 570 
 jaw, excision of, 781 
 fracture of, 550 
 Urethra, chancroid of, 224 
 foreign bodies in, 940 
 lacerations of, 938 
 stricture of, 941 
 
 electrolysis in, 950 
 Urethral excrescences, 1052 
 Urethrotomy, external, 946 
 
 internal, 947 
 Uric acid calculi, 952 
 Urinary deposits and urinary calculi, 951 
 fistula, 937 
 
 organs, male, injuries and diseases of, 
 914 
 malformations of, 914 
 Urine, retention of, 931 
 Uterine tumors, 1021 
 
 enucleation of, 1025 
 injection of ergot, 1026 
 removal by hysterectomy, 1028 
 by laparotomy, 1028 
 through vagina, 1030 
 Uterus, cancer of, 1018 
 examination of, 1016 
 hard cancer of, 1018 
 lacerations of cervix, 1052 
 ulcerating epithelioma of, 1018 
 vegetating epithelioma of, 1019 
 Uvula, elongation of, 775 
 
 Vagina, atresia of, 1049 
 
 Vaginal extirpation of the uterus, 1030 
 
 Vaginismus, 1047 
 
 Varicocele, 1000 
 
 Varicose ulcer, 133 
 
 veins, 481 
 Varied methods of dressing wounds, 291 
 Varieties of hernia, 857 
 
 of inflammation, 103 
 
 of pus, 110 
 Varix, 481 
 
 aneurismal, 441 
 Vascular tumors, 155 
 
 of the lip, 750 
 
 Vaso-motor nerves, 89 
 Vegetating epithelioma of uterus, 1019 
 Vegetations, dendritic, 180 
 sycotic, 220 
 
 treatment of, 220 
 Veins, calculi in, 484 
 
 entrance of air into, 483 
 excision of, 483 
 inflammation of, 480 
 injuries and diseases of, 479 
 varicose, 481 
 
 treatment of, 481 
 wounds of, 484 
 Venereal disease, 205 
 
 condvlomatous, 220 
 warts, 220, 237 
 Venous haemorrhage, 316 
 Verrucse, 422 
 Vertebrae, dislocations of, 656 
 
 fractures of, 555 
 Vesico- vaginal fistula?, 1043 
 
 Bozeruan's operation for, 1046 
 Sims's and Emmet's operation for, 
 1043 
 Villous cancer, 180 
 Vinegar as a disinfectant, 65 
 Vital turgescence, 91 
 Volvulus, 846 
 
 Wandering cells, 90 
 Warts, 422 
 
 venereal, 220, 237 
 Weak ankles, 639 
 Weaver's bottom, 431 
 Whale tendon ligature, 39 
 Whiskey as an anaesthetic, 76 
 White blood-corpuscles, 90 
 Whitlow, 411 
 Wiring the patella, 602 
 Wounds, 245 
 
 of the abdomen, 832 
 amputation in, 354 
 articles for dressing, 246 
 classification of, 245 
 contused, 246 
 
 and lacerated, requiring amputa- 
 tion, 289 
 danger of, 246 
 dissection, 285 
 
 dressing of, with adhesive plaster, 251 
 with gauze and collodion, 250 
 by sutures, 246 
 varied methods of, 291 
 by alcohol, 294 
 antiseptic, 307 
 
 Lister's, 295 
 aseptic, 303 
 by compression, 293 
 occlusive, 293 
 open method, 293 
 gunshot, 270 
 healing of, 245, 251 
 incised, 252 
 insect, 259 
 of the joints, 608 
 lacerated, 257 
 
INDEX. 
 
 1111 
 
 Wounds, maggots in, 288 
 
 methods of dressing, 291 
 of muscles and tendons, 427 
 }f the nerves, 494 
 poisoned, 259 
 punctured, 255 
 
 treatment of, 256 
 the question of amputation in, 289 
 
 Wounds, by rabid animals, 261 
 
 of the scalp, 718 
 
 tooth, 285 
 
 of the veins, 484 
 
 of venomous snakes, 260 
 Wrist-joint, amputation at, 387 
 
 . excision of, 699 
 Wry neck, 790 
 
1886. 
 
 NEW CATALOGUE 
 
 OK STANDARD 
 
 Homeopathic Publications, 
 
 F. E. BOERICKE, 
 
 Hahnemann Publishing House. 
 
 921 ARCH STREET, PHILADELPHIA, 
 
 ALLEN, DR. TIMOTHY F. The Encyclopedia of Pure Materia 
 Medica ; a Record of the Positive Effects of Drugs upon the 
 Healthy Human Organism. With contributions from Dr. Richard 
 Hughes, of England ; Dr. C. Hering, of Philadelphia ; Dr. Carroll Dun- 
 ham, of New York ; Dr. Adolph Lippe, of Philadelphia, and others. Ten 
 volumes. Price, bound in cloth, $60.00 ; in half morocco or sheep, $70.00. 
 This is the most complete and extensive Avork on Materia Medica ever 
 attempted in the history of medicine — a work to which the homoeopathic prac- 
 titioner may turn with the certainty of finding the whole pathogenetic record 
 of any remedy ever used in homoeopathy, the record of which being published 
 either in book form or in journals. 
 
 " With the Volumes IX and X now before us Allen's Encyclopedia of Pure 
 Materia Medica is completed. It comprises all remedies proved or applied by Homoe- 
 opaths. With truly wonderful diligence, everything has been carefully collated from the 
 whole medical literature that could be put Under contribution to Homoeopathy, thus en- 
 abling any one who wants to make a thorough study of Materia Medica, or who wants to 
 read up a special remedy to find what he needs and where to look for it." . . . — From the 
 Allegemeine Homozopathische Zeitung. 
 
 ALLEN, DR. TIMOTHY F. A General Symptom Register of 
 the Homoeopathic Materia Medica. — 1,331 pages. Large 8vo. 
 
 Cloth, $12.00 
 
 Half morocco or sheep, 14.00 
 
 This valuable work was eagerly welcomed by the homoeopathic profession, 
 
 and a large portion of the edition has already been disposed of. The work can 
 
 be obtained through every homoeopathic pharmacy, and those desiring to secure 
 
 a copy should send in their orders without delay, as but a limited number of 
 
 copies remain available. 
 
 " The long-hoped-for ' Index ' has come, and now lies before us in all the glory of a 
 
 comelv volume of 1,331 pages, beautifully printed on good, clear paper, and bound in 
 
 cloth. 
 
 " Every scientific practitioner in the world will heartily thank the indefatigable author 
 
 for crowning his pharmaco-encyclopedic edifice so promptly with a workable repertorial 
 
2 F. E. BOEEICKE S 
 
 index. The thing we are most thankful for is that the arrangement is strictly alphabetical. 
 First, the part affected; second, the sensation, conditioned or modified. Xo fads or 
 fancies, theories or hypotheses. Of course, everybody has a copy of the ' Encyclopedia/ and 
 now everybody will get a copy of the Index. We cannot pretend to review such a work. 
 It bears every mark of care, capability, and conscientiousness, and to hunt about for specks 
 of dirt on such a grand picture is not the kind of work for us. The only piece of advice 
 we offer to intending purchasers is that they ask for it bound in leather, for common cloth 
 binding, no matter how nice to the eye, soon begins to tear at the back and becomes the 
 source of endless annoyance. This applies, of course, to a work for frequent reference, and 
 Allen's 'Index' is practically a dictionary to his 'Encyclopedia,' and as such will be used 
 many times a day." — From the Homoeopathic World. 
 
 ALLEN AND NORTON. Ophthalmic Therapeutics. See Nor- 
 ton's Ophthalmic Therapeutics. 
 
 ALLEN, WILLIAM A. Repertory of the Symptoms of Inter- 
 mittent Fever. Arranged by William A. Allen. 107 pages. 12mo. 
 
 Cloth. Price, . 81.00 
 
 AVe give a letter of Timothy F. Allen, M. D., recommending the publica- 
 tion of this little work : 
 
 " I have carefully examined the repertory of Dr. Wm. Allen, of Flushing, and assure 
 you that it is exceedingly valuable. It should be printed in pocket form. I should use it 
 constantly. Dr. Allen has a large experience in the treatment of intermittent^ and his 
 own observations are entitled to great respect." 
 
 ALLEN, H. C. The Therapeutics of Intermittent Fever. By H. 
 C. Allex, M. D., of the University of Michigan. Second edition, revised 
 and enlarged. 342 pages. 8vo. Cloth, 82.75 
 
 This is the Second Edition of the author's work, which originally appeared 
 in 1879, and found a rapid sale and met with a hearty reception from the pro- 
 fession. It has been very carefully revised, and to meet an evident demand to 
 the bracketed comparison of the former edition have been added some leading 
 characteristics of each remedy, and a complete repertory. In advance of the 
 coming malarial season, the homoeopathic practitioner can furnish himself with 
 no better or more indispensable guide than this excellent monograph, as the 
 following notices abundantly testify : 
 
 "And noAV, is it too much to say that with its full Materia Medica, its comparisons, 
 clinical illustrations, and repertory, all in good type, it is the best work on the subject that 
 lias ever been issued?" — A. F. Randall, M.D., in Investigator. 
 
