Digitized by the Internet Arciiive in 2010 with funding from Open Knowledge Commons V •■'.:■;>»». http://www.archive,org/details/practiceofsurgerOOmill PRACTICE OF SURGERY. C^ — ' ' ( THE kifi^^^'AAMi- PRACTICE SURGERY JAMES MILLEE, F.R.S.E., E.E.C.S.E, StTEGEON IN ORDINARY TO THE QUEEN TOR SCOTLAND; SURGEON IN ORDINARY TO HIS ROYAL HIGHNESS PRINCE ALBERT TOE SCOTLAND ; tEOPESSOK OF SURGERY IN THE UNIVERSITY OE EDINBURGH ; CONSULTING SURGEON TO THE ROYAL INriEMAET ; ETC. ETC. ETC SECOND EDITION. Illustrated by Two Hundred and Twenty-Seven Engravings on Wood. EDINBURGH: ADAM AND CHAELES BLACK, NORTH BRIDGE. LONGMAN AND CO. LONDON. EDINBCKGH: PKINTED BY R. AND R. CLAKK. PREFACE TO THE SECOND EDITION. The Author's original intention was to write a System or Text Book of Surgery for the use of his Pupils. It so happened, however, that the Volumes were issued with a considerable interval between their respective dates of publication, and in consequence acquired the appearance of distinct Treatises on the Principles and Practice of Sm'gerj. In the present Edition, they stiU differ as to the date of publication 5 and are intended to retain their accidental cha- racter as distinct Treatises ; each complete in itself. At the same time, however, it is hoped that, when considered as first and second Volumes of an entire Work, they may be found to constitute a tolerably complete System of Sm'ger}% The Author has aimed at making the present Volume — The Practice — uniform in all respects with its companion — The Principles. And in the accomplishment of his task he has again to acknowledge the kind assistance of Dr. W. T. Gairdner. He is also indebted to Mr. Walker for revision of the chapter on Affections of the Eye 5 and to Dr. Matthews Duncan for remodelling the chapter on Affections of the Female Organs. vi PREFACE. The Bibliographical references, as in the former Volume, are "■ selected with a view to usefulness and accessibility, rather than to completeness of illustration." And, in addition to those introduced, the Student is referred generally to the copious record of authorities in Mr. South's excellent translation of Chelius. 51 Queen Street, July 1862. CONTENTS. CHAPTER I. Operations PAGE 1 CHAPTER II. INJURIES OF THE SCALP . Bruise of the Scalp . ..... Wounds of the Scalp ...... Wounds of the Temporal Artery ..... CHAPTER III. INJURIES OP THE CRANIUM; AND THEIR CONSEQUENCES. Concussion of the Brain Compression of the Brain Compression by Extravasation of Blood Extravasation between the Bone and Dura Mater Extravasation of Blood on, or in the Brain Abscess of the Dura Mater Fractures of the Cranium Fissure .... Fissure at the Base of the Cranium Fracture, without Displacement Fracture with Displacement Punctured Fracture Fracture of the External Table, alone Fracture of the Inner Table, alone Depression without Fracture The Operation of Trephining Wounds of the Brain Lodgment of Foreign Bodies Hernia Cerebri Paracentesis Capitis CHAPTER IV. DISEASES OF THE SCALP AND CRANIUM. Erysipelas of the Scalp ..... Tumours of the Scalp ..... Pericranitis . . . . . . Affections of the (Jrauium .... 7 9 12 14 22 26 27 28 32 36 37 38 40 41 43 45 45 46 46 49 50 51 52 55 57 58 59 All! CONTENTS. CHAPTEE V. AFFECTIONS OF THE OEBIT, AKD ITS CONTENTS. I. Affections of the Oebit. Orbital Inflammation Wounds of the Orbit Tumours of the Orbit II. Affections of the Eyelids. Injuries Foreign Bodies Blepharitis . Ophthalmia Tarsi Hordeolum Encysted Tumours Hypertrophy of the Upper Eyelid Cancer of the Eyelids Closure of the Eyelids Lagophthalmos Ptosis Trichiasis and Distichiasis Entropion Ectropion Blepharoplastics III. Affections of the Lachkymal Apparatds Epiphora ....... Inflammatory Affections of the Lachrymal Sac Fistula Lachrymalis ..... Obstniction of the Nasal Duct .... Obliteration and Absence of the Nasal Duct Dacryolithes ...... Affections of the Lachrymal Gland Encanthis . . . . IV. Affections op the Eyeball. 1. Affections of the Conjunctiva. Simple Conjunctivitis Purulent Conjunctivitis Strumous Conjunctivitis Granular Conjunctiva Pterygium Pannus 2. Affections of the Coknea. Corneitis Abscess of the Cornea Ulcer of the Cornea Opacities of the Cornea Staphyloma of the Cornea Conical Cornea Over-distension of the Cornea PAGE 63 64 64 CONTENTS. IX 3. Affections op the Scleeotic Coat. Sclerotitis ..... Staphyloma of the Sclerotic . 4. Affections of the Choeoid Coat. Choroiditis ..... Muscse Volitantes .... 5. Affections of the Ibis. Iritis ..... Changes in the Pupil and Iris Occlusion of the Pupil Formation of Artificial Pupil 6. Affections of the Eetina. Eetinitis ..... Amam'osis ..... 7. Affections of the Cetstalline Lens and Capsule. Cataract ..... 8. Affections of the Humodes. PAGE 106 107 108 109 109 113 114 114 117 118 120 Hydrophthalmia Synchysis Oculi 127 127 Glaucoma 127 Ophthalmitis ... .... Wounds of the Eyeball . .... Tumours of the Eyeball ...... Extirpation of the Eyeball ...... Congenital Deficiency of the Eyeball .... Strabismus . . . . . . . 128 128 129 129 130 130 CHAPTER VI. AFFECTIONS OF THE NOSE. Fractiu'e of the Nasal Bones Lipoma of the Nose Nasal Polypus Rhinolithes Epistaxis .... The passing of Nasal Tubes Foreign Bodies in the Nostrils Congestion of the Schneiderian Membrane Abscess of the Septum Narium Ulcers of the Nostrils Ozaena .... Lupus .... Rhinoplasties Partial restoration of the Nose 134 134 136 140 140 142 142 143 144 144 144 145 146 149 CONTENTS. CHAPTEE VII. AFFECTIONS OF THE SUPERIOK MAXILLA. Collection of fluid in the Antrum Abscess of the Antrum Polypus of the Antrum Tumours of the Superior Maxilla Extirpation of the Superior Maxilla PAGE 152 153 154 154 155 CHAPTEK Vni. AFFECTIONS OF THE FACE. AVouncIs of the Face 159 Warts of the Face 159 Erysipelas of the Face 159 Spasm of the Face . 159 Neuralgia of the Face 160 Tumours of the Cheek 160 Sinus of the Cheek . 161 Salivary Fistula 161 Fracture of the Os Malse 162 CHAPTER IX. AFFECTIONS OF THE LIPS. Harelip 163 Ulcers of the Lips 165 Cancrum Oris 167 Cheiloplastics 168 CHAPTER X. AFFECTIONS OF THE PALATE. Congenital Deficiency Velosynthesis Ulcer and Exfoliation 169 169 172 CHAPTER XI. AFFECTIONS OF THE TEETH. Crowded Teeth Caries of the Teeth Toothache Extraction of Teeth Hemorrhage after Extraction Tartar on the Teeth Recession of the Gums Iniaries of the Teeth 173 174 174 175 176 176 176 177 CONTENTS. CHAPTEK XII. AFFECTIONS OF THE JAWS. Parulis Epulis . • • Tumours of the Lower Jaw Extirpation of the Lower Jaw Caries and Necrosis of the Lower Jaw Fracture of the Lower Jaw Dislocation of the Lower Jaw Anchylosis of the Jaw CHAPTER XIII. AFFECTIONS OF THE TONGUE. Glossitis Wounds of the Tongue Ulcers of the Tongue Hypertrophy of the Tongue Induration of the Tongue Erectile Tumour of the Tongue Removal of Portions of the Tongue Division of the Frsenum Linguae Ranula Tumours beneath the Tongue Salivary Concretions CHAPTEE XIV. AFFECTIONS OF THE UVULA AND TONSILS. Qidema of the Uvula Elongation of the Uvula Tonsillitis Abscess of the Tonsil Ulcers of the Tonsils Hypertrophy of the Tonsils Malignant Disease of the Tonsils CHAPTER XV. AFFECTIONS OF THE PHARYNX. Pharyngitis Pharyngeal Abscess Stricture of the Pharynx Spasm of the Pharjaix Paralysis of the Pharynx Sacculated Pharynx Tumours of the Pharynx Foreign Bodies in the Pharynx The passing of Instruments by the Pharynx PAGE 178 178 179 180 183 183 184 185 186 186 187 187 188 188 188 189 190 190 191 192 192 193 193 194 194 196 197 197 198 199 199 199 199 200 201 CONTENTS. CHAPTER XVI. AFFECTIONS OF THE (ESOPHAGUS. Stricture of the (Esophagus Foreign Bodies in the (Esophagus (Esophagotomy Palsy of the (Esophagus CHAPTEE XVII. AFFECTIONS OF THE EAR. PAGE 203 204 206 207 Foreign Bodies 208 Polypus of the Ear . 208 Otitis .... 209 Otorrhoea .... 210 Abscess of the Mastoid Cells 212 Otalgia .... 213 Deafness .... 213 Perforation of the Membrana Tynipani 216 Hemon-hage from the Ear 216 Hypertrophy of the Auricle 217 Otoplasties .... 217 Congenital Occlusion of the Meatus 217 CHAPTER XVm. AFFECTIONS OF THE NECK. Glandular Enlargement and Abscess .... 219 Hydrocele of the Xeck ...... 220 Tumours of the Neck ....... 220 Opening of the External Jugular Vein .... 221 Torticollis . . . . . . • 221 Wounds of the Throat ...... 223 Bronchotomy ....... 227 Foreign Bodies in the Windpipe ..... 227 Asphyxia ........ 232 Injuries of the Larjmx ...... 232 The accidental swallowing of boiling water, acids, or other irritant fluids 233 Spasm of the Glottis ...... 234 Laryngitis . . . . . . . 235 I. Acute Laryngitis ..... 235 a. Laryngitis Simplex ..... 235 b. Laryngitis (Edematosa . . . , . 235 c. Laryngitis Fibrinosa ..... 237 Diphtheritis, or Cynanche Membranacea 239 d. Laryngitis Purulenta . . . . . 240 II. Chronic Laiyngitis ...... 240 o. Thickening of Mucous Membrane 240 b. Follicular Disease of Larynx .... 241 c. Chronic (Edema Glottidis .... 241 d. Ulceration of the Larvnx .... 242 CONTENTS. XIU PAGE Warts of the Larynx ....... 244 Stricture of the Windpipe 245 Formation of Matter near the Larynx 246 Laryngotomy 248 Tracheotomy 248 Bronchocele or Goitre 251 Tumours over the Thyroid Gland 254 Enlargement of the Thyro-hyoid Bursa 255 Hernia Bronchalis 255 Disease of the Cervical Vertebrse 255 CHAPTER XrX. AFFECTIONS OF THE ARTERIES OF THE NECK AND SUPERIOR EXTREMITY. Deligation of the Carotid Deligation of the Arteria Anonyma Deligation of the Subclavian Deligation of the Axillary Deligation of the Humeral Deligation of the Arteries of the Forearm Wounds of the Palmar Arch 257 258 259 261 262 263 264 CHAPTEPv XX. AFFECTIONS AT THE BEND OF THE ARM. Venesection Accidents of Venesection Affections of the Bursa over the Olecranon 265 266 267 CHAPTER XXI. AFFECTIONS OF THE WRIST AND HAND. Ganglia, and Thecal Collections Paronychia . Onychia Onyxis Contraction of the Palmar Fascia Tumours of the Metacarpal Bones and Phalanges Other Diseases of the Metarcarpal Bones and Phalanges Hypertrophy of the Fingers Congenital Deformities of the Hand 268 268 270 271 271 272 273 274 274 CHAPTER XXIL DISEASES OF THE ARTICULATIONS OF THE SUPERIOR EXTREMITY. Disease of the Shoulder-Joint ...... 275 Resection of the Shoulder-Joint ...... 276 Resection of the Elbow-Joint ...... 276 Resection of the M''rist ....... 278 XIV CONTENTS. Fkactukes. Fracture Fracture Fracture Fracture Fracture Fracture Fracture Fracture Fracture Fracture Fracture Fracture Fracture Dislocations. CHAPTER XXIII. INJURIES OF THE SUPERIOR EXTREMITY. of the Clavicle of tlie Body of the Scapula of the Acromiou of the Coracoid Process of the Neck of the Scapula of the Neck of the Humerus of the Shaft of the Humerus of the Condyles of the Humerus of the Ulna of the Kadius of hoth Eadius and Ulna of the Metacarpal Bones of the Phalanges Dislocation of the Clavicle Displacement of the Angle of the Scapula Dislocation of the Humerus, at the Shoulder Dislocation of the Eadius and Ulna, at the Elbow Dislocation of the Ulna, at the Elbow Dislocation of the Eadius, at the Elbow Dislocation of the Wrist Dislocation of the Fingers Dislocation of the Thumb CHAPTER XXIV. INJURIES AND DISEASES OF THE SPINE. Concussion of the Spinal Cord Compression of the Spinal Cord Fracture of the Spine Dislocation of the Spine Lateral Curvature of the Spine Disease of the Bodies of the Vertebrse Lumbar and Psoas Abscess . Spina Bifida Malignant Disease of the Spine CHAPTER XXV. INJURIES AND DISEASES OF THE CHEST. Fracture of the Eibs Dislocation of the Eibs Fracture of the Sternum Cai-ies and Necrosis of the Eibs and Sternum Hernia of the Lungs or Pueumocele Wounds of the Chest Hsemato-Thorax Pneumo-Thorax Paracentesis Thoracis Wounds of the Heart CONTENTS. XV PAGE 314 316 317 318 319 CHAPTER XXVI. AFFECTIONS OF THE MAMMA AND MAMMILLA. Irritable Mamma Mammitis, Acute and Chronic Chronic Abscess Lacteal Tumour Hypertrophy Pendulous Breast Partial Hypertrophy Various Tumours of the Mamma Extirpation of the Mamma Affections of the Mammilla 320 320 321 322 322 322 323 323 325 326 CHAPTER XXVII. AFFECTIONS OF THE ABDOMEN. Abscess of the Abdominal Parietes Tumours of the Abdominal Parietes Bruise of the Abdomen Wounds of the Abdomen Artificial Anus Fsecal Fistula Pelvic Abscess Eetro-Uterine Sanguineous Tumours Ovarian Dropsy and Tumours Fibrous Tumours of the Uterus Gastrostomy Gastrotomy . Affections of the Diaphragm 327 328 328 329 331 338 333 334 335 342 344 344 345 CHAPTER XXVIII. Reducible Hernia Irreducible Hernia . Incarcerated Hernia Strangulated Hernia Oblique-inguinal Hernia Ventro-inguinal Hernia Femoral Hernia Umbilical Hernia The other Varieties of Hernia HERNIA. 349 352 353 353 365 368 368 371 372 XVI CONTENTS. CHAPTER XXIX. AFFECTIONS OF THE RECTUM. Abscess Exterior to tte Kectum Ee otitis Fistula in Ano Fissure and Ulcer of the Anus Hemorrhoids Polypus of the Eectum Prolapsus Ani Stricture of the Eectum Irritable Eectum Hemori'hage from the Eectum Injuries of the Eectum Foreign Bodies in the Eectum Imperforate Anus Artificial Anus PAGE 374 376 375 380 381 385 386 388 390 391 391 392 393 394 CHAPTEE XXX. CALCULOUS DISEASE. Urinary Calculi . . . Formation and Varieties of Calculi 397 410 Eenal Calculi Vesical Calculus 414 417 Treatment of Stone in the Bladder . 422 Lithotripsy .... Lithotomy . . • • Varieties in Lithotomy Palliation of Vesical Calculus Urethral Calculus Prostatic Calculus . Calculus in the Female 427 432 444 446 447 449 449 CHAPTER XXXI. AFFECTIONS OF THE BLADDER. Cystitis Irritable Bladder Hsematuria . Incontinence of Urine Eetention of Urine . Eetention of Urine in the Female Puncture of the Bladder Extravasation of Urine Injuries of the Bladder Tumours of the Bladder Displacement of the Bladder 451 453 455 457 459 465 465 467 469 470 471 CONTENTS. XVll CHAPTER XXXII. AFFECTIONS OF THE PROSTATE. Prostatitis ...■•■ Abscess of the Prostate . . . ■ Simple Enlargement of the Prostate Malignant Disease of tlie Prostate CHAPTER XXXm. THE VENEREAL DISEASE. Gonorrhoea ...-■• Gonorrhoea in the Female .... Syphilis ....•■ The Simple Venereal Ulcer .... The Ulcer with Elevated Edges, and its Results The Hunterian, or True Chancre The Phagedcenic and Sloughing Sores, and their Results Condyloma ....•• Buho ...... A General View of the Subject The Use of Mercury in Syphilis Syphilis in the Child .... Syphilis in the Female .... Pseudo-Sj'philis . . ■ ■ . CHAPTER XXXIV. AFFECTIONS OF THE URETHRA. Stricture . = . . • • Urinous Abscess . . ■ ■ Urinaiy Fistula ..... Laceration of the Urethra .... PAGE 472 472 473 476 477 486 487 489 492 493 496 500 502 504 509 515 515 516 517 530 532 533 CHAPTER XXXV. AFFECTIONS OF THE TESTICLE. Orchitis . . . Fungus of the Testicle Scrofulous Testicle . Tumours of the Testicle Irritable Testicle Atrophy of the Testicle Hydrocele Hydrocele of the Cord Hfematocele Cirsocele Tumours of the Cord Castration Impotence Spermatorrhcea 534 536 538 539 540 541 541 546 547 548 550 550 551 552 CONTENTS. CHAPTER XXXVI. AFFECTIONS OF THE SCKOTUM AND PENIS. Erysipelas of tlie Scrotum Elephantiasis of the Scrotum Chimney-Sweeper's Cancer Priapism Phymosis Paraphymosis Hypospadias Hyperspadias Imperforate Urethra Malignant Disease of the Penis Amputation of the Penis PAGK 554 554 556 556 557 559 560 560 561 561 562 CHAPTER XXXVII. AFFECTIONS OF THE FEMALE GENITAL ORGANS. Inflammation of the Vulva Abscess of the Vulva Thrombus of the Vulva Warty Excrescences of the Vulva Oozing Tumour of the Labium Pruritus of the Vulva Malignant Ulcer of External Parts Tumours of the Labia Hypertrophy of the Clitoris and Nymphfe Fleshy Excrescence in the Orifice of the Urethra Laceration of Perineum Vaginal Fistula Stricture of the Vagina Obliteration of the Vagina Imperforate Vagina or Hymen Foreign Bodies in the Vagina Prolapsus of the Vagina The Passing of the Female Catheter Plugging of the Vagina Leucorrhcea . Inversion of the Uterus Prolapsus of the Uterus Displacements of the Uterus Stricture of the Cervix Uteri LTterine Polypus Extirpation of the Cervix Uteri Malisrnant Disease of the Uterus 563 564 564 565 565 565 566 566 567 567 567 567 570 570 571 572 572 573 573 574 .577 578 581 582 583 586 586 CHAPTER XXXVIII. OPERATIONS ON THE BLOOB VESSELS OF THE LOWER EXTREMITY. Deligation of the Aorta . . . . . . .590 Deligation of the Uiacs ....... 591 CONTENTS. XIX Deligation of the Femorala ..•••■ Deligation of the Popliteal ...••• Deligation of the Tihials ..••■• Deligation of the Peroneal ..-••• CHAPTEK XXXIX. AFFECTIONS OF THE JOINTS OF THE LOWER EXTREMITY. Morhus Coxarius ....••• Eesection of the Hip-Joint . • • • • Change of Form in the Hip-Joint . . . • • Affections of the Knee and Ham . . . ■ • PAGE 594 597 598 600 601 608 609 610 CHAPTEE XL. INJURIES OF THE LOWER EXTREMITIES. Fractures. Fractures of the Pelvis Fractures of the Femur Fracture of the Patella Fractures of the Leg- Fractures at the Ankle Fractures of the Foot Dislocations. Dislocation of the Pelvis Dislocations of the Hip Dislocations of the Knee Dislocations of the Patella Dislocations of the Ankle Dislocations of the Tarsus Dislocation of the Metatarsus Dislocation of the Toes Suhluxations and Sprains of the Lower Extremity Lijuries of the Tendo Achillis and Gastrocnemius Muscle 612 613 620 621 624 624 624 625 632 633 634 636 638 638 638 639 CHAPTEE XLI. AFFECTIONS OF THE FOOT, Talipes ....•• Flat-foot ...... Podelkoma . . . . • Corns and Bunions . . . ■ ■ Onyxis and Onychia .... Exostosis of the Distal Phalanx of the Great Toe . Contraction of the Toes .... 641 645 646 646 648 648 648 CONTENTS. CHAPTER XLII. AMPUTATION. Amputations of the Superior Extremity. Amputation of the Fingers . Amputation of the Thumb Amputation of the Wrist Amputation of the Forearm . Amputation of the Elbow-Joint Amputation of the Arm Amputation of the Shoulder-Joint Amputation of the Scapula Amputations of the Lower Extremity. Amputation of the Toes Amputations of the Foot Kesection of the Ankle Amputation of the Ankle Amputation of the Leg Amputation of the Knee-joint Amputation of the Thigh Amputation of the Hip-joint . PAGE 655 658 659 660 661 662 662 664 664 665 666 667 668 671 671 672 Affections of Stumps 673 THE PRACTICE OF SURGERY. CHAPTER L OPERATIONS. It is a favourite phrase by which operations are stigmatized as the "opprobria of surgery." Nothing can be more unjust. Safely and expeditiously to remove parts which accident has rendered totally use- less, and which would prove highly injurious if longer attached to the body ; to take away diseased formations, or other noxious substances, and, at the expense of but brief suffering, to dispel torture which had rendered existence a burden for previous weeks, months, and years ; to accomplish such results, though it be by blood and suffering, is alike creditable to the operator and beneficial to the patient. It is not the operation — but the operation unseasonably, unnecessarily, unskilfully performed — that brings disgrace ; and to refrain from operating when we are loudly and plainly called upon to do so, would carry not only opprobrium to surgery, but guilt and shame to the surgeon. In former times, it is true, operations were the disgrace of our art. Knives, hot irons, screws, files, gimlets, gouges, hammers, and saws, were employed with cruel and ignorant recklessness. Of late years, however, every good surgeon has sought not only to simplify and diminish the number of instruments, but also to use them as seldom as possible. He does not hesitate to employ them, when his knowledge and experience inti- mate that they have become indispensable ; on the contrary, he will then probably be urgent in their application, knowing that an early wound may save much after-suffering. But, in the first place, he will exert all his skill and all his powers, by milder measures, so to counter- act injury and restrain disease, as to supel^sede the necessity of operat- 2 OPERATIONS. ing. To eifect this, is doubtless the true triumph of his profession ; and to this triumph he often attains. But he must be Utopian indeed who can seriously hope that the period will ever arrive, when opera- tions shall have altogether ceased to be required. Modern surgery, accordingly, while anxious to limit the necessities for operation, is not the less aware of its importance as a means of cure ; and has not only directed attention towards its improvement, but also extended its application, and with the happiest result, to diseases formerly without remedy. Many patients, for example, are now by the knife fi'eed from morbid growths and natural deficiencies, who were formerly left an unprotected prey to deformity and disease. A prominent cause of modern improvement in the art of operating, is an increased simplicity of the instruments, their arrangement, and use. On this subject, one who was pre-eminently distinguished among the operators of the present day, observes:* "Our armamentaria should contain simple and efficient instruments only; the springs, grooves, notches, and curves, seeming to be chiefly intended to com- pensate for want of tact and manual dexterity. The apparatus, though simple, ought to be in good order, and should always be placed within easy and convenient reach of the operator, so that he may be in a great measure independent of the lookers-on ; who, owing to anxiety or curiosity, hurry and agitation, are apt to hand any thing but what may at the instant be required. He will consider well what place he himself may most conveniently occupy during the operation ; and, having obtained proper assistants, he will make sure that they all understand what is expected of them. In short, before he ventures to begin, he will ascertain that every thing is arranged, and in proper order ; more particularly, that the cutting instruments have good points, that their edges are keen, and that the joints of forceps and scissors move freely and readily. The principle, too, on which the in- strument is made to cut should be well considered. Every knife is to be looked upon as a fine saw ; the teeth of some are set forwards, and these cut best from point to heel, as does a razor ; but the greater number are set in the opposite direction — for example, the common scalpel and bistoury — and act efficiently only in being drawn from heel to point. " The skin, and in many instances the subjacent parts, should be divided at once and completely, by a single incision made lightly and rapidly — the parts being placed in a state of tension by the fingers of the sm'geon or of an assistant — for the pain experienced is in propor- tion to the pressure and tardiness of movement in the instrument applied. Partial division of the skin, in tails left at each end of an incision, is also to be avoided ; for the pain of such a cut is imneces- * Ltston, Operativp Sdrgeiy. OPERATIONS. 3 sarily sevei'e ; and, besides, such wounds are not so available, as they would otherwise be, for the intended purpose of evacuating fluid, for permitting the extraction of foreign bodies, or for the dissection of morbid growths. Also, the pausing of a surgeon in the midst of a dissection, and the resort to fresh and more extensive incisions of the surface, is not only always awkward, but attended with additional and unnecessary pain to the patient. Every cutting instrument should be well balanced, and placed in a steady, smooth handle ; the point should either be in a line with the back, which ought then to be per- fectly straight, or both edge and back should be equally convex, with the point corresponding to the middle of the blade. " The form and size of the instrument ought always to be in pro- portion to the extent of the proposed incisions, as regards both their length and their depth : nothing can be imagined more cruel and re- prehensible, for example, than an attempt to remove the lower extre- mity of a full grown person with a common scalpel or dissecting knife. If an extensive incision is necessary, an instrument should be em- ployed possessing length of edge sufficient to separate the parts smoothly and quickly. Should the operator, on the contrary, be re- quired to cut on important parts — to perform a delicate dissection of the living tissues — he will choose a short-bladed instrument, with a handle rather long and well rounded ; and, after the supei'ficial inci- sions have been effected, he will hold it as he would a writing pen, lightly but firmly, so that he can turn the edge, and cut either towards or from himself, as occasion may require. A small well-made scalpel, with a good point, and less convexity than those usually employed, is the instrument best adapted for such a purpose. Grooved probes and directors should be used as little as possible. With a little practice, incisions may be made upon the most delicate parts without risk, one layer being cut after the other. And if any instrument is wanted to make the proceeding more safe — if the closely investing fasciae of a hernial tumour, for example, are to be cautiously raised — dissecting forceps will be found the most convenient instrument for elevation previous to incision. " In dividing the skin, the knife, whether a scalpel or a bistoury, is to be held and entered with the point and blade at right angles to the surface. It is carried with a decided movement down to the sub- cutaneous cellular tissue ; the blade is then inclined towards the part to be divided, and by a rapid and slightly sawing motion — as little pressure being applied as possible — division is effected to the desired extent. The incision is finished by withdrawing the knife in a posi- tion perpendicular to the surface, so as to divide the entire thickness of the skin, at the extremity as well as at the origin of the wound. For dexterously effecting such manipulations, the fingers must be edu- b2 4 OPERATIONS. cated ; and diligent practice in the dissecting-room will be found the best foundation for surgical dexterity, as it is for sound surgical knowledge : it is only when we ha^^e acquired dexterity on the dead subject that we can be justified in interfering with the living." By practice, the pupil will be enabled to use either hand almost equally well ; and none should neglect to attain this power — for an ambidex- trous surgeon possesses great advantages as an operator.* An ordinary degree of expertness is within the reach of any one, who will industriously seek for and improve the opportunities for its acquirement ; but yet a certain combination of natural qualifications is undoubtedly necessary to the attainment of pre-eminence in operative surgery ; a great operator in one respect resembling a great poet, — " nascitur, non fit." The importance of these natural gifts did not escape Celsus. " He must be young, or at most but middle-aged," says he, " and have a strong steady hand, never subject to tremble. He must be ambidextrous, and of a quick, clear sight. He must be bold, and so far void of pity that he may have in view only the cure of him vrhom he has taken in hand, and not, in compassion to cries, either make more haste than the case requires, or cut less than is necessary, but do all as if he were not moved by the shrieks of his patient." The coolness and courage thus inculcated are among the most valuable natural gifts of the surgeon ; and it would be well did every patient remember that they are equally important in himself, for on his steadiness and patience under suffering much of the celerity and success of an operation may sometimes depend. In the present day, however, the operator is much less dejDendent on his patient than he was wont to be; in the great majority of cases the latter being absolutely passive in his hands, because quietly re- cumbent under the influence of complete anaesthesia. The obtaining of such quietude and non-resistance, the abolition of pain, the mitiga- tion of shock, and various other advantages affecting both operator and patient, fi'om the judicious use of chloroform, have been already fully considered-l and on that subject it is not necessary again to enlarge. The necessity for an operation, in any case, having been cleai-ly established, our object is to perform it as safely and expeditiously as possible. The mere absence of protracted pain confiers a most impor- tant advantage on the reparative powers of the system ; and, so far, celerity is commendable, when chloroform is not employed. But it is a very common as Avell as dangerous error, to suppose that excellence is alwavs commensurate with the rapidity of performance. In the * Tlie making of woiinds, with a view to the promotion of their cure, has been already considered. — (Principles, p. 648). ■j- Principles of Siirgery, Appendix, p. loo, kc. OPERATIONS. O great majority of cases, haste is incompatible with safety ; while the latter is the paramount object in view. "Tuto et celeriter" is the operator's motto ; but the " tuto" precedes its accompaniment. And now, more than ever, as has already been stated (Principles, p. 776), haste and hurry are altogether inexcusable. The student, as an opera- tor, should learn to be rapid ; but rapid, because skilful ; and rapid only when safe. And, in some procedures, he will not fail to learn that attempted rapidity must ever prove injurious. Perhaps a more common, and still more serious error is — the imagining that operations constitute the greater and more important part of Practical Surgery. The student is very apt to be led away by the more garish and imposing parts of his profession, to the neglect of that which is in truth by much the more valuable ; and he may also forget that, in after life, he will be only occasionally called upon to perform the greater operations, while daily he must exert his general knowledge and skill, as well as his minor handicraft, to avert the necessity for the knife's employment. In the case of a diseased joint, for example, he is not at once to contemplate amputation or resection. Such procedure is the ultimatum, not the initiative of his art. Local depletion, rest, counter-irritation duly timed and conducted, pressure, splints, attention to the general health (Principles, p. 500), these — to some apparently a simpler, but in truth a far higher adaptation of knowledge — conspire, and often with success, not to mutilate the frame and endanger life, but to save both life and limb, at little or no cost of either pain or danger. Again, in the torturing complaint of stone in the bladder, it is doubtless a great matter to be able, by a speedy operation — severe, and perilous to life though it be — to free the patient from his misery. And the accomplished surgeon must be at all times competent to undertake fearlessly this hazardous procedure. But it is surely a higher exercise of a better skill, and both the means and the result will prove infinitely more creditable and satisfactory, if, by the internal use of simple remedies, and suitable attention to hygiene, the disease shall be in its very origin frustrated, pain and danger dispelled, and health and comfort restored — all without the infliction of a scratch, or the loss of one drop of blood. In the case of injury, too, the para- mount importance of general treatment will be found equally to obtain. The surgeon is ready, at a moment's warning, to amputate skilfully a crushed limb, which has obviously no chance of retaining its vitality, and which, if not speedily removed, must inevitably peril the whole frame's existence ; and when, by such severe operation, he suc- ceeds in averting the greater calamity, he has most just ground for self-gratulation, and may truly say that a good thing has been done by his art for suffering humanity. But when, in the case of an injury a shade less severe, there is a doubt whether or not the limb may be 6 OPERATIONS. enabled to resist tlie threatened gangrene ; when he hesitates not to give to his patient the benefit of that doubt ; when, by great patience, care, and skill, he arranges the mangled fragments in their proper place, re- tains them so by suitable apparatus, affording due support, and yet permitting no undue pressure, regulating the play of the general circu- lation, controlling the eiforts of the vis vitce — ^in short, averting both local and general disaster, and bringing the healthful action of repara- tion to complete, though it may be slowly, its valued process of cure ; and when ultimately a thorough and permanent success crowns such patient and anxious labours, surely the cause for self-gratulation is in- creased a hundred fold ; the surgeon may well say that a far better thing has been done by his art ; and the discerning public will not fail to award a higher and truer meed of praise. The advance of sui-gery will ever be found characterised by a cor- responding decrease of its operations, both in amount and in severity. The true object of our mission is not to cut, but to cure. See on this subject, John Bell's large Treatise on Surgery; and the various modern Avorks on Operative Surgery, more especially those of Listen, Fergusson, and Skey. CHAPTER 11. INJURIES OF THE SCALP. Bruise of the Scalp. The scalp is especially liable to severity of contusion. It is a part much exposed to external injury ; it is stretched over dense resist- ing bone ; it is possessed of very considerable vascularity ; and its arterial branches, being neither inactive nor minute, are apt to part with blood freely when torn. Hence, when external violence is applied, the higher results of contusion are very apt to follow (Princi- ples, p. 744). The integument may give way; causing a contused wound, of greater or less extent, whose margins will slough and sepa- rate, and which will not heal without considerable suppuration, and a corresponding amount of attendant inflammatory action. Or, the skin, at fii'st unbroken, may slough to a greater or less extent ; either imme- diately, from the direct effect of violent contusion ; or secondarily, by inflammation induced in a pai't whose vitality had been only lowered by the bruise, not annihilated. Or, the integuments remaining entire, blood is copiously extravasated from ruptured vessels; breaking up the areolar tissue, and producing a large fluctuating tumour — some- times forming rapidly, with tension of the skin, and much pain in the part. Or, subsequently to sanguineous infiltration, inflammatory action may be lighted up in the implicated texture ; inducing suppuration of an unhealthy kind, with a considerable amount of constitutional dis- turbance, and with a risk of the latter being unfavourably affected by the suppuration assuming the asthenic, diffuse, and infiltrating charac- ter (Principles, p. 228). The danger of such occurrences must be remembered in the prognosis. But the ordinary result of bruise, in this locality, is the formation of a bloody tumour ; blood escaping more or less freely from torn ves- sels, and accumulating in the part ; while room is made for its recep- tion, partly by disruption of texture, partly by that which remains entii'e being pushed aside and condensed. As already stated, the integument is tense or not, according to the I'apidity and amount of extravasation. At first, the indications by touch are uniform through- out the whole swelling, all the blood being as yet fluid ; and uniform fluctuation is more or less distinct, with elasticity. Soon, hoAvever, the blood in part assumes the solid form ; and then the characters of the O BRUISE OF THE SCALP. tumour change. At the circumference, there is a hard, resisting ring, more or less elevated, composed of coagulum. In the centre, the part is soft, }delding, fluctuating ; the extravasation there remaining fluid, consisting chiefly of serum, and situated immediately beneath the inte- gument. The clot occupies the margins. At this period, care is required in examination, lest a false diagnosis be arrived at. The finger, placed firmly on the centre, readily displaces the serous fluid, and may seem to penetrate to some depth ; v\^hile similar pressure, made at the margins, meets with hard, unyielding resistance — and that at a considerably higher level than had just been passed by the finger in pursuit of the retreating serum. The careless observer of such things is apt to imagine them undoubted indications of fracture, with depression, having occurred in the cranium ; supposing the hard ring to be the bone in its normal position, with an abrupt broken margin, beneath which a detached portion has been driven down. Attention to three or four circumstances, however, will suffice to undeceive. The symptoms of depressed cranium do not exist. Press firmly on the soft and yielding centre ; the subjacent bone will be reached, by displacement of the intervening fluid blood, and will be found fii'm. The hard rim of the swelling will be found on a higher level than the general calvarium ; and, besides, by a little firmness of manipulation, if such be deemed necessary, the clot can be displaced somewhat, leaving firm bone beneath. The treatment of such a bruise is conducted on the principles generally applicable to this description of injury (Principles, p. T-Ao). In certain situations — as directly over known branches of the temporal or occipital arteries — swelling may be in a great measure prevented, by moderate pressure being steadily maintained on the cardiac aspect of the implicated vessel ; and this indication may be further fulfilled, by continuous application of cold to the part, and its immediate vici- nity. When the tumour has formed, even tension will not warrant either puncture or incision ; for the admission of atmospheric influence to the extravasated blood, and infiltrated tissue, is likely to induce inflammatory action under very unfavourable circumstances. By fomentation rather — associated, if need be, with restraining pressure on the arterial branch — let accommodation be obtained for the escaped fluid by a yielding of the recipient texture ; ward off inflammation by general antiphlogistics ; and await the disappearance of swelling, gradual and tedious though it be, by the natural action of absorption. The fluid portion of the extravasation is taken up first ; the coagulum follows, more tardily. But if inflammatory action shall have occurred, and suppuration formed, free and du'ect incision must not be ^vithheld. By no other means can diffuse suppuration be prevented, and constitutional dis- order checked. At once lay the part freely open ; turn out the WOUNDS OF THE SCALP. 9 coagulum, and permit all fluids to escape. An unhealthy abscess remains for a time, but duly changes, contracts, and heals ; and the knife is not again required. But, delay incision ; and then the knife is called for, not merely in the bruised part, but in the parts adjacent, now the seat of a spreading asthenic inflammation, and in imminent danger of perishing thereby. The asthenic tendency, as formerly hinted, is probably owing to the bruise having lowered the vitality of the parts; so impairing their tolerance of inflammatory action. Constitutional management is not to be neglected. It is obviously of great importance to avert, or at least to moderate, the accession of an inflammatory process in the injured part. On this ground alone, rest and c|uietude, antiphlogistic regimen, and perhaps depletion, are expedient. But the necessity for recourse to such precautions becomes still more apparent, when it is remembered that the brain, in all cases of severe bruise of the scalp, must have suffered more or less by con- cussion, and has to be protected from the consequences. When all risk of inflammatory accession has passed, and swelling has not yet disappeared, absorption may be hastened by discutient measures. The part may be kept wet with a solution of the muriate of ammonia, or with a weak dilution in water of the tincture of arnica; afterwards friction may be used, and, if need be, pressure. Bloody tumours, of the foregoing nature, not unfrequently form on the presenting parts of the heads of children, newly born ; especially if the labour have been tedious, or the pains very violent.* Wounds of the Scalp. Simple incised ivoiinds of the scalp are apt to prove troublesome by bleeding. The arterial point or points are to be exposed, and secured by ligature. Pressure may, in some instances, succeed ; but, in general, it is decidedly inferior to the use of ligature ; being not only less certain as a hemostatic, but also liable to induce sloughing, or at least a troublesome ulceration in the compressed part. When neces- sary, therefore, the surgeon need not hesitate to extend the wound, to facilitate accurate deligation. When bleeding has been arrested, the wound is to be brought together, and retained in apposition ; but sutures are, if possible, to be avoided ; experience having shown that here they are especially liable to prove the exciting cause of erysipelas. * This afFectioa is designated by obstetricians Cephalhcematoma ; while simple bloody- infiltration of the presenting part of the scalp is termed the caput succedanevm. In the commonest form of Ceplialhasmatoma, the siibpericranial, the timiour becomes sur- rounded at the base by an osseous ring, and the pericranium, too, is sometimes the seat of osseous deposit, so as to be felt crackling over the contained blood. This blood disap- pearing, the ossified pericranium approaches the bone, and unites with its rough and bare surface, causing slight thickening of the bone at that pait. 10 WOUNDS OF THE SCALP. The subsequent management is such as is ordinarily adopted for securing adhesion (Principles, p. 635). One simple precaution should never be omitted at the commencement of the treatment ; namely, the shaving of the scalp, not only at the wounded part, but to some distance around. The retentive straps, and other dressings, are then more readily and securely applied ; the part is more certainly kept free from irritation ; coolness is more easily maintained ; and inspec- tion of the wound's progress is more complete. In contused and lacerated wounds, there is the same risk of unfavour- able inflammatory action as in bruise ; and this is, accordingly, to be guarded against. Very often, the wound is extensive, and irregular in form ; a portion of the scalp is detached from the subjacent bone, and hangs over, an unseemly flap. Formerly, it was the custom to cut away the pendulous portion ; it being considered incapable of Fig. 2. re-attachment. Now, it is invariably preserved, and carefully re- placed. It seldom sloughs, even in part. Equally seldom, however, Fig. 1. The Couvre-chef ; a handkerchief so aiTanged as to cover the head, with a view to retain dressing. The handkercliief having been folded into a triangular shape, the centre of the base is placed on the centre of the forehead, the body of the handkerchief covering the head, and the apex or corner hanging doAvn the neck. The two long ends, previously lying on the cheeks, are crossed beneath the occiput, covering " the apex or corner," and are brought forward and tied on the forehead. The handkerchief is then smoothed by pulling "the apex or corner," which is turned over the crossed "ends," and secured. — After Lonsdale. Lancet, No. 1417, p. 470. Fig. 2. A double-headed roller, applied so as to cover the head; making equable pressure on every point. The centre of the roller is placed low down on the forehead, and the two heads are carried back and made to cross low down beneath the occiput. One head is then brought over the vertex, while the other is carried horizontally round to lap its extremity; and this, turned up over the horizontal one, is carried back to the occiput, slightly overlapping the former vertical band. At the occiput, the heads are again crossed (the surgeon shifting hands), and a third turn is made on the other side of the vertical band, while a third horizontal round secures it as before. And this is con- tinued until the whole head has been imiformly invested. — After Lonsdale. WOUNDS OF THE SCALP. 11 will it unite at once by adhesion. It suppurates, granulates, and becomes slowly, yet fii-mly and satisfactorily, rejoined to the subjacent parts. When a congested and flabby state of the flap occurs, as often happens, during the suppuration, support by carefully applied ban- daging is highly expedient. For retaining dressings, and affording gentle support to the scalp, a common handkerchief may be applied, as in Fig. 1. But when direct, accurate, and considerable pressure is required, the double-headed roller is preferable, as in Fig. 2. For retaining dressings on any particular part of the head, the four-tailed bandage is often very useful, as in Fig. 3. Not unfrequently, the bone is rudely denuded of all its soft invest- ments ; as in heavy falls, when the head comes violently in contact with stone. The pericranium is rubbed off, and the bone is not only wholly exposed, but roughened in its own texture. In such cases, we are not to refrain from re-adjusting the soft parts, in the belief that exfoliation must necessarily ensue, and that a patent condition of the wound is conse- quently to be desired. Many bones thus cir- cumstanced recover entirely. They may, for a day or two, become white and dry on their mere surface, as if undergoing necrosis there ; yet it is by no means unusual — when such necrosis is not favoured by the treatment em- ployed — to find this dry bone revive, be- coming vascular, brown, and exhalent, as before, and in due time contributing its quota to the general process of reparation. Should inflammation supervene, and advance to sup- Fig-. 3. puration, either in the limited or in the diffuse form, early incision is demanded ; in the one case, to evacuate pus, and prevent accu- mulation ; in the other, to limit its formation, and prevent infiltra- tion. When the areolar tissue beneath the occipito-frontalis' expansion is implicated in the latter event, incision is required to be especially early and free ; not only to avert destruction to texture, but also to prevent, or moderate, implication of the all-important cranial contents. These, indeed, must be duly regarded, throughout the whole period of treatment, as in simple contusion (p. 9.) Punctured wounds of the scalp, usually oblique and penetrating, are always important ; being very apt to be followed by severe Fig. 3. The four-tailed bandage ; of use in retaining dressings oo any particular part of the head. A piece of cloth split at either end : the central unsplit portion placed on the dressing. The two posterior ends secured below the chin ; the two anterior ends, ove:- lapping these, cross at the occiput, and are also secured below the chin. — After Lonsdale. 12 WOUNDS OP THE TEMPORAL ARTERY. inflammatory action ; and at an early period, and on this account, demanding incision. As a general rule, it may be stated that inflam- matory action in the scalp must always be treated with great activity. First, because the textures are unfavourable for safe advancement of the process ; they are vascular, tense, unyielding, fibrous ; the action is apt to be acute ; the exudation is copious and rapid, accom- modation afforded by the recipient texture is insufficient, tension ensues, and, as usual, aggravation follows thereon ; supj)uration is speedy, and apt to be diffuse ; and the pus tends to burrow rapidly, and in all re- spects destructively, beneath the fibrous structures. Secondly, the part affected is in close and dangerous proximity to the cranial contents ; and these are apt to be involved in a secondary, but not less important, inflammatory process. Wounds of the Temiwral Artery. Arteriotomy. — Under certain circumstances it is deemed advisable to abstract blood, with a remedial object in view, from an artery, and from one situate in the upper part of the body. The anterior branch of the temporal artery is usually selected. Being quite subcutaneous, it is of easy access ; and being also placed immediately over resisting bone, it is favourably situated for hemostatic purposes. A suitable part of the vessel having been fixed upon, it is steadied by the fingers of the left hand, while a lancet, moved by those of the right, is made to perforate the arterial tube, in an obliquely transverse direction. The entrance and exit of the lancet are managed so as to make the wound of the integument considerably larger than that in the arterial coats ; in order that there may be no obstruction to the free escape of blood. A section of the wound, in fact, should resemble that of a cone ; the truncated apex corresj)onding to the aperture in the vessel, the base to that in the integument. When a sufficiency of blood has flowed, it is well to reintroduce the lancet, and to move its point so as to effect complete sec- tion of the vessel ; in order that contraction and retraction of each orifice may take place, and natural hemostatics may so be favoured (Principles, p. 347.) A graduated rig 4 compress is accurately applied over the wound, and securely retained by a bandage. The dressing should not be disturbed for several days. If blood do not escape readily enough, a cupping-glass should be Fig. 4. Compress applied to the temporal artery, after arteriotomy. WOUNDS OF THE TEMPORAL ARTERY. 13 applied; care being taken to raise the rim gently over the artery on its cardiac aspect ; otherwise the pressure must inevitably arrest the Sow. And this is the only mode of cupping which can be considered warrantable in this situation. Use of the ordinary scarificator here leaves a very unseemly scar, especially in the female. The lancet's puncture in arteriotomy is, on the contrary, slight, and its scar scarcely appreciable ; and, at the same time, it is to be remembered, that from this one puncture blood will flow much more freely than from all the twelve incisions of the ordinary instrument. In accidental wounds of the temporal artery, deligation is generally preferable to pressure, as already stated. In the case of a mere branch, it may be sufficient to tie the cardiac orifice. But when the main trunk is implicated, the distal orifice must also be secured, other- wise recurrence of hemorrhage is almost certain (Principles, p. 362). Unpleasant consequences sometimes follow wounds of the temporal artery, whether accidental or intended. False aneurism may form. This, usually, has attained to but a small size, ere the patient's atten- tion is arrested by it, and the surgeon's aid sought. If deligation be practised at a distance, it is necessary to secure the vessel on each aspect of the tumour ; otherwise collateral circulation may prove too free for due completion of the cure ; and, on the distal aspect, the vessel is not likely to be discovered without much difficulty. In the majority of cases, it is sufficient to put in force the ordinary treatment for recent false aneurism ; to cut through the tumour, turn out the clot, and secure the vessel by ligature above and below the wounded point (Principles, p. 594). In those cases to which such procedure may seem inapplicable, ablation of the small swelling, by two elliptical in- cisions, may be had recourse to ; securing each of the bleeding points in the ordinary way, and bringing the wound together for adhesion. On removing the compress, after arteriotomy, the wound may be found to have degenerated into ulcer. The ulceration spreads, the vessel is opened, hemorrhage occurs ; and, by repetition, the loss of blood becomes hazardous. Pressure, reapplied, may temporarily arrest the flow ; but necessarily favours the advance of ulceration, and so renders return of the bleeding certain, on removal or change of the dressing. It is better to abstain from pressure ; and to tie the artery on each aspect of the sore ; either by regular dissection in the line of the vessel ; or, when swelling and condensation of texture render that difficult, by transverse wounds — securing the bleeding points by forceps in the ordinary way. Or, if the ulcer be minute, ablation of the changed part may be efi'ected, as for false aneurism. In connexion with this Chapter, confjiilt the ordinary authorities in Systematic Siu'gery. 14 CHAPTEE III. INJURIES OF THE CRANIUM; AND THEIR CONSEQUENCES. Br external violence the cranium may be shaken, fissured, or frac- tured with comminution. In any case, more or less injury is at the same time sustained by the cranial contents. The brain and its investing membranes may be torn, and blood may become extra- vasated. The inflammatory process may be kindled, pei'illing life by exudation, suppm-ation, or chronic change of structure. Or the brain may be merely shaken, and temporarily impaired in its function. Concussion of the Brain. In strict acceptation, this term denotes a mere shaking of the organ ; without any appreciable lesion of structure, and consequent escape of blood, immediate or secondary. Function is impaired, often most seriously ; usually, it is after a time restoi'ed, more or less com- pletely ; yet not without much insk of an inflammatory process inter- vening, in either the brain or its membranes, to modify, protract, or prevent the fortunate issue. Under the impulse of a blow or fall, the brain must sustain more or less vibration, if the cranium remain entire. It is "a pulpy organ, which exactly fills a nearly spherical bony cavity, whose parietes are elastic in a considerable though very variable degree ; and if these parietes sustain any sudden change of shape, their contents must sustain a corresponding amount of compression. As any alteration in the shape of a spherical cavity must lessen its capacity, whenever any external force impinges on the cranium with sufficient violence, it must be flattened at the point of impact, and ex- panded in some opposite direction ; but these changes are, in virtue of the very cause whence they originate, of but momentaiy duration ; the point primarily flattened by the compressing force immediately resumes its original shape, which is necessarily followed by a corresponding return of the expanded portion of the cranium to its previous dimen- sions. These oscillations may occur several times in rapid succession, their number and extent depending on the elasticity of the cranium, and on the amount and direction of the force applied. In concussion. CONCUSSION. 15 then, the entire brain sustains a series of vibrations and momentary compressions, varying in number and amount in every imaginable degree in different cases."* The force may be applied either directly or indirectly ; the cranium may be the part struck ; or the patient, alighting on his feet or nates, may have concussion conveyed to the calvarium through the spinal column. This vibration of the brain, with disturbance of its circulation, and perhaps temporary condensation of its substance, is attended vv^ith symptoms of marked disorder in the organ's functions. Sensation, mental power, and voluntary motion are more or less disturbed ; and a depressing effect is exerted on the general circulation. The patient, stunned, and more or less insensible, lies motionless, pale, and cold. Insensibility, however, after a time, is found not to be complete except in extreme cases ; by loud calling, monosyllabic acknowledgment may be obtained ; by pinching the skin, or otherwise causing pain, some evidence is usually given of pain being felt, and an attempt is made by the patient to move the part from the supposed source of injury. Power of motion is depressed and latent, not destroyed ; and the voluntary muscles, though relaxed, are not truly paralyzed. Respira- tion is feeble, slow, and sighing. The pulse is rapid, small, and flut- tering ; and especially weak at the extremities. The pupils are usually contracted, and insensible to light ; but their state is variable ; some- times one is contracted, while the other is either natural or dilated. Squinting is not uncommon. Vomiting is often present; rather of favourable portent than otherwise, — premonitory of recovery from this state of depression. The patient becomes more easily aroused ; and responds more dis- tinctly to interrogation, either by words or by gesture. Respiration becomes more full and composed. The pulse is less frequent, and more distinct ; but, at this time, the circulation is peculiarly iri'i table, the mere effort of change of posture usually inducing marked increase in the frequency of the heart's action — or even syncope. Pain now is more felt by the patient ; and is referred to the head. Vomiting may continue. The retui'ning mental power is apt to prove errant and deceptive. Not unfrequently, a state resembling somnambulism continues for some hours during the transition to recovery. Motion, sensation, some of the special senses, and much of mental power, seem to be restored, yet the patient remains as if in a deep sleep. He may rise, wash, shave, dress, perambulate ; all the while unconscious. But reaction seldom stops at mere restoration of the normal state ; * British and Foreic/n Medical Review, No. 29, p. 163. See also M. Gama's Experi- ments on this suVijoot. Traite des Plmes dc Tefe, p. 101. 16 GGNCUSSION. the boundary of health is crossed, in an opposite dii"ection. Reaction proves excessive ; and symptoms ai*e evinced of an inflammatory pro- cess begun in the injured part — the brain, its membranes, or both. The pulse becomes full and hard ; the skin hot and dry ; the face flushed ; the eyes bloodshot ; the pupils more contracted and insensible to light. Pain, great and increasing, is complained of in the head ; restlessness is more and more marked ; the mind, which may have in great measure recovered, again loses its healthful balance ; delirium supervenes ; and so the symptoms advance. Resolution may occur. Or effusion accumulates ; coma is induced ; and the issue may be fatal. Practically, concussion may be divided into three stages. 1. De- pression; marked by insensibility, and feeble circulation. This may be intense and enduring ; proving fatal, and that speedily — the patient quite unconscious throughout. 2. Reaction. The symptoms of depression pass off; circulation is restored; and cerebral function re- turns. In the slighter examples of injury, there may be no further progress made untowardly. Reaction does not prove excessive. The head is confused and giddy for a day or two ; but the pulse remains quiet ; and, within a few days more, all has passed off in safety. 3. Excessive reaction. The inflammatory symptoms set in, and a state opposite to that of depression is established ; all is excitement and perversion, both in the general circulation, and in the functions of the brain ; and life is brought into imminent jeopardy, by phrenitis, or meningitis, and by proportionate inflammatory fever. Treatment. — This necessarily varies according to the severity of the injury and the intensity of its results; but more especially is it diffe- rent at different periods of the case. In the first stage — that of de- pression — if we act at all, it will be with the view of favouring at least the commencement of reaction. An opposite procedure were plainly at variance with common sense ; but, unfortunately, it is found to be not equally at variance wdth common practice. A man stunned by a blow or fall, and labouring under simple concussion, is often bled on the instant — or an attempt, at least, is made to bleed him — by the rash and thoughtless practitioner. In other words, a fresh and power- ful agent of depression is exerted on the general circulation, when such depression is already great, and has probably brought life to the very verge of extinction. If blood flow from the wound in venesec- tion, under such circumstances, perhaps life is lost ; at all events, the direct untoward result of the injury is aggravated; and the case is ren- dered both more urgent and more protracted than it otherwise would have been. The lancet is certainly not to be used, during this stage. In many cases we should be little more than passive spectators. The depression is not extreme, nor giving indications of long continuance ; signs of reaction^^ on the contrary, are slowly manifesting themselves ; TREATMENT OF CONCUSSION. 17 and we await the natural progress of events. Not altogether idle, hoAvever. Although not engaged in active treatment, we are pre- pared for activity, when circumstances shall call for our interference. The patient is stripped and put to bed. His whole body is carefully examined. He cannot tell us whether or not other parts have been injured, besides the head. Besides an anxious investigation as to the existence or not of other internal injuries (Principles, p. 101), we must ourselves carefully examine each joint and bone ; detecting fracture or dislocation, and having it immediately rectified, Avhile circumstances are all so peculiarly favourable for the required manipulations (Prin- ciples, p. 732). On recovering his senses, he has not to complain of a painful and distorted limb, now for the first time observed ; but finds Avhat was distorted duly replaced, and already some way advanced in the process of repair. The head is carefully shaved ; and is placed on pillows, considerably elevated. If wound of the scalp exist, hemorrhage is arrested, if need be ; and approximation is efifected in the ordinary' way. Should the depression prove great and continued, plainly indicat- ing risk to life by syncope, something moi'e is required of the practi- tioner. He endeavours gently to originate reaction. Warmth is applied to the surface ; and friction is used over the chest and abdomen. If this be not sufficient to turn the course of the symptoms, a stimu- lant enema of tui'pentine is given. If still the progress be downwards, an attempt is made to convey to the stomach some warm tea, or soup, or wine and water ; and stimulants are held to the nostrils, for insufila- tion. These last, however, are always to be warily managed, so as to avoid risk, of injury by their too free application to a patient at the time insensible of pain ; and the giving of fluids by the mouth, too, must be effected with care, lest they pass into the air-passages, and produce asphyxia. So soon as reaction has begun, we cease from our auxiliary efforts ; and again become passive onlookers ; completion of the second stage being always safest in the hands of Nature. If stimulants are used at all internally, it must be only in urgent circumstances, and with much caution ; begun with a sparing hand, and repeated warily. And, in general, we are well content to do nothing, in this way ; knowing that moderate depression is a favour- able occurrence; and that premature cessation of it, especially when followed by abrupt and marked reaction, is apt to prove most injurious. For, at first, we can never be certain that the case is one of pure con- cussion. There may be a lesion, by laceration, of the brain's substance. During the existence of concussion's first stage, the case remains — practically — one of concussion still ; circulation is weak in the torn part, as elsewhere ; extravasation of blood does not take place from the open vessels ; valuable opportunity is afforded for. theii- closure by c 18 TREATMENT OP CONCUSSION. natural hemostatics ; and Avhen at last — it may be after some hom-s — the natural reaction slowly sets in, and circulation is proportionately restored, still no escape of blood occurs ; and the symptoms may re- main those of mere concussion to the last. Whereas, had the period of depression been abridged, and reaction rendered not on\j prema- ture, but also abrupt and active, circulation would have been restored in the injui-ed part ere the open vessels had closed, blood would have been extravasated, and compression of the brain must have ensued. Or, even if no lesion of the brain have occurred, the case being in all re- spects one of mere concussion, still premature and excessive reaction is most hazardous ; by tending not only to kindle an inflammatory process in the brain or its membranes, but also to secure its being of an aggravated and perhaps uncontrollable character. Thus, then, it is plain that two great errors may be committed in the treatment of the first stage of concussion. Blood may be drawn prematurely ; lowering the vital powers still further ; unnecessarily, untowardly, perhaps fatally. Or stimuli may be imprudently em- ployed ; too soon, and too freely ; hurrying on reaction ; and endanger- ing life, either by compression in consequence of extravasation of blood, or by an inflammatory process of an urgent and untoward character. Let both errors be studiously avoided ; for each is of a most grave nature. While we take care that the depression does not proceed too far, let us beware of doing anything to effect either a pre- mature or an excessive reaction. And Avhen we attempt to fulfil the former indication, let us beware both of inducing asphyxia, by the mis- conducting of ingesta ; and of causing troublesome excoriation and subsequent inflammation in susceptible and important parts, by the spilling of irritant stimuli upon them. In the second stage, while reaction is in progress, we have still either hand ready — to favour, or to repress — yet very often find it prudent to abstain from active interference ; leaving the task, almost entirely, in the more skilful and competent hands of Nature. We content ourselves with carefully excluding all source of excitement, either to the general circulation, or to the brain's function — more especially light and noise ; and cold is continuously applied to the shaven scalp, by wetted cloths, or by evaporating lotions. Such treat- ment is not calculated either to thwart or to prevent the normal amount and form of reaction ; while, at the same time, it leans to the side of repression sufficiently, to guard against the excess of reaction which not improbably is speedily to threaten. It may happen that though the reactive efibrt is Avell begun, it ceases, flags, and retrogrades ; a period of depression again sets in ; and this relapse looks more formidable than did the first efi"ect of the injury. Under such cii'cumstances we are no longer inactive specta- TREATMENT OF CONCUSSION. 19 tors ; but commence a cautious system of stimulation, as formei'ly ex- plained. If, on the other hand — as more frequently happens — reaction threatens to prove both " fast and furious," we interpose our repressing agency. We empty the bowels by the exhibition of an aperient enema ; and aid this, by the more leisurely working of an internal purge. Seclusion from light and noise, elevation of the head, and continuous application of cold, are most carefully maintained. And if still the action is sthenic and in excess, we prepare to obtain a seda- tive result by blood-letting. In the third stage, when reaction is plainly in excess, and inflam- matory symptoms are fast developing themselves, the treatment is decidedly and actively antiphlogistic. Quietude and seclusion are more strictly enforced than ever ; it being all important to obtain rest of the oi'gan affected, as completely as circumstances will permit. Blood is taken from both the system and the part ; by venesection or arteriotomy, and by leeching. And such depletion is repeated as oft and as freely as circumstances seem to demand. Purgatives are actively administered ; and it is well to remember that in inflamma- tory affections of the cranial contents, especially powerful doses are re- quired. Antimony, or aconite, may be given. But when the substance of the brain is plainly indicated as the site of the crescent inflammatory process, we do not hesitate to place the system rapidly under the in- fluence of mercury ; having full warrant for this in the delicacy of structure and importance of function which are involved (Principles p. 167). Calomel is given in small doses, frequently repeated ; and, usually, it is neither necessaiy nor expedient to combine it with opium. Not necessary, for there is a sluggishness of action in the in- testinal canal, engendered by the disease, and consequently but little risk of the mineral proving purgative ; and not expedient, lest we endanger the production of narcotism and consequent determination of blood to the part affected. Sometimes delirium, with convulsive movements, continues after full bleeding, and is aggravated by its further repetition. In such circumstances, the pulse and other characteristics of nervous reaction (Principles, p. 158) will be found; and relief will follow the exhibi- tion of opium, guarded by antimony (Principles, p. 171). In the antiphlogistic management of advanced cases of injury of the head, the occurrence of convulsions is by no means to be considered as suffi- cient warrant for continuance and ■pushing of the antiphlogistics — espe- cially blood-letting ; for, often, they are found to be of an asthenic, or purely nervous character ; aggravated by antiphlogistics, alleviated and checked by amendment of diet, and cautious exhibition of opium. The brain and membranes, having recovered from the inflamma- tory process, remain long weak, and require still a watchful and c2 20 TREATMENT OF CONCUSSION. patient care. Light and noise must not be soon or abruptly admitted. Conversation, reading, thouglit, or other exercise of the mental powers must be discouraged. Even the functions of special sense should be held in comparative abeyance. The head is kept shaved, elevated, and cool. Food is sparing and non-stimulant. The bowels are kept freely moving. If resolution do not occur, exudation and effusion take place ; compression of the brain supervenes on the concussion ; coma is formed ; and the case becomes one of the utmost danger. There is now no tolerance of active antiphlogistics. The lancet is laid aside. Purging is cautiously continued. And the main reliance is placed in powerful counter-irritation. Even without effusion, recovery from concussion is often tedious, and imperfect. The eye remains wild and vacant in expression ; memory is impaired ; conversation is childish, and often incoherent ; sometimes the demeanour is timid and gentle ; sometimes the patient is very irascible, and apt to be moved to much violence. In short, there remains an imbecility of the whole mental powers. In other cases, certain only of the mental faculties thus suffer; and of these, memory is the one most frequently affected. Sometimes the recollec- tion of all past events is either lost or obscured ; sometimes a portion of these remain tolerably vivid and distinct. Sometimes the past is vmtouched, and the present only affected. Extraordinary results have occurred, in regard to languages ; when the knowledge of a plurality of these has been previously possessed by the patient. Certain of them have gone quite from him ; and on recovery from the first effects of concussion, he has spoken with fluency, and continued to do so, in a tongue to which he had been long a stranger.* Again, intellect may remain clear and entire, while special sense sustains an injury. Hearing and smell may be lost, impaired, or perverted. Weakness of sight, with or without squinting, is no un- common result. Such remote and chronic consequences of concussion may prove but temporary ; or they may remain for life. The affections of the mind are especially liable to prove obstinate; and ought always to receive a very guarded prognosis. The treatment found most suitable consists in a mild alterative mercurial coui'se, with moderate and long- continued counter-irritation ; an uniformly lax state of the bowels, and occasional purging ; a most carefully regulated diet ; restriction to moderate exercise of both body and mind, but more especially of the latter ; avoidance of all sources of mental excitement, especially of such as are known to be besetting to the patient ; the use of the cold shower-bath ; and residence in genial exposure and climate. * Sir A. Cooper's Lectures, p. 112. CONSEQUENCES OF CONCUSSION. 21 Many patients recover, to all appearance, pei-fectly from concus- sion ; and yet are subject to frequent and unpleasant remembrances of the injury. On attempting any usual exertion, either of mind or body, or on the occurrence of any otherwise trifling stomachic or intes- tinal disorder, intense headach supervenes, Avith some fever, and per- haps attended with disorder of sight or other special sense. Or, by even slight indulgence in wine, they are liable to undergo great mental excitement, little short of temporary delirium or insanity. Such persons, it is obvious, ought to pay great attention to regimen, to the state of the bowels, and to the avoidance of all circumstances likely to excite, or cause determination to the cranial contents. Indeed, it may be laid down as a safe general rule, that all who have once sustained any considerable concussion of the brain, must ever after regard their head as a weak point, which requires constant prophylactic care. And, for some time immediately succeeding the infliction of the injury, this truth should be more especially forced upon them. For, many most serious cerebral disorders have been the result of premature return to bodily exercise, mental occupation, or pleasures of the table, after a concussion thought at the time to be but very trivial. A very insidious, and consequently dangerous, affection of the brain is apt to ensue as a remote consequence of concussion, more especially in young people. A slight injury of the head has been re- ceived, by a blow or fall ; and its immediate effects seem to be satis- factorily recovered from. Weeks — or, it may be, months — afterwards, the i^atient is out of health ; he loses colour, appetite, flesh, and energy both of body and mind; he is subject to headach, and occasionally complains of giddiness ; the skin is dry and feverish ; the secretions are altered ; the eye has an unwonted expression, rather of languor than of excitement ; the stomach is irritable, and occasionally rejects food ; sleep is disturbed and unrefreshing. The ordinary remedies, directed to stomach, skin, and bowels, fail to relieve. The general ailment continues slowly to advance. By and by, the head symptoms assume a pre-eminence ; and at no distant period from that event, symptoms of pressure on the brain become plainly manifest. Most probably the issue is fatal. An inflammatory pi*ocess has been slowly advancing in the cerebral substance ; suppuration has at length occurred ; and, in consequence, it is not unlikely that an acute acces- sion has supervened on the previous chronic change of structure. It is very obvious how the inobservant practitioner must be apt to mistake the true nature of such cases. The head is not suspected of originating the evil, until towards the close ; when treatment, how- ever suitable, can prove of but little avail. Diet is attended to, laxa- tives are given, then alteratives ; and then, probably, tonics ; all with- out relief ; the last class of remedies inevitably inducing marked aggra- 22 COMPRESSION OF THE BRAIN. vation of the disorder. It may be that the treatment is from the first of a tonic nature, and blindly persevered in, notwithstanding its mani- fest failure ; the result is consequently still more untoward ; and coma is rendered more early, more urgent, and more hopeless, than it other- wise might have been. The treatment, on the contrary, should be such as to counteract a chronic inflammatory process ; conducted with such care and skill as the importance of the texture implicated so im- peratively demands. Leeches are applied to the temples or occiput ; and ai'e repeated, perhaps, once and again. The head is shaved, and moderate counter-irritation is patiently maintained. A mild course of mercury is given. The intestinal and other excretions are attended to. Diet is sparing, and most carefully regulated. All excitement of both body and mind is avoided. And such treatment must be duly maintained, notwithstanding the patient, or other inexperienced ob- servers, may not scruple to say that its rigour is quite disproportionate to the importance of the case. The sui'geon knows the insidious and covert nature of the evil with which he is called upon to cope ; and is not deceived by appearances. His main difficulty may lie in enforcing the measures which he knows to be essential. It w^ere well that patients were in general as fully convinced, as are the members of the medical profession, of the truthfulness of the axiom, that '' no injury of the head is too slight to be despised ;" and that Avhenever any serious concussion has been sustained, the greatest prophylactic caution is expedient, long after the infliction of the injury.* It is needless to expose the unsuitableness of the operation of tre- phining, in all cases of simple concussion. Compression of the Brain. It is unnecessaiy here to consider the question, Whether the substance of the brain is capable of condensation by pressure or not. We know that pressure applied to it, according to its suddenness and intensity of application, produces derangement of the functions of that important texture ; and the consequent train of symptoms, A-arying in degree, are usually termed those of " compressed brain," or of " com- pression." In concussion, tlie whole brain is afiected ; in compression, a por- tion only may be acted on. In the one case, the cause of disorder is of temporary application ; in the other, it is of some duration. The * " It will in general be found very difficult to persuade a person who has had what may be called oul}' a knock on the pate, to submit to discipline, especially if he find him- self tolerably well. He will be inclined to thinlc that the surgeon is either uimecessarily apprehensive, or guilty of a much worse fault ; and yet, in many instances, the timely use or the neglect of this shigle remedy (blood-letting) niiikes all the difference between safety and fatality^'" — Pott, i. 47. COMPEESSION or THE BEAIX. 23 symptoms, tlierefore, may naturally be expected to difier. In concus- sion, the depressing eifect on the heart and general circulation is immediate and prominent ; and the patient lies pale, cold, and pulse- less. In compression — the injury being usually limited to but a part of the brain — the heart's action may, at first, be little if at all affected ; the skin, consequently, may retain its natural warmth and hue, and the pulse its fulness. In concussion, immediately fatal, death takes place by syncope. In compression, the fatal result is due to coma. The essential peculiarity of the latter is, " that respiration takes place imperfectly, and ultimately is suspended, probably by reason of the defect of sensation. The circulation, and sometimes the auimal heat, not only continue entire up to the moment when the last breath is drawn, but even survive the respiration for a short time; during which time, of course, venous blood moves along the arteries; but the venous blood, according to the general law established in the physiology of respiration, soon ceases to make its way through the capillaries of the lungs, and the circulation is therefore soon brought to a stand We know from physiology, that the part of the nervous system which must be specially affected in these cases, when the failure of respiration is the immediate cause of death, must be at the sides of the medulla oblongata ; but the part visibly injured is often considerably distant from this."''^ Pressure may be made on the brain in various Avays. By extra- vasation of blood ; in its substance, on its surface, or between the membranes. By formation and accumulation of pus, or other products of the inflammatory process ; also, either cerebral or intra-mem- branous. By fracture of the cranium, with depression of the broken part or parts. By lodgment of foreign bodies in the brain, or on its surface. By the formation of adventitious gi'owth, in connexion with either the cranium or its contents ; exostosis, osteosarcoma, or osteo- cephaloma of the cranium ; tubercular, or other tumour of the brain or its membranes. It is probable that compression is also occasioned by mere congestion ; a state of over-distension of the blood-vessels, with advancing serous effusion. It is highly important to bear in remembrance, that symptoms pre- cisely similar to those ordinarily produced by compression of tlie brain may be, and frequently are, induced by other circumstances, when no apparent pressure is in operation. Certain poisons, for example, have this effect. But, what is of more consequence, in a surgical point of view, such a train of symptoms almost invariably attends on disorga- nization of the cerebral tissue by inflammatory action ; and that, too, when the inflammatory products seem to be of such a nature as not to occasion pressure in any great degree. * Alison, ( )uHine« of rathology, p. s. 24 COMPRESSION OF THE BEAIN, In surgery, we have chiefly to do with those examples which are induced by depressed fracture, extravasation of blood, inflammatory exudation, and suppuration. The most characteristic symptoms are found affecting the respira- tion and the pulse. Breathing is slow, labouring, and loudly stertorous; in concussion it was gentle and sighing. A peculiar Avhiffing, by the mouth, is not unfrequent, during expiration — as is observed in smoking, or in the ordinary repose of heavy sleepers ; it is a symptom of un- toward portent. The pulse is distinct and full, usually slow, but often at first not much altered as to frequency — not unfrequently inter- mittent ; in concussion it was from the first rapid, low, and feeble, perhaps wholly imperceptible. Loss of consciousness is more complete than in concussion ; the patient cannot be roused by any movement or noise. Loss of sensation is more complete ; he may be pinched, or burnt, without in any way evincing perception of pain. Special sense is wholly dormant ; he neither sees, nor hears, nor smells ; at least no result follows the application of stimuli to the eye, ear, or nose. Power of motion is wholly gone ; the voluntary muscles are relaxed, flabby, and powerless; the limbs lie loose and incapable of motion. The eye is fixed ; its pupils are dilated, and insensible to light. The skin is of a normal temperature, or pei'haps even warmer ; not unfi'e- quently wet with perspii'ation ; in concussion, it was cold, pale, and shrunken. The sphincters are relaxed ; feeces pass involuntarily. Expulsive muscles are similarly affected; the urine is, in consequence, retained ; or, from paralysis of the sphincter as well, the urine may pass off involuntarily, not in a stream, but insensibly by drops. Such is the general character of the symptoms peculiar to com- pression ; varying, of course, in degree, according to the amount or nature of the injury sustained. They are of immediate or secondaiy accession, according to the cause ; immediate, when the consequence of sudden hemorrhage, depi"essed bone, or impacted foreign body ; secondary, when the result of tardy extravasation, suppuration, or inflammatory exudation. However originating, they are, after a time, masked and modified by the results of the inflammatory process which seldom fails to become established in the injured part. But the brain has the power of I'eco^-ering from the effects of pressure to a certain extent, even although the agent of compressioii undergo no alteration ; the organ seeming to accommodate itself gradually to its change of circumstances. Thus, in depressed fracture, symptoms of compression may be at first marked and even urgent ; and yet may pass off in a day or two, without any elevation of the depressed portion of bone. This being borne in mind, we can readUy understand how, by the time that the inflammatory process has begun, the symptoms of compression, at first considerable, may have ^ CONCUSSION AND COMPRESSION, 25 in a great measure passed away ; and how the case, consequently, may only present the ordinary symptoms of urgent inflammatory action in the brain and its membranes. This is something more than mere masking of compression, by the inflammatory process ; it is supersedence. Certain functions of the brain are plainly re-established, though perverted ; convulsive movements of the limbs occur ; and delirium may supervene. Compression may, like concussion, prove directly fatal ; the patient perishing by coma. Or — when the cause of pressure is removed, or even, as already stated, independently of this — the symptoms gradually abate, and the patient slowly recovers. Or, ere yet any great miti- gation in the symptoms of compression have occurred, those of an urgent inflammatory process kindled in the injured part become estab- lished ; and these prove fatal. Or, a similarly fatal issue may take place, through inflammatory action, even although the immediate effects of compression had seemed to have been recovered from. The indications of treatment adapted to compression are sufficiently simple. To remove, if possible, the compressing cause. To watch the subsequent favourable progress of the organ to resumption of its normal state and function. To interfere, if need be, to avert inflam- matory action. And to oppose the untoward advance of this, when vmfortunately it has become established. When symptoms of simple compression persist, without any opportunity being afforded of remov- ing the cause of pressure, to maintain by suitable means the action of the heart and lungs ; so as, if possible, to afford time for the brain, by accommodating itself to its altered circumstances, slowly and im- perfectly to resume its fimctions. Between pure examples of Concussion and Compression of the brain there is no difficulty in dra-wing a sufficiently broad distinction ; in practice, as T\'ell as in theory. The one, a case of syncope ; the other, of coma. In concussion — the symptoms immediate ; insensi- bility usually incomplete ; the organs of special sense capable of being roused ; the muscles contractile, and the limbs, under strong stimulus, undergoing movement ; the breathing soft and gentle ; the pupils not uniformly dilated, though insensible to light ; the pulse rapid, small, indistinct, perhaps for a time imperceptible; vomiting; no involuntary evacuations ; the skin cold, pale, and shrunk. In compression — the symptoms not necessai'ily immediate ; insensibility complete ; the organs of special sense incapable of being roused; the muscles relaxed, paralyzed ; the limbs motionless, until recession of the state of com- pression, and advance of the inflammatory process; breathing laboured, slow, and snoring ; the pupils dilated and insensible ; the pulse slow. 26 COMPEESSION BY EXTEAVASATION, distinct, perhaps full, sometimes intermittent ; no (or seldom) vomit- ing ; fasces passed involuntarily ; retention or dribbling of urine ; the skin warm, and often bedewed by perspiration. But it is very plain that comparatively seldom will pure examples of either state be presented to the surgeon. The blow or fall which produces severe concussion, is very likely to cause also laceration of the substance of the brain, or rupture of a vessel in the membranes, whence blood will escape, sooner or later, inducing a certain amount of compression. And, on the other hand, the injury which causes com- pression, whether by fi'acture or extravasation, must, at the same time, and primarily, have caused more or less concussion. In consequence, the two states, and their corresponding symptoms, are often — nay, usually — more or less commingled. According to the preponderance of either class of symptoms, the case receives its title ; and, sometimes, it is not easy to say to what side the preponderance is inclined. There is one class of cases, however, sufficiently distinct. The ordinary symptoms of concussion follow an injury of the head, and the patient rallies from them. Consciousness is completely restored, and is retained for some time. But without the operation of any new external cause, insensibility returns ; unconsciousness is more complete than before ; and the symptoms now will be found presenting the characters of coma. Here is a combination of concussion with com- pression ; yet there is no difficulty in separating the case into its two component parts. The first insensibility was that of concussion ; the second is undoubtedly due to compression. If the interval of con- sciousness have been brief — of hours — the compressing agent is, doubtless, extravasated blood ; if it have been of considerable duration — days — the compressing agent is pus, or other inflammatory product. It is right also to remember that, not unfrequently, part of the insensibility attendant on injuries of the head may be attributable to intoxication ; and that although this influence is of a transient nature, and to that extent favourable, yet that it predisposes to inflammatory accession. Compression hy Extravasation uf Blood. Escape of blood may take place, immediately on infliction of the injury ; or not until reaction has followed the direct effects of con- cussion. During the depressed state of circulation Avhich obtains during the first effect of the injury, no blood may escape from even extensive cerebral laceration ; but, if reaction be both speedy and intense, even the slightest lesion will be certain to afford a dangerous amount of that fluid. The extravasation may be variously sitxiatcd : between the skull COMPKESSION BY EXTERNAL EXTRAVASATION. 27 and dura mater ; between the membranes ; on the surface of the brain — on its hemispheres, or at its base ; within the ventricles ; or infil- trated into broken-up cerebral substance. For practical purposes, it is sufficient to divide compressing extravasations into two great classes ; those which are exterior to the dura mater, and those Avhich are Avithin that membrane. I. — Extravasation between the Bone and Dura Mater. One of the effects of a fall or blow on the head is, by disruption of the soft parts constituting the scalp, to produce more or less swelling by sanguineous infiltration of that texture. Occasionally, a similar result is produced on the internal aspect of the part of the cranium struck, in the areolar and vascular connexions of the dura mater with the bone. These being torn, es- cape of blood follows ; either at the time, or subsequently on re- action ; or at both periods ; spai'- ingly at first, more profusely afterwards. If any considerable vessel have been torn, the extra- vasation may be expected to be both instant and great. By such abnormal accumulation of blood, the dura mater is proportionally bulged inwards ; and compression of the brain necessarily results. The blood, as in other examples of extravasation, is at first fluid, but sooner or later assumes the solid form ; or, rather, by coagulation it separates into clot and serum. Extreme cases of this nature, it is plain, are most likely to occur when the injury has been inflicted in the course of the middle meningeal artery. And, to occasion rupture of that vessel, it is not essential that fracture of the superimposed bone should take place. Mere con- cussion may suffice. If compound fracture exist, the blood is more likely to escape externally, than to accumulate, to any inconvenient amount, between the bone and membrane. As indications of the event : — In addition to the ordinary symp- toms of compression, we have the peculiar site and nature of the injury. A smart blow has been received in the course of the meningeal artery ; and is speedily followed by ui'gent. symptoms of compression. Fig. 5. Extravasation of blood separating the dura mater from tlie cranium, at the ordinary site; by rupture of the middle meningeal artery, a. — Liston. 28 COMPEESSION BY INTEENAL EXTEAVASATION. Sucli compression may be so grave as to cause death, by its direct eflFect. Or, farther escape of blood ceasing, the brain begins to accom- modate itself to the amount of pressure already applied ; at the same time, the compressing agent is being gradually diminished in bulk by absorption of the extravasated blood ; and the patient slowly recovers. Or the inflammatory process is kindled after a time ; and unhealthy suppuration is apt to ensue ; reinducing symptoms of compression, more urgent than before, after perhaps a considerable interval of con- sciousness. Treatment. — When the circumstances of the case are such as to leave little doubt as to the occurrence of this form of extravasation, at an accessible and defined portion of the skull, we can have no hesita- tion — if the symptoms of compression are urgent— in using the tre- phine ; for the purpose of exposing the site of extravasation, and effecting relief by evacuation. If the blood be still fluid, it escapes at once ; if coagulated, the solid portions may, if need be, be detached by a probe — delicately used. Unfortunately, we cannot be certain, in almost any case, of the exact site of the extravasation ; and, consequentlj^, both our operation aiid prognosis require to be extremely guarded. A concussing blow operates chiefly on two parts of the cranium; the part struck, and the part immediately opposite ; the one effect often termed the coup, the other the contrecoup. It not unfrequently happens that extravasation takes place in the latter situation ; not at the part struck. But, fail- ing in our search at one point, we ai'e scarcely warranted in making a similar attempt at the other ; for the extravasation may be yet else- Avhere, in a site not ascertained, and perhaps inaccessible. If the symptoms of compression be not virgent, we do not interfere by operation. The brain gradually recovers. The extravasation is slowly absorbed. Our duty is to avert inflammatory action, if pos- sible, by the ordinary means ; to moderate it, should it occur. II. — Extravasation of Blood on, or in the Brain. As already stated, the blood may be variously situated ; intra- membranous ; diffused on the surface of the hemispheres, or at the base of the brain ; within the ventricles ; or infiltrated into the cere- bral tissue. And, unfortunately, the most careful examination of the history, symptoms, and progress of the case, "will often not enable us to ascertain, with anything like certainty, the exact site of the evil. The symptoms are those of compression ; more or less urgent in their character, and more or less speedy in their accession, according to the site, amount, rapidity, and time of the extravasation. Usually, the escape of blood is not immediate — at least to such an extent as to COMPRESSION BY INTERNAL EXTRAVASATION. 29 cause symptoms of decided compression — but secondary, on the occur- rence of reaction. The patient may have been from the first insen- sible, by concussion ; and this minor insensibility may be simply merged in the naajor insensibility of compression ; or between the two there may be a greater or less interval of consciousness. The cerebral or membranous lesion, which permits the sanguineous escape, may follow on a concussive injury of the cranium ; on extensive fracture of the cranium, with or without depression ; on mere fissure of the skull — more especially when this is situate at the base; or on a penetrating wound, of any kind. There is the same prognosis as in the case of extravasation exte- rior to the dura mater. The brain may recover, and the extravasa- tion be absorbed ; or the brain, recovering partially from compression, suffers, perhaps fatally, by inflammatory accession — immediate or remote ; or the compression is most urgent, and directly terminates existence by coma. Rapidity of extravasation is more important than the amount ; and the site of the escape is of more consequence than either. A comparatively small quantity of blood rapidly, or at once, extravasated, will induce more urgent symptoms of compression than twice the amount which has slowly oozed from the torn vessels ; and while a large flat coagulum may press with comparative impunity on the upper and anterior part of the hemispheres, a slight amount of blood acting on the base of the brain — more especially at its posterior part — never fails to induce the most serious and urgent consequences. Treatment. — Prevention may be in our power. Concussion may occur, along with slight lesion of the cerebral substance ; and from this lesion little or no blood may escape during the period of depression. The injury having been such as to engender a suspicion of these cir- cumstances, it is plainly our duty to pi'otract and repress reaction ; when it does occur, to endeavour that it proceed slowly and calmly ; or, if need be, by bleeding from the system, to reinduce the state of depression, and maintain it during a second period. The object being, to afford time and opportunity for efficient occlusion of the injured ves- sels by natural hemostatics. If too late, or otherwise unable, to pre- vent ; we may yet hope to moderate and limit the extravasation. And this is to be effected by opposing reaction ; keeping the patient quiet, with the head elevated ; applying cold to the head, face, and neck ; interdicting all nutritive ingesta ; taking blood from the system, as circumstances may require ; and acting freely on the bowels by pur- gatives. Our object still is to have not only the general circulation quiet and gentle, but to have blood circulating within the cranium as sparingly and as calmly as is compatible with such maintenance of the cerebral functions as is essential to life. Extravasation having ceased, we hope that in due time the 30 COMPRESSION BY EXTKAVASATION. symptoms of compi'ession will begin to abate ; the brain accommodat- ing itself to the compressing agent, and this latter beginning to dimi- nish by absorption. We ward off inflammatory symptoms, should they threaten ; and maintain strict rest, quietude, and regimen ; the last being very rigidly limited in regard to both tluids and solids, in order that there may be a state of system not only unfavourable to inflam- matory accession, but also favourable to absorption of the extravasated blood. Unfortunately, we have no direct means of assisting in the latter indication, A paramount indication undoubtedly is, removal of the compress- ing cause, the extravasation. This can be artificially effected only by operation ; by removing a portion of the cranium ; puncturing the membranes, if need be ; exposing the site of extravasation, and per- mitting — if not effecting — external discharge. Were the operation of trephining capable, always, or even often, of achieving this result, it would be held as generally advisable in such cases. As it is, however, the profession is much divided upon the question ; some in favour of, others opposed to the proceeding. Among the latter we would beg to be enrolled ; and for the following reasons : — 1. It is difficult, if not impossible, to determine, at what part of the periphery of the cranial cavity the extravasation has occurred ; whether at the point struck, or at the site of the contrecoup, or at some other part — superiorly, or laterally, or at the base. 2. It is equally difficult, if not impossible, to determine previous to the operation, at what part the extravasation has occurred as regards the diameter of the cranial cavity ; whether be- tween the membranes, on the surface of the brain, within its ventricles, or in its broken up tissue. 3. Supposing that the extravasation has been reached and exposed, it may be foi;nd either difficult or impos- sible to effect its removal. Coagulation has taken place. The fluid portion trickles away at once ; but the clot is expanded in the form of a flat and broad cake, which cannot be dislodged and extruded without the infliction of such further mechanical injury as shall render the oc- currence of disastrous inflammatory action inevitably certain. 4. Sup- posing that the coagulum has been exposed and not removed, the patient is obviously much more unfavourably situated after than before the operation. Now there is a certainty of inflammatory accession — in addition to the unrelieved evil of compression ; and, under the com- bination, it is but too likely that life may give way. Before, there was but the compression ; inflammation might have been averted ; the brain, by accommodation, might have gradually recovered. Thus, then, we hold, that in the case of compression by extrava- sated blood, the operation of trephining is to be considered as generally COMPRESSION BY EXTRAVASATION. 31 inapplicable. Opei'ating, we are uncertain whether or not the trephine is over the site of extravasation ; we are uncertain whether it may be necessary to puncture the membranes of the brain — and, that having been done, we may still fail in exposing the blood ; we are uncertain of being able to remove the blood, even after it has been exposed ; and we are almost certain to light up an inflammatory process of a most urgent, and perhaps unmanageable character. In other words, we are sure to inflict injury — by perforation, and exposure ; we may succeed in counterbalancing this injury by a preponderating amount of benefit — ^by extrusion of the compressing agent, the escaped blood ; but we are fully more likely to fail in obtaining the contemplated advantage ; and then the proceeding proves to be altogether injurious. But to all general rules there are exceptions. And here the ex- ception consists in those cases of injury applied in the course of the middle meningeal artery, immediately followed by urgent symptoms of compression, with or without fracture of the skull, in which we can have little doubt of the following circumstances : — 1. That the com- pression is caused by extravasation of blood ; 2. That the blood has been extravasated at or near the point struck ; 3. That the extravasa- tion is situate exteriorly to the dura mater ; 4. That the blood is yet mainly fluid, and therefore likely to escape readily outwards, on an aperture of communication being established ; .5. That even if it have coagulated, extrusion may yet be effected, without necessarily exciting inflammation, either in the brain or in any of its membranes. Under such circumstances, we need not hesitate to apply a trephine to the in- jured part — when the symptoms of compression are sufficiently urgent to demand direct interference — with the full hope of affording most important and salutary relief. We can also conceive it possible, that an injury may be sustained at a part of the cranium not connected with the course of the menin- geal artery ; that the symptoms of compression by extravasation may be both very urgent and very plain ; and that the surgeon, after care- ful examination and consideration of the case, may feel satisfied that the site of extravasation corresponds to the part struck. The trephine is applied. If blood be found at that part, exterior to the dura mater, the issue is most fortunate. But if no blood be found, two questions naturally arise : Are the membranes of the brain to be perforated ? or is another part of the cranial contents to be exposed by reapplication of the trephine ? The latter question is certainly to be answered in the negative ; the former, in the affirmative, only when the dura mater is elevated through the trephine-hole, tense, comparatively non-pulsat- ing, perhaps fluctuating, or otherwise affording tolerably distinct evidence of the sought-for blood being lodged beneath. 32 ABSCESS OF THE DUEA MATER. Compression hy the Accumulation of Pus heticeen the Cranium and Dura Mater. Such an occurrence may be preceded or not by sanguineous exti'a- vasation. There may be at first disruption of the dura mater from the internal surface of the cranium, with accumulation of blood between ; perhaps to such an extent as to cause compression of the bi'ain. This organ slowly recovers ; and the patient seems convalescent. But, after some days, the inflammatory process is kindled in the injured part; suppuration occurs, and the intenial bruise degenerates into an unhealthy abscess. Or there may be no previous extravasation. The bone and dura mater sustain a shock by the injury, but undergo no disruption either of themselves or of their connexions. There may be at first some symptoms of concussion, and these pass away ; but convalescence is interrupted by febrile disturbance of the system, followed by symptoms of compression. The inflammatory process has been established in the cranium, in the dura mater, or in both ; and abscess forms between. The inflammatory action may have originated in the membrane, or in the connexions of this Avith the bone, or in the bone ; or it may have begun in the diploe, causing abscess there, and extending inwards ; or the origin may have been exterior to the cranium, in the soft parts, secondarily involving the corresponding portion of the interior. If a portion of the cranium have been rudely sti'ipped of its peri- cranium, it may die ; but it does not necessarily do so — as was formerly stated. Should necrosis take place, and involve the whole thickness of the skull at that point, there is necessarily detachment of the dura mater, interposition of pus between it and the bone, con- sequent bulging inwards of the membrane, and proportionate compres- sion of the brain. But detachment of the pericranium, with advancing necrosis of the external part of the bone, does not necessarily imply a corresponding state of matters within. The issue may be, and often is, merely an external exfoliation. The dura mater is a more important and efiicient membrane than the pericranium, as regards vascular nutrition of the bone. Detach the dura mater, and the bone may hardly live ; strip off the pericra- nium, and exfoliation is by no means inevitable. K the injury have not only denuded the external table of its investing membrane, but have also removed, at a corresponding point, the dura mater, by disruption and consequent extravasation, necrosis of the portion of bone so circumstanced, necessarily involving accumulation of pus between the dura mater and cranium, is inevitable. ABSCESS OF THE DURA MATER. 33 Also, if the dura mater be alone detached, and subsequently suppurate, necrosis of the entire thickness of the bone is still more than probable ; though there may not be even an external wound. However occasioned, the symptoms of compression from this cause differ very obviously from those produced by extravasation of blood. They are not of early occurrence ; days, and sometimes weeks, elapse between their accession and the infliction of the original injury. Whereas, compression by escape of blood is either immediate, or removed from the time of infliction only to the extent of a few hours, at the utmost. Also, in the case of abscess, the symptoms of compres- sion are invariably preceded by signs of the inflammatoi'y process which causes the suppuration. As regards the result, the difference is still more striking. In compression by blood, the extravasation may cease, the blood is absorbed, and the brain recovers. But, in com- pression by pus, the compressing agent is ever on the increase ; the abscess enlai'ges more and more ; and pus is but little amenable to absorption. The bone is exfoliating, and, if it were separate, the matter would doubtless find an outward escape ; but exfoliation is a tedious process ; ere it has been accomplished^ the membrane, growing more and more tense, and itself involved in structural change, ulcer- ates, or sloughs ; purulent irruption takes place inwards ; and a more extensive, serious, and uncontrollable inflammatory action necessarily ensues. Or, previous to the giving way of the dura mater, a minor yet equally fatal inflammatory extension inwards, by contiguity, may have occurred. Or a sad complication may take place, by invasion of all the symptoms of pyaemia. Or, independently of any such aggra- vations, the primary evils of fever and compression may prove fatal. The symptoms denoting formation of this dangerous abscess are two-fold ; as affecting the system ; and as affecting the part. A man receives an injury of the head, without fracture of the cranium. He may undergo concussion or compression by extravasation ; one or other, or both ; or he may not. If he does so suffer, he rallies ; and, for a time, seems advancing favourably towards complete recovery. But, after some days, he becomes restless, wakeful, and generally un- easy ; his pulse rises and gets hard ; the skin is hot and dry ; and the other symptoms of inflammatory fever present themselves — moderate or intense, obscure or manifest, according as the inflammatory process happens to be chronic or acute ; very frequently it is the former. Pain is complained of in the head ; the eyes change their expression ; and the cerebral functions begin to evince disorder. Eigor occurs, and is repeated. Suppuration is begun ; and then supervene, more or less rapidly, the symptoms of compression — masking, in their turn, those of the inflammatory character. Then, as to the part. The bone is in a state of necrosis ; and this condition will certainly be in- D 34 ABSCESS OF THE DUEA MATEK. dicated externally. If there be a wound, the granulations, instead of presenting the appearance of health and healing, will disappeai', or become pale and glassy ; and the discharge may for a time cease — returning thin, non-laudable, perhaps sanguineous. If the peri- cranium be exposed, it will be found separating more and more from the bone beneath, ^^^dth pus interposed. If the bone be denuded, it will be found white, dry, sonorous, non-vascular — in fact, at first dying, and speedily dead. If the scalp have not been divided, either by accident or by design, it is the seat of what is termed " the puiFy tumour ; " a swelling of greater or less extent, caused partly by accumulation of pus between the necrosed bone and its pericranium, partly by change of structure in the soft parts exteriorly, which are involved more or less in the extending inflammatory process, and are consequently the seat of effusion and exudation. Indeed, this " puffy tumour," though a valuable and peculiar sign of the internal evil, is not to be regarded as of a ...---"'"' -- special nature; being only the ..---' ordinary product of ripe in- ..- — "^ ---,. flammation ; oedema by serum ^ --== externally, infilt)"ation by fib- ^^■^ c ^ — ■ — " a _ / / X ^ ^ rmous exudation more deeply, / / f y^ ^^ y^ and accumulated pus overlaying ■ / v'^ y^^..^-'^ the bone (Principles, p. 114). ■ /a j^ These symptoms, local and / constitutional, occurring to- I'ig- 6. gether, denote interior suppu- ration at the injui-ed part. The local signs " following a smart blow on the head, and attended Avith languor, pain, restlessness, watch- ing, quick pulse, headach, and slight irregular shiverings, do almost infallibly indicate an inflamed dura mater, and pus either forming or formed between it and the cranium."* Treatment. — The genei'al principles applicable to the treatment of abscess must be carried out, if possible. The pus must be evacuated externally ; and that at as early a period as possible ; as soon as we are satisfied, by conjunction of the local and constitutional signs, that matter has formed. The local symptoms alone are not a sufficient warrant for operative interference ; neither are the constitutional ; but, when they come together in a marked and jDlain form, the sur- geon is culpably negligent who withholds the trephine. By this in- PoTTj vol. i. p. 41. Fig. 6. Plan, illustrative of abscess of the dura mater, a, the cranium ; 6, a sxippurated space left \>j detachment of the dura mater ; c, ditto, by elevation of the pericranium ; h and c constitute the central space of true inflammation ; d, the arc of active congestion ; e, that of simple excitement ; c, d, e, constituting Pott's puffy tumoiu-. ABSCESS OF THE DURA MATER. 35 strumeiit — chosen of a large size, to make the probability all the greater of disclosing the suppurated part — the dead portion of bone is perforated ; and then the abscess is discharged externally, with imme- diate relief to the symptoms of compression. Be it remembered, how- ever, that those of inflammation still remain, perhaps aggravated by the addition which the injury of the operation has occasioned. Anti- phlogistics must still be continued ; and much careful management is required, even in the most favourable cases, ere the patient is con- ducted to safe completion of the cure. It may happen that the inflam- matory action is not checked ; but, sjsreading both widely and in depth, proves ultimately fatal. In short, while it is obvious that the only chance of the patient's safety is by artificial evacuation of the matter, it is equally plain that the operation alone will not suffice, but must be followed up by the most careful general treatment. It has happened that the abscess, burrowing between the dura mater and bone, has eventually reached the internal ear, and discharged itself externally by the meatus ; the patient recovering. But, obviously, such an occurrence is a rare exception to a general rule, and cannot be trusted to in practice. If, on removing a portion of skull by the trephine, matter is not found, a question arises whether our efforts at direct relief are to cease, or whether further exploration is to be attempted. Is the dura mater to be perforated, in the hope that the site of abscess may prove to be beneath ? Not, if the membrane present its usual normal charac- ters at the part exposed ; level, moving synchronously with the cere- bral mass, smooth, of a brownish hue, and showing something of a silvery lustre. But if it be protruding through the cranial aperture, flocculent, non -pulsating, and either too dark or too pale in colour — and, more especially, if it afford anything of a feeling of fluctuation when touched — we need not hesitate to puncture, and need not doubt to find an issue of purulent or other fluid from the wound. If the dura mater appear sound, and its puncture consequently be unwarrantable, are we permitted to re-apply the trephine ; either at the site of contrecoup, or in the immediate vicinity of the first application ? Either of these procedures may be warrantable, if the symptoms of dura-matral abscess are peculiarly marked, and the surgeon is thoroughly convinced of its existence. But, as can readily be understood, the latter site of reap- plication is the preferable. And, as already stated, a large size of trephine should be employed at first, to anticipate the necessity of such repetition. Only in very extreme cases, should the site of contrecoup be trephined. Having failed in the indicated spot, Ave proceed to other explorations with great uncertainty. Fortunately, however, it is comparatively seldom that the site of abscess is elsewhere than at the injured part. d2 36 FRACTURES OF THE CRANIUM. But, if the case be under our cognizance from the first, we have a higher aim than the mere exercise of our art by operation ; seeking to prevent the formation of abscess, not to attempt its cure. The patient who has sustained an injury of the head, of any severity, is carefully watched throughout the whole period of convalescence ; and the first symptoms of inflammatory accession within the cranium are met by active and sustained antiphlogistics — more especially blood-letting, quietude, avoidance of all stimuli of both part and system, low diet, pui'gatives, and perhaps calomel ; assisted, if need be, after a time, by counter-irritation. When suppuration has taken place either in the substance of the brain or on its surface, the case is obviously not amenable to direct surgical interference, and may scarcely fail to prove fatal. Cure is beyond our reach ; but prevention was not. And the latter indication should sufficiently occupy our regard in the previous treatment of the injury. When a severe scalp wound has been sustained, with bruising or fissure of the bone, it is not uncommon for the character of the wound to degenerate as in the case of dura-matral abscess, Avith some constitu- tional distui-bance of an unpleasant character. But neither the meh- ingitic symptoms, nor those of compression, appear. Suppuration has taken place in the diploe. If fissure exist — perhaps extending only through the external table — pus will be found slowly oozing otit- wards. Enlargement of the chink is necessary, however, for more free evacuation. If there have been no previous solution of con- tinuity, the trephine may be used for removal of a portion of the external table. The mischief may extend inwardly, and dura-matral abscess form, as previously stated ; but, fortunately, such is by no means the invari- able result ; and is indeed little likely to take place, if suitable treat- ment have been adopted. If phlebitis occur in the diploe, the case becomes eminently serious; partly on account of the direct effects of this disease ; but mainly from the risk of pyaemia (Principles, p. 231). After injuries of the head, abscess of the liver is by no means uncommon ; and it is probable that at least many of these cases are connected with unhealthy suppuration, with phlebitis, in the diploe. Fractures of the Cranium. In the child, much violence may be sustained by the cranium, with impunity. The osseous tissue is then elastic ; it yields to the force. FISSURE OP THE CRANIUM. 37 and is temporarily depressed, but without solution of its continuity; and, after a time, the depression is gradually effaced by a vital resi- lience, independent of external aid. In the adult, and more espe- cially in the aged, the bone is of a much more brittle natiu'e ; and less force succeeds in effecting solution of continuity, more or less extensive. The skull may be merely fissui'ed; or the injured part is broken into fragments, implicating the whole thickness of the bone, Avith or without depression of these ; or the external table alone is broken ; or the internal table exclusively suffers ; or both are penetrated by a sharp-pointed weapon, the internal sustaining the greater amount of iiijury. The fracture may be at any part of the periphery of the cranium, or may travei'se its base ; and, further, it may be either simple or compoimd. The dangers attendant on the injury are various. 1. By concus- sion. 2. By extravasation of blood within the cranium. 3. By ex- cessive escape of blood externally from the wound. 4. By displace- ment of the fractured portions inwards, causing compression. 5. By inflammatory action, occurring in either the brain or its membranes. The treatment wiU comprise various indications calculated to oppose these several results. Fractures of the cranium, whether simple or compound, unite only by definitive callus (Principles, p. 709). Want of provisional callus, doubtless, may delay completion of the healing process ; but all incom- moding of the brain or its membranes, by osseous bulging, is avoided — which otherwise could not fail to occur. Fissure. Capillary solution of continuity is, in itself, a thing of but little importance. But the shock Avhicli has caused it may well occupy our attentive regard. The fissure itself, indeed, may in its formation have proved an actual advantage ; rendering the concussion less intense and less hazardous than it might have been, had the ringing calvarium re- mained entire. The fissure may be short, and bounded by suture ; or it may tra- verse several of these, and be of great extent. It may take place at the part struck, or at the site of the contrecoup. It may be conjoined, or not, with rupture of the dura mater at the fissured part ; and if it be so conjoined, compression by extravasation is likely to ensue. When the injury is situate at the base of the cranium, it is usually associated with such rupture ; and extravasation occurring at this site, even to a slight extent, we have already seen to be of the gravest import (p. 29). 38 FISSUEE AT THE BASE OF THE CRANIUM. The symptoms attendant on fissure aj;e usually those of concussion, in the first instance ; and these may be followed by those of compression by extravasation. Inflammatory accession is not unlikely ; giving the ordinary train of symptoms, varying according to the part and texture involved. And these, again, may be merged in the symptoms of com- pression by suppuration. If the injury be compound, the existence of fissure is ascertained by the finger or probe. If it be simple, the fissure may very probably elude detection ; the case being treated as one of simple concussion. Long ago, it was the custom, in the treatment of this injury, to expose the fissure thi'oughout its whole extent, by incision ; and to apply the trephine repeatedly in its course ; probably in the hope of liberating extravasated blood. But no one now thinks of thus aggravat- ing what is in itself comparatively simple. It is time enough to take up the trephine, when symptoms of compression, by blood or by pus, are so plain and so urgent as to demand its use. It is not often, as already explained, that on the first count we are called upon to operate ; and, if we have seen the case from the first, it may be our own fault if we have to interfere on account of the untoward result of inflammatory action. The treatment is chiefly expectant. We await reaction from the effects of concussion ; watch the period when extravasation is likely to occur ; and, if need be, then interfere — repressingly. That period of danger having passed, we are again quiescent, though alert ; looking out for symptoms of inflammatory accession ; and ready to oj)pose these with energy, should they appear (p. 18). Fissure at the Base of the Cranium. Solution of continuity, in this situation, is usually a fissure ; dis- ruption, more or less extensive, without comminution or displacement. The fissure may either extend through previously compact bone ; or be a kind of diastasis — separation of the sphenoid from the temporal bones, for example, at the original points of union. As already stated, it is generally accompanied with laceration of the dura mater, and internal hemorrhage ; and consequently is invariably attended with the greatest danger to life. The important parts of the brain implicated are almost certain to be compromised in function, sooner or later ; either almost immediately, by extravasation ; or by inflammatory action at a more remote period. The injury may be occasioned in various ways. The head may be crushed laterally ; as by being jammed between a wheel and a wall or post. Or, while the body is at rest, a severe blow is received on the vertex; and the strain of the shock, communicated through the temporal bones, produces a splitting of these, or tears open the con- FISSURE AT THE BASE OF THE CRANIUM. 39 Fig. 7. nexions with the sphenoid.* Or the body, falling, alights on the vertex ; and the spinal column, carrying both the weight and mo- mentum of the body, is driven down upon the cranial base — the basilar process being probably broken through. Or, falling from a height, the patient alights on his breech, or on his heels ; and, again, a con- cussion sufficient for disruption may be so communicated to the cranial base. The extravasation is not always slight ; it may be great, one or more of the large venous sinuses having been torn ; then the symptoms are from the first most grave, and cannot but end fatally and soon. The circumstances which lead to a suspicion of fracture at the base of the skull are : The kind of injury inflicted, such as already described ; symptoms of compres- sion, early and severe ; escape of blood from the ears, nose, mouth ; and discharge of a watery fluid from the ear, sometimes in considerable abundance. The last symptom — often termed " welling of the ear" — is not immediate, but occurs after some days have elapsed. By some it is considered to denote escape of serous fluid from the sac of the arachnoid ; others, contending that the pheno- m.enon has been known to occur when certainly that sac was not opened into, believe that the fluid is but the serum of extravasated blood, trickling through the fissure ; by all it is held as a sign of most un- toward import, f Bleeding from the nose, mouth, or ear, following on * " If a force be applied to the vertex, the superior border of the parietal boues resist displacement downwards, inasmuch as their inferior borders cannot be tlirown outwards in consequence of their being supported laterally by the overlapping of the squamous portions of the temporal bones ; while the temporal bones, as M. Malgaigne has pointed out, are themselves supported by the zygoma, which constitutes on each side a true buttress, sustained by the superior maxillary bone. A shock, then, applied to the vertex, is directly transmitted to the temporal bone, and propagated through its petrous portions to the posterior part of the body of the sphenoid bone, tlie parts which most fractures of the base of the cranium traverse." — Brit, and For. Med. Eev. ISTo. 29, p. 174. f Laugier, Archives Generales, Aout, 1845 ; also, Brit, and For. Med. Chu'. Rev. April 1850, p. 342; Ranldng's Retrospect, vol. ii. p. 100. Fig 7. Fissure at the base of the skull, involving the occipital and sphenoid bones. The patient fell from a ladder on the vertex, and lay comatose for some days before death. Extensive extravasation was found over the cerebellum and middle lobes of tl;e brain. — LiSTOx. 40 FEACTUEE WITHOUT DISPLACEMENT. severe injury of the head, is always suspicious ; more especially if the patient be found in a state of insensibility. But let it be borne in mind that such a combination of circumstances by no means certainly de- notes the existence of fracture at the base ; the insensibihty may be that of concussion or of intoxication ; the bleeding may proceed from mere laceration of the schneiderian membrane and of the lining of the meatus, and from injury of the tongue by the teeth. When, however, we have such bleedings accompanied by urgent insensibility, obviously of the nature of coma ; when the head symptoms either remain unim- proved, or advance untowardly ; and, more especially, when by and by the "welling of the ear" appears — we may safely conclude that fracture at the base has occurred. The treatment must plainly be prophylactic and expectant, as already advised in the case of compression by inaccessible extravasa- tion. There is no room for direct operative interference. If the com- pression be happily got over, we must then be very watchful of in- flammatory accession. In all cases, prognosis is unfavourable ; the majority prove fatal — either immediately by coma from extravasation, or more remotely fi'om the effects of inflammatory action. But it must be remembered, that fissure of the cranial base may occur without any characteristic symptoms being evinced ; the patient seeming to labour under mere concussion. The fissure may have been slight ; and the solution of continuity may have been confined to the bone alone. The membranes remain entu'e ; and there is no inward escape of blood. Compression, by extravasation, necessarily does not supervene ; and inflammatory danger may be warded ^off by ordinary care. Such cases, however, are of comparatively rare occurrence. Fracture without Displacement. The most common solution of continuity in the cranium is not a mere fissure ; but a fracture, analogous to comminuted fracture of the long bones ; reducing the injured part to the condition of being broken up into one or more fragments ; and these may or may not be dis- placed. Wlien there is no displacement, the dangers to be apprehended •ire such as are common to other injuries of the head, apparently less severe ; concussion ; excessive reaction, bringing either compression by extravasation or untoAvard inflammatory action ; or a more in- sidious inflammatory process, occurring at a more remote period. The fracture may be simple, or compound, or with wound (Principles, p. 699). The compound is necessarily of a more unfavourable character than the others ; danger by inflammatory action being greater and more probable. But the difference is, on the whole, not so marked as between corresponding injuries of the bones of the extremities. It is PKACTURE WITH DISPLACEMENT. 41 possible that the existence of a communicating wound may prove even an advantage ; by permitting outward escape of inflammatory or other effusions, and so saving the important internal parts. The treatment is prophylactic and expectant ; according to the general principles already explained. There is as little necessity for immediate trephining, as in the case of mere fissure. If the injury have been sustained at the lower and anterior angle of the parietal bone, and is speedily followed by urgent compression, it may be advis- able to apply the trephine in order to afford a freer vent for the meningeal hemorrhage. But, usually, the aperture already existing is sufficient for an outward drain. And again, should symptoms of compression by suppuration supervene, at a more advanced period, operative interference may be necessary to effect a free evacuation. In general, however, there is no necessity for the use of the trephine. Fracture vntli Displacement. If the fractured portion, or portions, be displaced inwards, the brain is more or less incommoded, and symptoms of compression ensue ; proportioned usually to the amount of depression, and to the relative importance of that part of the brain which is injui^ed. The upper and anterior surface of the brain, as formerly stated, may bear a very considerable amount of compression with comparative impunity. The injury may occur without corresponding wound of the soft parts ; but usually the fracture is compound. The dangers are formidable. 1. By concussion. 2. By extra- vasation of blood. 3. By the results of inflammatory action on the brain and its membranes. 4. By compression, caused by the dis- placement. The three first are to be opposed by fulfilment of the ordinary indications. The last is to be removed by operative interference. But in regard to this the question at once arises : — Whether, in all cases of depressed fracture, operative interference, for the purpose of replacing the depressed portion of bone, is necessarily demanded? Formerly, the answer was in the afiirmative ; at present, it is not so. Elevation of the depressed portion is had recourse to, with two remedial objects in view ; to remove the cause of compression, and consequently the symptoms of this, when they exist ; and also to re- move a likely exciting cause of inflammatory action from the portion of cerebral tissue and membranes acted upon by the depressed bone. When the symptoms of compression are great and urgent, there is no room for hesitation ; it is plainly the duty of the surgeon at once to attempt removal of the cause ; and fulfilment of the former of the two 42 FRACTURE WITH DISPLACEMENT. indications is sufficient warrant for recourse to the operation. But if symptoms of compression either do not exist, or are slight, and are recedent rather than gravescent, the case is very different. If we operate then, it is only to fulfil the latter indication ; removal of the exciting cause of an apprehended inflammatory process. And then this other question arises : — Whether the continued pressure of a smooth portion of depressed bone, or the injury inflicted by per- formance of the operation, is the more likely to excite an untoward amount of inflammatory action? Experience has answered to the effect, that the greater risk is encountered by recourse to operation.* And, consequently, the rule is, to refrain from operation in all cases of ordinary depressed fracture, in Avhich symptoms of compression do not exist. Further : we know that the brain has the power of slowly recovering under a certain amount of pressure, even when that pressure continues undiminished. And, consequently, the rule of non-intei'ference is extended also to those cases in which the symp- toms of compression exist, but are by no means urgent, and seem to be slowly receding rather than on the increase. In young subjects, the call for artificial elevation must be especially urgent before it can with propriety be obeyed For in them, it is to be remembered, a system of mutual accommodation may be said to be in progress ; the brain not only becoming accustomed to its altered circumstances, but the compressing agent being also gradually withdrawn — the bone, by its inherent elasticity, slowly re-approaching its former level. In the adult, there is not the same resiliency ; but then too something- is done, on the part of the bone, to favour complete recovery of the functions of the incommoded organ. For after some considerable time, the depressed portion is found to have become wonderfully smooth on its internal surface, and bevelled at its margins, by absorp- tion ; not ceasing to press, but now pressing with all gentleness on the parts beneath. In ordinary fracture with displacement, therefore, we do not interfere by operation, unless symptoms of compression not only exist, but are urgent. And in these cases the operation may not wholly succeed ; the compression being perhaps by blood as well as by bone. In all other cases, we content ourselves with the expectant and pi'ophy- lactic treatment, as if depression did not exist. When the fracture is compound^ comminuted, and depressed — that is, when fragments are not only displaced, but completely detached * Abuudance of cases are on record, testifying the power which the brain has in bear- ing long-continued pressure, with comparative impunity, so far as inflammatory acces- sion is concerned. One very remarkable instance is related by Sir A. Cooper (Lectures, p. 128), in which certain symptoms of compression endured for upwards of thirteen mouths, in consequence of the existence of depressed fracture ; complete and almost in- stant recovery following removal of the depression by operation, at the end of tliat period. PUNCTURED FRACTURE. 43 from the rest of the cranium — we of course do not hesitate, in all such cases, to remove the loose fragments, with gentleness and care, whe- ther symptoms of compression exist or not. Also, let it be undei'stood, that when, in a case of compound frac- ture, with displacement, sharp fragments seem to be dangerously in contact with the dura mater — much more, if this membrane be pene- trated or punctured by them — we ought as soon as possible to raise or remove the oifending portions, whether head symptoms exist or not ; for in no other way can violent inflammatory accession be averted. When operative interference is determined on, the indications to be fulfilled are sufiiciently plain. To expose the parts, by suitable in- cision of the soft textures superimposed. To use the sound margin of bone, as a fulcrum, on which the elevating lever may rest. To insi- nuate the extremity of the lever beneath the displaced part, and to effect replacement with as little violence as possible. For the inser- tion and Avorking of the elevator, sufficient space may ali'eady exist. If not, this is to be acquii'ed ; by gently lifting away a loose fragment ; or by removing a portion of the sound bone, by means either of the saw or of the trephine. After the operation, much antiphlogistic care must necessarily be maintained. Punctured Fracture. By the term "ordinary fi-acture, with or without displacement," is meant injury done by an obtuse body ; causing solution of continuity throughout the whole thickness of the bone ; and producing fragments com- posed of both tables of the skull, separated from their general con- nexion in nearly equal proportions. A smooth, uniform, non-penetrating, surface is consequently presented by the depressed portion to the brain and its membranes. But when a sharp-pointed substance — as the point of a poker or pitchfork, the corner of a spade, shovel, or hammer, or the angle of a shai'p stone — impinges on and penetrates the cranium, the nature of the injury is very different. The external table is crushed by the penetrating body, to an extent proportionate to its lodgment. But the inner table, being much more brittle, gives way to a greater extent. It is broken up into fi-agments — usually small and spiculated — which, being driven inwards by the force of the Fig. 8. Punctiu'ed fracture, at a : at h, tlie dura mater represented detached, and spicnla of hone lodged in the vacant spnce. 44 PUNGTUEED FEACTURE. blow, iDenetrate, or at least seriously kritate the coveriugs of the brain, ■ producing inflammatory action. This may be general, involving the brain itself, and to the last degree dangerous ; or it may be limited to the injured dura mater, causing abscess there — a result still most perilous to life. And to accomplish the latter evil, it is not necessary that the fi-agments of the inner table should penetrate, or in any way mechanically injure the dura mater. It is sufficient that they are detached from the general cranium, and remain unremo^^ed; they necessarily die ; and, as sequestra, they inevitably become sun-ounded by purulent formation. The rule of practice, then, comes to be plain. Whenever we are satisfied that punctured fracture has occurred — in other words, that the kind of fracture is such that splintering of the internal table is certain — we cannot too soon proceed to operation. We trephine immediately, so as to expose the fragments, and admit of their being carefully and efficiently removed. Unless they are taken away, antiphlogistics are practised in vain; inflammatory action becomes established at the part ; sooner or later abscess forms ; and then we find ourselves com- pelled to operate for relief of compressed brain, under very unfavour- able circumstances. The least result is abscess of the dui'a mater ; but it may be, that even the questionable chance by operation is not afforded, the inflammatory action having proved general — cerebral, as well as meningitic — and speedily can-ying off the patient. Taking the most hopeful view of the case, a necessity for operation is certain to arise, at some stage. And surely it is most prudent to operate at that time which plainly is most promising of an auspicious result. Better to operate at once, removing the paramount exciting cause of inflammatory action, and probably averting all casualties ; than to attempt, subsequently, to retrieve or limit danger and disaster, already sustained. The rule as to operation, then, is very different in the case of punc- tured fracture, from what is applicable to any other injury, hitherto considered. We at once proceed to the operation of trephining, whether head symptoms are present or not. The mere existence of this form of injury is an amply sufficient warrant for our interference. Head symptoms, and those of a most urgent kind, are certain to super- vene, if the operation be mthheld ; and they can be averted only by early removal of the splintered fragments resting on the dura mater. After the operation, antiphlogistic treatment must be sedulously main- tained. As in the case of concussion, it may be difficult, at fu'st, to per- suade the patient — as yet suffering but little — of the propriety of instantly submitting to treatment which may seem to him unneces- .sai'ily severe, and indeed quite unwarrantable. This obstacle is to be FRACTUEE OF THE EXTERNAL TABLE. 45 overcome, by a calm yet earnest exposition of the certain danger which otherwise awaits him. Obviously, it is our first duty to come to a just conclusion as to the existence or not of this kind of fracture. A most minute examina- tion is accordingly made. The scalp is freely divided, if need be, to expose the fractured point to sight as well as touch ; and by a gentle yet determined use of the finger and probe, we endeavour to satisfy ourselves thoroughly ; assisted in our decision by regard to the mode in which the injury has been inflicted. Penetrating cuts of the Cranium — as by a sabre, axe, or sharp spade, — often closely resemble punctured fracture, as to the kind of injury done to the inner table, and the immediate necessity for operation. When the cut passes sheer through both tables, the inner one is usually splin- tered ; and the fragments press inwards, untowardly. They must be removed. The chasm of the wound is often sufficient to disclose theu' presence and site, to finger or probe ; and it may suffice for removal also. If not, room is to be made by application of the trephine, or saw, as may seem most convenient. Fracture of the External Table, alone. This is not an uncommon result of comparatively slight violence done to the calvarium ; by bodies either sharp or obtuse. The ex- ternal table alone gives way ; and is perhaps driven inwards on the diploe. The most marked sample of the injury is afforded by fracture over the fr'ontal sinus ; in other parts of the calvarium the accident occurs only in those of middle age, in whom diploe, with marked dis- tinction between the cranial plates, exists. No operative interference is required ; except in the case of the frontal sinus ; and then elevation of the depressed part is expedient. The treatment is, locally and generally, antiphlogistic. But, as formerly stated, inflammatory action may become excessive, and extend inwards ; and suppuration in the diploe may lead to suppuration also on the internal aspect of the bone, necrosis of the implicated part ensuing. Under such circumstances, the operation of trephining is likely to be required, to relieve com- pression. Sometimes diploal phlebitis, with its sad consequences, ensues ; too often baffling all treatment. Fracture of the Inner Table, alone. Fortunately this is of comparatively rare occurrence ; for, the outer table remaining entire, we have no means of ascertaining the nature of the injury, at the time of infliction. It may follow on a sharp concus- 46 OPERATION OF TREPHINING. sing blow ; in a patient, who, by reason of age or other cause, has a vitreous table of unusual brittleness. The table may be simply severed, and not much depressed; then head symptoms are likely to prove both slight and transient. But, more probably, there is comminution as well as displacement ; and then the usual hazard is incurred from the depressed and perhaps penetrating spicula. The trephine is likely to be called for, after a time, on account of dura-matral abscess. Depression without Fracture. As already stated, this occurs only in children ; in whom bones are more prone to bend than to break. A dimple is made in the skull by external violence, and is slowly effaced by virtue of the in- herent elasticity of the tissue. For a time, there may be symptoms of compression ; but seldom of a marked character ; and still more rarely urgent. Operative interference is neither necessary nor expedient. The treatment is simply antiphlogistic ; and prophylaxis is long main- tained (p. 21). The Operation of Trephining. The Trephine is a circular saw, woi'ked by a light and rapid move- ment of the hand, whereby a portion of the skull is divided, and may be removed. For its application, complete exposure of the bone is necessary. If a wound ali'eady exist, it is enlarged to the necessary extent. If there be no previous wound, a crucial or other incision is ■ made ; so that, by reflection of flaps, the required exposure may be effected. The pericranium is carefully raised, to an extent sufficient to admit of the free play of the instrument ; but no farther. The centre-pin, sharp-pointed, having been made to protrude a short way bej^ond the serrated edge, is securely fixed there by its screw. And then, by firm pressure, accompanied with a slight rotatory motion, the centre-pin is fixed in the bone, so as to steady the instrument in its first movements on the external table. The teeth of the trephine are usually set so as to work from left to right ; and it is well to have the crown fluted, on its lower half — this being found to favour its free play. The turnings are made steadily and rapidly ; with very light pressure, after the centre-pin has been fixed ; and the light pressure is exerted only during the movement from left to right. When the sulcus has advanced to such a depth as is sufficient to retain the saw steady in the groove, the instrument is withdrawn, and the centre-pin pushed back entirely ; to proceed with it still protruding, were not only to do what is unnecessary, but also to encounter much risk of injury to the dura mater at the latter part of the operation. The plain crown is OPERATION OF TREPHINING. 47 reapplied, and worked steadily as before. There is no occasion for hurry; the operation itself, so far as the sawing of the hone is concerned, is comparatively painless ; besides, it is usually undertaken while the patient is insensible ; and in those cases where sensibility remains, experience has shown that antesthesia by chloroform may be practised with perfect safety (Principles, p. 786). If diploe exist, a change of sound and feeling is imparted to the operator, intimating that the saw has passed the external table. Then the instrument is worked very warily ; and it is well to remove it from time to time, examining the sulcus with a probe or toothpick, to ascertain whether or not at any point section of the inner table may have been completed. If an aper- ture be detected, then the instrument, when reapplied, is inclined to the opposite side, and moved with increased caution and lightness. Want of parallelism in the two tables of the skull renders such precau- tions essential to a safe performance of the operation. Section having been completed at all points, the detached circle is to be removed. Perhaps it may come away in the crown of the instrument. If not, dislodgment is elFected by the point of a lever, or by forceps ; and the circle is gently withdrawn : — in this step of the procedure, as well as iu the last of the sawing, much care being taken to avoid injury to the dura mater. If any rough or sharp points are found on the margins of the aperture, these are to be removed by the elevator ; otherwise, the dura mater might sustain injury. When the opei'ation is undei'taken for elevation of depressed bone, it is seldom necessary to remove an entire circle. All that we desire is room suffi- cient for raising the depressed portion, and removing fragments if need be ; and this can usually be accomplished by fix- ing the centre-pin on the bi'ink of the sound bone, and so removing by the saw only a segment of the circle. The operation, and the object for which it was undertaken, having been accomplished, the flaps are carefully replaced, and the general wound is in- ^^^^^ vested by tepid water-dressing ; care -^ being taken that no undue bleeding takes place from the scalp; and, in regard to this point, it is to be re- membered that vessels which do not bleed during the state of depres- sion, may part with their contents freely on the establishment of Fig. 9. Trephining, a, the sound portion of cranium ; &, the depressed. The centre- pin fastened on the brinl; of the sound portion. Fig. 9. 48 OPERATION OF TREPHINING. reaction. Above the water-dressing it is well to place a few turns of a bandage, lightly applied, so as to afford support (p. 10); and this is more especially necessary when deficiency of the cranium happens to be considerable. The wound, in other respects, is treated in the ordinary way; union taking place by the second intention. Of course, rest is absolute, severity of regimen is extreme, and antiphlogistics are held in readiness, for some considerable time after the operation. It has been proposed to replace the removed circle of bone, after completion of our object, in the hope of its becoming reunited ; but such hope has been proved vain, as might have been expected. When the wound has healed, the dura mater is found to have be- come incorporated with the soft parts exteriorly, and the breach in the cranium is not filled up by bone, but by dense membranous formation. A meagre film of new bone may be found at the mere margin of the aperture. And this, in time, extends centripetally ; apparently by the slow secretive action of the parent bone alone, the pericranium, dura mater, and other soft parts, seeming to be incapable of ossific action. At the margin of the aperture the new bone may be of similar thick- ness with the cranium ; but, as it extends, it shelves rapidly ; becom- ing very thin as it approaches the centre. Many years are required, ere osseous reparation is complete. And in consequence, it is expe- dient for a long time to guard the imperfect part from external injury ; a piece of leather or metal being worn over the cicatrix. At one time, trephining was frequently performed ; and on grounds much too slight. From the preceding remarks, the following brief deductions may be di'awn, as to its present use. It is had recourse to, 1 . On account of punctured fracture, as soon as possible ; whether head symptoms exist or not ; the object being to remove splintered fragments of the inner table. 2. On account of depressed fracture, accompanied with urgent symptoms of compression ; when elevation of the depressed portion cannot otherwise be effected. 3. On account of dura-matral abscess, when local and constitutional symptoms suffi- ciently concur in pointing out the existence and site of this morbid condition ; the object being to effect external evacuation of the pus. 4. On accoxmt of urgent compression caused by extravasated blood ; only when the circumstances are such as to indicate the seat of extra- vasation, and when that happens to be accessible. Occasionally the surgeon has been called upon to trephine, in cases of epilepsy, in Avhich the disease seemed to be connected — in the rela- tion of effect and cause — Avith a depression of the cranium, the result of former injury ; or in which circumstances seemed to point with much plainness to a certain spot of the cranium — perhaps the seat of internal enlargement of either a globose or spiculated character. The operation, under such circumstances, is of doubtful expediency ; but WOUNDS OF THP] BKAIN, 49 may be performed, at the suspected spot, in obedience to the urgent entreaty of the patient or his friends. Trephining has also proved successfril on account of neuralgia de- pendent on inward growth from the cranium.* In general, it is well to avoid applying the trephine in the direct course of the middle meningeal artery, or over the longitudinal sinus. Yet if it seem of decided importance that the instrument should be ap- plied at such localities, the risk of hemorrhage need not deter us. A compress of lint, du-ectly and accurately applied, will readily restrain the venous bleeding (Principles, p. 367); and if a similar application fail to stanch the arterial flow, the osseous canal, in which the vessel is usually imbedded, may be temporarily plugged, by the insertion of a small portion of wood or cork (Principles, p. 357). Wounds of the Brain. The brain may sustain an incised wound, as by a sabi'e cut ; a contused and lacerated wound, as by depressed fracture ; a punctured wound, as by the thrust of a bayonet, pike, or any other sharp-pointed weapon ; or a gunshot wound — of the class " contused and lacerated," — by the penetration of a bullet. The likelihood of disaster is grave and imminent ; by extravasation of blood, in the first instance ; by inflammation and its results, secondarily. Treatment requires to be proportionally watchful and energetic. Incised wounds may simply penetrate, or partially detach a slice of the organ. Such a flap is not to be at once removed ; but should be replaced along with the corresponding investing textures, in the hope that reunion may occur. Examples are not wanting of a fortunate result. I In contused and lacerated wounds, a certain amount of inflammation is inevitable. It is our business to moderate and control this, by the ordinary means ; so preventing disorganization and protrusion of the cerebral tissue at the injured part. In punctured wounds, inflammation is not inevitable — unless foreign matter lodge — yet it is very likely to occur. The antiphlo- gistic precautions require to be very rigid. In gunshot wounds, danger by inflammatory action is pre-emi- nently great. Not only is the wound of the contused and lacerated kind ; there is also great probability of lodgment of the bullet, or portions of it, or of fragments of bone which have been displaced and driven in. And it is well to remember, that the want of an appa- rently sufficient aperture of entrance is no sure proof of the ball having * Boston Med. and Surg. Journal, August 184(>, p. 53. t Larkey, Clinique Chirurgicale, torn. i. p. 140. K 50 LODaMENT OF FOREIGN BODIES. not penetrated and lodged; for, in the young more especially, the inherent elasticity of the osseous tissue may be so great as to diminish the space of entrance-wound very considerably. Contusion and lace- ration of the cerebral tissue, and its investments, render a certain amount of inflammation inevitable ; and the lodgment of foreign matter determines the amount and intensity of such action to be gi-eat and hazardous. Further; foreign substances, penetrating deeply, are not unlikely to interfei*e with the most important portions of the organ — at its lower and posterior part — producing death, either instantly or at no protracted period, by direct interference with function. Lodgment of Foreign Bodies. When foreign bodies penetrate the brain, and then* site of lodg- ment can be ascertained through the wound, the surgeon naturally becomes desirous of effecting removal of so palpable an exciting cause of the coming inflammatory action — the results of Avhich he so much dreads, and not without good cause. If extraction can be effected easily, by forceps, probe, or hook, Avithout much additional injmy being inflicted on the cerebral tissue, it should certainly be attempted with as little delay as possible. If, however, the site of lodgment is un- known, or if the foreign body, of no great size, is found both difficult of access and fii-mly imbedded, it is better to abstain from the infliction of exploratory and evulsive violence ; which v/ould be certain to kindle an amount of inflammation quite uncontrollable. It is better to with- hold all direct interference ; contenting ourselves with busy antiphlo- gistics, to meet that amount of inflammatory action — ^pei'haps amenable to control — which the infliction of the wound and the lodgment of foreign matter cannot fail to induce. We may happily succeed ; though the general prognosis is doubtless unfavourable. There are instances on record of bullets, lodged deeply in the brain, remaining there harmless for years ; incased in adventitious cysts — as happens in other textures (Principles, p. 674). Such fortunate patients, however, require ever to be most careful in avoiding all inordinate excitement of the cerebral functions, and of the general circulation ; for it has happened, again and again, that — after years of immunity — a debauch, or violent emotion, has induced a sudden and fatal coma. The rule of practice then is : That, while it is very desirable, at as early a period as possible, to remove foreign substances which have lodged in the brain, in order that we may hope to contend more suc- cessfully with the coming inflammation — such removal is not to be attempted at the expense of further and serious injury to the cerebral tissue. Such additional injury will render the inordinate action un- controllable ; and the patient must perish thereby. Leave the part HERNIA CEREBRI. 51 undisturbed, and trust to general antiphlogistics ; for it is possible that the inflammatory action may be kept within moderate limits, and the patient saved. Sometimes they make wonderful escapes, as in the recent instance of recovery after an iron bar had completely traversed a large portion of the brain,* Hernia Cerebri. By this term is meant protrusion of the cerebral substance through cranial deficiency. To constitute this morbid state, three things usually conspire ; deficient space in tlie cranium ; a corresponding aperture in the membranes of the brain, by wound, ulceration, or sloughing ; and disorganization of the corresponding portion of cerebral substance by inflammation. It is most likely to follow on compound and com- minuted fractures of the skull, with depression of the fragments, and laceration of both brain and membranes. The pouting prominence of brain at first merely fills the cranial orifice ; it then shoots above it ; and, in no long time, it may attain to a considerable size. Now, pro- bably, its neck becomes impacted in the cranial aperture, is strangu- lated there, and sloughs ; a fresh protrusion, however, takes place, and the progress is as before. Portion after portion of the upper part of the brain may be lost in this manner, without apparent and direct injury to the cerebral functions ; f but, sooner or later, the formidable constitutional irritation which accompanies will prove fatal ; and there is besides a risk of the disorganizing inflammation extending widely and fatally from the original site. Prevention may be in our power. When the brain has been ex- posed by compound and comminuted fracture ; and when there is a deficiency of the cranium, by removal of the fragments, with or Avith- out use of the trephine — the occurrence of cerebral protrusion, in con- sequence of inflammatory accession, is always to be apprehended. And two indications fall to be fulfilled. 1. To atone for the cranial deficiency, by afibrding uniform, steady, yet gentle support to the part, by compress and bandage ; renewing the dressing as often as cleanli- ness and propriety of management require. 2. By antiphlogistics, timeous and efficient, to prevent or control the otherwise disorganizing inflammatory action. An attempt to cure comprises gi'eater difficulty. The obvious in- dications are, to restrain the inflammatory action ; and to repress the exuberant growth. The former is to be fulfilled by antiphlogistic * Bigelow ; Brit, and For. Rev., Oct. 1850, p. .543. f It has been supposed that the lost portions of cerebral substance are regenerated by a reparative effort on tlie part of the brain ; and that thus the non-inipairmeut of cerebral function may be accounted for. — Lancet, No. 1399, p. 760. e2 52 PAKAGENTESIS CAPITIS. treatment ; but this must be most -svarily couducted, inasmuch as by this time there is no tolerance in the system of severe remedies of that character. To fulfil the second, three means may be considered effectual ; pressure, ablation, escharotics. Pressure is to be preferred ; direct, accurate, steady, firm, but not severe — otherwise symptoms of compressed brain might be induced, Avith, not improbably, aggi-avation of the inflammatory action. The hydrostatic pressure, as recommended by Dr. Arnot, may be found higlily available. Ablation of the cere- bral protrusion is not expedient, unless the protruded part be in a sloughy condition, and must ultimately be lost ; or unless pressui'e, alone, have been duly tried, and found ineffectual. In either case, the protruding portion may be shaved smoothly off, by a knife, on a level with the cranial aperture ; and then restraining pressure is to be resumed. The use of escharotics is, in no case, advisable. The true hernia cerebri consists of cerebral substance more or less disorganized ; often mixed with gTumous blood, and other inflamma- tory products. Its formation is always a most unfavourable sign ; and the ultimate issue is seldom but unfortunate. The affection is sometimes simulated, however, by coagulum. A mass of clotted blood, mixed with inflammatory exudation, but containing little or no cerebral substance, may protrude ; presenting almost the same appearances as the genuine tumour. This is amenable to more summtuy treatment, and bespeaks a more hopeful issue — although usually a sign of active inflammatory action having seized on the part, and calling for a pro- liortionate activity in antiphlogistics. The projection is at once re- moved, by knife or fingers ; and firm occupying pressure is applied to the cranial aperture. Paracentesis Capitis. The operation of tapping the brain in chronic hydrocephalus, known to Hippocrates, and practised by the surgeons of the middle ages,* enjoys in the present day no great repute. Of modem practi- tioners, Dr. Conguest has shewn the greatest favour to the procedure ; and his experience of it has been by far the most favoured by suc- cess. I Of nineteen cases in which the operation was performed, ten were "living when last heard of"^ Dr. West has collected, fi'om various sources, fifty-six cases ;§ of which forty died, sixteen only recovering. Of the fatal cases, six died within four days ; six within fourteen days ; three mthin one * Philosoph. Transact, vol. xlvii. Ann. 1751. t Medical Gazette, March 1838. % In Dr. Conguest's cases, the greatest quantity of fluid dravni off" at one time was 5^0 J; the largest total quantity 5-57, or '^od^; the gTeatest numher of operations in any one case, five ; performed at intervals of from two to six weeks. § Medical Gazette, April 15, 1842. PARACENTESIS CAPITIS. 53 month ; nine within three months ; only one survived the puncture six months ; and none survived the last puncture more than thirty-five days. Death took place either by exhaustion or under cerebral symptoms. In many cases, in addition to the presence of much fluid, the substance of the brain was found softened ; and, besides, " there existed in sixteen of the cases serious organic disease, or malformation, of the brain itself." The serous accumulation usually takes place in the ventricles ; and the brain, if not congenitally deficient, is spread out and attenuated, with its convolutions smoothed away ; the ventricles ultimately consti- tuting one large cavity covered by a thin layer of cerebral substance, which lies immediately beneath its own membranes. Sometimes, on the other hand — though comparatively rarely — the liquid is immediately Avithin the dura mater ; and the brain, which in these cases is usually partially deficient in its commissures, lies at the bottom of the serous cavity. Remedial means in chronic hydrocephalus consist of purga- tives, and mercurials, assisted by gentle and uniform pressure on the head. Failing these, the question arises whether the patient is to be abandoned to his fate, or an attemjot made to save him by tapping. Some, acting on the pi'inciple " anceps remedium melius quam nullum," operate ; the majority decline interference. Statistics, in the aggre- gate, as we have seen, hold out no flattering prospect of success. At the same time, in an otherwise hopeless case, if the parents, on a fair and full representation of eveiy circumstance having been made to them, are willing and desirous to undertake the risk, there seems to be no insuperable reason against the operation being then performed. One of three events may occur ; death may ensue speedily ; or matters may be left much as they were, the head refilling ; or a cui*e may be effected. Hoping for the last, the surgeon proceeds thus — A small trocar is introduced perpendiculai'ly through the bregma, or in the coronal suture, at a safe distance from the longitudinal sinus and its feeding veins ; and it is seldom necessary to penetrate further than about two inches. Withdrawing the trocar, clear serum flows through the canula, and the more gradually it escapes the bettei* ; compensating pressure being at the same time made on the head, by the hands of an assistant. Should the pulse become quick, the pupils contract, and the face suddenly change its expression, the flow is stopped for a time. Faintness occurring, the child is laid horizontal, and a few drops of ammonia given in water. Sometimes blood comes through the canula, a sign that a vein has been punctured ; * sometimes the flow becomes obstructed by a portion of brain, and the canula re- quires to be cleared by a probe. After enough has been drained away, the wound is shut by means * Watson's Lectures, Medical Gazette, March 1841. 54 PARACENTESIS CAPITIS. of collodion, and the whole head is carefully and uniformly supported by elastic strapping. Should slight cerebral excitement follow, it is well ; for success is most probable in such cases ; a healthful action being induced by the excitement, as after injection of hydrocele (Principles, p. 196). But in general, mild doses of the hydrargyrum c. creta are useful, as a check against over action. And when this does occur, our main reliance Avill be placed on mercurial influence, with topical depletion by leeches. In the most favourable cases, we can scarcely expect a successful issue but by rej^etition of the tapping ; and the amount of interval must be regulated by circumstances. In but one case have I ventui"ed to operate. The first tapping proved highly satisfactory ; the second terminated fatally by convulsions. In connection with this chapter, besides the foot-note references, see Dease on Wounds of the Heart, Dub. 1760 ; Pott on Injuries of the Head, Lond. 1760 ; Pott's Sui-gery, by Earle, Lond. 1790; Desault, Oeuvres Chirurgicales, Paris, 1812; Abernethy's Surgery, vol. ii. Lond. 1815; Brodie, on Injiu'ies of the Brain, Med. Chir. Trans, vol. xiv. part ii. p. 325; Gama, Traite des Plaies de tete, Paris, 1835; A. Cooper, Lectures on Surgery, Lond. 1835; Sharp, on Injuries of the Head, 1841; Guthrie, on Injuries of the Head, Lond. 1842. 55 CHAPTER lA' DISEASES OF THE SCALP AND CRANIUM. Erysipelas of the Scalp. This disease may be idiopathic ; and then it is usually of a mild character, so far as intensity of the local action, and its effect on texture, are concerned. It is very apt, however, to supervene on wounds ; more especially if numerous dragging stitches have been unwisely used to effect approximation ; and, still more especially, if these stitches have been allowed to work their own way out by inflam- mation and ulceration. Such untoward accession to scalp wounds is also much favoured, by ungenial conditions of the atmosphere at certain seasons ; as well as by previous derangement of the primae vise, or habits of intemperance on the part of the patient (Principles, p. 383). If the phlegmonous form occur, danger to texture is great ; by diffuse infiltration, both above and beneath the tendinous expansion of the occipito-fi'ontalis ; and the constitutional symptoms are proportionally ui'gent. The chief peculiarities of erysipelas of the scalp, in a practical point of view, may be considered to be ; — the unfavourable nature of the parts for suitable treatment of the milder examples, on account of the presence of hair ; the unfavourable nature of the parts, on account of the presence of a large amount of tendinous expansion, for safe pro- gress of the more grave forms of the disease ; and the dangerous pro- pinquity of the affected part to an organ of the greatest importance, which is ever liable to suffer — either by extension of the inflammatory action, or by metastasis. Treatment. — When erysipelas threatens to seize upon the scalp, either directly, or by extension from the face, it is our first duty to have clean abrasion of the hair effected, so that the necessary measures may be fully in our power when the accession does occur. In the case of extension from the face, the disease is usually of the simple character, and limited to the skin. And it is well to attempt to turn it from its upward course, by placing a guard by means of nitrate of silver (Principles, p. 178), while time aiid space still permit. For cui'e, hot fomentations, with or without punctures, usually suffice, in addition to the ordinary constitutional management. Cold, or other repellents, OQ EEYSIPELAS OF THE SCALP. must never be employed ; they may be grateful to the sensations of the patient, at the time; but the risk by metastasis is overwhelming. Even the direct application of niti-ate of silver to the erysipelatous part is not advisable ; for a similar reason. Especial regard must be had to the interior of the head, both during the progress of the disease, and for some days after its apparent decline. For, it has not unfre- quently happened, that convalescence has been suddenly — and perhaps ruinously — interrupted, by inflammatory re-accession, not in the part originally affected, but in the membranes of the brain. Throughout the treatment the head is kept high ; the patient being almost in a sit- ting posture. If the phlegmonous form declare itself in the scalp, and dangerous infiltration have already begun, v^e cannot too soon make the requisite incisions (Principles, j). 390) in those parts Avhich plainly demand them. At first the knife need not pass beyond the sub-integumental adipose tissue, for the action has, as yet, gone no deeper ; but if, from neglect or otherwise, infiltration be already subtendinous, the knife must pierce tendon too ; otherwise the invariably aggravating tension cannot be relieved ; pain will increase greatly, and the inflammatory fever will rise higher; matter will burrow rapidly over the pericranium, and probably beneath it also ; and the action will extend widely, — perhaps involving the cranial contents, in at least a minor form. Timeous incision through the tendinous expansion is the only means whereby such extreme mischief may be mitigated ; but it is surely better practice, by an earlier and less extensive wound, to prevent all such casualties ; effecting recedence of the action Avhile it is yet limited to its original site, the skin and subintegumental tissues. When bui'rowing of matter has taken place beneath the tendinous expansion, it is not necessary to lay the track open throughout its whole extent ; but only, by the formation of a dependent opening — Avith a suitable counter-opening, if need be, — to prevent purulent ac- cvimulation, and to afford the parts an opportunity of effecting reunion by granulation. To assist in this indication, uniform support by bandaging is very useful, after the acute stage has passed by (p. 10). "When the scalp has been undermined by pus, even extensively, it does not follow that it must necessarily slough, in any part of the un- dermined portion. Its vascular supply is not so dependent on the subjacent areolar tissue as is that of ordinary integument ; the course of the ramifications of the occipital and temporal arteries being rather cutaneous than subcutaneous ; and the isolated skin — bearing its own vessels — consequently retaining its supply of blood but little impaired. Aware of the dangers of erysipelas of the scalp, it is plainly our duty in the management of all wounds of the head — however trivial they may at first seem to be — to avoid everything, in part and system, TUMOURS OF THE SCALP. 57 calculated to induce an undue amount and kind of inflammatory action ; more especially if, by previous indisposition, or sinister atmospheric influence, the patient seem to be predisposed to erysipelatous accession. Tumours of the Scalp. Encysted tumours, commonly called "Wens, are found more frequently on the scalp than in any other situation ; and they are seldom single. In general they are regarded mainly as deformities ; but when they inflame and open, they may become both troublesome and dangerous. In some cases danger has arisen from the progress of mere growth ; the calvarium having become absorbed, and consequently deficient, by the inward pressure of the tumour. The only advisable mode of treatment is removal by the knife. The main danger to be encountered is inflammatory action, assuming the erysipelatous character ; and this must accordingly be provided against by suitable constitutional treat- ment, as well before as after the operation, and by gentle and careful management of the Avound. If the tumour be of large size, it is removed by regular dissection. By two elliptical incisions, of merely subcutaneous depth, the redun- dant integument is detached ; and then the cyst, carefully preserved entire and tense, is leisurely dissected from its connexions, and taken away along with the portion of sacrificed integument. The flaps of saved skin are then replaced ; and, on oozing of blood having ceased, they are brought into accurate contact ; the wound being treated with the hope of adhesion. Approximation is effected by strips of isinglass plaster ; or by collodion and lint ; and to facilitate the application of these retentive means, the surrounding scalp has been previously shaved. If oozing of blood have not wholly ceased, it is advisable to maintain accurate pressure on the whole wound for an hour or two, so as to prevent inward accummulation of coagulum, an event neces- sarily fatal to adhesion (Principles, p. 198). Stitches are neither necessary nor advisable. If the tumour be no larger than a nut, or small egg, it is unneces- sary to remove any integument ; and regular dissection is therefore not required. A more summary process suffices ; that by incision, extru- sion of the contents, and evulsion of the cyst (Principles, p. 343). If an encysted tumour, in a patient advanced in years, have in- flamed and suppurated, and be in process of intractable ulceration, it is well to destroy the part effectually, either by escharotics or by ex- cision — the latter method the preferable ; for malignancy of action is othenvise apt to be assumed. Solid tumours, of various kinds, are occasionally found in this locality. Of these, the most common is the adipose ; seldom of large 58 TUMOURS OF THE SCALP. size ; and amenable to the ordinary treatment — excision. Of what- ever nature the tumour be, its removal should be early ; ere incorpo- ration has taken place, either with the scalp above, or with the fibrous textures beneath (Principles, p. 311). Erectile tumours very frequently occur in the scalp. They are best treated by deligation ; with or without previous reflection of the integument, according as this happens to be involved or not in the morbid structure (Principles, p. 600). The very large tumours of this class, sometimes met with on the side of the head, need not be tied all at once, but may be dealt with in portions ; different parts being strangulated at different periods. Experience has proved that, in such cases, attempted excision is fraught with the utmost danger to life, and that deligation of the main arterial trunk, or trunks, is an insufficient remedial means ; cases may occur, however, in which, as part of the cure, the principal arteries may be obliterated as they enter the tumour ; the tvdsted suture being employed for this purpose, as in the case of veins* (Principles, p. 615). Malignant tumours occasionally form in the scalp ; folloAving the usual course ; and amenable to the ordinary treatment. Benefit is to be expected only by free excision ; and that can be practised with expediency only at an early period. Medullary tumours may commence in the soft tissues, and involve the hard secondarily; fully as often, they originate in the bone. Malignant ulcer of the scalp is not uncom- mon ; beginning as a warty excrescence ; or the result either of an originally simple sore, or of an open and degenerate encysted tumour. Early ''"■ ^"' and free removal is had recourse to ; if the lymphatics as yet present no contra-indication. Pericranitis. The pericranium becomes the seat of an inflammatory process, with or without external injury having been applied. Acute action may be the result of wound or bruise ; following the ordinary course of such action in fibrous tissues. Or acute and suppurative action may extend from the surface ; as in erysipelas of the phlegmonous form. The usual antiphlogistic indications require to be fulfilled. Idiopathic pericranitis is more frequently chronic than acute ; and seldom occurs but in the adult, who is saturated with the rheumatic - Dr. WaiTeTi, American Journal of Medical Science, April 1846. Fig. 10. Cancerous ulcer, from the scalp. PERICRANITIS. 59 diathesis, or who has sustained injury of the system by mercury and syphilis — one or other, or both. The ordinary symptoms are present ; pain, swelling, heat, tightness ; and the nocturnal exacerbations are peculiarly marked (Principles, p. 414). The affection may resolve, leaving little or no structui-al change ; or the resolution is incomplete, an enlargement of bone remaining — resembling a diffused node. Or true inflammation is established ; and the bone suffers, to a greater or less extent, by ulceration, caries, or necrosis. Usually the periosteum of other parts of the skeleton is at the same time and similarly affected; and the bones most likely to suffer along with the cranium, are the clavicles, sternum, tibise, and ulnee. Treatment is mainly constitutional. The primte vias having been brought into a tolerably satisfactory condition, a sustained exhibition of the alteratives well known to be suitable to such cases is proceeded with — sarsaparilla and iodide of potassium, either together or alter- nately. The latter, especially, is found most beneficial. Locally, leeches and fomentations are applied, at first ; then, counter-irritation. The inflammatory process having been removed, and its results only remaining, nothing is more effectual than the endermic use of a strong solution of iodine. Throughout the whole period of cure, the hair is kept either shaved or short. Atmospheric exposure is carefully avoided ; and regimen is rigidly non-stimulant. If matter form acutely, it must be evacuated, fi'eely and early. If the abscess be chronic, opening is delayed, and discussion by iodine attempted. Even when rough and spongy bone can be plainly felt through the chronic collec- tion of pus, iodine should still be persevered with — along with the in- ternal use of iodide of potas.sium — when the affection is dependent on a constitutional cause ; for, in such cases, discussion is not unlikely to follow patient perseverance, even under circumstances by no means promising. Should acute or subacute accession supervene, however, the abscess becoming tense and crescent, let incision be no longer de- layed. In obstinate examples of pericranitis, causing mere change of structure, with slight swelling but great pain, the general health is apt to give way greatly, from want of sleep, and consequent exhaustion. In such cases it is essential to give opiates ; and if the more proper alteratives have proved ineffectual, mercury may be given in guarded doses (Principles, p. 419). Affections of the Cranium. Abscess and ulcer of the cranium occur from ordinary causes ; and are amenable to ordinary treatment (Principles, p. 433). Caries of the skull is preceded and accompanied by interstitial 60 AFFECTIONS ()F THE CRANIUM. absorption (Principles, p. 294) ; and seldom occurs but with a vice of system — seeming to be rather a symptom and sign of this, than to con- stitute a disease in itself And the predisposing vices of system are — Fig'. 12. scrofula in the young ; syphilis, mercurio-syphilis, or the ill effects of mercury alone, in the adult. Treatment, accordingly, is chiefly consti- tutional. Locally, the diseased structure is exposed ; and removal of the carious surface is effected by the gouge, or by escharotics — chloride of zinc, or red oxide of mercury (Principles, p. 440). Sometimes Nature is provident in this matter ; and herself effects the necessary clearance ; the useless parts coming away spontaneously, as small sequestra. If the whole thickness of the cranium be involved, there is of course additional danger, by dura-matral involvement ; and pi'ecau- tion requires to be exercised accordingly. Sometimes, unfortunately, a triumvirate of scrofula, syphilis, and mercurialism reigns in the system of the miserable patient ; and then, as can readily be under- stood, the local affection proves particularly intractable. Necrosis may involve the whole thickness of the skull ; the result Fig. 11. Interstitial absorption in progress, in the cranium ; at a, just begun ; at b, more advanced. It may stop here ; producing a merely cancellous state of the tissue ; or it may advance, becoming merged in ulceration, and producing caries, as in Fig. 12. Fig. 12. Different portions of the same skull as Fig. 11 ; at c, ulceration established, surrounded by interstitial absorption ; at d, caries, with necrosis, in the centre — intersti- tial absorption still accompanying. AFFECTIONS OF THE CRANIUJI. 61 of wound or not — usually the former. Then, as already stated, there is risk to life by purulent accumulation between the bone and dura -e^^i. mater ; and, if no external apei'ture al- ready exist — as by fracture — the use of the trephine is de- manded (p. 35). Exfoliation, or death of the external portion, is more frequent than complete necrosis ; the result either of external in- jury, or of chronic idiopathic peri- cranitis. The usual course of su- perficial necrosis is followed, here as elsewhere. Ordinarily, we await patiently spontaneous separation, and then remove the sequestrum. Sometimes, when detachment is tedious, acceleration may be effected by the application of escharotics (Principles, p. 462). And sometimes it is necessary to interfere and forcibly elevate the dead portion, which, though separated from the hard textures, is yet confined by soft granulating structures around (Principles, p. 462). In no form of necrosis of the cranium does the ordinary formation of cortical and substitute bone occur. And how fortunate such an arrangement is at once becomes apparent, when we consider what would be the in- evitable consequence of new bone bulging inwards on the dura mater. If the se- questrum have been superficial, healing is effected by a depressed cicatrix, as after simple ulcer of bone (Principles, p. 434). When the whole thickness has perished, atonement is made for the deficiency as after the operation of trephining (p. 48). As in the case of caries, many ex- amples of exfoliation of the cranium are dependent on the mercurio- syphilitic vice of system ; and require constitutional treatment accor- dingly. Fig. 13. jMercurio-Syphilitic Caries of the skull, a, A portion uetaelieil, in the form of sequestrum. Fig. 14. Ulcer of cranium, healed. The margins bevelled olf. and sloping down. The surface studded with imperfect granulation. From the same cranium as Figs. 11, 12. I'ig. 14- 62 AFFECTIONS OF THE CEANIUM. In connexion with the traumatic form, it is well to remember that detachment of the periosteum — even rudely and with some bruising of the bone itself— does not render the occurrence of exfoliation inevitable (Principles, p. 445). The part may, and frequently does, recover. And the treatment, in the first instance, is to be conducted with a view to such a result ; the flap of integument being carefully replaced, the wound approximated, and speedy healing sought for. Exostosis of the cranium is not uncommon ; of a dense, ivory character ; and usually of small size. Fortunately the site of growth is on the external aspect of the bone. No treatment is required. The affection is a mere de- formity ; and not even that, unless apparent from want of covering by hair. SpicLilated exostosis some- times grows from the inte- rior of the calvai'ium ; inducing intense neuralgia, or epilepsy. As already stated, there are some few cases so plainly marked as to admit of the offending body being removed by the trephine (pp. 48, 49). Tumours of the calvarium — osteosarcoma and osteocephaloma — are rare ; moi'e especially the true osteosarcoma. When they do form no treatment save mere palliation is advisable. The site and con- nexions of the affected part forbid operative interference. Polypus of the frontal sinus is a rare affection ; and, in its first stages, of difficult diagnosis. When detected, cure may be obtained by removing the bone to such an extent as will permit evulsion of the growth, with subsequent cauterization of its site.* * Brit, and For. Med. Rev. ; Jan. 1846, p. 186. Fig. 15. Fig. 15. Several ivory exostoses clustered on the os frontis. 63 CHAPTEH V. AFFECTIONS OF THE OKBIT, AND ITS CONTENTS. I. AFFECTIONS OF THE ORBIT. Orbital Inflammation Is usually the result of injury, when primary. Sometimes it is of a secondary character, and unconnected with violence done to the part; an extension of inflammatory action from a neighbouring part — from the eyeball, or from the scalp. Most frequently it follows injuiy. And the action is usually intense ; suppuration being certainly and soon attained. Pain is great and increasing ; tension is great, for swelling is hindered by the unyielding process of the periosteal lining of the orbit — termed orbital ligament — which confines the orbital contents in front ; vision is more or less impaired by compression of the eyeball, and this organ, according to the amount of deep swelling, is more or less protruded ; the eyelids are red and oedematous ; in- flammatory fever is intense, and the cerebral functions are often promi- nently disordered. Treatment comprises the ordinary antiphlogistic indications. When a wound exists, careful examination is expedient, to ascertain whether or not any foreign substance — as straw, wood, iron — has penetrated and lodged ; and if such an obvious exciting cause of inflammation be detected, it is forthwith removed. Leeches are applied in numbers ; in some cases, general blood-letting may also be found advisable ; and the antiphlogistic accessaries to blood-letting — aconite or antimony, purgatives, quietude, &c., will not be neglected ; vomiting being avoided, for obvious reasons. The part is diligently fomented ; and so soon as indications exist, — however faint — of matter having formed, an evacuating incision is practised ; it being obviously of the greatest importance to penetrate the orbital ligament at an early period of the suppuration. On evacuation of matter, the symptoms are speedily mitigated ; the tension, throbbing, and intense pain almost immediately. If incision be delayed, spontaneous evacuation takes place ; but not till after much suffering, considerable destruction of texture, and dangerous impairment of function in the eyeball. 64 WOUNDS OF THE ORBIT. Wowids of the Orbit. These are usually of the punctured kind. As just stated, they are liable to prove the exciting cause of intense inflammation, more especially when there is lodgment of foreign matter. And the pro- bability of the latter circumstance must always be regarded in practice. The wound having been ascertained to be clean and free, is carefully approximated ; and cold is continuously applied, with much care, in order to avert inflammation, if possible, and secure union by adhesion (Principles, p. 635). If inflammation supervene, antiphlogistic treat- ment must be early and active ; a suppurating wound is then inevitable; but we hope to avert deep and confined abscess, which is prone to form by extension of the inflammatory action beyond the wound's track. But such injuries acquire a still higher importance, in reference to the parietes of the oi'bit. A penetrating wound of the orbit — as by a bayonet, pike, or pitchfork — is not unlikely to produce fracture of the orbital plate ; and the fragments of the broken bone, driven inwards, are certain to penetrate or otherwise injure the brain or its membranes; endangering life, perhaps immediately, by extravasation of blood — more probably by the results of inflammation at a more remote period. Such wounds, therefore, require to be treated with the greatest caution. The extent of injury done to the bone is ascertained as soon, as accu- rately, and yet as gently as possible. If loose fragments are found to exist, these it is well to remove ; the external wound being dilated, if need be, for this purpose. And when the spicula are certainly dis- placed inwards, injuring the important parts in that direction, an attempt should be made to take them away ; whether they seem detached or firm. The indication is as paramount, as in punctui'ed fracture of any other part of the cranium (p. 43). This important part of the treatment having been satisfactorily accomplished — by dilatation of the external wound, and the suitable use of fingers, forceps, and probe — the patient is placed on his face, with the wound unapproxi- mated, until bleeding cease ; internal extravasation being thus ren- dered less likely to occur. Then the parts are brought together ; and antiphlogistics are diligently employed, both locally and generally, in order to avert, if possible, an untoward amount and extent of the inflammatory process. Tumours of the Orbit, Hard Tumours of the orbital parietes are uncommon. The dense ivory exostosis produces little inconvenience, is usually of inconsider- TUMOURS OF THE ORBIT. 65 able size, and requires no treatment. The cancellated exostosis — of a pedunculated character, and larger dimensions — may incommode the eyeball. If so — the nature of the case being plain — an incision may- be made on the origin of the growth ; its neck may be cut by the bone-pliers ; and, by careful dissection, tlie offending substance may then be removed (Principles, p. 477). Soft Tumours are of more frequent occurrence. And they may be practically divided into three classes. 1. The simple and sarcomatous ; amenable to excision. 2. The erectile ; capable of cure, but not by direct operation. 3. The malignant; usually forbidding operation, and admitting only of palliation. 1. The simple tumours — simply sarcomatous, fibrous, fatty, cystic — may form in the orbital areolar tissue, unconnected with either the bone or its periosteum ; and the growth may be either of idiopathic origin, or a remote consequence of slight injuiy. Enlargement is slow, gradual, comparatively painless, and unattended with inflammatoi-y signs ; not likely therefore to be mistaken for orbital abscess. As in the latter affection, however, outward growth is prevented by the orbital ligament ; compression of the eyeball follows ; and this organ may be more or less protruded from its socket. At first, sight is not lost, and scarcely even impaired ; for stretching of the optic nerve is gradual, and nervous as well as cerebral tissue has a very considerable power of accommodating itself to displacing agencies gradually applied. Ulti- mately, however, the sti'etching and displacement are attended with more or less impairment of vision. By careful inquiry into the history of the case, we satisfy ourselves that the tumour is of the simple kind. Of what exact species it may be, it is not easy to determine ; for the tense orbital ligament stretched over the swelling obscures tactile examination. Generally, however, we are able to satisfy ourselves on another point ; whether or not the tumour is moveable — connected or not with the bone and periosteum — consequently removable or not, entire, by operation. When con- vinced that the tumour is simple and moveable, we do not hesitate to attempt its extii-pation. A wound is made of sufficient extent, in a line parallel to the fibres of the orbicularis muscle. By cautious dis- section, the tumour is reached and exposed. It is then laid hold of by a volsella, or hooked forceps ; and evulsion outAvards being steadily yet gently maintained, extirpation is rendered both easy and safe. The point of the knife is moved very warily, v/hen near or in contact with the orbital parietes ; for these, by the pressure of the tumour, may have been much attenuated ; and a careless movement of the instru- ment might cause penetration. The eyeball and optic nerve are also carefully avoided. After removal of the tumour, the former is care- fully readjusted in its proper place ; and restoration of its functions QQ INJURIES OF THE EYELIDS. usually ensues. The wound is brought together, and treated for ad- hesion. Partial removal even of the simplest tumour, in this situation, is obviously inexpedient. For, reproduction vpill almost certainly occur from the portion v^hich remains ; and such second formations are very apt to prove of an unfavourable kind. 2. The Erectile tumour is occasionally found occupying the orbit. It is seldom congenital ; but occurs suddenly, in after life ; and its origin is usually attended with a considerable amount of pain. At first an obscure deep swelling is found, causing more or less incon- venience ; but as it enlarges, and approaches the surface, the ordinary characteristics of erectile tissue become sufficiently apparent. Often tlie cheek is covered with large veins — recipients of the blood from the more active vessels within. This tumour cannot be treated directly ; neither knife nor ligature are advisable. Yet, if no remedial means be adopted, the probable issue Avill be unfortunate ; by enlargement, ulceration, hemorrhage ; by involvement of the orbital parietes, and subsequent pressure on the brain ; or by mere constitutional irritation. Experience has shewn that deligation of the corresponding carotid is capable of effecting a cure ; not by obtaining consolidation and obliteration of the dilated vessels ; but, probably, by diminishing their supply of blood, remov- ing the impulse of the heart's action, and so favouring resumption of the normal calibre. And free blood-letting, after the operation, would seem to conti'ibute materially towards this result (Principles, p. 601). 3. Tumours of a malignant kind — medullary — are no unfrequent occupants of the orbital cavity. Generally they originate in the eye- ball : but occasionally this is involved only secondarily — the origin being in the orbital areolar tissue, in the periosteum, or in the bone. The sole hope of cure is by extirpation of the whole orbital contents. And tliis is expedient only when the disease is recent, apparently limited to the soft parts, and capable of entire removal. II. Affections of the Eyelids. Ecchymosis is of frequent occurrence in the eyelids ; the areolar tissue being lax and delicate. Ordinarily it is the result of a bruise or blow ; but it may follow a wound, more especially if oblique or sub- integumental ; the application of leeches is almost certain to produce it, to a greater or less extent. It is important as a deformity. A patient, having received an injury likely to be followed by ecchymosis, is anxious that this should be prevented ; and, the escape of blood FOREIGN BODIES IX THE EYELIDS. G7 having occurred, he is equally anxious that the discoloration should be removed. Many remedies are popularly in vogue for both of these ends. For the former, the continuous application of cold by wetted lint, with quietude and abstraction of all stimuli, is both suitable and easily obtained : if begun immediately on receipt of the injury, and properly maintained, the natural hemostatics will be much favoured, and very probably little or no blood will escape from the torn vessels. Ecchjonosis having occurred, the natui'e of the application must vary according to the presence or not of inflammatory action in the part ; in the one ease, fomentation is emj^loyed, subjugation of the morbid vascular action being the paramount indication ; in the other, a solu- tion of the muriate of ammonia, or other sorbefacient, is applied, in order to hasten removal of the extravasated blood by absorption. Wounds of the eyelids, if contused, are treated by the water-dress- ing. If incised, approximation is effected by fine sutures ; other re- tentive means being plainly inapplicable to this locality. Great care should be taken to restore the normal relative position with accuracy, lest deformity ensue. In the case of burns, much precaution is required during the pro- cess of healing ; lest by contraction ectropion supervene. And the careful dressing and bandaging necessary for this purpose is continued even for some time after the parts have healed. Foreign Bodies. Foreign bodies of small size — as particles of sand, dust, glass, coal — very frequently lodge in the eyelids, on their conjunctival lining. The patient, suffering much pain and iri-itation — with the eye already red, intolerant of light, and profusely lachrymating — applies for our aid on account of " something in his eye." Gently opening the eye- lids, before a steady light, we scrutinize the eyeball in the first place ; directing the patient to roll the organ in various directions, in order to facilitate such examination. If particles are found adherent, they are in general easily removed ; by a curette, or fiat end of a probe ; by a hair pencil ; or by a fold of a soft handkerchief. If fine dust only have lodged, fomentation and ablution will ordinarily suffice ; assisting the lachrymation in its spontaneous cleansing effort. Sometimes it may be necessary to inject a gentle stream of tepid water, by means of a small syringe. In other cases, it is enough to shut the eye, or keep it shut, for a few minutes — occasionally blowing the nose ; thus favour- ing the natural Avashing away of the foreign particles, by increased lachrymal and conjunctival secretion. The eyeball having been duly scanned, the lower eyelid is next examined; its conjunctival lining being readily exposed to a sufficient extent, by simple depression of the part. But the upper eyelid is the site most frequently occupied by f2 68 BLEPHAEITIS. the foreign substance ; and it cannot be sufficiently exposed, Avithout eversion. This is effected by placing a probe horizontally across the lid, above its cartilage ; taking hold of the eyelashes with the finger and thumb; and bending the eyelid backwards over the probe. If the foreign matter be loose, it is removed by any of the means already mentioned. If it be firmly lodged, the point of a tooth-pick, or of a couching needle, will most conveniently eflfect its dislodgment. In certain occupations, particles of steel or iron are apt to get be- tween the eyelids, and often become impacted in the cornea. When loose, they may sometimes be brought to the surface and I'emoved, by means of a magnet of strong power; but generally the point of a couching needle is required to effect their detachment. "When no assistance is at hand, the patient may himself, in many cases, get rid of the irritating matter ; by elevating the upper eyelid with the fingers of one hand, and pulling it downwards, while he at the same time closes the lower, and pushes it upwards. Having pi'essed gently over the globe, the finger is then -withdrawn, and the lids allowed to separate. The eyelashes of the lower lid are thus made to sweep the conjunctival lining of the upper ; and it is in the latter situation, as already stated, that foreign bodies of small size usually lodge. The foreign body having been removed, the eye is closed ; light is excluded ; and antiphlogistics are employed according to circumstan- ces. It is plain that if the foreign substance be not removed, infiam- matory action will certainly be established, and probably prove unto- ward and intractable. Cases are not wanting in which complete de- struction of vision has been the ultimate result of but a small particle of foreign matter lodging in the conjunctival lining of an eyelid ; per- haps with much injury done to the system by severe and sustained treatment directed against the inflammatory action and its results.* Blepharitis. The inflammatory process, attacking the eyelids, is so named. It may follow injury; assuming the ordinary character and course, and amenable to the ordinary treatment. In erysipelas of the face, affection of the eyelids is usually a most prominent symptom ; the laxity of their areolar tissue admitting of much and unseemly swelling. Punctures are usually necessary ; not so much to abstract blood, as to evacuate serous effusion. After recession of the primary symptoms, this part must be closely watched ; for, during convalescence, reaccession of inflammatory action is very apt to occur, advancing rapidly to suppuration (Principles, p. 280). And unless an early incision be made here, the abscess will be large, and the integument will probably slough. * Lancet, Xo. 1061, p. 43.5. One among many. SWELLINGS OF THE EYELIDS. 69 Ophthalmia Tarsi. By this is meant a congestion, or clironic inflammatory process, affecting the eyelids ; more especially at their mai-gins. The Meibo- mian follicles are prominently affected ; and a viscous, disordered se- cretion adheres to the parts, tending to cause cohesion of the ciliary margins. More or less lachrymation, in general, exists. The eye- lashes are stunted, or deficient. Itching, heat, and intolerance of light, are usually present ; and the general expression is bleared and unple- sant. The disease will usually be found co-existent "vvith some vitiated condition of the general system ; and to that the treatment must be mainly du-ected. Not unfrequently, the constitutional vice will be found of the scrofulous character. If pain, heat, redness, and other ordinary characteristics of the inflammatory process exist at all promi- nently, blood is to be taken sparingly from the part, by scarification of the conjunctiva, or by leeches at the inner canthus. For a few days afterwards, fomentations, medicated or not, are to be apiilied. Then stimulants are used ; such as solutions of zinc, or nitrate of sil- ver ; or the ung : nitratis hydrargyri dUuted. In obstinate cases, counter-irritation is sometimes useful ; and this is best effected by the application of blisters behind the ears. In children, the state of the gums and teeth must be looked to. An advanced form of this chronic affection of the eyelids is sometimes termed Lippitud.o. The ciliary margins are red, thickened, everted, and denuded of hair ; and the eye seems to be surrounded by an angry red circle. The general expression is consecpieutly very un- pleasing ; and the patient's discomfort is also great. Local and general alteratives are pre-eminently required ; but they often fail to prove quite satisfactory. Stimulants applied to the parts are useful; such as pencilling the lids with a solution of nitrate of silver, and the like. Not unfrequently, ophthalmia tarsi is but a part of a more general affection of the eye, of a strumous character. Hordeolum^ and other Sioellings. By Hordeolum, or Stye, is meant a circumscribed inflammatory swel- ling, which may either remain of an indolent and indurated character, or advance to suppuration. In the latter case, discharge of matter takes place, and discussion slowly follows. Yery fi-equently the affec- tion originates in a Lleibomian follicle, and resembles an ordinary pimple. The follicle is obstructed, and its contents accumulate ; an inflammatory process is then kindled in the perverted part, suppura- 70 ENCYSTED TUMOURS OF THE EYELIDS. lion takes place, and the enlarged follicle becomes the seat of a small acute abscess. Here, too, the general health will be found amiss ; and purgatives, alteratives, with regulation of diet will probably be required. While the swelling is nascent, fomentation and light poultices, or water- dress- ing, are suitable. When matter has formed, a puncture should be made at the apex of the swelling, for efficient discharge ; and then water- dressing is again applied. If a chronic hardness should threaten to remain, discussion of this will be promoted by pencilling the part lightly over with a solution of iodine, or nitrate of silver. An inflammatory swelling, similar to the true hordeolum, may form in the ordinary areolar tissue of the eyelid ; resembling a small furunculus. It is amenable to ordinary treatment. Small, hard swellings, of a whitish colour, very superficial, pain- less, and almost stationary, occasionally form beneath the integument of the eyelid. According to their size, they are termed either Grando or Milium ; according as they most resemble a piece of hail or a millet- seed. Causing deformity, they requii'e removal. A scratch is made through the thin skin stretched over them, and the white pearly-look- ing substance is squeezed out. No escharotic is necessary. The wound scarcely bleeds, and heals simply. Warts sometimes form on the eyelids. They may be taken away by scissors, ligature, or caustic. E^icysted Tumours of the Eyelids. Encysted tumours are of frequent occuiTence in this situation ; more especially in the upper lid. They are usually of small size ; the contents are white and glairy ; the cyst is extremely delicate. Their site may be either subcutaneous or submucous ; on the conjunctival or on the external aspect of the tarsal cartilage. The majority of the patients are of the female sex. Removal by regular dissection need not be attempted : the cyst is too delicate. And, for the same reason, incision, with evul- sion of the cyst, is inapplicable. It is suflii- "' " cient, in many cases, to incise the part, to squeeze out the contents, and vv^ith the point of a probe to dis- turb and break up the tender cyst. But, in some cases, it is well to apply an escharotic, so as to ensure the cyst's destruction, and conse- quent non-reproduction of the tumour. The nitrate of silver is very suitable ; escharotic enough to annihilate the cyst ; and not likely to Fig. IG. Encysted tumour of the lower eyelid. The lid everted. CANCER OP THE EYELIDS. 71 cause such loss of substance as would delay the cure, extend the cica- trix unnecessarily, or risk the occurrence of either inversion or ever- sion of the lid by contraction of the cicatrix. Incision is facilitated by effecting previous tension of the part. This is done by simply stretch- ing the skin over the swelling, and cutting through the attenuated in- tegument — taking care to make the incision in a direction parallel to the fibres of the orbicularis muscle ; or by everting the lid (p. 68), and then cutting through the stretched and pi'ominent muco-us mem- brane. Either form of procedure is the preferable, according as the site of the tumour happens to be subcutaneous or subconjunctival. Hypertrophy of the Upper Eyelid. The upper eyelid is occasionally affected by hypertrophy of both its integument and mucous membrane. The swelling is considerable, and causes deformity ; it also obstructs vision ; and there is an unplea- sant puriform discharge. By two elliptical incisions, a sufficiency of the diseased integu- mental texture is removed ; and the wound is approximated by suture. The conjunctival change is subsequently remedied by scarification, followed by the use of sorbefacients. Or, should the conjunctiva resist this gentler means, partial ablation of it may be practised, as in the case of the integument.* Cancer of the Eyelids. Malignant ulceration is usually preceded, in the eyelids, by warty formation. The only cure is by excision ; early and free. If the disease be limited, sufficient removal may be effected, yet without deformity or exposure of the eyeball ; the wound being so shaped as to come well together by suture. But when the disease is extensive, and an operation warrantable, the prevention of deformity need not enter into our thoughts. One paramount indication is pi'esent — removal of all the diseased part. That must be effected, at whatever sacrifice of texture. When it is found necessary to remove the whole or greater part of the eyelids, more especially the upper, on account of malignant ulcer, it comes to be a question whether or not it be politic to spare the eyeball — supposing it to be apparently sound. Some writers recommend its removal at once, considering that the organ, being deprived of its natural protection, Avill be destroyed by inflam- mation. This, however, is not always the case. It is better to wait till this event has actually taken place, and then to induce collapse of the globe, by puncturing the cornea, and allowing the humours to * LisTON, Lancet, jSTo. 1080, p. 489. 72 CLOSURE OP THE EYELIDS. escape ; this is more safe and simple than immediate extirpation, and equally efficient. Intractable ulcers of the eyelids — not malignant — are best treated by regard to the state of the system, more especially of the digestive organs ; and by occasionally touching the parts with the fluid nitrate of mercury or nitric acid. Sometimes they are of a syphilitic cha- racter ; obviously dependent mainly, for cure, on constitutional treat- ment. Closure of the Eyelids. By the term Anchylohlepharon is understood, union of the eyelids at their tarsal margins ; congenital ; or accidental, the result of cica- ti'ization after burn or scald. When congenital, the cohesion is seldom to a great extent ; occupying only the angles. No interference may be deemed necessary. "When more extensive, causing not only an unseemly deformity, but likewise interfering with vision, separation of the preternaturally united parts may be readily effected by incision. Afterwards, all necessary means should be taken to prevent reunion ; each lip of the wound being made to cicatrize separately, by granulation. When the closure is complete — a circumstance of rare occurrence — a fold of the parts should be first raised from the ball, and cut through in a horizontal direction ; through this aperture a director is carefully introduced ; and on it the subsequent division to the angles is safely effected. The accidental form is amenable to similar treatment. But greater care is necessary, in the after management, to avoid reunion. This is prevented by the interposition of dressing, frequent movement of the parts — and, if necessary, by forcible separation of the lids by plaster, and the application of some gently astringent lotion. By Symhlepliaron is meant adhesion of the eyelids to the eyeball ; seldom congenital; usually the result of cicatrization after injury. In some cases, the cicatrix is dense and contracted; admitting of no attempt at cure. In others, the adhesions are comparatively slight, and there is sufficient laxity of texture. In these latter, the lids are to be liberated by careful dissection; their separate cicatrization being afterwards carefully attended to. Reunion is much more liable to take place in symblepharon than in anchylohlepharon ; and is best prevented by frequent motion of the eye, by proper dressing, and by the occasional introduction of a probe to separate the new adhesions. The temporary insertion of an artificial eye has been suggested ; but even the most persevering exertions have often proved unsuccessful. Lagoplithalmos. Lagophthalmos, or Hare-eye, means an inability to close the eye- lids ; and the eye being deprived of its natural protection is exposed to PTOSIS. , 73 the action of the ah' and other external irritants, which rnay cause inflammation of the conjunctiva, eventually terminating in opacity of the cornea. The disease often results from paralysis of the orbicularis muscle ; more frequently it is caused by retraction or shortening of the lid, arising from contraction following abscess, or burns and other injuries. Sometimes it proceeds from cold or other causes acting upon the facial nerve in its transit or distribution. The treatment varies according to the cause. When the affection arises from paralysis, blisters, friction, electricity and strychnine are appropriate ; when from retraction of the lid, division of the cicatrix may be of use ; and when from affection of the facial nerve, leeches, blisters, and stimulants in the course of the nerve are to be employed. When it is caused by cerebral congestion, antiphlogistic remedies are to be had recourse to. Ptosis. Ptosis is a falling downwards of the upper eyelid ; producing no inconsiderable deformity, and seriously interfering with vision. It may constitute a disease of itself; or it may be but a symptom of serious affection of the brain. When original, it may depend on debility of the elevating muscle, or on superfluity or thickening of the integument; or it may be connected with both of these circumstances. Redundancy of integument is easily got rid of, by removing a suf- ficient portion, either by knife or by scissors. Atony of the muscle may be overcome by stimulant frictions, the passing of electricity, or the endermic use of strychnine. Ordinary means having failed, an operation may be had recourse to. A large portion of integument is removed from the eyelid, and also from a corresponding portion of the eyebrow ; the two raw surfaces are then brought into apposition by suture, and when union has taken place the lid will be elevated by the action of the occipito-frontalis muscle, to such an extent as to admit of useful vision. In the secondary form, dependent on affection of the brain, treat- ment must of course be directed to the cerebral disease. Trichiasis, and Distichiasis. Trichiasis denotes inversion of the eyelashes, whereby much irritation is induced on the surface of the eyeball. The inversion may implicate the whole cilia, or only a few. It may occur in either lid ; but is most frequent in the upper. The position of the eyelid itself is not altered. At first there is merely inconvenience ; but, sooner or later, an inflammatory process is established on tlie surface of the eyeball, and consequent danger to vision may prove great. 