 '"This work is a necessity where one has to cope with that often most discouraging of 
 all diseases, and its careful study may insure success. You are not complete without it." — 
 The Regular Physician. 
 
 ARNDT, H. C. A System of Medicine, Based upon the Law of 
 Homoeopathy. In three volumes, royal octavo. Vol. I, 960 pages ; 
 vol. II, 900 pages ; vol. Ill, 990 pages. Price per volume, bound in cloth, 
 87.50 ; the complete work, $22.50. Price per volume, bound in half mo- 
 rocco or sheep, 88.50 ; the complete work, .... 825.50 
 This great work has been, without exception, received with unqualified 
 praise both in Europe and America, and has been unhesitatingly pronounced 
 the most exhaustive work of its kind in homoeopathic literature. The result of 
 so much labor, the combined effort of so many of the best minds in our school, 
 we are glad to say 'has not been lost upon the profession : it is now clearly 
 demonstrated that "A System of Medicine, Based upon the Law of Homoeopathy" 
 will long remain a standard work in the homoeopathic school of medicine. The 
 large demand for the work is especially flattering, showing how many physicians 
 
HOMOEOPATHIC PUBLICATIONS. 3 
 
 realize that books that are universally applauded are books to be bought and 
 studied — else they will fall behind the progress of the age. 
 
 Contents of volumes as follows : 
 
 Vol. I. — General Introduction — Chapter on Physical Diagnosis — Diseases 
 of the Respiratory Organs — Diseases of the Organs of Circulation — Diseases of 
 the Organs of Digestion. 
 
 Vol. II. — Diseases of Blood-Glandular System — Diseases of Urinary Or- 
 gans — Diseases of the Genital and Reproductive Organs — Diseases of the 
 Nervous System — Diseases of the Organs of Locomotion. 
 
 Vol. III. — Diseases of the Skin of the Eye and Ear — Constitutional 
 Diseases. 
 
 "The complete work is one that every physician ought to possess, and one that he will 
 make no mistake in securing." — The Medical Era. 
 
 "The work consists of a number of essays by some of the ablest members of our school 
 on the subjects assigned to them, under the editorial supervision of Dr. Arndt, who has done 
 his work well. Like all of Boericke's publications, the book is in the highest style of the 
 printer's art." — The Medical Advance. 
 
 "The work, if Vol. I is ? sample, is creditable to the numerous contributors, to its 
 editor, and to the publisher. The text is clearly rendered, is concise, and, so far as our 
 reading shows, up to date in symptomatology, diagnosis, and pathology. 
 
 "In regard to paper, printing, and binding, we desire to thank our industrious and 
 pains-taking publisher for offering such a perfect book. Printed with virgin type, on ex- 
 cellent paper, the book vies with, if it does not excel, any previous effort of any publishing- 
 house." — Hahnemannian Monthly. 
 
 " The System of Medicine, Vol. I, came to hand just in time to save the life of one of my 
 patients — hence I am much pleased with it. Inclosed please find the amount due." — 
 Private Letter. 
 
 " Whatever opinions one may have upon the contested points of homoeopathic practice, 
 whether he be a loose prescriber or a strict Hahnemannian, he cannot fail to be proud of 
 the handsome volume which Dr. Arndt here presents to his fellow practitioners. 
 
 "It is a volume which, in extent and completeness, exceeds and excels anything of its 
 kind vet published. Its descriptions of diseases are clear and full — amply full, although 
 not so large as works like Ziemssen's and Pepper's System of Practiced Medicine, which are 
 spun out to a tedious length 
 
 "The best portion of the volume, to our mind, is the chapter on diseases of the organs 
 of digestion. This is worth the price of the volume." — The Homoeopathic Physician. 
 
 " I am more than pleased with the volume. The long-felt want for such a work would 
 make me appreciate it even were it ordinary work, but the clear bold type, the neat and 
 solid binding, and the completeness of each subject treated of, makes it the most welcome 
 book that ever came into my office. I read it like a novel for half the night." — Private 
 Letter. 
 
 " This great work will be to the homoeopathic school what Reynold's System of Medicine 
 and Ziemssen's Encyclopedia of Medicine is to the allopathic. The homoeopathic system of 
 practice has never been represented, in this country at least, by a text-book on general 
 practice which met the wants of that school. They'have been deficient in the etiology, 
 pathology, and diagnosis of disease. But this work is very complete in these respects, and 
 is fully up to the requirements of the condition of medical science of to-day. Every disease 
 treated of in this volume is written up in the most exhaustive manner. The therapeutics 
 of each disease is concise, plain, and not incumbered with that amount of svmptomatology 
 which has been a great fault of homoeopathic works on practice. The characteristic or 
 guiding symptoms are alone given, greatly increasing the value of the work 
 
 " The typography and binding are excellent, and the text is very free from errors. It 
 will be a work of which the new school will be proud, and it will show a rapid advance in 
 that method of practice, an advance in accord with the general advance in therapeutics, in 
 liberal scientific methods, and a gradual breaking away from some of the visionary and 
 early dogmas of the followers of Hahnemann. But the fundamental truth of homoeopathic 
 law of similia is ably defended." — Chicago Inter-Ocean. 
 
4 F. E. BOERICKE S 
 
 BAEHR, DR. B. The Science of Therapeutics according to the 
 Principles of Homoeopathy. Translated and enriched with numer- 
 ous additions from Kafka and other sources, by C. J. Hempel, M.D. Two 
 
 volumes. 1387 pages. Half morocco, $9.00 
 
 "The descriptions of disease — no easy thing to write — are always clear and full, some- 
 times felicitous. The style is easy and readable, and not too prolix. Above all, the rela- 
 tions of maladies to medicines are studied no less philosophically than experimentally, with 
 an avoidance of abstract theorizing on one side, and of mere empiricism on the other,' which 
 is most satisfactory." — From the British Journal of Homoeopathy. 
 
 BELL and LAIRD, DRS. The Homoeopathic Therapeutics of 
 Diarrhoea, Dysentery, Cholera, Cholera Morbus, Cholera Infantum, and 
 all other Loose Evacuations of the Bowels ; by James B. Bell, M.D. 
 Second edition. 275 pages. 12mo. Cloth, . . . . $1.50 
 
 " This little book, issued in 1869 by Dr. Bell, has long been a standard work in Homoe- 
 opathic Therapeutics. We feel quite within bounds in asserting that it has been the means 
 under our law of saving thousands of lives. Than this no greater commendation could be 
 penned. ... In this second edition, Dr. Bell has been assisted by Dr. Laird, of Maine ; also 
 by Drs. Lippe, William P. Wesselhoeft, and E. A. Farrington. Thirty-eight new remedies 
 are given ; the old text largely rewritten ; many rubrics added to the repertory ; a new 
 feature, the 'black type,' for especially characteristic symptoms, introduced. 
 
 " This is a typical homoeopathic work, which no homoeopathic physician can afford to 
 be without. The typographical setting is worthy of * the book." — From the Homoeopathic 
 Physician. 
 
 BERJEAU,J. PH. The Homoeopathic Treatment of Syphilis, 
 Gonorrhoea, Spermatorrhoea, and Urinary Diseases. Revised, 
 with numerous additions, by J. H. P. Frost, M.D. 256 pages. 12mo. 
 
 Cloth, $1.50 
 
 This valuable little book, compiled from the results of the experience of 
 the best homoeopathic authorities, by Dr. Berjeau, of London, in 1856, has 
 since been revised and enlarged by J. H. P. Frost, M.D., and is now perhaps 
 the best and most concise presentation of the subject to be had. 
 
 BREYFOGLE, DR. W. L. Epitome of Homoeopathic Medicines. 
 383 pages, $1.25 
 
 We quote from the author's preface. 
 
 ' It has been my aim throughout to arrange in as concise form as possible the leading 
 symptoms of all well-established provings. To accomplish this, I have compared Lippe's 
 Mat. Med. ; the Symtomen-Codex ; Jahr's Epitome ; Boenninghausen's Therapeutic Pocket- 
 Book, and Hale's New Kemedies." 
 
 BRIGHAM, DR. GERSHAM N. Phthisis Pulmonalis, or Tuber- 
 cular Consumption. Pp. 224. 8vo. Cloth. Price, . . $2.00 
 This interesting work on a subject which has been the " Opprobrium Med- 
 icorum " for generations past, has met with a favorable reception at the hands 
 of the profession. It is a scholarly work and treats its subject from the stand- 
 point of pure Homoeopathy. 
 
 "Our author's work must be pronounced as decidedly able, and its principal defects are 
 those of the subject itself in its present state of development. In our opinion the whole 
 question is still involved in too much doubt and difficulty to admit of its being handled very 
 lucidly at present. Dr. Brigham tries very hard to clear the deck of all notions that might 
 be in the way of handling the subject scientifically, but he does not quite succeed even in 
 defining clearly one single form of phthisis. Why? because in the present state of the sub- 
 ject it is impossible for any man to do so, and we question whether a much better book on 
 phthisis is possible at present." — From The Homoeopathic World for October, 1882. 
 