74 , TRICHIASIS, AND DISTIOHIASIS. Treatment is either palliative or radical. The former consists in evulsion of the erring cilia, from time to time, and mitigation of the irritation and inflammatory action which they may have occasioned. For evulsion, a pair of broad-pointed forceps, with their opposing surfaces in accurate contact, are required ; for the hairs are usually both slender and light coloured ; and the assistance of a lens is often necessary. This method is on the whole unsatisfactory ; and is only applicable to those cases in which but a few of the cilia are in fault. To effect a radical cure, it is essential that the lashes be not only removed, but that their non-reproduction shall be insured. One of two methods may be followed. The errant cilia may be plucked out, and their bulbs destroyed. Or the bulbs and cilia both may be re- moved by cutting instruments. The former method is applicable to the partial trichiasis ; the latter to the complete. If the former be chosen, an incision is made with the point of a lancet, on the free margin of the lid, down to the roots of the inverted cilia ; into this little opening a needle or another lancet, coated with powdered tar- trate of antimony, is inserted — allowing it to remain so that its coating may dissolve there ; and the hairs are then pulled out. A small pustule forms, and the bulbs are destroyed.* When it is our object to remove not only the cilia but their bulbs, a horn spatula is introduced beneath the lid, an incision is made down to the tarsus along the whole length of the inverted portion, parallel to, and about a line from the ciliary margin, to which it is to be connected at each extremity ; the ciliary edge is then to be laid hold of with the forceps, and the integuments carefully dissected from the cartilage, so as to include the bulbs without interfering with the mucous edge of the lid. When the part cicatrizes, little deformity will result. Or, the margin of the lid is laid hold of and stretched by the fingers of the left hand, or by forceps ; and by the stroke of scissors, or the SAveep of a fine bistoury, the requisite amount is taken away. By operating in this way, more deformity will be produced than by the former plan ; but by either the eyeball will be freed from a con- tinual source of irritation. By Distichiasis is understood a row of supernumerary cilia, grow- ing inwards, and causing the same iinpleasant and untOAvard results as the foregoing affection. The same treatment is required as for tri- chiasis. But more careful examination is expedient ; inasmuch as the observer is apt to be deceived by seeing the ordinary eyelashes of their normal character ; and, even when the lid is raised and scrutinised, the paucity, slimness, and paleness of the stray lashes may often cause them to be overlooked ; — a serious matter ; for unless they be noticed and removed, inflammatory action Aviil not only become establislied, * Edinburgh Monthly .Journal, April 1841, p. 2r,9. ENTROPION. 1 5 but will prove uncontrollable. To detect them readily, the lid should be inspected laterally as well as in front, and the patient should be desired to turn his eye in different directions, so as to form a dark back-ground of the iris and pupil. Entropion. This is a turning in, not only of the eyelashes, but of the margin of the eyelid itself, attended with all the unpleasant consequences of trichiasis, in an aggravated form. It may be temporary or permanent. In the former case, it is the result of inflammatory swelling of the eyelid ; "the tumefied conjunctiva pressing out the orbital edge of the tarsus, while its ciliary margin is turned inwards bv the action of the orbicularis."* When . Fig. 17. permanent, it may depend on relaxation of the integument of the lid, whereby displacement inwards of the ciliary margin is both permitted and favoured ; or on contraction of a cicatrix on the conjunctival aspect of the lid, whereby the ciliary margin is directly pulled inwards ; or on a perverted form having been assumed by the tarsal cartilage itself, in consequence of ophthalmia tarsi, psorophthalmia, or other chronic disease. Either eyelid, or both, may be affected. It is evident that treatment must be both early and suitable, if we wish to save the eyeball from serious injury. In the temporary form, it will be suflBcient to oppose inversion by the application of retract- ing plasters, frequently renewed, until the cause of displacement has been removed by treatment directed towards subjugation of the inflammatory process and dispersion of its swelling. In the perma- nent form, operative interference is essential. If the integument be redundant, a portion is to be removed. And it is necessary that, in the first instance, a very careful examination be made, to determine how much is to be taken away, so as to insure rectification of the position of the eyelid ; while yet we avoid removing an unnecessary amount, and so causing an opposite condition of the parts — ecti'opion. A horizontal fold is pinched up by suitable forceps, or by the fingers, and is removed by either knife or scissors. The edges of the wound are then united by sutures, and adhesion follows, Escharotics may be employed for the same purpose ; but they are inferior to the cutting instruments, being possessed of no exactitude as to the amount of texture * LiTTEix on Diseases of the Eye, p. 95. Fig. 17. Entropion, aflecting botli eyelids. 76 ENTROPION. to be destroyed. Sulphuric acid is the most effectual, not only destroy- ing skin, but consolidating the areolar tissue, and producing ever- sion by contraction of the granulations. When acid is used, a piece of round hard wood is dij^ped into it, and applied behind the tarsal cartilage in a line extending the whole length of the inverted portion. Cold water dressing is applied, and in a few days the slough separates, the granulations contract, and the lid is restored to its proper position. The eye, however, must be carefully guarded from the acid, during its application, by a piece of wetted lint introduced between the lid and the globe. This action of sulphuric acid causes in general exquisite pain, and is only applicable to cases where the patient will not submit to an operation by sharp instruments. When the disease is dependent on a perverted state of the ciliary margin and tarsal cartilage, one of two methods may be adopted. The cilia and their bulbs may be removed, as for trichiasis ; care being taken to leave the puncta lachrymalia intact. Or, by such an operation as the following, an attempt may be made, retaining the eyelashes, to liberate and restore them to their normal position. " The patient having been placed in a sitting posture, and the head supported by an assistant, the inverted lid is separated from the globe of the eye by means of the finger or a sharp hook ; and then with a pair of strong scissors, two perpendicular incisions are made through the tarsal cartilage, each about a quarter of an inch in length, the one upon the temporal, the other upon the nasal side, avoiding the punctum, and including the whole inverted portion of the lid. This part being now everted, and held in that position, the two perpendicular incisions are connected by a horizontal incision upon the conjunctival surface, close to the ciliary margin, by means of a scalpel ; cutting through the conjunctiva and tarsal cartilage, and leaving the inverted portion of the margin united to the rest of the lid merely by the integument. And especial care is taken that the knife does not penetrate through the skin." Water dressing is applied. And " the success of this operation depends in a great measure on the edges of the incision being prevented from uniting by the first inten- tion, particularly the horizontal incision upon the conjunctival surface. This is effected by everting the lid occasionally during the first few days, and by touching the edges immediately after the operation Avith the sulphate of copper, so as to cause them to suppurate and heal by granulation."* Mr. Cramp ton's operation for entropion consists in making a perpendicular section of the lid, with scissors, at each can- thus, from a quarter to half an inch long ; taking care not to wound the punctum. An elliptical portion of skin is then removed from the outer surface of the lid. Two or three ligatures having been introduced " Dulilin Medical Press, Julj^ 27, 1842, p. 54. PXTROPION. 77 through the skin at the tarsal margin, the eyelid is everted by means of them, and drawn up towards the eyebrow ; in which position it is retained for a few days, by the ligatures being fixed to the forehead with a strip of adhesive plaster. In the meantime, the exposed mucous membrane is covered with a piece of wetted lint ; and as the pei'pendi- cular incisions heal by granulation, a sufficient degree of eversion will be pi'oduced. Mr. Tyrrell recommended that the lid should be merely divided at its centre by a single perpendicular incision. The pressure caused by the contracted cartilage was thus relieved ; and as the wound, shaped like an inverted /\, became filled by granulations, very little deformity would result. Both operations are only applicable to cases where the disease arises from a contracted state of the cartilage. Ectropion. Ectropion denotes an opposite condition of the eyelid ; its eversion ; and is more frequently met with in the lower, than in the upper lid. The conjunctival liningis exposed, the eyeball is partially denuded, > i and much deformity is produced. ' After a time, the exposed palpe- \ ,i' bral conjunctiva loses much of its ^ """" membranous character ; the sur- face of the eyeball becomes irri- table, inflames, and undergoes change of structure — probably fatal to vision ; and a degree of Fig. 18. epiphora invariably exists, in consequence of the natural course of the lachrymal secretion towards the puncta being interrupted. The mal- position most frequently results from contraction of cicatrices of the in- tegument ; and these may exist in the eyelid or its immediate vicinity, in the corresponding cheek, or extensively on the face and neck as after severe burns (Principles, p. 694). The lower eyelid is the more fre- quently afiected. The cicatrix may follow a burn, wound, sloughing abscess, or exfoliation ; the first and last are the most unfavourable. Ectropion, however, ai'ises from other causes than the contraction of sores. Simple relaxation of the lower lid will produce it ; and this may depend on flabbiness and redundancy of all the component textures, or on atony only of the fibres of the orbicularis. The last circumstance is no uncommon occurrence in old people. Frequently ectropion is caused by a faulty condition of the conjunctival lining of the lid; which is the seat of swelling, of either an acute or chronic kind. And it Fig. IS. Ectropion, affecting tlie upper eyelid ; the result of exfoliation. ECTEOPION. 'fyf'ifamrfi Fix. 19. is Avell to remember, how general inflammatory swelling of the lid is able to cause either inversion or eversion, according to the accident of displacement ; just as a similar condition of the prepuce may be the cause either of phymosis or of paraphymosis. Eversion is no uncom- mon attendant on purulent ophthalmia ; from the acute and great swelling of the lid, more especially of its conjunctival lining. It also results from an indolent enlargement and thick- ening of that membrane. The accidental divi- sion of either canthus, too, may cause it; the lid becoming loose and pendulous. Or it may arise from an elongated and irregular state of the tarsal cartilage. Treatment necessarily varies according to the nature of the cause. Acute swelling of the eyelid and its lining is subdued by the usual means. Chronic enlargement of the membrane is first treated by scarification, and astringents. If these be resisted, the redundancy may be removed, either by curved scissors, or by caustic ; the former obviously to be preferred ; great care being taken lest, by the removal of too much, entropion be produced. Atony or paralysis of the fibres of the orbicularis may be combated by the usual means ; but, generally, this form of the aifection, occurring in those of advanced years, may be regarded simply as one of the many signs of decay, and irremediable. When there is elongation of the tarsal cartilage, or redundancy of the whole lid, abbreviation, sufiicient to restore normal position, is effected by a simple operation. Towards the centre of the lid, a triangular portion of its whole thickness is to be removed in the form of the letter V ; the margins of the wound are brought together by suture, a proper compress is applied, and when the parts heal the lid wiU be in close apposition to the globe. In the case of faulty cicatrices, the procedure is more diflBcult and less promising. Occasionally, the simple division of a tight adhesion may sufiice for liberation and replacement. But generally, there is loss of substance connected with the cicatrix, and consequently simple incision proves inadequate. In the case of a moderate cicatrix, at some distance fi-om the ciliary margin, amend- ment, if not complete restoration, may be effected as follows : Supposing the lower eyelid to be affec- ted, a Y wound is made, through the integument only, the apex pointing to the cheek.. By means of the knife's point, Fig. 19. Ectropion, affecting the lo-n^er eyelid. Fig. 20. Plan of this operation; the dotted line marking the original wound; the plain line representing the flap of skin in its new and elevated position. Fig. 20. EPIPHOEA. 79 the included skin is freed a little from its areolar connections ; and re- silience upwards is favoured by the necessary manipulation. Dis- placement upwards is then definitely secured by bringing together late- rally the wound that remains beneath, by means of sutures. In not a few cases, there is not sufficient laxity of parts to admit of this. Under such circumstances, something may be done by incising the eye-lid, and re- placing its ciliary margin ; then filling up the chasm beneath, which necessarily results, by a flap of integument borrowed fi'om the adjoining cheek. When ectropion has resulted from accidental wound at the canthus, rectification is easily obtained by reunion of the divided parts ; the margins of the cicatrized wound being made raw by paring, and retained in accurate apposition by suture. Blejyharoplastics. When either eyelid has been partially or totally destroyed, by injury, or by disease not of a malignant kind, an attempt may be made, not without good prospect of success, to supply the deficiency by a suitable flap brought from the immediate vicinity. No precise rules can be given for such an operation ; the details must necessarily vary in each case.* III. Affections of the Lachrymal Apparatus. Epiphora. Stillicidium. Epiphora consists in an increased secretion of tears, which flow over the cheek. Stillicidium lachrymarmn depends on some affection of the excreting lachrymatory apparatus, which prevents them from taking up the tears as they are secreted. The wateiy eye may be either congenital, or the result of injury or disease. It is best treated by means of astringent collyria ; by weak solutions of nitrate of silver, or wine of opium, dropped upon the eye once a-day ; or by exposing the eye to the vapour of lau- danum ; and by using at the same time some weak red precipitate ointment to the edges of the lids at night, when there is any derange- ment of the Meibomian secretion. In all cases, not prominently connected with some more important affection of the eye, the state of the general system must be care- fully looked to ; for it is extremely probable that no slight declen- sion from health will be found ; and, unless this be remedied, all local treatment will prove of comparatively little avail. When a * London and Edinburgh Monthly Journal, 1843, p. 359. Cyclopsedia of Practical Surgery. Siih voce. 80 AFFECTIONS OF THE LACHEYMAL SAC. watery eye results from a contracted state of the puncta, these are to be dilated by means of fine probes, or a stiff bristle. When there is relaxation or atony of the lachrymal sac, then stimulating injec- tions or collyi-ia are to be used. These are thrown into the sac by means of Anel's syringe, through the punctum. Occasionally, a small blister applied over the sac is of use. When the nasal duct is obstructed, measures must be taken to effect its clearance. Often the watery eye is but a symptom of general ophthalmia, and is only to be cured by its subjugation. Xeroma denotes an opposite condition ; a dryness of the eye, de- pendent on deficiency of the lachrymal secretion. Frequently it is a temporary prelude to graver affections of the eye, of an inflammatory nature. When it occurs singly, and persists — as is but seldom — re- storation of the secretion is to be courted by ordinary stimulant means. Infiammatory Affections of the Lachrymal Sac. The areolar tissue over the lachrymal sac sometimes is the seat of an inflammatory process ; while, in the first instance, the sac itself is free. A red, itchy, painful swelling exists at the corner of the eye ; and the system sympathises slightly. The cause usually is exposure to cold. Purging, and antimonials internally, with low diet, and pen- cilling of the affected part with nitrate of silver, or tincture of iodine, will ordinarily suffice to obtain resolution. If they fail, then local de- pletion by leeching must be had recourse to ; the leeches being applied over the part itself. It is obviously of much importance to be early and active in such treatment ; so as, if possible, to prevent involve- ment of the lachrymal sac. If suppuration should occur, a very early incision should be practised ; lest perforation of the sac take place. Not unfrequently, notwithstanding every precaution, the sac is in- volved, and suppurates acutely. The same treatment is necessary ; an early evacuating incision, or enlargement of the spontaneous oj)ening ; and light water-dressing afterwards. The opening granulates and heals; and usually the breach in the sac closes, leaving its cavity unoccluded. The Lachrymal Sac may itself be the primary seat of acute inflamma- tion. This may occur idiopathically in those of Aveak system ; or in any one, after exposure to cold. A small, hard, circumscribed, and very pain- ful swelling is formed below the tendon of the orbicularis muscle ; the superimposed integuments soon become red ; the eyelids are more or less oedematous : the corresponding side of the nostril is dry ; and the system sympathises considerably. The swelling increases, often almost obscur- ing the eye ; and severe headach usually is complained of. The course of the tears is obstructed, by the tumid state of the duct's lining AFFECTIONS OF THE LACHRYMAL SAC. 81 membrane — inflammation having extended to it — and they find their way over the cheeks. Suppuration occurs ; and, sooner or later, the matter is discharged externally. Then a slow recovery may ensue ; the nasal duct becomes again open, the tears resume their proper course, the suppurated aperture granulates and heals. Or the obstruc- tion in the nasal duct remains, the tears do not reach their wonted outlet, the aperture contracts but does not heal ; and the condition of fistula lachrymalis is established. In severe and neglected cases — more especially if occurring in a debilitated frame — the subjacent periosteum may be destructively involved, and tedious exfoliation ensue. Antiphlogistics are obviously demanded here; leeches over the in- flamed sac, warm anodyne fomentations, and a full dose of morphia at night, to allay pain and procure rest. These ought to be used early to avert suppuration if possible. When matter has formed, it must be evacuated at once. This is done by introducing a bistoury into the sac, below the tendon of the orbicularis, which ought to be rendered prominent by drawing the lids outwards. After evacuation, light water-dressing or poultice is applied ; and the sac, after a time, may be occasionally syringed with warm water. We hope that the mem- brane of the duct will duly recover from its tumid state, that the natural course of the lachrymal fluids will be restored, and that tlie outward opening in the sac will close. A chronic affection of the lachrymal sac is not uncommon ; the vas- cular process reaching no higher than congestion, and limited almost entirely to the lining membrane. An indolent swelling occurs be- neath the tendon of the orbicularis, soft, fluctuating, comparatively painless, and capable of being emptied by pressure ; for the puncta remain open, and through them the puriform secretion escapes up- Avards. The passage downwards is obstructed ; and, indeed, this cir- cumstance seems in most cases to be the origin of the malady. Sometimes this chronic distension of the sac is the result of an acute or subacute attack. In other cases, it is chronic from the first ; and in these, the state of the general system is usually imsatisfactory. There is a constant liability to acute accession, from but slight causes; and when such an aggravation does occur, the progi'ess is likely to be rapid and untoward. Suppuration and outward discharge take place; and fistula lachrymalis is established, perhaps with necrosis of the os unguis. Treatment consists in prophylactic care, so as to avert such unto- ward events ; in attention to the general health ; in maintaining a comparatively empty state of the sac, by occasional pressure ; and in the use of stimulant injections, collyria, or ointments. Sometimes vesication over the sac, by nitrate of silver or tincture of iodine, is of use; atother times, the application of a few leeches will prove serviceable. G 82 FISTULA LACHRYMALIS. It is in such cases that Auel's syringe is of most use ; to clear out accumulated discharge, and to convey alterative and stimulating fluids to the congested membrane. For overcoming structural obstruction in the nasal duct, any such injection is quite inadequate. Fistula Lachrymalis. How this condition is produced, has already been explained. Obstruction takes place in the nasal duct ; the lachrymal sac inflames, suppurates, and ulcerates — the ulcerated aperture discharging exter- nally ; and the wound, only contracting, does not heal. This train of events may originate in the lachrymal passages, and usually does so. But the origin may be in the subcutaneous areolar tissue, as ali'eady stated ; or in the bone and peri- osteum, in those with a mercurio-syphi- Fig. 21. litic taint of system. The greater num- ber of cases, however, are of a simple nature ; originating in the lachrymal passages ; and involving the deeper parts secondarily, if at all. The essential parts of the disease are, obstruction in the nasal duct, and an external opening in the lachrymal sac. In treatment it is our object to close the latter; and that can be done only by remov- ing the former. To this end, an operation is necessary. The patient having been seated on a chair, with the head supported, a narrow sharp-pointed straight bistoury is inserted into the fistulous opening beneath the orbicularis tendon ; and is not only lodged in the sac, but pushed into the osseous nasal canal as well. To accomplish this dexterously, reference to the anatomy of the parts is necessary, in order that the penetrating instrument may receive the requisite direc- tion ; downwards, a little backwards, and a very little inwards. By the side of the bistoury a stout probe is passed down ; and as the for- mer is slowly withdrawn, the latter is pushed steadily onwards, until it has overcome the obstruction, and is felt to touch the floor of the nostril. To effect this perforation, a little force is sometimes neces- sary. A few drops of blood, escaping by the nostril, prove re-esta- blishment of the duct complete ; also, if the patient be made to ex- pire forcibly, while the nostrils are shut, air and bloody mucus will be ejected upwards through the duct, if the probe have been withdrawn. But it is not enough that the knife and probe procure a temporary re-establishment of the canal. This must be kept permanently open. And to accomplish this, styles — or small bougies — are employed ; of Fig. 21. Fistula laclirymalis. The chronic stage established ; and the aperture small. FISTULA LACHRYMALIS. 83 various sizes, and made of silver. One about the thickness of an ordinary probe, and sufficiently long to reach from the upper wound to the nasal aperture of the duct, is lodged in the canal ; its flattened head resting on the integument. No fixed size can be defined /f^ as generally suitable for the commencement of the treatment. Ov\ It is enough if the style pass easily, after withdrawal of the or- dinary probe. Having been lodged, it is allowed to remain. After some hours, the usual resenting of the presence of a foreign body is evinced. The part becomes hot, painful, and swollen ; still, the exciting cause is not to be removed ; the stj-le is left untouched. Fomentation, or a poultice, and the minor general antiphlogistics are employed ; and usually, after a day or two, the inflammatory signs subside, the style feels ^'^- -- loose again in its site, and a purulent discharge escapes freely by it. After a few days of quietude, the original style is withdrawn, and one a size larger gently substituted. This, in its turn, gives place to a third ; and so on ; until one is passed of sufficient bulk completely to occupy the canal ; the passage being syi-inged once a day with tepid water, to keep it clean. This last style is worn for some con- siderable time, until there is good reason to suppose that the normal calibre of the passage is fully restored, and that its lining membrane has returned to a tolerably sound condition. Then the instrument — which had only been taken out occasionally, for the purpose of being cleaned and replaced — is withdrawn, and a smaller substituted. This, after having been worn for some days, is succeeded by a less ; and by this gradual abstraction of the stimulus, relapse is rendered improbable. Then, if the tears continue to flow naturally, and all else seem favourable, the use of the instrument may be wholly aban- doned ; and the external aperture, now much contracted, may be permitted and encouraged to close entirely. Frequently no aid is ne- cessary to secure this latter event. But should a small fistula threaten to prove obstinate, the touch of a heated Avire, or point of caustic, will usually effect its contraction and closure. At one time, tubes Avere employed instead of styles. Experience, however, has declared them to be inferior. They create the same dis- turbance in the part, are apt to become obstructed, equally require occasional removal, and, in some cases, their attempted removal has been attended with the utmost difficulty. At one time, also, it was no uncommon practice to seek a more direct road to the nasal outlet, than through the obstructed lachrymal duct ; by perforation of the os unguis. This destruction of unimpli- cated texture, however, is in the present day very properly deemed unwarrantable. Fig-. 22. Style for the lachrymal duct. G 2 84 OBSTRUCTION OF THE NASAL DUCT. If necrosis accompany the condition of fistula lachrymalis, exfolia- tion must be patiently awaited ; for not until the dead portion of bone has been thrown off, can the soft parts be expected to heal. At the same time, constitutional treatment will certainly be necessary. It is well to remember that fistula lachrymalis may be simulated, tolerably closely, by malignant disease. A medullary tumour, or a malignant polypus, formed in connexion with the nasal passages, may project towards the surface at the inner angle of the eye ; and its first prominence, yet covered by the stretched and attenuated integument, may occupy the exact locality of the lachrymal sac. But a touch of the part will evince elasticity instead of fluctuation ; a glance at the nostrils will shew the true seat of the disease ; and the cachectic face and general appearance will sufficiently testify to the malignant cha- racter. Obstruction of the Nasal Duct. We can readily understand how this should be a not unfrequent result of an inflammatory process in the lining membrane. The mem- brane is at first turgid by soft exudation ; and this narrows, and may obstruct, the canal. Such obstruction is temporary in its nature, and capable of yielding to ordinary treatment, whereby cessation of undue action and absorption of extraneous deposit may be obtained. If the process continue, exudation becomes more and more dense, and more enduring ; partly mucous, in its site, but chiefly submucous ; and by continuance or aggravation of such structural change, diminution and obstruction of the canal are rendered plainly inevitable. For the minor form of obstruction, rectification of the general health, counter-irritation applied over the part, and the use of sorbe- facient collyria or injections, will oi'dinarily suffice. In the more advanced form, the stimulus of the lodgment of a foreign substance in the part is essential to efficient restoration by absorption. In some instances, this indication may be fulfilled without incision ; by passing a probe upwards, from the nasal orifice of the duct. The probe, Gen- souTs, bent nearly to a right angle, at about three-fourths of an inch from its point, is passed carefully along the floor of the nostril, until it arrives below the anterior extremity of the inferior turbinated bone ; then its point is directed upwards, into the canal. This manipulation is always doubtful, in the first instance, on account of the valvular pro- tection by which the nasal orifice of the duct is guarded, and which must be forcibly broken up ; often it proves most difficult to the sui'geon, and both teazing and painful to the patient ; not unfre- quently it fails altogether. It should never be attempted, unless after repeated practice on the dead body. And, even Avhen the introduction can be effected with tolerable facility, it is not unlikely that such AFFECTIONS OP THE LACHRYMAL GLAND. 85 means will in the end be found quite inadequate to remove the disease. In all serious cases, therefore, of obstruction in the nasal duct, it is better at once to have recourse to the same treatment as for fistula lachrymalis ; to puncture the sac, and proceed Avith gradual dilatation by styles. Obliteration and Absence of the Nasal Duct. 1. The nasal duct may be obliterated by change of structure in the membrane. Restoration by perforation may be attempted. 2. It may be shut up entii*ely by change of structure in the bone. Then restoration in the original site is hopeless ; and if anything remedial is attempted, it can only be by perforating the os unguis, and rendering the unnatural aperture permanent. A case is related by M. Berard, of congenital absence of the nasal duct ; from which there had resulted a congenital iistula, which con- tinued open and discharging at the age of twenty-one. An artificial outlet was formed for the secretion, by perforation of the os unguis.* Dacryolites. Concretions are sometimes found in the lachrymal passages ; mainly lodged in the sac ; and consisting chiefly of carbonate of lime, cemented, by concrete mucous and albuminous matter. The foreign substance produces swelling and lachrymation, and may ultimately cause fistula. Its presence is easily detected by manipulation, and by the introduction of a pi'obe through one of the puncta. The remedy is simple ; incision and removal. The wound may be expected to heal kindly, and without any fistulous tendency. In minor cases, mere expression, without wound, may prove sufficient. Affections of the Lachrymal Gland. Dacry adenitis. — The lachrymal gland may be the seat of an inflam- matory action, chronic or acute ; but either form of attack is rare. The secretion is first increased, afterwards arrested, and then restored in a perverted form. A painful swelling forms in the region of the organ ; the eyeball is displaced, and inconvenienced in function and movements. The eyelids are oedematous ; and the conjunctiva is apt to sympathise, and take part in the action. In the acute form, the system suffers severely ; the pain grows intense, and shoots through the head ; and suppuration may take place. If the matter be discharged spontaneously, a fistulous aperture may remain. * British aud Foreign Review, No. 24, p. .54L 86 ENCANTHIS. The treatment is according to general antiphlogistic principles ; when matter forms, an early and free opening is to be made. Atrophy of the Lachrymal Gland may take place, but this is very rare ; the (*i'gan ultimately becoming almost effaced. Then either xeroma results ; or the conjunctival secretion is augmented, to atone for the glandular deficiency. Tumours of various kinds may form in the substance of the gland. It is liable to simple hypertrophy ; amenable to discutients. Some- times it is the seat of cystic formation ; remediable by simple punc- ture — or, if that fails, by excision. Carcinoma may attack the gland. Thsn there is obviously no hope but from early removal. And, in extirpation of the eyeball on account of malignant disease, it is well always at the same time to remove the lachrymal gland — its occupa- tion now gone — whether involved or not ; lest, by its continued pre- sence, return and reproduction of the tumour should be favoured. Encanthis. By this term is meant an enlargement of the caruncula lachrymalis. The enlargement may be a simple and somewhat acute engoD'gement of the part, the result of an inflammatory process resident therein. This will readily give way to ordinary treatment — scarifica- tion, or leeching, fomentation, and sorbe- < -_^ |i, ^ facients. ?//' A chronic swelling, of the nature of hypertrophy or simple tumour, may occur ; ^'?- ~8- less amenable to discussion, and often re- sistful of it. It slowly increases ; producing deformity by its pro- minence and bulk ; displacing and obstructing the puncta and lachrymal canals, whence troublesome lachrymation results ; jDrevent- ing due closure of the ej^elids ; and favouring the occurrence of ophthalmia. If discutients fail, under such circumstances, excision is to be practised ; care being taken to leave the puncta, canaliculi, and lachrymal sac uninjured. Sometimes the caruncle is the seat of tumour of a malignant, or at least suspicious character. In such a case, discussion is hopeless ; and palliatives of any kind are not employed, if excision be practicable. By early as well as free removal only, can immunity from return be hoped for. It is very i*arely, however, that excision of this texture, on any account, is required. Fig. 23. Encanthis. SIMPLE CONJUNCTIVITIS. 87 IV. Affections of the Eyeball. Ophthalmia. In such a work as this, it is not to be expected that so wide a sub- ject as the affections of the eyeball — so important, varied, and numerous — should be fully discussed, in all its details. The leading points only can be overtaken ; the student being referred for further infor- mation to the many excellent monographs in this department of Surgery. Ophthalmia is the general term, in which all affections of the eye- ball of an inflammatory nature are comprehended ; and, according as the superficial or more deeply seated '•-,. ' ..••■' textures are involved, the ophthal- "---.. --''' mia is said to be External or In- Fig. 24. ternal. Affections of the Conjunctiva. The inflammatory process, in all its grades, is very fi-equently found established in the conjunctiva ; and the affection varies mate- rially, not only according to the intensity of the action itself, but also according to the cause which induced it, and the state of the system in which it has occurred. Different varieties of the disease may in consequence be enumerated. The most prominent of these are the Simple, Purulent, and Strumous. Simple Conjunctivitis. The eye becomes the seat of pain, heat, and lachrymation ; there is intolerance of light, and consequent shutting of the eyelids — more or less spasmodic ; frequently there is a sensation as if sand or other foreign matter Avere lodged in the part. On separating the eye- lids, the membrane is seen to present an appearance of unusual vascu- larity ; not from formation of new vessels, but from enlargement of those already there. It is important to remember that these vessels have a peculiar character, whereby affection of this membrane may be Fig. 24. Diagram shewing the characteristic vascularity of extemal and internal oplithalmia. a, external ; h, internal. — W. Jones. SIMPLE CONJUNCTIVITIS. distinguished from the affections of more deeply seated parts. The vessels are of considerable size, they seem to advance from the periphery of the globe, where the membrane is reflected from off the palpebrae, are tortuous in their course, freely inosculate with each other, and ter- minate gradually at the margin of the cornea; they are also observed to follow the movements of the mem- brane ; sometimes they are distinct and separate, because not very nume- rous ; sometimes they are numberless^ constituting one mass of angry red ; and the redness is usually of a bright scarlet hue. Whereas, in sclerotitis, the vessels are small, straight, not affected by the movements of the Kg- 25. eyeball, appear first near the margin of the cornea, become paler towards the periphery of the globe, do not inosculate, plainly occupy a deeper plane, and cause a redness of a pink or purplish hue (Fig. 23). In what is strictly termed Simple Conjunctivitis, the range of the inflammatory process does not reach higher than active congestion. Effusion takes place copiously; partly beneath the conjunctiva, but chiefly external to it. If the crisis of true inflammation be approached, a temporary drying up of the discharge, with aggravation of all the symptoms, marks the untoward advance. The system is symjDathetically involved ; but, in general, its dis- order is neither prominent nor severe. The disease may occur per se ; or be but a part of a more general inflammatory attack. ISot unfrequently, it is merely a symptom of eruptive fever; as in measles and small-pox. The predisposing causes are numerous ; over-exertion of the organ in many ways ; derangement of the general health ; a glaring, sunny, or dusty season. The exciting causes are equally numerous ; exposure to cold, heat, wind, or light ; the application of all chemical and mechanical irritants, dii'ectly ; and the indirect influence of ii'ritaut causes, more remotely. The most obstinate forms of the disease are to be expected, when the exciting cause is by a direct irritant which remains in constant operation ; as when a particle of sand, dust, or glass, lodges in the membrane, or when it is constantly rubbed or fretted by stray eyelashes. In the treatment, our first care is to remove the cause. Then antiphlogistics are to be used ; but these need not be of the highest Fig. 25. External ophthalmia; catarrhal conjunctivitis. SIMPLE CONJUNCTIVITIS, 89 class. If the cause — as a foreign substance lodged in the membrane — have been removed at once, nothing may be required in addition to rest of both body and part, low diet, abstraction of light, and con- tinuous application of cold over the shut eyelids by means of wetted lint. The inflammatory process may be entirely averted ; or, if just begun, it may very speedily resolve. If not, then blood is to be abstracted locally, and ti-ansition made gradually from cold cloths to warm fomen- tations. The blood may be drawn from the temple, or by cupping at the nape of the neck ; or by the application of leeches in the neigh- bourhood of the eye itself. The last method and locality are generally preferred ; and care should be taken that all the animals fasten near the inner angle only, immediately beneath the tendon of the orbicularis ; for thei^e less pain will be occasioned, more blood will be drawn, and less risk both of ecchymosis and of erysipelas will be incurred, than Avhen application is carelessly and diffusely made along the eyelids. The amount of local depletion will of course vary according to the intensity and duration of the disease, and the age and constitution of the patient. The action may simply and steadily resolve ; or may pass from the acute to the chronic condition, and there tend to remain. It is to be borne in mind, that in all cases of this affection, no.t of a traumatic origin, and not occurring in a robust and vigorous frame, the chronic condition, a state differing little from that of mere passive congestion, is very apt to be assumed at an early period — after the lapse of but a few days. Then, continuance of antiphlogistics would but aggravate the morbid state. A change has to be made. It may be advisable to unburthen the distended vessels; and this will be best done, by scari- fication of the conjunctiva on the lower lid. By fomentation, the flow of blood is encouraged ; and after this has ceased, gently stimulating- collyria are employed, to restore tone to the vessels ; — solutions of zinc, alum, or of nitrate of silver, are the best; or a dilution of vinum opii begun very Aveak, and gradually increased in strength. Also the ordinary stimulus of light is again gradually admitted. In those cases in which amendment is tardy or fluctuating, it is well to adopt the aid of counter-irritation ; which is best applied by blistering, behind the ear. Constitutional treatment is not to be neglected during any period of the case ; first moderately antiphlogistic, then alterative, and ultimately tonic. If the occurrence of the attack have been connected with the drying up of any habitual or normal discharge, return of this should be sought for and secured. When one eye only is affected, it is well to remember the close sympathy which exists between the two organs. The unaffected eye, therefore, should, dui'ing the acute stage, be kept equally quiet and 90 PURULENT CONJUNCTIVITIS. shaded from the light, and otherwise treated with prophylactic care. Confinement to a dark room is not generally necessary however ; and when the case is chronic, free exposure of the organ to the open air will often prove beneficial. In the obstinately chronic cases, beneficial change of action may often be obtained by the application of nitrate of silver in solution, or very lightly in substance, to the inner surface of the lower lid imme- diately after scarification. A common variety of simple conjunctivitis is termed the Catarrhal; whose prominent characteristics are — in addition to those of the simple form — a profuse secretion of vitiated muco-purulent fluid from the membrane, oedema of the eyelids, irritation of the tarsal margins, less intolerance of light, more marked remissions, and the presence of the usual indications of catarrh. Purulent Conjunctivitis. Purulent ophthalmia seems to be merely an aggravated form of catarrhal conjunctivitis; running its course, however, much more rapidly ; and mainly distinguished from the latter, in its mild form, by the discharge being purulent instead of muco-purulent. But when purulent discharge occurs in the simple form, an aggravation of the in- flammatory process having been somehow induced, such a circumstance is to be regarded as an accidental intensity in acute simple conjuncti- vitis, rather than as an example of true purulent ophthalmia. Usually, action is from the first intense, and suppuration is very speedily attained. The first symptoms are pain and itching in the palpebral conjunctiva, and often there is a sensation as if foreign matter were lodged there. Then the ordinary characters of conjunctivitis appear, in an aggravated form. The pain is not confined to the eye, but shoots through the head, and not unfrequently extends to the face also. The eyeball becomes quickly covered with meshes of enlarged conjunctival vessels ; the membi'ane itself is infiltrated and tumid ; a profuse puru- lent secretion is poured out ; the eyelids are swollen, and oedematous, often to a great extent ; ordinarily, the eyeball is concealed by the tumid lids ; on opening them forcibly, purulent matter escapes in in- creased quantity, and eversion is apt to ensue — the engorged and red conjunctiva becoming exposed. As the disease advances, the conjunctival lining of the eyelids, more especially of the upper, changes from the uniform, vascular, and vil- lous appearance, to one of more irregularity, as if granulating. The conjunctiva is then said to be granular. This term, however, does not imply that the membrane becomes actually studded with true granula- tions ; the fleshy elevations being mere enlargements of the natural PUEULENT CONJUNCTIVITIS. 91 papillae. These continue to furnish a profuse discharge ; and the fric- tion of them over the ocular conjunctiva doubtless maintains the gene- ral morbid action. The ocular conjunctiva, it has been already said, undergoes change of structure. Exudation and extravasation take place both intersti- tially and beneath it. Serum, or fibrin, if the disease be very acute, is effused between it and the sclerotic, causing it to bulge considerably over the margin of the cornea, and leaving that texture in the relative position of a depression or dimple. This state is termed Chemosis ; the result of true inflammation in the conjunctiva. When the action is acute, and the chemosis great, the cornea is in danger of sloughing ; partly from over-action, and partly by the strangulating effect of the surrounding swelling, checking the supply of blood to the cornea, and causing it to die fi'om want of nutrition. The system sympathizes to a great extent. At first inflammatory fever is developed. Afterwards, the form of Constitutional Irritation is often assumed. Vision is in imminent danger, by change of struc- ture in the cornea, and also by disorganization of the entire globe ; for to the latter result this affection may advance, under circumstances of either neglect or severity. In Egypt the disease prevails as an epidemic, and has done so for ages ; of the most virulent and intractable form ; very fatal to sight ; originally induced by sun and sand, propagated, also, by direct con- tagion ; and in effecting reproduction by the latter mode, the flies are said to be active agents — passing from one eye to another, tainted with the contagious matter. In this country, it is happily both less frequent and less severe. It may follow injury ; and then the purulent dischai'ge is to be looked on as the mere consequence of a high amount of inflam- matory action induced by a powerful exciting cause. Want of cleanli- ness, and of ventilation, and the over-crowding of inmates — as in schools and barracks, and on board of ship — predispose to the production of this form of disease, under the influence of a comparatively slight exciting- cause. Thus occasioned, it is undoubtedly contagious ; the matter of one patient applied to the sound conjunctiva of another being capable of inducing a similar affection. And when many patients happen to be crowded together, without due cleanliness and ventilation, there is good reason to believe, that the infectious character is also acquired. Treatment, in energy and promptitude, requires to be jjropor- tioned to the rapidity and intensity of the disease. It is only by active and early, as Avell as suitable measures, that we can hope to avert change of structure and impairment of function. When the patient is I'obust and plethoric, and there is intense supra-orbital pain, headach, chemosis, and a feeling of tension and throbbing in the eye, blood is to be drawn not oiily from the part, but from the svstem ; 92 PURULENT CONJUNCTIVITIS. with a full antiphlogistic effect in view. The bowels are to be well acted on. Regimen should be most sparing ; with quiet, and seclusion fi'om all stimuli — light more especially. If not strongly contra-indi- cated, by constitutional or other causes, calomel and opium are to be freely administered, to excite gentle ptyalism ; for the action is intense, the texture delicate, and the function important (Principles, p. 168). The eye is to be diligently fomented with an anodyne fomentation. If the case be not seen till the disease has made progress, and lost much of its acute type, both locally and constitutionally, such severe measures are of course unwarrantable. And a like reservation will be required in the case of the puny adolescent, perhaps scrofulous as well as sickly, who may happen unfortunately to become a victim. When the second stage has set in, we cease from constitutional antiphlogistics — though still maintaining the most guarded regimen ; the local, too, are proceeded with differently. The swollen conjunc- tiva is to be freely scarified, in order to empty its sanguineous con- tents, and at the same time to afford ample space and opportunity for the interstitial and subconjunctival exudation to escape. The pal- pebral conjunctiva is divided with a lancet or scarificator, in a hori- zontal direction ; the eyelids being freely everted for this purpose ; and separation of the lids ought to be maintained for some time, so as to favour the escape of blood. The chemosed ocular conjunctiva is to be divided also in a horizontal direction ; otherwise, the cornea, already in a critical condition, will have its sloughing accelerated and made certain by interruption of the vascular supply. Or, rather, the incisions are begun at the corneal margin, and made to radiate out- wards to the circumference, as recommended by Mr. Tyrrell ; there being thus less risk of cutting across the vascular supply of the cornea, than in any other form of incision. This incision of the chemosis is not always to be reserved for the second stage ; but is often highly expe- dient at an early period, when the action is yet acute ; in order to save, if possible, the threatened cornea, as well as to obtain a genei'al reso- lutive effect upon the inflammation. Fomentation is to be used for some hours after the scarification, so as to favour the flow of blood ; and then the nitrate of silver is advisable. Probably the best way of employing this remedy is to apply it, either in substance, or in solution, to the eyelids ; on these it exerts a direct and powerful reme- dial effect, opposing the congested and granular state ; and from these it is gradually diffused over the globe, with an effect more gentle but equally beneficial. The application is made daily, or every second day, according to circumstances. Throughout the whole treatment, it is essential that matter be not allowed to accumulate beneath the swollen and shut lids ; these are to be gently opened from time to time, and the pus washed aAvay by warm water, or by some gently astringent PURULENT CONJUNCTIVITIS. 93 fluid — anodyne or stimulant, according to the stage of the disease. For general use, there is nothing better than a weak solution of nitrate of silver dropped into the eye once or twice a day. It ought to be borne in mind, throughout the whole period of treatment, that the discharge is of a contagious nature ; and the pa- tient, practitioner, and attendants should guard accordingly against direct propagation of the disease. If the morbid state still persist, and become more and more chronic in character, the nitrate of silver may be well superseded by some more purely stimulating remedy ; as the sulphates of zinc and copper. Or some of the preparations of mercury may be employed ; in form either of ointment or of solution. At this period, too, counter-irrita- tion, by blistering behind the ears, or on the nape of the neck, will not be without its use. The state of the system throughout the whole course of the disease, must be well considered ; often a combination of tonics with alteratives will probably be required. When a swollen and altered state of the palpebral conjunctiva obstinately remains, after comparative disappearance of the other symptoms, this lingering one must be attacked with more energy. The sulphate of copper or nitrate of silver is applied lightly over the parts. Or the enlarged granulations may be at once removed, either by knife or scissors. The surface which remains is then made the subject of ordinary treatment. Of course, care must be taken that the removal of texture be not excessive ; otherwise entropion is likely to ensue. Such is the nature of the ordinary Purulent Ophthalmia. Two varieties of the disease require a separate though brief notice. Ophthalmia Neonatorum. — By this term is understood Purulent Conjunctivitis occurring in the recently born child. It may be in- duced by mere want of cleanliness, by imprudent exposure of the delicate organs of sight to intense light, or by the direct application of other stimuli. But frequently it owes its origin to direct contamina- tion of the conjunctiva by vaginal secretion — during parturition. The disease presents its ordinary characters ; and there is much risk of permanent loss of sight by pearly opacity of the cornea. Children have been born with opaque corneae, apparently the result of purulent conjunctivitis. It has been inferred, therefore, that this disease may occur in utero. Such opacity, however, may be the result of mere arrest in development. The treatment is founded on antiphlogistic principles ; proportioned to the age and condition of the sufferer. But much depends on an early commencement being made. Then mild measures suffice ; bleed- ing will seldom be required, either by leeches or by scarifications ; and 94 STfiUJIOUS CONJUNCTIVITIS. counter-irritation, also, will rarely be necessary. It is enough to em- ploy simple ablution, frequently repeated — perhaps every second hour ; soon gently medicating the coUyrium by means of alum, decoction of oak bark, or other astringent, — the proportion of which is gradually increased. A Aveak solution of nitrate of silver dropped into the eye, once a day, is of much benefit. Great attention to cleanliness is to be always maintained, and the eyelids should be prevented from ad- hering together, by applying a little red precipitate ointment to their edges at night. Attention is at the same time paid to the primse viae, and general system. Gonorrhoeal Ophthalmia. — The application of recent gonori'hoeal matter from the urethra to the conjunctiva, produces the most intense form of purulent conjunctivitis. One eye ordinarily is affected ; for it is seldom that both are at once inoculated ; and in this respect there is a difference from the ordinary purulent conjunctivitis. In the latter also, the morbid action usually commences in the palpebral conjunc- tiva, resides there chiefiyj and extends only secondarily to the ocular portion of the membrane. But in the gonorrhceal form, the reverse is the case ; the disease would seem, in most cases, to commence in the ocular conjunctiva, and to extend thence to the palpebral. Action is unusually intense ; and the hazard to vision is great : for the cornea, surrounded by a firm fibrinous chemosis, is in a most perilous state, and not unfrequently perishes by sloughing. Or the action may pass deeply ; and terminate in general disorganization of the globe. The treatment is in no way peculiar ; only proportioned in activity to that of the disorder. General bleeding ought seldom to be omitted at the outset ; and this may be regarded as imparting a proper tone to the rest of the treatment. Strong solutions of nitrate of silver are found to be of much service, so soon as the first acuteness of the inflamma- tion has been subdued. The rest of the treatment is similar to that ah'eady recommended in ordinary purulent conjunctivitis ; but it should be borne in mind that this disease is more acute, and runs its course more rapidly than the other. Strumous Conjunctivitis. This affection of the membrane — in addition to the ordinaiy traits of the strumous cachexy — is characterized chiefly by remarkable photophobia, or intolerance of light ; often with comparatively little pain, and vascularity — though sometimes the vascularity is con- siderable ; by tendency of the enlarged vessels to collect into fasciculi which stretch towards the corneal margin, terminating there in pustules or phlyctenulae ; by exacerbations occurring in the morning, while there are remissions at night — the opposite of what obtains in GRANULAR CONJUNCTIVA, 95 Other ophthalmia3. Corneal change of structure, as ulcer, is extremely apt to ensue. The aiFection seldom occurs after puberty ; and pre- vails chiefly during childhood. At that age, the intolerance of light, with spasmodic closure of the eyelids and copious lachrymation, is certainly the most prominent symptom. The child " keeps its hands pressed on the shut eyelids, and turns its face on the nurse's shoulder, or, if in bed, on the pillow, even in comparative darkness. In chronic cases, the edges of the lids are kept in this manner in an almost in- verted condition, and the eyelashes get under and are there retained, augmenting the distress." The cheeks are scalded by the discharge which almost constantly wets them, and become covered with an angry eruption. The features are contorted ; and a confirmed expression of pain and discontent is assumed. On attempting to open the lids, much suffering is occasioned ; the lachrymation increases, the lids become more inverted, and the eyeball is rotated upwards and out- wards so as to conceal the cornea. The treatment consists in constitutional management, suited to this particular cachexy conjoined with an inflammatory process in an important part ; in slight local depletion by leeches ; in applying nitrate of silver to the integument of the lids, lightly, so as to blacken merely ; in the use of a weak solution of this substance as a collyrium ; and in counter-irritation by blistering behind the ear. The last remedial means, however, is to be used with caution ; otherwise it is apt to excite troublesome scrofulous enlargement of the cervical glands. Sometimes benefit is obtained by the local use of belladonna, smeared over the eyelids, which seems to act as a sedative in such cases. Or it may probably afford relief by temporarily paralyzing the iris, and so placing that contractile texture in a condition of repose. In the early stage of the disease, an emetic is generally of much service. No medicine, however, seems to act so beneficially as quinine, which often displays a decided influence in allaying the morbid sensibility, relieving the intolerance of light, and removing the inflammation. For bathing the eyes, warm water is used, simple or medicated with opium. The child should have a solid and nutritious diet, and should not be confined to the house, unless during cold and wet weather. Granular Conjunctiva. The granular condition, dependent on a hypertrophied state of the mucous papillfe, of the palpebral conjunctiva, has been already noticed — as constituting an important integi'al part of purulent conjunctivitis. But a similar change of structure may occur, quite independently of this latter disease. It may be the result of chronic inflammatory pro- cess resident in the palpebral membi'ane. At first, doubtless, there is 96 PTERYGIUM. mere enlargement of the normal structure ; but after a time, this is more or less altered by continuance of plastic deposit ; the surface be- coming dense as well as prominent, rough, irregular, and sometimes fissured. The upper eyelid is more prone to suffer than the lower. It can be readily understood how such a structure, at each movement of the lid, must greatly fret the ocular conjunctiva ; causing an irritation there sufficient to light up inflam- matory action, and more than suffi- cient to maintain an action which has been already established. To remove the alteration of structure, therefore, becomes a most important therapeutic indication. In the first instance, scari- ^'°' ^^' fication of the eyelid is to be employed ; followed by the application of nitrate of silver, used either lightly in substance on the part, or in strong solution. If the nitrate prove unsatisfactory, other astringents may be employed instead. Failing these, the altered part is to be removed ; by knife or caustic. The nitrate of silver, or sulphate of copper, may be applied firmly to the surface, so as to have a destructive effect. But in general, it is better to remove at once, by knife or scissors, the enlarged granules ; great care, as usual, being observed, lest by excessive ablation en- tropion be established on cicatrization. The general health ought in all cases to be attended to, as the disease frequently occurs in lym- phatic or strumous individuals. Repose of the eye ought to be en- joined, with due attention to diet, exercise and change of air. Pterygium. Pterygium denotes a vascular and fleshy thickening of the ocular conjunctiva. The formation is of a triangular form ; the base resting on the internal or external can thus, and the apex stretching to- wards the cornea. When of moderate size, and not advanced further than the corneal margin, vision is not interfered Avith ; but when it begins to encroach on the cornea, the affection then ceases to be a mere deformity or inconvenience; sight is in danger ; and remedial measures are required. Sometimes the web is thin and membranous ; consisting chiefly of varicose vessels held together by fine areolar tissue. Sometimes the structure is dense, firm, and fleshy; sometimes it contains a large proportion of adipose substance. Fig. 26. Granular Coniunctiva. The evelid everted. CORNEITIS. 97 The term Panmis is applied only to those cases in which the cornea is completely covered with red vessels, presenting the appearance of a piece of red cloth, and very materially interfering with vision. In the milder cases of Pterygium, a cure may be attempted by scarifica- tion and astringents ; the scarifications being made across the dilated vessels, in the sclerotic conjunctiva. In those cases in which the cornea is encroached ^y upon, excision of the sclerotic portion is to be had recourse to, if the milder ^ ,, Fig. •il . measures fail — as they are likely to do. The membrane is elevated by a fine hook, and carefully removed by knife or scissors. The corneal covering is then usually found to disappear. When, in Pannus, the whole cornea is covered, a cure is said to have been effected by inoculation of the morbid tissue with the discharge of purulent conjunctivitis; the inflammatory action which thence results having the effect of breaking up the morbid tissue, and rendering it amenable to removal by absorption. This, however, is a very dangerous mode of treatment; the eye may be lost in conse- quence of the violent inflammation which is induced, and the patient's health may be much injured by the severe measures which may be requisite to subdue that inflammation. Such procedure, therefore, is plainly inapplicable, except to those extreme cases in which the cornea presents no sound part, but is completely and thickly covered ; and in which, consequently, the condition of the eye can scarcely be made worse. Affections of the Cornea. Corneitis. The inflammatory process, affecting the cornea, may be either an original affection, or merely an extension fi'om previously existing conjunctivitis. It may originate either from injury done directly to the part itself, or from an exciting cause applied to some other part of the surface of the eye. The conjunctival investment only may be involved — and this is most likely to occur when the affection is a mere extension from conjunctivitis ; or the action maybe mainly and origi- nally resident in the proper substance of the cornea. All forms of conjunctivitis, when of any duration, are apt to implicate the cornea; but the strumous form more especially. A red zone of dilated vessels encircles the corneal margin, gene- rally at the upper part ; and between the two there is no intervening Fig. 27. Pterygium, double. H 98 CORNEITIS. clear space of white sclerotic, as in affections of the deeper parts of the eye. When the conjunctival covering is involved, small hair-like vessels are seen ramifying on it, in greater or less number, continuous with those constituting tha outer zone. When the proper substance alone is affected, such vascularity is, in the first instance, not dis- cernible, unless by the aid of a magnifying glass. There is pain in the eye, and in the orbit generally ; lachrymation and intolerance of light. By and by, the cornea loses its transparency, becoming turbid, and of a bluish white appearance. The various results of the inflamma- tory process may then ensue — vary- ing according to the intensity of the action ; deposit of plastic lymph, pro- ducing thickening and opacity ; for- mation of pus between the corneal layers, afterwards absorbed, or making its way either externally or into the ~~~^" anterior chamber; chronic ulceration, ^^s-^s. commencing superficially with mere abrasion, in which case the surface of the cornea is more or less rough, and bears some resemblance to a piece of ground glass, but which appearance, on close inspection, is found to consist of a crowd of minute ulcers ; or, there may be a large ulcer, originating in the giving way of a pustular formation ; lastly, sloughing, either of the whole or of a part — seldom occurring in the case of simple corneitis alone, but only when this is part of an extensive and severe ophthalmia. If a foreign body be left imbedded in the cornea, it is very evident that inflammation, suppuration, and ulceration must ensue ; in obe- dience to the general law, whereby natural extrusion of foreign matter is effected in all living textures. In the treatment, general depletion is not often necessary ; lo- cal abstraction of blood, however, by leeches, is of much service. Counter-irritants, by means of blisters behind the eai's, are of use. Purgatives, antimony, and mercury, are the most appropriate remedies for arresting the progress and removing the effects of the disease. But of these, mercury seems to act more beneficially than any other. When a debilitated condition of the system causes protraction of the malady, the eye continuing irritable and intolerant of light, quinine and an improved diet will be required. At first, the local applications should consist of opiate fomentations ; but as the disease becomes more chronic, weak stimulants, as vinum opii, or a solution of nitrate of silver (four grains to the ounce) are to be employed. Strumous Corneitis is of very frequent occurrence in the young ; it Fig. 28. Corneitis. ABSCESS OP THE CORNEA. 99 is more chronic than the simple form ; and usually mainly resident in the conjunctival covering. The vascularity is less, and more diffuse; and the zonular arrangement at the corneal margin is less distinctly marked. Opacity is the ordinary result; and pustules, ending in troublesome ulcers, are not uncommon. The treatment is such as is calculated to subdue chronic conjunctivitis ; v^ith an especial reference to the depraved state of system. Mild mercurials should be given to check the deposition of opaque matter in the cornea ; and, combined w^ith these, quinine is useful to improve the general state of the system. In general, the affection proves of rather an intractable nature. Aquo- Capsulitis. — This term denotes the inflammatory process resident in the serous membrane of the aqueous humour, including the internal layer of the cornea. It may occur per se ; or it may form an integral part of the preceding affection. It is characterised by "a pale, deeply-seated opacity, which is unequally distributed, imparting to the cornea a mottled appearance ; and by a tui'bid or cloudy state of the aqueous humour." Sometimes lymph is exuded, and coats the mem- brane. This disease is very apt to run on to inflammation of the iris. The treatment is as for corneitis, or iritis. Abscess of the Cornea. Matter, as we have seen, may form between the layers of the cornea ; a result of corneitis. If it collect at the lower part, the accumulation usually assumes a crescentic form ; resembling the white semilunar mark at the root of the nail ; and hence such an appearance is termed Onyx. But it may be deposited elsewhere ; in the form of dots or points, which may either remain separate, or may unite with each other by increase and extension. The fluid seems to be purulent. It may, however, be a less advanced inflammatory exudation. Antiphlogistics will plainly be the most likely means whereby the secretion may be arrested, and its disappeai'ance by absorption favoured. And in order to effect these two indications rapidly, in time to save structure and function, the systemic influence of mercury is highly available — obtained as soon after local blood-letting as pos- sible. Failing absorption, one of three events may occur. The small collection may spontaneously discharge itself internally, into the aqueous humour, forming an hypopion ; or it may assume the pustular form, and escape externally, when an ulcer will be the result ; or an artificial opening may be made for its external evacuation. In the greater number of cases, the artificial opening is withheld, in the hope that disappearance by absoi-ption may take place ; and the frequency with which this result does occur, would lead to a suspicion that II 2 100 ULCER OF THE CORNEA. the fluid is not truly purulent. If, however, the fluid be of consider- able quantity, causing tension in the part, and painful symptoms of an aggravated character, the apex of the abscess may sometimes be touched beneficially, with a fine point of the nitrate of silver. A small slough is thrown ofi^, the matter is discharged, and an ulcer re- mains, which heals readily. The only application to the eye should be opiate fomentations. Ulcer of the Cornea. Ulcers are often the result of corneitis. Their origin may be from without, when the conjunctival covering of the cornea is chiefly affected, and then the commencement is with superficial abrasion, sometimes extensive; or a pustule forms, elevating the conjunctival layei' — and on the giving way of this, ulceration follows, still superficial. Or the origin may be from within ; matter collects between the true corneal layers, and is discharged externally, leaving an ulcerated aperture ; or foreign matter has lodged in the cornea, and is extruded by suppura- tion and ulceration. In either of these latter cases, the ulcer is deeply seated, and sei'ious. The ulcer here, as elsewhere, presents different characters, under different circumstances. Sometimes it is acute ; the inflammatory action is still in progress, loss of substance is advancing, and there is no attempt at repair. In this state, the ulcer looks as if a portion of the corneal substance had been dug out mechanically; the edges are abrupt, or they may be thickened and swollen, and in and around them are the usual signs of inordinate action. Very fre- quently, a distinct plexus of vessels is found leading to the ulcer. The pain, lachrymation, and photophobia are most distressing. Or the ulcer degenerates into the irritable form ; the loss of substance growing neither larger nor less ; the margins and surface showing an angry and vascular appearance, often as if covered with a layer of wetted chalk ; and the symptoms all undergoing intense aggi'avation. Or the sore may be of a healthy and healing disposition. Then the edges are less abrupt, and as if bevelled off; the chasm is diminishing ; a white haziness surrounds the margins, and invests the surface, denoting the deposit of plastic exudation ; and the unpleasant symptoms are all very much diminished. Or the ulcer may stop short in the progress towards cicatrization, and assume the indolent character ; becoming stationary, and causing comparatively little inconvenience. This last phase, however, is certainly not the one of most frequent occurrence. In the case of the acute ulcer, it is obvious that the only suit- able treatment is antiphlogistic ; with mercury given if necessary in ULCER OF THE COENEA. 101 small quantity in order to change the perverted condition of the capil- laries; and this is to be continued,, along with an especial regard to the general health, until the over-action is subdued, and symptoms of repair succeed those of destruction of texture. Then, in the healing sore, we must content ovirselves with watching the natural progress of cure, and carefuUy guarding against reaccession of inflammatory action ; by exclusion of light and other stimuli, by regulation of diet, and by the use of tepid soothing applications. In the irritable sore, nothing is so useful as the nitrate of silver ; applied either lightly in substance to the ulcer, or in solution by means of a hair pencil. It acts probably in two ways ; by its escharotic power destroying the sentient extremities of the nervous tissue ; by its coagulating power forming a protecting film for the raw surface. The application is repeated every second or third day, until the irritability cease ; or the interval is shortened or increased as circumstances may seem to require. When either the irritable or inflamed condition threatens to prove obstinate, great benefit often is derived from counter-irritation by blistering behind the ears. For the indolent sore, the various stimu- lant coUyria are suitable. When the strumous habit is strongly declared — as it too often is, in ulcerated cornea — little permanent good will be done by any local management, unless constitutional treatment be at the same time duly employed. As a general rule, the preparations of lead should never be em- ployed as collyria, in the case of ulcer of the cornea. An insoluble chloride of lead will be formed ; and this, becoming entangled in the cicatrix, will render it more irremediably opaque than it other- wise would have been. The sustained use of nitrate of silver, also, should be conducted with caution; lest an olive - coloured stain ensue. When the ulcer is deep, acute, and situate near the centre of the cornea, there is great risk of perforation of the inner layer, escape of the aqueous humour, and protrusion of the free margin of the iris, to a greater or less extent. To obviate this last accident, as much as possible, belladonna is employed to maintain a dilated state of the pupil ; so that the mai'gin of the iris may be retracted, out of harm's way. If, however, the site of ulcer be towards the circumference, the use of belladonna Avould probably be prejudicial. Previously to completion of the perforated aperture, the membrane of the aqueous humour sometimes protrudes, in the form of a small transparent vesicle ; this condition is termed Hernia of the Cornea. It ought to be touched occasionally with a solution of nitrate of silver, and the iris should be kept fully dilated by belladonna to prevent its being prolapsed, in the event of complete perforation taking place. Sometimes the perforating ulcer heals only in part ; contracts, but 102 MYOCEPHALON. does not close ; becoming a fistulous aperture, through which the aqueous humour continues to escape. This is remedied by the occa- sional application of nitrate of silver, finely pointed, to the part ; and by a tonic system of treatment constitutionally. The iris, protruding through the perforated cornea, forms a black tumour, usually of no great size ; bearing a slight resemblance to the head of a fly ; and therefore termed Myocephalon. Sometimes the iris does not protrude, but simply rests upon the aperture, and closes it up ; and in this abnormal position it may become adherent. In either case, the pupil will be deformed ; and vision may be seriously impaired. The indica- tions of cure are, to restore the iris to its normal Fig. 29. position, and to hasten cicatrization of the aper- ture. In recent cases, the protrusion, when slight, may be overcome by placing the patient on his back, and applying belladonna ; and anti- phlogisfcics are to be employed, to avert or moderate the inflammatory action which is to be expected to ensue. When, however, protrusion is considerable, the aperture being capacious, immediate replacement is not desirable ; temporary and partial protrusion being the salutary means whereby Nature prevents complete escape of the aqueous humour, and consequent collapse of the eye. Under such circum- stances, we content ourselves with rest, exclusion of light, supine posture, use of belladonna, and occasional application of the nitrate of silver ; thus jDromoting healing of the sore, removing irritability of the texture involved, and favouring gradual replacement of the iris. In cases in which the displaced portion of the iris has contracted permanent adhesions with the cornea, replacement cannot be effected ; removal of the protruded part is had recourse to, either by cutting instruments, or by caustic ; and then cicatrization of the remaining sore is attended to. Opacities of the Cornea. Nebula is the thin cloudy opacity which follows inflammatory afifection of the conjunctival covering of the cornea. It arises from slight structural change remaining in that tissue ; and is the form of opacity most likely to be removed, so as to leave the part altogether of its healthy character. The indications of treatment are — to obtain final extinction of any inflammatory excitement which may remain ; and, afterwards, to favour disappearance of the structural change, by absorption. The former indication is fulfilled by the usual means ; the latter, by the guarded use of various stimulant applications. The Fig. 29. Myocephalon. OPACITIES OF THE CORNEA. 103 nitrate of silver, sulphate of zinc, or other substances, may be applied in solution ; or fine powders — as calomel, oxide of zinc, alum, &c. — may be blown on the part through a quill ; great care being always taken, that this part of the treatment is not overdone, and inflam- matory reaccession, with probable extension of the opacity, conse- quently re-established. In the more obstinate cases, iodine is said to be advisable, both externally and internally. And of late, the local use of hydrocyanic acid has been found of considerable avail. The state of the eyelids should, in aU cases, be carefully attended to ; for, not unfrequently, agranular condition of the palpebral conjunctiva is the cause of the opacity's continuance, if not of its first formation. The curative process is necessarily gradual ; and patient perseverance in the use of remedial means is consequently required. Albugo denotes the more deeply seated opacity, which results from plastic exudation between the layers of the cornea. It, too, is amenable to absorption ; but not so favourably as the conjunctival deposit. The treatment is conducted on the same principles ; but with a certainty of longer perseverance being required, and with a less sanguine expec- tation of an altogether successful issue. If the changed part be seen traversed by blood-vessels, the prospect of complete cure may be re- garded as especially unpromising. Leucoma is the dense, pearly opacity, which results from cicatri- zation of a granulating wound or ulcer of the cornea ; it is, in short, a corneal cicatrix — thick, opaque, and little amenable to change. Some- times there is a black point in the otherwise white opacity ; denoting- entanglement, at that part, of a portion of the iris. Treatment, with the hope of discussion, is of little or no avail. Kemaining over-action is subdued, and stimulants employed. But the latter are not used with the hope of altering the cicatrix itself; but only in order to dissipate the nebulous or the albuginous halo, with which the leucoma is usually surrounded. If the opacity be central and small, vision will be greatly improved by habitual dilatation of the pupil by means of belladonna ; if it be both central and large, the only hope of amendment is by the formation of an artificial pupil. It has been proposed to dissect off opacities of the cornea ; but obviously success can never follow any such procedure ; inasmuch as the loss of substance, caused by the dissection, must heal in the ordinary way, and, so healing, must prodiice at least an equally opaque and extensive cicatrix. It has been proposed, however, to operate in one class of cases ; with a rational and fau' prospect of ultimate benefit. The opacity which follows injury of the cornea by sulphuric acid would seem, occasionally at least, to be a chemical incrustation on the cornea, rather than a vital change of and in its structure ; sulpho- proteic acid is said to be produced, and adheres to the external layer 104 STAPHYLOMA OF THE CORNEA. of tlie cornea ; and this may be scraped away, immediately after receipt of the injury, by the edge of a fine knife, leaving the I'est of the part clear and free.* In advanced years, and sometimes even in the comparatively young adult, the corneal periphery gradually becomes opaque, and of a grey colour. The affection is termed Arcus senilis ; a mere deformity ; and not amenable to remedial treatment. Staphyloma of the Cornea. Staphyloma of the cornea is an opaque projection of a part, or of the whole of this membrane. Partial staphyloma is usually situated at the lower or lateral part of the cornea. The iris is adherent to the whole inner surface of the pi"o- jection, and consequently the anterior chamber is much diminished in size ; generally the pupil itself is more or less involved, and vision ren- dered very imperfect. The afiection is caused by an ulcer penetrating the cornea, and allow- ing the iris to become prolapsed through the opening. When a considerable portion of the iris has protruded, it does not shrink when the ^°' ■ inflammation subsides, but remains, and forms a projection at that part of the cornea. After a time the exposed projection of the iris is covered by an opaque firm tissue, of the nature of cicatrix, the edges of which become incorporated at the base with the sound cornea. It is generally the consequence of strumous, catarrhal, or purulent ophthalmia. Total staphyloma is formed exactly in the same way ; it difiers only in degree. When, as is often the case in purulent ophthalmia, the whole or greater part of the cornea is destroyed, the iris falls for- wards, the pupil closes, and the aqueous humour, accumulating in the posterior chamber, keeps the iris distended in the form of a tumour in the front of the eye. The surface of this tumour, as in the partial staphyloma, becomes gradually covered with a firm opaque cicatrix- like tissue of more or less thickness ; and a total staphyloma results. This pseudo-cornea or staphyloma has the form and appearance of a small globe stuck on the front of the eye, with sometimes a ring of the proper cornea surrounding its base. It is often so large as to project considerably from between the eyelids, and prevent them from closing. When the staphyloma is large, the iris, being unable to expand * Lancet, No. 1010, p. 537. Fig. 30. Staphyloma. STAPHYLOMA OF THE CORNEA. 105 to the same extent as the pseudo-cornea, is torn and separated from the choroid ; and when the staphyloma has been removed, the iris is found in contact Avith its posterior surface, broken up and in shreds. This does not occur in a small or partial staphyloma. Vision in total staphyloma is completely destroyed. For the treatment of a small partial staphyloma, the less that is done the better ; except to guard against any tendency to inflammatory action. If it be large and implicate the pupil, the projection may be diminished, by touching it from time to time with some caustic — as the caustic potass — in order to produce condensation and contrac- tion ; which it does by exciting a slow inflammatory process. In the total staphyloma, relief is sometimes obtained by puncturing it from time to time with a large cataract needle, and allowing the aqueous humour to escape ; when the projection collapses. As the aqueous humour, however, becomes almost invariably reproduced in the same or even greater quantity ; and as the staphyloma is a great deformity, besides keeping up a constant state of irritation which is apt to extend to the other eye, its removal should be recommended, so that an artificial eye may be worn. In removing a staphyloma, the eyelids being properly fixed, and a hook passed through the projection in order to command the globe, the base of the tumour is transfixed with a cataract knife from its temporal to the nasal side, a little below its transverse diameter ; the knife is then pushed on, and a flap is formed as it cuts itself out. This flap is seized with a pair of beaked forceps, and that part of the base of the staphyloma which remains uncut is divided with curved scissors, and the whole removed. The lens and some of the vitreous humour often escape ; but generally sufficient re- mains to form a good stump for an artificial eye. After the operation, a pledget of lint, soaked in cold water, should be kept applied upon the eyelids, as a preventive of inflammatory action. If severe reaction supervene, it is to be treated by active antiphlogistics. When bleeding follows the operation, it is checked by cold wet compresses, or by ice applied over the eye. * Conical Cornea. Sometimes the cornea, " retaining its transparency, gradually as- sumes a conical or pyramidal form ; and when viewed from certain positions, reflects the light so strongly as to exhibit a peculiarly bril- liant and sparkling appearance, characteristic of the disease. It gene- rally affects both eyes, though not in an equal degree ; has been observed at all periods of life, but more commonly about the age of puberty ; and is said to be most prevalent among females." f On the * Vide Wharton Jones' Manual, p. 186, et seq. f Littell, p. 188. 106 SCLEEOTITIS. whole, it is a rare affection ; and fortunately it is so, being but little capable of amendment. If the apex protrude from between the lids, it is liable to become opaque. Or ulceration may take place ; and then staphyloma is not unlikely to supervene. In the clear conical cornea, palliation may be obtained by adapting concave spectacles pro- vided with a small central trans- parency. Lately, it has been said, that amendment, if not cure, has followed perseverance in the use of purgatives and emetics;* but how the beneficial result is so obtained, it is not easy to understand or say. When the apex is opaque, temporary amelioration of sight may be secured, by trans- ferring the pupil to a point of the circumference which is as yet clear. Fig. 31. Over-distention of the Cornea. Simple over-distention of the cornea, by an unwonted accumula- tion of the aqueous humour, produces both dimness and prominence. If this state be the concomitant of an existing inflammatory process pervading the eye, as corneitis, by subjugation of this the cornea will sometimes be restored. If, on the other hand, the morbid state is not so connected, but of a passive and indolent nature, antiphlogistics will do no good, and are likely to do harm. From the internal use of the iodide of potassium, or — failing this — from a cautiously given alterative course of mercury, more benefit is to be expected ; a dimi- nution being thus made in the aqueous humour, on whose plethora the over-distention depends. Repeated evacuation of the aqueous humour, by means of a needle, is often of service. Affections of the Sclerotic Coat. Sclerotitis. This may occur as part of a general inflammatory process, how- ever excited. Not unfrequently, it exists per se, and then almost uni- formly is of rheumatic origin ; exposure to cold, probably, having proved the exciting cause. It is most frequent in the adult, and about the middle period of life, and is often limited to one eye. Pain is * Dublin Journal of Medical Science, January 1844, p. 357. Fiff. 31. Conical Cornea. STAPHYLOMA OF THE SCLEEOTIC. 107 complained of, of a dull, aching kind ; increased by px'essure, and by movement of the globe ; partly resident in the eye, but mainly in the forehead and temple ; and mai'ked exacerbation occurs at night. At the commencement of the disease, the eye feels hot and dry ; but this state is soon succeeded by an increased secretion of tears. There is gene- rally, however, little lachrymation or intolerance of light. The minute sclerotic vessels are seen enlarged, i-adiating in straight lines, to form a vascular plexus or zone of a pink hue, around the circum- ference of the cornea (Fig. 23) ; and a narrow white line often encircles the cornea, between that membrane and the pink zone. Not unfre- quently, the pupil is contracted, and incapable of its wonted activity of motion ; this denotes that the iris has participated in the morbid action. The conjunctiva, too, frequently sympathizes more or less ; and by its large, florid, tortuous vessels, the sclerotic characters may be in part obscured. There are often rheumatic pains in other parts of the body. Antiphlogistic treatment is to be had recourse to ; with an activity and continuance proportioned to the intensity of the symptoms. The iris ought to be placed and kept under the influence of belladonna. Mercurial and anodyne frictions should be made on the temple and brow. And the system is to be put under the influence of colchicum, iodide of potassium, guaiac, salines, or other remedies of anti-rheu- matic virtue. Cinchona and soda, five grains of each, given three times a day, sometimes cut this disease short when exhibited at its commencement. Counter-irritation, by blisters behind the ears, is also of service. The only local application should be tepid fomen- tation, either simple or medicated. Occasionally, the affection is found associated with ague ; and then a combination of quinine with colchi- cum is found of much service. Should the iris become involved, the systemic influence of mercury is to be unhesitatingly employed, con- joined with the ordinary antiphlogistic treatment proper for the cure of that affection. Staphyloma of the Sclerotic. This is much less frequent than staphyloma of the cornea. Gene- rally, it is the result of inflammatory action in the choroid and change of structure so induced. The sclerotic becomes attenuated, and yielding ; the choroid coat, engorged, shines through it ; and irregular bulging forwards takes place, constituting several swellings of a bluish or leaden hue. The external vessels are usually enlarged and tortuous. The bulging is often to a great extent; and consequently demands surgical interference. When protrusion takes place from between the lids, then diminution by either puncture or incision is expedient, as in 108 CHOEOIDITIS. the analogous affection of the cornea (p. 105). Puncturing the staphy- lomatous swelling from time to time, and allowing the fluid within to drain off, sometimes diminishes the size of the globe ; but if this be not Kg. 32. Fig. S3. effectual, the humours ought to be discharged through an incision in the cornea ; or the cornea itself may be altogether removed, and then the globe will collapse, and the eye shrink to a small size. In the early stage, internal use of the arsenical solution seems to exert a beneficial influence in preventing or checking the bulgings of the sclerotic. Affections of the Choroid Coat. Choroiditis. Choroiditis, though a fi-equent associate of iritis, sometimes evinces an independent existence. It is generally confined to one eye ; and is most common in females of a strumous tendency. The early symptoms are often gradual and insidious — because chronic. Musc^ volitantes, and an impaired state of vision, usually first attract the attention of the patient. These slowly increase, and terminate eventually in more or less complete amaurosis. Sclerotic vascularity is exhibited, in a faint and imperfect degree, at an early period of the disease ; it soon becomes aggravated, how- ever, and is generally more distinct at one or two points than at others. It is accompanied v/ith a feeling of tension, and deep-seated pain ; often severe, and extending to the surrounding parts ; the eye- ball is tense and hard to the touch, and by pressure the pain is aggra- vated ; sometimes there is intolerance of light and photopsia. The sclerotic now becomes attenuated by absorption, assuming a dull blue or leaden hue from the dark' choroid shining through it ; it also becomes irregularly prominent at certain points. The pupil is dilated, irregular, and of impaired mobility ; it is frequently dragged Fig. .32. Staphyloma of the Sclerotic Coat; seen in profile. Fig. .33. The same disease ; seen in front. Staphyloma racemosum. MUSCiE VOLITANTES. 109 and displaced in the direction of the prominences on the sclerotic ; vision is more or less impaired. Ultimately, the whole globe becomes enlarged, and staphyloma of the sclerotic takes place — the thinned coat having been pushed forwards, either by the swelling caused by the enlarged and tortuous vessels of the choroid, or by the exudation which has taken place from them. By the inward pressui*e, too, the retina has become more and more affected ; being pressed towards the centre of the eye, where occasionally it may be seen through the pupil, in the form of a glistening or whitish cord ; loss of vision is at length complete. General internal ophthalmia is not unlikely to supervene. Teatment should consist in the abstraction of blood both gene- rally and locally, but more particularly in the latter way ; in the early stage of the disease, the extreme vascularity of the choroid being more decidedly influenced by abstraction of blood than by almost any other remedy. In the sub-acute form, blood is to be withdrawn with more caution ; and, in both forms of the disease, counter-irritation is of good service. Purgatives also are useful. Mercury, given so as slightly to affect the system, seems in many cases to arrest the untoward progress ; but when the malady is connected with a strumous habit, it requires to be given with great caution, and generally should be combined with quinine, iron, iodine, and the like. In such cases, nutritious diet, good aii', and exercise are also beneficial. The arse- niate of potash given in small doses, three times a day, has often proved beneficial in the advanced stage, when other remedies have failed. If staphyloma of the sclerotic have occurred, puncture or in- cision may become necessary, as already explained. Muscce VoUtantes. Weak vision, rendered imperfect and interrupted by opaque bodies seeming to float before the eye, is generally understood to depend on congestion of the choroid coat. The ordinary cause is over-exertion of the organ, combined with sedentary habits ; it is also often sympto- matic of derangement of the stomach. The remedial treatment consists of moderate depletionfrom the neighbourhood of the part, gentle purging, alteratives, careful diet, repose of the organ, bodily exercise, and ulti- mately tonics. Affections of the Iris. Iritis. Inflammatory action in the iris may be the result of injury, or it may be of idiopathic origin ; it may occur primarily, itself constituting 110 lEITIS, Fig. 34. a disease, or it may be but a part of general deep opbtbalmia ; it is often connected with the syphilitic, and mercurio-syphilitic taints of system ; and not unfrequently it is of a rheumatic character. A pink or brick-red vascular zone is seen on the sclerotic, formed by the minute subdivisions of the anterior ciliary arteries. This zone is most distinct near the edge of the cornea, and becomes gradually shaded off towards the circumference of the globe ; it is more or less mai'ked according to the extent and stage of the inflam- matory action. There is at first a distinct interspace of white, be- tween the vascular zone and the corneal margin ; ultimately this white line becomes obscured by involve- ment of the conjunctival vessels in the inflammation. The pupil is contracted, and much less moveable than in health, under the ordinary stimulus of light. Indeed, returning mobility of this part is one of the first and surest signs of amendment having fairly begun.* The iris changes its hue ; if of a light colour naturally, it becomes greenish ; if dai'k, it assumes a reddish brown appearance. It is also perceptibly swollen, or thickened at its pupillary margin ; sometimes it is seen of increased vascularity, and bulging forwards in the anterior chamber. The eye is painful, intolerant of light, and there is increased lachryma- tion ; pain is felt in the brow, temple, and head, and undergoes marked nocturnal exacerbation. Sight is greatly impaired. As the disease advances, these symptoms increase. The aqueous humour becomes turbid. Plastic deposition takes place from the surface of the iris ; sometimes coating it with a thin layer, sometimes studding it with nodulated points ; sometimes diffused in the anterior chamber ; often and most frequently situate at the free margin of the iris, hanging pendulous in fringes from the circumference, forming a delicate network stretched across, or perhaps completely blocking up the already contracted pupil. And at this stage, if not before, the contracted pupil is found to be irregular in form, in consequence of adhesions having taken place between it and the capsule of the * Gromelli, from the observation of successful injection, concludes the iris to be an erectile tissue. He supposes that contraction of the pupil during the inflammatorj' pro- cess depends simply on engorgement of the radiating vessels, which are fixed at the cir- cumference, and free at the pupillary margin ; and that return of the blood, in resolu- tion, allows the u'is to shrink, and the pupil consequently to expand. — Brit, and For. Rev., No. 29, p. 233. Fig. 34. Iritis; shewing the characteristic vascularity of the globe, the iris clogged with lymph, the pupil contracted and irregular. IRITIS. Ill lens ; an irregularity which becomes especially distinct, when partial dilatation has been effected by belladonna. Extravasation of blood from the surface of the iris may occur ; small clots are sometimes to be seen resting on it ; or the blood may gravitate to the bottom of the anterior chamber, and accumulate there, constituting the state termed Hypocema. Or effusion of pus into either chamber may take place. The pus forms small abscesses on the iris, which soon give way and discharge their contents ; and, gravitating to the bottom of the anterior chamber, it collects there, constituting Hypopion. Such events indicate an intense action ; not only likely to prove most preju- dicial to the delicate texture involved, but also almost certain to extend to those adjoining. The result of fibrinous exudation is denoted by various terms, according to its extent and site. When fibrin blocks up the pupil permanently, the case is termed one of False Cataract. When ad- hesion has formed between the posterior surface of the iris and the capsule of the lens, it is termed Synechia posterior. When the iris, bulging forwards, has reached the posterior layer of the cornea, and become adherent thereto, the term Synechia anterior is applied. After a time, the vascularity of the organized fibrin can often be distinctly seen, when a strong light is thrown upon the part. During active advance of the inflammatory action the system sym- pathises to a considerable extent ; there is often a marked form of in- flammatory fever. Treatment. — Our principal object is to arrest the progress of the disease at an early period, ere exudation or structural change has taken place-; in order to avert all hazard to the important part, if possible. Our remedies ought to be early, active, and powerful. Blood should be abstracted freely, both generally and locally. The eye is kept dark or shaded, and should be frequently fomented. The bowels are freely moved ; and then, as rapidly as possible, the system is brought under the full influence of mercury — unless there be some pre-existing and undeniable contra-indication ; for in gene- ral it is not till the mouth is affected mercurially, that the disease begins to amend. If the system, however, be strumous, and con- sequently intolerant of mercury ; or when there is a known idio- syncrasy rendering all exhibition of the mineral dangerous by the induction of erethismus : — then a substitute must be sought, likely to aid general antiphlogistics in preventing exudation, or in causing its absorption. Turpentine is often a valuable remedy for this pur- pose, when given in full and continued doses ; * but it is not always to be trusted to alone ; it seems to act better when a small quantity of * Mr. Carmichael's Formula is as follows : — Recipe — 01. Terebinth, rect. unc. unam — Vitel. unius ovi — -Tere simul, et adde gradatim, Emuls. Amygd. unc. quatuor — Syrup, cort. aurantii unc. duas — Spir. Lavend. comp. drachmam, c. semisse — Olei Cinnamomi, guttas quatuor. M. Dosis — unc. un. ter in die. 112 IRITIS. mercury has been previously given, and then its use frequently proves beneficial, not only at the time, but also in preventing relapse of the disease. From the fii'st, belladonna is applied, so as to oppose the tendency to contraction in the pupil, and effect dilatation if possible. The semi-fluid extract is smeared on the eyebrow and temple, or an aqueous solution may be dropped between the eyelids ; but the former method of application is usually preferred, at least in the first instance. In those cases in which mercury is not contra-indicated, mercurial friction on the temple and forehead is advisable, to maintain the con- stitutional effect which internal exhibition of the mineral has produced. In the more chronic form of the disease, counter-irritation may take the place of the direct antiphlogistics. And, ultimately, when traces of the affection still linger, the internal administration of tonics, espe- cially of quinine, proves beneficial by dissipating the state of passive congestion which threatens to remain. When Hypopion has formed rapidly, and when the purulent ac- cumulation is considerable, it has been proposed to make an opening at the lower part of the cornea, by means of a cataract knife, so as to effect evacuation. This, however, is dangerous ; it is better to trust to the sorbefacient powers of mercury, than to encounter the risk of aggravated inflammatory action. The extravasated blood of Hypoaema should receive the same treatment. Active antiphlogistics are had recourse to ; and these having told favourably on the action, the extravasated blood may be expected to disappear gradually by absorption. The occurrence of Hyposema, however, as indicating a high degree of inflammation, is always of bad omen. The adhesions, or Synechice, are superable in the recent state. By perseverance in the local use of belladonna, the imperfectly organized fibrin is extended or torn, and the iris recovers its normal play. At the same time, absorption of the deposit is to be favoured, by moderate continuance of the mercurial friction. Syphilitic Iritis is a frequent variety of the affection, occurring as part of the secondary train of venereal symptoms. Its characteristics are : — the accession along with other venereal symptoms ; marked noc- turnal exacerbations ; a dark hue of the vascular zone ; fibrinous deposit occurring in nodules of a brownish hue, studded on the margin of the pupil as well as on the surface of the iris ; and the margin of the pupil often observed to be thickened, and corrugated. This form generally is more severe, and runs its course more quickly, than the idiopathic variety of iritis. Treatment is as for ordinary examples of the disease. The Rheumatic and Arthritic Iritis is not of such frequent occur- rence. It is characterised by : — accession taking place along with CHANGES IN THE PUPIL AND IRIS. 113 other symptoms of a rheumatic or gouty character ; the vascular zone is of a purplish hue, and not a little obscured by early involvement of the conjunctival vessels ; the whitish ring surrounding the cornea is more perceptible in this species of iritis, than in any other ; the pupil, con- tracting, inclines to assume an oval form ; and there is peculiar prone- ness to relapse. Treatment consists of the ordinary antiphlogistic remedies directed against acute and inflammatory rheumatism. Mei'cury should be given cautiously, and often requires to be com- bined with quinine as a tonic ; in many cases its place may be advan- tageously taken by colchicum, guaiac, or iodide of potassium. Strumous Iritis frequently results from extension of the inflammatory process inwards, in cases of strumous corneitis, and is the form of iritis most generally met with in childhood. The previously existing opacity of the cornea is very liable to mask the internal and more important action ; deceiving the practitioner as to its existence, until the opportunity for successful treatment has passed. Mercury should be used very sparingly ; and, at a comparatively early period, the ad- ministration of quinine, iron, iodine, &c., with a tonic regimen, is required. Changes in the Pupil and Iris. Unusual dilatation of the pupil is termed Mydriasis. It may be of idiopathic origin ; or it may be connected with disorder in the cerebral functions ; it is a common symptom of Amaurosis ; and frequently it is caused by contusions ; often it is sympathetic of intestinal irrita- tion. The admission of an excess of light to the retina is found to be a serious inconvenience ; and vision is confused and impaired ac- cordingly. The remedial treatment consists in detection of the cause ; removal of this, if possible ; and subsequent stimulation of the part, by frictions on the temple and brow, and by exposure of the eye itself to ammoniacal vapour. Electricity and galvanism are also sometimes useful. In the idiopathic forms of paralysis of the iris, M. Serres re- commends cauterization of the corneal margin by nitrate of silver. In other cases, palliation results from contracting the space for admission of light, by spectacles darkened except at a small opening in the centre, as in the case of conical cornea (p. 106). When dilatation of the pupil accompanies amaurosis, of course it cannot be expected to disappear, unless the amaurotic condition have been previously removed. Myosis denotes unusual contraction of the pupil. This is one of the consequences of Iritis, as we have already seen ; it may also attend on disorder of the cexebral functions ; sometimes it is induced by habitual straining of the eye on small objects — as in microscopists, I 114 OCCLUSION OF THE PUPIL. engravers, watchmakers, &c. Ordinary and useful vision is necessarily impaii'ed. The means of cure consist in removal of the cause. In the artificers just enumerated, temporary abstinence from the usual avoca- tions will often suffice to restore the normal state. Tremulous Iris. — A trembling, or oscillatory movement of the iris, not unfrequently accompanies amaurotic afiections ; and seems also, in most cases, to be connected with softening of the vitreous humour. It is but little amenable to treatment; and is chiefly notable as a sufficient contra-indication of operative interference, in connexion with cataract and artificial pupil. Adhesions of the h'is — Synechice — have been already considered (p. 111.) They may be the result of wound, of corneitis, or of iritis. In synechia anterior, complete, and accompanied with opaque cornea, cure is manifestly hopeless. When incomplete, and the cornea clear, amend- ment by the formation of an artificial pupil is within our power. When the adhesion is partial and recent, it may sometimes be remedied by mercurials, and the use of belladonna. Similar treatment will avail in synechia posterior, when I'ecent and partial. But, when complete, it is usually accompanied with opacity of the crystalline capsule, and it may be of the lens itself; under such circumstances, amendment of vision can be eiFected only by an operation directed against the ca- taract. Occlusion of the Pupil. The pupil may be closed in various ways. Remaining itself in a normal state, it may be obscured by the cornea which has become simply opaque, or opaque and staphylomatous. Or, the cornea re- maining clear, the iris may contract during inflammatory action, and the pupil may become occupied by organized fibrinous deposit. Or both iris and cornea may undergo serious structural change ; as when complete synechia anterior takes place in staphyloma. In the last mentioned case, restoration of sight is manifestly impossible. But in the other examples, something may be done by forming an Artificial Pupil. Before proceeding to any such operation, however, certain cii'cum- stances are invariably to be taken into consideration. It must be ascertained : — that the adhesions of the iris are irremediable by the influence of mercury and belladonna ; that the opacity of the cornea is permanent; that the other parts of the visual apparatus — especially the retina and vitreous humour — are in a sound and healthy condi- tion ; that the eye has not only ceased to be the seat of all inflamma- tory action, but, also, that it is not prone to resume such action on the application of a fresh exciting cause. An operation is also OPEEATIONS FOE ARTIFICIAL PUPIL. 