HOMOEOPATHIC PUBLICATIONS. 5 
 
 BRYANT, DR. J. A Pocket Manual, or Repertory of Homoeo- 
 pathic Medicine, Alphabetically and Nosologically arranged, which 
 may be used as the Physicians' Vade-mecum, The Travelers' Medical Com- 
 panion, or the Family Physician. Containing the Principal Remedies for 
 the most important Diseases ; Symptoms, Sensations, Characteristics of 
 Diseases, etc. ; with the principal Pathogenetic Effects of the Medicines 
 on the most important Organs and Functions of the Body, together with 
 Diagnosis, Explanation of Technical Terms, Directions for the Selection 
 and Exhibition of Remedies, Rules of Diet, etc. Compiled from the best 
 Homoeopathic authorities. Third edition. 352 pages. 18mo. Cloth, $1.50 
 
 DR. BURNETT'S ESSAYS. Ecce Medicus ; Natrum Muriati- 
 cum ; Gold ; The Causes of Cataract ; Curability of Cataract ; 
 Diseases of the Veins ; Supersalinity of the Blood. Pp. 296. 
 
 8vo. Cloth. Price, $2.50 
 
 Dr. Burnett's essays were so favorably received in this country, that they 
 would undoubtedly have commanded a very large sale, had they not been so 
 liigh in price. As it was, the six essays would have cost over five dollars, and 
 in order to bring them within reach of the many we reprinted them, by special 
 arrangement with the author, who contributed a new essay, " The Causes of 
 Cataract," not hitherto published, and a general introduction to the. volume. 
 
 The book is printed in good style on heavy toned paper and well bound, 
 and we are able to furnish it at less than half the. price of the imported 
 volumes. 
 
 We feel sure that these suggestive and sprightly monographs will be 
 highly appreciated by the profession at large. 
 
 BUTLER, DR. JOHN. A Text-Book of Electro-Therapeutics 
 and Electro- Surgery ; for the Use of Students and General 
 Practitioners. By John Butler, M.D., L.R.C.P.E., L.R.C.S.I., etc., 
 etc. Second edition, revised and enlarged. 350 pages. 8vo. Cloth, $3.00 
 " Among the many works extant on Medical Electricity, we have seen nothing that 
 comes so near 'tilling the bill' as this. The book is sufficiently comprehensive for the 
 student or the practitioner. The fact that it is written by an enthusiastic and very intelli- 
 gent homoeopathist, gives to it additional value. It places electricity on the same basis as 
 other drugs, and points out by specific symptoms when the agent is indicated. The use of 
 electricity is therefore clearly no longer an -exception to the law of similia, but acts cura- 
 tively only when used in accordance with that law. We are not left to conjecture and doubt, 
 but can clearly see the specific indications of the agent, in the disease we have under obser- 
 vation. The author has done the profession an invaluable service in thus making plain the 
 pathogenesis of this wonderful agent. The reader will find no difficulty in following both 
 the pathology and treatment of the cases described. Electricity is not held up as the cure- 
 all of disease, but is shown to be one of the most important and valuable of remedial agents 
 when used in an intelligent manner. We have seen no work which we can so heartily 
 recommend as this." — Cincinnati Medical Advance. 
 
 BUTLER, DR. JOHN. Electricity in Surgery. Pp. 111. 12mo. 
 
 Cloth. Price, $1.00 
 
 This interesting little volume treats on the application of Electricity to 
 Surgery. The following are some of the subjects treated of : Enlargement 
 of the Prostate ; Stricture ; Ovarian Cysts ; Aneurism ; Naevus ; 
 Tumors ; Ulcers ; Hip Disease ; Sprains ; Burns ; Galvano-Cautery ; 
 Hemorrhoids ; Fistula ; Prolapsus of Rectum ; Hernia, etc., etc. 
 The directions given under each operation are most explicit and will be hear- 
 tily welcomed by the practitioner. 
 
6 F. e. boericke's 
 
 DUNHAM, CARROLL, A.M., M.D. Homoeopathy the Science 
 of Therapeutics. A collection of papers elucidating and illustrating 
 the principles of Homoeopathy. 529 pages. 8vo. Cloth, . $3.00 
 
 Half morocco, 4.00 
 
 " More than one-half of this volume is devoted to a careful analysis of various drug- 
 provings. It teaches us Materia Medica after a new fashion, so that a fool can understand, 
 not only the full measure of usefulness, but also the limitations which surround the drug. 
 .- . AVe ought to give an illustration of his method of analysis, but space forbids. We not 
 only urge the thoughtful and studious to obtain the book, which they will esteem as second 
 only to the Organon in its philosophy and learning." — The American Homceopathht. 
 
 DUNHAM, CARROLL, A.M., M.D. Lectures on Materia 
 
 Medica. 858 pages. 8vo. Cloth, $5 00 
 
 Half morocco, ......... 6.00 
 
 " Vol. I is adorned with a most perfect likeness of Dr. Dunham, upon which stranger 
 and friend will gaze with pleasure. To one skilled in the science of physiognomy there will 
 be seen the unmistakable impress of the great soul that looked so long and steadfastly out of 
 its fair windows. But our readers will be chiefly concerned with the contents of these two 
 books. They are even better than their embellishments. They are chiefly such lectures on 
 Materia Medica as Dr. Dunham alone knew how to write. They are preceded quite natu- 
 rally by introductory lectures, which he was accustomed to deliver to his classes on general 
 therapeutics, on rules which should guide us in studying drugs, and on the therapeutic law. 
 At the close of Vol. II we have several papers of great interest, but the most important fact 
 of all is that we have over fifty of our leading remedies presented in a method which be- 
 longed peculiarly to the author, as one of the most successful teachers our school has yet 
 produced. . .. . Blessed will be the library they adorn, and the wise man or woman into 
 whose mind their light shall shine." — Cincinnati Medical Advance. 
 
 EDMONDS on Diseases Peculiar to Infants and Children. By W. 
 A. Edmonds, M.D., Professor of Paedology in the St. Louis Homoeopathic 
 College of Physicians and Surgeons, etc., etc., etc. 1881. Pp. 300. 8vo. 
 
 Cloth, . $2.50 
 
 This work meets with rapid sales, and was accorded a flattering reception 
 
 by the homoeopathic press. 
 
 " This is a good, sound book, by an evidently competent man. The preface is as manly 
 as it is unusual, and engages one to go on and read the entire work. In the chapter on the 
 examination of sick children we read that 'no physician will ever have full and comfort- 
 able success as a psedologist who has a brusque, reticent, undemonstrative manner. It is 
 indispensable that a physician having children in charge should convince them by his 
 manner that he likes them, and sympathizes with them in their whims, foibles, and peculi- 
 arities. Their intuitions as to whom they ought to like and ought not to like are marked 
 and wonderfully accurate at a very tender age.' The physician who writes thus is a born 
 ppedologist, and most assuredly a very successful practitioner. 
 
 "After the examination of children has been dwelt upon, our author proceeds to dis- 
 cuss of the hygiene of children in a very able and sensible manner. He then discourses 
 upon the various diseases of children in an easy and yet didactic manner, and any one can 
 soon discover that he knows whereof he writes." — From the Homoeopathic World. 
 
 EGGERT, DR. W. The Homoeopathic Therapeutics of Uterine 
 and Vaginal Discharges. 543 pages. 8vo. Half morocco, $3.50 
 The author here brought together in an admirable and comprehensive 
 arrangement everything published to date on the subject in the whole homoeo- 
 pathic literature, besides embodying his own abundant personal experience. 
 The contents, divided into eight parts, are arranged as follows : — Part I. 
 Treats of Menstruation and JDysmenorrhoea. Part II. Menorrhagia. Part 
 III Amenorrhea. Part IV. Abortion and Miscarriage. Part V. Metror- 
 rhagia. Part VI. Fluor albus. Part VII. Lochia, and Part VIII. Gen- 
 
HOMCEOPATHIC PUBLICATIONS. 7 
 
 e\al Concomitants. No work as complete as this, on the subject, was ever 
 before attempted, and we feel assured that it will meet with great favor by the 
 profession. 
 
 GUERNSEY, DR. H. N. The Application of the Principles and 
 Practice of Homoeopathy to Obstetrics and the Disorders Pe- 
 culiar to Women and Young Children. By Henry N. Guernsey, 
 M.D., Professor of Obstetrics and Diseases of Women and Children in the 
 Homoeopathic Medical College of Pennsylvania, etc., etc. With numer- 
 ous Illustrations. Third edition, revised, enlarged, and greatly improved. 
 
 Pp. 1004. 8vo. Half morocco, $8.00 
 
 In 1869 this sterling work was first published, and was at once adopted as 
 a text-book at all homoeopathic colleges. In 1873 a second edition, consider- 
 ably enlarged, was issued ; in 1878 a third edition was rendered necessary . 
 The wealth of indications for the remedies used in the treatment, tersely and 
 succinctly expressed, giving the gist of the author's immense experience at the 
 bedside, forms a prominent and well-appreciated feature of the volume. 
 
 "This standard work is a credit to the author and publisher The 
 
 instructions in the manual and mechanical means employed by the accoucheur are fully up 
 to the latest reliable ideas, while the stand that is taken that all derangements incidental to 
 gestation, parturition, and post partum are not purely mechanical, but will in the majority 
 of cases, if not all, succumb to the action of the properly selected homoeopathic remedy, 
 shows that Professor Guernsey has not fallen into the rut of methodical ideas and treatment. 
 
 The appendix contains additional suggestions in the treatment 
 
 of suspended animation of newly born children, hysteria, ovarian tumors, sterility, etc., 
 suggestions as to diet during sickness of any kind, etc., etc. After the index is a glossary, a 
 useful appendix in itself. Every practitioner should have a copy of this excellent work, 
 even if he has two or three copies of old school text-books on obstetrics and diseases of 
 women." — From the Cincinnati Medical Advance. 
 
 GUERNSEY, DR. E. Homoeopathic Domestic Practice. With 
 full Descriptions of the Dose to each single Case. Containing also Chap- 
 ters on Anatomy, Physiology, Hygiene, and abridged Materia Medica. 
 Tenth enlarged, revised, and improved edition. Pp. 653. Half leather, 
 
 82,50 
 
 HAGEN, DR. R. A Guide to the Clinical Examination of Patients 
 and the Diagnosis of Disease. By Richard Hagen, M.D., Privat 
 docent to the University of Leipzig. Translated from the second revised 
 and enlarged edition, by G. E. Gramm, M.D. Pp. 223. 12mo. Cloth, 
 
 $1.25 
 " This is the most perfect guide in the examination of patients that we have ever seen. 
 The author designs it only for the use of students of medicine before attending clinics, but 
 we have looked it carefully through, and do not know of 223 pages of printed matter any- 
 where of more importance to a physician in his daily bedside examinations. It is simply 
 invaluable." — From the St. Louis Clinical Review. 
 
 HAHNEMANN, DR. S. Organon of the Art of Healing. By Sam- 
 uel Hahnemann, M.D. Aude Sapere. Fifth American edition. Trans- 
 lated from the fifth German edition, by C. Wesselhoeft, M.D. Pp. 244. 
 
 Svo. Cloth, $1.75 
 
 "To insure a correct rendition of the text of the author, they (the publishers) selected 
 as his translator Dr. Conr.td Wesselhoeft, of Boston, an educated physician in every respect, 
 and from his youth up perfectly familiar with the English and German languages, than 
 whom no better selection could have been made. That he has made, as he himself de- 
 
8 F. e. boericke's 
 
 dares, 'an entirely new and independent translation of the whole work,' a careful compar- 
 ison of the various paragraphs, notes, etc., with those contained in previous editions, gives 
 abundant evidence ; and while he has, so far as possible, adhered strictly to the letter of 
 Hahnemann's text, he has at the same time given a pleasantly flowing rendition that avoids 
 the harshness of a strictly literal translation." — Hahnemannian Monthly. 
 
 HALE, DR. E. M. Lectures on Diseases of the Heart. In three 
 pans. Part. I. Functional Disorders of the Heart. Part II. Inflamma- 
 tory Affections of the Heart. Part III. Organic Diseases of the Heart. 
 Second enlarged edition. Pp. 248. Cloth, .... $1.75 
 
 "After giving a thorough overhauling to the lectures of Dr. 'Hale, with the full inten- 
 tion of a close criticism, I acknowledge myself conquered. True, there are text-books on 
 the same subject of thrice the number of pages — more voluminous, but not so concise ; and 
 in this very conciseness lies the merit of the work. Students will find there everything 
 they need at the bedside of their patients. It fills just a want long felt by the profession." 
 — North American Journal of Homoeopathy. 
 
 HALE, DR. E. M. Materia Medica and Special Therapeutics of. 
 the New Remedies. By Edwin M. Hale, M.D., Professor of Materia 
 Medica and Therapeutics of the New Remedies in Hahnemann Medical 
 College, Chicago, etc., etc. Fifth edition, revised and enlarged. In two 
 volumes — Vol. I. Special Symptomatology. With new Botanical and 
 Pharmacological Notes. Pp.770. 1882."* Cloth,- . . . $5.00 
 Half morocco, . . 6.00 
 
 " Dr. Hale's work on New Remedies is one both "well known and much appreciated on 
 this side of the Atlantic. For many medicines of considerable value we are indebted to 
 his researches. In the present edition the symptoms produced by the drug investigated, 
 and those which they have been observed to cure, are separated from the clinical observa- 
 tions, by which the former have been confirmed. That this volume contains a very large 
 amount of invaluable information is incontestable, and that every effort has been made to 
 secure both fullness of detail and accuracy of statement is apparent throughout. For these 
 reasons we can confidently commend Dr. Hale's fourth edition of his well-known work on 
 the New Remedies to our homoeopathic colleagues." — From the Monthly Homoeopathic Rciieu: 
 
 HALE, DR. E. M. Materia Medica and Special Therapeutics of 
 the New Remedies. By Edwin M. Hale, M.D. Vol. II. Special 
 Therapeutics. With illustrative cases. Pp. 901. 8vo. Cloth, 85.00 
 Half morocco, 6.00 
 
 '• Hale's New Remedies is one of the few works which every physician, no matter how 
 poor he may be, ought to own. Many other books are very nice to have and very desir- 
 able, but this is indispensable. This volume before us is an elegant specimen of the 
 printer's and binder's art, and equally enjoyable when we consider its contents, which are 
 not only thoroughly scientific, but also as interesting as a novel. Thirty-seven new drugs 
 are added in this edition, besides numerous additions to the effects of drugs, previously 
 discussed. . . . We must say and reiterate, if necessary, that Dr. Hale has hit the nail on 
 the head in his plan for presenting the new remedies. It does well enough to tabulate and 
 catalogue, for reference in looking up cases, barren lists of symptoms, but for real enjoyable 
 study, for the means of clinching our information and making it stand by us, "give us vol- 
 umes planned and executed like that now under consideration."— From the New England 
 Medical Gazette. 
 
 HALE, DR. E. M. Medical and Surgical Treatment of the Dis- 
 eases of Women, especially those causing Sterility. Second edition. 
 Pp. 378. 8vo. Cloth, . . . . ' . . . . 82.50 
 
 " This work is the outcome of a quarter of a century of practical gynaecological experi- 
 ence, and on every page we are struck with its realness. It is one of those books that will 
 be kept on a low shelf in the libraries of its possessors, so that it may be found readily at 
 hand in case of need . . . 
 
 " In many obstinate uterine cases we shall reach this book down to read again and 
 
HOMOEOPATHIC PUBLICATIONS. 9 
 
 again what this clinical genius has to say on the subject. We have never seen Professor 
 Hale in the tlesh, but we have had scores of consultations with him in the pages of his 
 New Remedies, and he has thus feelessly helped us cure many an obstinate case of disease." 
 — From The Homoeopathic World, London. 
 
 HART, DR. C. P. Diseases of the Nervous System. Being a 
 Treatise on Spasmodic, Paralytic, Neuralgic, and Mental Affections. For 
 the use of Students and Practitioners of Medicine. By Chas. Pouter 
 Hart, M.D., Honorary Member of the College of Physicians and Sur- 
 geons of Michigan, etc., etc., etc. Pp. 409. 8vo. Cloth, . 83.00 
 
 "This work supplies a need keenly felt in our school — a work which will be useful 
 alike to the general practitioner and specialist ; containing, as it does, not only a condensed 
 compilation of the views of the best authorities on the subject treated, but also the author's 
 own clinical experience ; to which is appended the appropriate homoeopathic treatment of 
 each disease. It is written in an easy, flowing style, at the same time there is no waste of 
 
 words We consider the work a highly valuable one, bearing the evidence 
 
 ef hard work, considerable research and experience." — Medico-Chirwrgical Quarterly. 
 
 HART, DR. C. P. A Treatise on Intracranial Diseases. By Chas. 
 Porter Hart, M.D., Honorary Member of the College of Physicians 
 and Surgeons of Michigan, etc. 312 pages. 8vo. Cloth, . 82.00 
 The Author's Nervous System, with above as Supplement, bound in one. 
 Price, . $4.00 
 
 " Well bound, beautifully printed, up to the times in pathology, replete with homoeo- 
 pathic therapeutics, supplemental and completory of the author's work on Nervous Diseases 
 —these are its qualifications." — Hahnemannian Monthly, April, 1884. 
 
 " It is written in Dr. Hart's elaborate manner, clear and unambiguous, and will prove a 
 valuable guide to the proper understanding and treatment of inflammatory, organic, and 
 symptomatic affections of the brain and its membranes." — American Observer. 
 