115 very properly held to be inexpedient, so long as the patient enjoys a tolerable degree of vision vdth the other eye ; and it is plainly contra- indicated, when one eye only is affected. Three distinct modes of operation are practised ; all implying divi- sion of the iris — so as to make a sufficient gap in it — opposite a clear portion of the cornea. The desired space in the iris may be obtained by incision, excision, or laceration. Accordingly, the operation is said to be by Coretomia, Corectomia, or Coredialysis. The situation of the proposed nevf pupil requires consideration. The centre of the iris is the best position ; but when this is impracti- cable from central opacity of the cornea or other cause, the nasal side is to be preferred ; or it may be made on the temporal or lower sides. When made above the centre, it is apt to be covered by the upper eyelid. The patient, by previous preparation, should be placed in a condi- tion favourable to the avoidance of inflammatory action. Coretomia, or incision, is performed in cases where the greater portion of the cornea is clear, and the iris is apparently in a state of tension, with the pupil closed. It may be performed either through the sclerotic, or through the cornea. In operating through the sclerotic, an iris-knife is introduced through this membrane about a line from its junction with the cornea, as in the operation for cataract, and the point of the knife is made to pierce the iris at about a line from its temporal margin ; the instrument is then carried across the front of the u'is in the anterior chamber, to the nasal side of the cornea (Fig. 35, 1) ; and, while it is withdrawn again, gentle pressure should be made with its edge upon the iris, the tense fibres of which when divided will separate, and an elliptical or ovoid pupil will be the result. The fibres of the iris should be divided for about a half of the diameter of the membrane. When the lens is opaque, as is generally the case, it should be broken up at the same time. In operating through the cornea, a method practised by Maunoir, an opening is made in this membrane by a cataract knife, involving about a third of its circumference ; into this aperture a pair of fine scissors is introduced, the pointed blade of which is thrust through the iris, while the blunt one is carried between that membrane and the Fig. 35. 1, Coretomia through the sclerotic. The knife introduced — ^rather far back. 2, Coretomia through the cornea, showing the lines of the incisions. 3, The same after the operation. 4, Coredialysis, or separation. — From Whakton Jones. l2 116 OPEEATIONS FOR ARTIFICIAL PUPIL. I'ig. 36. cornea. The scissors are puslied on, till their farther progress is arrested by the junction of the cornea with the sclerotic, Avhen their blades are brought together, and the iris is divided as in the former instance. Or, another incision may be made with them, diverging from the first, and including a triangular portion, the apex of which is near the centre of the iris. The flap so formed will shrivel up in the direction of its base, and leave a sufficient opening for the admission of light (Fig. 35, 2 and 3). Corectomia, or excision, is performed through the cornea, in cases where a portion of that membrane is opaque. When the pupil is non-adherent, and only the centre of the cornea opaque, a broad flat needle, or the point of a cataract knife, is passed into the anterior chamber at the lower or outer side of the cornea; through this aper- ^ ture Mr. Tyrrell's fine blunt hook is introduced, and having been en- tangled over the free margin of ^s- ^'^• the pupil, is withdrawn through the open- ing ; the included portion of iris being either excised with scissors, or allowed to rub ofi" with the friction of the lids, after having become strangulated in the wound of the cornea. When the pupil is adherent either to the capsule of the lens, or to the cornea, a larger incision than in the former case should be made, near the junction of the cornea with the sclerotic, and through a clear portion of the cornea. The aqueous humour escapes, and is generally followed by a protrusion of the iris, which should be increased by gentle pressure Fig. 38. on the globe ; or a portion of it may be dragged out of the opening by a small hook; and when a sufficiency has been protruded, it should be excised with the curved scissors. Sometimes it is necessary to separate the adhesions with a needle, before the iris will prolapse. A portion of the pupillary margin should, if possible, be included in the excised part. Coredialysis, or separation, is performed when the cornea is opaque, except a small part at its circumference. Having made an opening about two lines in length through the opaque membrane, a fine sharp hook is introduced, which is fixed in the iris close to its ciliary border, and behind the clear portion of the cornea. When the hook is withdrawn, the iris is torn away from its ciliary attachment till an opening of suf- Fig. 36. Extensive opacity of the cornea. A portion left clear, suitable for an arti- ficial opening in the iris, by corectomia. Fig. 37. Tyn-ell's blunt iris hook. Fig. 38. Corectomia. EETINITIS. 117 ficient size is obtained (Fig. 35, 4). The portion of the iris which is drawn out of the anterior chamber, may either be allowed to become strangulated in the edges of the incision, or it may be excised. This operation may also be performed by introducing a curved cataract needle through the sclerotic, and carrying it across the posterior chamber, till it reaches that portion of the iris which it is wished to separate from its ciliary attachment ; here it is made to perforate the iris, and separation is effected by pressing the point downwards and outwards. There is generally a considerable quantity of blood effused into the anterior chamber after all of these operations, and more or less inflam- matory action follows. Strict antiphlogistic treatment should be pur- sued, with confinement in a dark room. It is to be remembered that the new pupil, on its first formation, should seem rather too large than otherwise ; there being always a decided tendency to subsequent con- traction. Affections of the Retina. Retinitis. The acute form of this affection may follow direct injury by wound, or the pressure of a depressed lens, or exposure to intense light or heat, or undue and continued exertion of the eye ; or it may be of idiopathic origin. It is accompanied with agonizing pain, deep seated, shooting through the head, aggravated by the slightest motion, and often with delirium. There is very great intolerance of light, with lachrymation ; luminous bodies seem to pass before the eyes ; vision is greatly impaired from the commencement ; the pupil is at first much contracted, but afterwards becomes dilated, and remains motionless. Then the intolerance of light abates, and blindness becomes complete — the retina being no longer capable of obeying the accustomed stimulus. The system is involved in marked inflammatory fever. At first, the outward indications of increased vascularity are not very apparent ; but, ultimately, as the action extends to the other deep textures of the eye, the usual signs of internal ophthalmia become developed. Treatment, which should be decidedly antiphlogistic, consists in seclusion from all stimulus of both the eye and the system ; bleeding, both local and general, repeated if need be; purgatives; counter-irri- tants ; and free exhibition of mercury so as to exert its full influence on the system. Mere abatement of the acute symptoms is not suffi- cient ; therefore, the remedies ought to be persisted in, till a perfect cure is established ; due regard being paid to the safety of the patient. If the disease be allowed to degenerate into a chronic form, it will ultimately prove injurious to the function of sight. 118 AMAUEOSIS. Amaurosis. By this term is understood impairment of vision, more or less com- plete, dependent on change in the retina, optic nerve, or brain ; and that change may be either structural or functional. In the latter case, there is good hope of cure by suitable treatment ; in the former, even palliation is often hardly within our power. The causes are : — change in the retina, optic nerve, or brain, by the injflammatory process, acute or chronic ; compression of these parts in any way — as by extravasated blood, inflammatory effusion, or for- mation of a tumour ; a congested state of these parts, induced by over exertion of the eye or brain, by irregularity of bowels, by habitual exposure to much light and heat, by intemperance, by gout — by, in short, whatever tends to cause determination of blood to the head. Sometimes, on the contrary, amaurosis is caused by want of the circulating fluid in the eye or in the head; as in cases of anaemia from prolonged lactation, profuse uterine discharge, or the like. "Wounds of the supraorbital branches of the fifth nerve have often been followed by amaurosis. The symptoms are : — impairment of vision, gradual and increas- ing ; at first there is perhaps mere obscuration of sight, but this soon gives place to thorough perversion of that function ; objects are often seen of erroneous proportion and colour. In the congestive and in- flammatory forms, more or less pain is complained of. At first, there may be intolerance of light ; but ultimately a glare is borne with im- punity, or is rather desired than otherwise. Ocular spectra are seen, either constantly, or from time to time, especially after exertion of the eye ; they may be dark or luminous, massy or scintillated, steady or flickering. The pupil is dilated ; the iris is sluggish, and ultimately motionless ; the eye has a vacant, staring expression ; and the patient acquires a peculiar, uncertain gait. Often there is no fixed or decided pain in the part ; but rather a sensation of tension and uneasiness. Sometimes the eyeball has a tremulous or oscillatory motion. On the whole, the ordinary and characteristic symptoms are, the painful sensa- tions, the impairment and perversion of vision, the ocular spectra, and the state of the pupil. In applying the catoptrical test (p. 121), the three images of the candle are seen as in the healthy eye — a sufficient dis- tinction from both glaucoma and cataract. From the latter it is further distinguished by vision being improved in strong light, and impaired by belladonna ; by the state of the pupil ; by the absence of crystalline opacity ; by perversion of sight existing — not mere impairment ; and by the characteristic stare and gait of the patient. But there is no uniformity as to symptoms. In most examples, pain ceases on full establishment of the disease ; in others it continues AMAUEOSIS. 119 unabated. In most, the symptoms gradually advance to complete loss of sight ; in others, independently of treatment, the symptoms reach a certain point and then remain stationaiy. One patient may continue to have intolerance of light throughout ; the majority of ad- vanced Amaurotics, on the conti'ary, seek a strong light, finding their vision improved thereby. Some see objects double ; this variety is called Diplopia. Others see but the half of an object; and this is termed Hemiopia. In many, the pupil is at first contracted, there being an originating inflammatory process present ; in most, ultimate and permanent dilatation exists ; but, in a few cases, the iris seems natural in both form and hue, and is perfectly obedient to the stimulus of light. The untovs^ard progress is very various. Sometimes vision is lost at once, as v^^hen extravasation takes place by sudden congestion. Sometimes months elapse ; or even years may be occupied in the gradual decay. The affection is most common in the middle period of life ; and vs^hile it seldom attacks both eyes at once, both are ulti- mately involved in the great majority of cases. In the inflammatory form, the mode of treatment is plain ; the ordinary antiphlogistics are demanded, in cases which are at all acute ; and the system ought to be brought, and maintained for some time, under the influence of mercury, which often evinces a striking control over the disease. In the chronic examples, moderate depletion, followed by an alterative course of mercury, is most likely to prove useful ; and counter-irritation is at the same time advisable. When congestion is suspected, moderate depletion should be practised with purgation ; and then the ordinary means are to be taken for preventing local determi- nation of blood. If the affection have followed disappearance of an accustomed discharge, normal or not, return of that discharge is to be sought. If an atonic state of the system exist, a stimulating plan of constitutional treatment is plainly indicated. If the disease be appar- ently but a secondary symptom, as it were, of some constitutional malady — as jaundice or hysteria — that malady is to be thoroughly eradicated from the system, if possible. If intestinal irritation exists, or be suspected, it is to be treated by the ordinary means. In short, the predisposing and exciting causes should, if possible, be ascertained and removed. And this paramount indication having been more or less perfectly fulfilled, certain means are sometimes in our power whereby to rouse the retina to a resumption of its function. Stimulants, when applied directly to the eye, or to its neighbourhood, are sometimes useful for this purpose ; or the endermic application of strychnia may be made on the temple or forehead. A blister having been applied, a quarter of a grain of the powder is sprinkled on the part, once or twice a-day. The dose is gradually increased, until a bitter taste is felt in 120 CATARACT. the mouth ; and then temporary discontinuance of the remedy is expe- dient. Failing strychnia, electricity may be employed, but its use is seldom attended with much benefit. Affectmis of the Crystalline Lens and Capsule. Cataract. The term Cataract is applied to opacity of the crystalline lens. It is said to be l&nticular, when the disease is situated in the lens itself; capsular, when the capsule only is opaque ; and capsulo-lenticular, when both the lens and its capsule are affected. The affection may occur at any age, and is said to be owing to " defective nutrition from the changes which are going on in the vascular or lymphatic system." Or it may be induced by external injury of the part. Sometimes it is a congenital defect. Most frequently it occurs in advanced years ; one sign, among many, of the frame's gradual decay. The prominent symptom is impairment of vision. At first, objects are seen as if obscured by a gauze or mist ; this obscuration gradually increases ; and ultimately vision is almost, but not entirely, lost. Some- times uneasy sensations are complained of in the eye and forehead ; more frequently the part is the seat of no abnormal sensation. Sight is improved by a diminution of light ; it is better at twilight than at noon, and also better when the patient is seated with his back to the light, than when facing the window ; for the pupil, then dilating, per- mits the rays of light to pass to the retina through the margin of the lens, which is as yet unobscured. For a like reason, the use of bella- donna materially improves the sight. On looking into the eye, an opacity is discernible, occupying the pupil, and situate immediately behind it. Whenever deliberate examination is contemplated, bella- donna should be previously applied, to dilate the pupil, so as to afford every facility for ascertaining the extent and character of the opacity. In proportion as sight is impaired, the opacity is found to have in- creased. It is greatest at the centi-e ; when complete, it is of a grey, white, bluish, or amber hue ; and this is not unfrequently contrasted with a dark annulus or ring on its exterior — the shadow of the iris falling on the periphery of the cataract. In the most advanced cases, the patient is still able to distinguish light from darkness. The iris is not necessarily impaired in its functions. Both eyes are seldom attacked at once ; but usually both are ultimately involved. What is termed the catoptrical test of cataract is conducted thus. The pupil having been dilated by belladonna, the patient is seated with his back to the light, and the surgeon holds a lighted taper in CATAEACT. 121 front of the eye. In a sound organ, the depth of the clear pupil exhibits three reflections, or images, of the light ; one superficial, bright, and distinct, caused by reflection from the cornea ; one deep seated, pale, and indistinct, caused by reflection from the anterior portion of the lens ; and one in the mesial plane, or between the two former, small and obscure, caused by reflection from the posterior portion of the lens ; the two flrst, erect, move consentaneously with the lighted taper ; the last mentioned, inverted, moves slowly and in an opposite direction. In the case of cataract, the middle inverted image is first extinguished ; and afterwards the deep erect one also becomes invisible. Or, to speak more accurately, " opacity of the posterior capsule prevents the production of the middle inverted image ; and opacity of the anterior capsule destroys the two posterior ones. In other words, in posterior capsular cataract, the middle or inverted image is not seen ; in cataract of the anterior capsule, and in capsulo-lenticular cataract, the anterior straight one only is visible." In amaurosis, the three images are always distinct, as in the sound eye. " Glaucoma, only when much advanced, obliterates the inverted image ; while, in all its stages, it rendei's the deep erect one more evident than it is in the healthy eye." From glaucoma and amaurosis cataract is further distinguished, by the state of the pupil, the site and character of the opacity, the nature of the vision, and the expression and gait of the patient. Spurious Cataract is said to exist, when organised fibrin occupies the pupil. This is distinguished from true cataract by being of a yellow or whitish colour ; and by the lens being adherent to the iris, which is puckered, altered in hue, and irregular in its pupillary margin. Cataracts vary as to density. Hard cataract is most frequent in the old ; and is characterized by its brownish or amber tint. The lens is apparently shrunk in its dimensions, and the greatest amount of opacity is central. The iris is free and movable ; the dark ring surrounding the cataract is remarkably distinct ; and in the twilight, as also after the use of belladonna, objects may often be discerned with tolerable accuracy. Soft cataract, of fluid or semifluid consistency, is large and bulging, and completely occupies the pupil. It is most common in the young and middle aged, and is characterized by its bluish-white or milky colour. The iris is clogged in its movements, from the increased size of the lens ; and the impairment of vision is great. The opacity is not always homogenous ; dots or streaks are occasionally observed on it ; and these may change their form and site from time to time. In what is termed the Radiated Cataract, the opacity is formed in streaks ; and not unfreqiiently commences at the circumference, thence extending towards the centre. This peculiarity is readily observed on inspection ; and, as can be easily understood. 122 CATARACT. vision will for sometime prove better with a contracted than with a dilated pupil. Treatment. — Unfortunately our art has as yet proved impotent, in attempting to stay the progress of advancing cataract ; and, when it has fairly formed, no faith need be reposed in any attempts at simple dis- cussion of the opaque structure. By operation only can amendment be obtained. The obstructing body may be wholly extracted from the eye ; or it may be pushed out of the axis of vision ; or it may be broken up into fragments, which are expected to be afterwards absorbed ; or it may be simply drilled ; or it may have its capsule opened, so as to admit the aqueous humour, and thus favour absorption of the crystalline sub- stance. Before any operation, however, is undertaken, certain prelimi- naries require to be adjusted, as in the case of Artificial Pupil (p. 114). We must first be satisfied that the eye is in other respects sound ; so that, when the obstruction to light is removed, there may be a fair prospect of vision being restored. There must be no amaurosis, glaucoma, change in the vitreous humour, ophthalmia, or affection of the eyelids. The patient must be free fi'om any marked constitutional ailment. The state of the atmosphere should be mild and favourable. "While there is a tolerably useful amount of vision enjoyed by either eye, it is more prudent to I'efrain from operation ; the results of operation being found most favourable in cases well matured. One eye only should be operated on at a time. Finally, by careful regimen, and medicinal treatment if necessary, the system is brought into a favourable state, and is rendered not morbidly susceptible of inflammation. In the congenital variety an operation should be performed early ; otherwise the unsteady rolling motion which the eyeball is so prone to assume, will prove an impediment to subsequent interference, and to the successful result of operation. Extraction. — In the operation by extraction, the opaque lens is re- moved from the eye through an aperture in the cornea — an operation, necessarily comprehending a considerable extent of wound, and no slight amount of injury done to the parts. If inflammatory action can be prevented, the result is often most successful. But if inflammation supervene, or an accident happen to the vitreous humour during the operation, sight is lost irretrievably. Many favourable circumstances require to be present to warrant an attempt at extraction. The cornea should be sound, the anterior chamber of proper size, the iris mobile and non-adherent, the globe prominent and steady, the cataract lenti- cular and hard. The patient should be in good health ; neither ple- thoric and inflammatory, nor weak and incapable of plastic exudation ; capable of self-control, and of maintaining the supine posture; not troubled with cough, sneezing, or asthmatic ailments. And this series of qualifications necessarily limits the operation by extraction to a minority of the cases of cataract. CATARACT. 123 The pupil should not be dilated, otherwise escape of the vitreous humour is favoured. The patient is placed before a steady light, but with his head slightly inclined from it, and either seated, or recum- bent ; the sound eye may be covered by a bandage. The surgeon, holding the knife in his right hand, should be placed either in front or behind, according to the eye which is to be operated on. An assistant now opens one lid, with his fore and middle fingers, at the same time steadying the eyeball by a little gentle pressure ; the surgeon opens the other eyelid, and assists in steadying the globe, by the fingers of his left hand. If the patient sits, his head is secured against the lower part of the assistant's chest. The flap may be made superiorly or inferiorly, according as it is the right or left eye which is to be operated on. It is usually made superiorly when it is the right eye, the surgeon standing behind, and elevating the upper lid himself; when it is the left eye, the flap is made inferiorly, the surgeon being seated before his patient, and depressing the lower lid, while the assistant raises the upper. The knife used is the triangular one, known as Beer's. It should be held lightly between the thumb and points of the fore and middle fingers, the ring and little fingers resting upon the cheek. The flat edge of the point is first made to touch the cornea gently, in order to reassure the patient, and secure steadiness of the organ ; it is then entered at about a line from the corneal margin, and passed into the anterior chamber in a pei'pendicular direction, lest separation of the corneal laminae should take place from the knife getting between them. Penetration having been effected, the direction is changed, and made parallel to the surface of the iris ; the knife is then pushed steadily across the anterior cham- ber, the point emerging at a spot directly corresponding to that of its enti'ance ; and the steady advance of the instrument is continued, until section of the cornea is complete. All pressure is now to be removed from the eyeball. If the aqueous humour escape prematurely, the iris falls forward, and is consequently brought into contact with the edge of the knife. In this case a stop is made, and gentle pressure must be applied to the cornea yet uncut, without however withdrawing the knife. This may succeed in replacing the iris, and then section is continued. If not, the knife is withdrawn, and probe-pointed scissors are substituted, with which the wound is finished.* Fig. 39. Extraction. The knife cutting through. * Or, according to the method of Sichel, and others, the opei'ation may be interrupted, and postponed till the humour is reproduced. 124 CATAEACT. The corneal section having been completed, the eyelids are permitted to close, the eye to rest, and the pupil to dilate. Then, the lids having been gently re-opened, the sharp end of a curette is cautiously introduced beneath the flap, and as gently as possible made to divide the capsule. The slightest possible pressure is then made on the upper eyelid — over the anterior part of the globe, just behind the corneal margin — so as to dislodge the lens — and nothing more. On escape of the opaque body, the corneal flap is properly adjusted, and the eyelids are permitted finally to close. Should the iris have prolapsed, sudden exposure to a bright light will probably suflB.ce for its reduction, by causing contrac- tion of the tissue ; if not, the protruded portion may be replaced by gentle use of the blunt extremity of the curette. The eye is coA'^ered with a light pledget of lint, and a bandage. The patient should be laid on his back, vnth. the head elevated ; light and all other stimuli are to be I'igidly excluded ; the most sparing regimen is to be en- joined, the act of mastication even being interdicted; precautions are to be taken against coughing, vomiting, and sneezing ; and, if need be, involuntary rubbing of the eye is to be provided against also. If pos- sible, the eye should not be uncovered, and exposed to the stimulus of light, for at least three or four days. The symptoms of inflammatory action must be carefully watched, and treated when they occur ; by bleeding, purging, and abstinence — but obviously not by nauseants. Mercury, too, is inexpedient, lest it prevent such exudation as is neces- sary for the healing of the cornea. The pei'iod of inflammatory action having passed, the eye is gently and gradually accustomed to its wonted stimulus ; but exercise of its full function is to be very slowly resumed. Depression, or Couching, implies downward displacement of a solid cataract, which it is not found expedient to extract. The pupil having been dilated by belladonna, the position of the patient is arranged as for extraction. The needle used for this purpose is the one known as Scarpa's, and which is curved at its point. ^'°' *"■ It is pushed through the sclerotic, on the external side of the cornea, in the transverse axis of the eye, at the distance of a line from the corneal margin ; this point being selected in order to avoid the two divisions of the long ciliary artery, which vessel usually bifurcates at a distance of two or three lines from the corneal margin ; also to avoid wounding the retina and the ciliary body. The needle having entered, is pushed steadily forwards into the anterior chamber, between the iris and the lens. By depressing the hand a very little, its point is brought into contact with the upper part of the lens, the concaAaty of the instrument being opposed to that Fig. 40. Depression. — From Wiiaktox Jones. CATARACT. 125 \ body. By now elevating the hand, the lens is depressed towards the bottom of the eye, gently and steadily ; and the instrument, having been allowed to rest there for a few moments — de- taining the displaced body, till the vitreous humour closes over it — is gently extricated and withdrawn. The eye is now closed, a piece of wetted lint, with a light bandage is applied, and the ordinary precautions against inflammation are to be adopted, as after extrac- tion. Comparative facility of performance is in favour of depression. But the manifest objections are ; danger of chronic inflammatory action, in consequence of the displaced body pressing upon or irritating the retina and ciliary processes ; disorganization of the vitreous Kg- ^i. humour ; and the possibility of future escape of the lens upwards — again to obstruct the transmission of light. Reclination is a modification of depression. The instrument used, and the manner of introducing it, are the same as in the operation for depression ; but the lens, in- stead of being completely dislocated and pushed downwards, is simply made to revolve partially, so as to turn its superior margin backwards into the vitreous humour ; while its anterior surface is directed upwards, and remains nearly on a level with the lower edge of the pupil. Less injury is done to the retina than in depression ; but reobstruc- tion of the pupil is at least equally probable. The operation to promote absorption, or Dissolution, is practised when the lens is of fluid or semifluid consistence. The procedure is simple, and easily performed, but requires repetition ; and the result is tardy, and may be uncertain. The object is, to admit the aqueous humour to a free and general contact with the substance of the lens — a circumstance which experience has shown to be conducive to absorp- tion or solution of the latter. When breaking up is intended, the needle is introduced as for depression. Its point, having reached the pupil, in front of the lens, is made to divide the capsule by a slight rotating motion, and also to break up the lens into fragments. If the lens be fluid, no division of its substance is necessary ; it escapes at once into the aqueous humour, on its capsule being opened. When of soft con- sistence, a few of the fragments often find their own way into the anterior chamber; if not, they are gently placed there by the needle; for in that locality absorption or solution seems to advance 'more Fig. 41. Scarpa's needle. 1, Front view. 2, Side view. Fig. 42. Eeclination. — From Wharton Jones. Ms. 42. 1 26 CATAEACT, rapidly than behind the iris. Care must be taken, however, not to dislodge the lens forward in a mass, or in bulky fragments ; otherwise untoward inflammatory action may be induced, in the iris and other parts, by pressure of the lens upon them. At the first operation, the lens is divided but slightly. Many deem it sufficient to divide the capsule only ; and certainly it is well not to attempt any displacement ; when the operation, however, requii'es to be repeated, the lens may be more freely broken up. A few weeks are allowed to intervene between the operations ; and after each, ordi- nary antiphlogistic precautions are to be adopted. The operation by drilling is performed through the cornea. A straight needle is entered near the corneal margin, and passed through the pupil into the substance of the lens. Having penetrated into this, to the extent of about a sixteenth of an inch, it is rotated freely, and carefully withdrawn. The proceeding is repeated from time to time, as in the breaking up ; on each occasion a fresh part of the lens being chosen as the site of puncture. The object is to admit the aqueous humour ; and, by its agency on the lens, gradual absorption of that body takes place. After removal of the lens, in any way, a convex glass requires to be adjusted to the eye ; in order fully to restore vision. This is the duty of the optician. Only let it be the surgeon's care not to permit any such adjustment, and resumption of the full exercise of the organ, until at least two months have elapsed after the operation — and more especially if that operation have been by extraction ; for not until then will the eye be safe from accession of inflammatory action. If after removal of the lens, by operation, the capsule become opaque, and, occupying the pupil, obstruct vision, it may be got rid of in one of three ways. It may be extracted, through a minute aperture in the cornea, by a hook, or by small forceps. It may be detached at its ciliary margin, by a needle, and depressed, like a lens. Or it may be crucially divided by the needle ; and the flaps, shrinking fi-om the centre, may leave the pupil patent and sufficiently free to admit light. Affections of the Humours of the Eye. Hydrophthalmia. Dropsy of the eye may depend on excess of the aqueous humour, of the vitreous humour, or of both. In the first case, there is tension, prominence, change of form, and increasing nebulosity of the cornea ; HYDROPHTHALMIA, 127 the iris is changed in colour, and impaired in mobility ; the pupil is dilated ; vision is much affected ; there is a sense of fulness in the eye; and more or less headach is complained of. When the vitreous humour is increased in quantity, enlargement and tension of the whole eye occur ; the iris is motionless, and arched forwards ; the sclerotic is attenuated, and has a bluish or brown ap- pearance ; vision is wholly lost ; and the pain is deep-seated and severe. Ultimately, the eyeball protrudes between the lids, inflames, and ulcerates ; or rupture takes place, with partial evacuation of the humours. Palliation is in our power, by evacuation of the redundant fluid — by puncture of the cornea or sclerotic, or by incision of the former texture. Sometimes the progress of the disease may be delayed, if not arrested, by coimter-irritation and constitutional treatment. Syrichysis Oculi. The term Synchysis denotes a deficiency, and unnatural fluidity, of the vitreous humour. The eye is shrunk and flaccid ; the iris is tre- mulous ; the pupil is motionless, and vision is either impaired or lost. Not unfi'equently the lens becomes opaque. The disease is usually regarded as incurable. Glaucoma. By Glaucoma is understood an amaurotic state of the eye ; with a greenish opacity, behind the pupil, concave, and deeply seated. Ac- cording to some, this state is mainly attributable to affection of the retina ; according to others, the choroid coat is chiefly implicated ; while a third class are of opinion that change in the lens and vitre- ous humour is the principal cause of the disorder. It is probable that all these textures are more or less involved. The prominent and cha- racteristic symptoms are, impairment or loss of sight, permanent dila- tation of the pupil, green discoloration of the vitreous humour, and in the advanced stage of the disease opacity of the lens. Diagnosis fi'om cataract is made easy, by observing that the opacity is more deeply seated than the lens ; and that it becomes indistinct, or even invisible when viewed laterally. The catoptrical test shows the three images of the candle at first ; by and by the middle inverted one is extinguished ; but the deep-seated erect image generally remains throughout. At the commencement of the disease, amendment may sometimes be obtained by local depletion, counter-irritation, alteratives, and a mild mercurial course, or exhibition of the iodide of potassium. If gouty or rheumatic symptoms exist — as is not unfrequently the case — 128 OPHTHALMITIS. the ordinary appropriate treatment is directed against that particular state of system. The advanced form is incurable. The disease sel- dom occurs, except in those of mature age. Ophthalmitis. This term, in its correct acceptation, denotes involvement of the entire globe of the eye in inflammatory action — an affection of much danger to structure and function, as can be readily understood ; and one which demands the most careful and active treatment. The ordi- nary results of this inflammatoxy process are opacity, ulceration, or staphyloma of the cornea ; adhesions of the iris, with contraction of the pupil ; cataract ; and often complete destruction of the organ of vision. A very severe form of this disease occurs in puerperal women — sometimes in connection with the malignant childbed fever — sometimes independently of this. The symptoms are generally of the highest in- tensity, vision is rapidly impaired, and often there is great chemosis. Cases occasionally occur where the inflammation goes on to suppura- tion ; the eye becoming a phlegmon. In such circumstances, great relief is experienced by opening the abscess. Wounds of the Eyeball. These are very common causes of acute ophthalmitis. And, accordingly, their ti'eatment must be carefully conducted in order to avert disastrous results. If foi'eign matter lodge in the interior of the eye, antiphlogistics wiU avail but little, so long as the foreign body remains ; the globe will suppurate, burst, and collapse. It is an im- portant indication, therefore, to ascertain the presence and site of a foreign body, and to eflFect its removal. But the same difficulty is en- countered as in the case of the brain (p. 50). It is difficult to ascertain either the site or presence of the foreign matter ; and, even when these are plain, it is often very difficult to effect its removal, Avithout most serious injury to the organ. In regard to prognosis, it is impor- tant to bear in mind, that there may be foreign matter in the interior of the eye, "ndthout any apparent solution of continuity in either the cornea or sclerotic. For, the elasticity of texture may at once close the chasm in the tunic, and conceal it from even minute inspection. Entozoa. The Filaria mecUnensis has been found beneath the conjunctiva ; the Filaria oculi humani in the lens. In the latter texture, also, have been TUMOUES OF THE EYEBALL. 129 found the Monostoma lentis, and the Distoma oculi. The Cysticercus telce ceUulosce has more than once occupied the anterior chamber ; it may be removed, by section of the cornea. Tumours. The eyeball is liable to be the seat of two kinds of tumour ; both malignant — the medullary, and the melanotic. Carcinoma is rare. The medullary tumour is most common at an early age, and seems usually to originate in connexion with the retina ; growing from the bottom of the eye, occupying the chamber of the vitreous humour, and rapidly making its way externally. Loss of vision is early and com- plete ; the tumour in its first stage can be seen dimly, through the pupil ; and the pain, cachexy, and other signs of the medullary tumour are present to testify its character (Principles, p. 332). When the coats of the eye have given way, the tumour increases more rapidly than before ; a fungus is thrown out ; and this may assume the hemorrhagic tendency. The end is death. Cure can be attempted in but one way — by extirpation of the eyeball ; and that only at an early period, when the disease is confined to the interior of the globe ; and even after removal of the globe, the disease frequently returns again in the optic nerve ; eventually destroying life. In the advanced stage, all operative interference is contra-indicated; reproduction is certain ; and the progress of the disease, instead of being arrested or retarded, is likely to become accelerated. Indeed, the cases are very few in which the operation has proved thoroughly successful. Lately, however, I had occasion, on account of false aneurism at the bend of the arm, to tie the humeral artery of a gentleman aged thirty-three, who, at the age of nine, had undergone extirpation of the eyeball on account of medullary tumour ; * and in him there has never been the slightest symptom of return. The melanotic tumour generally occurs after the middle period of life ; it slowly fills up the interior of the eye ; is seen dim, black, and bulging, through the pupil ; ultimately thinning the coats, and forming dark coloured external projections of the sclerotic ; attended with pain, tension, and early loss of vision. In some cases, care is required not to mistake the disease for simple staphyloma of the sclerotic (p. 108). The only cure is extirpation of the eyeball, and this should be done at as early a period as possible. Extirpation of the Eyeball. This operation may be required on account of tumour of the eye- ball ; tumour of the orbit, involving the globe secondarily ; cancerous ulceration of the eyelids, involving the globe, or destroying the whole * Edinburgh Medical and Surgical Journal, rol. xix. p. 51. K 130 CONaENITAL DEFICIENCY OF THE EYEBALL. of the eyelids — as formerly explained (p. 71). The commissure of the eyelids having been divided, at the outer angle, so as to afford space, the globe is laid hold of by a volsella ; and by this instrument is steadied and directed, throughout the remainder of the procedure. A straight bistoury is entered at the margin of the orbit, and made to move round, so as to detach the muscles and other parts from the bone ; the point, however, being used very carefully at the bottom of the orbit lest perforation of the thin orbital plate should occur. The optic nerve is then cut across, and the tumour withdrawn. If there be reason to suspect unusual attenuation of the bone — perhaps partial deficiency — it were no unwise precaution to effect the deeper dissection by the handle of the scalpel. If the lachrymal gland have escaped the general removal, it may be seized by a hook, and dissected away; but this is not absolutely necessary. Having become satisfied of the entire removal of the diseased structure, the cavity is sponged clear of blood ; dossils of dry lint or chai'pie are placed so as to fill the orbit and project somewhat beyond the margin, and a retaining bandage is passed around, with sufficient firmness to arrest bleeding from the ophthalmic vessels. After a few days, the dressing is gradually undone and re- moved ; suppuration is e.stablished ; granulation succeeds ; and the granulating wound is to be treated in the ordinary way. After cicatrization, an artificial eye may be adapted to the socket. Congenital Deficiency of the Eyehall. An interesting example of this occurred to me some years ago. A girl, strumous, and of strumous parentage, laboured imder con- junctivitis, which proved very obstinate, and had already produced considerable opacity of both cornefe. The mother, naturally of an anxious temperament, had her every thought engrossed by the state of this child — then an only one. She again became pregnant ; and still persevered in her watchful nursing unweariedly, and, if possible, with an increased solicitude. The second child was born at the full time. It pi'oved a male, well-formed, and seemingly perfect in every way. But, on opening the eyelids, not a vestige of either eyeball could be found. The lids were perfectly normal in both form and size, but gave no sign of globular projection beneath; and on opening them, red, fleshy, mucous-looking membrane, flat and loose, was found to be the apparently sole occupant of the orbits. As the child grew, the con- genital deficiency remained unaltered. SU-abismus. Squinting may affect one eye, or both. Very frequently both are implicated ; but one only in a minor degree. The immediate cause obviously depends on inharmonious action of the recti muscles. One STRABISMUS. 131 may act excessively, while its antagonist retains quite its normal character ; and displacement is effected by the former. Or — as there is good reason to believe frequently happens — one retains its normal condition, vv^hile the other is enfeebled, or altogether paralyzed; and displacement is caused by the former. The ordinary varieties of squinting are the Convergent, looking inwards ; the Divergent, looking outwards. The former is by much the more frequent. A great advance has been made in the treatment of this deformity, by having recourse to division of the muscle on the side towards which there is displacement — an operation suggested by Stromeyer, and first performed by the late Dr. Dieffenbach of Berlin. The patient is placed as for other ophthalmic operations. The eye which is not the subject of treatment is closed ; and the patient is made to turn the affected organ in the direction opposite to that of the squint. A fold of conjunctiva, between the cornea and the angle of the eye, but nearer to the latter than to the former, is then seized and ele- vated, by means of common dissecting forceps; and is divided by a stroke of the scissors. By one or two touches of the scissors, aided by the forceps, the subconjunctival areolar tissue is cut, and the muscle exposed — at that point where it ceases to be fleshy and begins to be -^^s- 43. tendinous. It may either be gathered up by the forceps, or elevated oh a blunt hook passed beneath. It is then divided completely. And it is well to make, at the same time, a clean dissection of the sclerotic, for some little distance on either aspect of the muscle ; so as to divide any bands of fibrous or areolar tissue, which might otherwise act re- tentively on the malposition of the eye. If the organ prove unsteady during the operation, it may be expedient to control its motions by means of a sharp, short, double hook, inserted into the sclerotic con- junctiva at a safe distance from the corneal margin. The operation over, and all instruments withdrawn, the patient is du-ected to look as he formerly squinted. If he finds a difficulty in re-effecting the dis- placement, the immediate result of the operation maybe considered as fully attained. But, otherwise, it is necessary to make a more free division of the textures implicated ; in aU cases, however, taking care not to occasion an unseemly exophthalmos, by carrying such division to an undue extent. The eye is covered up for a day or two ; and moderate antiphlogistics are used. Untoward inflammatory action seldom occurs. The wound may unite by adhesion. More frequently, it heals by the second intention. Sometimes a fungous granulation forms ; this is removed by the scissors, and is subsequently kept down Fig. 43. Plan of the ej'e, showing the line of incision in the conjunctiva. K 2 132 STRABISMUS. by gentle escharotics. After a few days, the functions of the eye are to be resumed, and they should be so arranged as to give the organ a habitual movement in the direction opposite to that whereto it Avas formerly directed. Indeed, this exercise or training of the eye, sub- sequently to the operation, is a very essential part of the treatment; and should be begun at an early period after the operation — almost immediately ; otherwise an improper reunion of the divided muscle may take place, and maladjustment of the eyeball be restored. Occasionally the cure is more than comj^lete ; squinting in the oppo- site direction being threatened. And were the other rectus muscle now to be divided, unseemly projection of the eyeball could not fail to be produced. Fortunately, it is often sufficient to excise merely a portion of the conjunctiva near the cicatrix of the wound ; the contraction of this new sore, in healing, tending to restore the normal position. Sometimes it is sufficient to operate on one eye only. At other times we are compelled to operate on both. For, when both eyes are implicated in squinting — though in very unequal degrees — it will be found quite impossible to restore parallelism in position and motion, if the myotomy be limited to that organ which is most prominently affiscted — ^let the division be as extensive as it may. When operation proves in all respects successful, not only is de- formity removed ; the function of sight is also materially benefited. But all squints do not require myotomy. According to the cause and circumstance, the treatment varies. Strabismus may be congenital. During early adolescence, attempts are to be made to remedy the evil by due exercise or training of the organ ; when one only is affected. The sound eye is to be covered up, for some hours in the day ; and the other, employed exclusively, may in time be compelled, as it were, to look straight upon the objects of sight. But care must at the same tkne be taken, that the sound eye do not suffer fi-om undue confinement and disuse. Or a pair of spec- tacles, or goggles, may be worn occasionallj^, through which the patient cannot see with both eyes, unless they are directed in a parallel man- ner. When such means fail, myotomy may be had recourse to. Squinting not unfrequently is the result of imitation. This must be cori'ected by breaking off the habit, and removing the patient from circumstances likely to induce its repetition ; also by the remedial exercise of the organ just noticed. The like treatment is available, when squinting has been induced by the presence of marks on the nose or cheek, to which the eyes are fi'om time to time directed ; when it has followed on a long confinement of the patient to one posture, perhaps consti-ained ; when it is the result of using one eye habitually and pain- fully directed on small objects, as in certain mechanical professions. In children, squinting is not unfrequently connected with gastric STRABISMUS. 133 and intestinal irritation ; and is remediable by purgatives, alteratives, or anthelmintics. In such cases the strabismus is almost invariably convergent ; as can be readily understood, when it is remembered how closely the sixth pair of nerves is connected with the sympathetic. Sometimes squinting is but a sign of general disorder in the system ; and disappears, along with the other symptoms, under appropriate con- stitutional treatment. At any age, it may be the concomitant of impor- tant cerebral disorder. Not unfrequently, squinting occurs as a sequela of some infantile disease. In such cases, the affection is of an atonic character ; and may be mitigated — perhaps removed — by a general tonic system of treatment, by the application of strychnia to the temple and forehead, or by the passing of electro-magnetism through the part. As a general rule, the operation should not be performed, until other means likely to prove remedial, have been found insufficient. And in the case of the female near the age of puberty, the operation should always be withheld, until the catamenia have appeared ; inas- much as, on this occurrence, rapid amendment and removal of the deformity is by no means unlikely to occur, English. — J. C. Saunders, Treatise on some Practical Points relating to the Diseases of the Eye, 2d ed. London, 1816. — J. Wardrop, The Morbid Anatomy of the Human Eye, vol. i. Edinburgh, 1808 ; vol. ii. London, 1818. — B. Tr avers, A Sjmopsis of the Diseases of the Eye and their Treatment, 3d ed. London, 1823. — G. J. Guthrie, Lectures on the Operative Surgery of the Eye, London, 1823. — A. Watson, A Compendium of the Diseases of the Human Eye, 2d ed. Edinbm-gh, 1828. — H. Middlemore, A Treatise on the Diseases of the Eye, 2 vols. London, 1835.— i^. Tyrrell, A Practical Work on the Diseases of the Eye, &c. 2 vols. London, 1840. — TT'. Machenzie, A Practical Treatise on the Diseases of the Eye, 3d. ed. London, 1840. — W. Lawrence, A Treatise on the Diseases of the Eye, 2d ed. London, 1841.— ^S. Littell, A Manual of the Diseases of the Eye, 2d ed. Philadelphia, 1846. — T. Wharton Jones, A Manual of Ophthalmic jNIedicine and Surgerj-, London, 1847. — A. Jacob, A Treatise on Inflammations of the Eyeball, &c. Dublin, 1849. J. Dalrymple, Pathology of the Human Eye, London, now publishing in parts. French. — A. P. Demours, Traite des Maladies des Yeux, 4 vols. Paris, 1818. — J. Sichel, Traite de I'ophthalmie, &c. Paris, 1837. — Carron du Villards, Guide Pratique pour I'Etude et le Traitement des Maladies des Yeux, 2 vols. Paris, 1838. — Velpeau, Manuel Pratique des Maladies des Yens, &c. Paris, 1840. — M. F. Rognetta, Traite Philo- sophique et Clinique dophthalmologie, &c. Paris, 1844. — Deval, Chirurgie Oculaire, Paris, 1844. — Desmarres, Traite des Maladies des Yeirs, Paris, 1847. German. — Beer, Lehre von den Augenkrankheiten, 2 vols. Vienna, 1813-1817. — C. H. Weller, Die Ki-ankheiten des Menschlichen Auges, 4th ed. Berlin, 1830. — F. A. Von Ammon, Zeitschrift fiir ophthalmologie, Dresden and Heidelberg, 1830-1837. — A. Rosas, Lehre von den Augenkrankheiten, Vienna, 1834.— ,7. C. Juemjken, Die Lehre von den Augenkrankheiten, 3d. ed. Berlin, 1842. Italian.— .4. Scarpa, Saggio di Osservazioni sulle Principali Malattie degli Occhi, Pavia, 1801; or Translation by Briggs, 1818.— C Quadri, Annotazioni Pratiche sulle Malattie degli Occhi, 4 vols. Naples, 1818-1830. 134 CHAPTER VL AFFECTIONS OF THE NOSE. Fracture of the Nasal Bones. Fracture of the nasal bones is the result of external violence, directly applied. It may be either simple or comminuted ; and the latter form is of frequent occurrence. It may be either simple or compound ; and the latter form may be constituted by wound of the integument, or by laceration of the internal mucous membrane, or by a combination of both circumstances. Deformity, by displacement, is a very prominent feature of the injury ; the slightest manipulation suffices to detect crepi- tation ; and this sensation is often greatly extended, by an emphysema- tous condition of the areolar tissue, in those cases in which the mucous membrane has sustained greater injury than the skin. Swelling and discoloration occur, to a greater or less extent; and usually pass laterally and downwards, to the eyelids and cheek. Replacement is easily effected, by passing a pair of small dressing forceps, or the ordinary polypus-forceps, shut — or a goose-quill, blow- pipe, director, or female catheter — into the upper part of the nostril ; pressing outwards with the instrument, so as to restore the normal position of the fi'agments ; and at the same time modelling them into their proper place by the fingers of the other hand applied externally. Sometimes, indeed, it may be in our power to improve on the original elevation, and to impart to the organ a more pleasing contour than it originally possessed. If any small fragments be completely detached and exposed, they should be at once removed. No retentive appara- tus is necessary ; for re-displacement is not likely to occur, unless under re-application of external violence. But if bleeding prove troublesome from the membrane, it may be necessary to plug the nares gently -with lint. If there be wound of the soft parts, it is treated ac- cording to ordinary principles. And, in all cases, the requisite pre- cautions are put in force against the accession of over-action, and the risk of erysipelas. Lipoma of the Nose. By this term is understood a hypertrophied condition of the integu- LIPOMA OF THE NOSE, 135 ment and subcutaneous adipose tissue of the apex and alee ; seldom occurring but in the male, of advanced years, who has lived freely. When the enlargement is partial and of no great bulk, no operative interference is required. It is sufficient to attend to regimen, and to the state of the general system, so as to prevent, if possible, further growth ; and direct medical treatment may be applied to the organ itself, with a view towards restoi'ing it to a normal state. But when the growth is large, it proves a serious inconvenience ; interrupting Eig. 44. vision, and interfering unpleasantly with the spoon and the wine-glass ; and, in consequence, surgical aid may be asked, and granted. The redundant growth is to be cai'efully pared away. A finger having been placed in the nostril, so as to distend the part, and facilitate dis- section — while, at the same time, division of the cartilage is provided against — the scalpel and forceps are carefully used, so as to remove the whole of the changed integuments. The bleeding is considerable; but is quite amenable to arrest by cold, pressure, and ligature. Some- times the parts are so dense as to preclude ordinary use of the liga- ture ; in which case, if pressure fail, the curved needle is to be employed (Principles, p. 362). Cicatrization is tardy; but, when obtained, is satisfactory. Apparent reproduction may take place, by growth from the surrounding integument, formerly unaiFected ; but the cicatrix itself usually remains firm and depressed. Fig. 44. Lipoma of the nose. 136 POLYPUS OF THE NOSE. Polypus of the Nose. Nasal polypi are of various kinds; simple-mucous, and cysto- mucous ; fibrous ; and medullary (Principles, p. 410). The first are, fortunately, of most frequent occurrence ; and usually are found ad- herent to the investing membrane of the superior turbinated bones. The symptoms of the common mucous polypus are sufficiently characteristic. The patient feels that something unusual, and apparently fleshy, is occupying the nostril ; calls to blow the nose are un- usually frequent, and can be but imper- fectly obeyed — passage of air through that nostril being found to be much ob- structed ; there is a jDreternatural amount of mucous discharge from the part ; on attempting to blow the nose, a great portion of the mucous secretion is thrown into the pharynx ; there is a constant feeling as if there existed " a cold in the head ;" very frequently, there is lachrymation, the ex- tremity of the nasal duct being compressed by the growth, or the lining membrane of the duct being sympathizingly involved in congestion ; and these uncomfortable circumstances are aU aggravated in damp and variable weather. On looking into the nostril, the tumour is seen ; and, when the speculum is used, a very distinct exploration of its bulk and form may in most instances be effected. When the mass has attained to some considerable size, it renders itself apparent, by projecting on the upper lip. As it enlarges backwards, deafness may be produced, by pressure on the Eustachian tube ; and giddiness may be occasioned by compression of the jugular. The sense of smell is necessarily much impaired ; and so .in many cases is that of taste. Speech is indistinct, and snuffling. In sleep, the patient is a habitual and sonorous snorer. After a time, the countenance may undergo a formidable change ; the nasal bones becoming gradually disjoined and expanded ; giving a very unpleasant breadth to this part, and establish- ing the condition which is ordinarily termed " Frog's Face." Then — and often, also, at an early period of the case — pain is complained of in the head, especially in the forehead. In the minor cases, it is essential that diagnosis be accurate. Symptoms are not trusted to alone. The speculum must be employed, so as to expose the nasalcavity ; enabling us to ascertain v/hether the obstruction depends on nascent polypus or not. For the disease is apt to be simulated. There may be merely a general congestion of the Fig. 4.5. Simple mucous polypi, seen growing in the nasal passages. POLYPUS OF THE NOSE. 137 lining membrane. Or there may be a bulging of the septum to one side, with or without congestion of the membrane on the convexity of the bulge. There may be abscess forming between the septum and its investing membrane. Or there may be a hypertrophied condition of the spongy bone. Any of these circumstances may produce more or less occlusion of the nostril, increase of discharge, snuffling of speech, and most of the ordinary s}Tiiptoms of polypus. By use of the speculum only can the true condition of parts be determined. If there be no polypus, no forceps are required. For congestion, abstraction of blood and astringent lotions are sufficient, with roborant treatment constitutionally. Abscess of the septum may be prevented by leeching ; Avhen formed, it requires evacuation. Displacement of the septum, and enlargement of bone, call for no interference. Removal of the common polypus is effected by twisting and evul- sion (Principles, p. 411). Care is taken to apply the forceps accur- Fig. 46. Frog-face ; the polypi causing much deformity by expansiout of the bones, and change of relative position in the soft parts. 138 POLYPUS OF THE NOSPL ately to the neck of the tumour, so as to insure removal of the entire mass ; and gentleness is used, so as not to endanger avulsion of bone. The forceps are v^ell toothed, firmly jointed — and secured by a pin between the blades, so as to prevent them passing each other during the twisting movement ; strong, yet not so bulky as those commonly in use — less than the " di'essing forceps " of the ordinary pocket-case. Sometimes forceps considerably curved are useful in reaching small soft polypi, which not unfrequently grow fi'om the upper and front part of the nares, and which the ordinary instrument passes by. The tumours being generally numerous, more than one operation is usually required, to effect eradication of the whole ; and of this the patient should be warned in the first instance, to prevent disappointment. After temporary clearance of the nostril has been effected, the cavity is plugged with lint ; to arrest bleeding, and prevent the access of cold air to the raw surface. A second operation is not attempted, until the inflammatory results of the former have completely subsided ; nor until examination by the speculum has revealed the fresh crop of tumours, somewhat advanced to mature development. This may be after weeks or months. After the nostril has been finally cleared, the use of an astringent is advisable — such as a solution of zinc, niti'ate of silver, alum, matico — with a view to prevent reproduction, and restore the mucous mem- brane to a sound state. The following form is often found very suit- able : — Sulphate of Zinc half a drachm. Tincture of Galls one drachm. Water eight ounces. If evulsion be found to cause inordinate pain, with inflammatory symptoms, the attachments of the polypi, in the repeated operation, may be severed by pi'obe-pointed scissoi"s or knife. The dense fibrov^ polypus, when originating from the posterior part of the nasal cavity, projects backwards, is of a somewhat pyriform shape, and hangs pendulous in the fauces. For removal of such a tumour, the use of ligature is most suitable. A long double loop of wire, catgut, or strong cord, is passed through the affected nostril. The noose is caught, as it appears in the posterior fauces, by forceps introduced through the mouth. And then, by fingers or forceps, the loop may be carried over the fundus of the tumour ; so that on drawing the ends hanging out of the nostril, the noose may be run tight upon the upper part of the growth. This having been done, the nasal ends are passed separately, through a double silver canula, which is then pushed into the nostril until its extremity rests on the polypus. By pulling the ends, the noose is now completely tightened, so as to strangu- late the mass at its attachment. And the ends, drawn tightly, are secured through rings placed for this purpose at the anterior extremity of the canula. From time to time, a renewal of the tightening may POLYPUS OF THE NOSE. ] 39 b*e had recourse to. The tumour at last di-ops away ; and is either swallowed, or coughed up and discharged by the mouth. Sometimes, however, the noosing of the mass cannot be so easily accomplished. The double ligature having been passed as before, the loop hanging out of the mouth is divided, so as to constitute two single ligatures. The oral end of one is passed through a long single canula, and is carried carefully under the base of the tumour on one side. Li the same way, the corresponding end of the other ligature is managed ; so that this ligature passes round the tumour on the opposite side. The directing canula having been then withdrawn, the double form of ligature is restored, by uniting the oral ends in a firm knot. The nasal ends are now drawn ; and the noose is run tight on the tumour, at its upper part, as before ; tightening of the noose being effected by means of the double canula passed through the nose.* But a dense and firm polypus may occupy the anterior part of the nares ; broad in its attachment, and firmly united with both periosteum and bone. Such tumours experience has declared to be prone to degeneration ; early becoming vascular, softening, and ultimately assuming the medullary character. Removal therefore is highly expedient ; and, to be eifectual, it must be both early and complete. Ligature will not suffice. The morbid structure must be cut out, along with the parts from which it springs, and with which it is intimately incorporated. The operation is formidable and severe — but not the less expedient. No fixed rules can be given to guide the operative procedure. It may be possible to disclose the tumour and its site sufficiently by simple incision of the nostril. Or it may be necessary to remove a portion of the superior maxilla, f The medullary and malignant nasal polypi may be regarded as incurable. By the time the case has been submitted to the surgeon, the morbid structure has so extended as to render its entire removal, by any feasible operation, impracticable ; and we content ourselves with palliation. If much disti-ess be occasioned by occlusion of the nostril, the soft obstructing mass may from time to time be pushed away by the finger or probe ; but even this interference must be very carefuUy practised, lest troublesome hemorrhage ensue. Also, let us beware of mistaking protrusion and pointing of the tumour, at the internal can- thus, for fistula lachrymalis about to form (p. 84). The erectile tumour has been found growing from the anterior nares ; not merely an inconvenience, but dangerous by tendency to hemorrhage. Cure has been obtained by destructive application of the actual cautery to the diseased tissue.| * Beodie, Lancet, No. 1058, p. 316. t Syme, London and Edinburgh Monthly Journal, 18i2, p. 791. I Dublin Quarterly Journal, Feb. 1847, p. 31. 140 EPISTAXIS. Rhinolithes. Rhinolithes, or calculi of the nasal fossae, are composed of mucus, phosphate of lime, and the carbonates of lime and magnesia ; and are most frequently found in the inferior meatus. In volume they vaiy from a pea to a pigeon's egg ; in colour black, grey, or white ; of rough surface ; and often containing a foreign body, or the root of an incisor tooth, as a mulens. Sometimes they create but little disturbance ; in other cases chronic inflammatory action is lit up ; in some suppuration occurs, with profuse foetid discharge ; and the septum may ultimately give way by ulceration, the whole organ becoming seriously deformed. The eye too may sympathize ; and that seriously. Treatment is by extraction of the offending substance ; and this is to be eifected either by forceps or by scoop, as may seem most convenient ; antiphlogistics being afterwards employed to subdue excitement.* Epistaxis. By this term is undei'stood, an inordinate hemorrhage fi-om one or both nostrils. It may be the immediate result of an operation for polypus ; it may follow external injury, with or without fracture of the nasal bones ; it may be one of the untoward results of medullary formation, within the nasal cavity, or connected with it ; it may be a critical depletion, of natural occurrence, tending towards resolution of an inflammatory process ; or it may be the consequence of a passively congested and hemorrhagic state of the schneiderian membrane. The common bleedings of the nose, in adolescents, caused by plethora, and tending to relieve the system from that unsafe condition, scarcely come under the designation of epistaxis ; usually the bleeding is not inordi- nate, is in all respects safe and beneficial, and certainly requires the adoption of no means for its arrest. Our first duty when called to a case of alarming hemorrhage from the nose, is not at once to attempt to check it ; but to determine whether such an attempt be advisable or not. If the bleeding be habitual, in a robust and plethoric patient, not very far advanced in years — if it be at all critical in its history, as connected with an inflammatory attack advancing in some adjacent part — if we are told that the patient has been subject to giddiness, or other afiections of the head — we are certainly not to interfere, unless evident signs exist that a greater amount of blood has already flowed than the system can well bear, and that further loss would probably be attended with hazardous con- sequences. Then — but not till then — we endeavour to prevent con- tinuance. The patient's head is elevated ; and cold is applied to the * Demarquay, Annales de la Cliivurgie, July 1845 ; and Ranking's Retrospect, vol. ii. p. IOC. EPISTAXIS. 141 nose, forehead, and back of the neck. All stimuli are forbidden, and absolute rest and quietude enjoined. This treatment failing, astrin- gents may be taken into the nostril, and applied to the bleeding surface, by injection or by insufflation — Ruspini's styptic, a solution of zinc or alum, turpentine dilute, powdered gall nuts, matico, &c. And this method of arrest may be assisted by obstruction of the anterior nares ; either by compression, or by stuffing the cavity firmly with lint, after the styptic has been sufficiently applied. Lately, it has been proposed to elevate the arm, or arms, and to retain them raised above the head ; and certainly this proceeding would seem occasionally to contribute, at least, towards the successful result ; perhaps in consequence of greater power being required to propel the arterial blood upwards in the arm, and less consequently being expended on the carotid circula- tion — as the originator,* Dr. Negrier, imagines ; or perhaps in conse- quence of the increased facility of venous return in the subclavian vein " hurrying the return-blood in the jugulars, and thus deriving from the bleeding vessels of the nose." When such minor means fail, it is necessary to plug the nares, both anteriorly and posteriorly. A long stout ligature is passed through the nostril into the mouth ; by means of a flexible bougie, a loop of wire or catgut, or a springed instrument made for the express purpose. To the upper part of the oral extremity of this ligature, a portion of sponge or a dossil of lint is attached, of sufficient size to occlude the posterior opening of the nostril ; and by pulling the nasal extremity of the ligature, this obstructing substance is firmly impacted ; the extremity of the oral portion of the ligature remaining still pendent * Archives Generales de Medicine, June 1842. Fig. 47. The arresting of hemorrhage by plugging. A plug, a, aljout to be lodged firmly in the posterior nares, b}- means of the ligature, b. This having been done, and a plug afterwards placed in the front nares, the' bleeding from tJ/fit nostril is fairly commanded. 142 THE PASSING OF NASAL TUBES. from tiie mouth. The anterior nostril is then filled Avith lint, pushed firmly from the front. After three or four days have elapsed, the ap- paratus is removed, gently. The anterior plug is withdrawn by means of forceps ; the posterior is extracted by pulling the oral extremity of the ligature, previous dislodgment, if need be, being effected by the cautious pushing of a probe passed through the nostril. Sometimes it is necessary to plug both nostrils ; but, generally, the hemorrhage pro- ceeds from one only. Constitutional treatment is not forgotten ; more especially if there be reason to suppose that a hemorrhagic tendency exists in the system (Pi'inciples, p. 374), Another method of plugging the nares has been lately proposed ; by inserting a tube of vulcanized caoutchouc, and distending this either by air or water.* When syncope has occurred from epistaxis, in an elderly patient predisposed to head affection, we should be very careful not to excite premature and excessive reaction, otherwise extravasation within the cranium is not unlikely to follow. The head is not to be placed low, as in restoration from ordinary syncope, but should be kept elevated ; and stimuli should, if possible, be avoided. The passing of Nasal Tubes. Flexible tubes may be readily enough passed along the floor of the nostrils into the posterior fauces ; and thence they may be directed into either the larynx or oesophagus, as circumstances may require. The former destination is necessary in attempts to restore breathing, in cases of suspended animation ; the latter, in order to introduce nutritive ingesta into the stomach — as in cut throat. If, in the latter case, the tube is to be left permanently inserted, the passage by the nose is plainly preferable to that by the mouth ; avoiding profuse salivation, and much discomfort. Foreign Bodies in the Nostrils. Foreign bodies may lodge accidentally in the nasal cavities ; more frequently they are introduced wilfully, by the young and incon- siderate ; peas, beads, portions of pencil, and such like substances are very commonly inserted by the thoughtless child. On the foreign body decidedly disappearing inwards, the patient is alarmed ; and probably makes desperate efforts to extrude it by the fingers, but with the effect only of pushing it further into the nostril. The parent or nurse is now made aware of the circumstance, and by them similar efforts at dislodgment are made, again with the effect of causing a * Lancet, No. 1370, p. .579 ; also Cyclop, of Pract. Surgery, p. 142. CONaESTION OF THE SCHNEIDERIAN MEMBRANE. 143 deeper lodgment. By this time the foreign substance is beyond the reach of the eye ; and its site is further obscured by the slight bleed- ing which has probably taken place during the abortive efforts at extrusion. And in this condition, the surgeon finds the case. It is well, in the first instance, to inject a stream of warm water into the nostril ; it clears away coagula, loosens the foreign body, and may effect its expulsion. If not, the probe is to be used, the patient's head having been fii-mly secured ; and the best way of accomplishing this, in the child, is to place the head firmly between the knees of the operator — unless indeed anaesthesia be employed, as in most cases it should be. By the probe, used gently, we first ascertain the presence and site of the foreign substance — for it may have passed outwards, by the mouth, or downwards by the pharynx. Having discovered the foreign body, the flat end of the probe, slightly bent, or the scooped end of a direc- tor, or a curette made for the purpose, is passed down upon it, and in- sinuated past it ; then, by raising the handle of he instrument, and bringing the point to bear upon the posterior aspect of the foreign substance, the latter is dislodged forwards, and may be readily removed. Forceps, however slim, are very likely to fail. They seize the anterior part of the body only ; and, slipping, have the effect of causing a firmer and deeper impaction. Congestion of the Schneiderian Mernbrane. The lining membrane of the nostrils is liable to become the seat of a minor inflammatory action; chronic, and unimportant as regards struc- tural change ; but troublesome and inconvenient by its continuance. There are redundancy of secretion (often foetid), uneasy sensation, and a feeling of stuffing in the part ; not unfrequently the tone of voice is considerably impaired, and the sense of smell may also be rendered imperfect. Many of the symptoms of mucous polypus are present ; and careful exploration by the nasal speculum is necessary, to insure accuracy of diagnosis. If the action be at all of an acute nature, a few leeches may be required, more than once — applied directly to the membrane by means of a suitable glass tube; and in the passive form of congestion, leeching may also be expedient, once, to unload the vessels of the part. Then astringents are employed ; solutions of nitrate of silver, sulphate of zinc, chloride of soda, alum, matico, &c., and these are patiently persevered with, either singly or combined. But in all cases an especial regard must be had to the state of the general system. Usually an atonic condition is found ; and the greatest benefit is derived from sustained exhibition of the chalybeates. In very many cases, indeed, without this tonic general treatment, all local care would prove of but little avail. 144 ULCERS OF THE NOSTRILS. Abscess of the Septum Nariuin. Abscess may form beneatli the mucous covei-ing of the septum ; and, when acute, the inflammatory action which causes it is usually the result of external violence. The chronic form may be independent of all apparent exciting cause, occurring in a patient of broken-down system — probably a victim of the mercurio-syphilitic taint. The bulging swelling is apt to simulate the growth of polypus. During the nascent stage, leeches are to be applied to the part, and other suitable antiphlogistics employed, to prevent suppuration if possible. When matter has formed, an evacuating incision cannot be made too soon, in order to save the cartilage ; otherwise great deformity may ensue, by a falling in and shrinking of the most prominent part of this important feature. Ulcers of the ISfostrils. 1. Simple ulceration of the schneiderian membrane is liable to occur from the ordinary exciting causes of ulceration of mucous tissue (Principles, p. 409) ; exposure to cold, contact of acrid matter, irrita- tion communicated from diseased teeth, &c. The treatment accord- ingly consists, first, in taking away the exciting cause ; seclusion from atmospheric exposure, discontinuance of snufF-taking, removal of diseased teeth or stumps in the upper jaw. And then, according as the ulcer manifests the inflamed, irritable, or Aveak characters, the ap- plications are bland and soothing, or nitrate of silver in substance or solution, or various gently stimulant lotions (Principles, p. 242, &c.) 2. Mercurio- Syphilitic ulcers not unfrequently form in this situation ; of a secondary, or, more commonly, of a tertiary character (Princi- ples, p. 63). They are obstinate, and likely to resist all mere local treatment. The more important remedial agents are those which affect the system ; especially the iodide of potassium and sarsaparilla. 3. Ozcena. — By this term is understood an unhealthy ulceration of the lining membrane of the nose, with affection of the subjacent bone — caries, necrosis, or both combined. Discharge is profuse, and offensive ; the ulceration tends rather to spread than to heal ; portions of bone from time to time come away ; the nose sinks inwards, and is more or less deformed ; both articulation and respiration are interfered with ; and ultimately the general health may seriously give way. The nasal bones themselves may perish and exfoliate ; and then the deformity is not only great but almost irremediable. The peculiarity of this ulcer is, that the ulceration is of a spreading character — simply acute, or slowly phagedgenic ; and that the bones are more or less extensively involved. In the adult, few examples will be found in which the abuse of mercury, for syphilitic or other ailments, cannot ULCERS OF THE NOSTRILS. 145 be traced out as the paramount cause. In children, the affection would seem to he connected with the strumous cachexy. Treatment is mainly constitutional ; as in the simple mercurio- syphilitic sores, without affection of bone. Besides the iodide of potassium, and sarsaparilla, arsenic is found a very useful internal remedy — steadily persevered with, in small doses. In obstinate cases, benefit has often resulted from exhibition of the liquor hydriodatis arsenici et hydrargyri — a powerful alterative.* The local applications are necessarily varied. At first, bland and tepid injections are advis- able ; afterwards those which are stimulant and alterative. A weak solution of arsenic, solutions of the nitrate of silver, sulphate of zinc, &c., may be employed, as circumstances seem to indicate. Through- out the cure, the chlorides should be used, at least occasionally, as correctives of foetor. By some, the following combination is held in high repute ; an injection composed of from one to two drachms of chloride of lime, rubbed up with thu'teen ounces of decoction of rhatany root. — strained after standing half an hour. In scrofulous cases, ordinary antistrumous constitutional treatment will, of course, not be neglected. 4. Lupus, or Noli me tangere, is a confirmed phagedfenic ulcer ; commencing usually in the upper lip, or at the exterior of the nasal cavity ; spreading upwards, inwards, and around, but more in breadth than in depth ; often healing at one part, while it extends at another ; ultimately involving the bones, denuding them, and inducing, by caries or necrosis, such deforming results as at an earlier period follow on ozsena. In advanced cases, the soft parts of the nose, and not a little of the hard, may be wholly destroyed ; while an unseemly chasm has also been made in one or both cheeks. The destructive action may proceed still more extensively, producing deformities more and more hideous, and ultimately proving fatal by hectic exhaustion. The disease is most common in adults — of the poorer sort, ill-fed, ill- clothed, scrofulous, or tainted in system by mercury, and too probably also given to habits of intemperance. Sometimes, however, it attacks the most careful and correct. As in other phagedsenic ulcers, the action may be either chronic or acute (Principles, p. 258). Treatment is partly constitutional — such as recommended in oz^na ; partly local, consisting of such applications as are found most suitable for arrest of phagedsena (Pi'inciples, p. 260). An escharotic, such as chloride of zinc, nitric acid, or nitrate of mercury, is first employed ; and then the sore is subsequently treated according to the characters which it presents. When it threatens to become irritable, and verges again towards phagedsena, a weak solution of arsenic is found of much service. Of escharotics, the chloride of zinc is perhaps most * Dublin Journal of Medical Science, September 1840, p. 98. L 146 EHINOPLASTICS. employed, in the form of paste ; and is especially useful when bone has become aiFected ; for it seems to hasten exfoliation. Occasional use of the simpler chlorides is as essential as in oz^na. Sometimes repeated leeching is useful. After arrest and cicatrization, the greatest constitutional care is still required ; otherwise reaccession of the disease is extremely probable. 5. Cancerous ulcer may implicate the nose, by extension from the face ; or may originate in the former site. It is amenable to but one treatment — early removal by knife or escharotic, or by both. Ehinoplastics. When the soft parts of the nose have been destroyed, partially or wholly, by wound, ulceration, or sloughing, they may be restored in some measure, by transplanting a compensating amount of cutaneous and subcutaneous tissues, borrowed from an adjoining part. When ulceration has been the destroying agent, no restorative operation is ever to be attempted, until satisfactory evidence have been aflForded that all ulceration has ceased, and is not very likely to return on the application of a common exciting cause of inflammatory action. Under any circumstances, it is plain that the sequela of lupus presents a much less favourable prognosis, than when the cicatrix is the result of wound, or any other simple casualty. When almost the entire organ has been removed, its restoration is attempted as follows : — A piece of card or leather is shaped of the required dimensions, to constitute new alse and apex ; the columna being left for an after proceeding. And this outline of the new struc- ture should always be rather too large than otherwise, there being great tendency to shrivel by absorption, after the flap has become fixed in its new locality. The edges of the cicatrized sore, on which the borrowed flap is to be adjusted, are made raw by the knife. The out- line of the flap is then laid flat on the forehead ; the fundus pointing upwards, the neck resting between the eyebrows. It is there steadily held by an assistant, while the surgeon, with ink, or at once with the knife's point, draws its boundaries. Thus defined, it is carefully dis- sected down, of uniform thickness, until the narrow part is reached ; and then the incisions are carried to a greater depth, to insure an abundance of vascular supply. In no part of the wound is the peri- cranium interfered with ; and, if possible, the flap should not be made to encroach upon the hairy scalp — for obvious reasons. The neck of the flap is made sufiiciently long to admit of its being twisted, without serious interruption to the circulation ; and, to facilitate this movement, the knife is carried lower down on that side to which the twist is to be made. A little time is allowed for the oozing of blood to cease ; then RHINOPLASTICS. 147 the flap, having been twisted so as to bring the integument upwards, is adjusted to the rudiments of the old feature, carefully and accurately, by the requisite number of points of interrupted suture ; and support is afforded to the flap beneath, by the lodgment of dossils of lint, so as to give that prominence and character which seem best suited to its new office of repair and imitation. The lower part of the wound Fig. 48. Fig. 49. in the forehead is brought together by suture, and may unite by the first intention ; the rest is covered with water- dressing, and left to granulate. The flap adheres, in part by adhesion, in part by granula- tion ; the stitches are cut away at the ordinary period ; and the in- terior stuffing is changed from time to time — medicated if necessary. Ultimately — in twelve or fourteen days, usually — the borrowed sub- stance becomes firmly seated in its new abode ; and then attention is directed to the connecting slip. If the ossa nasi have been left entire, with their integument, the apex and alse only having been destroyed, the connecting slip may be divided and removed. A wedge-shaped portion is taken away by means of a narrow bistoury ; and adjustment is effected with the integument beneath — made raw by the knife for reception. But if the ossa nasi have been lost, it is well to leave the medium of attachment uninterfered with ; only securing its incorpora- tion with the subjacent surface ; for, by its continued presence, the want of prominence which the loss of the nasal bones could not fail Fig. 48. Plan of flap for a new nose, according to the original Indian method ; columna, apex and alse being all made at once. Fig. 49. Plan of flap for new nose, as modified by Mr. Liston. The apex and alffi provided for ; the columna to be brought, subsequently, from the upper lip. L 2 148 RHINOPLASTICS. otherwise to produce will be very much compensated. Besides, con- tinued nutrition of the transplanted flap will be fully secured, and its shrivelling by atrophy may be in a great measure prevented. If the prominence should threaten to be excessive, it may be reduced by compression suitably applied. Certain precautions are always to be attended to in such proceed- ings. As already stated, the flap should at first seem too large ; if neatly fitting at the time, it is sure to prove insufiicient afterwards. Twisting is effected very gently and carefully, lest strangulation ensue. Should engorgement occur, relief is to be obtained for the passively congested vessels, by punctures, or by drawing blood from the still raw edges. Erysipelas may supervene; if it does, the transplanted part need not be exempted from puncture or incision, if these be deemed necessaiy ; for experience declares it to possess at least an equal tolerance of such remedial treatment as the original textures. When peculiar circumstances render the ordinary operation im- practicable, the flap may be taken from the hairy scalp, as practised by Dieffenbach ; the hair having been previously removed by means of the bichloride of mercury in solution ; and the flap being connected with a long narrow strip of the integuments of the forehead. When consolidation of the new alse and apex has been duly effected, formation of the columna is then proceeded with ; according to the method first proposed by Mr. Liston.* The centre of the upper lip is found tumid and elongated ; in consequence, removal of a portion of the redundancy would of itself be a considerable improvement ; and when the portion so removed can be converted to the useful purpose of constituting a most efficient new columna, the expediency of the proceeding becomes very apparent. " 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 assistant — close to the ruins of the former columna, and about an eighth of an inch on one side of the mesial line. The in- cision 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 op- posite 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 fr^enulum is then divided, and the prola- bium of the flap removed. In order to fix the new columna firmly and with accuracy in its proper place, a sewing-needle — its head being covered with sealing-wax to facilitate its introduction — is passed from without through the apex of the nose, and obliquely through the ex- tremity of the elevated flap : a few turns of thread over this suffice to approximate and retain the surfaces. The flap is not twisted round * Practical Surgery, p. 253. FORMATION OF NEW COLUMNA. 149 as in the operation already detailed, but simply elevated, so as to do away with the risk of failure. Twisting is here unnecessary ; for the mucous lining of the lip, forming the outer surface of the columna, readily assumes the colour and appearance of integument, after expo- sure for some time, as is well known. The fixing of the columna having been accomplished, the edges of the lip must be neatly brought together by the twisted suture. Two needles will be found sufficient, one being passed close to the edge of the lip ; and they should be in- troduced deeply through its substance — two-thirds, at least, of its thickness being made superficial to them. Should troublesome bleed- ing take place from the coronary artery, a needle is to be passed so as to transfix its exti'emities. The whole surface is thus approximated ; the vessels being compressed, bleeding is prevented ; and firm union of the whole wound is secured. The ligature of silk or linen, which is twisted round the needles, should be thick and waxed ; and care must be taken that it is applied smoothly. After some turns are made round the lower needle, the ends should be secured by a double knot ; a second thread is then used for the other needle, and likewise secured. With the view of compressing and coaptating the edges of the inter- posed part of the wound, the thread may be carried from one needle to the other, and twisted round them several times ; but in doing this, care must be taken not to pull them towards each other, else the object of their application will be frustrated, and the wound rendered puckered and unequal. Last of all, the points of the needles are to be cut off with pliers. No farther dressing is required. The needles may be removed on the third day ; their ends are cleaned of coagu- lated blood, and, after being turned gently round on their axis, they are cautiously withdrawn, without disturbing the threads or the crust which has been formed about them by the serous and bloody dis- charge. This crust often remains attached for some days after removal of the needles ; and, besides forming a bond of union, is a good pro- tection to the tender parts. Some care is afterwards required, fi'om both surgeon and patient, in raising up the alee, by filling them with lint — thus compressing the pillar, so as to diminish the oedematous swelling which takes place in it, to a greater or less degree, and re- pressing the granulations. It is, besides, necessary to push upwards the lower part of the column, so that it may come into its proper situation ; and this is done by the application of a small round roll of linen, supported by a narrow bandage passed over it and secured behind the vertex." Partial Restoration of the Nose. When a portion of either ala is destroyed, the deficiency may be readily supplied from the adjoining cheek ; if there be the ordinary 150 PARTIAL RESTOKATION OF THE NOSE. fulness there. The flap is raised, transplanted, and has its vascular supply maintained, by conducting the operation in the same way as rig. 50. for restoration of the whole organ. The wound in the cheek may, generally, be approximated entirely; and, in consequence, may be expected to unite by the first intention. The entire ala may be restored in a similar way. But if the cheek be either naturally spare, or already occupied by cicatrices, the flap must be brought from the forehead. An operation is performed, similar to that for restoration of the whole organ, but on a minor scale. When the ridge of the nose is long, it is well to make a suitable furrow in its centre — by incision — for reception of the long connecting slip ; which, othermse, finding itself but indifferently supported on the exterior of the nasal integument, might fail to afford due nourishment to the flap, and induce its sphacelation. After union has occurred throughout the whole wound, the connecting slip may be raised from its temporary bed, and the raw edges of its site approximated ; or it may be left undisturbed ; according as circumstances may seem to indicate. Loss of the apex and both alai is supplied by a frontal flap ; with or without lodgment of the connecting slip, according to the length of the nasal ridge. The ridge itself, when deficient, may be restored by a frontal flap, very readily and efiiciently ; either by adapting a suitable portion to its surface, made raw ; or by inserting a slip into a sulcus made for its reception. By cutting out the depressed portion, and approximat- Fig. 50. " The al«e of the nose, deficiencies in the upper, anterior, or lateral parts of the organ, in the forehead, &c., may be supplied from the neighbouring integument, on the same principle as the preceding repairs. In many of these operations the flap can be so contrived and cut out, as that it can be applied without its attachment being twisted. The form of such flaps is here given." — Liston. PARTIAL RESTORATION OF THE NOSE, ^151 ing the margins of the wound by suture, depression may be removed, in some cases satisfactorily ; but, in most, such an attempt would be followed by an elevation of the apex, causing a deformity little less unseemly than the original. "When the columna alone is deficient, the operation for its restora- tion is performed, as detailed at page 148. Not unfrequently, the columna, and the integumental part of the alge and apex, remain entire, while the cartilaginous texture has suffered more or less dilapidation ; and the nose, in consequence, shrinks, falls inwards, and is much deformed. Autoplasty is not re- quired to remedy this case. In some examples, it is sufficient to divide carefully the abnormal adhesions within, to elevate the nostrils then to their normal level, and to maintain this elevation subsequently by suitable stuffing of the cavities. In other cases, however, such mani- pulation is found insufficient ; and then it is expedient to approximate the cheeks, so as to force the nose into increased prominency ; the original insertions of the ala3 on the cheek having been previously detached, by subcutaneous incision. The organ, thus rendered mov- able, is transfixed at its base horizontally, by silver needles, which are made to perforate a piece of leather, or wood, after emerging from the nose ; and by twisting the extremities of the needles, on this exterior foreign substance, the due amount of approximation is effected and maintained.* When there is both depression of the ala3 and apex, and loss of the columna, the depression is first to be removed ; and then a new columna is to be constructed in the ordinary way. But, in truth, no exact details can be established for any auto- plastic or simply restorative operation on this organ ; the proceed- ings must vary, in almost every case, according to its peculiar circum- stances. It is right further to state, that the majority of such operations come under the category of those of " complaisance" — undertaken under no absolute necessity, but rather to please the patient — prover- bially prone to untoward casualties in the after-treatment. The flap may shrink or slough ; ulceration may recur ; erysipelas, phlebitis, pyaemia, may peril existence. And, at the same time, it is to be remembered that a very passable substitute for the lost organ may be adapted by the mechanic, without pain or danger. For further information on Rhinoplasties, the student is referred to the Practical Surgery of Mr. Liston, and the writings of Dieffenbach — who, in this department, bid fair to rival the fame even of Tagliacotiiis. * Feegu&son's Practical Surgery, p. 454. 152 CHAPTER VII. AFFECTIONS OF THE SUPERIOE MAXILLA. Collection of Fluid in the Antrum. The antrum is liable to become the seat of a chronic collection of fluid, whereby its parietes are expanded and attenuated, and its cavity much enlarged. The condition is ordinarily termed abscess ; but it seems very doubtful if this appellation be accurately applied. The fluid may be puriform, but is seldom purulent. It is more like what is usually found in serous cysts ; sometimes thin and serous, sometimes glairy, sometimes sanguinolent, sometimes puriform, not unfrequently mingled with more or less of solid curdy matter. The parietes of the cavity are not tliickened by fresh osseous deposit, as in chronic abscess ; on the contrary, they are simply expanded, becoming thin, and in some places perhaps deficient — the loss being supplied by membranous struc- ture, contributed probably by the periosteum. In short, the morbid condition more resembles that of osteo-cystoma, than that of chronic abscess of bone (Principles, p. 430). The symptoms are — uneasy sensation in the part ; swelling of the cheek, which ultimately crackles on pressure, and may be felt to fluc- tuate — the parietes having become much attenuated ; the palate may bulge considerably downwards ; sometimes there is increased secretion from the corresponding nostril ; and from the hanging and stiffness of the lip on that side, articulation may be interfered with. The change may be attributed to a slight and remote injury ; or to the presence of decayed teeth in the corresponding maxilla ; but, very frequently, there is no assignable exciting cause. The remedy is by evacuation ; and the aperture must be both free and dependent. An aperture sufficiently dependent may be formed in the corresponding alveoli, of the canine or first molar teeth ; and some- times a communication is found already established there, on removal of the decayed teeth or stumps. But such an opening is seldom if ever sufficiently free, when of spontaneous formation ; indeed, sufficient space is not readily obtained at this part, even by operation. And it is essential that the opening shall be of some considerable size ; otherwise the fluid wiW not escape by it ; but will be retained by ABSCESS OF THE ANTRUM. 153 atmospheric pressure — as in tlie case of the narrow-necked bottle, which, when filled with water, is suspended in an inverted position for baro metric purposes. It is better to make an opening through the most dependent part of the attenuated parietes; above the first molai's. The membrane of the cheek is incised there ; and, by means of the same instrument — a strong bistoury — the parietes of the cavity may also be perforated, in the greater number of cases. If the bone, however, prove thick and resisting, a pointed lever, as used for the extraction of decayed teeth, may be employed. An aperture having been made, of sufficient dimensions to admit the point of the little finger, through this the contents readily drain away. Besides, re-accumulation is effectually prevented ; and, by pressure from without, return to the normal state by contraction is favoured. Abscess of the Anti'um. The lining membrane may undergo inflammatory action, with or without the application of external violence ; and suppuration may ensue. The action may be either chronic or acute. In the former event, the case will very much resemble the cystic enlargement just detailed. This, however, is of rare occurrence, and is usually uncon- nected with external injury. Acute abscess generally results from violence applied, or from irri- tation communicated by decayed teeth or other affections of the gums. The symptoms are severe. With a considerable amount of constitu- tional disturbance, there are deep-seated and great pain, tension and throbbing, and swelling of the superimposed soft parts. Usually partial evacuation takes place, spontaneously, by the side of a tooth ; with relief from the more prominent symptoms. Such imperfect evacuation and relief, however, are not enough; the operation, above the bicus- pid teeth, as for emptying the indolent fluid collection, must be had recourse to. But, of course, in the first in- stance, attempts are made to forego the necessity of all operative interference, ^ig- ^i- by timeously arresting the inflammatory process, if possible, ere matter has at all formed. When purulent accumulation has taken place, the artificial opening cannot be too soon established. For from the turgid state of the membrane, it is very obvious that no partial relief can be Fig. 51. Enlargement of the antrum, by accumulation of fluid within. 