 " We are glad to observe how closely our author adheres to the rigid (and hence suc- 
 cessful) homoeopathic method of prescribing. Even in insomnia, where the temptation to 
 use chloral, etc., is so pressing, we have given us the truth — to the exclusion of empirical 
 nonsense." — Homoeopathic Physician, April, 1884. 
 
 HELMUTH, DR. W. T. A System of Surgery. Copiously illus- 
 trated. By Wm. Tod Helmuth, M.D. 
 
 The present edition (the third) of this work is exhausted, but a new, en- 
 larged, and greatly improved edition has been for some time iu preparation, 
 and will be issued early in the fall of 1886. Helmuth's Surgery has for many 
 years been used as a standard text-book in all homoeopathic colleges, and will 
 long maintain its rank as the best work on the subject ever brought out by our 
 school. Ever since it was issued the necessity for student or practitioner to 
 invest in allopathic works on the subject ceased to exist, and when this new 
 fourth edition, which will be up to date, abounding in valuable hints, and 
 giving the results of the author's ripe and extensive experience in homoeopathic 
 medication in connection with surgery, — when all this, in our author's forceful, 
 elegant diction, shall be placed before the profession, it is certainly to be 
 doubted that a work better adapted to the needs of the practitioner can be 
 found anywhere. 
 
 The profession will be promptly informed on all necessary points as soon 
 as the work is issued. 
 
 We append a notice of a former edition : 
 
 . . . "We have in this work a condensed compendium of almost all that is known in 
 practical surgery, written in a terse, forcible, though pleasing, style, the author evidently 
 
10 F. E. BOERICKES 
 
 having the rare gift of saying a great deal in a few words, and of saying these few words in 
 a graceful, easy manner. Almost every subject is illustrated with cases from the Doctor's 
 own practice ; nor has he neglected to put before us the great advantage of homoeopathic 
 treatment in surgical diseases. The work is in every respect up to the requirements of the 
 times. . . . 
 
 " Taken altogether, we have no book in our literature that we are more proud of. 
 
 " One word of commendation to the publishers is naturally drawn from us, as we com- 
 pare this handsome, clearly printed, neatly bound volume with the last edition. The dif- 
 ference is so palpable that there is no necessity of making further comparisons." — Homos- 
 opathic Times. 
 
 HELMUTH, DR. W. T. Supra-Pubic Lithotomy. The High 
 
 Operation for Stone —>- Epicystotomy — Hypogastric Lithotomy — "The 
 High Apparatus." By Wm. Tod Helmtjth, M.D., Professor of Surgery 
 in the N. Y. Horn. Med. College ; Surgeon to the Hahnemann Hospital 
 and to Ward's Island Homoeopathic Hospital, N. Y.. 98 quarto pp. 8 
 
 lithographic plates. Cloth. Price, $4.00 
 
 A superb quarto edition, with lithographic plates, printed in five colors*, 
 and illustrated by charts and numerous wood-cuts. 
 
 HEINIGKE, DR. CARL. Pathogenetic Outlines of Homoeo- 
 pathic Drugs. By Dr. Carl Heinigke, of Leipzig, Translated from 
 the German, by Emil Tietze, M.D., of Philadelphia. Pp. 576. 8vo. 
 
 Cloth, $3.50 
 
 "The reader of this work will gain more practical knowledge of a given drug from its 
 
 pages in the same space of time than from any other book on the same subject. 
 
 "To the English-reading portion of our colleagues, this book will be a boon to be 
 
 appreciated in proportion that it is consulted, and will save them many weary researches 
 
 when in doubt of the true homoeopathic remedy." — American Homoeopath. 
 
 HERING, DR. CONSTANTINE. Condensed Materia Medica. 
 
 Third edition, more Condensed, Ke vised, Enlarged, and Improved. 960 
 
 pages. Large 8vo. Half morocco, $7.00 
 
 This well-known standard work on Condensed Materia Medica needs no 
 array of flattering press notices to recommend it anew to the rising homoeo- 
 pathic profession. It has nobly stood the test, and for many years to come will, 
 no doubt, take the lead among the works of its class. The important task of 
 revising the text for this, the third edition, was entrusted to Dr. E. A. Farring- 
 ton, Professor of Materia Medica, whose able editorship has resulted in all that 
 could be desired. 
 
 We quote from the editor's preface : 
 
 " In the preparation of this . . edition . . . additions have been made, and 
 a few typographical errors corrected, but in justice to the lamented author, no alterations 
 have been made in the substance of the text as he left it. 
 
 " More than twenty new remedies, arranged after the plan of the book, are given in 
 full ; and over forty partially proved drugs, with brief but distinctive indications, are added 
 to the sections on ' Relationship.' Besides all this, about six hundred choice and well- 
 attested symptoms have been incorporated in their proper place in the text. All the late 
 works have been drawn upon for the new material, and even private sources have been 
 unsparingly taxed; but still, great caution has been used in making selections. The plans 
 and purposes of the work demand clinical as well as pathogenetic symptoms. But of the 
 former sort only those have been employed which agree with the provings, and which show 
 every evidence of genuineness. Such discrimination demands the exercise of one's best 
 judgment and the expenditure of much time. But it is believed the benefits to be derived 
 far outweigh the trouble. The book is now offered to the profession and to students, not as 
 a rival of other works, but as a rich treasury full of information common to homoeopathic 
 literature, and also of gleanings from the vast collection which Dr. Hering made during a 
 busy half century of medical study and labor." 
 
HOMOEOPATHIC PUBLICATIONS. H 
 
 HERING, DR. CONSTANTINE. Domestic Physician. Seventh 
 
 American Edition. 464 pp., $2.50 
 
 The present editor, Claude R. Norton, M.D., a former assistant of Dr. 
 Hering, undertook, at his desire, the task of superintending the publication of 
 the work. Some additions to the text have been made, a few remedies intro- 
 duced, and, at times, slight alterations in the arrangement effected, but the well- 
 known views of the author have been respected in whatever has been done. 
 
 HOMCEOPATHIC POULTRY PHYSICIAN (Poultry Veterina- 
 rian) ; or Plain Directions for the Homoeopathic Treatment of the most 
 Common Ailments of Fowls, Ducks, Geese, Turkeys, and Pigeons, based 
 on the author's large experience, and compiled from the most reliable 
 sources, by Dr. Fr. Schroter. Translated from the German. 84 pages. 
 12mo. Cloth, $0.50 
 
 HOMCEOPATHIC COOKERY. Second edition. With additions by a 
 Lady of an American Homoeopathic Physician. Designed chieflv for the 
 Use of such Persons as are under Homoeopathic Treatment. 176 pages. 
 Price, . $0.50 
 
 HULL'S JAHR. A New Manual of Homoeopathic Practice. 
 Edited, with Annotations and Additions, by F. G. Sxellixg, M.D. Sixth 
 American edition. With an Appendix of the New Remedies, by C. J. 
 Hempel, M.D. In two volumes. Vol. I, price, $5.00. Vol. II, price, 
 $4.00. The complete work, 2,076 pages, . . . . . $9.00 
 The first volume, containing the symptomatology, gives the complete patho- 
 genesis of two hundred and eighty-seven remedies, besides a large number of 
 new remedies added by Dr. Hempel, in the appendix. The second volume 
 contains an admirably arranged Repertory. Each chapter is accompanied by 
 copious clinical remarks and the concomitant symptoms of the chief remedies 
 for the malady treated of, thus imparting a mass of information and rendering 
 the work indispensable to every student and practitioner of medicine. 
 
 JAHR, DR. G. H. G. Therapeutic Guide ; the most important results 
 of more than Forty Years' Practice. With Personal Observations regard- 
 ing the truly reliable and practically verified Curative Indications in actual 
 cases of disease. Translated, with Notes and New Remedies, by C. J. 
 
 Hempel, M.D. 546 pages, " $3.00 
 
 " With this characteristically long title, the veteran and indefatigable Jahr gives us 
 another volume of homoeopathies. Besides the explanation of its purport contained in the 
 title itself, the author's preface still further sets forth its distinctive aim. It is intended, he 
 says, as a ' guide to beginners, where I only indicate the most important and decisive points 
 for the selection of a remedy, and where I do not offer anything but what my own indi- 
 vidual experience, during a practice of forty years, has enabled me to verify as absolutely 
 decisive in choosing the proper remedy. The reader will easily comprehend that, in 
 carrying out this plan, I had rigidly to exclude all cases concerning which I had no 
 experience of my own to offer.' .... We are bound to say that the book itself is agreeable, 
 chatty, and full of practical observation. It may be read straight through with interest, 
 and referred to in the treatment of particular cases with advantage." — British Journal of 
 Homoeopathy. . 
 