154 TUMOUES OF THE SUPERIOR MAXILLA. expected from spontaneous evacuation through the nasal aperture — as sometimes happens in the indolent collection of fluid. Polypus of the Antrum. The lining membrane of this cavity, like that of the nostrils, may give origin to polypous formations. But the occurrence of benign polypi here is comparatively rare. The medullary formation is not uncommon ; constituting the origin of osteocephaloma, as affecting this bone ; and amenable to the ordinary rules of treatment (Principles, p. 484). Did plain indications exist of the presence of a benign polypus — mucous or fibrous — within the antrum, it would certainly be our duty to expose the cavity, by suitable incision, from the mouth ; with or without division of the lip ; and to eradicate the morbid growth thoroughly. Such cases, however, are extremely rare. Tumours of the Superior Maxilla. Two forms of tumour are liable to occur in this bone ; Osteosar- Fig. 52. coma and Osteocephaloma. Tumours very different in themselves, and requiring very different treatment ; the one early irremediable ; . Fig. 52. Large Osteosarcoma of upper jaw; macerated, shewing the osseous stroma. Still limited to the superior maxilla, in which it originated. — Howsiiip. EXTIEPATION OF THE SUPEEIOR MAXILLA. 155 the other capable of cure, at an advanced date, and after a large or even enormous size has been attained (Principles, p. 485). The osteosarcoma may reach a large size by external bulging, and by expansion of the bone ; but, unless it degenerate in structure, it remains limited within the confines of the superior maxilla ; and, con- sequently, by removal of that bone alone, the vp^hole of the diseased formation may be taken aw^ay. The swelling projects into the fauces, into the mouth, and outwards on the cheek ; the main protuberance is in the last named direction, interfering with articulation, mastication, and vision ; a thin serous discharge escapes by the mouth, seldom bloody, and seldom offensive ; and the general health may be hale in all respects. The remedy is excision of the superior maxilla; and this, though a severe and somewhat difficult operation, may be fear- lessly undertaken, even in the most advanced cases of this disease — if genuine ; experience having proved that the issue of such operations is almost invariably prosperous. The osteocephaloma may be of original formation, or may be the result of osteosarcoma degenerated. When of the former character, the diseased formation has extended beyond the limits of the superior maxilla, ere any considerable prominence has appeared externally. The outward tumour may be yet trifling, while the mouth and fauces are completely occupied, and the base of the cranium hopelessly involved. The system, too, is already worn by malignant hectic. In such cases, we cannot — by excision of the superior maxilla, the palatine bones, and the malar — hope to take away the whole of the tumour ; a portion remains, deep-seated and inaccessible ; from this, reproduc- tion of a tumour, soft, fungated, and bleeding, takes place ; and a most disastrous issue is precipitated. Or, not improbably, the already much enfeebled system speedily sinks under the immediate effects of the operation, ere ever a new production has had time to form. In short, while we may perform excision of the upper jaw with the best prospect of success, even at a late period of the case, in osteosarcoma ; we ought to refrain from operation in all examples of osteocephaloma, excepting those in which we are satisfied that the disease is yet recent, and limited to the bone in which it began — and such cases are very rare. Extirpation of the Superior Maxilla. The patient is seated firmly on a chair, or reclines on a table with the head and shoulders considerably elevated ; for so the manipula- tions of the surgeon are facilitated, and the outward escape of blood is favoured. As elsewhere stated (Principles, p. 784), my own impres- sion is, that anaesthesia by chloroform is at least of doubtful propriety here. The experience of others, however, among whom I may place 156 EXTIEPATION OF THE SUPERIOR MAX3LLA. the high authority of Mr. Lawrence, testifies that this important agent may be employed, under due precaution, even here with perfect safety. If used, every care must be taken to prevent the main risk, namely, asphyxia by accumulation of blood in the air passages. The jaw having been made clear of teeth at the point where section is intended to be made, a strong bistoury is inserted near the inner corner of the eye, over the nasal process of the superior maxilla, and is brought down to the mouth ; cutting the lip in the mesial line, and dissecting the ala of the nose from its basis. The knife is again entered over the external angular process of the frontal bone, and carried obliquely downwards to the angle of the mouth ; dividing the whole thickness of soft parts. The flap, indicated by these two incisions. is then dissected upwai'ds off the tumour ; and is held raised by an assistant. The orbital contents are separated from the bone, on their lower aspect ; and are gently elevated and protected by a flat copper spatula, which is also retained by the assistant. The soft palate is incised in the mesial line, correspondingly with the wound of the lip ; and, by cross cutting, the pendulous velum of the palate is separated from the doomed parts — now isolated, so far as the soft textures are concerned. By a small saw — stronger and longer than vv'hat is ordinarily sold as Hey's — the union between the maxilla and malar bone is severed. By the same instrument the alveolar process is cut through, at the part exposed by the labial wound ; and a groove is also made in the palatine process, at the part incised. A pair of stout and long bone-pliers may then be used to complete the section at this part ; one blade resting in the palatine and alveolar groove, the other Fig. 53. Tumour of the upper jaw; shewing the lines of incision for removal. EXTIEPATION OF THE SUPERIOR MAXILLA. 157 jiassed into the corresponding nostril. If such an instrument be not at hand, however, the section may be completed readily enough by means of the saw alone. The nasal process is severed by the ordinary cutting pliers. And, now, by pressing the tumour down- wards it is dislodged from its connexions ; while complete separation is readily effected by touching with the knife those soft parts which require its edge. The velum of the palate, formerly separated, is care- fully preserved — and, if possible, also the palatine plate of the palate bone. One or two vessels, hanging in the deep wound, will probably require ligature ; and the facial vessels, which during the operation were restrained by the fingers of an assistant, are also secured. The Fig. 54 amount of deep bleeding is often but slight ; the vessels being torn, not cut, during evulsion of the tumour. The vacant space, having been cleared of coagulum, is filled with lint ; and over this the flap is replaced. Both incisions are then brought together with great accuracy, by means of the twisted and interrupted forms of suture ; treatment is conducted for adhesion ; and, generally, this does not fail to occur, in almost the entire extent of the facial wound. The deep cavity of course inflames and suppurates. The lint loosens, and is brought away. A less amount of dressing is daily renewed, medi- cated with a weak solution of the chlorides ; granulation advances, Fig. 54. Portrait after removal of the upper jaw, for osteosarcoma. An example of how little deformity may in some cases remain. 158 EXTIRPATION OF THE SUPERIOE MAXILLA. and cicatrization is in due time obtained. In some cases, a marked deficiency remains ; and this may be remedied by the skill of the dentist. But in other cases, the deficiency is wonderfully atoned for, by Nature's effort alone ; partly by the formation of new matter, partly by contraction and accommodation of the old. When the tumour is of large size, the malar bone is encroached upon, and has to be taken away along with the maxilla. In such a case, a third incision is made along the zygoma, terminating in the upper part of that which passes from the outer corner of the eye to the angle of the mouth ; the zygomatic and orbital processes being divided by the bone-pliers. If the tumour be small, one incision may sufiice — that from the outer corner of the eye to the angle of the mouth ; it being quite pos- sible to expose the parts suificiently, by raising the triangular flap while the lip and front-face are retained entire. Dieffenbach's mode of procedure is as follows : — Having made the central incision by the side of the nose, the knife is carried across beneath the eye to the temple ; and the flap thus indicated is dissected off. This admits of a thorough exposure of the tumour ; subsequent deformity by the cicatrix is comparatively slight ; and paralysis from division of the facial nerves will probably be avoided. K any doubt should occur to the surgeon as to the solidity of the growth, an exploratory puncture should be made in the direction of the antrum, previous to operation. For, excision of the upper jaw is rather too severe a remedy in the case of mere distension of the antrum by accumulation of fluid. See Bibliography of Diseases of Bones in Principles of Surgery ; also Lizars, London Medical Gazette, vol. v. p. 92 ; and System of Anatomical Plates, part ix. Edin. 1826 (where excision of the superior maxilla is first proposed). Blandin, Gazette Medicale de Paris, vol. ii. 1834. Guthrie, Medical Gazette, vol. xvii. 1835. O'Shaughnessy on Diseases of the Jaws, &c., Calcutta, 1844. Listen's Practical Surgery, last edition. Liston on Tumours of the Face, Med. Chir. Trans, vol. xx. Dieffenbach's Operative Surgery, Leipsic, 1848. 159 CHAPTER VIIL AFFECTIONS OF THE FACE. Wounck. Wounds of the face are apt to bleed freely, and usually require deligation of the vessels. Coaptation should be most carefully effected, and adhesion courted, in order to avoid deformity by cicatrization, as much as possible. Transverse wounds may interfere vuipleasantly with the parotid duct ; and, by division of the branches of the portio dura, may paralyze the cheek, at least for a time. After cicatrization, resumption of the nervous function may be expedited by friction. Warts. Warts not unfrequently form on the integument of the face. They should not be allowed to remain : for, by the time old age has super- vened, they will be found either already degenerated, or prone to become so. It is well to remove them early, by the ordinary means — (Prin- ciples, p. 406) — while they are yet simple. Erysipelas. Erysipelas seldom assumes the phlegmonous form in the face. Punctures, consequently, suffice for abstraction of blood, and relief of tension. They may be made freely ; for the cicatrices leave no un- seemly trace. After disappearance of the main attack, the patient must be carefully watched for some days ; reaccession, with secondary abscess, being very apt to occur in the areolar tissue of the lower eyelids (Principles, p. 382). As in erysipelas of the scalp, cold, and other repellent applications, should never be employed. Spasm. Spasmodic twitching of the muscles on one side of the face — the orbicularis oculi, the levators and retractors of the upper lip, and the corresponding movers of the nose — is an unpleasant affection of no uncommon occurrence. Often it will yield to general treatment ; 160 NEUEALGIA OF THE FACE. more especially to rectification of the primge viae. Sometimes, also, patient counter-irritation is of use, directly over the part ; and probably the preferable mode of applying this, is by rubbing on nitrate of silver in substance, so as to vesicate. In chronic and obstinate cases, teno- tomy has been had recourse to.'^ In one example, permanent cure followed subcutaneous division of the zygomatici, the levator anguli oris, a portion of the orbicularis oculi, and the depressor alee nasi. In order to restrain hemorrhage, and consequent ecchymosis, likely to result from such a cross wound of the face, accurate pressure is neces- sary immediately after withdrawal of the knife. Neuralgia. Neuralgia affecting the branches of the fifth pair of nerves is termed Tic Douloureux ; at once, unfortunately, one of the most distress- ing and most unmanageable affections to which the human frame is liable. The treatment is supposed to fall within the peculiar province of the physician ; and consists in carrying out the general principles on which the management of neuralgia is ordinarily conducted (Principles, p. 628). At one time, the surgeon's aid was not unfrequently called upon ; division of the trunk of the affected nerve being supposed likely to afford at least an alleviation of the distressing symptoms. Expe- rience has proved, however, that such an operation is in most cases inexpedient ; the relief, if any, is but partial and temporary ; and the neuromatous enlargements, which form on the truncated extremities of the nerve, are likely to produce ultimate aggravation. The operation, in truth, may be the means of converting an example of neuralgia, unconnected with structural change in any part of the nerve, into a worse form, dependent on structural change, not only considerable but probably irremediable. Sometimes the operation has proved success- ful upon one nerve, only to drive the neuralgia to another — perhaps inaccessible. Very seldom does it effect a complete cure. Tumours of the Cheek. Tumours form in front of the ear, and are of various kinds. They may be simple, fatty, fibrous, or cystic. Calcareous formations, too, are not unfi'equent ; the earthy matter being deposited in the stroma of a chronically enlarged lymphatic gland. In removing such growths by the knife, the gi'eatest caution should guide the movements of the hand ; lest the branches of the portio dura be cut across, and paralysis of the cheek ensue ; and lest by division of the parotid duct, salivary fistula be established. In order to meet such indications, the dissection * DiEFFENBACH on Division of Tendons and Muscles, Berlin, 1841, p. 315. SINUS OF THE CHEEK. 161 should be proceeded with in the direction of the endangered parts — horizontally ; contravening the general rule of cutting in the direction of subjacent muscular fibre. Tumours of the parotid are rare, fortunately. For this gland is so situated as to render extirpation of it, entire, even in the healthy state, an operation of extreme difficulty. If it be the site of a benign tumour, of no great size or duration, removal may be attempted. The dissec- tion will be deep and difficult ; and, after every care, a portion of the morbid structure is likely to be left behind ; but it is quite possible that reproduction may not occur. Malignant formations, however, are uniformly let alone ; for in their case reproduction is certain, if any portion of the original growth, however slight, be permitted to remain. Tumours over the parotid are comparatively frequent. They displace the subjacent gland, cause it to shrink by absorption, and occupy its place. Their extirpation can be effected both readily and safely. Sinus of the Cheek. Patients frequently present themselves under the following circum- stances. They are adolescents, or recently adult ; and are more fre- quently female than male. Many months previously, a phlegmon formed on the lower part of the cheek, over the body of the lower jaw ; suppuration took place ; copious discharge has continued ever since ; and though many and various remedial means have been employed, cicatrization, or even marked amendment, has never been obtained. There is a weak sinuous ulcer, with a pouting external surface ; and the surrounding integuments are swollen and discoloured by passive congestion. In the great majority of such cases, if not in all, the exciting and retaining cause is to be found within the mouth. Opposite, or nearly opposite the affection of the cheek, a decayed tooth or stump will be found, probably imbedded in a very diseased gum. And on removal of this — and not until then — will the sinus and ulcer be brought to heal. Without extraction of the offending tooth or teeth, the most energetic and sustained practice may be put in force against the cheek, without success. After extraction, healing may occur even without any remedial means having been applied directly to the part. Salivary Fistula. In consequence of wound or ulcer, the duct of the parotid gland may open externally on the cheek. And by outward discharge through the fistulous aperture, not only are deformity and inconvenience occa- sioned, but also a serious loss is sustained of secretion very valuable in M 162 PEACTUKE OF THE MALAR BONE. the processes of mastication and digestion. The principles on which a cure is to be attempted are very simple ; namely, the establishment of an internal opening, by which the saliva may be poured into the mouth and saved ; and the shutting up of the external aperture whence this fluid has previously run to waste. A puncture is made through the mucous membrane, communicating with the duct's cavity ; and the permanency of this new passage is secured, by the lodgment of a suitable foreign substance — either left there for some days, or intro- duced at frequent intervals. The external aperture, having been made raw in its edges, is shut by means of a point of twisted suture. Adhe- sion may take place ; if not, subsequent contraction is induced by the application of a heated wire, at long intervals (Principles, p. 226). Autoplasty may be of use, in those cases in which there is much loss of substance, and in which the ordinary means of effecting closure have failed. Fracture of the Malar Bone. This accident is rare. The deformity is considerable, and unfortu- nately not easily remedied ; as in the following example : — A lad, aged eighteen, was struck on the face by a full blow from the fist of a heavy athletic man. The zygoma had given way, and also the union between the malar bone and superior maxilla. The former bone had been driven much down, giving a remarkably sunk appearance to the face, with deficiency of orbital margin. By examination from the mouth, it was also apparent that the roof of the maxillary antrum had been broken and depressed. In addition to the deformity, the patient complained of much pain ; there was also a numbness of that side of the mouth ; and considerable difficulty was experienced in attempting to close the jaw, the redundant soft parts of the cheek lodging between the teeth. By pushing upwards with the finger-points, insinuated from behind, the malposition of parts was in some degree rectified ; but still considerable displacement and deformity remained. Reich, Dissert, de Maxillse Supevioris Fractura, Berol., 1822. Cloquet, Memoire sur les Fractvu'es par Contrecoup de la Machoire Siiperieui'e, Paris, 1820. 163 CHAPTER IX. AFFECTIONS OF THE LIPS. Harelii:). This term is applied to congenital fissure of the lip ; the part, so deformed, being supposed to have a resemblance to the natural develop- ment of the hare. In general, there is a strong wish, on the part of the parents and friends, to trace the untoward result at birth to some sinister impression made on the mind of the mother during uterogesta- tion — with what success it were more curious than useful to inquire. The affection may be single or double, simple or complicated. Single Harelip consists of a fissure, extending through the whole thickness of the lip, usually situate on one side of the mesial line, and either partially dividing the lip, or extending completely into the cavity of the nostril. When the affection is both simple and single, there is no other deformity in the mouth ; the hard and soft palates are entire and fully developed, and the gums are normal. Deformity is great, however, even in the simplest form ; and the functions of the parts are also much interfered with. The only remedy is by opera- tion ; making raw the edges by incision, approximating the fissure accurately at every point, and securing union by adhesion. The pre- ferable period for performing this operation, probably, is after the child has passed the second year.* By this time the trying process of den- tition has usually gone by ; and there is consequently a better tolerance of pain and loss of blood than at an earlier period. Also, at this age, the patient, though unruly to its utmost, is yet easily managed and controlled ; and the procedure is manifestly favourable to the due advancement of articulation, and the important educational results which follow thereon. For a like reason as in extirpation of the upper jaw, ansesthesia is here inexpedient. The child, rolled firmly up in a linen sheet — mummy-wise — with its arms by its side, is held on the lap of a nurse or an assistant, and has its head secured between the knees of the surgeon, who is seated on a chair in front of the patient and nurse. The free margin of the lip, on one side of the fissure, is taken hold of * The operation has been successfully performed, seven hours after birth. — Eaxking's Retrospect, vol. v. p. "249. m2 164 HARELIP. Kg. 55. by the finger and thumb, and put on the stretch, A narrow and straight sharp-pointed bistoury is then inserted at the upper or nasal angle of the deficiency, and carried steadily downwards, after trans- ,__ fixion, so as to leave a smooth cut surface on the fissure's margin. The like is done on the opposite side. But in neither case is the section made com- plete. Near the prolabium the knife is arrested and withdrawn, and the two flaps are left pendent. The lip is temporarily brought together, and an estimate is made of how much of the lower part of these flaps should be retained, in order to fill up completely the notch which is otherwise so apt to remain at the prolabium ; and, this having been ascertained, the necessary abbrevia- tion of the pendent flaps is made by*knife or scissors. The wound is then finally closed, accurately, by points of twisted suture, in the same way as in the operation for restoring the columna nasi (p. 148). For this modification of the operation, in Kg. 56. order to obviate the prolabial notch, we are indebted to M. Malgaigne. If a pouting redundancy should be found, after cicatrization, it may easily be reduced to the proper outline, by knife or scissors if need be ; but, in general, absorption will render all secondary interference unne- cessary. In double harelip, there is a fissure extending from each nostril, and usually complete. The intermediate portion of lip may be fully Fig. 57. Fig. 58. developed, or it may be short and deficient. In the one case, two lines of wound are necessary — the ordinary operation being applied to each Fig. 55. The twisted suture. Pig. 56. Malgaigne's operation. The dotted lines mark the fissure. Fig. 67. Simple harelip. The dotted lines mark the incisions, as in the ordinary- operation. Fig. 58. Single operation for double harelip. The dotted lines mark the incisions, as ordinarily practised. ULCEES OF THE LIPS. 165 fissure ; in the other, a single approximation will suffice — as is suffi- ciently illustrated in the diagram (Fig. 58). Complicated Harelip. — Complication attends on the double form more frequently than on the single. The hard and soft palates may be cleft. Or the gum is in an abnormal state ; projecting forwards between the fissures, sometimes adherent to the apex of the nose, and presenting teeth growing viciously. The abnormal state of the palate makes no difference in the operation on the lip ; except to expedite its performance, in the hope that the traction so exerted may have some good effect, in favouring diminution of the palatine chasm during pro- gressive development of the parts. In the case of projecting gum, it is usually expedient to begin the operation by removing the faulty part, on a level with the normal gum, by means of bone-pliers ; and then to complete the procedure in the ordinary way. Li some few cases, repression of the prominence may be effected, by adapting a springed instrument calculated to exert the necessary amount of pressure. Ulcers of the Lips. The lips are liable to ulceration of the ordinary kind ; induced by exposure to weather, irritation of tartar or decayed teeth, gastric disorder, external injury, or direct application of an irritant cause. The prolabium is the part most frequently involved. Treatment is begun by removal of the cause, when that is appa- rent ; avoiding atmospheric exposure, subduing over-action caused by external injury, removing sources of irritation from the gums, discon- tinuing the habitual use of a short pipe, correcting the digestive organs, &c. Then applications are made to the sore, according as its appear- ance may seem to require ; and nitrate of silver, either in substance or in solution, is found to be the application most generally useful — the ulcer usually partaking more or less of the irritable character (Principles, p. 253). Throughout the treatment, it is of great impor- tance to secure rest of the part as much as possible. In the child of strumous habit, ulceration of the prolabium and lining of the upper lip, near its centre, is very apt to occur, with much swelling of the part ; and in such cases the binding of a riband tightly over the lip is found to be very beneficial — securing comparative rest of the part, and promoting discussion of the swelling by pressure. Malignant Ulcers of the lips are unfortunately by no means rare ; but are peculiar to the advanced in years, as cancer usually is ; and the lower lip is much more frequently affected than the upper. The disease may commence by carcinomatous formation of a warty cha- racter, or may exhibit at once the condition of cancer (Principles, p. 322). The most common inducing cause is the habit of smoking with 166 ULCERS OF THE LIPS. a short clay pipe ; which becomes hot, and irritates the prolabium — daily, or many times a-day. The only remedy is by free and early removal of the diseased part ; while the disease is yet limited, and no in- volvement of the lympha- tics is apparent. For su- perficial, suspicious sores, affecting the mere pro- labium, escharotics may suffice ; nitric acid, ni- trate of mercury, chloride of zinc, or potassa fusa — freely applied. But when other textures are involved, the knife alone is worthy of confidence. When the affection is mainly on the surface of the lip, the whole may be taken away, and yet with very little deformity. By two elliptical incisions, the diseased space is included ; the knife being entered in the middle of the prolabial space, and made to pass first on the integumental, and then on the mucous aspect of the disease. The mor- bid structure, thus marked, is carefully dis- sected out ; and then the saved integument and mucous membrane are brought together by points of interrupted suture. When the disease is more extensive, and the lip lax, it is yet pos- sible both to I'emove the diseased part satisfactorily, and to prevent any great deformity. The including incisions are made in the form of the letter V, the apex pointing downwards ; and with care taken that the good general rule is not transgressed, of taking away a border of apparently sound texture along with the truly carcinomatous formation (Principles, p. 825). The wound is approximated and secured, by twisted suture ; as for harelip. In not a few cases, however, almost the whole surface of the lip is involved, the disease at the same time extending deeply towards the chin. Under such circumstances, we have but one paramount indica- tion to fulfil ; namely, complete excision of the diseased part ; and this is uncompromisingly effected by a free sweep of the knife. Approxi- mation is not attempted. But the part is left to granulate and heal, as Fig. 59. Cancer of the lip. The disease too extensive for any consen'ati^■e operation. CANCEUM OEIS. 167 ordinary suppurating wounds do. And sometimes the ultimate defici- ency of lip, after such an operation, proves much less than might have been anticipated ; partly on account of formation of new matter, but mainly by resilience and centripetal movement of the old textures. The lower lip, when destroyed by carcinoma, may sometimes be restored in great measure by incision and elevation of the adjacent parts, without transplantation of flaps; as has been practised by Blasius, Dieffenbach, Serre, Syme, Lawrence, and others.* The ope- ration is thus described by Mr. Syme, in a case in which removal of the cancer and restoration of the lip was done at the same time : — " Two incisions were made from the angles of the mouth, so as to meet at the chin, and remove the whole of the morbid part in a tri- angular form. The lines ah and be being supposed to represent these incisions, I cut from the point b outwards and downwards, on each side, to d and e, in a straight direction, and then, with a slight curve a cab c Fig. 61. outwards and upwards, to / and g. The flaps a b df and cbeg were next detached from their subjacent connexions, and raised upwards, so that the edges a b and c d came into a horizontal line ; while those represented hj bd and b e met together in a vertical direction, and the lateral extensions to / and g allowed sufficient freedom to prevent any puckering or overstraining. The respective surfaces were lastly retained in contact by the twisted and interrupted suture ; four points of the former being inserted in the middle line from the lip downwards, and the same number of the latter in the curved portion on each side. The wound then presented the appearance shewn by Figure 61. It healed entirely by the first intention." Cancrwn Oris. This is an example of Sloughing Phagedsena (Principles, p. 258). It originates in the mucous membrane of the lip or cheek, and extends * See Blasius, Klinischeii Zeitschrift, Halle, 1886. Dieffenbach, Haudbuch der Plas- tichen Cliirui-gie, Berlin, 1838. Serre Traite sur I'Art de Eestaurer les Defomiite's de la Face, Paris, 1842. Syme, Monthly Journal, March 1847, p. 642. 168 CHEILOPLASTICS. sometimes both rapidly and far, presenting the usual characters of that class of sore. It is almost exclusively met with in the Hi-fed, ill- clothed, and ill-housed children of the poor, in densely populated towns. But in any child of weakly habit it may be induced, by imprudent mercurialism. The constitution sympathizes greatly ; in the form of irritative fever, tending to the typhoid character. Treatment consists in amending the outward condition of the patient, if possible, by change of air, ventilation, &c. ; rectifying the primse vige, but studiously avoid- ing all mercurial medicines ; carrying out the active local treatment suitable to this form of sore (Principles, p. 259) ; and administering internally the chlorate of potass — found to be a very appropriate alte- rative, in the dose of from one scruple to two scruples in the course of twelve hours. In the worst form, nourishment, tonics, and even stimuli may be imperiously demanded, to prevent sinking. And if the patient survive, the loss of substance will probably be such as can be remedied only by a determined autoplastic operation. Cheiloplastics. AVhen the Hp has been lost, either entirely, or in its greater part, in a patient othermse of tolerable health, and not far advanced years, restoration by autoplasty may be contemplated. The part may have been destroyed by wound, sloughing, or intractable ulceration. In the last mentioned case, we must be very careful not to attempt the engrafting of a substitute, until all ulcerative tendency has for some time wholly ceased — for very obvious reasons. After removal of truly cancerous disease, restorative interference is seldom expedient ; unless by the peculiar arrangement of incision already spoken of (p. 167). The autoplastic operation is conducted on the same principles as for restoration of the nose. A flap, of suitable form and dimensions, is brought from beneath the chin. A connecting slip is left at the symphysis ; there gentle twisting is made, so as to bring integument to the surface ; the part is secured in its new site by suture ; and, by the like means, a portion of the submental wound is approximated — the rest being left to heal by granulation. After adhesion of the flap is completed, the mental slip of attachment is divided, and smoothed down, by the bistoury. See Dieffenbach, &c., as in the footnote of the former page. Liston's Practical Sur- gerj-. On Cancrum Oris, see Marshall Hall, Lancet, 1839-40, p. 409. Cycl. of Pract. Surgen-, suh voce. Hunt, ^IcA. Chir. Trans, vol. xx%-i. Also Lancet, No. 102-3, p. 60. 169 CHAPTER X. AFFECTIONS OF THE PALATE. Congenital Deficiency. Extensive deficiency of the hard palate is with difficulty remediable. Mitigation of the deformity and inconvenience may be effected by the dentist ; a metallic plate being fitted into the chasm, on completion of the part's development. Also, something may be done by surgery ; as recommended by Dr. J. M. Warren. The soft parts, having been carefully dissected ofi" the bony arch, are brought together by suture, after the edges of the gap have been made raw. What filled the arch will probably meet readily on a plane surface ; but should difficulty be experienced, further relaxation may be obtained by dividing the anterior pillars of the soft velum.* A mere fissure of the hard palate may disappear spontaneously, during the progressive development in adolescence. And if the mucous membrane should be slow in closing over, this process may be expedited by occasionally applying a heated wire, or by raising and approximating the raw edges. The soft palate may be fissured, alone. Then, if the want of sub- stance be not great, we have it in our power to attempt remedy by operation. Three cu'cumstances, however, are essential, as prelimi- naries to the attempt. There must be no great deficiency, otherwise traction in approximation will be considerable, and adhesion will almost certainly fail. The patient must be of adult age, or nearly so ; great steadiness and self-control being indispensable on his part, both during the operation and afterwards. The patient should also be of sound system, and in good health; so as to afford every possible facility to the occurrence of adhesion in the wound. And unless a concurrence of these circumstances can be obtained, the prudent sur- geon will refrain from interference. The operation is termed Staphyloraphe, or Velosynthesis. It con- sists of three distinct parts ; preparation of the velum, paring of the edges, and approximation of the fissure by suture. The first part requires some considerable time for its completion. For weeks before * New England Quavtevlj' Journal of Modicine and Surgen', April 1843. 170 STAPHYLOKAPHE. the actual operation, the patient accustoms himself to open his mouth wide, and to retain it so, steadily and enduringly — with no effort at deglutition of saliva : and he also seeks to reduce the irritability of the parts, by frequently touching them with his finger, or otherwise. The nature of the operation is fully and candidly explained to him, and his willing co-operation secured. Then he is seated before a good light, with the mouth widely opened, and the edges of the fissure are made raw, by a narrow sharp-pointed bistoury, used as in harelip ; a volsella being employed to seize the uvular extremity, and so to make the part tense during incision. This completes the second part of the operation. Some hours are now allowed to intervene; and it is well to give some simple nourishment at this time — it being obviously important to avoid the effort and movement of deglutition for some time after approxima- tion has been effected. The third part of the procedure consists in bringing the wound into accurate apposition at every point ; diminishing the strain on the ^^ sutures, by lateral and parallel incision of the I ^ - ^ I mucous membrane ; and keeping the part in a i.^'\ state of as complete quietude as circumstances '^^^ — ~~ will possibly allow. Approximation is not made immediately after incision, because it is expedient to allow all oozing of blood to cease in the first instance ; so as to avoid the irritation, and involuntary movements of the palate, which its trickling does not fail to produce. But bleediiig having wholly ceased, there is no necessity for further delay. The necessary number of sutures are passed; and may be secured either by the 'ordinary knot, or by passing the oral ends through a soft metallic Kg- 63. bead, running this up to the line of wound, and clasping it on the threads there by means of firmly pointed forceps. Not a few instruments have been contrived for facilitating the sewing department in this operation — undoubtedly one of great difficulty ; but it is probable that the curved needle in a fixed handle — as used for deligation of vascular tumours (Principles, p. 637, Fig. 207, b) — ^will be found quite suitable in experienced hands ; or a short needle, very much curved, may be conveniently enough passed by means of a porte- aiguille. When approximation has been completed, a longitudinal incision is made on either side of the palate, through the anterior mucous membrane ; so as by permitting expansion at the cut part, to diminish Fig. 62. Plan of Staphj'^loraphe. The double ligature in the act of being drawn. The dotted lines mark the liberating incisions of the mucous membrane. STAPH YLORAPHE. 171 traction on the line of union. Absolute starvation is not desirable. But simple farinaceous food is sparingly and carefully administered from time to time ; the patient being as passive as possible in the act of swallowing. And the ordinary constitutional treatment, favour- able to the occurrence of adhesion, is of course rigidly enforced. Not a little self-denial is necessary, on the part of the patient, to avoid the oft-occurring excitements to coughing, hawking, and swallowing; compliance with which would have a manifestly unfavourable effect upon the wound. Mr. Fergusson has introduced a very ingenious modification of the ordinary operation ; obtaining steadiness and quietude of the parts operated on, by means of myotomy. Looking on a split palate, from the mouth, the pai'ts are seen hanging quiet in the fauces, with a distinct central gap in the velum. If the flaps be touched, they will be raised upwards, by the action of the levatores palati muscles. If a stronger stimulus be applied — as by the rude touch of a finger — "each flap is forcibly drawn upwards and outwards, and can scarcely be distinguished from the rest of the parts forming the sides of the nostrils and throat ;" and this is done by the action of the palato-pharyngei muscles, added to that of the levatores palati. On exciting the parts situated more posteriorly, " as in the second act of deglutition, the margins of the fissure are forced together, by the action of the superior constrictor muscle of the pharynx." The main opponents of approximation in staphyloraphe are thus shewn to be the levatores palati and palato-pharyngei. And Mr. Fergusson's operation is planned so as to divide and temporarily paralyze these muscles. " With a knife, whose blade is somewhat like the point of a lancet, the cutting edge being about a quarter of an inch in extent, and the flat surface being bent semicircularly, an incision is made about half an inch long, on each side of the posterior nares, a little above and parallel with the palatine flaps, and across a line straight downwards from the lower opening of the Eustachian tube. By this incision — placed about midway between the hard palate and the posterior margin of the soft flap, just above the thickest and most prominent part of the margin of the cleft — the levator palati muscle on each side is divided, just above its attachment to the palate. Next, the edges of the fissure are pared with a straight blunt-pointed bistoury, removing little more than the mucous membrane. Then, with a pair of long blunt-pointed curved scissors, the posterior pillar of the fauces is divided, immediately behind the tonsil ; and, if it seems necessary, the anterior pillar is cut across too ; the wound in each part being about a quarter of an inch in extent. Lastly, the stitches are introduced. . . . Or, it may be found more convenient to divide the palato- pharyngeus first, next the levator palati, and then to pare the edges 172 ULCER AND EXFOLIATION OF THE PALATE. when the muscular action has been taken off."* When the pared edges look thin, it may be well to increase their breadth by applying the curved knife so as to split the margins to a slight depth ; so rendering the occurrence of satisfactory union more probable. Ulcer and Exfoliation of the Palate. The lining membrane of both the hard and the soft palates is liable to ulceration, from ordinary or specific causes. The most intractable, and not least frequent examples, are those which are connected with the mercurio-syphilitic taint of system. In such, constitutional treat- ment is aU important ; the local applications varying, according to the characters of the sore. Exfoliation of the hard palate, not unfrequently complicated with caries, and necessarily accompanied with ulceration of the correspon- ding mucous membrane, is seldom if ever found to occur except when mercury has been freely administered. Again, treatment is mainly constitutional. Locally, separation is patiently awaited ; and, when this has been completed, removal of the sequestrum is duly effected, if necessary. If the whole thickness of bone have perished, an aperture of communication necessarily results between the nasal and buccal cavities. If this be large, the deficiency can be supplied only by mechanical contrivance. If, however, it resemble a merely fistulous . opening, closure of the mucous membrane may be obtained by the occasional application of a heated wire. * Med. Chir. Transact, vol. xxviii. p. 291. Also Fergusson's Pract. Surgery, p. 531. For Dieffenbach's procedure in this operation, see his Operative Chirurgie, 1845, p. 856. 173 CHAPTEE XL AFFECTIONS OF THE TEETH. It is unnecessary here to enter fully on the various and important topics connected with the subject of this chapter. A few leading surgical points may be stated ; reference being made, on other matters, to the various separate works which treat of Dentistry in detail. First, it is well that the student remember how affections of the teeth are not connected only with the convenience, comfort, and good looks of a patient — but with his health and very existence. The causes — sometimes remote, sometimes tolerably direct — of many affections implicating the general frame, as well as important parts of it, proceed entirely from the contents of the alveoli. Bad teeth " are frequently the cause — and the sole cause — of violent and continued headach ; of glandular swellings in the neck, terminating in, or combined with abscess ; of inflammation and enlargement of the tonsils, either chronic or acute ; of ulcerations of the tongue or lips, often assuming a malignant action from continued irritation ; of painful feelings in the face, tic douloureux, pains in the tongue, jaws, &c. ;" of abscess and sinus of the cheek ; of enlargement and change of structure in the gum, which may lead to dangerous tumour of the bone ; " of disordered stomach, from affection of the nerves, or from imper- fect mastication ; and of continued constitutional irritation, which may give rise to serious constitutional disease." Crowded Teeth Are important in a surgical point of view. Behind, the irritation so caused may induce swelling, vascularity, and ulceration of the mucous membrane ; probably with repeated attacks of troublesome and even dangerous cynanche. In front, crowded incisors are very apt to cause abscess ; not confined to the soft parts, but imphcating the bone also. The remedy is plain ; early to prevent mischief, by removal of one or more of the redundant organs ; or, at a later period, to retrieve disaster by the same procedure — removal of the cause. 174 TOOTHACH. Caries of the Teeth Is the term usually employed to denote decay of the osseous matter ; which usually commences on the surface, at one or more points, and proceeds inwardly until the pulp is exposed — the enamel also giving way at an early period. When the disease is yet recent and limited, its progress may be arrested; by clearing away the disorganized substance, and " stopping " the cavity, either with gold or with cement. But after the pulp has been fairly exposed, and pain established, it may be stated as a general rule — not to be rashly or often deviated from — that under such cu'cumstances " stopping" is not advisable, and extrac- tion of the offending pai't is highly expedient. Long to retain a decayed tooth, or portion of a tooth, in the ^ hope of by various means quelling the pain of tooth- ach, and so avoiding the pain of extraction, is to court rig. 63. the accession of some of the more important evils already enumerated as likely to spring from such a source of irritation. Toothach, It is important to remember, may proceed from different causes ; and so requires different treatment in different cases. It may be an example of neuralgia, with or without any connexion with diseased teeth or gums ; requking the ordinary anti-neuralgic treatment, local and general (Principles, p. 628). It may be caused by caries of the tooth, advanced so as to expose the pulp ; and then may be palliated by anodynes ; temporarily arrested, painfully, by escharotics ; or entirely quenched by extraction of the tooth ; and the last, as already stated, is in most cases the preferable proceeding. It may arise from inflammatory action in or around the tooth — in the interior of the tooth's cavity, or in the alveolar investing parts — not necessarily con- nected with decay of the tooth at any part ; and this form is plainly to be assuaged by antiphlogistics, local and general ; locally, leeches and fomentation to the gum ; constitutionally, purgatives, antimony, and low diet ; the patient at the same time affording as much rest as possible to the affected part, especially avoiding all frritation of it by tongue, finger, or toothpick. Also, severe pain may be felt in the teeth, apparently sound, quite of a rheumatic origin and character ; and this is to be got rid of by anti-rheumatic remedies, mainly con- stitutional in their operation. Change of structure in the fang of the tooth — it becoming coated by rough osseous deposit — may induce Fig. 63. Hopeless destruction of the tooth. EXTEACTION OF TEETH. 175 intense pain, though the organ be in other respects sound ; by such hypertrophy, it is probable, the nerves are incommoded and compressed ; and the only remedy is extraction. And, lastly, the fang, or fangs, of a tooth may become necrosed, the crown and cervix remaining apparently sound ; chronic abscess forms around the affected part, the matter accumu- lating in a distinct membranous pouch ; and much pain is likely to be thus occasioned, until either the tooth is ex- tracted, or becomes loose and permits spontaneous evacuation and discharge. Extraction of Teeth. Extraction of a tooth is demanded, not unfrequently, of the surgeon ; Fig. 64. Fig. 65. Kg. 66. as an operation of itself; or as a means towards the cure of another, and perhaps distant affection — such as neuralgia; or as part of a more serious opei'ative procedure — as in extirpation of a por- tion of the jaw. Forceps and the tooth-key, are the instruments usually employed. The former, in general estimation, is by much the preferable ; '^' '■ equally certain to effect the object in view ; and possessing the great recommendation of Fig. 64. Purulent cyst at the fang of a decayed tooth ; often the simple origin of most serious mischief. Fig. 65. Diagram shewing the application of the tooth-key. Fig. 66. Forceps for the upper jaw ; constructed so as to adapt themselves closely to the form of the tooth. In a, the tooth, sawn across, shewn embraced. Fig. 67. Forceps for the lower jaw. In a, the tooth embraced. 176 HEMORRHAGE AFTER EXTRACTION OF TEETH. exerting all the force on the doomed part, and leaving the alveolus and gum comparatively, or absolutely, uninjured. Practice is, no doubt, essential to the skilful and efficient use of forceps ; and many instru- ments are required in the well-equipped armamentarium, adapted to the configuration and lodgment of the tooth to be removed. Stumps are removed either by means of sharp forceps, introduced beneath the gum ; or by a lever passed between the offending part and its alveolus, making use of a neighbouring sound tooth, if possible, as a fulcrum. Hemorrhage after Extraction. Troublesome bleeding may follow the ordinary extraction of a tooth, and may proceed from one of two causes. An arterial branch, of some size and activity, may have been implicated in the injury inflicted on the alveolus. Or the patient may be one of those unfortunates afflicted with the hemorrhagic diathesis. The former case is usually manageable enough. The cavity is sponged dry, and an escharotic applied — nitrate of silver, probably the preferable — so as temporarily to arrest the flow, and afford a dry bed for the compress. Then, with all convenient speed, strips of lint, steeped in a strong tincture of matico, are inserted firmly into the cavity, by means of a stout probe or director ; and the jaws, having been brought together with a com- press interposed at the injured part, are made to exert and maintain a sufficiency of pressure on the bleeding point. In the other case, the same local treatment is advisable, with the means suitable to the hemorrhagic diathesis (Principles, p. 374). Tartar on the Teeth. Accumulation of salivary deposit is to be prevented, for obvious reasons ; its presence being prejudicial to the teeth themselves, to the gums, to the mucous membrane of the cheek and lips, and to the tongue. The teeth are apt to loosen and decay, the gums to become congested, the mucous membrane to become the seat of obstinate and painful ulceration. In effecting removal, care must be taken to leave the enamel uninjured. Eecession of the Gums. In advanced years, and sometimes even in middle age, the gums recede from the cervices of the teeth, especially in front, exposing the fangs ; occasioning looseness, pain, irritation, and final decadence — though in other respects the organs may be quite entire. In the senile cases, but little can be done by remedial treatment ; the occurrence is only a part of the general decay, and is in all respects to be regarded INJURIES OF THE TEETH. 177 as such. A similar result may follow the accumulation of tartar ; it is to be averted by removal of the offending matter. Congestion of the gums may induce it ; and this cause is met by local abstraction of blood — by leeches or scarification — and by the subsequent use of astringent dentifiices. At the same time it is very necessary to look to the state of the primae viae, and to correct the irregularities vsrhich will probably be found there. Injuries of the Teeth. A tooth struck smartly may be deprived of a part of its compact structure, without any serious injury to the integrity of the rest. If, however, it have been displaced, and its vascular connection broken up, necrosis is the result. Sometimes simple dislocation occurs, with- out fracture. By replacing a dislocated tooth, an imperfect union with the alveolus may take place ; but the tooth will eventually lose its colour, and induce an unhealthy action in the gums. C. Delabarre, Traite de la Seconde Dentition, Paris, 1819. F. Maury, Traite Com- plete de I'Art du Dentiste, Paris, 1833. Thomas Bell, Anatomy and Physiology of the Teeth, London, 1835. William Eobertson, Practical Treatise on the Human Teeth London, 1839. Chitty Clendon, On Extraction of the Teeth, London, 1844. Goddard and Parker, Anatomy, Physiology, and Pathology of Human Teeth, Philadelphia, 1844. John Tomes, Lectures on Dental Physiology and Surgery, London, 1848. Chaplin Harris, M. D., Principles and Practice of Dental Surgery, Philadelphia, 1850. CHAPTEE XIL AFFECTIONS OF THE JAWS. Parulis. The term Parulis denotes the condition of Gumboil j inflammation of the gum, usually connected with a decayed tooth or portion of a tooth. The swelling causes much pain and discomfort, sometimes with smart constitutional disturbance. On suppuration taking place, relief is obtained by evacuation of the matter ; but so long as the de- cayed tooth remains, a certain discharge, with swelling and pain, continues to prove the source of no slight annoyance. Treatment varies according to the stage of advancement. At first, the affection just originating, the decayed tooth should be removed at once, and bleeding from the wound encouraged ; and afterwards, if need be, blood may be further withdrawn by leeching the affected part — the animals being most conveniently applied through a glass tube. "When matter has formed, it should be early and fully evacuated ; and after the excitement following incision has abated, under ordinary antiphlo- gistic means, the offending tooth or stump should be gently extracted. To perform extraction earlier, might be to aggravate the inflammatory action unnecessarily. When the matter has formed and been discharged, extraction of the tooth will ordinarily sufiice for effecting contraction and closure of the discharging aperture, wath vSubsidence of the swelling and pain. If not, some of the many suitable astringent solutions may be applied to the part. Epulis. Epulis denotes a solid tumour of the gum, of non -inflammatory origin ; but, like parulis, often, if not usually, connected with the presence of a decayed tooth, or portion of alveolus. It may be either simple or malignant. The simple form is a sarcomatous growth, at first seated in the soft parts of the gum, but tending soon to involve the subjacent bone ; in short, the tumour, at what may be termed its period of maturity, may be truly considered an examj^le of osteosar- TUMOUES OF THE LOWER JAW. 179 coma, on a small scale. It spreads slowly. Teeth loosen, and are surrounded by the fleshy growth ; and the body of the bone becomes more and more involved. In the early condition, it is sufficient to remove the offending tooth, or piece of bone ; and, with a bistoury, to excise the altered portion of gum ; repressing subsequent tendency to growth, if need be, by the application of an escharotic. When the bone has become involved, it is essential that the affected portion shall be taken away — early, and freely — for obvious reasons ; and this is readily effected by knife, saw, and cutting pliers (Principles, p. 485). The malignant form is, fortunately, by much the more rare. Very early the bone is affected ; and the tumour is a true specimen of osteocephaloma. Soon the surface ulcerates and fungates, with bloody loathsome discharge, and the spread is rapid in all directions. Ob- viously, the only remedy is by ablation ; and that at a comparatively early period. Sometimes, malignant disease commences in the upper jaw, not with the formation of tumour, but at once by ulceration — osteocancer (Principles, p. 487). The loss of substance speedily wastes the alveoli, and, opening into the antrum, discloses a foul and hideous sore — at a very early period beyond the reach of the most active surgery. Tumours of the Lower Jaw. The lower jaw, like the upper, is liable to be the seat of a chronic collection of fluid — here usually termed Spina ventosa — as w^ell as to be occupied by both osteosarcoma and osteocephaloma. Spina ventosa of the lower jaw, as formerly exj^lained (Principles, p. 430), is an example of osteocystoma. The remedy is by puncture and evacuation ; gradual contraction and consolidation of the cavity being sought for, by pressure from without, and by maintaining a certain amount of inflammatory action within — as by a seton, or stimulant in- jections. The solid tumours require the same treatment as in the upper jaw. But, with this difference, that, in consequence of the relative anatomy of '^' ^' the parts, complete ablation of an osteocephaloma is within our power at a much more advanced period, than in the case of the superior maxilla ; inasmuch as the whole diseased structure can be included in the incisions, and taken away. Fig. 68. Cyst at the root of a decayed tooth ; lined by secreting membrane, and filled with puriform fluid ; chronic. Supposed to be the origin, in many cases, of osteocystoma. N 2 180 EXTIEPATION OF THE LOWEE JAW. The simple Osteoma (Principles, p. 478) has occurred in the lower jaw ; at first, to be treated by attempts at arrest of growth, and subse- Fig. 70. quent discussion ; this failing, ablation of the affected part is to be had recourse to, for even this simple structure has been known to degenerate. Extirpation of the Lower Jaw. Amputation of tlie whole bone has been practised, on account of tumour ; but with such a result as scarcely to warrant repetition of the operation. The dangers to life are many and almost insuperable. Besides those by loss of blood, and constitutional shock, there is an im- mediate risk of suffocation by the uncontrolled condition of the tongue and fauces. Inflammatory action, causing oedema, is, at a more ad- vanced period, certain to cause laryn- geal obstruction, threatening asphyxia. And, supposing these dangers past, another remains, by bronchitic or pneumonic seizure, cold air being at once and constantly admitted to the lai-ynx ; whereas, for a long Fig. 69. Osteosarcoma of lower jaw. Hard, smooth, noir-ulcerating. Slow in growth. Fig. 70. Osteocephaloma ; contrasted with the preceding. Soft, fungous, ulcerous, rapidlj' enlarging, and involving all textures. Fig. 71. Osteosarcoma of the lower jaw, supervening on osteocystoma. — Liston. Vide Elements, p. 420. EXTIEPATION OF THE LOWER JAW. 181 time previously, atmospheric access had been by a most circuitous and gradual route, in consequence of the presence of the large obstructing tumour. Partial removal of the lower javp is a very feasible operation ; and, as formerly stated, vv^hen undertaken on account of genuine osteosar- coma is seldom followed but by a fortunate issue. Not unfrequently the jaw is so occupied by tumour, as to render removal of the entire half necessary ; by disarticulation, and division at or near the symphysis. An incision is begun opposite the articu- lation, and continued downwards and forwards, along the posterior and inferior borders of the bone, first on its ramus and then on the body. Opposite to where it is intended to saw the bone in front, the forward course of the knife is arrested, and the instrument is directed upwards to divide the lip — leaving, however, the prolabial portion entire. The flap, thus indicated, is dissected upwards ; including all the soft parts, and fully exposing the tumour. Then the anterior portion of the bone, where section is to be made — wide of the tumour — is fully cleared of soft parts, on every aspect ; a tooth, if necessary, is extracted ; the external surface is notched by Hey's saw, and section is comjDleted by stout cutting pliers. Now the internal attachments of the tumour and implicated bone are divided by the bistoury. And as the articulation is approached, the anterior portion of the bone is depressed by the operator's left hand, so as to facilitate disarticulation ; yet avoiding such an amount of pressure as may occasion fracture of the altered structure. Depression being made by the surgeon, and an assistant now compressing the common carotid, the muscular attachments to the coronoid process are cut across, and afterwards disarticulation is effected ; this part of the operation being completed as rapidly as possible, from before backwards, opening the joint in front, and with the knife's point moving closely to the bone, so as to avoid an unnecessary loss of blood. The bleeding vessels are then tied at the upper angle of the wound, either singly, or by deli- gation of the common trunk of the temporal and internal maxillary arteries — which may happen to be exposed — by means of an aneurisn. needle. The facial, temporarily commanded by the fingers of an assistant, is last secured. And then the flap is replaced, and retained by suture ; the entireness of the prolabium in front obviously contri- buting much to the facility of accurate adjustment. The wound, in its major part, is likely to heal by adhesion ; a portion suppurates and gapes, not inopportunely, to permit suitable discharge of the purulent secretion from within. Dressing of the interior is conducted as in the case of the upper jaw ; and consolidation, with reparation, in like manner results. During the process of cure, material benefit will sometimes accrue from the use of a mechanical contrivance, adapted 182 EXTIEPATION OF THE LOWEE JA^Y. to the teetli, whereby ovei'lapping and displacement of the mutilated part is prevented. " Metallic caps are fitted to the teeth of the upper and lower jaws of the sound side, and are riveted and soldered together at their bases, so that, when applied, they shall have the effect of preventing the dragging of the remaining portion of the bone and chin to the opposite side by the external pterygoid, mylohyoid, and digastric muscles, and by the elasticity of the soft parts. This appa- ratus should be worn for many weeks after the operation."* Contri- vances may also be temporarily worn, on the injured side, to prevent undue shrinking of the cheek, during granulation. A tumour implicating the body of the bone only, on one side, may be removed by a similar but less extensive incision ; section of the bone being made at the angle and symphysis. But the propriety of such a proceeding is very questionable. Experience has shewn that, in such cases, return of the disease is very apt to take place in the truncated ramus ; and when this happens, difficulty of disarticulation is found to be gi'eat, from want of power in depressing the coronoid process, and consequently in dividing the insertion of the temporal muscle. It is expedient, therefore, in all such cases, to anticipate retui-n of the tumour, and the difficulties of a second operation, by at once performing disarticulation. Besides, this is a principle of ope- ration quite analogous to what determines excision of a long bone, affected by tumour, rather than its partial removal ; preferring, for example, amputation at the shoulder joint to an operation with section of the bone, on account of tumour of the humerus (Principles, p. 484). Sometimes, though rarely, osteosarcoma originates in the ramus. Then it is necessary to effect disarticulation, after performing section at or near the angle of the bone. In such a case, it is expedient to grasp the ramus, after section, by means of fii'm and sharp-pointed forceps, so that the requisite lever-power may be obtained for depression. Also, it may be possible to effect this operation, without opening the cavity of the mouth. •{• The symphysis may be removed on account of tumour ; a hori- zontal wound being made along the lower border of the bone, with a perpendicular incision at each extremity, leaving the prolabial surface entire. Section of the bone is made partly by the saw, partly by cutting pliers ; the requisite teeth having been previously extracted. After excision has been effected, some care of the tongue is necessary; lest after division of its anterior attachments it should be unduly retracted, and threaten asphyxia. To obviate this, the organ may be temporarily restrained either by ligature, or by forceps. * Liston's Practical Surgery, p. 318. t Syme, London and Edinburgh Medical Journal, 184.3, p. 964. FRACTURE OF THE LOWER JA^Y. 183 Sometimes it is necessary to remove the symphysis along with one half of the jaw ; the tumour being so extensii-e. This is effected by such a form of incision as recommended for disarticulation with section at the symphysis. Sometimes it is expedient to remove a portion of the jaw, on account of ulcer or tumour of the soft parts which has implicated the osseous tissue secondarily. One paramount indication must in all cases be fulfilled : to remove the whole of the morbid structure, and to cut wide of the disease. During these operations on the mouth, it is plain, for reasons formerly assigned, that chloroform, if employed at all, must be used warily (p. 155). Cai'ies and Necrosis of the Loicer Jaw. The lower jaw is liable, like other bones, to these common affec- tions. But, in the present day, it suffers much less frequently and extensively in this way, than it did when mercurialization was more in vogue for venereal affections — real and suspected. Many teeth, large portions of the jaw, and even the greater part of the entire bone, not unfrequently were tediously and painfully discharged, as worm- Fig- "2- "^ eaten sequestra; causing much dis- turbance, both local and general, at the time, and great subsequent deformity. AVhen either of these affections do occur, the general principles of surgery ai-e brought to bear on them ; by treatment partly local, partly directed to the system. Necrosis of the jaws, from the agency of phosphorous acid, generated in the manufacture of lucifer matches, has been already alluded to (Principles, p. 444).* Fracture of the Loicer Jaiv. The lower jaw may be broken by violence applied either directly or indirectly. Fracture near the middle of the body of the bone may be the result either of a blow delivered on the symphysis, or of injury directly sustained by the part fractured. The body of the bone is most fi'equently injured, but all parts are liable. The ramus has been * Vide also Laa-cet, No. 1367, p. 498. Fig. 72. Ulcerative destruction of the coronoid process of the lower jaw, caused by " the awkward position of the wisdom tooth." The patient " perislied in consequence of the extensive abscesses of the mouth and neck."' — Listox. 184 DISLOCATION OF THE LOWEE JAW. fissured, the condyle has been broken off, the coronoid process has been snapt through, and the symphysis itself has given way. The fracture may be either simple or compound. Almost always, there is laceration of the mucous membrane, with consequent hemorrhage into the mouth, and exposure of the fractured ends in that direction. The signs of the occurrence are sufficiently plain ; by deformity, ci-epitus, loss of power, and evident displacement. The mental portion is usually displaced downwards, by muscular action. Reduction is easily effected ; and, usually, retention is not difficult. Supposing the fracture to be at its ordinary site, near the middle of the body of the bone, the fragments are carefully adjusted, with the teeth in a line ; and two wedges of cork, sloping gently backwards, with their upper and under surfaces grooved for the recep- tion of the upper and lower teeth, are inserted on each side of the mouth ; the jaws having been firmly closed on them, a pasteboard splint is adapted to the exterior surface ; and the whole is retained by suitable bandaging. The object of the wedges is twofold, and obviously bene- ficial ; namely, to secure accurate apposi- tion of the fragments, and to leave a Kg. 73. vacant space in front, suitable for the passage of fluid nourishment without movement of the parts. The objection to their use is, that, as foreign bodies, they may cause sali- vation or other inconvenience ; if this should happen, they can readily be removed ; and meanwhile, by their temporary presence, considerable benefit may have been obtained. Sometimes, if firm teeth occupy the verge of each fractured portion, it may be well to secure these in apposition by silk ligature. Teeth quite detached should be removed at once ; and so ought fragments of bone, similarly circumstanced — in cases of comminution. For some time, the patient must be content with such articles of food as require no mastication ; and all move- ment of the fractured part must be avoided. Dislocation of the Lower Jaw. Dislocation of the jaw is forwards; the condyles in front of the base of the zygomatic process, and the coronoid processes resting on the edge of the malar bone.* The accident may be complete or partial ; * Nelaton, Memoires de la Societe de Chirurgie de Paris, 1849. Fig. 73. Four-tailed bandage, applied to secure the lower jaw. ANCHYLOSIS OF THE JAW. 185 according as one or both condyles are displaced. And it may be the result of mere muscular action, as in yawning ; or of force applied to the symphysis, with the mouth more or less open. The mouth gapes, and cannot be shut ; the chin is depressed, and saliva trickles over it ; the condyloid space is vacant, and prominence is felt beneath the zygo- matic process ; considerable pain is experienced, and articulation is very indistinct — perhaps altogether obstructed. Reduction is effected by a combined movement ; depression of the angle, elevation of the symphysis, backward pressure on the coronoid processes, and traction forwards of the whole bone. Thus the bone is extricated from its entanglement ; and, brought within the uncontrolled play of the muscles, is by them pulled back into its normal position. The thumbs, placed over the last grinders, within the mouth, effect the first movement ; the rest of the hand makes the extension, with elevation of the symphysis ; and an assistant presses back the coronoid processes from their rest on the cheek bone. It is not necessary to protect the thumbs, by a towel or otherwise. As the jaw is felt to yield, they are made to slide on to the alveoli on the outer side ; and the snap, which accompanies and denotes replacement, finds nothing interposed between the teeth. For some days afterwards, the motions of the jaw should be very limited ; and in most cases it is well to restrain them by a bandage. Anchylosis of the Jaw. This maybe spurious or real (Principles, p. 537); the result of change in the soft parts or in the hard. Mastication, deglutition, and speech, are seriously interfered with ; and the patient anxiously seeks relief. This may be afforded by the knife alone, when cicatrices are in fault ; dividing adhesions, and preventing reunion by careful dress- ing subsequently. Sometimes, in addition, subcutaneous section of the masseter is advisable.* When rigidity is extreme, and depends on true anchylosis, it may be necessary to operate on the jaw itself, in order to prevent death from inanition ; sawing the bone through, so as to make a false joint ; or removing a central portion entirely, for the admission of food. On removal of the jaw, see Koecker on Diseases of the Jaws, &c. London, 1828. Boyer, Memoire sur 1' Amputation cle I'os maxillaire inferieiir, in Journal Complem. du Diet, des Sciences Medicales. Dupuytren, Lecons Orales. Mott, American Medical Recorder, vol. i. Cusack, Dublin Hospital Reports, vol. iv. * Fergusson, Practical Surgery, p. 534. 186 CHAPTER XIII. AFFECTIONS OF THE TONGUE. Glossitis. The inflammatory process in the tongue may be variously ijaduced ; by wounds, stings, or other injuries ; by ptyalism ; by acrid applica- tions. Or it may occur spontaneously. The symptoms are — pain, swelling, salivation, intense thirst, impairment of the ordinary func- tions of the organ. In extreme cases, the swelling may occlude the fauces, and threaten asphyxia. The treatment is by abstraction or counteraction of the cause ; leeches to the part, or the opening of a ranine vein ; and the ordinary antiphlogistics internally. In cases of urgency, we need not hesitate to make longitudinal incisions, freely, as if for phlegmonous ery- sipelas; the escape of blood is copious, the exuded fluids also find a ready exit, usually the swelling rapidly abates, and the wounds, which at first were gaping and deep, dwindle down to mere scarifications. The antiphlo- gistic result is satisfactory, and no impor- ^' ' tant lesion of structure is inflicted on the part. Should a case present itself too advanced to admit of waiting for the effects of incision, life must be saved at all hazards — by bronchotomy. Wounds of the Tongue. Wounds of the tongue bleed copiously. Hemorrhage is to be commanded by ligature and styptics ; if need be, the cautery may be applied. In uniting the wound, after bleeding has ceased, it is plain that we can avail ourselves only of the common interrupted suture — other retentive means being inapplicable to the part. In the slighter cases the use of sutures may effect not only approximation but also a hemostatic result. Fig. 74. Tongue swoln, by glossitis. HYPERTROPHY OF THE TONGUE. 187 Ulcers of the Tongue. Ulcers of the tongue, like those of the lips, may be either simple or malignant. The former may depend on local irritation, as from tartar or decayed teeth ; or on gastric irritation ; or on a general febrile con- dition ; or on a mercurio-syphilitic state of system. And the treatment, it is obvious, will vary accordingly. The preferable local applications are — nitrate of silver, either in substance or in solution ; and, in obstinate cases, the fluid pernitrate of mercury ; the former applied frequently, the latter at long intervals. The malignant ulcers are to be got rid of, by knife, ligature, or cautery. The two first methods are usually to be preferred ; and due care must ever be taken, that the whole of the apparently diseased part, with a border of apparently sound texture, is re- moved (Principles, p. 325). Persons of advanced years should be very careful to avoid all continued irritation of the tongue, as by tartar, false teeth, &c., lest troublesome and ultimately malignant ulceration be induced. Hypertrophy of the Tongue. The tongue is occasionally the seat of simple enlargement — con- genital, or acquired. The normal texture is gradually expanded ; and the papillos become greatly enlarged. Much inconvenience necessarily I'esults ; even though, as usually happens, the jaw in some proportion accommodates itself to the altered interior. Ultimately the tongue pro- trudes ; and a wasting discharge of saliva necessarily results. Degluti- tion, articulation, and even breathing, are more or less interfered with. The treatment is by rectification of the primse vi^ — usually very prominently disordered ; by repeated leeching of the part ; and by internal administration of the iodide of potassium. Should such means fail, it may be expedient to remove a portion at the apex, of a wedge shape, and of such a size as to restore the organ to something like its normal bulk, on approximation of the wound's edges ; at least render- ing the organ capable of residence within the mouth, so removing the principal deformity and inconvenience — protrusion — and reducing the risk of excessive inflammation in the wound. Fig. 76. Excavated malignant ulcer of the root of the tongue, supervened secondarily'. OEdema glottidis has 188 TUMOUES OF THE TONGUE. Induration of the Tongue. The tongue, instead of undergoing a general hypertrophy, may be aflPected by partial enlargement; certain portions becoming elevated, hard, and painful — being the seat of a chronic inflammatory process of low grade. The swellings may remain of an indolent nature, slowly enlarging, or altogether stationary. Or they may slowly suppurate ; the matter imperfectly discharging itself by a ragged and somewhat sinuous aperture ; the general appearance of the part closely simulat- ing malignant disease. The treatment is as for hypertrophy, by leeching, alteratives, and attention to the primte vise. In many cases, the internal use of arsenic has been found of signal benefit. And, when sarsaparilla, iodide of potassium, arsenic, fail, a cautious course of mercury may be admi- nistered. The combination in Donovan's liquor often proves useful. The unhealthy cavities made by suppuration are to be exposed by potass, freely applied ; and then sound cicatrization may be expected. Erectile Tumour of the Tongue. The erectile tumour may form in this organ. A few examples are on record. If the diseased structure be limited and accessible, it is to be removed by inclusion in ligature. If it involve the whole organ, or be otherwise not amenable to deli- gation, attempts may be made to induce a remedial change of struc- ture, either by ulceration or by plastic exudation (Principles, p. 601). Failing this, the disease must be I'egarded as beyond the reach of our art. Deligation of both lingual arteries has been prac- tised ; but Avith a result which does not invite repetition ; fatal slough- ing of the organ ensued.* Removal of Portions of the Tongue. On account of malignant disease, occult or open, as well as on account of erectile tumour, it may be necessary to remove a part of the tongue. Malignant disease involving the whole organ may be regai'ded as irremediable. » Liston's Elements of Surgeiy, p. 409. Fig. 76. Expansion of the lower jaw; the result of pressure by the tongue, enlarged by erectile tissue. — Liston. Vide his Elements of Surgery, p. 410. DIVISION OF THE FRiENUM. 189 Carcinoma and Cancer shew their ordinary characteristics here, and follow their usual course, A detailed statement of the symptoms and progress of such affections is therefore unnecessary (Principles, pp. 318, 321). Removal may be effected either by knife or by ligature. The former is employed when the doomed part is situate anteriorly, and not extensive ; hemorrhage, under such circumstances, being readily under control. By a volsella the part is seized, stretched, and made to project outwardly ; and by a bistoury satisfactory ablation is leisurely and carefully effected. Hemorrhage having been arrested, the wound is approximated by suture, if its size and form permit. In other cases, the ligature is preferred. A stout cord is passed on the proximal aspect of the diseased part, in sound texture, by means of a large needle in a fixed handle, as recommended for erectile tumours (Principles, p. 600) ; the noose of the ligature having been divided, each half is drawn tight separately, so as completely to isolate and strangulate the diseased portion ; and it is well to notch with a knife the line of constriction, previously, so that strangulation may be at once complete. By whatever mode removal is effected, the prognosis must be but gloomy ; for it can be readily understood, that return of malignant disease is but too probable, in an organ which has been only in part taken away. Sometimes it may be warrantable, even in avowedly hopeless cir- cumstances, to remove a malignant ulcer of the tongue by operation, solely with the view of palliation (Principles, p. 328).* Division of the Frceimm. In the child, the frgenum lingufe may be so short as greatly to incommode the organ ; at first impeding suction, afterwards embar- rassing articulation. Or the defect may be more accurately expressed, perhaps, as an abnormal prolongation forwards of the frfenum, tying down the apex of the tongue. The faulty texture is readily divided, by means of probe-pointed scissors — the point of the tongue being elevated, so as to stretch the part, by the finger, or by means of a split card ; and, cutting rather on the jaw than on the tongue, troublesome bleeding by wound of the ranine vessels is avoided. During healing the tongue should be exercised so as to prevent recon traction. In the adult, a somewhat similar condition may supervene, in consequence of troublesome suppuration beneath the tongue. During cicatrization, the apex of the organ is drawn down, and becomes confined by a dense band of adventitious formation. This spurious fraenum may be dissected through ; and, by dint of careful dressing, a more favourable cicatrix may be obtained. * See also Bennett on Cancerous and Cancroid Growths, p. 129. 190 TUMOUES BENEATH THE TONGUE, Ranula, Ranula denotes a tumour, foi'med beneath the tongue, in conse- quence of obstruction in one or both of the salivary ducts. It consists of a cyst, produced by expansion of the duct, and condensation of the surrounding parts ; and of clear contents — perverted secretion of the cyst, and of the corresponding salivary gland. Inconvenience is felt in mastication, deglutition, and articulation ; indeed, the term Ranula has been applied on account of the croaking change of voice. The tumour is distinctly seen on elevating the apex of the tongue ; and but slight manipulation is necessary to ascertain its cystic and salivary nature. Two modes of treatment are applicable ; restoration of the normal opening, or the making of an artificial substitute. In recent cases, the former method may succeed. The occluded original orifice is dilated, by probes of suitable dimensions ; and the due degree of patency and calibre is subsequently maintained, by the occasional passage of a bougie or probe for some time afterwards. In most cases, however — as in the somewhat analogous circumstances of subcutaneous encysted tumour (Principles, p. 343) — the normal orifice cannot be detected and restored. An artificial opening is made, at an anterior and dependent part. The contents readily escape ; but they soon re- accumulate ; and the difficulty in the case consists in keeping this artificial opening so patent as to allow of constant discharge, and consequent contraction of the secreting cyst to the capacity and cha- racter of the original duct. To effect our object, it is well to touch the aperture occasionally with the potassa fusa, as if to compel cica- trization of the margins A^athout closure. And this object may be further facilitated, by the occasional use of a large probe or bougie, after the caustic has been disused. Failing in our attempts thus, a seton is passed through the cyst, and retained until the requisite con- traction is obtained. A piece of silver wire — retained by twisting the ends — may sometimes be found more suitable than the caoutchouc tape, or skein of silk or cotton. Tumours beneath the Tongue. Encysted tumours are not unfrequently found in this situation ; simulating the condition of ranula very closely. The cyst is thin ; the contents are clear and glairy ; the size may be considerable. The remedy is by incision and cauterization. The cyst is opened anteriorly by a free puncture ; the contents are allowed wholly to escape ; and then to the lining membrane is applied either the nitrate of silver firmly, or the potassa fusa lightly ; care being taken to confine escha- SALIVAEY CONCRETIONS. 191 rotic action to the part intended. After the use of potass, rinsing of the mouth repeatedly with vinegar and water is a safe and prudent precaution. Fatty tumours beneath the tongue have also simulated ranula (Principles, p. 310, Fig. 60). The attachments are delicate and loose ; and, for extirpation, little more than mere incision of the investing membrane is sufficient. For obvious reasons, removal by the knife cannot be practised too early. In the after treatment of suppurating wounds in this locality, it has already been stated that care must be taken lest, by cicatrization, the condition of tongue-tie become established. Salivary Concretions. Concretions form in the extremities of the Whartonian ducts, more frequently than in coiniection with the parotid gland ; with or without obstruction of the saliva's course. Inconvenience is considerable, by the bulk and irritation of the foreign substance. By manipulation and use of the probe, the presence of the concretions can, in most cases, be very readily detected. When of large size, they become fully exposed in the progress of ,^~~':z7y ^ ^.^^'^''^h. working their own way out by ulceration, after the manner of a sequestrum, or any other fox'eign substance. The operation for removal '^ is then simple ; after suitable incision, the calculus is laid hold of by forceps and extracted. But when the foreign body is small in a large containing cavity, it may retreat, and elude the attempts at seizure. In such a case, let the patient masticate any agreeable article of food ; and by the outward current of saliva the concretion will be either washed away, or at least made prominent and superficial. On enlargement of the tongue, see Percy, article Langue in Diet, des Sciences Medi- cales, vol. x^^i. Van Doeveren, Dissert, de Macroglossa, Lugd. Batav. 1824. Clanny, Edin. Med. and Surg. Journ. vol. i. p. 317. On affections of the tongue in general, see Brodie, Lancet, No. 1059, p. 346. Fig. 77. Salivary calculus, of considerable size ; removed by operation. 192 CHAPTER XIV. AFFECTIONS OF THE UVULA AND TONSILS. CEdema of the Uvula. (Edema of the Uvula, with a relaxed state of the neighbouring soft palate, may occur singly ; but more frequently it is the result of an imperfectly resolved inflammatory affection of the whole fauces. There is a feeling of very considerable discomfort in the part ; the quality of the voice is altered ; articulation is impeded ; and not un- frequently a tickling and annoying cough exists. The various astrin- gent gargles are of service ; with attention to the general system. Failing these, stimulants and astringents may be applied directly to the part, in solution or in powder ; as alum, capsicum, tannin, &c. Or the part may be touched occasionally with the nitrate of silver, or sulphate of copper, in substance or solution. In obstinate cases, it is well that scarification precede the last-named remedies. Elongation of the Uvula. Relaxation of the uvula, with elongation, is of no unfrequent occurrence ; the extremity of the organ passing downwards, and by titillation of the glottis causing a very unpleasant and sometimes distressing cough. Sometimes the extremity is cedematous and bul- bous ; sometimes it is thin and fimbriated. In the slighter cases, ordinary astringents and stimulants may be tried. But when elon- gation is considerable, as regards both extent and duration, there is no suitable remedy but by cutting off" the redundant part ; an operation which has never yet been followed by any untoward consequences. The patient, seated before a good light, is directed to cough, so as to bring the pendulous uvula on the dorsum of the tongue. Then a suitable portion may be at once cut off" by the stroke of sharp cutting scissors — probe-pointed, lest the patient should prove unsteady. Or — better — by a volsella the apex is laid hold of ; and then, by stretching the part, section will be facilitated as well as rendered more accurate ; care being taken not to stretch until at the instant of cutting, otherwise troublesome retching is apt to ensue. Complete extirpation of the uvula ABSCESS OP THE TONSIL. 193 has been recommended in such cases, on the plea that relapse is other- wise probable. But, even supposing the fear to be justly founded, such a ruthless proceeding is scarcely warrantable ; the organ being doubtless endowed with some useful function in the general economy. Tonsillitis, or Cynanche Tonsillaris, This term denotes an inflammatory affection of the fauces, chiefly resident in and around the tonsils ; ordinarily the result of atmospheric exposure ; and characterized by swelling, redness, heat, and pain of the part, impeded and painful deglutition, inability to separate the jaws, difiicult articulation, marked alteration of the voice, and the ordinary constitutional accompaniments according to the intensity and advancement of the action. Treatment is by ordinary antiphlogistics, local and general. Scarification of the part is sometimes advisable, with the view of abstracting blood, controlling swelling, and rendering suppuration less likely to supervene. Sometimes large doses of Guaiac — half a drachm of the powder, thrice daily — ^have a resolutory and almost specific influence ; Dover's powder, too, is often useful in a similar way. The affection may prove formidable by assuming the erysipelatous type, and spreading downwards into the air passages. Abscess of the Tonsil. An acute abscess, of some size, in the tonsil, requires active surgical interference. If allowed to follow its own course, much distress is likely to be occasioned by pain and swelling, ere evacuation and subsidence take place ; indeed, the swelling may be such as not only to prevent deglutition wholly, but also to impede respiration and threaten asphyxia. Besides, spontaneous bursting of the abscess may take place during sleep ; and a considerable quantity of pus and blood passing suddenly into the glottis, unexpectedly, may induce spasmodic dyspnoea of the most formidable character, not improbably suffocating the patient. To avert such pains and perils, the general principles of surgery should be fuUy carried out ; by artificially evacuating the pus, so soon as it has been formed. This may be readily and safely effected thus : The patient, placed before a strong light, is exhorted to gi-eat steadiness. With the fore-finger of the left hand the tongue is de- pressed, and the mouth opened, so as to expose the red and prominent tonsU — perhaps already occupying the middle of the fauces, and dis- placing the uvula, the ordinary occupant of that space. A straight sharp-pointed bistoury, with its back resting on the tongue, is passed into the mouth and entered into the centre of the swelling, with the point directed straight backwards, as if with the intention of impinging o 194 ULCERS OP THE TONSILS. upon the anterior surface of the cervical vertebrse ; and a puncture having thus been made, a sufficient aperture is then established by- moving the instrument with a slight savfing motion. The pus escapes upon the tongue, and is discharged externally. Lateral movement of the knife, outwards and backwards, is especially to be avoided ; other- wise important blood-vessels are in danger — the internal cai'otid artery and the internal jugular vein posteriorly, and the common trunk of the temporal and internal maxillary arteries on the external aspect. A chronic stage is not unfi-equent, in which the tonsil remains swollen, painful, and stationary ; affording no sign either of recession, by resolution, or of advancement by suppuration. Such uncertainty is best dispelled — and usually at once — by the application of a blister over the part, beneath the angle of the jaw. It is of use to remember, that a patient once affected by tonsillary abscess is extremely liable to return of the affection, on the applica- tion of comparatively slight causes, until the first period of adult age has passed ; and then the attacks become less frequent and severe, at length altogether disappearing. Ulcers of the Tonsils. The tonsils are liable to ulceration from ordinary causes ; from ex- posure to cold or wet, from the irritation of decayed teeth, or from the " cutting " of the last grinders. Treatment is by touching the part occasionally with nitrate of silver, after removal or mitigation of the cause — extraction of the decayed teeth, or scarification of the tense gum. Other ulcers of the tonsils are of constitutional origin ; connected with taint of system, venereal, mercurial, or both ; sometimes of secondary, sometimes of tertiary accession ; the local characters of the sore varying accoi'ding to circumstances — simple, weak, indolent, irritable, inflamed, sloughing, or phagedgenic. Treatment, in such cases, is mainly constitutional. Hypertrophy of the Tonsils. In adolescents of weak habit, chronic enlargement of the tonsils is very apt to occur, connected with a minor inflammatory affection of the fauces ; the swollen part partially and slowly subsiding between the inflammatory attacks, which are of frequent occurrence and in- duced by slight causes. In such cases, it is not uncommon for the tonsils to become permanently enlarged, by simple hypertrophy. Both are, in general, affected ; projecting, as fleshy eminences, into the HYPEETEOPHY OF THE TONSILS. 195 fauces ; interfering considerably with deglutition, somewhat with respiration, and greatly with articulation ; often causing deafness, by pressure on the Eustachian tubes ; and rendering the patient -very liable to acute inflammatory affections of the fauces, on the slightest exposure to atmospheric inclemency or vicissitude. In the state of excitement, mild antiphlogistics are necessary for a few days ; low diet, aperients, gentle diaphoretics, sinapisms or other light counter-irritation. In the indolent state, it is our object to amend the general health by a tonic system of general treatment ; to obtain gradual subsidence of the swellings by discussion ; oi', this failing, to remove the redundant texture. As discutients, nitrate of silver, alum, and iodide of zinc, ai"e most in use ; the two first rubbed on the parts in substance ; the last applied in strong solution, by means of a hair pencil or a piece of sponge. The constitutional treatment is as for the strumous cachexy — a condition very similar to, if not identical with the state of system found to prevail in such patients (Principles, p. 58). When discussion fails, the knife's Fig. 78. use is expedient ; not to extirpate the glands, but merely to take away the redundant and projecting parts. The mouth being opened before a strong light, the prominence of the swelling is seized firmly by a volsella ; and by means of this instrument the part is made tense and steady, and brought more into the central space. A probe-pointed bistoury is passed into the mouth, with its back resting on the tongue ; and its edge having been brought in contact with the lower part of the base of the swelling, section upwards is effected by a slight sawing motion. A similar procedure is repeated on the opposite side. Bleeding and pain are generally inconsiderable. The raw surfaces granulate and heal ; occasional application of the nitrate of silver being made lightly, if need be. It is seldom that reproduction is even threatened. Objections have been taken to such operations, on the ground that dryness of the fauces is apt to follow, with imperfect articulation ; and that sometimes also there has seemed to be a certain amount of sexual impotence induced. The experience of most surgeons does not tend to Fig. 78. Excision of the tonsils ; the knife turned the wrong way. o2 196 MALIGNANT DISEASE OF THE TONSILS. sustain such objections ; at the same time there is no doubt that most cases of chronic enlargement of the tonsil, in adolescents, can be got rid of by local discutients and constitutional alteratives, and that there- fore operative interference should be reserved wholly for those cases v/hich have been found to resist milder means. Extirpation of the entire tonsil, by ligature, or by knife — the one operation very hazardous, the other accomplished with great difficulty — is in the present day never contemplated ; being well superseded by the partial removal just described. Malignant Disease of the Tonsils, Cancerous ulceration may extend to the tonsil from the tongue ; or may originate in the gland itself. The latter event is rare. Carcinomatous or medullary tumour may occupy the tonsil, as a primary disease ; but more frequently such enlargement of this part is but an extension of malignant disease from the lip or lymphatic glands. All such affections are incurable ; and operative interference is out of the question — unless, indeed, at an advanced period of the case temporary relief by bronchotomy be deemed advisable, on account of impending asphyxia. Le Cat, Memoire sui- rextirpation des amj^gdales squirrheuses, Journal de Mede- cine, vol. ii. 1765. Louis, sur la resection des amygdales, Mem. de I'Academie de Chir., vol. V. p. 423. Lisfranc, Considerations, &c. sur la Luette, Eevue Medicale, July 1823. Watson, Lectures on Practice of Medicine, vol. i. London, 1843 ; Allan Burns, Sui-gical Anatomy of Head and Neck, Edinburgh, 1811 ; Harvey on Excision of the Enlarged Tonsil, London, 1850. 197 CHAPTER XV. AFFECTIONS OF THE PHAKYNX. Pharyngitis. The inflammatory process, affecting the pharynx pre-eminently or solely, is of comparatively rare occurrence. Most frequently it is the result of a direct exciting cause ; as the lodgment of foreign bodies, or the contact of acrid substances. The membrane becomes red and, swollen, at first dry, afterwards affording an increased and perverted secretion ; deglutition is difficult and painful ; pain is felt on pressure from without ; and the ordinary constitutional symptoms attend. The action may simply resolve ; or ulceration may take place in the mem- brane, vdth copious purulent discharge ; or the submucous tissue may become the seat of abscess ; or by submucous deposit of plastic matter, and change of structure in the membrane itself, contraction of the pharyngeal space may result. Pharyngeal Abscess. When matter has formed beneath the mucous membrane, a fluctu- ating yet tense swelling may be perceived ; and deglutition becomes more and more impeded, according to the increase of the tumour. In children the affection is apt to simulate croup,* Treatment is by early and free evacuation. The ordinary site of abscess is on the posterior aspect of the pharynx, in front of the cervical vertebra and their coverings ; and here cutting instruments may be used in all security. If the abscess be large, it is well to use a trocar and canula ; lest the pus, suddenly escaping in quantify, might endanger suffocation by passing into the windpipe. If opening be delayed, not only are risk and inconvenience great by the lai-ge size of the tumour ; there is also the same danger from sudden spontaneous discharge, as in abscess of the tonsil ; besides, the bones may be involved by a burrowing of the matter ; and, in the ultimate cicatrization of a large cavity, contraction and stricture of the pharynx may result, * Vide Monthly Journal of Medical Science, August 1846, p. 146. Ibid, October 1847, p. 220. 198 STRICTURE OF THE PHARYNX. Stricture of the Pharyrix. . Simple strictiu-e may be the result of simple pharyngitis, causing structural change in the mucous membrane, with accumulation of plastic deposit in the submucous tissue ; and on the latter occurrence the con- traction mainly depends. Or it may be the consequence of ulceration of the membrane, with or without suppuration in the parts beneath. The prominent and characteristic symptom is difficulty of swallowing, more especially of solid and imperfectly masticated food. And certainty of the existence of the change is determined by the use of a probang or tube, whose passage downwards is resisted by the contracted part. The ordinary site of contraction is at that part of the cavity which is naturally most naiTow — the lowest. 3Ialignant contraction is produced by carcinomatous formation in the mucous and submucous tissues ; the surface speedily assumes the open condition, and much unhealthy matter is discharged. The symp- toms are, great pain in the aifected part, increased by motion and pressure ; expectoration of foetid, copious, bloody discharge ; great and increasing difficulty in swallowing ; gi-adual wasting of the frame, partly by inanition, partly by progress of the usual malignant cachexy. The simple stricture is treated by dilatation. A probang — a rounded piece of whalebone, Avith a bulbous extremity made of ivory — is passed gently down to the obstruction ; or a gum-elastic bougie may be used for the same purpose. One having been selected of such a size as will pass Avithout the use of force, it is lodged in the con- tracted part, and retained there for some time — according to the sen- sations of the patient. After a day or two, the u-ritation caused by the former instrument having subsided, another, a size lai-ger, is similai'ly employed. And thus, gi'adually, the normal calibre is restored. An instrument of full size should be passed occasionally, however, for some time afterwards, to obviate the tendency to recon- traction which exists in aU mucous canals so affected. The object of the passing of instruments is, not to excite inflammation or ulceration in the contracted part ; for this would plainly tend to ultimate aggravation of the morbid state ; but to excite absorption of the submucous deposit, and a resolutory action, with discharge, in the membrane itself. At the same time, some benefit is also obtained by mechanical dilatation. The malignant stricture admits only of palliation. Great attention is paid to the administration of nutritive ingesta, so as to husband the failing strength ; while pain and discomfort ai'e assuaged by opiates. Direct interference with, the part, by means of bougies, or otherwise, with dilatation in view, cannot but do harm. Often, however, the pain of the ulcerated surface may be relieved, by occasionally touching it with a solution of the nitrate of silver. SACCULATED PHARYNX. 199 Sjjasm of the Pharynx. In patients of nervous temperament, prone to hysteria, Avith stomach and bowels disordered, spasm of the muscles of the pharynx is not an unfrequent occurrence ; causing pain in the part, with an uneasy and apprehensive feeling of tightness, and materially interfering with deglutition. The attacks are only occasional, sudden in accession, and gradual in remission. The treatment is mainly constitutional ; of an alterative, tonic, and antispasmodic character. Locally, external counter-irritation of a slight grade, or opiate friction, or a belladonna plaster over the nape of the neck, may be of service. Sometimes even the passing of the probang will not convince the hysterial patient that the affection is merely nervous, PcDxdysis of the Pharynx. This, occurring in the sequel of any disease, is usually of very unfavourable import; denoting affection of the brain, probably by effusion, which is likely to prove fatal. It may occur singly, how- ever ; as after external injury of the head or neck ; and then the prognosis may be somewhat more hopeful. The prominent symptom is simple dysphagia ; without obstruction to instruments, or any other sign of stricture in the passage. Treatment is to be directed mainly to the head and neck, by counter-iri-itation, and such internal remedies as may seem advisable ; while life is meanwhile sustained by supplying the stomach with nutritive fluids, by means of a tube passed into the oesophagus. Sacculated Pharynx. Sometimes the lower part of the pharynx becomes dilated into a pouch, of greater or less size, situate immediately behind the oesopha- geal orifice. Food lodges there, sometimes for many hours, coming up again in a kind of rumination. Deglutition is difiicult and imper- fect; often accompanied, especially when liquids ai'e taken, with a churning noise. Frequently, too, there is a copious secretion of glairy mucus ; sometimes accumulating spontaneously in the mouth, more commonly brought up by hawking. The affection plainly admits of no direct treatment ; and cai'e must be taken in using the probang — should that be thought necessary for an exact diagnosis — lest it should enter the pouch, and be forcibly impelled thence through the parietes. Tumours of the Pharynx. Tumours occasionally, though rarely, form in the pharynx. They are troublesome by the dysphagia which their bulk necessarily occa- 200 FOREIGN BODIES IN THE PHARYNX. sions, and dangerous by the tendency wlaicli all tumours have to enlargement and degeneration. They may be simple, and of the polypous character ; and these may be detached by ligature, applied to their base by means of a double canula. Or they are medullary ; and then irremediable. Foreign Bodies in the Pharynx. Portions of food, and other articles held in the mouth, not un- frequently become arrested in their passage downwards ; even though no abnormal contraction exist at any part of the canal. Substances of some size and solidity are likely to rest at the narrowest — the lowest — part of the pharynx. Those of a slim and spiculated character, on the contrary — as needles, pins, fish bones, pigeon bones, &c. — are more frequently entangled in the folds of the soft palate. In both situations, the foreign matter is within reach of the finger ; and this is the best instrument by which to ascertain the exact site and nature of the lodgment — as well as the best guide to the forceps in extraction. Even a minute substance entangled in the fauces causes much discom- fort ; and besides, if not i-emoved, will probably induce a certain amount of inflammatory action. But the larger and solid substances, lodged lower down, call more urgently for our aid ; inasmuch as by their bulk and pressure, and by the spasmodic movements which their im- tation induces in the larynx, they threaten suffocation. The patient is seated firmly on a chair ; the fore-finger is thrust determinedly into the fauces ; and its point is moved about in every direction, until either the foreign substance is discovered, or the surgeon is satisfied that there is no foreign body there. Much retching will be occasioned in all probability ; but this must be unheeded by the examiner, and endured by the patient ; perquisition of the soft palate being got over as speedily as possible, the extremities of the nerves concerned in the production of vomiting being chiefly situated there. The presence and site of the foreign body having been ascertained, it is seized by forceps, and gently withdrawn. For pins and small bones in the arches of the velum, the ordinary dressing forceps, or merely the finger-nail, will suffice. For solid matter lodged loAver down, longer forceps, gently curved at the extremity, are more suitable. It is important to remember that very frequently the painful sen- sation of a foreign body lodged in the pharynx remains, after the substance itself has passed down into the stomach. When, therefore, we have made a careful examination of the parts, and satisfied our- selves that no foreign body is there, we treat such abnormal sensation by leeching, followed by counter-irritation, or by anodyne embro- cation. THE PASSING OF INSTRUMENTS BY THE PHARYNX. 