 JAHR, DR. G. H. G. The Homoeopathic Treatment of Diseases 
 of Females and Infants at the Breast. Translated from the French 
 by C. J. Hempel, M.D. 422 pages. Half leather, . . $2.00 
 
12 F. e. boericke's 
 
 This work deserves the most careful attention on the part of homoeopathic, 
 practitioners. The diseases to which the female organism is subject are de- 
 scribed with the most minute correctness, and the treatment is likewise indi- 
 cated with a care that would seem to defy criticism. No one can study this 
 work without deriving both profit and pleasure. 
 
 JONES, DR. SAMUEL A. The Grounds of a Homoeopath's Faith. 
 Three lectures, delivered at the request of Matriculates of the Department 
 of Medicine and Surgery (Old School) of the University of Michigan. 
 By Samuel A. Joxes, M.D., Professor of Materia Medica, Therapeutics, 
 and Experimental Pathogensy in the Homoeopathic Medical College of 
 the University of Michigan, etc., etc. 92 pages. 12mo. Cloth (per 
 dozen, $3), .......... $0.30 
 
 The first Lecture is on The Law of Similars ; its Claim to be a Science in 
 that it Enables Prevision. The second Lecture, The Single Remedy a Necessity 
 of Science. The third Lecture, The Minimum Dose an Inevitable Sequence. A 
 fourth Lecture, on The Dynamization Theory, was to have finished the course, 
 but was prevented by the approach of final examinations, the preparation for 
 which 'left no time for hearing evening lectures. The Lectures are issued in a 
 convenient size for the coat-pocket ; aud as an earnest testimony to the truth, 
 we believe they will find their way into many a homoeopathic household. 
 
 JOHNSON, DR. I. D. Therapeutic Key ; or Practical Guide for the 
 Homoeopathic Treatment of Acute Diseases. Eleventh edition. 306 
 
 pages. Bound in linen, $1.75 
 
 Bound in flexible leather cover, 2.25 
 
 It is with pleasure that we announce a new edition of the above, which, 
 since its first appearance in 1870, has been a leading work of reference for the 
 clinical student and busy practitioners of our school. The many editions 
 through which it has passed is sufficient evidence of its value, and it may now 
 be said to represent the condensed experience of the leading physicians of the 
 homoeopathic profession. 
 
 In the present edition the author has spared no pains to render the work 
 more accurate and complete, having re-examined every point of doubtful 
 accuracy, rewritten a large portion of the original text, and added nearly one 
 hundred pages of new subject-matter. Among the additions may be noted : 
 Diagnostic Hints ; Auxiliary Measures ; Diet ; Dietic Preparation ; Ventila- 
 tion ; Artificial Digestion ; Peptonized Food ; Antiseptic Dressings ; Cata- 
 plasms ; Enemata ; Pressing Emergencies ; Post-mortem Examinations ; In- 
 spection of Dead Bodies ; Death of New-born Infants ; Medico-legal Ques- 
 tions ; Signs of Death, etc., etc., together with the treatment of a large number 
 of diseases and accidents not found in former editions. 
 
 a This is a wonderful little book, that seems to contain nearly everything pertaining to 
 the practice of physic, and all neatly epitomized, so that the book may be carried very com- 
 fortably in the pocket, to serve as a source for a refresher in a case of need. 
 
 " It is a marvel to us how the author has contrived to put into 3d7 pages such a vast 
 amount of information, and all of the very kind that is needed. No wonder it is in its 
 tenth edition. 
 
 "Right in the middle of the book, under P, we find a most useful little chapter, or 
 article on 'Poisonings,' telling the reader what to do in such cases." — Homoeopathic World, 
 London, notice of the Tenth edition. 
 
 JOHNSON, DR. I. D. A Guide to Homoeopathic Practice. De- 
 signed for the Use of Families and Private Individuals. 494 pages. 
 Cloth, $2.00 
 
HOMOEOPATHIC PUBLICATIONS. 13 
 
 This is the latest work on Domestic Practice issued, and the well and 
 favorably known author has surpassed himself. In this book fifty-six remedies 
 are introduced for internal application, and four for external use. The work 
 consists of two jmrts. Part I is subdivided into seventeen chapters, each being 
 devoted to a special part of the body, or to a peculiar class of disease. Part II 
 contains a short and concise Materia Medica. The whole is carefullv written 
 with a view of avoiding technical terms as much as possible, thus insurino- its 
 comprehension by any person of ordinary intelligence. 
 
 "Family Guides are often of great service, not only in enabling individuals to relieve 
 the trifling maladies of such frequent occurrence in every family, but in the graver forms 
 of disease, by prompt action to prepare the way for the riper intelligence of the physician. 
 
 "The work under notice seems to have been carefully prepared by an intelligent physi- 
 cian, and is one of the handsomest specimens of book-making we have seen from its pub- 
 lisher." — Homceopath ic Times. 
 
 JOHNSON, DR. I. D. A Guide to Homoeopathic Practice. De- 
 signed for the Use of Families and Private Individuals. Translated into 
 
 German. 4(53 pages. Price, $2.00 
 
 This valuable domestic homoeopathic guide, which has become so popular 
 in English, has now been published in German, under the belief that in time 
 the translation will be equally in demand. A work of such practical usefulness 
 cannot fail to win its way to the German homoeopathic household. 
 
 LAURIE and McCLATCHEY. The Homoeopathic Domestic 
 Medicine. By Joseph Laurie, M.D., Ninth American, from the 
 Twenty-first English edition. Edited and revised, with numerous and im- 
 portant additions, and the introduction of the new remedies. Bv R. J. 
 McClatchey, M.D. 1044 pages. 8vo. Half morocco, . . * $5.00 
 " We do not hesitate to indorse the claims made by the publishers, that this is the most 
 complete, clear, and comprehensive treatise on the domestic homoeopathic treatment of dis- 
 ease extant. This handsome volume of nearly eleven hundred pages is divided into six 
 parts. Part I is introductory, and is almost faultless. It gives the most complete and 
 exact directions for the maintenance of health and of the method of investigating the con- 
 dition of the sick, and of discriminating between different diseases. It is written in the 
 most lucid style, and is above all things wonderfully free from technicalities. Part II treats 
 of symptoms, character, distinctions, and treatment of general disea-es, together with a 
 chapter on casualties. Part III takes up diseases peculiar to women. Part IV is devoted 
 to the disorders of infancy and childhood. Part V gives the characteristic symptoms of 
 the medicines referred to in the body of the work, while part VI introduces the repertorv.'' 
 — Hahnemannian Monthly. 
 
 "Of the usefulness of this work in cases where no educated homeopathic phvsician is 
 within reach, there can be no question. There is no doubt that domestic Homoeopathv has 
 done much to make the science known ; it has also saved lives in emergencies. The "prac- 
 tice has never been so well presented to the public as in this excellent volume." — New. Eng. 
 Med. Gazette. 
 
 LILIENTHAL, DR. S. Homoeopathic Therapeutics. By & 
 Liliexthal, M.D., Editor of Xorth American Journal of Homoeopathv, 
 Professer of Clinical Medicine and Psychology in the Xew York Homoeo- 
 pathic Medical College, and Professor of Theory and Practice in the 
 New York College Hospital for AYomen, etc. Second edition. 835 pases. 
 
 8vo. Cloth, .... 85.00 
 
 Half morocco, 6.00 
 
 " Certainly no one in our ranks is so well qualified for this work as he who has done 
 it, and in considering the work done, we must have a true conception of the proper sphere 
 of such a work. For the fresh graduate this book will be invaluable, and to all such we 
 unhesitatingly and very earnestly commend it. To the older one. who says he has no use 
 for tnis book, we have nothing to say. He is a good one to avoid when well, and to dread 
 
14 F. e. boemcke's 
 
 when ill. We also hope that he is severely an 'unicum." — Prof. Samuel A. Jones in American 
 Observer. 
 
 ".'..'. It is an extraordinarily useful book, and those who add it to their library 
 will never feel regret, for we are not saying too much in pronouncing it the best work on 
 therapeutics in homoeopathic (or any other) literature. With this under one elbow, and 
 Hering's or Allen's Materia Medica under the other, the careful homoeopathic practitioner 
 can refute Niemayer's too confident assertion, 'I declare it idle to hope for a time when a 
 medical prescription should be the simple resultant of known quantities.' Doctor, by all 
 means buy Lilienthal's Homoeopathic Therapeutics. It contains a mine of wealth." — Prof. 
 Chas. Gatchel in Ibid. 
 
 LUTZE, DR. A. Manual of Homoeopathic Theory and Practice. 
 Designed for the use of Physicians and Families. Translated 
 from the German, with additions by C. J. Hempel, M.D. From the six- 
 tieth -thousand of the German edition. 750 pp. 8vo. Half leather, $2.50 
 
 MALAN, H. Family Guide to the Administration of Homoeo- 
 pathic Remedies. 112 pages. 32mo. Cloth, . . . $0.30 
 
 MANUAL OF HOMOEOPATHIC VETERINARY PRACTICE. 
 Designed for all kinds of Domestic Animals and Fowls, prescribing their 
 proper treatment when injured or diseased, and their particular care and 
 general management in health. Second and enlarged edition. 684 pages. 
 
 8vo. Half morocco, $5.00 
 
 " In order to rightly estimate the value and comprehensiveness of this great work, the 
 
 reader should compare it, as we have done, with the best of those already before the public. 
 
 In size, fullness, and practical value it is head and shoulders above the very best of them, 
 
 while in many most important disorders it is far superior to them altogether, containing, as 
 
 it does, recent forms of disease of which they make no mention." — Hahnemavnian Monthly. 
 
 MARSDEN, DR. J. H. Handbook of Practical Midwifery, with 
 full Instructions for the Homoeopathic Treatment of the Dis- 
 eases of Pregnancy, and the Accidents and Diseases incident to 
 Labor and the Puerperal State. J. H. Marsden, A.M., M.D. 315 
 
 pages. Cloth, $2.25 
 
 " It is seldom we have perused a text-book with such entire satisfaction as this. The 
 author has certainly succeeded in his design of furnishing the student and young prac- 
 titioner, within as narrow limits as possible, all necessary instruction in practical midwifery. 
 The work shows on every page extended research and thorough practical knowledge. The 
 style is clear, the array of facts unique, and the deductions judicious and practical. We are 
 particularly pleased with his discussion of the management of labor, and the management 
 of mother and child immediately after the birth, but much is left open to the common 
 sense and practical judgment of the attendant in peculiar and individual cases." — Homoeo- 
 pathic Times. 
 
 MORGAN, DR. W. The Text-book for Domestic Practice ; being 
 plain and concise directions for the Administration of Homoeopathic Medi- 
 cines in Simple Ailmeuts. 191 pages. 32mo. Cloth, . . $0.50 
 This is a concise and short treatise on the most common ailments, printed 
 in convenient size for the pocket ; a veritable traveler's companion. 
 NORTON, DR. GEO. S. Ophthalmic Therapeutics. By Geo. S. 
 Norton, M. D., Professor of Ophthalmology in the College of the New 
 York Ophthalmic Hospital, Senior Surgeon to the New York Ophthalmic 
 Hospital, etc. With an introduction by Prof. T. F. Allen, M. D. Sec- 
 ond edition Re-written and revised, with copious additions. Pp. 342. 
 
 8vo. Cloth, $2.50 
 
 The second edition of Allen and Norton's Ophthalmic Therapeutics has now 
 been issued from the press. It has been re-written, revised, and considerably en- 
 larged by Professor Norton, and will, without doubt, be as favorably received 
 
HOMOEOPATHIC PUBLICATIONS. 15 
 
 as the first edition — out of print since several years. This work embodies the 
 clinical experiences garnered at the N. Y. Ophthalmic Hospital, than which a 
 better appointed and more carefully conducted establishment does not exist in 
 this country. Diseases of the eye are steadily on the increase, and no physician 
 can afford to do without the practical experience as laid down in the sterling 
 work under notice. 
 
 RAUE, DR. C. G. Special Pathology and Diagnostics, with Thera- 
 peutic Hints. Third edition, re-written and enlarged. Pp. 1,094. 
 
 Large 8vo. Half morocco or sheep, $8.00 
 
 This is a book which has made for itself a name and a place in the litera- 
 ture of our homoeopathic school of medicine, and, in connection Avith this Third 
 Edition, it is enough to say that the work has been greatly improved and con- 
 siderably enlarged, and, as Homoeopathy now stands, is doubtless as near as 
 possible to all that can be desired. Practitioners who own the first and second 
 editions, will find it to their interest to own also the third, with its new and 
 valuable features, and thus keep pace with the progress of the school. 
 
 " The third edition of this classical work will be welcomed by every homoeopathic 
 
 practitioner We know of no book in either school of medicine at once so concise 
 
 and accurate." — California Homoeopath. 
 
 "By the revision and enlargement of this excellent work, the author has again con- 
 ferred a boon upon the entire homoeopathic school. Asa work on practice, this book is 
 undoubtedly the best representative of Homoeopathy to be found in our literature. Its aeti- 
 ology, pathology, diagnosis, are clear and concise, and the ' Therapeutic Hints,' with ' Digest,' 
 
 enable the practitioner to cure his patient The office of every homoeopath will be 
 
 incomplete without this work for reference. It will repay its cost many times a year." — 
 Medical Advance. 
 
 "Each group of symptoms, constituting what is usually known as a given form of dis- 
 ease, in addition to a full account of symptoms, pathology, and treatment, is supplemented 
 by a 'Digest,' making a complete and elaborate repertory of symptoms and treatment. 
 This plan must render the work very valuable for office and bedside reference use." — St. 
 Louis Periscope and Clinical Review. 
 
 "The young physician of limited means, and consequent limited library, would find it 
 to his special advantage to possess it, as it really stands as a fair equivalent to many mono- 
 graphs on many subjects ordinarily considered desirable possessions." — Medical Era. 
 
 " Prof. Kane, as a teacher, was always noted for his practical conciseness in stating 
 things, and his statements have always been looked upon as eminently reliable, hence it is 
 no wonder that his work should reach a third edition." — N. Y. Medical Times. 
 
 "To the general practitioner, no matter how 'busy,' to the student, to those who are 
 seeking light in this new and rapidly enlarging field of medicine, and to the old school phy- 
 sician we recommend this work as one far superior to any now in existence, taking the size 
 into consideration." — Physicians* and Surgeons 1 Medical Investigator. 
 
 REIL, DR. A. ACONITE, Monograph on, its Therapeutic and 
 Physiological Effects, together with its Uses, and Accurate 
 Statements derived from the various Sources of Medical Lit- 
 erature. By A. Kiel, M. D. Translated from the German by H. B. 
 Millard, M. D. Prize essay. 168 pages, * $0.60 
 
 RUSH, DR. JOHN. Veterinary Surgeon. The Handbook to Veteri- 
 nary Homoeopathy ; or, the Homoeopathic Treatment of Horses, Cattle, 
 Sheep, Dogs, and Swine. From the London edition. With numerous ad- 
 ditions from the Seventh German edition of Dr. F. E. Gunther's " Homoeo- 
 pathic Veterinary." Translated by J. F. Sheer, M. D. 150 pages. 18mo. 
 Cloth, . . . . . $0.50 
 
 SCH^FER, J. C. New Manual of Homoeopathic Veterinary 
 Medicine. An easy and comprehensive arrangement of Diseases, adapted 
 to the use of every owner of Domestic Animals, and especially designed 
 
16 F. e. boemcke's 
 
 for the farmer living out of the reach of medical advice, and showing him 
 the way of treating his sick Horses, Cattle, Sheep, Swine, and Dogs, in the 
 most simple, expeditious, safe, and cheap manner. Translated from the 
 German, with numerous additions from other veterinary manuals, by C. J. 
 Hempel, M. D. 321 pages. 8vo. Cloth, .... $2.00 
 
 SCHUSSLER, DR. MED. An Abbreviated Therapy ; The Bio- 
 chemical Treatment of Disease. By Dr. Med. Schussler, of 
 Oldenburg. Translated from the Twelfth German edition by Dr. J. T. 
 
 O'Connor. 94 pages. 12mo. Cloth, $0.90 
 
 Some time since it was decided to republish Schussler's Twelve Tissue Reme- 
 dies, which had been out of print with us for more than four years, and on 
 writing to the author, Dr. Schussler, of Oldenburg, about the matter, he called 
 our attention to the fact that a new edition (the Twelfth) of his work was forth- 
 coming — an edition which would contain many and considerable changes — and 
 the necessity of getting the benefit of all these changes in our new English edi- 
 tion has caused the w T ork to be delayed until now. 
 
 The translation, which has been done by Dr. O'Connor, is altogether new, 
 and the rendering is as close to the original as possible. Dr. O'Connor has also 
 added a very useful repertory, which greatly enhances the value of the work, 
 and many who already possess the old edition will find it to their advantage to 
 procure also the new. 
 
 SHARP'S TRACTS ON HOMOEOPATHY, each, . 5 
 
 Per hundred, . . ." . . . . . . $3.00 
 
 No. 1. What is Homoeopathy? No. 7. The Principles of Homoeopathy. 
 
 ]So. 2. The Defense of Homoeopathy. No. 8. Controversy on 
 
 No. 3. The Truth of " No. 9. Kemedies of " 
 
 No. 4. The Small Doses of " No. 10. Provings of " 
 
 No. 5. The Difficulties of " No. 11. Single Medicines of " 
 
 No. 6. Advantages of " No. 12. Common Sense of " 
 
 SHARP'S TRACTS, complete set of 12 numbers, . . ' . $0.50 
 
 Bound, 75 
 
 SMALL, DR. A. E. Manual of Homoeopathic Practice, for the use 
 of Families and Private Individuals. Fifteenth enlarged edition. 831 
 pages. 8vo. Half leather, . . . . . . . $2.50 
 
 SMALL, DR. A. E. Manual of Homoeopathic Practice. Translated 
 into German by C. J. Hempel, M.D. Eleventh edition. 643 pages. 
 