102 The passing of Instruments hij the Phai^ynx. The surgeon is not unfrequently called upon to pass instruments into the pharynx and oesophagus ; curved forceps for the extraction of foreign bodies ; probangs and bougies for the pi'opulsion of impacted articles of food, or for the relief of simple organic stricture ; hollow tubes for the conveyance of noui'ishment into the stomach, in cases of wound of the pharynx or oesophagus — as in cut throat ; and the tube of the stomach pump, in cases of poisoning. The points to be attended to are ; — to use all gentleness, so as to avoid lesion of the lining membrane of the canal ; and to take especial care, particularly when it is our object to throw in ingesta, that the tube does not pass into the air passage. If the patient be sensible, he is seated on a chair, with the head thrown much back, so as to bring the upper part of the alimentary canal into as straight a line as possible. The mouth having been opened vsdde, and the tongue depressed with the left fore-finger, the tube is moved rapidly past the soft palate, so as to avoid retching ; and its extremity is then gently propelled, resting on the posterior part of the pharynx and made to glide, as it were, on the anterior surfaces of the vertebrae in its passage downwards. When the instrument's point is opposite the rima glottidis, the patient is directed to make an effort to swallow his saliva ; or, with the left hand, the surgeon raises the box of the larynx, and at the same time puUs it gently forwards from the oesophagus ; such movement being plainly conducive to the fi'ee passage of the iustrument into the latter canal. When insensibility exists, the operation is in one way facilitated ; inasmuch as there is no resistance on the part of the patient. But, in such cases, it is plain that our care to insure a right passage for the instrument must be doubly exerted ; the patient having no power to warn us of a threatened deviation from the proper ti'ack. In most cases, it is well to assure ourselves fully that the tube is in the oesophagus, and not in the larynx, before fluids are passed downwards to the stomach. For this purpose, a sheet of paper may be placed over the face, with the extremity of the tube projecting through it; while in front of the tube a lighted taper is put, Avhich by the paper is effectually screened from the flatus of the nostrils in expiration. If, on expiration, the flame remain steady, no air impinging on it, we may proceed with injection ; the tube is certainly in its right place. If the flame be extinguished, or even made to bend considerably, it is equally plain that an error has been made ; and that injection would almost cer- tainly occasion fatal asphyxia. It is possible, however, that the flame may be affected a little in expiration, although the tube be quite in its right track. For, it is probable that in inspiration a certain amount 202 USE OF THE STOMACH PUMP. of air may pass downwards by the tube, which during exj)iration may be again extruded. It is well to remember how a large instrument is preferable, in such cases, to one of small size ; being much less likely to enter the windpipe. And it is also worthy of note, how, in emergencies, a syringe is not essential to effect clearance of the stomach ; a tube having been passed, the fluid contents of the stomach may be made to flow out by it, on merely bending the body, and bringing the mouth to a lower level than that of the epigastrium. When a syringe is employed, it should always be with caution ; otherwise, ecchymosis and laceration of the gastric mucous membrane are not improbable. Also, unless previously aware that the stomach contains much fluid, it is prudent to begin the operation by injecting tepid water, which is afterwards pumped out along with the previous contents ; and this injecting and ejecting may be repeated as often as may seem necessary, with the double view of washing out the viscus thoroughly, and at the sametime avoiding injury to the lining membrane. Watson, Clinical Lectiu-e, Med. Gazette, vol. xvii. Kunze, Commentatio Patholo- gica de Dysphagia, Lips. 1820. Monro, on the Morbid Anatomy of the Gullet, Edin. 1830. C. Bell, Institutes of Surgery, vol. i. Appia, de Stricturis (Esophagi, Heidelb. 1842. 203 CHAPTEE XVI. AFFECTIONS OF THE GESOPHAGUS. Stricture of the (Esophagiis. CEsoPHAGiTis, of a most intense character, is occasionally induced by the swallowing of acrid fluids ; as scalding water, the nitric or sulphuric acids, soap lees, caustic alkalies, &c. A more moderate action may be induced by slighter causes, or may occur when no cause can readily be assigned ; and its probable result will be contraction of the canal, partly by change of the mucous membrane, partly and mainly by submucous deposit. But contraction of the oesophagus may be of three kinds, as in the case of the pharynx. It may depend on spasm ; of sudden accession, and only occasional ; removable by general treatment. Or it may be the result of a chronic inflammatory process ; of gradual approach, constant, and curable only by a cautious use of the simple probang or bougie. Or it may be caused by struc- tural change of a malignant kind, followed speedily by ulceration, and capable only of palliation. The simple organic stricture is of most frequent occurrence. Its ordinary site is at the narrowest part of the canal ; oppo- site the cricoid cartilage. When tight, and of considerable duration, the tube is prone to become dilated above the stric- tured part, forming a pouch in which food inconveniently accumulates. The con- strictors of the pharynx are usually hyper- trophied ; and the upper cornua of the thyroid cartilage may become closely approximated.* Above the stricture, too, ulceration is apt to take * Lancet, No. 1209, p. 483. Tig. 79. Fig. 79. Stricture of the gullet, at its most orcliuary site. A bougie shewu introduced by the mouth. 204 FOREIGN BODIES IN THE CESOPHAGUS. place ; which, though not malignant, is nevertheless very intractable, and most inconveniently complicates the case. Besides, in consequence of obstruction to deglutition, the system is apt to suffer more or less by an approach to inanition ; and, therefore, it is obviously our duty to commence the suitable remedial interference at as early a period as possible. In using the bougie, even more gentleness and care, if possible, are expedient, than in the case of strictured pharynx ; force being more likely to produce lesion of the membrane, and even to cause perforation of the tube. It has happened that the head of a probang, supposed to have passed on to the stomach after having overcome the stricture, has been found, after death — at no distant date, and not unconnected with the event — to have lodged in the mediastinum ! Another pre- caution is equally necessary ; namely, to beware that there is no error in our diagnosis ; to be certain that the contraction is really caused by structural change in the oesophagus itself, and not dependent on the pressure of an aneurismal or other tumour. It is easy to understand how the thrust and pressure of a probang or tube, acting on the parietes of an advancing aneurism, may feai'fully accelerate the fatal issue. Foreign Bodies in the (Esophagus. Foreign bodies, whether obtuse and globular, or sharp and angular — portions of meat, or bones, pins, &c. — become arrested usually at the narrowest part of the canal, nearly opposite the cricoid cartilage. Or, lodging there in the first instance, they become displaced either upwards or downwards — usually in the latter direction — by the efforts either of the patient or of those whom he calls to his aid. The result varies, according to circumstances. There may be simply an irritation produced by the presence of a foreign body, with more or less dys- phagia ; or an inflammatory process is kindled, and advances perhaps to suppuration and ulceration ; or by the pressure and irritation of a bulky substance, life may be immediately perilled by impending asphyxia. Or, as very frequently happens, the foreign body slips down into the stomach ; leaving, however, a marked sensation of its presence at the site of its temporary arrest. The presence of foreign matter is ascertained by the bent forceps, or by the probang; passed carefully down, and moved gently. Accord- ing to the nature of the substance, either extraction or propulsion is practised. If the obstructing body be a piece of meat, or other article of food, not likely to injure the canal in a forced passage, and capable of being subsequently digested in the stomach, it is the simpler practice — and perfectly warrantable — to push the foreign substance gently downwards by means of the probang. When, however, the circum- stances are of an opposite character — as usually happens ; Avhen we FOREIGN BODIES IN THE ESOPHAGUS. 205 are satisfied that the oesophagus cannot fail to sustain lesion in attempts at propulsion, and that the stomach will be unable to make any satis- factory impression on the substance, should it be received there, ex- traction is invariably to be preferred. Long, curved forceps are the Kg. 81. most generally available instrument; the surgeon being provided with two pairs, of opposite movements in the blades. The one having missed the foreign substance, when this is narrow, or flat, the other can scarcely fail to seize it. Seizure having been made, dislodgment from the parietes of the canal is to be effected, by a cautious wriggHng move- ment of the hand, before extractive power is applied ; to avoid unne- Fig. 80. Forceps for extracting foreign bodies from the pharynx and oesophagus. Fig. 81. The companion forceps to Fig. 80 ; opening in the opposite du-ection. 206 CESOPHAGOTOMT. cessary injury of the parts. Needles or pins may be entangled in loops of thread attached to the end of a piece of whale-bone ; passed down to the site of lodgment, and moved gently about. Flat sub- stances, such as coins, presenting their edges to the operator, may be brought up by a flat and broad blunt hook. When no instrument is at hand, and the case is urgent, extrusion of the foreign substance may be effected by exciting vomiting ; and this may be done either by administration of the ordinary emetics, if swallowing be at all practi- cable, or by mechanically tickling the fauces. When indigestible substances have passed into the stomach, they usually find their way to the surface, by the natural outlet — per anum ; passing off with the feculent matter — often but little changed — after the lapse of some time. To assist the downward movement, purga- tives are often employed. If the foreign body be solid and obtuse, no harm is done, and extrusion will probably be exjDedited. But if the substance be sharp and sjDiculated. the practice cannot but be mis- chievous ; tending to produce entanglement in the mucous membrane, probably with perforation of the bowel ; and also tending to kindle inflammation in the affected part. In such cases, therefore, it is more prudent to await the working of Nature. Needles and pins usually do perforate the intestinal canal ; but, if left to themselves, the process is gradual, accompanied by protective plastic exudation, and consequently harmless. In due time, the foreign body appears at the surface, as if soliciting extraction — perhaps months after the date of its entrance, and after having traversed a most circuitous route. Fish-bones, and bones of rabbits or other small animals, are not unfrequently arrested by the sphincter of the anus, after having safely made the passage above ; and may require the use of both knife and forceps for their removal. Cheny stones, and such like substances, may lodge in the vermiform process of the caput ctecum, and excite either abscess there or general peritonitis. Occasionally, though rarely, it happens that the foreign body will move neither up nor down in the oesophagus. Extrusion and propul- sion having both failed, excision is the only other resource. The substance is cut down upon from without, and extracted through the wound. G^sophagotorny. The neck is stretched, by elevating and throwing back the head ; and, by the fingers of an assistant, the foreign substance is made to project as much as possible on the left side of the trachea. A free incision is made over the swelling, through the skin and platysma myoides ; and then by a cautious and more limited use of the knife, the oesophagus is exjiosed in its most projecting part. Here it is pene- CESOPHAGOTOMY. 207 trated by the knife ; and tlie opening thus formed is afterwards dilated to a sufficient extent, partly by the finger, partly by slight touches of the knife's edge. The offending matter is laid hold of, by the finger or by forceps, and removed. Hemorrhage having been arrested, the wound is brought accurately into apposition, and treated for adhesion. For some days a tube is worn, passed by the mouth ; and through this the necessary nourishment is conveyed, clear of the wound. • It may be imagined that foreign substances may be safely left to loosen themselves by suppuration, and so to facilitate, if not effect, their own extrusion. But experience declares that it is not so. The obstruction to deglutition, and impediment to breathing, are themselves circumstances sufficiently untoward to demand prompt interference. The inflammatory process, too, which is sure to follow, is fraught with both disadvantage and danger ; it may lay the foundation of a formid- able organic stricture ; it may cause a troublesome abscess, resulting perhaps in a fistulous opening in the canal ; or, in a low site, ulceration may open into the arch of the aorta, and prove speedily fatal. Palsy of the CEsojjJiagits. This, like the corresponding affection of the pharynx, is usually of evil import ; betokening disease of the nervous centre. Inability to swallow may be complete ; but the probaug meets no obstruction. In some cases benefit may be derived from counter-irritation and use of galvanism ; but in most we must be contented with palliation — sustaining life by matters introduced by means of the stomach pump, as well as by nutrient enemata. Kunze, Commentatio Pathologica de Dysphagia, Lips. 1820. Monro, on the Morbid Anatomy of the Gullet, Edin. 1830. C. Bell, Institutes of Surgeiy, vol. i. ; Arnott, on CEsophagotomy, Med. Chir. Trans, vol. xx. Appia, de Strictui-is CEsophagi, Heidelb. 1842. 208 CHAPTEE XVII. AFFECTIONS OF THE EAE. Foreign Bodies. Children are apt to insert foreign matter into the meatus audi- torius, as well as into the nostrils. Dislodgment and extrusion are effected by the same means; by the stream of water injected; or by the use of a flat and bent probe, or curette. Forceps are a still more reprehensible instrument here, than in the case of the nostril ; for im- paction is not only more probable, but likely to be followed by much more serious results. Abortive attempts to dislodge, by forceps, have occasioned deeper enti'ance, disruption of the internal ear, intense otitis, and death.* Larvae have lodged in the ear ; causing severe inflammation there, with much local suffering, and grave constitutional disturbance. White precipitate, suspended in milk, is found successful in killing the animals, when injected ; and they may be subsequently removed by forceps, curette, or a stream of water, "j" Polypus of the Ear. Two forms of Polypi may form on the lining membrane of the meatus externus — usually from that middle part of the meatus which furnishes the cerumen ; one soft and pulpy, analogous to the common mucous polypus of the nose ; the other more firm and fleshy, resem- bling rather the solid polypi of the uterus ; both simple in structure and tendency. Deafness is occasioned, along with uncomfortable sensations in the part ; and more or less discharge escapes, of a puriform and offen- sive character. Treatment is by evulsion ; slim forceps being employed for this purpose, as in the case of nasal polypus. By the use of the ear-speculum, cautiously introduced — an instrument similar to the nasal speculum, only of a more tubular extremity, suited to the cavity which it is intended to explore — the site of growth is ascertained; there the seizure by forceps is made ; and, by slight torsion combined * Lancet, No. 1062, p. 458. f l^i'^^ ^o- 134*' P- 588. OTITIS. 209 with evidsion, extirpation is effected. Or the attachment may be divi- ded by means of bkxnt-pointed scissors. TThen the growth springs from near the membrana tympani, however, evulsion is not safe ; and it is better to destroy it by caiistic — such as the potassa cum calce.* When bleeding has ceased and pain subsided — after the use of forceps or scissors — it is well to touch the part with nitrate of silver, so as to diminish the chance of reproduction. And if the morbid structure should not have been entirely removed, such cauterization may require repetition from time to time. During the healing process, relaxation of the membrane, with copious discharge, is apt to prove troublesome; demanding the daily and repeated use of gently stimulating and astrin- gent injections. Fungoid granulations, of a polypous character, not unfrequently spring from the membrane of the meatus, in cases of long-continued otorrhoea. They grow from the loAver part of the tube, or from the membrana tympani itself; and when of large size may simulate polypus. They are got rid of by nitrate of silver, used escharotically, and by the subsequent employment of astringent injections. Otitis. The inflammatory process may attack the mucous membrane of the ear, and textures connected therewith, either on the exterior or on the internal aspect of the membrana tympani. In the one case the affec- tion is said to be external ; in the other, internal. External Otitis. — This most frequently occurs in the young ; the result of exposure to cold, with or without irritation caused by affec- tions of the teeth or gums. It constitutes the common earache, from cold ; the pain being that which attends on the ordinary inflammatory process, occurring in a part of extreme sensitiveness. The action may simply resolve ; or it may cause a puriform exhalation from the mem- brane ; or abscess may form beneath the membrane, pointing, discharg- ing, and causing much aggravation of distress. Treatment is simply antiphlogistic ; leeching behind the ear, fomentation, hot poultices, purges, and antimony. When abscess forms, activity in the applica- tion of heat and moisture is redoubled ; and as soon as the appearance of matter is presented, evacuation is effected by puncture. Internal Otitis is a more serious affection ; and may be variously induced ; by injury, exposure to cold, or extension of a more outward attack. Pain may not be more acute, but is deeper seated and more intolerable ; attended with throbbing, and confusion of the head ; the system sympathizing in well marked inflammatory fever. If the action proceed to suppuration, disruption of the internal ear, Avith loss of * Toynbee, Medical Times and Gazette, Jan. 3, 1852. 1' 210 OTOREHCEA. hearing, is all but inevitable ; and very probably a still more serious result may ensue, namely, affection of the interior of the cranium. Treatment is actively antiphlogistic. When certain that acute inter- nal otitis exists, we wall not content ourselves with leeching behind the ear ; but may take blood both from the part and from the system. Calomel and opium, too, will be administered ; the invasion of an organ of delicate texture, of important function, and in near connexion with the brain, being sufficient warrant for such procedure (Principles, p. 168). In short, the best efforts will be made early and satisfactorily to subdue the rising process, so as to prevent suppuration if possible. TVlien matter has formed in the cavity of the tympanum, the mem- brana tympani acts injuriously by repressing outward discharge of the abscess ; occasioning tension, with aggi'avation of the symptoms. Here the general rules of Surgery ai*e to be fulfilled ; by incising the tense, resisting membrane — which is seen white and prominent — so soon as we ai*e satisfied by its change of colour and form, and the course of the general symptoms, that intra-tympanal suppuration has taken place. The membrane must yield ultimately, by ulceration or sloughing : probably too late to save the delicate and complicated apparatus of heaiing from irreparable injury; perhaps too late to pre- vent extension of aggravated inflammatory action to the brain or its membranes. Chronic Internal Otitis is common ; less formidable than the acute form at the time of invasion, but prone, if imchecked, to lead to equally serious consequences. The membrane may be simply changed in structure ; thick, rough, and vascular : clogging and enveloping the ossicula auditus. Or suppui^ation may take place, ^^ath perforation of the membrana, and probably with ultimate necrosis, and discharge of the ossicula. Treatment consists in attention to the general health, alteratives, and patient counter-irritation. Otorrhcea. By this term is understood a puriform or purulent discharge from the ear ; the result of chronic inflammatory action. Usually it is pre- ceded by the ordinary signs of an attack of otitis, acute, or subacute in character. Children are most liable to this affection ; and especially those of strumous habit. Often it is one of the sequelas of scaidatina. It is well to examine the meatus attentively, by means of the speculum, discharge having been previously removed by gentle ablution. For if the membrana tympani be found entire, and tolerably sound, the affection is so declared to be comparatively simple ; whereas, if that membrane be found imperfect, denoting an internal origin of the sup- puration, prognosis is rendered more guarded and unfavourable. OTOREHCEA. 211 It must never be foi'gotten that the term Otorrhoea, in truth, com- prehends many affections ; inflammation of the external ear, of the cavity of the tympanum, or of the mastoid cells. And it is equally important to observe that inflammation, begun in the external meatus, may at any time extend to the other parts, and thence to the contents of the cranium ; from the tympanum to the cerebrum, and from the mastoid cells to the cerebellum.* Treatment is mainly palliative and expectant, as regards the part ; restorative as regards the system. The constitutional cachexy is to be combated by the usual means. The ear is kept clean by frequent and careful use of tepid water, without and within the meatus. The state of the mouth is looked to ; and, if need be, amended. Re-acces- sions of inflammatory action are averted or subdued, by occasional leeching and fomentation, as circumstances may require. The chronic action, which is maintaining the structural and functional disorder ol the mucous membrane, is sought to be overcome by careful counter- irritation — such as blistering behind the ear ; this, however, being pro- ceeded with cautiously, lest enlargement of the glands of the neck, which frequently is an accompaniment of otorrhoea, should be either induced or aggravated. When nearly all the symptoms of inflam- matory action in the part have subsided, and when the general system has decidedly improved, Aveak astringents may be employed, to favour recovery of the membrane, and consequent cessation of the discharge. This part of the treatment, however, must always be conducted with the greatest possible care ; lest, by sudden arrest of the discharge, return of the inflammatory attack, in a deeper site, and in an aggra- vated form, should unhappily ensue. Such risk is in all cases great, when sudden arrest of discharge has occurred, from any cause ; but especially in those cases in which implication of the internal ear is indicated, by imperfection of the membrana tympani, and perhaps previous discharge of the ossicula auditus.f Otorrhoea in the adult may be connected with the lodgment of foreign matter in the meatus, long overlooked. A grass-seed, or such like substance, may be extruded after many years ; otorrhoea — occa- * " No person suffering from chronic catarrhal inflammation of the dermoid layer of the meatus, the membrana tympani, or of the mucous membrane of the tympanum, can be assured that disease is not being prolonged to the temporal bone, the brain, and its membranes ; and that any ordinary exciting cause, as an attack of fever or influenza, a blow on the head, &c., may not induce the appearance of acute symptoms, which, as a general rule, are speedily fatal." — Toyxbee, Med. Chir. Trans, vol. xxsiv. f An analogous afi^ection occurs in connexion with the nose. Purulent discharge has taken place for some time from the nostril ; suddenly it ceases ; death ensues, with head symptoms ; and on dissection, caries of the cribriform plate of the ethmoid bone is found, with corresponding afi^ection of the brain. p 2 212 ABSCESS OF THE MASTOID CELLS. sional or constant — having been maintained during the whole period of its residence. Otorrhcea is occasionally connected with a degenerated condition of the pars petrosa of the temporal bone ; which has softened, and become converted into a medullary mass. The symptoms are cerebral and obscure. The issue is hopeless. And it is very plain that the fatal event would certainly be much accelerated by a successful attempt to arrest the aural discharge. Abscess of the Mastoid Cells. Inflammatory action may oi'iginate in the cancellated texture of that part of the temporal bone which constitutes the mastoid process. It may be the result of external injury ; more frequently it occurs without any appreciable exciting cause, in systems of the strumous character ; and is most especially liable to invade those, whose original cachexy of system has been aggravated by imprudent exhibition of mercurials. Like the preceding affection, it is most frequent in the young. But veiy often this disease is but the extension of an originally mere outward affection ; namely, long continued inflammation of the external meatus. If suppuration be attained to — as is extremely pro- bable — caries may hardly fail to be established ; and is usually com- plicated vdth necrosis, portions of the osseous texture separating in the form of sequestra. From the near connexion of the posterior surface of the cells with the dura mater of the cerebellar cavity, it can easily be understood how readily, in advanced cases, the latter texture may be involved. The lateral sinus, too, is in close contact; and perfo- ration of this vessel gives rise to two formidable dangers, hemorrhage and pysemia. Supposing the affection to be primary, treatment in the first instance will be directed to averting suppuration and caries, if pos- sible, by the ordinary means. When there is reason to believe that matter has formed, we shall be very anxious to obtain an early and sufficient opening externally, and thus to limit the mischief already done. Otherwise, there is great danger by extension. The internal ear having been involved, hopeless deafness will ensue ; paralysis of that side of the face is not unlikely, from implication of the portio dura ; nay, it is possible that the contents of the calvarium may be attacked, as already stated, directly and imminently perilling existence. But, independently of such aggravations, life may be hazarded by the hectic of a continued and wasting discharge. From local treatment alone, but little good need be expected ; constitutional means must be at the same time, and sedulously, employed. When employing counter-ii'ritation, the blister should not DEAFNESS. 213 be placed over the part affected — otherwise the morbid action might be increased — but at a distance, as on the nucha, or between the shoulders. Otalgia. This constitutes true earache ; a neuralgic affection, unconnected, directly, with the inflammatory process. Yery frequently it is con- nected with irritation in the mouth. The pain is very distressing, and has aU the characters of neuralgia. It is amenable to the same treat- ment (Principles, p. 628), search for a dental cause or connexion never being neglected. Among the anodynes suitable for application to the part, aconite and belladonna deserve a prominent place. Deafness. Deafness may proceed from the affections already mentioned, and from many causes beside. In order to arrive at a true diagnosis, careful examination of the external meatus, and of the membrana tympani, is essential ; and to effect this, the well made speculum is of great service. Deafness is very frequently occasioned by Accumulation of inspissated Cerumen within the meatus. Or, perhaps, obstruction to the vibrations of sound is rendered still more effectual, by commixture of wool or cotton with the cerumen ; the patient having been in the habit of negligently stopping his ears, besides forgetting to practice requisite cleanliness. The presence of obstruction will be at once declared by use of the speculum ; and often that is not necessary ; tension and straight- ening of the tube, by pulling the lobe, before a clear light, being suffi- cient. Remedy consists in removing the offending mass. And this is best effected by washing out the meatus with hot water, by means of a stout syringe. Instruments such as employed for gonorrhoea, or for the injection of sinuses, are wholly inefficient; the syiinge should be of metal, well valved, and of considerable power. And the injection is persevered in, either at one or at repeated sittings, until the mem- brana tympani is disclosed clear, on the use of the speculum. When the cerumen is unusually hard and tenacious, it may be loosened, previously to syringing, by the careful use of a curette, or by moisten- ing it with bland oil for a day or two. Deficiency of ceruminous seci^etion is an occasional, but much less frequent cause of deafness. The meatus is found dry and empty, and the membrana tympani is seen clear and glistening. Stimulants are of use in restoring the secretion — as the essential oils, more or less diluted ; and their action may be further assisted by stimulant friction ai'ound the auricle. Exhaustion of the cavity is said also to have a 214 DEAFNESS. beneficial effect ; by means of a syringe, fitted witli a soft nozzle which completely occludes the meatus. Until the normal secretion returns, glycerine applied by means of a hair pencil will be found a valuable substitute.* Thickening of the lining membrane of the meatus is a cause of deafness ; the result of chronic inflammatory action. It is to be treated by the application of gentle stimuli — such as solutions of nitrate of silver, sulphate of zinc, &c. — which are best administered by means of a hair pencil. Rectification of the general health, and counter-irritation behind the ear, are often useful auxiliaries. The membrana tymiyani may be changed in structure ; thickened and congested ; the result of inflammatory action. Similar treatment is advisable ; the stimulants being applied by means of injection ; except Avhen the membrane is imperfect, and then again the hair pencil becomes preferable, lest undue excitement be caused in the internal ear. Imperfection of the membrane, by ulceration, or by rupture in consequence of external injury, may be repaired by Nature's effort. If not, hearing may be much quickened by applying a small shred of lint, or cotton wool moistened in glycerine, over the aperture.f By hypertrophy of bone, the osseous meatus may be so contracted and changed, as to produce a considerable amount of deafness ; an affection obviously but little amenable to treatment. The internal ear may be disordered ; and on this cause the great majority of cases of deafness are found to depend.^ The change may be in the lining membrane, in the osseous texture, or in the nerves. Fortunately, modern research has declared the most usual site of dis- order to be the texture first named — the one most amenable to suc- cessful treatment. This mainly consists in attention to the general health, and patient perseverance in the use of counter-irritation — ^the latter preceded by moderate local depletion. The extremity of the Eustachian tube may be obstructed, in various ways, and deafness ensue. It may be shut up and compressed by en- larged tonsils, or by nasal polypus hanging low from the posterior nares. In such cases, deafness will disappear on removal of the tonsil or polypus. Congestive swelling and relaxation of the fauces may cause obstruc- tion of the tube ; to be removed by astringent applications, counter- irritation, and attention to the general health.§ * Wakley, Lancet, No. 1346, p. 631. t Lancet, No. 1296, p. 10 ; and No. 1298, p. 64. + ToYNBEE, Med. Chir. Transact, vol. xxiv. § Clearness of the tube is ascertained by directing the patient to shut his mouth and nostrils, and then to expire forcibly, as if blowing his nose. He will be sensible of a click in the ear, produced by the shock of air acting on the membrana tympani — sup- posing this to be entire; and the sound will be very plainly heard by the surgeon, through a stethoscope placed on the mastoid process. If the tube be open, but clogged with mucus, the noise is of a gurgling or crackling kind. DEAFNESS. 215 Ulceration of the fauces, implicating the extremity of the Eusta- cian tube, may cause more serious obstruction by the contraction which occurs on cicatrization. This is to be obviated by speedily healing the ulcer, while yet superficial and of slight extent; and is to be remedied — if possible — by the introduction of probes, or catgut bougies, whereby to eifect gradual dilatation of the canal. The probe, or bougie, about six inches long, and sufficiently curved, is introduced along the floor of the nostril, with the convexity upwards ; and, just before the pharynx is reached, it is gently turned so as to bring the point outwards and a little upwards — the mouth of the Eustachian tube being above the level of the floor of the nostrils. If the tube is open, the instrument will be plainly felt entering it. When obstruc- tion or obliteration exists, pressure is to be made where the normal aperture ought to be ; in the hope that thus the obstruction may be overcome. Sometimes the opei'ation is at least partially successful. But in too many cases, this as well as the other operations on the Eustachian tube, are found to be not only difficult in performance, but also nugatoiy in their result. By catheterism, as it is termed, it is proposed to rid the tube of a redundancy of mucus : — another cause of deafness ; but that will pro- bably be as easily and certainly more safely accomplished, in most cases, by general treatment, gargles, and counter-irritation. In chronic affections of the membrane of the middle ear, it is possible that benefit may sometimes follow the careful injection of water, air, or medicated vapour, into that cavity ; and this is accomplished by means of the metallic Eustachian catheter — introduced in the same way as the probe, and fitted with a suitable syringe. All such operations, how- ever, must be conducted with the greatest caution ; seeing that it requires but little morbid change in the bony walls of the tympanum to produce an almost direct communication between that cavity and the interior of the cranium.* Organic change in the brain, or in the auditory nerve, is not an unfre- quent cause of deafness ; and seldom admits of successful treatment. Hopes of amendment will mainly rest on counter-irritation, and on mercurialism moderately employed. Functional disorder of the nerve is fortunately a more frequent, as well as more hopeful cause ; variously induced — as by blows, falls, loud noises, disorder of the general health, &c. Besides obviating the inducing cause, employing counter-irritation, and perhaps venturing on mercurialism, benefit may be obtained from the endermic use of stiychnine — as in the analogous case of functional amaurosis (p. 120). Or a few drops of an alcoholic solution of strychnine may be dropped into the ear, from time to time. * ToYNBEE, Medico Chiv. Transact, vol. xxxiv. 1851. 216 PEllFOEATION OF THE MEMBEANA TYMPANI. Determination of blood to the head, in consequence of suppression of normal or habitual discharge, or however induced, is not unlikely to produce a certain degree of deafness, along with noises and other unpleasant sensations in the head. Treatment is by leeching or cupping, purging, and other means ordinarily found available to overcome local plethora. Perforation of the Menibrana Tympani. This little operation is not frequently required. It is deemed advisable when, by insuperable obstruction of the Eustachian tube, access of atmospheric air is denied to the cavity of the tympanum ; and also when that cavity has become obstructed by extravasation of blood. The expediency of simple puncture, in the case of abscess of the tympanum, has been already noticed. In cases of deafness, caused by obstruction of the Eustachian tube, it is our object not merely to make an aperture in the membrane, but to keep that pervious ; and so permanently to atone for want of the accustomed atmospheric supply in the middle ear. This may be accomplished by using the instrument of Fabricci. " It consists of a canula, into which slides a spiral wire, somewhat resembling that of a cork-screw. It is to be used in the following manner : — Pass the canula with the spiral wire down upon the inferior part of the mem- brana tympani (so as not to interfere with the manubrium of the mal- leus), retain it there with the left hand, being careful not to press too firmly on the membrane ; then, with the right hand, take hold of the small handle which revolves the spiral wire, and turn it from right to left, being what is usually called turning the wrong way. The instant at which the membrane is perforated is sensibly felt by the operator. The wire is now no longer to be turned ; but by its handle the instru- ment is to be retained in its situation ; then gently revolve the canula, which has a cutting edge, from left to right, when a circular portion of the membrana tympani, corresponding to the diameter of the canula, will be cut out, and at the same time drawn into the canula and held fast by the spiral wire."* Or, instead of this instrument, a trocar, volute and sharp in the sides, may be employed ; turning it quickly in the membrane, so as to excise the punctured portion. Hemorrhage from the Ear, Blood, escaping by the ear, may proceed from various sources, and requires different treatment accordingly. 1. One of the most prominent symptoms of fracture at the base of the cranium is bleeding * Wii.LiAsis on the Ear, p. 204. CONGENITAL OCCLUSION OF THE MEATUS. 217 from the ear ; amenable to no direct treatment ; and usually an unfa- vourable omen (p. 39). 2. Mere laceration of the lining membi-ane of the meatus may furnish a copious discharge of blood ; independent of any injury done to the cranium, or elsewhere. It, too, requires no direct treatment — not being likely to prove excessive. And it is not a sign of an untoward character. It may be the result of a blow, fall, or direct injury done to the part. 3. Passive hemorrhage may take place from this, as from mucous surfaces ; amenable to the ordi- nary treatment, local and constitutional, suitable in such cases. 4. The internal carotid may have been opened into by ulceration. The hemorrhage is constant, copious, and of the arterial character. Pres- sure may be tried, with styptics, but may fail. The only sure remedy is ligature of the common carotid artery. 5. The lateral sinus, opened by ulceration, may be the source of bleeding — dark, and venous. In this case, while ligature of the carotid would prove wholly nugatory, moderate pressure is found to be quite effectual. Hypertrophy of the Auricle. Hypertrophy of the whole auricle is an occasional, though rare, occurrence. Partial hypertrophy — affecting the lobe only — is more frequently met with ; and chiefly in women. If excessive and irksome to the patient from its unseemliness, the redundancy may be removed by the knife. This deformity, however, may be artificially and intentionally pro- duced ; as by the native Indians who wear a dagger suspended from the lobe of the ear. Otoplasties. Deficiencies of the auricle — by wound, ulceration, or sloughing — may be repaired by autoplasty. Restoration of the entire organ is scarcely to be attempted ; but a portion may be readily replaced — when laxity of the surrounding integument is favourable — by an operation conducted on the same principle as rhinoplasty (p. 146). Congenital Occlmion of the Meatus. The meatus may be congenitally imperforate. It may be fully developed in all respects but covered by integument. In such a case, simple incision of the skin and careful dressing of the wound, so as to prevent contraction, will suffice to establish the normal state. Or a thick fleshy covering may conceal the cartilaginous tube, which is only partially developed. And in this case a more careful 218 CONGENITAL OCCLUSION OP THE MEATUS. and regular dissection may obtain a similar result, but perhaps more impei'fectly. Or, the external apparatus of hearing may be altogether deficient ; the bone itself being imperforate. Such cases are wholly beyond the reach of our art : yet it does not follow that hearing is denied, or even very imperfect. And of this a striking example occurred to me some years ago. A boy, aged fourteen, came from a distance, desirous of having an aperture made in each auricle ; and each of these organs was found very imperfectly developed, of a shrivelled appearance, and wholly imperforate. On making a very careful dissection down to the bone, in search of an external meatus, it became apparent not only that no such tube existed, however imperfect, but that also there was no aperture in the temporal bone. Yet the patient heard ordinary conversation, if distinct and rather loud ; he had gone to school at the same age as other boys, and had made equal proficiency in the ordinary branches of education, although no unusual means of teaching had ever been applied to him ; and he assisted his father in the occupation of a butcher, with much smartness and intelligence. A series of experiments, conducted by my colleagues. Professors Forbes and Thomson, seemed to show that he heard mainly by conduction of sound through the bones of the cranium to internal ears very perfectly constructed.* Itard, Traite des Maladies de I'OreiUe, Paris, 1821. Abercrombie on Diseases of the Brain, &c., Edin. 1828. Bright, Hospital Reports, vol. ii. part i. London, 1831. Kramer, on Diseases of the Ear, Berlin, 1836, translated by Bennett. Pilcher, on the Structure and Diseases of the Ear, London, 1838. Williams, on the Ear, Loudon, 1840. Wilde, on Otorrhoea, Dublin Jom-nal of Med. Science, Jan. 1844. Warden, Edin. Phil. Jour. Oct. 1844. Yearsley, Lancet, 1848, vol. ii. p. 10, 64, &c. And Mr. Toynbee's various papers— Medico-Chh. Transactions, vols. xxiv. and xxxiv. — Med. Gazette, July 1843 — Monthly Jom-nal, Feb. 1849. * Monthly Journal, Dec. 1846, p. 420 and 729. 219 CHAPTER XVIIL AFFECTIONS OF THE NECK. Olcmdular Enlargement and Abscess. In scrofulous adolescents, the glands of the neck are very liable to enlargement, by a chronic inflammatory process ; and frequently, notwithstanding every effort to the contrary, suppuration is attained to — causing more or less deformity by unseemly cicatrization. In the nascent stage, we endeavour to arrest progress ; by constitutional treatment suited to the strumous diathesis ; by leeching and fomen- tation ; and subsequently, by the application of iodine, or other dis- cutients, or by slight counter-irritation. When matter has formed, an early evacuation is practised by incision ; the wound being made as minute as possible, and in the direction of the folds of the neck, so that its cicatrix may escape observation. A common lancet is the preferable instrument. Sometimes, however, the use of potass is demanded ; the integuments having been much undermined, and the gland requiring disintegi'ation (Principles, p. 218). In the after-treatment of suppurations in the neck, cure is often delayed by over-dressing the part — covering it with too many envelopes — especially when the patient is not coniined to the house. The object of such dressing is to conceal the state of matters from public obser- vation, and to guard against exposure to cold ; but the result often is, to maintain a degree of congestion in the part, favourable to continued suppuration, and unsuited to contraction and consolidation of the abscess. When abscess has formed at all deeply in the neck, whether con- nected or not with glandular enlargement, evacuation by incision cannot be too soon had recourse to, otherwise serious mischief can scarcely fail to ensue. Fascia is made to slough; areolar tissue is broken down ; the trachea and oesophagus are each liable to be opened into by ulceration ; the jugular vein may communicate with the abscess ; or, still more disastrously, by communication with the carotid artery the cyst of the abscess may be converted into the sac of a false aneu- rism. And then, when the Avound for evacuation — too long delayed — is at length made, the most serious consequences are inevitable (Principles, pp. 211, 212). 220 TUMOUES OF THE NECK. Hydrocele of the Neck. This affection is not uncommon, and might in most cases be termed more appropriately Hematocele ; originating in lesion of a superficial vein, and the contents of the cyst being more or less sanguinolent. The cyst is thin, superficial, and seldom of very large size. Usually the production of the swelling is sudden ; and its progress in growth may be rapid ; after a time, however, becoming stationary, and prov- ing inconvenient mainly by its bulk. Treatment consists in tapping, and injecting iodine as in the more ordinary serous accumulations. Should this fail, a small seton may be inserted ; or free incision may be practised, with subsequent granulation from the bottom of the wound. In the necks of young children similar swellings are not unfice- quently observed, altogether unconnected with blood or blood-vessels ; the contents clear and albuminous. Tumours of the Neck. Solid tumours when of such a nature as not to be amenable to discussion, call loudly for an early use of the knife, otherwise each day will but add to the difficulty and danger of the operation ; and when at last matters are found to brook no further delay, it is not Fig. 82. Large fibrous tumour growing from the neck. Was successfully removed. 0PENINC4 OF THE EXTEENAL JUGULAR VEIN. 221 impossible but the hazard may be found so much increased as to render any attempt at extirpation quite unwarrantable. In connexion with this subject, it is well to remember, that in consequence of a tumour being bound firmly down by the deep and strong cervical fascia, it may seem to be less deeply seated than it is ; and that, consequently, much caution is always expedient in con- ducting the dissection, it being not at all improbable that the com- mon sheath of the large vessels may be fully exposed — perhaps to some extent. Opening of the External Jugular Vein. Occasionally it is deemed expedient to abstract blood by opening this vein, at its lower part. By pressure of the thumb, applied im- mediately above the cla- vicle, prominent bulging of the vein is produced ; and then an incision is made, as in venesection at the bend of the arm. The thumb's pressure is maintained, so long as the tlow of blood is desired ; it is then with- drawn ; and this circum- stance, of itself, is usually sufficient to arrest the bleeding. But, besides, it is well to place a small com- press on the wound ; retaining it by means of a long strip of adhe- sive plaster, or by a bandage very lightly applied. During the blood's flow, precaution is advisable to avoid entrance of air into the vein (Principles, p. 616). Torticollis. By this term is understood a distortion of the neck, dependent on muscular disorder — spasm, paralysis, or change of structure. The muscle usually to blame is the sterno-cleidomastoid. One, acting "v\ath the undue energy of spasm, overpowers its fellow, and displaces the neck accordingly ; or one, affected with a loss of contractility, fails to afford the usual counteracting power to its fellow ; or, by inflammatory action and its results, abbreviation and condensation of one or other muscle may occur, causing distortion of a very un- promising character ; or the malformation is congenital. Fig. 83. Venesection in the neck. The external jugular shown distended by pressure of the thumb, previously to insertion of the lancet. 222 TORTICOLLIS. Cliildi'en, shortly after birth, are not uufrequently found to labour under a certain amount of torticollis, fi'om the second cause ; one of the muscles seeming either to have been inadequately developed, or somehow to have become partially pai'alyzed. Friction over the spine, and on the muscle which is weak — with care, on the pai't of the nurse, to exercise the faulty muscle by position of the head, yet without fatiguing the extensors — usually suffices to effect gradual but satis- factory amendment. In a similar state of matters, in the adolescent or adult, the ender- mic use of strychnine, or the electro-magnetic stimulus, may be had recourse to. Spasm of the muscle may be either temporary or permanent. The former most frequently occurs in children ; and is to be treated by purgatives and alteratives, followed by anti-spasmodics internally ; locally by fomentation, leeching, and counter-ii-ritation. Permanent spastic rigidity of the muscle is more common in the adolescent and adult ; perhaps a remote consequence of the former affection. Mercu- rial friction and active comiter-irritation may be tried ; but with no sanguine hope of success. Sooner or later, tenotomy has to be em- ployed ; and that not merely on account of the deformity, but to avoid a more serious evil — cm'vature of the spine — wliich often supervenes, and which may, if unchecked, become both extensive and confii-med. The needle is inserted obliquely, at the origin of the muscle from the sternum and clavicle ; and division is effected by cuttmg either fi'om without inwards, or in the opposite direction, as circumstances may seem to require ; gi'eat care being of course taken not to injure the important parts which lie immediately behind that part of the muscle. To insure safety in this respect, it may be well, in some cases, to puncture with the ordinary tenotomy-needle or knife ; and then, with- di'awing this, to substitute an instrument with a probe-point wherewith to effect the muscle's section. Sometimes it may be sufficient to cut only one origin ; but, usually, diA-ision of both heads is essential. By resilience of the severed extremities, restoration of the nonnal state is at once produced ; and this is maintained by suitable bandaging, if need be, until consolidation of the divided pai'ts occur, with the due amount of elongation. A similar operation is the only means whereby we may expect to cure the third form of the affection ; that proceeding fr'om structural change by inflammation and its results. Twisting of the neck is caused also by tumours — glandular and others ; as well as by the contraction of extensive burns. The princi- ples of treatment in these cases are obvious. WOUNDS OF THE THROAT. 223 Wounds of the Throat. Wounds of the throat are of two classes ; those inflicted by the hand of the suicide, or the murderer; and those made by the surgeon. The former now engage our attention. They are usually made in a transverse direction ; and high in the neck — near or at the thyroid cartilage ; the latter circumstance being probably connected with the popular idea, that, to effect extinction of life, it is suflacient to open the air-passage, and so cause suffocation. The extent and consequent importance of such injuries vary very much ; from mere scratches, penetrating no deeper than the subcutaneous areolar tissue, to the most ghastly severing of all textures — almost to decapitation. Some- times the incision is made immediately beneath the chin. Not unfre- quently it is placed between the hyoid bone and thyroid cartilage ; the mouth being opened into, and the air-passage left intact. Some- times the weapon is di"awn across, a little above the clavicle ; and then, if any considerable depth be attained to, death is certain and 'immediate. Sometimes the knife, held as a dagger, is plunged into the lower part of the neck ; to the imminent risk of the larger blood- vessels. But the region of the laiyux is that which is most frequently involved. The first danger is by hemorrhage. If the carotid and jugular have been reached, death is very speedy, and may scarcely be pre- vented. Such extreme wounds, however, are of comparatively rare occurrence ; the vessels being protected, high in theu' course, by the depth of their situation in reference to the fi'ont of the neck, and by the density of the parts which have to be divided ere the sweep of the sharp edge can reach them. When, however, the deed is attempted, with a truer skill and deliberation, not by a horizontal gash, but by a puncture in the direction of the vessels, the escape of these is likely to prove rather the exception than the rule. A more limited transverse wound, leaving the carotid and jugular intact, may still cause death by hemorrhage, directly, and within a brief period ; by implication of the thyroid vessels — arteries and veins. And again, a compara- tively slight bleeding may prove fatal, more remotely ; blood trickling into the larynx, and accumulating within the air-passage, so as to induce asphyxia ; such accumulation being permitted by the insen- sibility of the patient, or by his inability, through faintness, to make the requisite efforts for expectoration. The second danger is by inflammatory changes at the wounded part ; occluding the laryngeal aperture or canal, or otherwise inter- fering with respiration. And this is all the more likely to occur, if the wound have been brought together tightly, with an imprudent 224 WOUNDS OF THE THROAT. haste. The mucous membrane, as well as the rest of the wound, becomes the seat of an acute inflammatory process ; and the con- sequent swelling may be such as to cause rapid and great occlusion. At the same time, mucous secretion is both increased in quantity and vitiated in quality — becoming more viscid and tenacious. This, accu- mulating in the already narrowed canal, renders suffocative hazard all the more imminent. And the risk is further contributed to, by the diminished power of expectoration which a patient so situated neces- sarily possesses. A third danger, liable to occur along with, and to aggravate that which has just been considered, is — that, during the movements of the part — voluntary" and involuntary — one portion of the wound is not unlikely to overlap the other, and thus, by suddenly producing a mechanical obstruction to the passage of air, at once to bring life into the greatest peril. A fourth danger is by the occurrence of inflammatory action in the trachea and lungs ; the inflammatory process extending downwards from the wound, or the unwonted direct access of cold air proving an exciting cause of original morbid action. Bronchitis, indeed, more or* less severe, is almost an invariable consequence of such injuries. A fifth danger arises from inanition, in those cases in which the gullet has suffered ; and when, consequently, it is not easy to main- tain a due supply of nourishment. Hectic, also, may ensue, in the case of an extensive, profusely suppurating, and slowly healing wound; more especially if much blood have been lost at the time of the inflic- tion of the injury. And lastly, the mental condition is, in all cases, likely to exert an untoward influence on the bodily frame. In not a few examples, when dissipation has led to the rash and guilty act, life is perilled at an early period by the occurrence of delirium ti'emens. Or this, indeed, may have been some time in progress, and may have caused the suicidal attempt. And in those cases which have been preceded by gloomy, brooding despondency, a continuance of low mania, accompanied with typhoid symptoms, will usually paralyze our best remedial efforts, and determine a fatal issue by sinking. Thus it can be readily understood, how few cases in Surgery pre- sent more obstacles to satisfactory treatment than do those of cut throat. We overpass one difficulty and danger only to meet another. And, too frequently, after the most prominent evils have been skilfully counteracted, the patient slowly yet surely sinks under obscure typhoid symptoms, intimately connected with mental alienation. Treatment. — When called to a case of cut throat, it is obviously our first duty to arrest the hemorrhage. And this is done by ligature of the arterial orifices ; pressure being applied, if need be, to venous WOUNDS OF THE THROAT. 225 points. Then tlie wound is to be approximated by suture; not wholly, but in part. The angles are drawn and kept together ; but the centre of the wound is left free, approximation there being effected solely by attention to position of the head — keeping the chin, by bandaging if necessary, depressed towards the sternum ; and even this is not done, until all bleeding from the wound has ceased. If the chasm be at once drawn tightly together, immediate risk is greatly enhanced, as already stated ; and yet this is an error very frequently committed, in the huriy of actual practice. Blood, oozing from the cut parts, does not find a ready escape externally, but either trickles into the air- passage and accumulates stealthily there ; or is infiltrated around the line of wound, causing compression of the windpipe by the increasing coaguluni ; in either way threatening suffocation. The viscid mucus, too, is more likely to entangle itself in the shut wound ; and inflam- matory turgescence is more prone to prove untoward. Air, also, is likely to be infiltrated into the areolar tissue, during expiration ; caus- ing troublesome and dangerous emphysema. When, on the contrary, the wound is left centrally free, these latter risks are not only less likely to occur ; but, also, in the event of their occuri'ence, untoward tendency can be much more readily and effectually counteracted. It need scarcely be added that the dressing of the wound should be most simple ; consisting, not of a complication of plaster, compress, and bandaging — but of a mere strip of lint, moistened in water, and loosely and lightly retained upon the part. The main bleeding having been secured, and the wound partially approximated, the patient is laid on his side so as to favour outward escaj)e of the continued oozing. And the cut part is protected from unfavourable atmospheric impression, by a covering of loose gauze, or of woollen texture, thrown lightly over the neck ; attention being at the same time paid to maintain an equable and genial temperature in the apartment. Duly qualified attendants are at hand, not only to guard against repetition of the suicidal attempt, but also prepared to separate and clear the wound, should swelling and entanglement of mucus render such a proceeding necessary to prevent suffocation. And the patient should be instructed to facilitate his expectoration, by completely shutting or very much diminishing the wound, by means of his fingers, at the time of the effort being made. It is hoped that the wound will inflame, granulate, contract, and cicatrize, in the ordinai'y way ; and the local treatment is conducted with that object in view. Constitutionally, we have to guard against favouring inflam- matory action in the wound, and in the air-passages, by neglect of antiphlogistic measures ; and, on the other hand, we must beware of aggravating the tendency to sinking which sooner or later becomes Q 226 WOUNDS OF THE THEOAT. apparent in the majority of cases. As a general rule, blood-letting from the system is seldom if ever Avarrantable. Should the pharynx or oesophagus have been Avounded, the use of a tube becomes necessary to convey nourishment to the stomach. In the ordinary effort of deglutition, the ingesta -would necessarily escape more or less copiously by the wound, and so do harm in many ways. The feeding tube cannot be inserted from the wound — although the facility of such a proceeding may invite the attempt — otherwise closure of the wound must be seriously interfered -with. If intended to be introduced and worn permanently, until the pharyngeal or oesophageal aperture shall have closed, it is to be passed by the nostril. But it is found to be more expedient to introduce the tube only occa- sionally, by the mouth ; twice or thrice daily, as circumstances may seem to require. It is not neces- sary to pass the instrument completely down to the stomach ; it is enough that its extremity is placed fairly beyond the wound. And, of course, the pre- caution is not neglected of ascertaining that lodg- ment is rightly accomplished, ere fluid noui'ishment is begun to be introduced. One very obvious objec- tion to the permanent retention of a tube, whether passed by the mouth or by the nose, is that its extremity, pressing against the posterior part of the vnndpipe, is apt to occasion ulceration thei'e, Fig. 84. which may perforate ; complicating the case unto- wardly, by the establishment of tracheal fistula. Should this occur — as has happened — the ordinary test of the tube being rightly placed will probably fail ; air, in expiration, escaping by the tube in the oesophagus, as well as by the natural outlet (p. 201). Throughout the whole cure, the state of respiration must be sedu- lously watched. And should threatening of suffocation supervene — as is not unlikely — and prove of such a nature as not to be removed by attention to the state of the wound, tracheotomy is to be had recourse Fig. 84. " A view from behind of the larynx of a patient who some weeks previously attempted suicide, by woimdmg the fore part of the neck. By some mismanagement, the edges of the incision were kept asunder ; and they cicatrized. The patient was seized witti difficult breathing ; the inspirations were rare, long, and laborious ; and he had threatening of suffocation during his distui'bed sleep. These s^-mptoms were dis- regarded. He started up suddenly in the night, caught hold of the patient in the next bed, and fell do^ii in a state of asphyxia, from which he could not be recovered. The (Edematous swelling of the rima glottidis is remarkable; beyond that, is seen the rounded openmg betwixt the thjToid cartilage and epiglottis — which last is in a normal state." — LtSTON, Elements, p. 432. FOREIGN BODIES IN THE WINDPIPE. 227 to unhesitatingly. Then, the canula being retained in the tracheal wound, the transverse aperture may be brought together, and treated so as to favour rapid union — there being no longer any risk from in- ternal swelling or other change at that site. I have often thought, that in extensive transverse wounds of the neck, implicating the windpipe, however inflicted, tracheotomy may be regarded as expedient at an earlier period ; that is, shortly after arrest of the hemorrhage, and partial approximation of the wound ; so soon, in fact, as the patient has rallied sufficiently to bear the im- mediate effects of the operation. For then we would have it in our power to place and maintain the whole track of the wound in pei'fect apposition, and perhaps to procure union almost by the first intention. So soon as the chasm had fairly closed, the canula might be withdraAvn, and the tracheal opening cautiously and gradually closed. And thus, also, would we be more likely to avoid the occur- rence of fistulous tendency in the suicidal wound ; which, in the ordinary progi*ess of cure, is not unlikely to prove troublesome. In performing the operation, it will be expedient to raise and steady the windpipe, by means of a hook fixed in the lower margin of the transverse wound. In those cases which recover, there is a risk of the larynx becoming contracted in its calibre, so as seriously to interfere with normal respi- ration ; and all the more probably, if there be at the same time a fistulous opening established by imperfect closure of the wound. Such cases are doubtless unpromising ; yet are capable of being brought to a prosperous issue. The contracted passage may be dilated by bougies passed from the mouth ; and, the normal capacity of the larynx having been restored, the fistulous opening may be made raw, and approximated by suture. A successful case of this nature occurred in the practice of Mr. Liston.* BroncJiotomy. Under this general term are comprehended the surgical wounds of the throat — Laryngotomy and Tracheotomy ; made in a longitudinal direction ; artificially opening the windpipe, vnth some important remedial object in view. But before treating of these operations, it may be well to consider briefly the various circumstances which may demand their performance. Foreign Bodies in the Windpipe. Foreign bodies, held in the mouth, are apt to pass into the wind- pipe, during sudden inspiration — as in speaking, crying, or laughing. * Liston's Elements, p. 435. Q 2 228 FOEEIGN BODIES IN THE WINDPIPE. During inspiration, the glottis is opened wide, and a foreign substance, even of considerable size, may pass readily inwards. For expiration, however, a comparatively narrow opening of the rima suffices ; an aperture quite insufficient for the backward escape of the intruding substance ; and, indeed, such escape is still further opposed by the eiFort to produce it, which, impinging the foreign substance on the tra- cheal aspect of the rima, stimulates that part to spasmodic contraction. The foreign substance may remain loose within the windpipe ; moving from part to part, according to the cii'cumstances of displace- ment. Or it may lodge at a particular site : 1. In the larynx ; becoming entangled in the ventricles ; or being of such form and size as to be impacted in the general cavity. 2. It may be similarly fixed across the trachea ; pins, portions of glass, and other sharp substances, for example, have been thus impacted. 3. In either bronchus. And the right being the more directly continuous with the trachea, in that the impaction is most likely to occur. 4. Or the body, of small size, may gravitate still lower, and take up a lodgment in one or other of the bronchiaa. 5. Or it may be impacted in the very rima glottidis. Thus : — a man, much intoxicated, becomes almost insensible, and is sick. The contents of the stomach are lazily evacuated upwards ; and a portion of the ingesta may enter the rima and remain there, causing suffiacation. A piece of potato-skin has thus proved fatal. Or, again, large substances, held in the mouth, and forced downwards in sudden inspiration, may prove too bulky to pass through the rima, and become impacted there ; inevitably causing suffocation, unless instant relief be obtained, either at the hand of Surgery, or by the patient's own expulsive efforts. And in such a case, unless the tightness of impaction be great, success is more likely to follow the instinctive throes, than in the case of smaller bodies within the larynx ; spasm of the glottis being mechanically prevented, and consequently proving no obstruction. The symptoms denoting the occurrence of such accidents are, in general, tolerably distinct. If impaction have taken place in the rima, the symptoms are those of rapid asphyxia ; the patient suddenly exhibiting the greatest distress, becoming livid and swollen in the countenance, staring with bursting eyeballs, gasping anxiously, strug- gling for breath, and speedily becoming insensible. When the foreign body has passed within the rima, the symptoms vary according to the site and nature of the lodgment ; but, in all cases, they evince two leading characteristics — denoting obstruction to respiration, and irri- tation produced in the part with which the substance is in contact. If it be loose in the windpipe, or lodged in the larynx or upper part of the trachea, the following are the ordinary symptoms. A violent fit of suffocative cough immediately succeeds the entrance of the foreign FOREIGN BODIES IN THE WINDPIPE. 229 body — seeming to cease, it is probable, only on Nature having been wholly exhausted. And, at short intervals, such paroxysms are renewed; more particularly if any new, movement of the foreign body have occurred. Inspiration is loud, strained, and of a harsh, croupy, or sawing sound. The voice is changed. Pain is complained of in the part. A more or less copious expectoration of mucus takes place ; and sometimes of blood. The countenance is suffused, and ex- pressive of great anxiety — an expression almost pathognomonic, espe- cially in the young. And the neck is stretched, with the head elevated and throvsTi back, in the position of orthopnoea. Often, all the auxiliary muscles of respiration are found in full play. It is right to remember, however, that in some cases — more especially when a considerable period has elapsed since the occurrence of the accident — the intervals between the paroxysms may be passed in comparative quiet, with au almost total absence of symptoms at that time. Wlien impaction has taken place in a bronchus, a chai-acteristic sign is indicated by auscul- tation — suppression of respiratory sound on that side, with puerile res- piration in the opposite organ. The respiratory movements of theparietes of the chest, too, are diminished or arrested in the obstructed part. Or a stiU more plain indication may be afforded, if the substance happen to be of musical capability, however rude, and so situated that the air passing by it in respiration may evoke its powers of sound. Rough substances soon occasion purulent discharge, which possesses great and characteristic fcetor. Sometimes the foreign body, when smooth and loose, may be felt distinctly impinging against the upper part of the larynx, during a convulsive effort at extrusion. The affection with which this accident is most apt to be confounded, is rapid obstruction of the upper part of the vvnndpipe by inflammatory action. But the history of the two cases must necessarily be very different ; urgent symptoms being in the one case immediate, unaccom- panied with febrile excitement of the system, and often most intense at first ; while in the other they are more or less gradual in their accession, of a crescent character, and invariably attended with inflam- matory fever. Also, in the accident, expiration is difficult, while inspiration is comparatively easy ; whereas, in the disease, the pre- cisely opposite condition obtains. That in all cases there is a necessity for the speedy adoption of measures calculated to effect removal of the foreign body, is tolerably plain. Otherwise, the risks to life will be neither few nor slight. 1. Sudden suffocation may occur, at a very early period, by impaction of the substance in the upper part of the larynx — as already shown. 2. Imperfect respiration may more gradually induce a fatal issue ; in consequence of partial obstruction caused by the foreign body, and accumulation of mucus at the incommoded part. 3. Laryngitis or 230 FOREIGN BODIES IN THE WINDPIPE. tracheitis may be excited, of formidable cbaractei'. 4. Congestion may take place in the lungs ; followed perhaps by apoplectic disrup- tion of the pulmonary tissue, or by pneumonia, or by bronchitis. 5. A foreign body of small size may perforate a bronchus or bronchial tube, and lodge in the pulmonary tissue ; and acting untowardly there, as all foreign substances must, may cause abscess, or lay the founda- tion for tubercular deposit and fatal phthisis. 6. Or the passage out- wards may be more advanced. The lungs may be passed through, and the cavity of the pleura reached ; and empyema may be the result. No doubt, it has happened that yet another step has been taken ; the foreign substance has perforated the walls of the chest, by tedious ulceration, and been discharged externally. And it has also happened that a foreign body has been expectorated by the mouth, along with purulent matter, at a long date from its introduction. But such occurrences ai'e much too rare to warrant theii" use as precedents, in determining the appropriate treatment. If the violent efforts of the patient fail to dislodge and extrude the foreign body — as is not unlikely — recourse must be had to broncho- tomy ; and through the artificial opening in the Tvindpipe the foreign body is sought to be extracted. Before proceeding to this operation, however, it is well in cases of comparative obscurity to explore the pharynx and gullet, in the first instance. Urgent symptoms of dyspncea, we have already seen, may be caused by foreign substances lodged in either of these passages ; thence compressing, irritating, and obstructing the air passage. And experience has shown that a foreign body, not bulky enough to cause dangerous compression, may lodge near the riiiia, and exterior to it ; may cause many of the ordinary symptoms of a foreign body within the windpipe ; and that in such a case, while bronchotomy must necessarily fail, expulsive efforts, duly aided by the surgeon, are most likely to succeed.* When the foreign body is of small size, and plainly indicated by the symptoms to be either loose in the air passage, or fixed in the upper part of the larynx, laryngotomy may be had recourse to. It is of easy performance ; and, though an aperture through the crico-thy- roid space be necessarily of limited dimensions, it is probable that through that space such a foreign body may be readily enough removed. In all other cases, however, tracheotomy, though a more troublesome operation, is for obvious reasons to be preferred ; the aperture is more free, and the facilities for extraction, both from below and from above the opening, are manifestly greater. When the foreign substance is loose, it is usually expelled forcibly by the outward cuiTent of air, so soon as the operation is completed. But if fixed, it must be sought for, and removed artificially. If lodged * Laxcet, 1069, p. 729. FOEEIGN BODIES IN THE WINDPIPE. 231 jxbove the opening, a common pi'obe is the most convenient instrument for exploration. By it the site is detected ; by it the foreign body may be pushed through the rima — to be coughed up ; or loosening is effected, with subsequent expulsion through the tracheal wound. When the site of lodgment is in the bronchus, long curved forceps — such as recommended for extraction of foreign matter from the pharynx and oesophagus (p. 205) — are very suitable for both exploration and extraction. Auscultation and percussion having previously imparted to the operator a shrewd suspicion of the site of lodgment, the instru- ment is passed down shut, and made if possible to impinge on the foreign substance ; then, slightly withdrawn, the blades are oj)ened ; and, pushing on again gently, the object is probably grasped; if not, the other forceps — opening in an opposite direction — is similarly employed, with almost a certainty of success. The wound is kept open, until bleeding has ceased ; it is then brought accurately together by adhesive plaster, and adhesion hoped for. But the air passage may prove intolerant of the forceps ; and per- severance in their use, searching for a foreign body, might peril life by violent paroxysms of dyspnoea.* In such cases, modern experience has pointed out a safer mode of procedure"}" — more especially if the foreign body be of some weight, as a stone, coin, or any piece of metal. The tracheal wound being kept open, let the patient's body be inverted, so as to make the head dependent ; and, if need be, let succussion of the frame be had recourse to, so as to favour dislodgment of the offending substance, and its descent towards the larynx by gravitation. Arrived at the rima, it will not find its outward passage there obstructed by spasm, nor will a paroxysm of dyspno3a be induced ; for, the opening in the trachea has the effect of obviating this difficulty and danger. Escape is made readily into the mouth, and thus extrusion is effected with both ease and safety. It has been proposed to supersede bronchotomy altogether, by the preceding manoeuvre. But such a proposal does not seem to be a prudent one. In most cases the attempt would probably fail, and life be imminently perilled, the foreign body being obstructed by spasm at the rima, and perhaps becoming impacted there. The proceeding is suitable only when the foreign body is small, smooth, and of high specific gravity ; and seems to be in all respects safe, only when a tracheal aperture has previously been established ; and when, in con- sequence, irritability of the rima has been assuaged, and accident by impaction there fully provided against. A case or two of accidental * In vising the forceps, ancesthesia is obviously calculated to prove of mucli service ; rendering exploration botli easy and safe. In applying the chloroform, it will be necessary to place it over the wound as well as on the mouth. — See a case hy Dr. Jolmston of Mon- trose, Lancet, No. 1478, p. 600. t Lancet, 1063, p. 502. 232 ASPHYXIA. success* will not suffice to overthro-w the general principle here incul- cated. It may happen that some considerable time — weeks or months — has elapsed since introduction of the foreign body, before aid is requested. Such lapse of time need not deter the surgeon from operat- ing, if other circumstances prove favourable. For experience has shown, that removal of the offending matter, even at a distant date, may be sufficient to avert all serious ulterior consequences. f Asjjhi/xia. In attempting resuscitation from asphyxia, it is necessary to main- tain artificial respiration ; and this is effected, in oi'dinary cases, by insufflation of air through the mouth or nostrils (Principles, p. 748). But Avere the rima glottidis spasmodically closed, such ordinary means would be likely to inflate the stomach only, leaving the lungs unaf- fected. Under such circumstances, therefore, one of two proceedings is necessary ; to pass a tube into the AAdndpipe from the mouth ; or to perform bronchotomy. The operation of passing a tracheal tube is always difficult ; and becomes especially so, even in an insensible patient, if the rima be closely shut — as in the case of suffocation by carbonic acid. It can readily be understood, therefore, how in many cases such an attempt is well superseded by the operation. Usually laryngotomy will suffice. One caution must be particularly attended to ; namely, to prevent blood from entei-ing by the wound, and accu- mulating in the au* passages. And should such entrance have been effected, means should be taken, by suction applied to the wound, to accomplish its expulsion. In cases of Suspension by the neck, it is plain that bronchotomy cannot avert a serious result, and may probably fail in the attempt at resuscitation. For, the cause of death is not from constriction of the windpipe only ; but by concussion of the brain and spinal cord, and by interference with the jugular circulation. And these latter circumstances may of themselves be sufficient to produce a fatal issue, independently of direct interference with respiration. Seldom does any displacement occur in the cervical vertebrge. Injuries of the Larynx. A blow on the larynx may directly peril life by arresting respi- ration. The rima glottidis may be wholly shut, either by spasm of the occluding muscles, or by paralysis of their antagonists — more * Northern Journal, Feb. 1845, p. 220. t London and Edinburgh Medical Journal, August 1842,. p, 722 ; and Liston's Prac- tical Surgery, p. 371. ACCIDENTAL SWALLOWING OF BOILING WATER, ETC, 233 probably by paralysis of all the muscles concerned ; or it may be but partially occluded, yet with such a tumult and difficulty of respiration as to render the case one of great and immediate hazard. And, under such circumstances, it is plain that the only prospect of relief is by tracheotomy — opening the wnndpipe below the injured part ; the aper- ture being kept patulous, until the organ has recovered, and is able to resume its wonted functions in normal respiration. Rupture of the trachea, by external injury, may prove fatal, by rapid and extensive emphysema ; the pressure of this producing asphyxia more or less rapidly. By making many and early punctures in the affected part — or by incision — we may give an outward escape to the air, and so avert the threatened disaster. Apoplexy of the larynx may occur ; blood being infiltrated copiously beneath the mucous membrane. Symptoms may be urgent, simulating croup or oedema glottidis, and so threatening asphyxia as to render relief by bronchotomy inevitable.* The thyroid cartilage, ossified, may be fractured by external violence, and serious consequences ensue ; requii'ing active antiphlogistics, and perhaps tracheotomy eventually. The Accidental Siccdloiving of Boiling Water, Acids, or other Irritant Fluids. It is common, among the poorer classes in some localities, to have but one vessel, a large kettle, to hold water for culinary purposes — sometimes cold, at other times hot, according to circumstances. A child, accustomed to have its thirst assuaged from such a source, is likely to help itself, when no one else is near ; and, in doing so, may unhappily fill its mouth -v^dth fluid of a boiling temperature. Instantly an attempt is made by the little sufferer to eject the fluid ; and in the backAvard movement of the hot water, partial entrance into the open rima glottidis is not unlikely to occur, during the expulsive paroxysm. The result is a scalding of the air passage, as well as of the pharynx and upper part of the cesophagus ; and by swelling in the former situ- ation, during the subsequent inflammatory process, the most serious results may ensue. Adults may swallow acids or other acrid fluids, either by accident or intentionally. In the latter case, the air passage is seldom injured. The determination to the act of swallowing shuts the glottis, and the fluid passes downwards in the gullet alone. But if a patient acciden- tally attempt to swallow a fluid of tliis kind, mistaking it for some other of a harmless nature, the expulsive effort is instantly made — as in the case of the child with hot water ; the glottis is opened in the paroxysm, and the noxious fluid effects a partial entrance there. * ifonthly Journal, August 1847, p. 126. 234 SPASM OP THE GLOTTIS. The treatment of such cases requires to be conducted "with an energy proportioned to the urgency of their nature. The inflammatory process may not be prevented; but it should be our anxious endeavour to moderate and delay its onset, and to effect its speedy retrocession. The most active antiphlogistics are employed — immediately ; bleeding from both part and system ; outward fomentation ; antimony. It may be that by such means the progress of inflammatory tumescence may be restrained, so as not to affect resj)iration urgently, and that exten- sion of inflammatory action from the pai'ts fii-st involved to the air passages in general may be prevented. If, however, antiphlogistics fail, and asphyxia threaten by obstruction in the larynx, tracheotomy is to be had recoui'se to ; at once ; not reserving the operation, espe- cially in the child, until by extreme urgency of the symptoms it cannot possibly be longer delayed, and when recovery is rendered more than problematical by congestion in the brain, in the lungs, or in both. Laryngotomy is plainly unsuitable ; to practise that, would be to cut into the affected part, and to fulfil very imperfectly, if at all, the object of the operation. The wound of tracheotomy, on the other hand, is below the seat of disease, the affected part is put at rest, life is saved from asphyxia, and the inflaming larynx, by being allowed quietude, is powerfully aided in the resolutory effort. On decadence of the inflammatory process, and when absorption, clearing away all swelling, has restored the normal state of the organ, the tube is withdi-awn, and the wound permitted to close. SjJasm of the Glottis. It has been already stated how bronchotomy may be highly available in the case of spasmodic closure of the glottis, threatening asphyxia ; as in poisoning by carbonic acid. Laryngismus Stridulus, a spasmodic affection of the windpipe, not uncommon in children, and occasionally met with in the adult, may in its paroxysms threaten suffocation ; and, in such circumstances, the question of the expediency of bronchotomy comes to be entertained. In general, the operation is to be Avithheld, unless the cu'cumstances prove extremely urgent ; and it is then employed as a means of palli- ation and protraction, rather than of cure. And more especially will the prognosis be guarded and unfavourable, if there be reason to believe that the spasmodic attacks are dependent on u-ritation produced by structural change at a low part of the windpipe ; as by enlargement of the thymus gland, affection of the bronchial glands, aneurism, or other formation of tumour. Li one form of aortic aneurism, when the tumour is small, and does not compress and contract the air passage, but acts on the larynx irritatingly by implication of the recun-ent nerve, causing suffocative paroxysms of spasm in the glottis, it seems LARYNGITIS. 235 very proper to have recourse to tracheotomy early, with a certain hope of relief, and a prospect of even something more than mere palliation. But when the tumour is large, compressing and contracting the air passage, and causing continuous dyspnoea, the prospect is not so ifavourable, and the grounds for operation are scarcely sufficient, pro- bably, to warrant its performance.* It were out of place, in such a work as this, to enter fuDy into the various interesting and important affections of the windpipe. But it is right to notice them briefly, in connexion with the operation of bronchotomy ; the leading features only being stated. Laryngitis. The inflammatory process, occurring in the larynx, may be either chronic or acute. I. Acute Laryngitis, a. Laryngitis simplex. — There is, in this affection, more or less turgescence of the mucous membrane, with the accustomed change of secretion — the results of a minor amount of the inflammatory process ; but the swelling is diffused uniformly, and not at any part great, and the secretion is not liable to be retained and accumulated ; no paroxysm of dyspncea threatening suffocation is likely to be caused by such changes ; and, consequently, in this affection the direct interference of surgery, by bronchotomy, is not required. Medical treatment suffices. b. Laryngitis (Edematosa. — This is the acute (Edema Glottidis ; an inflammatory process attacking the larynx, and rapidly causing much bulging of the lining membrane by serous and fibrinous infiltration of the submucous tissue ; active congestion being rapidly reached, and per- sisting of high intensity (Principles, pp. 106 and 114). In consequence of such change, the characteristic symptoms are soon developed ; increasing dyspnoea, liable to paroxysmal exacerbation ; inspiration protracted, laboured, stridulous ; expiration comparatively easy and silent ; anxiety of countenance, &c. And, besides, there is ultimately afforded to the surgeon a more plain indication ; inasmuch as the oedema- tous swelling may be felt, on the epiglottis and glottis, by the finger introduced from the mouth ; and may even * Monthly Journal, Aug. 1851, p. 185. Fig. 85. Acute ojdema glottidis ; exposed from behind. Fio;. 85. 236 (EDEMA GLOTTIDIS. be seen, on depressing the tongue forcibly by the speculum. Practi- cally, the disease may be divided into three stages. 1. There is the condition of laryngitis simplex ; while the action has not proceeded beyond turgescence, and when thei'e is no obstruction to breathing. But this state is quickly overpassed, in most cases. 2. The characteristic oedematous swelling is forming ; not diffused and uniform, but mainly affecting the glottis and its immediate neighbourhood, and causing prominent bulging there. Eespiration is now more or less impeded ; and obstruction is on the increase. 3. Breathing having been for some time seriously interfered with, and aeration of the blood imperfectly performed, untoward results begin to manifest themselves in both lungs and brain — congestion, followed by serous effusion ; the threatening of asphyxia is aggravated by threatened supervention of coma. Most frequently the obvious cause of death is by the former event ; obstruc- tion by mucous swelling becoming greatly augmented by accumulation of viscid mucous secretion, a paroxysm of dyspnoea is induced ; in the tumultuous disorder of respiration that ensues, it is not improbable that the patient may drop asphyxiated ; and recovery from that state will be seriously affected by the cerebral change akeady in progi'ess. In other cases, the fatal issue is more gi'adual ; asphyxia steadily ad- vancing, ^vithout paroxysmal aggravation. The suitable treatment is active throughout. At first ordinary antiphlogistics are plied industriously ; blood-letting, antimony, calomel and opium. These may arrest the affection in its first stage. If not, let them be persevered vnth ; for they may yet mitigate the swelling, prevent the occurrence of urgent symptoms, and procure a favourable resolution from the second or characteristic stage, without life having been ever seriously endangered by threatened asphyxia. In this stage, howevei', be it remembered, blood-letting must be had recourse to with very considerable caution ; it being well known, from experience, that there is an intolerance of this remedy, heroically employed, in all cases in which respiration is seriously obstructed. Let mercury take the place of loss of blood ; and by it, judiciously emjiloyed, let us hope to limit deposit and promote absorption successfully, and thus to make a satisfactory impression on the oedematous bulging. Not seldom marked benefit will follow free scarification of the epiglottis and lips of the glottis, by means of a curved knife ; the tongue being fully depressed by the mouth-speculum, so as to render these parts acces- sible to such procedure. Should, however, resolution fail to follow on the use of such means — the symptoms proving both crescent and grave — let bronchotomy be at once had recourse to ; regarding the operation as truly a part of the remedial treatment, whereby the peril of extreme urgency may be avoided, not as a last resource whereby a life half lost may only perhaps be regained. Tracheotomy is plainly CROUP. 237 to be preferred ; for thus oiily can we place the artificial opening beneath the seat of obstruction, so as to effectually avert the immediate danger bj impending asphyxia ; and thus only can we fulfil the very important indication of placing the affected part in the state of compa- rative quietude and repose, so suited for facilitating resolution and recovery. The medical treatment is not interrupted meanwhile. In due time it tells favourably on the swelling. This begins to subside ; and then the use of the tube may be begun to be discontinued, intro- ducing it only occasionally. Ultimately the part recovers itself wholly as to swelling ; and then, the tube having been finally withdrawn, the wound is approximated and encouraged to heal. During the first hours of the tube's use, great care is necessary in keeping the aperture clear ; viscid mucus is being copiously secreted ; the power of ex- pectoration being very weak, occlusion of the artificial rima is apt to ensue ; and such risk by sudden asphyxia is all the more likely to occur, if the patient have fallen asleep shortly after performance of the operation — as often happens. More than one day and night may have been passed in sleepless anxiety, pain, and distress ; and the relief at once experienced, after the first effects of the tube's introduction have passed away, is apt to lull the relieved sufferer into a deep and unconscious slumber — from which it were hard to be awakened, abruptly, only to perish by suffocation. The attention of a qualified attendant must be constant, to maintain clearance of the tube, until the excessive secretion of mucus has diminished, and the power of expectoration been regained. In this affection, then, let tracheotomy be had recourse to, so soon as it is plain that medical treatment has failed to effect timeous reso- lution. Do not delay, until both lungs and brain have been so far involved, as to render recovery under any treatment at that stage more than doubtful. c. Laryngitis Fibrhiosa is usually combined with a corresponding morbid state of the trachea — tracheitis fibrinosa— constituting Croup. This, too, may be conveniently divided into three stages, 1. Again the laryngitis simplex, but of greater intensity than in the previous case, and with a marked tendency to spread along the mucous mem- brane downwards. 2. The fibrinous exudation begun ; aggravating all the symptoms, and affording serious obstruction to breathing. 3. The lungs and brain implicated, as in the former case, by reason of the continuance of impeded respiration. The former organs, however, in this case are exposed to an additional source of danger. The in- flammatory action, by continuous extension, may have reached the bronchial ramifications ; and to the oppression of the lungs' play, otherwise occasioned, the additional and serious complication of bron- chitis may be added. In the first stage, medical treatment is practised, as in the corres- 238 CROUP. ponding period of the previous affection. There is no demand for bronchotomy, on account of urgency of symptoms con- nected with respiration ; and the spreading acute inflam- matory action is not likely to be limited, in either its extent or intensity, by the infliction of a tracheal wound, and re- tention of a foreign body therein. In the second stage the symptoms are sufficiently urgent to call for any aid which our art can afford. Tracheotomy will give a more direct and free entrance for aii' passing towards the lungs, than through the affected larynx ; and the larynx will be placed in a state of comparative rest, favourable to reco- very. But the same good result does not follow as in the case of acute osdema glottidis. The disease is not limited to the larynx, but has passed the site of tracheal wound, and is already established, too probably, in the bronchial tubes ; the wound is made — not in a comparatively sound part, to afford rest to the superior portion of the canal — ^g- 86. but in the midst of the disease, affording rest to but a part, and a minor part, of the disorder's seat, and inducing, by its additional stimulus, an aggravation of the whole. Air is let in towards the lungs, but with only a doubtful chance of reach- ing them ; for by this time the bronchial tubes are clogged with viscid mucus, the bronchial membrane is itself swollen and infiltrated, the trachea is more or less obstructed by false membrane, and perhaps, indeed, pseudo-membranous exudation has extended throughout almost the whole bronchial ramifications. Thus, the salutary indications are not fulfilled, and the operation fails of its expected issue. In the third stage, surgical interference must prove still more manifestly hopeless. In this disease, therefore, the practical inference from such considerations will be, that our principal confidence must be placed in medical treatment ; that the operation of tracheotomy — laryngotomy being in all respects obviously unsuitable — cannot be expected to prove of either great or frequent service, but that if it be had recourse to, it should be during the second stage, when plainly medical treatment has failed to arrest or mitigate — and before the third stage has set in, rendering recovery under any circumstances all but absolutely hopeless. Recourse to the operation may be regarded, therefore, as the exception rather than the general rule.* An operation of a simpler kind, and sometimes productive of benefit, * I am quite aware that authority is not wanting to enforce an opposite practice; Trousseau and Bretonneau, for example, warmly advocating the performance of tra- cheotomy in croup, and supporting their doctrine by an array of successful cases (Brit, and For. Rev. No. 23, p. 110). But, on this point, the question always obtrudes itself : — Were these cases all examples of true croup ? For it is well known how loosely medical Fig. 86. Example of false membrane, in croxip. Its evil consequences very apparent. LARYNGITIS PURU LENTA. 239 has lately been advocated by Mr, Green of New York, and others ; namely, the direct application of nitrate silver, in strong solution, to the affected part. By means of a powerful spatula, the tongue is depressed and brought forwards ; a bent piece of whalebone, tipped with sponge, and soaked in the solution (from two to four scruples of the salt to the ounce of distilled water) is passed behind the epiglottis, and then rig. 87- suddenly forced on into the larynx. The effect is twofold ; mechanical clearance of the canal, the sponge withdrawing much mucus and exudation, and the nitrate exciting a curative influence on the affected membrane. At first, the presence of the foreign body is resented by unpleasant spasm and irritation ; but these soon subside ; and the operation may be repeated at such intervals as circumstances may seem to require. But there are cases of true laryngitis fibrinosa, in which the action is mainly limited, and the pseudo-membranous exudation entirely confined, to the larynx itself. These are few certainly, compared with the ordinary examples of croup ; still they do occur ; and may be diagnosed by the absence of tracheal and pulmonary symptoms, and by the apparent concentration of laryngeal disorder. In such cases, if other treatment fail in the second stage, and symptoms are urgent, tracheotomy should be unhesitatingly practised, on precisely the same grounds as in acute oedema — and probably with the same fortunate result. Diphtheritis, or Cynanche niemlranacea, may be said to be a variety of nomenclature is often applied ; and as, by some, all sores on the penis are called chancres, all hard swellings on the breast dignified by the appellation of scirrhus, every bleeding fungus called fungus hematodes — so may all acute affections of the larynx be arrano-ed under the general denomination of croup. Fig. 87. End of the sponge-probang, for the larynx ; the sponge always carefull_v affixed to whalebone not made brittle by the caustic. 240 CHRONIC LARYNGITIS. laryngitis fibrinosa. The aphthous, exudation, however, and the action which causes it, do not originate in the larynx, but in the mouth and fauces, thence spreading rapidly downwards. The lungs, through the bronchial ramifications, are early involved, and cannot possibly be relieved by a tracheal wound. Bronchotomy, therefore, is in this affection inadmissible. d. Laryngitis Purulenta.* — In this, the inflammatory process is more advanced than in any of the preceding forms of acute laryngitis ; true inflammation is reached, and its charactei'istic product exhibited. Fortunately such a result is of comparatively rare occurrence ; and fortunately also, when it does occur, the action is usually confined to the upper part of the larynx, and corresponding portion of the fauces. The matter is not limited in the form of abscess, but is diffusely infiltrated into the submucous areolar tissue. The membrane gives way, the matter is discharged, and an ulcerated surface remains. The symptoms and progress are very similar to those of acute oedema. And the treatment is to be guided by precisely the same principles. By medical treatment we hope to arrest the action, in time to avert peril to life. If not, and dyspnoea increase threateningly, tracheotomy is to be performed, early, in the second stage, as a part of the remedial treatment. The prognosis is favourable — as in oedema, when timeously relieved. Acute ulceration of the larynx may result from this affection, as already stated ; almost certain to be attended with more or less swelling ; and consequently requiring the same surgical aid as the acute oedema glottidis. II. Chronic Laryngitis. — This may be the result of an acute or subacute attack ; moi'e frequently it is chronic from the first. But, however originating, it is ever liable to sudden and acute aggravation, from comparatively slight causes ; bringing life into peril, — all the more imminently on account of the insidious and comparatively mild nature of the previous symptoms. a. Thichening of the Mucous Membrane, resulting from what may be termed Simple Chronic Laryngitis, usually gives way to remedial treatment alone ; leeches, counter-irritation, mercury, and other alter- atives. Should an acute accession supervene — and to such the patient is constantly liable — obstruction to respiration may be speedily induced, threatening the most serious consequences. Under such circumstances, proportional augmentation of the medical treatment may fail to relieve ; and then tracheotomy comes to be required. As a general rule, when counter-irritation is employed in any affection of the larynx, it should be applied either laterally, or on the back of the neck, not in front. For, the remedial effect is the same ; * London Medical Gazette, January 12, 1833. CHRONIC CEDEMA GLOTTIDIS. 