 8vo. Cloth, $2.50 
 
 STAPF, DR. E. Additions to the Materia Medica Pura. Trans- 
 lated by C. J. Hempel, M.D. 292 pages. 8vo. Cloth, . . $1.50 
 This work is an appendix to Hahnemann's Materia Medica Pura. Every 
 remedy is accompanied with extensive and most interesting clinical remarks, 
 and a variety of cases illustrative of its therapeutical uses. 
 TESSIER, DR. J. P. Clinical Remarks concerning the Homce- 
 pathic Treatment of Pneumonia, preceded by a Retrospective View 
 of the Allopathic Materia Medica and an Explanation of the Homoeo- 
 pathic Law of Cure. Translated by C. J. Hempel, M.D. 131 pages. 
 
 8vo. Cloth, $0.75 
 
 TESTE. A Homoeopathic Treatise on the Diseases of Children. 
 
 Bv Alph. Teste, M.D. Translated from the French by Emma H. Cote. 
 
 Fourth edition. 345 pages. 12mo. Cloth, . . . . $1.50 
 
 Dr. Teste's work is unique, in that in most cases it recommends for certain 
 
 affections remedies that are not usually thought of in connection therewith ; 
 
HOMOEOPATHIC PUBLICATIONS. 17 
 
 but embodying the results of an immense practical experience, they rarely fail 
 to accomplish the desired end. 
 
 VERDI, DR. T. S. Maternity, a Popular Treatise for Young 
 Wives and Mothers. By Tullio Suzzara Verdi, A.M., M.D., of 
 Washington, D. C. 450 pages. 12mo. Cloth, . . . $2.00 
 
 " No one needs instruction more than a young mother, and the directions given by Dr. 
 Verdi in this work are such as I should take great pleasure in recommending to all the 
 voting mothers, and some of the old ones, in the range of my practice." — George E. Ship- 
 man, M. D., Chicago, III. 
 
 " Dr. Verdi's book is replete with useful suggestions for wives and mothers, and his 
 medical instructions for home use a.cord with the maxims of my best experience in prac- 
 tice.' —John F. Gray, M. D., New York City. 
 
 VERDI, DR. T. S. Mothers and Daughters : Practical Studies for 
 
 the Conservation of the Health of Girls. Bv Tullio Suzzara Yerdi, 
 
 A.M,M.D. 287 pages. 12mo. Cloth, . . . . 81.50 
 
 " The people, and especially the women, need enlightening on many p ints connected 
 
 with their physical life, and the time is fast approaching when it will no longer be thought 
 
 singular or ' Yankeeish' that a woman should be instructed in regard to her sexuality. ii> 
 
 org ms and their functions Dr. Verdi is doing a good work in writing such 
 
 books, and we trust he will continue in the course he has adopted of educating the mother 
 and daughters. The book is handsomely presented. It is printed in good type on tine 
 paper, and is neatly and substantially bound." — Hahnemannian Monthly. 
 
 VERDI, GIRO DE SUZZARA, M.D. Progressive Medicine : A 
 
 Scientific and Practical Treatise on Diseases of the Digestive Organs and 
 the Complications arising therefrom. By Ciro de Suzzara Verdi, M.D., 
 late Acting Assistant Surgeon at Balfour Hospital, Professor of Physi- 
 ology and Pathology in the Cleveland Homoeopathic College for Women. 
 
 Pp.349. 12mo. Cloth, $2.00 
 
 VON TAGEN. Biliary Calculi, Perineorrhaphy, Hospital Gan- 
 grene, and its Kindred Diseases. 154 pages. 8vo. Cloth, 81.25 
 
 WILLIAMSON, DR. W. Diseases of Females and Children, 
 and their Homoeopathic Treatment. Third enlarged edition. 256 
 
 pages, 81.00 
 
 This work contains a short treatise on the homoeopathic treatment of the 
 
 diseases of females and children, the conduct to be observed during pregnancy, 
 
 labor, and confinement, and directions for the management of new-born infants. 
 
 WILSON, DR. T. P. Special Indications for Twenty-five Reme- 
 dies in Intermittent Fever. By T. P. Wilson, M.D., Professor of 
 Theory and Practice, Ophthalmic and Aural Surorerv, University of Michi- 
 gan. '1880. 53 pages. 18mo. Cloth, . . . . $0.40 
 This little work gives the characteristic Indications in Intermittent Fever 
 
 of twenty-five of the mostly used remedies. It is printed on heavy writing- • 
 
 paper, and plenty of space is given to make additions. 
 
 The name of the drug is printed on the back of the page containing 
 
 the symptoms, in order that the student may the better exercise his memory. 
 
 WINSLOW, DR. W. H. The Human Ear and its Diseases. A 
 Practical Treatise upon the Examination, Recognition, and Treatment of 
 Affections of the Ear and Associate Parts, Prepared for the Instruction of 
 Students and the Guidance of Phvsicians. Bv W. H. Winslow, M.D., 
 Ph.D., Oculist and Aurist to the Pittsburg Homoeopathic Hospital, etc., 
 etc., with one hundred and thirty-eight "illustrations. Pp. 526. 8vo. 
 Cloth. Price • . . ... 84.50 
 
1^ 
 
 18 F. E. BOERICKES HOMOEOPATHIC PUBLICATIONS. ° £^ « 
 
 " It would ill become a non-specialist to pass judgment upon the intrinsic merits of Dr. 
 Winslow's book, but even a general reader of medicine can see in it an author who has a 
 firm grasp and an intelligent apprehension of his subject. There is about it an air of self- 
 reliant confidence, which, when not offensive, can come only from a consciousness of know- 
 ing the matter in hand, and we have never read a medical work which would more quickly 
 lead us to give its author our confidence in his ministrations. This is always the conse- 
 quence of honest and earnest and inclusive scholarship, and this author is entitled to his 
 meed." — Dr. S. A Jones in American Observer. 
 
 WINTERBURN, DR. GEO. W. The Value of Vaccination ; A 
 Non-Partisan Review of its History and Results. By Geoege William 
 Winterburn, Ph.D., M.D. Pp. 182. Price, bound in paper, . $0.50 
 
 Bound in cloth, 75 
 
 The MS. of this little work was placed in the hands of two physicians 
 directly opposed on the question of vaccination. The first, who was in agree- 
 ment with the position taken by the author, pronounced it a most interesting 
 and exhaustive treatise ; the second, while he did not assent to the conclusions 
 drawn, declared it to be a scholarly effort, and one that would be read with 
 interest by many in the profession — " Not a dull page in it," he said. 
 
 Such* comment from two physicians of opposite principles on this question 
 decided the publisher that the work could not fail to be of value to those inter- 
 ested in the subject, and under this belief it is now placed before the medical 
 profession. 
 
 WORCESTER, DR. S. Repertory to the Modalities. In their 
 Relations to Temperature, Air, Water, Winds, Weather, and 
 Seasons. Based mainly upon Hering's Condensed Materia Medica, with 
 additions from Allen, Lippe, and Hale. Compiled and arranged by Sam- 
 uel Worcester. M.D., Salem, Mass., Lecturer on Insanity and its Jur- 
 isprudence at Boston Universitv School of Medicine, etc., etc. 1880. 
 
 160 pages. 12mo. Cloth, . . ■ $1.25 
 
 WORCESTER, DR. S. Insanity and its Treatment. Lectures on 
 the Treatment of Insanity and Kindred Nervous Diseases. By Samuel 
 Worcester, M.D., Salem, Mass. Lecturer on Insanity, Nervous Dis- 
 eases, and Dermatology, at Boston Universitv School of Medicine, etc., 
 etc. 262 pages, . . . . . . . . $3.50 
 
 Dr. Worcester was for a number of years assistant physician of the Butler 
 Hospital for the Insane, at Providence, R. L, and was appointed shortly after 
 as Lecturer on Insanity and Nervous Diseases to the Boston University School 
 of Medicine. The work, comprising nearly five hundred pages, will be wel- 
 comed by every homoeopathic practitioner, for every physician is called upon 
 sooner or later to undertake the treatment of cases of insanity among his pat- 
 ron's families, inasmuch as very many are loth to deliver any afflicted member 
 .to a public institution without having first exhausted all means within their 
 power to effect a cure, and the family phvsician naturally is the first to be put 
 in charge of the case. It is, therefore, of paramount importance that every 
 homoeopathic practitioner's library should contain such an indispensable work. 
 "The basis of Dr. Worcester's work was a course of lectures delivered hefore the senior 
 students of the Boston University School of Medicine. As now presented with some alter- 
 ations and additions, it makes a very excellent text-book for students and practitioners. 
 Dr. Worcester has drawn very largely upon standard authorities and his own experience, 
 which has not been small. In the direction of homeopathic treatment he has received 
 valuable assistance from Drs. Talcott and Butler, of the New York State Asylum. It is 
 not, nor does it pretend to be, an exhaustive work; but as a well-dicested summary of our 
 present knowledge of insanitv, we feel sure that it will s?ive satisfaction. We cordially 
 recommend it."— New England Medical Gazette