241 and it is obviously expedient to leave the site of tracheotomy clear and available, in the event of recourse to that operation becoming necessary. h. Follicular disease of the larynx is an affection of great fi-equency ; the morbid action being resident and in most cases originating in the mucous follicles. These are seen on the back of the pharynx, in various stages and forms of alteration by disease — hypertrophied, vesicular, pustular, ulcerated ; and the presence of similar change Avithin the larynx is marked by characteristic symptoms — cough, expectoration, hoarseness of voice, &c. If permitted to advance, the consequences are serious ; loss of voice, increase of structural change in the air passages, and impairment of the general health. Treatment consists in rest of the parts ; application of the nitrate of silver, in the manner already described (p. 238), both to the fauces and within the larynx; and alteratives internally, according to circumstances — arsenic, iodide of iron, Donovan's liquor, &c. c. Chronic (Edema Glottidis. — This affection is more gradual and less marked than the acute form ; but is not less dangerous ; being liable to sudden and great exacerbation. The oedema is gi-adually formed, of more solid consistence, and more uniformly diffused. But from slight exposure to cold, error in diet, or other casualty, acute accession is very prone to supervene ; speedily blocking up the passage, and causing the most distressing and dangerous dyspnoea ; partly by acute swelling, partly by entanglement of viscid mucus, partly by spasmodic or otherwise disordered action of the muscles of the larynx. Sometimes, without any apparent source of aggravation, a fit of dyspnoea suddenly occurs ; dependent, probably, on the last mentioned cause — spasm. Such a patient is never secure. One moment he may be walking abroad, conversing, or otherwise enjoying life with tolerable comfort ; the next he may be prostrate, livid, and struggling for existence. A fatal result, however, seldom follows the first of such seizures. Minor attacks usually precede the fatal event. The duty of the practitioner is, by suitable treatment, to ar- rest the sluggish action, to undo the change of structure, and to restore tone to the enfeebled system ; and, by every care, to provide against the application of such causes as are likely to induce aggrava- tion. Should such aggravation occur, he must be on the alert. Medical treatment is continued, with redoubled care and anxiety ; and the patient is closely watched. If the treatment prove unsatisfactory — fits of dyspnoea continuing to recur — tracheotomy is certainly to be performed. Thus only can the tenure of life be rendered at all secure in such cases ; and then, too, the other remedial means may be ex- pected to have a more salutary effect on the original disease — as in the case of simple thickening. After some time, the tube may be with- K 242 ULCERATION OF THE LAEYNX. drawn, and the wound closed. However, prognosis as to discontinu- ance of the tube is not so favourable as in the acute form. Resolution may be slow and imperfect ; the part may never wholly regain its normal state ; perhaps respiration cannot be restored through the normal passages ; and the tube, consequently, may require to be worn during the remainder of life. d. Ulceration of the Larynx. — The larynx is liable to ulceration of different kinds — the result usually of chronic inflammatory action : 1. Simple ulceration may occur as a direct result of chronic laryngitis, or of follicular disease ; or the larynx may be implicated secondarily by extension of ulceration from the fauces — as is not unlikely to happen in patients who have the misfortune to labour under an aggra- vated form of mercurio-syphilis. The ulceration is very liable to be surrounded by cedematous swelling, which, by obstructing respiration, seriously complicates the case, and may demand both instant and ener- getic measures to save life. And such complication is especially apt to occur, if by exposure, or other cause, an inflammatory aggravation have supervened on the previously chronic form. Or the amount of oedema may be slight, respiration may never be seriously impeded, the ulcer may heal, and the normal calibre and function of the larynx may be almost wholly restored. Or, on cicatrization — long delayed — contraction and displacement of the parts are such as permanently to interfere most seriously with both voice and respiration. Treatment consists in constitutional alteratives, suitable regimen, careful protection from all sources of aggravation, patient continuance of moderate counter-irritation, and regulated use of nitrate of silver to the affected part; and thus we hope to effect cicatrization, ere dangerous loss of substance has occurred — to effect, in short, something like actual resolution. If oedema supervene, and life be threatened by paroxysmal dyspnoea, tracheotomy is imperatively demanded, and must be per- formed. At this juncture, it is indispensable to the preservation of life. But it comes to be a question, whether its earlier employment may not be expedient ; not to save life, directly, but to save structure ; by placing the larynx at rest, and so facilitating the action of remedial means — accelerating cicatrization while ulceration is yet both limited and superficial, and thus preserving unimpaired the important function of the organ. I would incline to the opinion that it is expedient to have recourse to tracheotomy, and temporary use of the tube, in those cases of simple ulcer of the larynx which threaten to resist ordinary remedial means, and which, by loss of substance, endanger the function of the part ; operating before life has been threatened by intercurrent oedema ; when there is soreness on pressure of the thyroid cartilage ; when pain is felt acutely, on the box of the larynx being rubbed laterally across the spine ; when there is a sensation of rawness PHTHISIS LAEYNGEA. 243 and soreness in the part complained of by the patient ; when there is decided and peculiar fcetor in the breath, with pain and difficulty in swallowing, cough, and purulent sputa — occasionally streaked with blood; and when these symptoms persist unsubdued. By the operation, the diseased part is put at rest ; counter-irritation and alterative treatment will have a much more powerful and salutary influence ; and besides, an additional opportunity is afforded of applying remedial means directly to the ulcerated surface. From the tracheal wound, the nitrate of silver may be applied freely to the diseased surface, more readily and accurately than through the glottis. And thus, healing may be obtained at an earlier period than otherwise could have been possible ; the part recovers without loss of substance ; and, after a time, the tube may be finally withdrawn, leaving the cure complete. When, however, tracheotomy has been performed at an advanced period of the case, on account of emergency caused by oedema, the tube's discontinuance is very uncertain ; a falling in of the box of the larynx is too probable, as the result of cicatrization ; and in consequence, permanency of the artificial opening may be rendered indispensable. 2. TvMrcular Ulceration not unfrec[uently attacks the windpipe ; constituting the true Phthisis Laryngea. There is first submucous or mucous deposit of tubercle, which softens, disintegrates, and opens up the membrane in patchy chronic ulceration. The scrofulous cachexy attends ; and too frequently, also, phthisis pulmonalis is co-existent. Although by no means likely to make a satisfactory impression on such a constitutional malady, still the ordinary treatment is to be patiently employed. Tracheotomy is certainly not advisable, as a means towards cicatrization and cure ; but it may be had recourse to as a mere palliative — a means of protracting existence — when, by the occurrence of oedema, life is threatened from suffocation. 3. A diseased state of the cartilage is not unfrequent, in broken down mercurio-syphilitic habits ; associated with chronic abscess and ulcera- tion. In advanced age, the cartilages become ossified, and may necrose. But this which we now allude to is a different affection ; bearing the same analogy to senile degeneration of cartilage, as atheromatous deposit in the arterial tissue, favourable to aneurism, does to the senile calcareous condition of arteries. The ccrLilage is thickened, indurated, changed in hue, and partially ossified ; portions die ; suppuration takes place around ; the matter bursts into the wind- pipe, and is expectorated ; a ragged ulcerated ajjerture remains ; the diseased portion of cartilage loosens, protrudes, and, having been wholly detached, is expectorated ; the cavity which held it may then contract and close, along with the ulcerated aperture through which it made its escape ; or additional suppuration takes place, fresh portions become necrosed, and the disease is both aggravated and protracted. R 2 244 WARTS OF THE LARYNX. In the most favourable point of view, prognosis is unsatisfactory ; for cicatrization cannot take place, without entailing such contraction and change of the canal as must seriously and permanently interfere with respiration. Sometimes a dead portion of ossified cartilage, having been detached, falls downwards ; and becoming impacted in a bron- chial ramification, leads to a fatal issue, either suddenly by asphyxia, or more remotely through pulmonary disease. Treatment is as in ordinary ulceration of this part, with especial attention to the constitutional vice. And when an emergency, peril- ling life, does occur, by intercurrent oedema of the larynx, tracheotomy is certainly advisable ; not with the hope of thorough cure, but in order to avert immediate danger, and perhaps to accelerate cicatriza- tion. If life continue, the tube must be permanently worn ; for, under the most favourable circumstances, it is not to be expected, in this affection, that normal calibre and function can be regained. Tracheal Fistula is apt to result from the preceding affection. The abscess connected with the necrosed portion of cartilage may discharge itself externally, as well as into the windpipe, and a fistulous aperture is not unlikely to remain. This may be brought to heal, by the occasional use, at long intervals, of heated wire (Principles, p. 226). But let no attempt at closure be made, until we are certain that the necrosed portion has been fairly extruded, and that no fresh sequestrum is in progress there ; otherwise, by confining the matter, and so causing swelling and obstruction, serious con- sequences to respiration may ensue. Warts of the Larynx. Warty excrescences have sometimes been found growing from the lining membrane of the larynx, at its upper part ; and solid en- !''&• 88. largements of structure, pendulous, pyi'iform, and of the nature of polypus, have also, though still more rarely, occurred. They necessarily impede respiration ; and, by leading to an inflammatory accession, with its attendant oedema, they may bring life into sudden and imminent jeopardy. The voice is hoarse, and ultimately lost ; a hard cough, like that of croup, is troublesome ; and during deglutition and expectoration, the sensation is felt of a foreign body in the larynx ; but the most characteristic evidences are the Fig. 88. Warts in the larynx ; growing in the situation of the vocal chords. STRICTURE OF THE WINDPIPE. 245 expulsion of small portions of the tumour by coughing, and the seeing and feeling its upper part by careful and deep exploration of the fauces. When an emergency by dyspnoea occurs, tracheotomy is plainly re- quired. Through the wound — made more free than usual — the growth is removed, by evulsion or knife. And for some days, at least, the use of the tracheotomy tube will be expedient, lest inflammatory swell- ing occur at the injured part.* Stricture of the Windpipe. Contraction of this tube is liable to occur, at various points, and from various causes ; by contraction of the wound after cut throat ; by contraction after cicatrization of ulcers ; by change of structure following on chronic laryngitis, independent of ulceration ; by necrosis and discharge of portions of cartilage, and consequent narrowing of the passage after closure of the ulcerated cavities. It is doubtful whether our art may be able to restore the normal calibre and function in such cases, by dilatation, as in similar affections of other mucous canals. The experi- ment has been made ; f but the present voice of ex- perience is as yet scarcely in favour of the measure — except in the case of contraction after wound (p. 227). Life may often be protracted, however, and suffering alleviated, by continued use of the tracheotomy tube, of full size ; and by unremitting attention to keep both tube and trachea free from accumulation of viscid mucus. The latter indication may become of easy fulfilment, in consequence of the tracheal and bronchial membrane losing much of its sensibility — becoming almost cutaneous in this respect, and not resenting a tolerably free use of probe, feather, sponge, or other means employed for clearing the passage. * Vide Monthly Journal, Dec. 1840, p. 4.58. f Liston, Elements, p. 453. Fig. 89. Double strictm-e of the trachea; the canal decidedly dilated on the lower aspect of the second contraction. "The patient had worn a small SLl\er tube in an open- ing in his windpipe for many years. It was originally introduced on account of long- continued disease of the larynx, with dreadful suffering and constant sense of impending sviffocation. He could not be made to dispense with the tube entirely, as he felt imme- diately on the wound closing a threatening of retm-n of his painful and dangerous symptoms. A small one was substituted for that at first used. He led a very irregular life, used a vast quantity of opium, and no small amount of spirituous liquors. He used to be out in the open air occasionally all night, and suffered repeatedly under attacks of bronchitis. He was under treatment again and again in the hospital, on account of rheumatic affection and deranged digestive organs. He used occasionally to present himself, complaining of difHcult breathing, and stating that his silver tube was too short. Fk'. 89. 246 CASES EEQUIEING BRONCHOTOMY. Formation of Matter near the Lai^nx. Diffuse infiltration of purulent matter may take place, deeply, in the neck; and the consequent swelling and tension may seriously impede respiration, by encroaching on the canal of the windpipe. The proper remedy is free incision of the infiltrated part, whereby both cause and effect are at once removed. Should this fail, or should the symptoms prove obscure so as not to warrant or even indicate incision, tracheotomy is certainly advisable. Circumscribed abscess may form in the vicinity of the larynx. And the rules of practice are the same ; an early evacuating incision, if possible; otherwise, tracheotomy. BroneJiotomy, then, is available, in the following cases : — 1. In the case of foreign bodies lodged in, or otherwise obstructing, the air pas- sages. Extrusion, independently of this operation, may be expected to be the exception to the general rule. 2. In suspended animation; when we cannot otherwise effect, with certainty, artificial inflation of the lungs — as will rarely be the case. 3. In sj^asm of the glottis. Threatened asphyxia from external injury may perhaps depend on this cause — perhaps on a precisely opposite condition ; in either case, the operation is demanded to save life. And there is a like necessity, in the spasmodic occlusion of the glottis which attends poisoning by cai'bonic acid. In laryngismus stridulus, Ave withhold the operation if possible, and trust to general treatment ; yet we are aware that urgent circumstances may arise to demand the tracheal wound, at least with the hope of palliation, and perhaps with the effect of affording time for the effectual working of other remedies. In cer- tain cases of thoracic aneurism, too, when laryngeal distress is occa- sioned by irritation of the recurrent nerve and threatens immediate death, tracheotomy is advisable — in some few cases, it may be, with more than the hope of mere palliation (p. 234). 4. In oedema glottidis, chronic and acute, there is no safety but by operation, so soon as the symptoms have become at all urgent. And, in the acute cases, there is good hope of speedy discontinuance of the tube, closure of the arti- He could articulate tolerably well when he stopped with his finger the orifice of the silver tube ; at all times a part of the respired air passing through the natural channel. Latterly, he used to suffer from thi-eatening of suffocation, and he used to relieve himself of the cause of this, viz., the inspissated and ropy mucus which got entangled in the trachea, then not suspected to be in a diseased state, bj^ pushing through the opening in his neck and into the bronchi, long turkeys' feathers ; of these he carried a good store, and some are now in my possession. This feat he performed without causing the slightest excitement or coughing. Ultimately, and about twelve years after the operation had been performed, he died, principally from diseased viscera." — Liston. Vide Elements of Surgery, p. 4o4. CASES REQUIRING BRONCHOTOMY. 247 ficial aperture, and complete restoration of normal respiration. 5. In laryngitis fibrinosa, the operation is as warrantable as in urgent oedema, when the disease is limited to the larynx. But in most cases of true croup, in which the whole windpipe with its ramifications is involved, operation may rather be regarded as an exception to the general rule of non-interference ; in the early stage, it is inexpedient, while mecha- nical obstruction to respiration is not yet threatened; in the more advanced period, it is likely to prove ineffectual. 6. In purulent laryngitis, there may be the same necessity for operation, and the same prospect of a good result, as in acute oedema. 7. In chronic laryngitis with thickening, the supervention of oedema, through in- flammatory accession, may render operation indispensable to the preservation of life. 8. In simple ulceration, the same event may occur as that just mentioned in connexion with mere thickening of the membrane. Or, independently of such an accidental crisis, operation may be deemed expedient, to assist the action of other remedial means, and by effecting early cicatrization to save structure and function. 9. In ulceration, ivith disease of cartilage, operation is likely to be required to save life from immediate danger by threatened asphyxia ; but with little or no prospect of discontinuance of the tube's use. 10. In phthisis laryngea, it may be similarly demanded for a temporary object ; scarcely with a hope of contributing to cure ; but rather as a means of protraction and palliation. 11. In pressure on the windpipe, caused by the formation of tumour or abscess, or by impaction of food in the oesophagus or pharynx — operation may be necessary, if the obstruction to respiration cannot be otherwise relieved, namely, by removal of the cause ; by evacuation of the matter, extir- pation or diminution of the tumour, or extrusion of the impacted substance. 1 2. In cut throat, tracheotomy is not unfrequently demanded to save life from impending asphyxia ; and it may be expedient, at an early period of the case, to avert all such hazard, and to favour as well as permit immediate and entire closure of the wound. 13. In glossitis, in tonsillitis, and in extreme cases of pharyngitis, it is required, when swelling is so great, rapid, and uncontrollable, as otherwise to render fatal asphyxia all but inevitable. 14. In carotid aneurism of large size — when by circumstances we are precluded from speedy recourse to deligation of the artery — life may be suddenly brought into peril, by supervention of the diffuse form on the circumscribed (Principles, p. 554), and consequent compression of the windpipe. Bronchotomy then is essential ; and the tube will require to be woni, until by deligation of the artery we have effected such diminution in the bulk of the tumour as altogether to free the respiratory canal. 15. Thoracic aneurisms, by compressing and narrowing the air^passages, may simulate the results of inflammatory disease in the larynx ; and. 248 LARYXGOTOMY. in such circumstances, little good can be expected from bronchotomy. In those cases, however, in which the tumour is small, and causes dangerous paroxysms of dyspnoea by spasm of the larynx arising from irritation of the recurrent nerve, the operation, as already stated, is certainly expedient (p. 234). In the great majoiity of cases, tracheotomy is preferable to laryn- gotomy, for obvious reasons. The passing of tubes into the windpipe, by the nose or mouth, has been proposed as a means of superseding bronchotomy. But modern experience limits their use to cases of suspended animation, unconnected Avith laryngeal or tracheal disease ; and even then, their superiority may come to be a matter of question and doubt. Laryngotomy. The performance of this operation having been determined on, the patient is seated on a chair, with the head thrown back and steadied. A longitudinal incision is made over the box of the larynx, in the mesial space ; by dissection, the crico-thyi'oid membrane is exposed ; and through this an opening is then made by the knife — as free as the cartilaginous boundaries of the space will allow. There will seldom be any trouble by hemorrhage. Tracheotomy. Excepting the case of artificial respiration on account of asphyxia unconnected with laryngeal disease, the case of a foreign body impacted in the rima, and the case of a loose foreign body of small size within the vpindpipe, tracheotomy is certainly preferable to laryngotomy. The patient having been placed as for the latter operation, an incision is made in the mesial line of the lower part of the neck, fr'om an inch and a half to two inches in length, the upper portion terminating a little above the cricoid cartilage. Skin, fat, and fascia having been divided, the commissure of the sterno-hyoid muscles is exposed ; and this is carefully separated by the handle of the knife. The tracheal rings are made bare ; detachment of the areolar investment being effected by either the point or handle of the knife, according to circumstances. Then the patient, if adult and conscious, is directed to swallow saliva. While the windpipe is rendered tense and elongated in the act of deglutition, the scalpel is made to penetrate at the lower part of the wound, with its back to the sternum ; and, by a sawing movemei* of the instrument upwards, the necessary extent of tracheal wound is completed ; the isthmus of the thyroid gland being pushed TEACHEOTOMY. 249 Fi''. 90. out of harm's way, by the finger — upwards. If operation have been undertaken on account of the lodgment of a foreign body, no tube is necessary. The wound having been made, the foreign substance, if loose, will be expelled at once ; if not, it is to be sought for by probe and forceps, as formerly stated. In the case of disease, it is our object to establish a constant and sufficient aper- ture for respiration, at the site of the wound ; accordingly a curved silver ca- nula is introduced ; and this is retained by tapes passing from a ring on each side of the canula, to be secured behind the neck. The canula is of sufficient size to atone, completely, for the temporarily occluded rima ; varying, consequently, according to age ; and, generally, of not much less diameter than the trachea which receives it. Yet it should not be so large as to press harshly on the lining membrane of the passage, lest ulceration be induced. The wound should be of size sufficient to receive the canula, without force, and yet not too freely ; the cut margins should be compressed by the ca- nula, internal escape of blood being so prevented ; and this object is further contributed to by the conical form of the instrument. To fa- cilitate introduction, the canula may be provided with a plug, the bulbous end pro- jecting — as in the va- ginal speculum ; an idea for which we are indebted to Dr. W. T. Gairdner. The patient is laid on his side, so as to render the wound dependent, and favourable to the outward escape of blood and mucus. After a time, when the conical form of the tube is no longer an advantage, on account of hemorrhage, an instru- ment of uniform calibre may be substituted, as more suitable for respir- ation. And in cases of old standing — more especially those in which the tube is permanently retained — a double canula maybe used ; one por- tion being removed from time to time, for the purpose of being cleaned, while the other remains keeping the canal constantly free. To the orifice of such an instrument, too, it is well to attach a valve, which Fig. 91 . Fig. 90. Ordinary canuJa; a, in profile; b, transverse section of orifice. Fig. 91. Canula, as recommended by Dr. Gairdner. From a to b the canula ; c, the end of the plug, projected ; d, the handle of the plug. The plug is of course withdra'vni, so soon as the caniila has entered the windpipe. 250 TRACHEOTOMY. opening to the full in inspiration leaves the whole space free, but shut- ting in expiration forms a sraaller aperture suitable for expectoration. The circumstance of the canula's introduction being itself an efficient hemostatic means, materially facilitates performance of the operation.* It is not necessary to wait for entire cessation of bleeding, before opening the windpipe ; no valuable time need be lost in stem- ming oozing; main jets of blood, if any, having been secured, the tracheal wound is at once made, and the tube as speedily introduced. At first the presence of the foreign body, and of the small quantity of blood which has necessarily entered along with it, is much resented ; a violent fit of spasmodic cough, threatening suffocation, ensues ; but the blood having been thrown back, through the tube, this fit of irri- tation passes off, and comparatively calm respiration is speedily esta- blished through the artificial opening. For many hours — but more especially during the first few — the patient must be carefully watched, lest the tube become obstructed by mucus ; and this is from time to time to be cleared away, by a probe armed with lint or sponge, or by a feather ; or the double canula may be used from the first, admit- ting of one portion remaining in the wound, while the other is with- drawn and cleaned occasionally. Such attention is particularly neces- sary, as formerly stated, if the patient have fallen asleep after the operation (p. 237). When expectoration is attempted, it is necessary to diminish the aperture of the ordinary tube very considerably, by temporary application of the finger ; so that the expired air may be expelled forcibly. At first, this narrowing is made by the surgeon ; but soon the patient becomes an adept in the simple manipulation. Should he grow too weak to expectorate, it is well to attempt extrac- tion of the mucus by suction ; by the adaptation of a syringe^ or by the mouth of an assistant — if possible. As already seen, in some cases the tube may be withdrawn, and the wound permanently closed, after a few days or weeks ; in other cases, normal respiration can never be restored, and the tube must be worn during the remainder of life. And in these latter, it is truly surprising how little inconvenience is sustained ; respiration becomes easy and silent, and even the voice may be regained, so far as to admit of the patient fulfilling the ordinary duties and customs of society. The prominent danger of the operation is by hemorrhage. During the incisions this is to be guarded against by caution in the placing and making of them ; more especially avoiding the large veins which are often to be found in the lower and front part of the neck ; and if any stray vessel be encountered, it should be held carefully out of the * The tube is a hemostatic, not only by its pressure on the edges of the wound ; but also, and very importantly, by freeing the venous return in the neck, which during dyspnoea is necessarily much retarded. BRONCHOCELE, OR GOITRE. 251 way by an assistant. Arterial branches, which spring, are to be secured by ligature ; to venous orifices, temporary pressure may be applied. On account of mere venous bleeding, hoAvever, no delay should take place ; more especially when the operation is being per- formed on account of dyspnoea ; for the most likely means of freeing respiration, favouring venous return, and obtaining a comparatively quiescent and empty state of the veins implicated, is by lodging the tube in the tracheal wound. It has been often proposed, with a view to render the operation both more simple and safe, to perforate the trachea by means of a trocar and canula ; discarding the knife. The proposal looks well in theory ; but has found no favour with the practical surgeon — for reasons too obvious to require their formal statement. In all cases, it is obviously of much importance to keep the patient in an equable and genial temperature, to cover the wound with some cloth of loose texture, and to take every other means which may suggest itself, as likely to ward off the accession of inflammatory action by the stimulus of cold air directly applied to the membrane — as in the case of cut throat (p. 225). In the child, operation may be rendered extremely difficult ; by the restlessness of the patient, the crying and struggling which engorge the veins, the small size of the trachea, the limited space of the neck, the number of veins likely to be encountered, and the intolerance of loss of blood on the part of the system. The dissection must be conducted with unusual caution ; and it is well, after exposure of the trachea, to fix it by means of a sharp hook, so as at once to facilitate and render more safe the performance of the tracheal wound. So soon as this has been effected, the child should be instantly turned upon its face, so as to prevent, as far as possible, escape of blood into the trachea. On cessation of the hemorrhage, the ordinai-y position may be resumed, should the circumstances of the case render this expedient. In most cases, anagsthesia will be considered inexpedient, except during exploration by forceps after the operation has been performed, on account of the lodgment of a foreign body (p. 231). Bronchocele., or Goitre. The term denotes swelling of the thyroid gland ; and this may be of various kinds. 1. Mere hypertrophy is common; the enlargement being essentially chronic and very gradual ; and ultimately making a transition into the state of simple tumour (Principles, pp. 292 and 306). The whole gland may be equally involved ; or the isthmus alone may enlarge, while the lobes remain of a normal character ; more frequently one or other lobe is the seat of the partial affection ; 252 BRONCHOCELE, and sometimes both lobes are involved while the central portion remains free. And, indeed, the same remarks, as to the partial or general character of the swelling, apply to the other varieties of the affection. 2. The swelling may be of a cystic nature ; the stroma being analogous to the structure of simple tumour ; the cysts either numer- ous and small, or few and capacious, delicate, and filled with a glairy fluid. This probably is the most frequent form of the disease. 3. The simple stroma may contain a greater or less amount of cal- careous matter ; giving much density to the tumour, which is seldom then of large size. 5. The i\xva.o\iv -ma,j he, malignant. Carcinoma is rare. Cephaloma, which is not so, follows its ordinary course, and presents its usual characters. Bronchocele is, in certain localities, an endemic disorder. In the Tyrol, and in the valley of the Rhone, it is especially so ; and there almost invariably associated with a sadly deteriorated condition of the frame, to which the term Cretinism has been applied. In this country, the disease is comparatively rare, and happily such an unfortunate combination but seldom exists. In Derbyshire, and some other coun- ties, both in Scotland and England, however, it merits the appellation of endemic. The majority of the patients are female ; and the ordi- nary period of invasion is about the time of puberty. The most pro- minent symptom is inconvenience, with deformity, occasioned by the bulky swelling. Growth is gradual and painless — unless in the malignant variety. The indications by touch vary according to the nature of the interior. As the tumour enlarges, the head becomes disordered, in consequence of venous return thence being interfered with ; and respiration also is more or less seriously impeded, by pres- sure on the windpipe — especially when the central portion of the gland is affected. Partial enlai-gement — affecting but one lobe — is apt to simulate carotid aneurism, receiving a decided impulse from the adjacent vessel; and careful manipulation is necessary to arrive at a correct diagnosis. In addition to the ordinary diagnostics (Principles, p. 563), it is to be borne in mind that, on deglutition being performed, a bronchocele will be found to move upwards with the larynx, while an aneurism remains unaffected. The causes of the disease are scarcely yet evolved from obscurity. Where endemic, it seems certainly connected with habitual use of un- wholesome water as an article of food, and habitual exposure to a humid atmosphere ; and this circumstance necessarily possesses an im- portant bearing on the question of cure. Treatment. — In reference to treatment, the examples of this disease may be conveniently divided into two classes ; those which are merely deformities, unseemly and somewhat troublesome by their bulk ; and those which bring life into peril, directly or indirectly, by interference BEONCHOCELE. 253 with the brain and the air passages. For the latter, the most deter- mined remedial means may be with all propriety resorted to ; for the former, heroics are not warrantable. And, fortunately, the majority of cases, in this country, demand only the milder form of treatment. Iodine has long been regarded as the most powerful remedy ; and justly. Internally, it is administered in the foi'm of iodide of potassium — or combined, as with iron. Externally, it is applied in the form of solution, painted frequently on the swelling — or ointment, or lini- ment, rubbed in — moderate leeching having been premised, in those cases in which continuance of nutritive excitement may seem to render such a measure expedient; our object being to arrest growth, as well as to discuss bulk already attained. At the same time, habitual exposure to a dry and otherwise salubrious atmosphere, with habitual use of sound water — chalybeate if possible — are curative indications by no means to be neglected. And such treatment will be carefully maintained, so as to prevent a tumour, originally of the first class, from becoming of the second, and seriously perilling life by interfering with both breathing and circulation. Central tumours, pressing on the windpipe, may be removed by operation, when of no great size ; partly by excision, partly by deliga- tion. By the scalpel the integuments are freely divided, and turned aside ; the tumour is laterally separated from its connexions, care be- ing taken to secure each arterial orifice by ligature, so soon as divided, and each venous orifice — as far as possible — by pressure of the fingers of an assistant ; and having proceeded as far with the knife, in the work of detachment, as prudence will allow, the remainder of the con- nexions are to be included tightly in ligature. A strong needle is passed beneath the base of the tumour, the double ligature is divided, and each portion is tied separately, so as to strangulate the mass (Principles, p. 600, Fig. 197). Tumours of the isthmus have been thus removed successfully ; and it is probable that the same principle of operation may sometimes be extended to other swellings not limited to that part of the gland. Large, solid bronchoceles, involving the whole gland, and of greatest bulk laterally, are not amenable to such radical cure. Their size, site, and attachments preclude the use of ligature ; and attempted removal by the knife could scarcely fail to prove fatal by hemorrhage. Of late, however, an ingenious mode of operation has been devised by M. Porta ; founded on observing that the large arteries which supply the thyroid gland do not enter the interior of it, but break up into numerous small branches at the circumference, and that consequently hemorrhage need be dreaded only when the exterior part of the tumour is interfered with. Besides, the majority of simple bronchoceles he found to consist of numerous cellular or cystic developments, which 254 BEONCHOCELE. push aside the proper texture of the gland, reducing that to the condition of a simple envelope, on dividing which the new products are exposed, or may be extracted without difficulty, injuring only small vessels, and leaving behind a fleshy sac which collapses, leaving no trace of the tumour. Accordingly, the operation is performed thus : — the integuments of the neck, and usually also the omohyoid muscle, are divided by incision ; the tumour is cut into, avoiding the trunks of the thyroid arteries ; if any of these spring, they are tied or twisted; the exposed cysts are removed by forceps, or the handle of the knife ; more solid structure, if it exist, is broken down and extruded by the same means ; and bleeding having been arrested, the wound is closed.* In hopeless cases life may be protracted, and great relief affiarded, by subcutaneous section of one or both sternomastoid muscles, so as to diminish tension, favour outward growth, and relieve the trachea and jugular from compression. In some cases also, protraction and palliation may be obtained by tracheotomy ; when the circumstances of the case are such as to render the performance of that operation practicable. For the purely cystic bronchocele, simpler means may supersede the more formidable operation of M. Porta. Iodine may be injected as in hydrocele (and to such affections some apply the term hydrocele of the neck, p. 220), or a seton may be used. The cyst having been punc- tured, and its contents evacuated, a few threads of silk may be passed through the substance of the swelling, and retained. It is probable that the inflammatory result will lead to obliteration of the cystic formation ; but much care is necessary in watching the action, lest it prove excessive, and threaten asphyxia through sudden and great enlargement of the swelling. For the solid tumours, the seton is not well adapted ; it not only fails to discuss, but is also exceedingly prone to accelerate growth. The malignant bronchoceles — ^fortunately rare — are incurable. Tumours over the Thyroid Gland. Not unfrequently cystic formations are found, not in the substance of the thyroid gland, but between this and the integument. If of small size and circumscribed, they may be dissected out. Those which are large may be treated by seton or injection. * Brit, and For. Med. Chir. Eev. Jan. 1851, p. 106. DISEASE OF THE CERVICAL VERTEBRA. 255 Enlargement of the Thyro-hyoid Bursa. Like other bursse, that which is situated between the hyoid bone and thyroid cartilage is liable to enlargement, chronic or acute ; caus- ing more or less swelling, with pain, and obstruction to the movements of the neck. The acute form is met by repeated leeching and fomenta- tion ; the chronic is appropriately treated by the local application of iodine in solution, or by other discutients. Hernia Bronchalis. A rare aflFection, so called, has been observed in those who habi- tually strain the throat in loud and sustained calling. A fold of the lining membrane is protruded outwards between two tracheal carti- lages ; and thus a greater or less tumour, soft and compressible, is formed, according to the extent of protrusion. The only remedial means advisable are such outward applications as are likely, by afford- ing external support, to oppose further enlargement. And the excit- ing cause — straining of the throat — is, of course, to be discontinued. Disease of the Cervical Vertehrce. The chain of cervical vertebrse, like other bones with their articu- lating surfaces, is liable to disease of various kinds : — 1. The bodies of the vertebrae may be interstitially absorbed. Then a greater or less degree of curvature is likely to ensue ; the head usually bending for- wards, with deviation to one or other side ; and, not unfrequently, there is thickening of the soft parts exteriorly, in consequence of a chronic inflammatory process slowly advancing there. 2. Or the bodies of the vertebrae are affected by the results of true inflammation. At first there are thickening, hardness, and tenderness on pressure ; indicating the ostitic and periostitic stage. Afterwards matter forms, the bones are eroded by ulceration, and portions may be detached in the form of sequestra. There are pain, swelling, tenderness on pres- sure, and the other usual signs of an advancing action of disorganiza- tion. More or less deformity, by curvature, necessarily ensues ; partly from change in the bones, partly from a wasted and paralyzed state of the extensor muscles. As can be readily understood, deglutition is early and much interfered with; and by encroachment on, and involve- ment of, the cervical nerves, serious results are likely to occur, as regards respiration. The functions of the superior extremities, too, may be perilled, by affection of the brachial plexus. The disease is generally connected, in the patient's narrative, with external injury ; and the persons most likely to be affected are the young and strumous. 256 DISEASE OF THE CERVICAL VEETEBE.E. 3. Or the disease may originate in the articulating textures; ultimately inducing similai'ly destructive results. 4. There is good reason to believe that, not unfrequently, such affections follow in regular suc- cession ; the diseased action commencing in interstitial absorption of the bones, advancing from absorption to true iniiammation, and ulti- mately disorganizing both bone and joint. The obvious treatment of such disease, is to endeavour to arrest its course by leeching and counter -irritation — the latter of the graver sort (moxa, or actual cautery), and patiently continued ; to exhibit iodide of potassium internally, more especially when taint of the system is suspected ; to keep the part at rest ; and, in the advanced cases, to relieve the aJBTected bones from the weight of the head, as much as possible, by mechanical means. A firm iron rod, fixed in a circular girth on the trunk, passes upwards, excurvating to receive the posterior part of the head, and terminating over the forehead ; and by a bandage or strap attached to the extremity of the rod, and passed under the chin, the required support is afforded. All suddenness of motion in the neck is especially to be avoided ; but indeed, in most cases, the patient has an instinctive dread of such risk, and carefully guards against it ; turning the head slowly, and with the chin supported on the hand. In the case of disease affecting the atlas and dentata, such precaution is particularly necessary ; lest by sudden ruptui'e of the ligamentous apparatus, disjDlacement should occur, causing fatal com- pression of the medulla. Should matter form in considerable quantity, and seek to approach the surface, at the lateral or posterior part of the neck, a free and early incision is to be made, for evacuation. In advanced cases, the only hope of cure is by anchylosis. Cheyne, The Pathology of the Larynx and Bronchia, Edin. 1810. Burns, Surgical Anatomy of the Head and Xeck, Edin. 1824. Lawrence, Med. Chir. Trans, vol. vi. p. 221. Bretonneau, des Inflammations Speciales du Tissu Muqueux, et en particulier de la Diphtherite, Paris, 1826. Cheyne, Cycl. of Pract. IMed. (art. Laryngitis), vol.* iii. London, 1833. Dupuytren, Clinique Chir. torn. iii. Paris, 1833. Tweedie, Cycl. of Pract. Med. (art. Throat, diseases of) vol. iv. London, 18-34. Porter, The Surgical Pathology' of the Larynx and Trachea, Dublin, 1837. Trousseau et Belloc, Traite de la Phthisie Larj-ngee, Paris, 1837. Trousseau de la Tracheotomie, L'Esperience, Nov. 5, 1840. Ley, on Laryngismus Stridulus ; Henderson, on Laryngismus Sti'idulus, Monthly Journal, Jan. 1841, p. 10. Brodie, Case of Mr. Brunei, Med. Gazette, July 7, 1843. "Watson, Lectures on the Practice of Physic, London, 1848. Green, Treatise on Diseases of the Air Passages, New York, 1849. Copeland, art. Bronchocele, Diet, of Pract. Medicine. Porta, Delle Malattie e deUe Operazioni della Ghiandola Tiroidea, Milano, 1849. Todd, Cycl. of Anat. and Physiology, art. Thyroid gland, London, 18-50. 257 CHAPTER XIX. AFFECTIONS OF THE AETEEIES OF THE NECK AND SUPERIOR EXTREMITY. Deligation of the Carotid. The common carotid artery may require deligation on account of aneurism, hemorrhage by ulcer or wound, or erectile tumour in the orbit. Carotid aneurism is usually situated at the upper part of the vessel, near the angle of the jaw ; forming a tumour there of the ordi- nary characters, which, should it become diffuse, might seriously interfere with respiration. It possesses a peculiarity of being ill sur- rounded by repressing tissues ; it grows chiefly towards the pharynx, and may imperfectly consolidate after operation (Principles, p. 577). Sometimes — but fortunately comparatively seldom — the disease affects the origin of the artery ; and then its interference with respiration is more early and serious. From sudden increase of the tumour — by diffusion or otherwise — immediate performance of tracheotomy may be demanded to save from urgent threatening of asphyxia. The artery may be secured at one of two points ; above or below where it is crossed by the omo-hyoid muscle. The former situation is the moi-e easy of access, and is to be preferred when circumstances are favourable ; but in cases of aneurism, the tumour mil generally be found to have encroached too far on the upper triangular space. The superior operation is performed thus : — The patient having been placed recumbent, with the head thrown back and turned slightly to the opposite side, an incision is made through the integuments, platysma myoides, and superficial fascia, extending in the direction of the inner border of the sterno-mastoid muscle, from near the angle of the jaw to the level of the cricoid cartilage. The deep fascia is care- fully divided, with the use of forceps ; cross veins are looked for, and avoided ; the margins of the wound are held asunder by means of bent copper spatulae ; and it may be useful to relax the parts some- what, by changing the position of the head. The descendens noni is pushed aside ; the common sheath of the vessels having been pinched up by forceps, is opened to the requisite extent ; and cautious isolation of the artery is proceeded with, so as to afford clear space for passao-e 258 DELIGATION OF THE CAROTID, of the aneurism needle — and no more. The needle is passed from the outside; the jugular vein being repressed, if necessary; and thus risk is avoided of injuring the vein, or including the par vagum.* Before securing the knot, especial care should be taken to ascertain that nothing but the arterial coats is included. The inferior operation is more generally suitable in the case of aneurism, as already explained. The patient having been placed as before, an incision of about three inches in length, parallel to the inner border of the sterno-mastoid, is begun a little above the level of the cricoid cartilage. The inner border of the muscle, having been exposed, is cautiously turned outwards ; while the sterno-hyoid and sterno-thyroid muscles are displaced in the opposite du'ection. The deep fascia is divided below the crossing of the omo-hyoid muscle ; and, the sheath having been opened, the operation is completed as before. The descendens noni, in the former case in front of the sheath, is here found inclining to the tracheal side of the artery. On the left side, the jugular vein is very apt to prove troublesome by overlapping ; on the right side, it recedes from the carotid, to meet the subclavian vein. After the operation, congestion of the lungs, with its baneful con- sequences, must be guarded against by use of the lancet. And, in the case of aneurism at the angle of the jaw, external pressure is to be made on the tumour, so as to atone for the deficiency of repressive textures, formerly alluded to. It is well, also, to keep the neck bent so as to relax the artery. The artery at its inferior part has been secured by a transverse wound ; cutting the sterno-mastoid across, upon a director, and then opening the sheath in the ordinary way.f In the case of aneurism at the root of the common carotid, deli- gation of the artery at its upper part may be practised, with a reason- able hope of cure. For, as formerly stated (Princii^les, p. 578), the common carotid is favourably adapted for Brasdor's operation. Deligation of the external carotid, and its branches, is required only in the case of hemorrhage ; and chiefly on account of wound. No definite rules need be given as to the operative procedure ; this must be guided by the general principles formerly inculcated (Principles, pp. 362 and 569), and modified by the particular circumstances of the case. Deligation of the Arteria Anonyma is an operation now considered * From inattention to this rule, at an early period of my professional life, I had the misfortune to include the par vagum in the noose of the ligature. But it is some con- solation to know that the accident was, in all probability, imconnected with the fatal issue of the case. I willingly record the circumstance here ; that it may be of use, as a beacon, to deter and Marn others from similar inattention and mishap. t Hargrave, Dublin Quarterly Journal, Aug. 1849. DELIGATION OF THE SUBCLAVIAN. 259 hopeless ; and, in all probability, will never be repeated by any judi- cious surgeon ; circumstances seeming to be insuperably hostile to satisfactory occlusion of the artery at the deligated point. Deligation of the Subclavian. This artery requires ligature, on account of axillary aneurism. Hemorrhage by wound or ulcer is likely to call for the operation but rarely. Surgically, the vessel is conveniently divided into three portions ; internal, from its origin to the inner border of the scaleni ; middle, where overlaid by the anterior scalenus ; external, between the outer border of this muscle and the passage over the first rib. On the right side, it is possible to secure the artery at any of these parts of its Fig. 92. course ; on the left, the two last only are practicable, the internal third being not only very deeply seated, but in close contact with most important parts, which can scarcely fail to sustain serious injury in the attempt. On either side, the middle third is not desirable ; there being risk of serious iiijury to the phrenic nerve, as well as a proba- bility of unsatisfactory occlusion on account of the near propinquity of large collateral branches at the deligated point. The external third is preferred. But if, in performing the ordinary operation on this part of the vessel, the coats appear unsound, we are fully warranted in cautiously turning aside the scalenus muscle, and seeking upwards for a more healthy portion. Deligation of the external third is accomplished thus: — The patient having been placed recumbent, on rather a high table, and the Fig. 92. Plan of the relative position of the suhclavian artery, in its outer third; a, subclavian vein ; h, brachial plexus of nerves ; c, subclavian artery ; d, scalenus muscle ; e, flap reflected. S2 260 DELIGATION OP THE SUBCLAVIAN. elevated shoulder having been forcibly depressed as much as possible, an incision is made over the clavicle, through the skin and platysma myoides ; extending from the anterior border of the trapezius, to a little beyond the posterior border of the sterno-mastoid. And it is well to pull the skin downwards before using the knife, so that, on resilience, the wound may be more directly correspondent with the course of the vessel. A minor incision is made to fall into the first, passing along the posterior border of the sterno-mastoid ; and the flap thus indicated is slightly reflected. The cervical fascia is divided ; the external jugular vein is looked for, and turned aside ; the posterior belly of the omo-byoid may be disclosed ; and then we know that in the triangular space between that and the clavicle, is contained the object of our search. The outer edge of the scalenus muscle is sought for ; at the same time a part of the brachial plexus is brought into view ; and now the field of search is further limited ; the artery will be found by tracing the border of the muscle downwards, on a lower and more anterior plane than the portion of the plexus exposed. Placing our finger on the tubercle of the first rib, the artery is felt pulsating between ; and the knife is guided accordingly. The vessel having been reached, is cautiously isolated to the requisite extent ; and the needle is passed from the clavicular aspect, so as to avoid injury of the vein. Before securing the noose, pressure should be made by the finger on the included texture, so as to make sure that it is the artery. In making the downward dissection, caution is neces- sary near the clavicle ; lest, first, the supra-scapular artery be wounded ; and, afterwards, lest the vein should sustain injury. The artery, if cut, proves troublesome by hemorrhage ; and, besides, the vessel is important as a means of collateral circulation after obstruction of the main trunk. In the great depth which has sometimes to be encoun- tered in this situation, assistance may be derived from one or other of the auxiliary needles which have been invented ; but it has so happened, hitherto, that the ordinary instrument, in skilful hands, has been found quite sufiicient. In all cases, however, difiiculty is to be contemplated ; and in the dissection allowance must always be made for the increased depth of the vessel's site, resulting from displacement of the shoulder upwards by the axillaiy tumour. To secure the middle third, a plan of incision very similar to that just described will suffice. The fibres of the scalenus are cut across with the greatest possible caution, so as to avoid injury of the phrenic nerve, which may be expected towards the inner margin ; and the noose is applied with equal caution, to avoid, as far as possible, the arterial branches of this part of the vessel. To expose the internal third, on the right side, let an incision be made a little above the clavicle, more anteriorly than in the former DELIGATION OP THE AXILLARY. 261 operations ; and into this a second incision is made to fall, along the inner border of the sterno-mastoid. The sternal attachment of this muscle is then divided and turned aside, outwards. The sterno-hyoid and sterno-thyroid muscles, having been exposed, are divided cautiously from their outer border, and displaced forwards. The lower part of the carotid may then come into view ; this is traced downwards, until the subclavian is reached ; and this vessel is to be secured, neatly and accurately, as near as possible to the origin of the vertebral, so as to afford space enough between the ligature and the origin of the carotid. The textures to be avoided are the par vagum, and its recurrent branch, the cardiac branches of the sympathetic, the pleura, and the vein. The needle is passed from below upwards, to avoid wounding the pleura and right vena innominata. The operation is one of great difficulty, and not auspicious of a pi'osperous issue. The varieties of distribution to which the arteries of the neck are liable, bear an important relation to the operations just described, and should ever be remembered and calculated upon by the surgeon.* Deligation of the Axillary. Modern surgeons seem to have almost agreed, that this vessel should not be made the subject of operation, unless in the case of wound of itself ; when the general principles of surgery are to be ful- filled, by cutting down upon the bleeding point, and placing a ligature above and below the aperture. In the case of aneurism high in the arm, encroaching so far upwards as to render deligation of the humeral either unadvisable or impracticable, the axillary, no doubt, may be secured ; but it is an easier, more feasible, and altogether preferable operation, to tie the subclavian in its external third. liike the subclavian, the axillary artery is surgically divided into three portions ; an upper, middle, and lower. And supposing that we have determined on deligation of the axillary, in preference to the subclavian — as, probably, will very seldom be the case — either the lower or the upper third will be selected, seeing that the middle is so covered and mixed up with other textures, as to be almost inaccessible — with safety. The operation, accordingly, is said to be either superior or inferior. The superior operation is performed thus : — The patient having been placed recumbent, with an assistant ready to compress the sub- clavian in case of accident, an incision is made, about three inches in length, and of a semilunar form — with its convexity downwards ; commencing about an inch from the sternal extremity of the clavicle, * Vide QuAiN on the Aiteries, with special reference to this subject. For the statistics of ligature of the subclavian^ see Nokris, American Journal of j\Ied. Science, July 1845. 262 DELIGATION OF THE HUMEEAL, and extending towards the acromion. Or a similar extent of wound may be made, with its convexity upwards, terminating at the anterior margin of the deltoid. In the one case, the clavicular portion of the pectoralis major is at once cut across, in the deep dissection ; in the other, the intermuscular space is dilated. Care must be taken to avoid the cephalic vein and thoracico-acromialis artery. To expose the latter vessel, however, is scarcely an untoward occurrence, as it may happen to prove a convenient guide to the vessel of which we are in search. The deep fascia and fat are carefully cut through ; and it may be necessary to turn down the upper border of the pectoralis minor. The vein, probably, will then be first disclosed ; this is pressed in- wards towards the ribs ; and, the artery having been carefully isolated to the requisite extent, the needle is passed from the thoracic to the acromial aspect. For the inferior operation, the arm is raised from the side, with the hand supinated. In the lower part of the axilla, thus exposed, the head of the humerus is felt ; and over this an incision is made of about two inches in length, rather more to the posterior than to the anterior border of the axilla. Then, on dissecting through fascia and areolar tissue, the axillary vein and median nerve are likely to be exposed ; the latter having been displaced outwards, and the former inwards, the artery wiU be brought into view. The needle is passed from the ulnar aspect. In the latter part of the operation, it is useful to relax the textures, by bending the fore-arm. Deligation of the Humeral. The brachial or humeral artery may be secured at any part of its course ; on account of aneurism, true or false ; on account of wound of the vessel itself; or on account of an otherwise uncontrollable hemorrhage from either the hand or the fore-arm. The arm having been steadied on a convenient table with the hand supinated, the operation is conducted thus : — In the upper part of the arm, an incision of about two inches in length is placed over the vessel — felt pulsating — along the inner border of the coraco-brachialis muscle ; and care is taken to avoid the basilic vein and internal cutaneous nerve, which may lie in the way. The fascia having been divided, the ulnar and internal cutaneous nerves, on the inside — the external cutaneous and median nerves, on the out- side — the brachial veins close on each side — are avoided; the arm being bent, for the purpose of relaxing these tissues, if necessary. And the vessel having been isolated, the needle is passed from the ulnar aspect. Sometimes the median nerve is superficial to the artery. DELIGATION OF THE AKTEEIES OF THE FORE-ARM. 263 At the middle of the arm, the incision is made along the inner border of the biceps muscle, which, overlapping the vessel, may re- quire to be raised slightly. The median nerve is to be expected, super- ficial to the blood-vessels ; and whUe this nerve is displaced inwards, and the muscle held outwards, the artery may be separated from its veins and secured. It is right to remember, however, that, in this situation, the inferior profunda may be mistaken for the main trunk ; and also that, if there be a high division of the humeral, one of the two vessels only may have been tied. Not until the surgeon has been fully satisfied on both of these points, should the operation be com- pleted by approximation of the wound. In the case of high division, the second trunk, if not close to the other, will be found either along the inner intermuscular septum, in a line with the inner condyle of the humerus ; or near its usual situation, but deeply placed, and covered by fibres of the brachialis anticus muscle. In the lower part of the arm, the median nerve is to be expected on the ulnar side of the artery ; but it is seldom that we are called upon to operate in this situation ; not, indeed, unless for wound of that part of the vessel. At the bend of the arm, false aneurism of the humeral is pro- verbially common. Its nature and progress have been already des- cribed (Principles, p. 556). If prevention by methodical pressure have failed, the sac is to be cut into, and the vessel secured by ligature above and below the aperture, in recent cases. In tumours of old standing, deligation of the humeral, near its middle, is a simpler and equally effectual operation (Principles, p. 594). Varicose aneurism, occurring at this site, requires the same treatment as the ordinary form of tumour. For aneurismal varix, support by careful bandaging is usually sufficient (Principles, p. 596). Deligation of the Arteries of the Fore-atm. Deligation here is seldom if ever required, except in the case of hemorrhage from injury of the arteries themselves ; and then it is suffi- cient to dilate the existing wound, and to secure the bleeding point, or points, in the usual way. For secondary bleeding in the palm, liga- ture of both ulnar and radial would not suffice ; the interosseous must also be secured. And, instead of this threefold and difficult operation, it is infinitely better at once to perform that which, while much sim- pler, is equally effectual — deligation of the humeral a little below its middle. The radial and ulnar ai'teries are most easily reached at the lower part of the fore-arm. For the radial, an incision is made on the radial side of the flexor carpi radialis. For the ulnar — made more superficial by 264 DELIGATION OF THE AETEEIES OF THE FOEE-AEM. bending back the hand and fingers* — the wound is placed on the radial side of the flexor carpi ulnaris. Near the elbow joint, the vessels can Fig. 93. be exposed only through a great thickness of muscular tissue. The prolongation of the radial, between the metacarpal bones of the thumb and fore-finger, may be exposed by an incision on the ulnar aspect of the extensor secundi internodii pollicis. Wounds of the Palmar Arch are apt to be troublesome by bleeding, both primarily and secondarily. In recent wounds, all bleeding points should be secured by ligature ; dilatation being practised, if necessary, and moderate pressure afterwards applied. For bleeding occurring after the lapse of some days, exposure of the wound, with application of energetic pressure (Principles, p. 353), should be had recourse to ; and if this fail, then deligation of the humeral should be practised, f * Malgaigne, Brit, and For. Med. Chir. Eev. July 1848, p. 265. f For Bibliographical reference, see p. 267. Fig. 93. Deligation of humeral, radial, and ulnar arteries ; also of the palmar vessels. 265 CHAPTER XX. AFFECTIONS OF THE BEND OF THE AEM. Venesection. This little operation — at one time, it is to be feared, too frequently performed — is conducted thus : — The patient having been placed erect, semi-erect, or recumbent, according as it is wished to withdraw much blood or otherwise (Principles, p. 157), a ligature — a riband, or bandage, or small tourniquet — is placed on the upper part of the arm, and secured with sufficient tightness to arrest the venous return, yet not so tightly as to interfere with the arterial influx — as indicated by the pulse at the wrist. The veins at the bend of the arm, thus made tense and bulging, are scrutinized with a view to selection. A branch which is superficial, and large enough to emit freely, is to be pre- ferred, for obvious reasons ; and, if possible, the median cephalic is chosen ; for then we are less likely to interfere with the brachial artery, the fascia of the fore-arm, or the cu- taneous nerves ; and thus are avoided the risks of aneurism, diiFuse inflammatory infil- tration, and neuralgic pain. But if no vessel except that over the brachial is found suit- able — as not unfrequently happens — then the operation must be con- ducted there with especial caution ; care being taken merely to open, not to transfix the vein. The arm is placed nearly in a middle posture between pronation and supination; and precautions are taken to secure its being retained in that position unmoved. By the fingers or thumb of one hand — and it is well that the surgeon be ambidextrous in this proceeding — the vein is steadied ; and, pressure being made at the same time on the distal aspect, spurting from the puncture is prevented. The lancet — neither too spear-pointed nor too rounded in its blade — Fig. 94. Tlliistration of venesection at the bend of the arm. 266 ACCIDENTS OF VENESECTION. held between tlie jfinger and thumb of the other hand, is introduced obliquely across the track of the vessel ; and by gentle movement of it a sufficient aperture is made — the instrument being made to cut more with the shoulder than with the point, so as to insure the super- ficial part of the wound being considerably more free than the venous orifice. Then the blood is allowed to flow. If the stream grow slug- gish, movement of the fingers wUl tend to its increase by forcing the contents of the intermuscular veins to the surface, and accelerating the general venous return ; but care must be taken to avoid any deviation from the original position of the limb, otherwise an overlapping of the wound by integument will necessarily follow. The desired effect hav- ing been obtaiiied, the ligature on the arm is slackened and removed ; a thumb is placed on the wound ; the arm is sponged and made clean ; a neatly fitting graduated compress is applied ; by a bandage passed in the form of 8, all is secured ; and the limb is placed comfortably in a bent posture, supported if need be by a sling. Within forty-eight hours, the bandage may be safely withdrawn ; but it is well to avoid use of the arm for some days. Accidents of Venesection. 1. Thrombus. — By this term is understood an accumulation of coagulated blood in the areolar tissue between the vein and integu- ment ; caused probably by overlapping of the latter ; interfering with, and perhaps arresting, the flow of blood at the time of the operation ; producing an inconvenient swelling afterwards ; and not unfrequently inducing troublesome suppuration in and around the wound. The accident is to be avoided, by a suitably free opening being made at once, and by maintenance of one position of the arm throughout the whole proceeding. When thrombus has formed, the coagulum should be carefully removed, an enlargement of the wound being had recourse to, if necessary ; and then a suitable compress is accurately applied, so as to keep the tissues in close contact. 2. Neuralgic pains may invade the limb ; dependent, probably, on puncture of a cutaneous nerve. To avoid such accident, place the wound where this texture is least likely to be implicated ; to cure it, dilate the wound by incision, and apply an anodyne epithem. 3. Simple erysipelas may follow ; and the ordinary treatment is required (Principles, p. 384). 4. Angeioleu- citis may occur j^er se, or in conjunction with the preceding affection. There is no peculiarity in the treatment (Principles, p. 621). 5. Not unfrequently, -diffuse inflammatory action occurs beneath the fascia, which has probably been injured by puncture. Free incision is im- peratively necessary ; otherwise serious results, both local and consti- tutional, are almost certain to ensue. 6. Sometimes this last accident AFFECTIONS OF THE BUESA OVEE THE OLECEANON. 267 is associated with a superficial and simple erysipelas, or erythema. 7. Aneurismal formations have been already considered. And in re- ference to these it is well to remember, that the arteries of the fore- arm, following an unusual course, may be found quite superficial, and not unlike the ordinary veins. Hence a careful examination of the part should uniformly precede the performance of phlebotomy. * Affections of the Bursa over the Olecranon. From habitual pressure — as in the miner — this bursa is liable to chronic enlargement, and the affection is to be treated in the ordinary way ; by abstraction of pressure, and the application of discutients (Principles, p. 544). Acute bursitis is a frequent consequence of blows on the elbow ; and is usually associated with an erysipelatous affection of the surface. Treatment is by puncture and general antiphlogistics ; and if matter form within the bursa, it should be early evacuated by free incision. * Lately a new variety of the aneurismal lesion has been observed ; the artery pro- jecting its contents through the wounded vein, and forming an aneurismal sac by con- densation of the areolar tissue exterior to the vein. The deep wound of the vein is closely incorporated with that of the artery ; and the superficial venous aperture is con- tinuous with the arterial sac. — Brit, and For. Med. Chir. Eev. April 1850, p. 338. Sometimes, too, the aneiirismal communication is not with the superficial, but with a deep vein. — Ihid, p. 349. Eamsden, Practical Observations, &c. London, 1811. Listen, Ed. Med. and Surg. Journal, vol. xvi. p. 348. A. Bums on the Surgical Anatomy of the Head and Neck, Edin. 1824. Dietrich, Das Aufsuchen, &c. Numberg, 1831. Manec on Ligature of Ar- teries, Paris, 1832. Harrison, Surgical Anatomy of the Arteries, Dublin, 1833. A. Cooper, Guy's Hospital Eeports, vol. i. p. 53, 1836. E. Quain, Anatomy of the Arteries, with large plates, Lond. 1840. Bibliographical Eeference to Chapter XIX. Lisfranc, Nouvelles Considerations sur la Saignee du Bras, Paris, 1813. Abernethy on 111 Effects of Bloodletting, Surgical Works, vol. ii. p. 13?_ Lond. 1815. Wardrop on Bloodletting, &c. Lond. 1825. Marshall Hall on the Effects of Bloodletting, Lond. 1836. 268 CHAPTER XXI. AFFECTIONS OF THE WRIST AND HAND. Ganglia mid Thecal Collections. G-ANGLIA frequently form on the wrist and back of the hand. When troublesome as well as unseemly, they may be got rid of, either by pressure, or by puncture of the cyst (Principles, p. .546). Collections of glairy fluid often occur in the thecae of the flexor tendons in the lower part of the foi"e-ai'm, with or without loose bodies contained; forming a soft bulging swelling, which usually extends also to the palm ; and more or less seriously interfering with the functions as well as with the symmetry of the limb. In the worst cases, it has latterly been the practice to make a free evacuating in- cision, dividing the annular ligament at the wrist completely through, in the belief that thus tension during subsequent inflammatory ac- cession will be avoided. But experience has yet to show, that the deformity and loss of power which result from condensation and deposit among the tendons by such cure, are less than those which attended the previously existing state of parts (Principles, p. 545). According to M. Velpeau, it is both safe and effectual to evacuate the contents by a trocar's puncture ; and then to inject iodine — as in the cure of hydi'ocele. Paronychia. No affection is more common than paronychia, or Whitloiv ; more especially among washerwomen, cooks, nurses, and others, whose fingers, by the nature of their avocations, are not only kept prone to the assumption of inflammatory action, but also much exposed to the application of its exciting causes. The disease varies both in site and intensity. 1. There is a mild form, limited to the very surface. The finger, at its point, and perhaps in its whole extent, is intensely hot and pain- ful, red, and somewhat swollen ; and vesications may be in process of forming. Treatment consists in leeching, fomentation, and general antiphlogistics. Or — as is more frequently practised — the part is rubbed lightly over with nitrate of silvei", so as to blacken and desic- PAEONYCHIA. 269 cate the surface (Principles, p. 178). Resolution is usually effected ; but often not without the formation of one or more vesicles — which sometimes degenerate into superficial ulcers of an irritable character. The disease usually commences at the root of the nail, a hot and pain- ful blush of redness surrounding this ; and hence the term. In con- sequence of the matrix of the nail, in many cases, being primarily and permanently affected, shedding of the nail need be no unlooked-for event. 2. A somewhat more serious action is found to pervade the sub- cutaneous areolar tissue, as well as the skin ; beai'ing the same analogy to the former affection, as phlegmonous erysipelas does to erythema. It is usually caused by a puncture, laceration, or other wound ; with or without inoculation of irritant matter. The swelling, heat, redness, tension, and pain are greater ; and there is a proneness towards acute suppuration. Treatment must be proportionally active ; copious leech- ing, at the sides of the finger ; or free puncturing of the affected parts ; active constitutional antiphlogistics ; fomentation and poultice ; early incision, if need be, as in phlegmonous erysipelas — not waiting till diffuse suppuration has formed (Principles, p. 390). 3. The worst form is the most deeply seated ; and, unfortunately, not the least frequent in occurrence. The action originates in the deep fibrous textures ; sometimes, there is every reason to believe, in the periosteum, or immediately ex- terior to it. Pain is excruciating from the first. For days and nights the patient may enjoy not a moment's sleep, or respite fi'om suffering. Tension and throbbing are early and intense ; so are the swelling, heat, and redness. The *'^' ^^■ back of the hand, and sometimes part of the fore-arm, are red and greatly engorged with serous effusion. Matter forms early in the finger ; deep, and confined, and consequently with aggravation. The con- ^^^r%'""-h-MM.i stitution labours under inflam- matory fever, often severe. At the outset, active anti- phlogistics, locally and generally, are to be employed — copious leech- ing, fomentation and poultice, purging and antimony — with the hope of averting suppuration. Failing these, there is no relief to suf- Fig. 95. Danger of delaying incision, in the worst form of paronychi:!, exemplilied. Thumb lost in consequence. Fig. 96. The illustration carried further ; after maceration. Fig. 270 ONYCHIA. fering, and no means of averting serious destruction of texture, but by early and free incision. It seems harsb practice to lay a finger open throughout almost its whole extent, on the palmar aspect ; but, soon after the infliction of such a wound, pain will rapidly abate, and in a short time the patient will probably be in a deep unconscious slumber. Free outward suppuration takes place ; the swelling abates ; bones, joints, and tendons are saved ; and the finger recovers, tediously it may be, but well. Withhold the incision, and there comes no relief but on spontaneous evacuation of the matter ; and then bones are found carious or necrosed, joints are opened into, tendons are sloughing or sloughed ; the fingers may recover, in some sense, but are stiif and useless ; more frequently, amputation is demanded sooner or later. In both of the more severe forms, extension to the palm is by no means unfrequent. The same principles of treatment are to be fulfilled there as in the finger. But in incising, care must be taken to avoid, if possible, wound of the palmar arch. Sometimes the virulent form of paronychia is limited to the distal joint of the finger. Then exfoliation of the corresponding phalanx is extremely probable. But, fortunately, the whole bone seldom comes away ; a portion at the articulation remains ; and, from this, regene- ration may take place, with but little ultimate deformity. Onychia. This term denotes a diseased condition of the matrix of the naU ; the result of a chronic infiammatory process, inducing intractable ulceration. The first indications are pain, swelling, and redness, around the root of the nail ; and, on pressure being applied, an ichorous discharge oozes from beneath the cuticle at this part. The nail separates more and more, and is ultimately detached ; disclosing an angi-y ulcer, of irregular margin and tawny surface, surrounded by dusky redness, emitting a thin foetid discharge, and the seat of intense pain. Usually, an aborted reproduction of the nail protrudes from the upper part of the sore. The indications of treatment are simple. To pluck away the stunted nail ; by an escharotic — as the potassa fusa or nitric acid — to destroy the morbid texture ; and, on separation of the slough, to make such application to the sore as its varying state may seem to require. In almost all cases, however, local treatment is not alone sufiicient. The general health will be found greatly disordered. Alteratives and tonics are necessary; and, in some cases, a mild mercux'ial course is followed by the best effects. Certain cases are very obstinate, and to such the term Onychia maligna has been applied ; inappropriately, however, inasmuch as the 0NYXI8. 271 sore, however unmanageable, possesses none of the characters of true malignancy. In such cases, the escharotic application must be made with unusual intensity ; or, under chloroform, the diseased parts may be shaved off with a knife ; and if, by this means, a satisfactory granulating surface cannot be obtained, it is well at once to perform amputation of the phalanx. This summary procedure is still more especially indicated, in those examples of the inveterate form in which the bone has become involved. Onyxis, Onychia occurs in both toes and fingers. Onyxis is usually con- fined to the former. By this term is understood a faulty condition of the margin of the nail ; original or secondary ; causing, or connected with, an irritable fungous sore of the soft parts. The root of the nail not unfrequently is surrounded by a red and swollen integument. The general matrix is sound ; but, occasionally, onychia follows on the minor affection. Wbether the nail have been originally to blame, or not, it is very important to remove its injurious contact with the angry sore beneath. For this purpose, either mild or rude measures may be employed ; the former in the first instance. The nail is softened, and, having been scraped thin, has its edge gradually and gently elevated above the fungous granulations ; and then there is interposed a layer of soft lint, or other suitable substance. The nail having been thus perma- nently elevated, the freed sore abandons its irritable character, and may be brought to heal under the ordinary applications. But, failing such measures, partial evulsion of the nail is to be had recourse to ; a harsh seeming remedy, but very effectual. The nail having been softened and thinned, as before, the blade of strong sharp-pointed scissors is run up from the point to the root ; the nail is severed at that part by one stroke ; the isolated portion of nail — usually about a quarter of the whole — is then laid hold of by strong dissecting forceps, one blade of which is pushed beneath; and by a sudden wrench evulsion is effected. Unless under chloroform, the pain is great, though momentary. Hot poultice or water-dressing is applied. A healthy character of sore, generally, soon appears; and healing is not long delayed. Contraction of the Palmar Fascia. The whole aponeurosis may be rigidly contracted ; or a portion only, connected with one or more fingers. When the whole is involved, all the fingers are rigidly bent, and the hand consequently is not only much deformed, but almost entirely useless. The disease is most 272 TUMOURS OF THE METACARPAL BONES. frequent in those who use the fingers much ; and is but little amenable to treatment. Obviously the change depends on a chronic inflamma- tory process affecting the aponeurosis ; and is to be met in its early stage with leeching, mercurial friction, local use of iodine, &c. The partial form is common in those of the better ranks, who are much given to horseback exercise and other field sports. In some of these cases, amendment may foUow subcutaneous division of the affected portion of fascia, the finger being subsequently straightened by the application of a splint and bandage. Spastic flexion of the thumb not unfrequently occurs during child- hood, in connexion with intestinal irritation. It is treated by the application of splint and bandage, while by purgatives and alteratives the primas viae are rectified. Those who Avrite much are liable to troublesome spasm of the thumb ; sometimes called writers' cramp. Treatment consists in rest of the part, with tonics constitutionally and locally. Tumours of the Metacarpal Bones and Phalanges. Exostosis may occur; but is rare. Treatment is seldom if ever required, the affection proving but little troublesome. Osteo-cystoma (Principles, p. 481) is more common. Its treatment depends upon the bulk. If small, it is incised ; and, on pressure being subse- quently applied, contraction and healing will probably ensue. Or, if need be, a seton is passed and temporarily retained ; and thus the desired obliteration is effected. Those of large size, involving the whole periphery of the bone, warrant amputation of the affected part. Enchondromata (Principles, p. 479) have here their most frequent site. If small and external, the tumour is dissected off, and the bone left uninjured. Those which affect Fig. 97. the whole bone require amputation. Gene- rally, the tumours are not single; yet usually we are able to save a part — and sometimes the greater part — of that most useful organ, the hand ; the avowed non-malignancy of this tumour admitting of incisions being made very close to the morbid formation. Sometimes, however, the size and connexions of the tumour are such as to demand amputation of the whole hand. Lately I had occasion to remove one of gi'eat Fig. 97. The large enchondroma refeiTed to. At a, a section made to show struc- ture. At h, the ulcerated surface, whence the bleeding came. For the microscopic cha- racters, see Principles, p. 314. OTHER DISEASES OF THE METACARPAL BONES. 273 size, weighing fourteen pounds. From the apex of the tumour repeated and serious hemorrhage had taken place ; and it was satis- factory to find, on a careful examination after injection, that the blood had escaped from ulcerated openings in large superficial veins, not from any degenei'acy in the structure of the tumour itself. Other Diseases of the MetacarjJcd Bones and Phalanges. These bones are especially liable to the inflammatory casualties — ulcer, caries, and necrosis. The ordinary treatment is to be put in force. When, as a last resource, amputation is unavoidable, one general rule should never ^- — — -^_ be forgotten — viz., that it is "^i^fe, ~?j our duty to save as much as circumstances will pos- sibly permit — a portion of the original hand being a much better organ of prehension, than any artificial substitute, however ingeniously constructed. Frequently, in consequence of whitlow, or inflammatory action traumatically induced, it may be in our power to retain a finger, but not without complete anchylosis of all its articulations. And, under such circumstances, it comes to be a question whether it were not better to amputate such a member at once, before anchylosis and cicatrization have occurred ; thereby not only shortening the cure, but also rendering the hand much more useful — especially in the case of the labouring man, by whom a stiff finger is felt to be constantly in the way. I believe that the question is to be answered in the affir- mative — in favour of amputation. The thumb, however, is in all circumstances to be preserved, if possible. Rigid or not, it proves extremely serviceable. Another question arises in the case of a hopelessly diseased meta- carpal bone, whose corresponding finger is perfectly sound. May the metacarpal bone be removed alone, or must the finger be taken along with it ? The latter is the preferable practice. The finger left with- out its metacarpal bone is worse than useless. Two or even three metacarpal bones, when carious, may be removed, with their corresponding fingers. The operation is prefer- able to amputation of the Avhole hand. For the paramount general rule of saving as much as possible, should ever be respected in such cases. Some years ago in amputating a metacarpal bone, its base was found carious, and also the corresponding portion of the carpal range. The latter diseased part was removed by means of a gouge ; and a most satisfactory cure resulted. Fig. 98. Scrofulous necrosis of finger ; macerated; after amputation. 274 CONGENITAL DEFOKMITIES OF THE HAND. Hypertrophy of the Fingers. This rare departure from ordinary nature has been occasionally noticed in young people ; affecting one or more fingers ; originating from no assignable exciting cause ; consisting of true hypertrophy of all the textures — bones, joints, tendons, skin, and nails ; and accom- panied with more or less deformity, and loss of function. Firm and continued pressure may moderate the unnatural growth. If not, incon- venience may be mitigated by amputation — partial or complete. Congenital Deformities of the Hand. Supernumerary fingers are usually attached, not by articulating apparatus, but by ordinary integumentary tissues. Their amputation is accordingly very easily effected. Webbed fingers are often hereditary ; and in some parts of the country are held in esteem. Should their amendment be wished, that is obtained by division of the abnormal band ; great care being taken, during cicatrization, to prevent reunion of the opposed parts. And, for this purpose, interposition of dressing is not enough ; it is essential, as in the case of burns (Principles, p. 694), to make constant and con- siderable pressure on the angle of union, at the knuckles ; and this is done by means of a piece of cord or tape, placed and retained there. Club-hand, a condition of the hand analogous to club-foot, occa- sionally occurs. It is remediable, at an early age — with or without the aid of tenotomy — by the wearing of suitable apparatus. And to the machinist, the management of such cases is usually intrusted. It is also the province of that profession to atone, by mechanical substitutes, for deficient development of the hand or fingers. Vogt, de Paronychia, Viteb. 1803. Wardrop, an Account of some Diseases of the Toes and Fingers, &c. Med. Chir. Trans, vol. v. p. 129. Duteil, Dissertation sur la Panaris, Paris, 1815. Craigie, Pathological and Practical Observations on Whitlow, Ed. Med. and Snrg. Journal, April 1828, p. 255. Dupuji;ren, Clinique Chirurg. t. i. art. 1. 275 CHAPTER XXII. DISEASES OF THE ARTICULATIONS OF THE SUPEEIOR EXTREMITY. Disease of the Shoulder-Joint. This joint, like others, is liable to the ordinary affections of such parts. But it is perhaps especially liable to disorganising disease, involving all textures ultimately, and usually originating in the cancellated tissue of the head of the humerus. To this the term Omalgia was formerly applied ; very inappropriately, because apparently inferring that the disorder was of the nature of irritation, or neuralgic, not structural and inflammatory. It may occur at any age ; and very frequently its origin is connected with external injury. One of the first and most prominent symptoms is wasting of the deltoid ; ultimately giving a pro- minence to the acromion. The arm is incapable of exertion ; and pain in the joint is increased by motion, especially when the arm is raised. Bending takes place at the elbow ; and the limb projects awkwardly from the body, feeble and wasted, and apparently increased in length. The shoulder simulates luxation. And, at length, this result may actually occur ; disorganisation of the joint having become complete. The constitution does not fail to suffer, in sympathy with the progress of this grave disorder. Swelling, as usual in primary affections of the hard tissues, is of secondary occurrence, and is seldom very great ; evacuation, by external opening, being soon attained by Nature's own effort. Treatment is to be conducted on the general principles formerly explained (Principles, p. 515). But, true caries having been esta- blished, with an open condition of the joint, it becomes very improbable that spontaneous cure will take place ; and usually the general health is then seriously and obviously on the decline. In such circumstances, the diseased parts must be removed by operation ; by amputation of the limb, or by resection of the joint. The latter operation is obviously preferable, when not contra-indicated (Principles, p. 535). T 2 276 RESECTION OF THE SHOULDER- JOINT. Resection of the Shoulder-Joint. To expose the articulation, a flap maj be made from the outer and fore-part of the deltoid; or a single incision may be placed longitudinally, over the outer aspect of the joint, the knife being entered below the acromion, and pushed at once down to the head of the humerus. In many cases the latter mode is quite sufficient; and, being less severe, is to be preferred. The knife and finger having penetrated the joint, the remaining portions of the retaining apparatus are divided — more especially the muscles inserted into the tuberosities of the humerus, towards which the finger is the best guide — and the diseased head is then made to shew itself, and project through the wound ; the limb being with this view brought forcibly across the thorax. By a saw abbre- viation is made to the required ex- tent. The glenoid cavity is then examined ; and, if found diseased, the affected part is taken away, by means of cross-cutting pliers, or by a gouge. Bleeding having been arrested, the parts are accurately reponed ; the wound is brought to- gether, and the limb is retained steadily in a convenient posture. Healing by granulation is to be expected ; with the formation of an artificial joint, more or less com- petent to assume the functions of the original. Often it proves in all respects an admirable substitute. And thus many useful limbs may be retained, under circumstances which, but a few years since, would have called for nothing short of amputation. The operation may also be required, primarily, on account of injury done to the bone ; as by gunshot wound. Fi-. 99. Resection of the Elbow- Joint. Few affections are more common than articular disease at the elbow. And not unfrequently it advances to disorganisation ; Avith or Mnthout strumous complication. To this joint, more than any other, the operation of resection is applicable. Care being always taken to select the case according to the ordinary tests (Principles, p. 536) ; lest, resection failing, amputation become necessary, and we discover, when too late, that the patient who could have stood one operation well, Fig. 99. Flap, placed in position, after resection of the shoulder-joint. m EESECTION OF THE ELBOW-JOINT. 277 must inevitably sink under both. The patient having been placed prone on a table, or seated with his back to the surgeon, and with the arm extended and held by an assistant, the joint is exposed from behind, by cutting, so as to form flaps; and the flap may be single, double, or quadruple ; 01- thus In freeing the soft parts from the inner condyle, and reflecting them over it, care is necessary to keep the ulnar nerve free from harm. The insertion of the triceps having been cut across, on bending the arm the olecranon is made prominent; and this, having been separated from its connection with the soft parts, is removed by saw or pliers, to the requisite extent. The joint can now be very i-eadily dislocated; the condyles of the humerus are isolated and sawn off; and the upper part of the radius, usually, is also removed — the saw being preferred, to avoid bruising of the softened bone. Eemoval of the olecranon by pliers is mainly to facilitate disarticulation ; afterwards it is usually ne- Fig. 100. Incision marked for resection of the elbow. 278 RESECTION OF THE WEIST. cessary to saw away so much more of the uhia as may seem hopelessly Should any suspicious portions appear at or near the cut surfaces, the gouge may be directed against them. Bleeding having been arrested, and the wound brought loosely together, the limb is se- cured in a slightly bent posture. Suppuration and granulation follow ; the wound slowly closes ; and an artificial joint by ligamentous structure is ultimately constructed — often of remarkable usefulness. Resection of the Wi'ist. It were easy enough to remove by operation the articulating ends of the radius and ulna, and Fisj. 101. to gouge out the affected parts of the corres- ponding surfaces of the carpal bones ; but the proceeding is not found to succeed. And, consequently, when this joint is deemed irre- claimable, amputation is preferred. Fortunately, a vast proportion of the cases of scrofulous disease of this joint, in adolescents, recover under use of cod-liver oil, and general antistrumous treatment — with or without anchylosis. Fig. 101. Caries of the elbow ; mainly affecting' the condyle of the humerus, vegetative effort around the carious surface well exemplified. The Moreau, Resection des Articulations, &c. Paris, 1803. Roux, de la Resection des Portions d'Os, &c. Paris, 1812. Crampton, Dub. Hosp. Reports, vol. iv. 1827. Velpeau, Nouv. Elem. de Med. Operator, tom. i. Syme on Excision of Joints, Edin. 1831. 279 CHAPTER XXIII. INJURIES OF THE SUPERIOR EXTREMITY. Fractdres. Fracture of the Clavicle. The clavicle is frequently broken ; and usually by violence applied to the acromial extremity, as by falls on the shoulder. The fracture is generally oblique, and near the centre of the bone. The limb is pow^erless, the part is pained and sv^^ollen, attempted movement aggra- vates the pain, and the shoulder is both sunk and dravv^n towards the sternum. Displacement is caused by depression of the lower fragment; whereby the sternal portion is made very prominent, causing palpable deformity, and seeming to be out of place, though truly remaining nearly in situ — the action of the pectoral and sterno-mastoid muscles nearly neutralizing each other, and the bone being also steadied by the costo-clavicular ligament. The acromial portion is dragged down- wards by the weight of the arm ; and forwards and inwards by the action of the subclavius — the attachment of this muscle to the first rib being then the fixed point. The indications of treatment are plain, but unfortunately not very easily fulfilled. They are to raise the acromial portion to the same level with the sternal ; to retain it there ; and at the same time to keep the shoulder removed from the sternum, so as to prevent dis- placement inwards, and consequent " riding " of the ends of the bone. Many and complicated are the means devised for this end. The sim- plest, most easily obtained, and not the least efficient, are as follows : A wedge-shaped pad is placed in the axilla, sufficiently large to occupy that cavity completely. The best pad is made of horse-hair, covered with soft leather ; but any temporary substitute may be taken at the first dressing. By means of a shawl or large handkerchief, within which it is placed, the pad is securely lodged in the axilla ; and, by tying the ends over the opposite shoulder tightly, elevation of the shoulder, and consequently of the acromial portion of the clavicle, is effected ; and the latter indication is further contributed to, by placino- the fore-arm in a short sling, well tightened over the elbow. To main- 280 FRACTURE OF THE BODY OF THE SCAPULA. tain extension of the bone is more difficult. Carry a bandage, hand- kei-chief, or other ligature, across the chest — including the lower part of the arm on the injured side — arranging it so that the arm shall be both approximated to the chest, and carried well backAvards ; making the humerus a lever, which, acting on the pad as a fulcrum, forces the shoulder outwards. And, if need be, maintain approximation of both scapulae by means of a figure of 8 bandage, so as to complete and secure the re-adjustment. It is well also to relax the sterno- mastoid by attention to the posi- tion of the neck ; for sometimes this muscle would seem to suc- ceed in elevating the sternal por- tion slightly. Retention will be more easily effected in the erect or semi-erect than in the recumbent posture. The knot over the shoulder may gall the patient ; and, to prevent this, the skin should be well protected by suitable padding. The application of pressure over the site of fracture can be productive only of evil. The integu- ments may be induced to slough ; and an injury, originally simple, may be rendered compound. In females, for obvious reasons, the treatment is to be conducted with especial care. rig. 102. Fracture of the Body of the Scapula. The body of the scapula may be broken across, by violence directly applied, or even by muscular force alone. There is but little displace- ment, or deformity. The part is pained, swollen, and limited in voluntary motion ; and, while movement is made, crepitus can be dis- tinctly felt by the hand placed flatly on the part. In treatment, it is sufficient to restrain motion, by wearing the arm in a sling, and by having a broad flannel bandage passed tightly over the chest, including the fractured bone. Fracture of the Acromion. The acromion process may be detached from the spine of the scapula, by du-ect violence. There are pain, swelling, and loss of power ; and a depression can be felt at the injured part, in conse- Fig. 102. Simple bandnging siiitaWe for fractured clavicle. The .sling omitted. FRACTURE OP THE NECK OF THE SCAPULA. 281 quence of the fractured portion being di'awn downwards on the head of the humerus, by the action of the deltoid muscle. At the same time, the clavicle is drawn downwards and forwards on the coracoid process, by the subclavius, and by the action of the deltoid and pec- toralis major muscles overcoming that of the trapezius and sterno- cleido-mastoid. Crepitus is not felt on rotating the limb, until the arm has been raised ; for then only can the fi-actured portions be brought into apposition. In treatment, it is sufficient to raise the arm fully by means of a sling, and to prevent motion by suitable bandaging to the trunk. No pad should be placed in the axilla ; otherwise the hiatus between the fractured portions will probably be increased. Union is generally by ligament. Fracture of the Coracoid Process. This injury is also the result of direct violence. The fractured portion is displaced downwards, by the action of the coraco-brachialis, pectoralis minor, and biceps muscles. There are pain and swelling of the part, with loss of power in the limb ; and crepitation is felt on rotating the limb, after the fore-arm has been flexed and the arm carried across the chest, in order to relax the muscles connected with the process, and so to permit replacement of the fragment. In treat- ment, it is sufficient to make this relaxation permanent. The fingers of the injured limb are made to touch the shoulder of the opposite side, and that position is secured by bandaging. • Fracture of the Neck of the Sca-pula. This accident — separation of the glenoid cavity and coracoid pro- cess from the body of the bone — is the result of great and direct violence, and, like the preceding, is of rare occurrence. Sometimes there is mere separation of the above named parts ; more frequently, the glenoid cavity is fissui'ed and broken up. The detached portion of the scapula is retained in close contact with the head of the humerus, by the long heads of the biceps and triceps muscles ; and both the fragment and the head of the humerus are displaced downwards and forwards into the axilla, by the action of the subscapularis and pector- alis major, and of the other muscles connected with the upper part of the humerus. The appearances are very like those of dislocation ; there is the same flattening of the shoulder, with palpable prominence of the acromion, and vacancy beneath it ; and the head of the bone may be felt plainly in the axilla ; at first, too, thei-e is no crepitation ; and the limb is somewhat lengthened. But, by very gentle effort, the head of the bone may be replaced — a tiling very unusual, if not actually 282 FEACTUEE OF THE NECK OF THE HUMEEUS. impracticable, in dislocation. Then crepitus may be plainly felt, on rotating the arm with one hand, while ^'pith the fingers and thumb of the other pressure is made deep in the axilla and on the coracoid pro- cess ; then, too, flattening of the shoulder is made to disappear ; but, on ceasing from manipulation, deformity and displacement are speedily reproduced. In treatment, a pad having been placed in the axilla, the shoulder is raised and the fore-arm supported by a sling. Fracture of the Neck of the Humerus. 1. Fracture at the Anatomical Neck. — Occasionally the bone gives way at this point, but not so frequently as below the tubercles. The injury is the result of direct violence ; and intracapsular. There is but little displacement or deformity ; the lower fragment being retained in its ordinary position by the muscles inserted into the tubercles. The chief signs are pain, impairment of motion, and crepitus. Sometimes impaction takes place, the upper fragment being driven into the cancel- lous tissue of the lower ; then the signs are unusually obscure ; but the circumstance is favourable to osseous and speedy reunion. When there is no impaction, the detached head of the bone may become necrosed ; and in that event inflammatory disorganization may be expected, for extrusion of the sequestrum. Treatment of this form of injury consists mainly in preserving quietude in the parts. 2. Fracture, hy Separncion of the Epiphysis. — This also is the result of direct violence. The head of the bone remains in its place ; Avhile the shaft is carried forwards on the coracoid process, by the action of the muscles inserted into the bicipital ridges. There is little or no flattening of the shoulder ; the head of the bone can be felt in situ, motionless on rotation ; the end of the shaft — directed obliquely up- wards and inwards — is felt and seen projecting on the coracoid process ; the arm is shortened, with the elbow awkwardly projecting from the side ; by slight extension and coaptation adjustment is readily effected, and then crepitus is emitted on rotation. The most characteristic sign is the remarkable prominence over the coracoid, produced by the resting of the end of the loAver fragment there. Sometimes impaction, however, occurs ; the lower fragment being driven into the upper ; and this necessarily obscures the signs of injury. In treating this form of fracture, a pad is placed in the axilla ; by two splints of pasteboard, wood, or leather, placed one on the outside the other on the inside of the limb, retention is secured ; * the fore-arm is supported by a sling ; but the elbow is left free and pendent. Were pressure to be made on the elbow, by adjustment of the sling in the ordinary way, displacement of the lower fragment would inevitably be * Sometimes tlie internal splint may be dispensed -w-ith. PEACTURE OF THE NECK OF THE HUMEEUS. 283 reproduced ; whereas, by following an opposite course, a certain degree of permanent extension is maintained on the humerus, which is of use in preserving apposition. 3. Fracture of the larger Tubercle. — This is the result of direct violence. The joint is preternaturally broad ; the acromion projects somewhat ; the deltoid is slightly flattened ; the arm is powerless as to elevation ; and two hard swellings are to be felt — one, internal to the coracoid process, the head of the bone — the other beneath the acromion, the detached tubercle. Treatment is as in the previous injury ; with the whole fore-arm supported. 4. Fracture at the Surgical NecTc. — This is also the result of direct violence. The upper fragment remains nearly in its place, moved slightly upwards and outwards by the action of the muscles inserted into the tubercles. The upper end of the lower fragment, or shaft, is drawn upwards and close to the side by the muscles inserted into the bicipital ridges ; Avhile its lower end, at the elbow, is abducted by the action of the deltoid on its point of insertion. The appearances con- sequently are — no flattening of the shoulder, on the contrary rather a fulness ; the head of the bone felt plainly in- situ, motionless on rotation ; the upper end of the fragmental shaft felt displaced on the side, and a depression plainly perceived at a corresponding point in the external outline of the limb ; the arm shortened and powerless ; the elbow abducted ; crepitus, on rotation after adjustment. In treatment, a full- sized wedge-shaped pad is placed in the axilla ; splints are applied along the limb, the outer one extending from the top of the shoulder to the external condyle, the inner from the internal condyle to the axilla ; the fore-arm is supported by a sling ; and again the elbow is left free and pendent. 5. Fracture loith Dislocation. — Fracture at either neck may occur, in consequence of great and direct violence, and be accompanied with dislocation of the head of the bone. Fortunately, the combination is of exceeding rarity. The symptoms are necessarily complicated. But the diagnostic mark is sufficiently plain ; the head of the bone is felt lodged in the axilla, not moving along with the shaft in rotation. On readjustment, too, characteristic crepitus may be de- tected. Treatment is difficult. An effort is to be made, by direct manipulation, to reduce the head of the bone if possible — of course under chloroform ; and if this be accomplished, then the case, hav- ing been reduced to one of fracture, requires the ordinary retentive treatment after due coaptation. Or, failing in direct coaptation, the fracture may be reduced and arranged tightly in splints, so as to admit of reduction of the dislocation by extension being attempted in the ordinary way. But, if the luxation remain, notwithstanding every Avarrantable effort to remove it, then it were well to adjust the end of 284 FRACTURE OP THE SHAFT OF THE HUMERUS. the shaft into the vacated glenoid cavity, and to retain it there for a time by splints, bandaging, and a pad in the axilla. The broken end becomes rounded off, assuming an articular character and function ; and the new joint is likely to prove more useful, than if reunion had been effected upon the displaced fragment in the axilla. Fracture of the Shaft of the Humerus. 1. Below the Bicipital Ridges, and above the Insertion of the Deltoid. — Here the position of the fragments is the reverse of what results from solution of continuity at the surgical neck of the bone. The upper fragment is drawn inwards, to the side, by the muscles inserted into the bicipital ridges ; while the lower is displaced outwards and up- wards by the action of the deltoid, causing an abnormal prominence at this part of the arm — immediately above the insertion of the muscle — with an inclination of the elbow to the side. The characteristic signs are, the prominence just spoken of, shortening of the limb, crepitus on adjustment and rotation, and adduction of the elbow. Coaptation having been effected, splints are applied, a pad is arranged so as to keep the upper fragment separate from the chest, the fore-arm is supported, and the whole is steadied and retained by suitable bandaging. 2. At the Middle of the Shaft. — At this point the nature of the injury is at once made apparent, by deformity, shortening, and powerlessness of the limb, with distinct crepitus emitted on the slightest manipulation. Reduction is easily effected, by extension and coaptation ; and retention is maintained by splints ; the fore-arm being also supported by a sling. 3. At the Shaft above the Condyles. — Here the solution of continuity is generally oblique ; sloping down from behind forwards. And the appearances simulate those of dislocation of both bones of the fore- arm backwards. The lower fragment is drawn upwards and back- wards by the action of the biceps, triceps, and brachialis anticus. The limb is shortened ; and there is much bulging posteriorly. On extend- ing the fore-arm, passively, the deformity is removed ; but on resump- tion of the flexed posture, it is instantly reproduced ; and by this test the accident is sufficiently distinguished from dislocation. Crepitus may be plainly perceived, on combining coaptation with rotation. When the line of fracture follows an opposite direction, passing obliquely upwards from behind forwards, the displacement is reversed ; the lower end of the upper fragment projecting behind^ while the upper end of the lower fragment is drawn upAvards in front. Reduction having been effected, rectangular splints are applied on the inside and outside of the limb, and are retained by bandaging ; the rectangular position of the fore-arm being obviously advisable, in order to relax FRACTURE OF THE ULNA. 285 the displacing muscles — the biceps, triceps, and brachialis anticus. The splints — made of pasteboard, leather, or gutta-percha — should extend from near the middle of the arm quite to the winst. Diastasis maj occur ; separation of the epiphysis, with or without rotation. Reduction having been effected, bj extension and coaptation, retention will be maintained best in the bent position. Fracture at the Condyles of the Humerus. 1. Of the Internal Condyle. — The line of fracture is oblique to the shaft, detaching the internal condyle. During flexion of the fore-arm there is little or no displacement ; but, on extension, the ulna is drawn upwards and backwards, by the action of the triceps, there being no longer any efficient resistance to the coronoid process. The signs are — crepitus, on direct lateral movement of the injured part ; obvious displacement of the ulna in extension, and replacement of it by flexion of the fore-arm. In treatment, the limb is arranged in a rectangular position, as for fracture above the condyles. But from time to time it is expedient to undo the apparatus, and practise passive movement of the joint, lest stiffening should occur. 2. Of the External Condyle. — There may be little or no displacement in any position of the limb. But crepitus is to be felt ; more especially during rotatory movement of the hand and radius. Treatment is as in the preceding case. Fracture of the Ulna. 1. Of the Olecranon. — This may be the result of direct injury, by a fall on the elbow ; or of muscular action only, in violent and sudden extension of the limb. Usually, ligament as well as bone is torn ; and, consequently, the olecranon, detached fi'om the shaft of the ulna, is displaced upwards by the action of the triceps ; leaving a vacant space where prominence should have been, and placing the prominence an inch or more above its ordinary site. Voluntary extension is imprac- ticable ; flexion aggravates the signs of the injury. On extending the limb, the displacement is in a great measure removed ; the two frag- ments ai'e brought sufficiently near for satisfactory ligamentous union ; and in treatment, therefore, it is enough to maintain the extended position, by the loose application of a splint on the palmar aspect of the elbow-joint. Very accurate approximation, indeed, is not desir- able ; a compact ligamentous bond of union being equally serviceable as an osseous one, and much less liable to a second disruption. Like- wise, the risk of excessive osseous deposit is avoided, whereby the fragment might become inconveniently anchylosed, on its articulating aspect, with the end of the humerus. 286 FEACTURE OF THE RADIUS. Compound fracture of the olecranon follows direct injury ; and is invariably to be regarded as an accident of serious import ; inasmuch as intense inflammation of the joint is very likely to supervene. And this tendency to sei'ious evil w^e should never lose sight of, in treat- ment ; endeavouring to prevent traumatic arthritis, if possible ; and when it has occurred, doing our utmost to avert disorganization. Not unfrequently, with the best care, the joint suppurates, and is with difficulty saved by anchylosis. Sometimes even amputation is de- manded. 2. Of the Coronoid ]process. — This rare accident is more likely to follow inordinate muscular action than direct injury. The ulna is dis- placed backwards, by the unresisted action of the triceps ; and the tendon of the biceps is rendered tense and unusually prominent by the bulging forwards of the trochlea of the humerus. The coronoid frag- ment is drawn upwards by the brachialis anticus. In treatment, the fore-arm is placed in a state of extreme flexion, and retained so by ban- daging, so as to relax the displacing brachialis. Ligamentous union is expected, as in the case of the olecranon. 3. Of the Shaft. — The weakest point of the shaft of the ulna is a little below its centre ; and there fracture is most likely to occur, from violence applied indirectly. The lower fragment is drawn to the radius, by the action of the pronator quadratus muscle ; and conse- quently a depression is made there in the outline of the bones, until obscured by sanguineous and inflammatory swelling. There is neither pronation nor supination of the hand. By coaptation and rotation crepitus is readily perceived. In treatment, splints are applied on the palmar and dorsal aspects ; each splint extending from the elbow to beyond the wrist, so as completely to command the latter articulation (Principles, p. 711). And, in order to prevent redisplacement by the pronator quadratus, a pad is placed on either aspect of the fractured part, of sufficient size to occupy the interosseous space fully, and so to offer a mechanical obstacle to undue approximation. 4. Of the Styloid process. — This process may be chipped off, with- out other injury to the bone. There is little indication for treatment beyond rest of the part until pain and swelling have subsided. Fracture of the Radius. In this injury, it is convenient to observe, as an aid in diagnosis, that there is invariably abnormal pronation of the hand ; whether the bone have suffered alone, or in company with the ulna. 1. At its neck. — This is an accident of rare occurrence, and diffi- cult diagnosis. The fragments are but little displaced, and crepitus has to be detected through a thick cushion of muscular substance. FRACTURE OF THE RADIUS, 287 The lower fragment is tilted forwards and inwards slightly, by the action of the biceps ; the upper is rotated somewhat outwards by the supinator radii brevis. Crepitus is to be sought for by firm pressure over the site of suspected fracture, while free rotation is made of the hand and fore-arm. In treatment, the fore-arm is tlexed, and placed in the middle state between pronation and supination ; long splints being applied on either aspect of the limb. 2. Near the Centre. — The radius very commonly gives way near its centre, from violence indirectly applied, as by falls on the hand, or by twisting of the fore-arm. And sometimes the accident is the result of muscular action alone. The unnatural degree of pronation is very marked and characteristic, the hand hanging awkwardly with the thumb directed downwards. The upper fragment is drawn upwards and inwards, by the action of the biceps ; and there is an apparent enlargement of the upper half, with a diminution of the lower half of the fore-arm. The lower portion of the fractured bone is drawn towards the ulna, as well as completely pronated, by the action of the pronator quadratus. And the supinator radii longus assists powerfully, by tilting up the styloid process to which it is attached, in displace- ment towards the ulna. In treatment, the fore-arm is flexed, and placed in the middle state between pronation and supination ; the in- terosseous pads are carefully adjusted ; the long splints are applied on either aspect, projecting beyond the knuckles ; the hand, bandaged separately to prevent congestion, is excluded from the retentive ap- paratus, and left pendent — so that by its weight it may counteract the displacing tendency of the long supinator, and separate the radius from the ulna at the point of fracture. ^. At the Distal Extremity. — This, too, is a very common result of falls on the hand. The radius being mainly concerned in the carpal articulation, to that bone the shock is chiefly and directly conveyed ; and solution of continuity is extremely probable, more especially if any degree of twisting have been at the same time applied. The line of fracture may be either transverse or oblique. The upper fragment is displaced inwards by the pronator radii quadratus ; causing an abnor- mal prominence on the palmar aspect, with a corresponding depression on the dorsal. There is pronation ; and, on coaptation and extension, crepitus may be detected. The hand, following displacement of the lower fragment of the radius outwards, leaves the end of the ulna un- usually prominent — as if dislocated. Luxation of the carpus, indeed, is in not a few cases closely simulated. The diagnostic marks are — de- tection of crepitus, mobility at the injured part, and in general non-con- tinuity of the bone as evinced on rotation. But the case becomes obscure when the line of fracture is oblique, and impaction has occurred (Prin- ciples, p. 703). The lower fragment having received the sharp end of 288 FRACTURE OF BOTH RADIUS AND ULNA. the upper into its cancellated tissue, the two become locked, continuity of the bone is apparently restored, and crepitus is felt but obscurely, if at all. When in doubt, let free extension be made, such as may undo the state of impaction, and then, if fracture exist, its ordinaiy signs will be evinced. In treatment, it is necessary to be very careful to effect accurate coaptation by reduction ; then to apply the long splints on the dorsal and palmar aspects, securing the wrist and hand against every motion. The fore-arm is placed in the state of easy flexion. Lately, it has been proposed to treat this fracture without splints. The hand " having been bi'ought into a position of strong flexion, the fore-arm is placed, pronated, on an oblique plane, with the carpus highest, the hand being permitted to hang freely down the perpen- dicular end of the plane."* Fracture of both Radius and Ulna. This is ordinarily the result of direct violence ; and the fractures consequently are at corresponding points — usually near the middle of the fore-arm. By the action of the pronator quadratus the hand is pronated, and the lower fragments are approximated to each other ; they are also drawn upward by the combined action of the extensor and flexor muscles in the fore-arm, and usually project on the dorsal aspect of the limb. On extension and rotation, crepitus may be very plainly perceived. The treatment is, as for single fracture, by long splints and interosseous pads. In young persons, both bones not unfrequently give way at their epiphyses ; an accident which closely simulates luxation of the carpus. Like fracture of the radius alone, it is usually the result of indirect violence, by a fall on the hand. The lower fragments, with the carpus, are displaced backwards ; the upper project on the palmar aspect. The latter are kept in close approximation by the pronator quadratus, while the fore-arm is pronated by the j)ronator radii teres. Considerable power is required, by extension, to undo the locking and displacement ; and then crepitus is emitted on rotation. The hand usually remains in the middle state between pronation and supination. In treatment, coaptation, by efiicient extension, having been accom- plished, is maintained by long splints, as in the other fractures. Fracture of the Metacarpal Bones. The Carpal bones are seldom fractured but by great and direct force ; and then the fracture is not only compound, but also generally * Lancet, 1236, p. 487. DISLOCATION OP THE CLATICLE. 289 accompanied with such injury to other parts as to call for amputation. The Metacarpal bones, however, not unfrequently give way — simply, and remediably — by force either direct or indirect ; most frequently the latter — as in violent blows delivered on the knuckles. The frag- ments may be made to ride, by the force which occasioned solution of continuity ; and lateral displacement may be subsequently caused by action of the interosseous muscles. The swelling, pain, and power- lessness of the limb, with characteristic crepitus on manipulation, are sufficiently indicative of the nature of the injury. Coaptation is effected by extension, and is secured afterwards by splints, extending from above the wrist to beyond the tips of the fingers, on either aspect. Interosseous pads may be arranged on each side of the fractured bone, on the dorsal aspect ; on the palmar, one large and suitable pad is placed, to occupy and maintain the hollow of the natural arch of the hand. In compound injuries of this part, amputation is to be had recourse to with reluctance. When it is inevitable, let it be as partial and limited as possible, for the obvious reasons formerly stated when treating of amputation on account of disease. Fracture of the Phalanges. Fractures of the phalanges are usually compound. But, whether compound or simple, their marks are so plain as to render mistake under any circumstances impossible. When preservation of the injured part is deemed practicable and expedient, reduction is carefully efiected ; and coaptation is maintained by slender splints of wood placed on the dorsal and palmar aspects. DISLOCATIONS. Dislocation of the Clavicle. 1. The Sternal Extremity may be displaced either backAvards or forwards. a. Forwards. — Dislocation forwards is by much the more frequent ; produced by force applied indirectly, through the shoulder. The dislodged extremity is seen and felt plainly resting in front of the sternum. Replacement is efiected by raising the shoulder, and by carrying it backwards so as to approximate the scapulte. Treatment is the same as for fracture of the bone, excepting the pad in the axilla, which is here unnecessary, h. Backwards. — Dislocation backwards is extremely rare. It has resulted from direct violence applied to the part, and also from the gradual displacement which attends on rotation and curvature of the spinal column. To effect reduction, let an assis- u 290 DISPLACEMENT OF THE ANGLE OF THE SCAPULA. tant grasp botli shoulders, and, placing his knee between, suddenly bend them backwards towards each other ; while the surgeon in front pulls forward the end of the bone. For retention it is necessary to remove the shoulder from the side ; and this may be done by placing a large pad in the axilla, and binding down the lower end of the humerus. In an example dependent on spinal curvature, it was found impossible to retain the end of the bone in its proper place ; and the distress occasioned by its backward pi'essure proved so great as to lead to extirpation of the offending part.* 2. The Scapular Extremity is not unfrequently displaced upwards on the acromion, by falls on the shoulder ; the amount of deformity and inconvenience being proportioned to the degree of laceration of the confining ligaments. The shoulder is depressed ; and the end of the clavicle is seen and felt rising over the spine of the scapula. Reduction is effected by elevation and retraction of the shoulder ; con- sequently the same treatment is necessary as for fractured clavicle ; but maintained with unusual accuracy, as well as for an unusual length of time — the bone being very liable to re-displacement, and consoli- dation of the ligamentous apparatus being apt to prove both tardy and imperfect. Displacement of the Angle of the Scapula. Young men, who use the arms violently in their habitual occupa- tions, are liable to this accident. The latissimus dorsi passes beneath instead of over the lower angle of the scapula, causing unseemly pro- jection of this, with pain and loss of function in the limb. Reduction is easily effected by direct manipulation, while the arm is much raised and brought backwards, so as to relax the muscle ; and by bandaging and rest the normal relation may be maintained. On resuming the use of the arm re-displacement is very apt to occur ; a circumstance of the less moment, however, as in time both power and extent of motion are almost completely regained, independently of reduction. A more serious deformity is connected with paralysis of the rhom- boid muscles, and occurs in young persons who follow constrained and sedentary avocations. Displacement of the lower angle not only takes place ; but, besides, the base of the bone projects forwards, on moving the shoulder, to such an extent as almost to admit of the hand being placed between the subscapularis and the ribs. In this case, treatment must be mainly constitutional; but the attention is also directed towards restoration of tone in the faulty muscles, by galvanism, fric- tion, and other means. * A. Cooper on Dislocations, last edition, p. 354. DISLOCATION OF THE SHOULDER. 291 Dislocation of the Humerus at the Shoulder. This is more likely to follow indirect than direct violence, as for- merly explained (Principles, p. 728). There are varieties ; three complete luxations, and two partial displacements. 1. Dislocation dotvnivards, into the axilla, is the most common — indeed is regarded as the ordinary form of injury. In addition to the general signs of dislocation, there are the following : — The shoulder is flattened, the deltoid having sunk inwards ; an ample and evident space exists beneath the acromion, which process is unusually and strikingly prominent ; the arm is slightly elongated ; the elbow is Fig. 103. abducted from the side ; on elevating the limb, the head of the bone is plainly felt in the axilla — and it is found to move with the shaft in rotation ; motion is greatly abridged, unless when the muscular system is unusually relaxed and flabby ; there is no true crepitus ; pressure of the bone's head on nerves and veins in the axilla is evinced, by tingling sensations and swelling of the limb ; paralysis may follow ; not unfrequently the circumflex nerve has been torn across, and per- manent paralysis of the deltoid has resulted. Reduction may be eflected, in a variety of ways ; pulleys being used, or not, according to circumstances (Principles, p. 734, &c.) In all cases of difficulty, chloroform is of course employed (Principles, p. 788). a. By rectangular extension — the axis of extension being intended to relax the deltoid, supra-spinatus, and infra-spinatus mus- cles, which, according to Sir A. Cooper, are the principal opponents of reduction. And it is well to relax the biceps, also, by flexion of the fore-arm ; the laque being attached, when required, above the elbow. The patient may be either seated or recumbent ; and counter- extension is made by a broad sheet or belt passed round the chest — pressure being at the same time made on the top of the shoulder, so as Fig. 103. Dislocation of the shoulder. The flattening shewn at a. The right shoulder is normal. u2 292 DISLOCATION OP THE SHOULDER. to fix the scapula more completely. After extension has been duly sustained (Principles, p. 733), it is suddenly slacked, and a jerking, coaptating movement is made on the head of the bone upwards ; the humerus being used as a lever. When the patient is seated on a chair, much power in this way is obtained by the knee placed in the axilla, on which the humerus is, as it were, suddenly and forcibly bent. Re- duction may take place suddenly and with a snap ; or gradually, and without a noise. Then the arm is secured to the side, by bandaging, and retained so for a few days. b. By extension parallel to the axis of the body. — Thus we may succeed, single-handed, in recent or otherwise favourable cases. The patient is laid recumbent ; and the surgeon places himself, sitting, by his side. Taking hold of the hand or wrist of the injured limb, the surgeon makes extension by pulling towards him ; while, placing his unbooted heel in the axilla, on the head of the bone, and pushing from him, counter-extension is made, and at the same time direct reductive force is applied. Or, instead of pulling by the wrist, a laque may be fastened above the elbow ; by a strap or towel attached to which, and passed behind the surgeon's back, extension may be made ; leaving the hands free to rotate the flexed fore-arm. Care must be taken, how- ever, that the heel's force is neither excessive, nor unduly directed ; for it has happened that, failing to reduce a dislocated humerus, the operator has caused fracture of the ribs. Rupture of the axillary artery, also, with subsequent formation of false aneurism, has been caused by the heel — booted, and used rashly. Failing with the heel, the strap for producing counter-extension is placed in the axilla, and extension made steadily with pulleys, Avith such rotation and manipu- lation as seem necessary (Principles, p. 733). c. By movement upioards. — This is the method of Malgaigne. The shoulder and chest are steadied, while the arm is forcibly raised above the head ; and, if need be, extension is made in that direction, with subsequent manipulation directed against the head of the bone. It is expected, however, that these latter proceedings may not be required, the bone slipping into its place during the upward movement. Such details as to reduction apply mainly to those cases, in which from some cause or other anaesthesia is not employed. With the full effect of chloroform the muscular frame is so relaxed, that in general little else than simple extension, with coaptation, is reqvdred; it being comparatively immaterial in what direction the extension is made. 2. Dislocation forwards, beneath the pectoral muscle. — The head of the bone is displaced to the inside of the coracoid process, and is locked between that and the clavicle. There is the same flattening of the shoulder, with abnormal subacromial space, as in the preceding accident ; but to a greater extent. There is less pain, the axillary DISLOCATION OF THE ELBOW. 293 plexus being free. Motion is more abridged. The elbow is abducted and thrown back. The head of the bone may be both seen and felt in its abnormal site. The arm is somewhat shortened. In reduction, the extending force is to be made downwards and backwards, in a line with the body, not in a rectangular direction ; in order to avoid the resistance of the coracoid process. 3. Backwards on the dorsum of the scapula. — This is the rarest form of complete luxation. Palpable presence of the head of the bone, in its new locality, is sufficiently diagnostic. Reduction may be effected very simply, by merely elevating the arm, and carrying the hand behind the head. Failing this, the ordinary means are to be employed, as for dislocation downwards. 4. Subluxation on the coracoid process. — A partial displacement may take place in this direction. There is slight flattening of the shoulder, with a corresponding degree of vacancy beneath the acromion ; and the head of the bone is felt and seen projecting on the coracoid pro- cess. Reduction is beset with no difficulty ; in fact the manipulation required for diagnosis generally succeeds in effecting replacement. The accident is rare. 5. Subluxation upwards, with displacement of the long head of the biceps. — The long tendon of this muscle may be displaced from the bicipital groove, and laid over the lesser tubercle. In consequence, the head of the humerus escapes upwards, coming into immediate con- tact with the acromion. The accident is obscure, and probably rare. It is noted by loss of power in the biceps, by pain in the -seat of injury, and by the peculiar deformity attendant on the upward displacement of the head of the bone. Reduction is effected by a coaptating mani- pulation, directed to the tendon, during flexion of the fore-arm. Dislocation of the Radius and Ulna at the Elboiv. 1. Backwards. — Both bones of the fore-arm are not unfrequently displaced backwards, without fracture of any part, by falls on the hand, with the elbow in a state of semiflexion. The joint is much deformed, and has its motion greatly abridged. The hand and fore- arm are supine ; the joint is bent nearly at a right angle, and can be neither completely flexed nor extended. The ulna and radius form a very marked projection posteriorly; and, on examination, the olecranon is found on a higher level than the external Fig. 104. Dislocation of both bones backwards. Kg. 104. 294 DISLOCATION OF THE ULNA, condyle of the humerus. The coronoid process of the uhia rests in the cavity which ought to receive the olecranon ; and on each side of the olecranon a hollow is caused, by absence of the lower part of the triceps from its wonted locality. The trochlea of the humerus, projecting forwards, forms a hard swelling behind the tendon of the biceps. Reduction may be effected in two ways. a. By extension, with co- aptation, from behind. This is the preferable mode. The patient is placed with his back to the surgeon ; and, the chest having been fixed, extension is made with the arm directed completely backwards, in a rectangular relation to the trunk, so as to relax the triceps muscle. Very frequently, in recent cases, the operator thus succeeds, single- handed, by extension alone. With the left hand he makes counter- extension on the scapula, while with the right he extends from the wrist. In difficult cases, extension is intrusted to assistants, with or without pulleys, while the surgeon conducts the direct coaptating manipula- tions of the joint — the patient under chloroform, b. By forcibly bending the joint over the hiee. — The patient hav- -^:- % ing been seated on a chair, the surgeon places his knee in the hollow of the elbow. Pressing the radius and ulna down upon the knee, the coronoid process is freed from the humerus, by separation ; and then, on forcible yet gradual flexion, reduction is effected. 2, Laterally. — Both bones may be displaced late- rally, as well as backwards, in two ways ; to the inside, or to the outside, a. Backwards and outwards. — The coronoid process rests on the back part of the external condyle. The ulna projects more backwards than in the ordinary dislocation. The radiusforms a protuberance behind and on the outer side of the elbow, where its head may be felt plainly rotating. The inner ' =if- • condyle projects palpably, b. Backwards and inwards. Fig. 105. — -pjjg external condyle projects. The ulna is pro- minent posteriorly, resting on the inner condyle, while the head of the radius is placed in the posterior fossa of the humerus. Reduction, in either case, may be effected as in ordinary dislocation. Dislocation of the Ulna at the Elbow. The ulna may be displaced, singly, in two directions. 1. Back- wards. — The olecranon projects behind. The fore-arm is much twisted inwards, with pronation of the hand. The elbow is bent Fig. 105. Dislocation of the elbow ; she-wing preternatm-al fulness in front. DISLOCATION OF THE WRIST, 295 nearly at right angles, flexion can be but very slightly increased, and extension is quite impracticable. Reduction is effected by bending the elbow over the knee, and drawing the fore-arm downwards. The radius proves of use, in this movement, by pushing the external con- dyle back upon the ulna. 2. Badavards and inwards. — The olecranon projects much behind, the coronoid process rests on the inner condyle, and a finger may be placed in the sigmoid cavity. The fore-arm is semiflexed, the hand pronated. Extension may be performed readily by the surgeon, but complete flexion is impracticable. Much pain is experienced, on account of pressure on the ulnar nerve. Reduction is effected by direct efforts of coaptation, during powerful and sustained extension. The accident is rare. Dislocation of the Radius at the Elboiv. The radius may be displaced, singly, also in two directions. 1. Forwards. — The head of the bone rests in the hollow above the exter- nal condyle, and may be felt there. The fore-arm is slightly bent, and can be neither completely flexed nor extended. On attempting flexion, the head of the radius is felt to strike against the humerus, abruptly arresting the move- ment. The hand is inclined to prona- tion. Reduction is effected by grasp- ing the hand firmly, pei'forming supina- tion, and extending the fore-arm '„ ° rig. 106. steadily. 2. Backwards. — The head of the radius is displaced behind the external condyle, and to its outside ; and in this locality it can be both seen and felt very plainly, especially on extending the limb. Reduction is managed as in the preceding accident ; but with the hand pronated, not supine. Dislocation of the Wrist. 1. Dislocation of the Radius and Ulna. — These bones may be dis- placed, together, either on the dorsal or on the palmar aspect of the wrist. Falling on the palm, the two bones may be displaced forwards on the annular ligament ; while, from a fall on the back of the hand, the reverse movement is likely to occur. In either case, the signs are plain ; a dorsal and a palmar SAvelling exist, composed either of the carpal bones or of the ends of the radius and ulna, as the case may Fig. 106. Dislocation of the radius fonvards. 296 DISLOCATION OF THE FINGERS. be ; and, by rotation and manipulation, it is ascertained that con- tinuity in the radius and ulna is unbroken. The accident is rare ; fracture of the radius being a much more common result of the same exciting cause. Reduction is readily effected, by extension and coap- tation. And it is well to maintain retention for some time, by splints, as for fracture of the bones. Subluxation forwards is by no means an uncommon result of falls on the palm ; the bones being not only displaced towards the palm, but also separated from each other. The nature of the accident is plain, and reduction is easy. But, unless splints be carefully worn for at least a fortnight, deformity by continuance of partial displace- ment may scarcely be averted. 2. Dislocation of the Radius at the Wrist. — The distal extremity of the radius may be displaced forwards, separately ; resting on the scaphoid bone and trapezium. The styloid process is no longer situated oppo- site to the latter bone ; and the end of the radius may be both felt and seen projecting on the fore part of the wrist. The hand is twisted. Reduction is effected by simple extension and coaptation. Splints are necessary for subsequent retention. 3. Dislocation of the Ulna. — Dislocation of the ulna, separately, may take place bachwards; the end of the bone projecting plainly, with twisting of the hand ; and the line of the styloid process shewing obvious altei'ation. Reduction and retention are managed as in the preceding accident. 4. Dislocation of the Carpus. — Complete luxation of any of the carpal bones is I'are. But subluxation of the os magnum and of the cunei- form bone is occasionally met with ; weakening the joint ; and causing projection on the back of the wrist, dui'ing flexion. Treatment is by continued pressure and support from without, and by disuse of the part, for some considerable time. Dislocation of the Finger's. By falls sustained on the tips of the fingers, dislocation of the phalanges is sometimes produced ; and the displacement is usually on the dorsal aspect. It is more common between the first and second phalanges, than between the second and third. The nature of the injury is exceedingly plain ; and replacement is effected by extension and coaptation. To render extension effective, it may be necessary to affix a laque — a piece of tape, or the end of a silk handkerchief, or a riband — to the distal phalanx, by means of the clove-hitch (Prin- ciples, p. 734). Sometimes the handle of a key may be used advan- tageously as an instrument of reduction. Splints are expedient fin- some days afterwards. DISLOCATION OF THE THUMB. 297 Compound dislocations almost always are of such severity as to demand amputation. Dislocation of the Thumb. The first j)halanx is not unfrequently dislocated backwards on the dorsum of the metacarpal bone ; and is reduced in general with diffi- culty, on account of the strong lateral ligaments which oppose the retrograde movement ; and also on account of the many strong muscles — eight — which are connected with this part, and require to be over- come in the extension. Extension having been maintained for some time, steadily, by means of a suitable laque attached to the first phalanx, flexion is made towards the palm ; and during this forced movement, slowly yet determinedly performed, reduction is usually accomplished. It may be necessary, in extreme cases, to have recourse to subcutaneous section of one or other lateral Ligament ; but such necessity, with the use of chloroform, may scarcely be expected to arise. Hind on Fractures, London, 1836. Lonsdale on Fractures, London, 1838. A. Cooper on Dislocations and Fractiu-es, London, 1842. Dupuytren on Diseases and Injuries of Bones, Sydenham Society, London, 1847. Smith on Fractures in the Vicinity of Joints, &c. Dublin, 1847. Vincent, Observations on Surgical Practice, &c. London, 1847. 298 CHAPTER XXIV. mJUEIES AND DISEASES OF THE SPINE. Concussion of the Spinal Cord. By falls or blows, the spinal cord, like the brain, may sustain a greater or less degree of concussion ; having its functions arrested or disoi'dered, without actual lesion done to its structure. The concussion may be either general or partial. In the latter case, it is probable that the whole cord suffers, though unequally ; the major effect being at and beneath the part struck — as denoted by paralysis, more or less complete, of the parts thence supplied by nerves. This paralysis is transient ; passing off, in a few hours — or days ; never of long duration when simple — that is, when not accompanied or followed by extra- vasation or effusion. As in the case of the brain, reaction may prove excessive, and inflammatory action may speedily supervene ; attacking the cord, its membranes, or both, and ushering in a completely new train of symptoms. Or — also as in the case of the brain — the imme- diate results of the injury may all seem happily to pass away; and, at a remote period, an insidious chronic inflammatory process may occur, in the cord or in its membranes ; causing, in the one case thickening with effusion, in the other purulent softening of slow progress. Treatment is guided by the same principles as in concussion of the brain (p. 16). Absolute quietude is enjoined ; and the period of reaction is carefully watched. If it threaten to prove excessive, antiphlogistic measures are adopted, according as circumstances may seem to demand. And, for a long period after receipt of the injury, the patient must be content to use all the precautions of a prudent invalid, so as to avert if possible the insidious and formidable remote results. These, having threatened, are best met by rest and patient counter-irritation — with appropriate constitutional treatment. Softening of the spinal cord, chronic, insidious, and intractable, is no unfrequent consequence of severe falls, or blows, upon the spine; more especially in those in the better ranks of life, who have lived hard, and indulged much in venery. The lower limbs first begin to fail, the extensor muscles proving unequal to maintain the erect pos- ture, and the knees consequently ever and anon threatening to give COMPRESSION OF THE SPINAL CORD. 299 way. The feet are moved oddly, and are not planted on the ground firmly, or with certainty on the spot intended ; the legs are thrown outwards in stepping, and bring the feet down with a slap. The body is stooped in walking ; and the line of pro'gress is seldom a straight one. The bowels get sluggish, and the abdomen enlarges. The urine is voided with difficulty. The arms are found to be weak ; and the fingers seem to be gradually freeing themselves from control of the will ; there being the same uncertainty and inefficiency in doing any thing with the hands and fingers, as was first observed in the lower extremities. Not unfrequently the patient is much harassed by neu- ralgic pains, shooting down the back and limbs, and sometimes affecting the head also. Gradually such symptoms increase ; urine and faeces come to be passed involuntarily, or almost so ; the use of the limbs becomes more and more feeble and uncertain ; the brain at last is in- volved ; the mind grows imbecile, as well as the body ; and the patient dies, often with symptoms of slow compression. The spinal cord is often found more or less affected with ramollissement ; sometimes, however, it presents no organic lesion. But little benefit can be expected from treatment. Of heroic remedies, there is no tolerance. Indeed, the prudent practitioner contents himself with enjoining great temperance in all things ; while by the employment of ordinary and simple means he seeks to palliate symptoms, and delay the fatal issue. Compression of the Spinal Cord. This may be caused, as in the brain, by extravasation of blood, on the surface or in the substance of the cord ; by fracture and displace- ment of the vertebrae, producing direct pressure on the cord, with or without laceration of its substance ; by inflammatory exudations and eflTusions exterior to the cord ; or by purulent disorganization of the cord itself, the result of inflammatory action. Very obviously, the direct interference of operative surgery is here of no avail; the trephine is not to be thought of. Treatment consists of expectant rest, in the first instance ; anxiously looking for the earliest appearance of inflam- matory action ; opposing this by the suitable means, yet not heroically — knowing that in such cases active and extreme depletion is ill borne; and mitigating the symptoms connected with the paralytic state, as far as the resources of our art will allow. In the case of extravasated blood, if the immediate risk be overpassed, we may reasonably enter- tain expectation of a fortunate result. On the other hand, few cases of displaced fracture are wholly recovered from. And the end of inflammatory disorganization, whether chronic or acute, is almost in- variably disastrous. 300 FEACTUEE OF THE SPINE. Fracture of the Spine, Severe and direct violence is more likely to cause fracture than dislocation of the vertebrse-; these bones being so intimately connected to each other by their articulating processes. The spinous processes alone may be broken. There is then little displacement ; and the con- sequences are but trivial. But fracture traversing the body of the bone, making a complete solution of continuity in the spinal column at that part, is fraught with the utmost danger. Structural injury has probably been inflicted, at the same time, on the spinal cord and its membranes ; extravasation of blood has taken place into the canal ; probably there is displacement of the fragments, and further injury thereby done to the soft parts within. Ordinarily, therefore, the most prominent sign of spinal fracture — besides pain, swelling, mobility, crepitus, and departure from normal out- line at the injured part — is paralysis of those muscles whose nervous supply pro- ceeds ft-om beneath the seat of injury. According to the seat of inj ury, the nature of the case materially varies. When the lumbar region has suffered, the more prominent symptoms are — paralysis of the lower limbs, usually with loss of sen- sation ; involuntary discharge of feeces ; retention of urine ; and, fre- quently, priapism, "When the ii^jury has occurred in the upper dorsal, or lower cervical region, in addition to these symptoms there are — paralysis of one or both arms, difficulty of breathing, sluggishness of the bowels, with distention of the abdomen. If, again, the fracture be alove the origin of the phrenic nerve — and compression there prove great — respiration will at once cease, causing death. An almost invai'iable result of spinal fracture, wherever situated, is a deteriorated condition of the urinary organs. The kidneys err in their function ; and the lining membrane of the bladder, becoming the seat of chronic congestion, assumes a most depraved action ; copious, foetid, turbid, ammoniacal urine passes aAvay, with sad aggravation of the general disorder of system. The bowels, too, are not merely dis- tended and sluggish, but become depraved in the function of their mucous membrane ; the dejections evincing a very vitiated character. Bed-sores are apt to form. Fig. 107. Fractui'ed spine, bisected; shewing the formidable and fatal injury in- flicted on the cord. FRACTURE OF THE SPINE. 301 The symptoms, continuing and gravescent, may terminate in death ; or, gradually mitigating, recovery may ensue — ^more or less complete. Obviously, the dangers to life are both many and formidable ; inflam- matory action in the cord or membranes, — effusion, exudation, disor- ganization ; secondary affections of the digestive and urinary organs ; bed-sores, and general exhaustion. It need not excite surprise to find the average of recoveries extremely small. The treatment may be reduced to simple principles. Very careful movement of the patient, and adjustment on a hard mattress, lest further displacement of the fragments occur. An equally careful re- duction of the displacement which is found to exist. Retention, by adaptation of a splint — of wood, pasteboard, gutta percha, or padded iron — on each side of the spine, for some distance above and below the site of injury. Enforcement of absolute quietude, antiphlogistic regi- men, and the other obvious prophylactic measures. Moderate anti- phlogistics, should symptoms of over-action exhibit themselves. Miti- gation of the unpleasant results occurring in the digestive and urinary organs ; obtaining regular and better movements of the bowels; reliev- ing the bladder by the catheter, at stated and frequent intervals ; and rectifying the state of the urine, by mineral acids and other medicinal means in ordinary use for that purpose. Ultimately — immediate danger having passed by — directing attention to amendment of circu- lation in the paralytic parts ; thus preventing shrinking by atrophy, and perhaps assisting in the recovery of function. The means usually employed to fulfil the last indication are, friction, shampooing, galvan- ism and electricity, and the use of strychnia. Galvanism and electri- city are to be used with caution, however ; it being the opinion of some, that, although by means of these agents, muscular contractility may for a time be roused, yet that the amendment is in general but temporary, and that the parts ultimately lapse into a worse degree of impotency. Counter-irritation is sometimes of service. In the obviously displaced spinal fracture, with symptoms of com- pression of the cord, it has been proposed to employ the trephine, with the view of relieving the injured medullaiy matter. Reason and ex- perience, however, have decided against the procedure ; inquiry hav- ing shown that the compressing agent is usually the fore part of the body of the vertebra, which cannot be reached and dealt -with from without. Sjyinal Jissure may occur, without displacement ; and yet may prove fatal, fi-om another cause than concussion. Into the cleft, a portion of the membranes may be received and retained ; the constriction acts as an uninterrupted exciting cause of inflammatory action, and fatal exudation or structural change ensue. The case is obscure in its course ; and is likely to be unfortunate in its issue, all remedial means proving 302 DISLOCATION OF THE SPINE. of little avail to arrest an action, which is being ever fed and main- tained by an influence which is inaccessible and consequently in- superable. Dislocation of the Spine. Luxation of the spine, without fracture of the processes, is a rare injury ; yet has occurred, occasionally, in the cervical region — ordin- arily between the fifth and sixth vertebrae. It has happened by mus- cular power alone ; a maniac, for example, having so caused death by, as it were, forcibly throwing his head from him, during restraint in a Fig. 108. Fig- 109. paroxysm of excitement. More frequently it is the result of violence applied from without ; as by falls on the head. Suspension sometimes causes it, but much more rarely than is generally supposed ; usually there is no displacement of the vertebrae whatever, even in criminal cases — death taking place from other causes (Principles, p. 747). The displacement is easily recognizable on manipulation ; and the concomitant symptoms of compressed or torn spinal cord are sufficiently explicit. If life, or the hope of life, remain — replacement is to be effected by careful extension and coaptation ; afterwards, untoward results are to be obviated by such management as has been advised in the case of fracture. Svbluxation., or partial displacement, of the vertebrae is by no means uncommon; and may take place at any part of the spinal column. It is probably of most frequent occurrence in the dorsal region ; caused by falling on the breech, from a considerable height. Fig. 108. Dislocation of the spine ; between the fourth and fifth cervical vertebr£e. The patient fell backwards over a high paling, and alighted on his head. Cord torn. Complete paralysis. Issue fatal, within a few days. Fig. 109. The same ; seen laterally. LATERAL CURVATURE OF THE SPINE. 303 with consequent forcible bending of the trunk forwards. The posterior ligamentous apparatus gives way, to a greater or less extent, and a hiatus between the spinous processes results. The symptoms, in addition to the marks of displacement, are those of severe spinal con- cussion ; and the subsequent dangers are also such as may be expected to follow that accident. By extension, replacement is gently effected. The same retentive apparatus is then applied as for fracture, and must be worn patiently for weeks ; the patient resuming use of his lower limbs very gradually, and not till after many weeks have elapsed. Throughout the whole period of treatment, an anxious regard is paid to the spinal cord ; and remedial measures are adopted, if necessary, to ward off morbid action there. Lateral Curvature of the Spine. Lateral curvature of the spine is usually held as contrasted with antero-posterior curvation ; the latter the result of ulcerative lesion in the bodies of the vertebrae, the former originally unconnected with structural change. In the one, there is mere change of position ; in the other, there is change and loss of bone, by the results of inflam- matory action which has originated there. It is right to remember, however, that in some cases the antero-posterior curve is found to be of the same nature as the lateral displacement — originally unconnected with structural change. Lateral curvation may arise from different causes. And it is im- portant to classify the cases accordingly ; that the suitable treatment may be afforded to each. 1. Peculiar avocations are not unfrequently the cause. Those, for example, which entail a habitual use of the right arm, much disproportioned to that of the left ; as in blacksmiths and dragoons. The muscles of the right side become largely developed, and powerful ; and the tx'apezius and rhomboids, thus changed, acting on the spinal column so as to overpower their fellows of the opposite side, have the effect of gradually inducing distortion — it may be to a con- siderable extent. Of course, this is most likely to occui* during adolescence. The remedy is simple ; partial discontinuance of the use of the right side, with increased employment of the left. The dis- placement, if recent and slight, can be perfectly removed. 2. Bad habits, of standing, sitting, or reclining, in an awkward position, are very apt to cause a greater or less amount of lateral'dis- tortion in the young. The spinal column is habitually thrown off its normal line of erection ; and, in course of time, both muscles and bones, becoming accustomed to their abnormal position, may refuse to assume any other. And thus curvature, both great and confirmed, may be- come established, without any actual vice in the skeleton, the muscles. 304 LATEEAL CURVATURE OF THE SPINE. or the general system. Obvioiislj, tliere is one class of human beings much more than any other exposed to this form of curvature ; namely, young girls occupied in the crowded details of an imprudently managed course of education. Young people of both sexes are also very liable, who are employed in sedentary occupations in trade ; as in sewing, knitting, engraving, colouring, &c. The indications of treatment are plain ; discontinuance of the hurtful habit or occvipation ; ample amount of exercise out of doors ; and a voluntary use of such gymnastic or other exercises as are calculated to produce a healthful play of the general muscular system, and more especially of the muscles of the trunk and spine.* And by means of light articles of dress, fashioned and worn so as to attract the patient's notice to the threatened de- formity, while at the same time they warn of the negligence or awk- wardness which has led to it, disuse of the habits in question may be greatly favoured. By some, the influence of a pulley and weight, horizontally extended on the opposite side, is made to act correctively on the curve, f But all cumbrous apparatus — in the shape of stays, or other machinery — are plainly to be avoided, as likely to prove most hurtful. 3. Hitherto we have spoken of simple deformity. Now we have to do with disease. General DeUlity, however induced, in the young, is a frequent cause of lateral curvature ; insufficient food and clothing, excess of confinement and work, febrile or other affections leaving the system exhausted — are all causes of such debility, with its consequent injurious influence on the spine ; and to these all ranks of life are subject. The muscular system grows especially weak; the extensors of the trunk are unequal to the task of duly maintaining the erect posture ; and deviation from the straight line results — at first occasional, afterwards habitual, and ultimately confirmed. In the previous ex- amples of lateral curvature — unconnected with actual disease — the curvation begins usually in the dorsal region, and is mainly situated there. But in this case, the beginning of curvation is more likely to take place in the lumbar region — at the basis of the pyramid of support. An inclination is made to either side ; then, to atone for that, an opposite curve is made in the dorsal region. And, not unfrequently, there is a third ultimately established in the cervical, in a direction opposed to that of the dorsal. As the amount of bending increases, rotation at the same time generally takes place — the rotation being towards the same side as the curve ; the height of the spinal column, too, greatly decreases ; and, in consequence, serious changes happen to the thoracic and abdominal viscera. The ribs expand on one side, while they are closed on the other ; and they fall inwards, narrowing * Sir B. Brodie, Lancet, No. 1218, p. 3, et seq. t Dr. Brown of Boston, U. S. Lancet, No. 1329, p. 178. LATEKAL CURVATURE OF THE SPINE. 305 the chest in its lateral direction, and producing prominence of the sternum and of the costal cartilages. The heart and lungs become incommoded, and labour in their function. The sternum, too — with its costal appendages — has approached unusually near to the pelvis ; the abdominal space is narrowed in consequence, and its organs are injuriously aflfected. At first, the spinal change is chiefly in the inter- vertebral spaces ; and the deformity, at that time, is capable of being undone, by appliances from without, or, partially at least, even by the eflforts of the patient. But, by and by, the bones become consolidated in their new relation ; interstitial absorption taking place at the com- pressed points, while corresponding expansion or growth occurs at those which are fi'ee ; and then the deformity has become fixed and irremediable — a circumstance of very important and obvious bearing on the question of treatment. The indications of treatment are directed fully more to the state of the general system than to the part affected. A tonic regimen is patiently persevered in ; at the same time, the deficient extensors are to be roused by friction, and by suitable exercise ; and from time to time, by manipulation, a restoration of the normal outline of the spine is to be attempted. To aid in the fulfilment of the last indication, a light mechanical contrivance may be occasionally employed, restorative yet not oppressive. But ail cumbrous or confining apparatus, con- tinuously worn, must prove prejudicial ; the muscles, already weak, will be enfeebled more and more ; and the original malady cannot fail to sustain aggravation. Good diet and clothing ; regulation of the bowels ; exposure to good air ; judicious use of medicinal tonics ; friction of the back, acting more especially on those muscles which seem most deficient ; healthful exercise, both of the general body, and of the muscles of the trunk — short of fatigue; and occasional attempts at readjustment by mechanical appliances — constitute the most important means towards alleviation and cure. Myotomy has been practised, both in this and in other forms of spinal distortion ; but with no good I'esult. The experience and judgment of the profession are alike op- posed to it. 4. A diseased condition of a muscle or bo?ie, in another pari, may cause curvature of the spine. Thus, a rigid and contracted state of the sterno-cleido-mastoid muscle of one side, producing the state called Torticollis, is very apt to cause spinal curvature, as has already been noticed. The remedy is simple ; by division of the ofiending muscle. And, again, shortening of a lower limb, by morbus coxarius, or by ill-united fracture — unless atoned for by suitable mechanical contriv- ance — can scarcely fail to cause more or less distortion of the vertebral column. 5. Eickets is certainly not the least common cause. And the 306 LATERAL CURVATURE OF THE SPINE. curvatures so occasioned are at once the most rapid and decided in tlieir progress, and the least amenable to treatment. The peculiar characteristic is indication of the rickety state ; — strumous complexion and character, and distortion of other parts of the skeleton, as well as of the spinal column (Principles, p. 472). The results of extreme spinal curvature, usually with rotation, are rapidly developed ; and, at Fig. 110. Fig. 111. the same time, the pelvis and lower limbs, as well as the clavicles and the superior extremities, are more or less distorted. Usually, the direction of the spinal curvature is lateral ; but it may be antero- posterior. The treatment — prophylactic and curative — is such as has been already considered (Principles, p. 473, &c.) It is here that the use of mechanical aids, in the shape of stays and belts, is not only allowable but highly necessaiy — when the patient is in the erect or semi-erect posture, and especially when exercise is taken ; yet requir- ing much prudence and skill both in their first adjustment and subse- quent use. Disease of the Bodies of the Vertebrce. Interstitial absorption frequently occurs, in connexion with simple Figs. 110 and 111. Permanent curvature of the spine, with rotation, produced by Rickets. DISEASE OF THE BODIES OF THE VERTEBEiE. 307 curvature, as already stated ; whereby a distortion, at first I'emediable, becomes ultimately confirmed and unalterable. It also occurs as a primary affection, in the bodies of the vertebras, as a prelude to carious ulceration (Principles, pp. 294 and 432). More rarely, it exists as a separate and distinct disease, causing displacement by curvation forvi^ards at the affected part ; and deposit, following on absorption, after a time, confirms the curve by con- ^^^^ i^HIMRIHI IB '^ solidation. Treatment is by rest and gentle counter-irritation. Continuous Absorption, and Simple Ulceration occur in the bodies of the vertebrae, as the results of pressure ; the former often is caused by the gradual action of an aneurismal tumour ; the latter may result from the more speedy operation of the same cause, and is sure ^ to be produced by the pressure of an abscess. Healing takes place, on removal of the cause — if that be in our power. Caries of the Vertehrce is a most formidable affection, and unfortu- nately not of rare occurrence. It is the ordinary cause of sharp antero- posterior curvature usually termed " angular ;" sometimes attributable in its origin to external injury, but often unconnected with any assignable exciting cause. The morbid action follows the ordinary course (Principles, p. 436); sometimes limited to one or two bones; often involving almost the whole chain. Its most frequent site is in the dorsal region. Usually it is associated vnth, and probably dependent on, the strumous diathesis. Obscure spinal symptoms generally precede ; pain, uneasiness, numbness, and weakness in the limbs ; spasmodic twitchings ; obstinate bowels ; alkaline urine, with trouble in discharging it. In the part there is dull uneasiness, and ultimately pain, which is increased by pressure, and rendered intense by sharp percussion. The gait is tottering and uncertain ; with the back kept peculiarly rigid, so as to avoid motion of the diseased vertebrae. Often a distressing sense of constriction is felt in the chest, as if this were girded by a tight cord. The symptoms of paralysis manifest them- selves gradually ; affecting different parts, according to the site of the vertebral disease ; and usually motion is impaired before sensation — as Fig. 112. Continuous absorption illustrated by the pressure of an aortic aneurism on the bodies of the vertebrae ; a, the arch of the aorta ; h, the descending aorta ; c, the vertebral column. Opposite d, the bodies of the vertebrae are seen excavated, -with cor- responding processes of the compressing clot ; while the intervertebral substances, suc- cessfully resisting the pressure, project into corresponding depressions of the fibrin. X 2 308 CAEIES OF THE VEETEBE^, can readily be understood on reference to the anatomical arrangement of the nerves given off from the spinal cord. Sharp curvature, Fig. 113. Fig 114 forwards, advances more and more. The matter, in which the carious mass is bathed, accumulates ; and, seeking an outlet, points at some part of the surface — directly, on the back ; or at some distant point, as in the loins or groin. The ultimate result may be cure by anchylosis, in the slighter cases ; the curve remaining per- manent. Much more frequently, the issufi is fatal ; occurring rapidly, by the effects on the spinal cord ; or more gradually, by hectic and exhaustion. Treatment consists in affording absolute rest to the part, by confinement to the recumbent posture ; with attention to the general health, and patient continuance of cod-liver oil. In the avowedly strumous cases there is usually an intolerance of all forms of active counter- irritation, which threaten to accelerate the fatal issue by exhaustion ; and, in such patients, vv^e are to content ourselves Fig. 113. Caries of the vertebra; macerated; the bodies extensively destroyed; marked curvation forwards. Fig. 114. The same diirlng life. Angulation. Fig. 1 L5. Caries of the vertebrae ; preAnously to maceration. The aorta overlays the cyst of the abscess. Kg. 115. LUMBAR AND PSOAS ABSCESS. 309 with rest aud general management, looking gloomily to the result. And in all cases, caustic issues are only serviceable at the com- mencement of the disease. The prone position is usually preferable to the supine ; as relieving the spinal column more thoroughly from the superimposed weight, and proving favourable to venous return from the bodies of the vertebrae. And " the prone couch," employed almost constantly, day and night, will be found in most cases a great assist- ance in the treatment ; becoming, after a time, not only not irksome but absolutely agreeable to the patient ; and of course so managed as to avoid, as far as possible, even the very appearance of restraint. In all cases, mechanical adjustment of the distorted spine by force is manifestly at variance with both surgery and sense. Caries of the upper cervical vertebrae requires the most careful management : lest, by sudden motion, displacement should occur, causing fatal compression of the upper part of the cord. The patient seems to be instinctively aware of this hazard ; and, on moving his head, always supports the chin carefully on the hand, while the whole body — as a pillar — is made to turn in obedience to the direction of its capital. Here mechanical contrivance is most suitable and necessary; in order to guard against sudden motion, and at the same time to relieve the diseased bones from the weight of the head (p. 256). By this and counter-irritation, with due attention to the general health, cure by anchylosis is to be sought for. And though in no case our hope need be sanguine, neither in any need it give place to despair ; seeing that our museums show cures by anchylosis under circumstances the most unfavourable — the spinal cord having accommodated itself to great displacement, as well as loss of substance, affecting even the atlas and dentata. Lumbar and Psoas Abscess. By Lumbar Abscess is understood, a collection of matter pointing somewhere in the lumbar region. It may originate wholly in the soft parts. More frequently it is the result of caries of the vertebra3. Treatment depends on the nature of the case. If there be no prospect of ultimate cure, no opening should be made ; the ordinary palliatives are to be administered, and every care is to be taken to keep the inte- guments entire. If the case present a favourable aspect, on the con- trary — the amount of disease in the spine seeming slight, and the system yet tolerably robust — a free evacuation should be made by puncture. By the inflammatory disintegration following on such opening, we are most likely to obtain such spontaneous change in the state of the bone, as vdll admit of the healing process (Principles, p. 441). But the action requires an anxious watchfulness, lest it involve the system 310 SPINA BIFIDA. in a dangerous amount of disturbance, and lest, also, by excess, it prove prejudicial to the affected part. If a case present itself, in all local respects promising, but with the system accidentally low, the open- ing should be delayed until, by time and suitable management, the constitutional powers have been somewhat restored, and a tolerance of the remedy regained. When the matter connected with vertebral disease points in the groin, having descended along the course of the psoas muscle, the affec- tion is termed Psoas Abscess ; but it, too, may occasionally be found unconnected with disease of bone. Treatment is the same as in the former instance. Under care, cod-liver oil, and the prone couch, some- times wonderful recoveries take place ; even after long continued dis- charge. Spina Bifida, or Hydroraehitis. This is a congenital malformation, usually situated in the lumbar region ; but it may be in the dorsal or sacral. The posterior part of one or more vertebrge is deficient ; and, in consequence, the membranes of the cord protrude, constituting a tumour of greater or less size — com- posed of the ordinary integuments, the changed spinal membranes, and the spinal fluid secreted in excess. In other respects, the child may be fully and well formed. More frequently, it is otherwise defective ; the lower limbs, especially, being shrunk and paralytic. Usually the tumour enlarges, by accumulation of the contained fluid ; the integument thins and ulcerates ; the fluid contents escape and the tumour collapses ; an asthenic inflammatory action seizes on the spinal cord and its mem- branes; and the patient perishes either directly in consequence, or by hectic. In the more favourable cases, the tumour may enlarge slowly, if at all ; and the child's growth may advance uninterruptedly. Some- times, by spontaneous ulcei'ation, a very minute aperture is formed, through which the fluid contents slowly drain away, the tumour gra- dually shrinking, and the parts becoming satisfactorily consolidated. Curative treatment is attempted only in those cases which afford a reasonable prospect of successful issue. In some cases, it is enough to palliate and prevent increase. In others, we get rid of the swelling, hoping that the fissure in the spinal column may close ; or, at all events, that such consolidation shall take j)lace as may effectually prevent recurrence of the protrusion. 1. By steady and uniform support and pressure from without, not only is increase prevented ; absorption may also be occasioned ; and the tumour having become slowly discussed, an opportunity may be thus given for closure of the vertebral hiatus. 2. Along with the use of pressure, occasional puncturing of the cyst may be practised, so as to expedite the process. 3. The fluid may be at once drawn off with a trocar and canula. MALIGNANT DISEASE. 311 Aiid it has been further proposed subsequently to inject iodine, as for hydrocele. 4. By including the prominence of the tumour in two elliptical incisions, which penetrate the whole thickness of its cover- ings, the fluid is at once evacuated ; and then, on bringing and retaining the margins of the wound in contact by means of suture, such a degree and kind of traction is made upon the parts beneath as may favour, very much, the desired closure of the spinal fissure.* In dissecting away the part included in the elliptical incisions, care must be taken to injure the nervous expansions on its internal aspect as little as possible. The head, too, should not be kept high ; otherwise the fluid of the sheath is apt to escape too suddenly. This last opera- tion is warrantable only in those cases in which the fissure is slight, and other circumstances are favourable. After such a proceeding, as well as in the modes of treatment by puncture, obviously there is much danger by inflammatory seizure of the spinal contents — which has to be guarded against accordingly. Malignant Disease. The spinal column has occasionally been found affected by malig- nant tumour ; j an affection which is fortunately rare, seeing that in all cases it must be quite incurable. Shaw on Distortions of the Spine, Lond. 1823 and 1825. C. Bell on Injuries of the Spine, Lond. 1824. Lawrence on Dislocations of the Vertebrag, Med. Chir. Trans, vol. xili. 1825. Teale on Neuralgic Diseases, Lond. 1829. Beale, a Treatise on Deformities, &c. Lond. 1830. Stafford on Injuries, Diseases, and Distortions of the Spine, Lond. 1832. Brodie on Injuries of the Spinal Cord, Med. Chir. Trans, vol. xx. 1837. Guerin, Gazette Medicale, 1840, Nos. 14 and 15. Hewitt, Cases of Spina Bifida, Lond. Med. Gazette, vol. xxxiv. 1844. Lonsdale on Curvature of the Spine, Lond. 1847. Stanley on Diseases of the Bones, Lond. 1849. Bishop on Deformities of the Himian Body, Lond. 1851. Tamplin on Lateral Curvature of the Spine, Lond. 1852. Pirrie, Principles and Practice of Surgery, Lond. 1852. Brodie on Injuries of the Spinal Cord, Med. Chir. Trans, vol. xxi. Brodie on Curvatures of the Spine, Lancet, No. 1218, et seq. * DuBOURG, Gazette Medicale de Paris, Juillet 31, 1841 ; and Brit, and For. Rev. No. 24, p. 547. t Medico-Chirui'gical Transact, vol. vi. art. 6. 312 CHAPTEE XXV. INJUEIES AND DISEASES OF THE CHEST. Fracture of the Ribs. The ribs are very liable to fracture ; by a blow, or fall, or tbe appli- cation of crushing weight ; and the ordinary site of injury is near the middle of the bones. The signs are, pain at the part, usually with discoloration and swelling ; difficult breathing ; full inspiration im- practicable — the attempt causing great aggravation of pain, with sudden catching of the breath ; crepitus felt, when the palm is held over the part, during respiratory movement. Displacement is seldom great; and is almost always in- wards. The injury may be com- pound, with corresponding wound of the integuments. More fre- quently it is in a manner com- pound, by wound of both pleurae, and consequent communication with the lung, the integuments remain- ing entire. Under such circum- stances, emphysema can scarcely fail to occur, to a greater or less extent ; air escaping outwardly from the lung, and becoming infiltrated into the subcutaneous areolar tissue — puffing up the surface of the chest, and probably also extending to the neck. Inflammatory affec- tion of the pleura is not unlikely to supervene, as can readily be ±is. lie. 1 i T understood. The objects of treatment are, to effect and maintain replacement, to prevent motion, and to avert inflammatory or other untoward con- sequences. A compress is laid along the sternum, so as to make that Fig. 116. General emphysema of the whole surface, after wound of the right side of the chest. After Larrey. FRACTUEE OF THE EIBS AND STERNUM. 313 surface equally salient with the spinous ridge of the vertebrte ; and then a broad flannel roller is applied tightly round the chest ; the effect of such deligation being to arrest respiratory movement of the ribs, and to force outwards the fragments of the rib or ribs — not only placing them in more accurate contact than they otherwise would be, but also removing their sharp extremities from the pleura, which they might seriously injure. In severe cases, when the cavity of the pleura contains much extravasated blood, bandaging must be conducted with great caution, lest it seriously aggravate the akeady existing dyspncea. Rigid antiphlogistic regimen is enjoined; and active antiphlogistics are not delayed, if inflammatory accession threaten in the chest. Cough, sneezing, and other involuntary movements of the pai-t, should be avoided, if possible ; and confinement to bed is expedient, during the first few days. The bandaging is likely to limit or prevent emphy- sema ; but if this prove excessive and inconvenient, relief may be obtained by punctures. Ordinarily, it does not occur to a great extent, and gradually disappears, probably by absorption. Dislocation of the Ribs. Sometimes, but rarely, the head of the I'ib is displaced from its connexion with the spinal column, without fracture. Displacement is usually slight. And the injury resembles fracture very closely, both in its history and treatment. Fracture of the Sternum. The sternum is sometimes broken by direct violence, and displaced inwards. The signs are plain ; deformity by displacement being at once discernible, and crepitus taking place during respiratory move- ment. Treatment is as for broken ribs ; but without any compress over the broken bone. And there is the same necessity for watchful anxiety as to the state of the thoracic contents. Caries and Necrosis of the Ribs and Sternum.. These bones are liable to caries and necrosis, in connexion with injury, and as results of mercurial poison — with or without syphilis. The ordinary treatment has to be put in force ; except in those cases of chronic caries in which the disease is slight, and has been of very long duration, in a feeble system. Then, sudden suppression of the discharge, by healing, would be apt to prove injurious ; and it is well to be contented with mere palliation. When operation on a diseased rib is necessary, freedom of mani- 314 WOUNDS OF THE CHEST. pulation is favoured by the previous condensation and thickening of those parts which lie between the bone and the pleural cavity. Hernia of the Lungs, or Pneumocele. This mal-position may be : 1. Congenital, from defective develop- ment of the thoracic parietes ; 2. Traumatic, a wound having left a portion of the parietes open to protrusion ; 3. Consecutive, following fracture of a rib, or perforation of the chest's wall by abscess ; 4. Spon- taneous, protrusion taking place through an intercostal space, during the exertion of coughing, or through the natural apertures at the root of the neck beside the large blood-vessels. The intercostal spaces most frequently affected are the seventh, eighth, and ninth, at their anterior part. When slowly formed, the protruded part acquires a sac from the pleura costalis ; and, from a small beginning, may come to be of great size — its dimensions greatest during forcible expiration. Aus- cultation reveals nothing in inspiration ; but during forced expiration an intense vesicular murmur is heard, similar to that of normal inspira- tion, and sometimes accompanied by a kind of crepitant rale. At the same time, too, an impulse is given to the hand, and the " vesicular rustling " may be felt as well as heard. In the traumatic form, reduction is to be effected, if the protruded portion of lung be in a fit state for replacement. Otherwise, it is to be removed by incision. If left to itself, the part wiU sphacelate, and spontaneous cure may result. No real strangulation, however, occurs; and on this account prognosis is more favourable than in abdominal hernia. In the other forms, the tumour is reduced, and a firm compress and bandage continuously worn.* Wounds of the Chest. These may be inflicted by the thrust of a sharp instrument, by the penetration of obtuse bodies, by gunshot, or by fractured rib. Danger is great both at once and secondarily ; immediately, by loss of blood, and by entrance of air into the pleural cavity; subsequently, by inflam- matory action, and its results. The latter danger is the more serious. And the general statement may safely be made, that in the early treat- ment active antiphlogistics are mainly to be trusted to; unless decid- edly contra-indicated by special circumstances of the case. Penetrat- ing wounds by sharp instruments, affecting the lungs, are always * Vide M. Morbll-Lavallee, Mem. de la Soc. de Chirurg. de Paris, 1847 ; and Brit, and For. Med. Chir. Rev. Jan. 1848, p. 133. WOUNDS OF THE CHEST, 315 formidable by bleeding. But, in the case of an obtuse body penetrat- ing, the elasticity of the lung saves that tissue from injury which, from a sharp pointed body, it could not fail to sustain. 1. Wounds of the Pleura Costalis. — If the intercostal artery have been wounded, bleeding is likely to be both troublesome and dangerous. The loss may be excessive through the external wound ; or blood, accumulating within the pleural cavity, may compress the lung, and constitute a dangerous hsemato-thorax. This point, therefore, should engage our first attention. And to secure the vessel, one of two methods may be adopted. It and its accompanying rib may be in- cluded in the noose of a ligature. Or, a linen bandage having been placed over the part, a fold of it is pushed into the wound, between the ribs ; and the linen pouch within the pleural cavity is crammed with charpie, by means of a probe or director; then, tightening the ban- dage, and securing it firmly round the chest, this internal plug is made to compress the vessel and occlude its orifice. But, indeed, the dangers by wound of this vessel seem to have been somewhat overstated ; and in most cases ordinary hemostatics, it is probable, will not be found to fail.* Entrance of air by the wound, and accumulation of it within the chest, are to be avoided by early and accurate closure of the wound. Otherwise, the condition of pneumo-thorax becomes established ; the lung is compressed, and made to collapse ; respiration is consequently rendered imperfect ; and the other lung, having suddenly a great amount of additional duty thrown upon it, labours in its function, becomes dangerously congested, may prove apoplectic, or is attacked by violent inflammatory action. These immediate dangers having been surpassed, others remain. The wound, suppurating, may lead to in- flammatory aiFection of the pleura or of the lungs, by extension of the inflammatory process ; and this has to be guarded against by antiphlo- gistic regimen, in the first instance, followed, if need be, by venesection and antimony. 2. Wounds of both PleurcB and of the Lung. — The dangers are still by blood, air, and inflammatory action. There is now a third outlet for the first ; by the bronchial tubes, as well as into the pleural cavity, - and through the external wound. And the bleeding, coming from so vascular an organ as the lung, is likely to prove formidable. The usual signs of wound of the lung are — a state of system bordering on collapse, difficult breathing, great anxiety of countenance, and expec- toration of florid arterial blood. Bleeding is dangerous, by direct loss, and by danger of hasmato-thorax ; and also by risk of accumulation in the bronchial tubes, or in the trachea, during the stage of collapse. Afterwards comes the peril of intense inflammatory action in lung and * GuTHKiE on Wounds of the Chest, p. 104. 316 H^MATO-THOEAX. pleura. And, lastly, by profuse and continued discharge from the suppurating wound, the patient may perish under the symptoms of phthisical hectic. The first danger is met by rest, quietude, and rigid antiphlogistic regimen ; recourse being had also, if need be, to more direct means of controlling the hemorrhage — derivative venesection, nauseants, acetate of lead and opium, &c. (Principles, p. 364). Rally- ing and reaction having occurred, antiphlogisLics come into use, and often not sparingly. Hectic having threatened or set in, a correspond- ing change must be made in the treatment. The local management is simple throughout. At first careful examination of the wound is made, in order that no foreign matter may be permitted to remain. Then it is covered by tepid water- dressing, retained by light bandaging. And the patient is laid, and directed to remain, on the wounded side, so as to favour outward escape of dischai'ge ; while by this posture, also, adhesion is favoured between the corresponding wounded portions of the two pleurae, so as to shut off the injured part from the general costal cavity.* When contusion exists, as in gunshot injuries, great watchfulness is necessary at the time of the separation of sloughs, lest secondary hemorrhage occur. Small doses of aconite are of use in averting this ; by subduing the febrile excitement of the circulation which usually precedes. Emphysema may occur in one of two ways ; but is seldom such as to requii-e direct treatment. Air, escaping from the pulmonic lesion, may not be wholly dischai'ged externally ; or, in a valvular form of external wound, air may enter more readily in inspiration than it can escape during expiration ; and, in either case, a portion is liable to be infiltrated into the subcutaneous areolar tissue. Hcemato-Thorax. This term denotes an accumulation of blood in the pleural cavity, causing compression of the corresponding lung, and the dangerous consequences of this, already noticed. It may be pi'oduced by spon- taneous escape of blood, through ulceration — as in aneurism ; much more frequently it is of traumatic origin — by wound of the lung, or of ^an intercostal artery. It may be either simple or compound ; the latter, if the result of a penetrating wound ; the former, if caused by puncture of the lung in a case of fractured rib with much displacement of the sharp ends of the bone — the integument remaining entire. According to the extent of accumulation, respiration is more or less oppressed ; there is dulness on percussion on that side, and no respiratory murmur can be heard ; on the opposite side, respiration is puerile ; the patient lies only on the affected side, and the corresponding cheek has often been observed of a purple colour ; the countenance is anxious ; the general * Guthrie on Wounds of the Chest, p. 63. PNEUMO-THOEAX. 317 surface is cold, pale, and bedewed by clammy sweat ; and there is feeble pulse, with cold extremities, and other signs of serious loss of blood (Principles, p. 370). K the affection be not compound, and slight in other respects, treatment is analogous to that of sanguineous collections in the external parts of the body, following bruise. "Wound of the surface is carefully abstained from, and gradual disappearance by absorption patiently awaited (Principles, p. 745). Venesection is advisable, unless when specially contra-indicated ; first, to arrest bleeding, and so to limit the accumulation ; secondly, to diminish the amount of circulating fluid in the labouring sound lung, and at the same time to avert or mitigate inflammatory action in all the injured parts. If, however, the ac- cumulation be obviously great — as evidenced by the amount of dulness and fulness of the side, and by the oppression in breathing — it becomes necessary to afford the confined blood means of escape, by making a suitable opening in the parietes. In the compound form, the wound is kept open ; means are taken to arrest the bleeding at its source, and at the same time to assist the respiration ; and inflammatory symptoms are timeously opposed. Pneumo- Thorax. This denotes accumulation of air in the pleural cavity. The case may be either medical or surgical ; the latter dependent on wound of the lung ; the former caused by perforating ulcer, connected with tubercular abscess. The traumatic form is the result of penetrating wound, oblique and valvular ; or of fractured rib, displaced inwards. It has also resulted from mere bruise of the chest ; the lung and pleura pulmonalis having given way by rupture. Its signs are : — absence of the respiratory murmur on the affected side, with a peculiarly clear resonance on percussion ; the ribs are fixed ; and, on the opposite side, respiration is puerile, as in the preceding affection. In the medical form, there is usually fluid as well as air in the chest ; consequently a splashing of this fluid is heard, on succussion ; and coughing pro- duces a ringing sound, termed metallic, or amphoric resonance. Treatment consists in affording ease to the working lung, and averting inflammatory action. Judicious loss of blood, as already seen, conduces powerfully to both objects. In urgent cases, an outward escape is to be afforded to the air, by acu-puncture, or by the thrust of a small trocar and canula. Emphysema sometimes co-exists with Pneumo-thorax. It has been already considered, incidentally. 318 PAEACENTESIS THORACIS. Paracentesis Thoracis. Puncture of the thoracic parietes may be required, we have seen, on account of accumulated air or blood in the pleural cavity. It may also be called for in consequence of fluids having collected there — the result of inflammatory action — Hydrothorax and Empyema ; diseases which belong to the department of the Physician, and which it is con- sequently unnecessary to consider here. In empyema the side is found dull on percussion and swollen, and the ribs are unusually separate; there are dyspnoea, difiiculty of lying on the sound side, and the other signs of pleural accumulation already noticed ; the side enlarges more and more ; fluctuation comes to be discernible in the intercostal spaces ; and, ultimately, by ulceration at the most prominent part, spontaneous evacuation may take place, as in ordinary abscess. For the discharge of purulent and sero-purulent fluids, an opening is made by means of a trocar and canula. This instrument may be employed, subintegumentally, as in the case of chronic abscess (Prin- ciples, p. 221). Or the opening may be made direct, and left patu- lous and dependent. However made, the margins of the ribs should be carefully avoided — especially the lower — lest wound of the inter- costal arteries occur. In the direct puncture, it is well to make an incision through the skin and muscular stratum, by means of a scalpel ; merely completing perforation by the trocar. As to the most eligible point for making such a wound, authorities greatly differ. The opening must be dependent, and sufiicient in all respects for evacuation ; and yet it must not be so placed as to endanger the diaphragm — though this muscle, it is to be remembered, is usually displaced downwards very considerably by the accumulation, and is further protected by the patient being directed to inspire during the act of puncture. The space between the fifth and sixth ribs is frequently chosen, midway between the spine and sternum. Some prefer that between the seventh and eighth ; others operate between the sixth and seventh. Some go as high as between the fourth and fifth ribs, having observed that natural pointing not unfrequently takes place there. Of late, the space between the sixth and seventh, or that between the seventh and eighth has been opened, by cautious dissection and the thrust of a small trocar, at the most dependent part — below the lower angle of the scapula. The patient is placed with the side prominent and dependent ; and arrangements are made for turning him on his face, should oppressed respiration ensue. In the case of direct opening, permanency may seem preferable to closure and re-opening; and this is secured by suitable dressing of the wound. To favour discharge, the patient remains recumbent on the affected side. If closure be attempted, the greatest care must be taken to avoid the entrance of air ; the patient WOUNDS OF THE HEART. 319 is exhorted to shallow breathing ; the canula is withckawn before all the fluid has escaped ; and the wound is instantly shut up. The physical signs of hydrothorax are not dissimilar from those of empyema. And often very marked benefit may be derived from paracentesis. Accumulation having proceeded so far as greatly to embarrass breathing, the patient is arranged as already described, and by means of a small ti'ocar the serum is cautiously withdrawn ; the utmost care being taken to prevent entrance of air into the pleural cavity. Enough having been removed, the puncture is treated so as to secure immediate union. And, subsequently, the operation may be repeated, if necessary. Relief is certain, for the time ; and in not a few cases this adaptation of surgery to medicine seems to have been instrumental towards a permanent cure. Wounds of the Heart. These have been already alluded to (Principles, p. 350). They generally prove fatal ; but are not necessarily so ; and therefore are amenable to the general principles of treatment formerly detailed (Principles, p. 364). Hennen, Military Surgery, Edin. 1820. Mayer, Tractatus de Vulneribus Pectoris, &c. Heidleb. 1823. Quesnay, Dissertatio de Hsemorrhagia Arterise Intercostalis Sistenda, Berol, 1823. Larrey, Memoires de Chir. Militaire, vol. ii. and Memoires de I'Acad. Eoyale de Medecine, Paris, 1828. De Jong, Diss, de Vulneribus Cordis, Groning, 1838. Guthrie on Wounds and Injuries of the Chest, Lond. 1848. Richerand, Nosog. Chirurg. vol. iv. p. 3. Diet, des Sciences Med. vol. iv. p. 217. Dupuytren, Leeons Orales, vol. ii. Cock and Hughes on Paracentesis Thoracis, Guy's Hospital Eepoi-ts, Second Series, No. iii. Lond. 1844. 320 CHAPTER XXVI. AFFECTIONS OF THE MAMMA AND MAMMILLA. Irritable Mamma. The female breast is not unfrequently the seat of Irritation (Principles, p. 81) ; giving rise to mucli local uneasiness, and tending also to involve the system in serious disorder. The gland is nowise altered in structure; sometimes there is slight puffiness in the superficial areolar tissue. The pain is very considerable ; not constant, liable to exacerbations — often periodic — and otherwise evincing the ordinary characters of neuralgia. Aggravation generally occurs at the men- strual period. The patient is young or of middle age ; and usually is pale, thin, and cachectic. The aifection is to be considered as symptomatic of more serious disease, and treated accordingly. In the majority of cases, the uterus is to blame — disordered either in structure or in function ; and until this source of evil be rectified, all other treatment wiU prove of little avail. In cases of functional derangement, the preparations of iron are indicated. Conium is of service in allaying the general irritation of system. Locally, the endermic use of nitrate of sUver, so as merely to blacken, often affords relief; and belladonna, aconite, and prussic acid may be used in the form of ointment, liniment, or plaster. Change of air, exercise, attention to diet, and the other ordinary correctives of chronic disease, are of great importance. In some cases the symp- toms seem dependent on neuromatous formation in the neighbourhood of the gland ; and under such circumstances, cure may be readily effected by excision of the superficial tumour. Mammitis. \. Acute. — Acute inflammatory action in the mamma may result from external injury, exposure to cold, or any of the other ordinary excitants ; most commonly it is connected with lactation. The pain and other local signs are intense ; fever is proportionally severe ; and suppuration is from the first imminent. The secretion of mUk is first perverted, and then an'ested. Matter, when formed, is seldom limited MAMMITIS. 321 to one part, pointing rapidly there ; but rather tends to pervade the whole gland, pointing slowly ; and the abscess, after having become open, is liable to degenerate into the condition of sinus (Principles, p. 224). In the outset, leeches are applied in abundance, with hot fomen- tation ; and the gland is carefully supported by a soft handkerchief or shawl, passed beneath it and round the neck. Small doses of sul- phate of magnesia, in acidulated solution, assist antimony in subduing the febrile state, and at the same time have the salutary effect of opposing determination of blood and consequent hyper-secretion in the gland. When resolution is to take place, this may be accelerated by gentle friction. When matter has formed, early evacuation should be made ; for thus only may future severities by incision be pre- vented. In severe or neglected cases, the gland may be, as it were, dissected out by the matter separating its component parts ; or many sinuses may form, communicating with each other, intersecting the whole mamma, and mixed up with intercurrent abscess. Such sinuses do not require to be each incised throughout its whole extent — the knife following mercilessly on the probe ; it is enough to secure satisfactory evacuation by suitable counter -opening, and then by pressure to favour contraction of the cavities. In this we generally succeed ; and continuance of the pressure is further useful, in pro- moting discussion of the morbid parenchyma in which the sinuses are placed. It may be applied by bandaging, by careful application of strips of adhesive plaster, or by means of air or water contained in caoutchouc tissue, as recommended by Mr. Arnott. 2. Chronic. — The mamma is subject to enlargement and induration, by reason of a slow, painless, and minor amount of the inflammatory process. The whole gland may be affected, or only a part. Young adults are most liable. The swelling is more diffuse than any form of genuine tumour ; and is little painful, even on manipulation ; it feels as if composed of numerous small granules, and has the nega- tive character of wanting the local and constitutional signs of carci- noma. Treatment consists, locally, in light antiphlogistics, followed perseveringly by discutients ; constitutionally, in attention to the general health, and to the uterine functions, by alteratives, tonics, &c. Galactirrhcea. — By this term is understood a persistent and exces- sive secretion of milk ; whereby emaciation, debility, and even hectic may be induced. To arrest and remove this condition, iodine given internally seems to possess almost a specific power; suckling being of course desisted from, and the uterine functions restored. Chronic Abscess. Chronic abscess is not unfrequently found of a somewhat peculiar 322 LACTEAL AND OTHER SWELLINGS. character in coimexion with this gland ; consisting of a firm cyst, con- taining a small quantity of thick creamy-looking pns ; existing for months or years, and enlarging slowly if at all ; situate sometimes in the gland, more frequently beneath it; firm, because tense, to the touch ; and closely simulating a solid tumour. It may be treated either by subintegumental or by direct puncture ; or, an error of diag- nosis having been committed, and a free incision having been made, the cyst may be dissected away — as if a tumour. Lacteal Tumour. One or more of the lacteal tubes are liable to distension, by occlu- sion of their orifices ; giving rise to a swelling analogous to ranula in its formation. The contents are milky during lactation ; at other times serous and fluid, or caseous and solid — or partly so. The swell- ing has a fluctuating feel, and extends, radius-like, from the nipple outwards ; often it is of a conical form, the apex towards the centre. Treatment is by puncture, near the nipple ; keeping the opening pervious. Should inflammatory action take place, inducing obliteration, the occur- rence need not be greatly deplored.* Sometimes abscess forms ; requiring the ordinary treatment. Hypertrophy. The mamma is liable to hypertrophy, at the period of puberty ; usually with an unsatisfactory condition of the menstrual secretion. Sometimes a state resembling nymphomania attends. The undue amount of development may usually be got rid of, by attention to the general health, and to the uterine functions — aided, if need be, locally, by gentle leeching, followed by discussives. Of these latter none are so efiBctual, locally, as pressure ; and this is very conveniently applied by means of the hydrostatic apparatus of Dr. Arnott. Pendulous Breast. The pendulous breast is an affection of advanced years ; being but an exaggeration of the ordinary dug-like condition which this organ so generally assumes, in those who have borne children, and who habitu- ally neglect support of the part in dress. The only warrantable treat- ment is palliation by suspension and support. * I have known this simple morbid condition prove the precursor of inveterate car- cinoma in the gland. VAEIOUS TUMOURS OF THE MAMMA. 323 Partial Hypertropliy. This is the " Chronic mammary tumour " of Cooper. A portion of the gland becomes hyperti'ophied, with ultimate change of struc- ture — yet simple ; and enlargement of the lobules takes place usually from the outward surface, constituting a soft unequal tumour. It is peculiar to the young adult, seldom if ever appearing after thii-ty years of age ; and is almost always connected with disorder of the uterine system. Treatment is the same as for general hypertrophy. Marriage, followed by pregnancy and suckling, sometimes proves a successful means of cure. The tumour, though originally most simple, is liable to degenera- tion. Consequently, when ordinary discussive means have failed, after due trial, it should be regarded as other tumours not amenable to dis- cussion. " Common snakes are killed, because vipers are dangerous." Various Tumours. The gland may be the seat of Simple sarcoma. The treatment is first by discussion ; and, if that fail, by excision. Fibrous tumours have a favourite site here. Though less liable to degeneration than any other morbid growth, they are certainly not exempt from that untoward occurrence ; and, therefore, except in the aged, it is well to remove by operation that which can never grow better and may grow worse (Principles, p. 309). Cystic sarcoma is very common. Like the simple mammary tumour, it is most frequent under thirty years of age, and prevails chiefly among the better classes. The tumour is composed mainly of serous cysts, the parenchyma consisting of little more than the substance of the gland slightly altered. And there is some reason to believe that these cysts may sometimes originate in partial lacteal dilatation. By puncturing the cysts, and afterwards applying pressure, the tumour may diminish, consolidate, and gradually disappear, in the minor cases. But when the whole gland is involved, extirpation should be at once had recourse to ; not only because other treatment will prove unsuccessful, but because such tumours are well known to be peculiarly prone to degenerate, more especially when irritated (Prin- ciples, p. 314). True Hydatids are also found in the gland. When single, they may be got rid of by puncture. When numerous, abla- tion of the part is expedient. The Malignant tumours of the mamma are unfortunately of proverbial frequency ; more especially carcinoma. The general description of this tumour (Principles, p. 318) is not departed from ; the chief peculiarity being in the nipple, which, early involved, is remarkably retracted and shrivelled in appearance. The glands of the axilla, too, are liable to be soon aftected. The disease y2 324 MALIGNANT TUMOUES OF THE MAIMMA. is known by tlie age of the patient, the hardness of the tumonr, the character of the pain, the rate and mode of growth, the invohement yMA ',iji I mi III I, , , (^ '/©^^^ Kg. 117. of the skin and retraction of the nipple, the cachectic state of the system as evidenced by the countenance and general appearance. Fig. 117. Carcinoma of the breast, bisected. The figure of the tumour, Tvith its effect on the gland and nipple shewn. Fig. 118. Carcinoma; secondary. An example of the numerous nodulated tumours, which often form in the cicatrix of the former growth. One is ulcerated in the site of the mammilla. Fig. 119. Fungus haematodes of mamma; fungoid, bleeding, and blood-like. EXTIRPATION OF THE MAMMA. 325 The ouly cure is by extirpation ; but, as formerly explained (Princi- ples, p. 326), it is only a small number, of the many cases which pre- sent themselves to the surgeon, which warrant operation ; and it may be well to repeat here, that if the skin be much involved, if the nipple be much retracted, if there be a marked depression over the tumour, if the open condition be arrived at, if there be adhesion of the tumour to the jjectoral muscle or to the ribs, if there be ominous signs of some obscure yet serious disorder proceeding within, and if there be glan- dular affection without — these, being all singly most unfavourable, and betokening relapse, do most certainly, when coming together, con- tra-indicate all operative interference. Extirpation of the Mamma. The patient having been placed recumbent, and duly anaesthetized, the arm on the affected side is raised and held by an assistant, so as to stretch the pectoralis major, and facilitate incision. The knife is entered on the axillary aspect of the tumour, in a line with the mam- milla, and is moved in a semi- elliptical direction towards the opposite point ; a similar proceeding is adopted — above or below, as the case may be — to complete the ellipse ; and the size of this space necessarily varies, according to the extent to which the integument seems to be involved, and according to the natural laxity of the parts. It is a fault to take away an undue amount of sound textures, so that difficulty is experienced in effecting and maintaining apposition of the wound ; but it is a worse error to leave tainted parts, whereby reproduction of the disease cannot fail speedily to ensue. It is well to make the lower incision first ; otherwise its course and position are apt to be uncertain, under the irrigation of blood. Then, on each aspect, the knife is sloped through the subcutaneous fat ; and regular dissection is pro- ceeded with from the axilla downwards, dividing the principal vessels and nerves at once, and so rendering the subsequent steps of the opera- tion comparatively bloodless and free from pain (Principles, p. 339). The diseased mass — with its border of apparently sound tissue, in the case of malignant tumour (Principles, pp. 325 and 340) — having been removed, is carefully examined on every aspect by both sight and touch ; and, if need be, the knife is re-applied where thorough removal is not assuredly apparent. The vessels having been secured, the wound is brought together, and treated in the ordinary way. Tumours external to the mamma — forming in its immediate vicinity, but not incorporated with it — are not uncommon. The simple are removed ; leaving the gland undisturbed. In the case of the avowedly malignant, the entire gland, as well as the tumour, is taken away. Of 326 AFFECTIONS OF THE MAMMILLA. this class of tumours — not in, but near the mamma — the majority are simple, and fibrous. Affections of the Mammilla. Hie mammilla of the male is liable to hypertrophy and to malignant disease. In the one case discussives are expedient ; the other demands fi*ee and early ablation. The nipple of the female is also liable to hypertrophy, and malig- nant disease. In the foi'mer case no direct interference is required ; in the other, there is safety in nothing short of summary removal — not only of the nipple itself, but of the mamma also. There is one case, however, in which it is unnecessary to sacrifice more than the former ; — when the nipple has been hypertrophied many years, and begins to degenerate in structure. Such degeneration usually commences in, and is at first limited to, the apex ; and, in such a case, to cut at the root of the nipple is to cut in sound parts. The fissured and excoriated nipple of the nurse is an affection as frequent as distressing. A bare enumeration of alleged cures would occupy much space. Sufilce it here to say that the same treatment is necessary as in inflamed and irritable sores, modified by regard to the uses of the part. During application of the child, the nipple is pro- tected by a shield ; and in the intei'val, some of the many remedies are applied, which are not likely to injure the child, while at the same time they tend to soothe and heal the affected part. Abemethy on Tumours, Lond. 1804. Cumin, a General View of Diseases of the Mamma, &c. Edin. Med. and Surg. Journal, vol. xxvii. art. 1, 1827. Cooper, Illus- trations of Diseases of the Breast, Lond. 1829. Jeanselme, ]\IemoLre sur les inflamma- tions et les absces du sein chez la femme, Gazette Medicale, Jan. 1839. C. Bell on Carcinoma Mammfe, Med. Chir. Trans, vol. sii. p. 713. Brodie, Lectures on Pathology and Surgery, Lond. 1840. Birkett on Diseases of the Breast, Lond. 1850. Forget, Bul- letin de Therapeutique, torn, xxvii. p. 355. 327 CHAPTER XXVII. AFFECTIONS OF THE ABDOMEN. Abscess of the Abdominal Parietes. Abscess of the abdominal parietes sometimes occurs spontaneously ; frequently, it is the result of external injury ; and, in some systems, but a slight blow — or a strain, as in retching — may suffice. The site of the abscess is more frequently deep-seated than superficial. At first there is a hard, tender, increasing tumour, which softens obscurely as it enlarges, and slowly points. Treatment varies according to the stage. At first, while the inflammatory process is but recent and slight, and the swelling consists of plastic exudation, resolution is in our power, by rest and antiphlogistics. Advancement of the tumour is arrested, and the hard swelling begins to disappear. This subsidence may be accelerated by judiciously used discussives — employed, however, always with the greatest caution, inasmuch as we know by experience that if they be used either too freely or too soon, there is here a great pro- bability of inflammatory reaccession, in an aggravated form. So soon as the formation of matter has been at all indicated, a free evacuating incision should not for an instant be delayed ; it being remembered that the pus is much nearer to the peritoneum than to the integument, and moreover bound down by strata of dense fibrous tissue. But it is surely advisable to go a step further ; and whenever we feel convinced that reasonable hope of arrest and resolution is gone, make an incision in the most prominent part of the swelling, where we anticipate that matter is first and mainly to form, in order that so soon as it does form it may find a ready drain for its outward escape ; all the hazards of its pent up accumulation, in any quantity, being thereby felicitously avoided. If artificial opening be withheld, one of two events is very likely to occur ; the pus, finding its way into the general cavity of the abdomen, excites a most hazardous peritonitis ; or, on spontaneous evacuation taking place, the condition of faecal fistula is declared — the perforation internally, surrounded by plastic exudation, having pene- trated into an adherent fold of intestine. As already stated (p. 206), cherry stones, and such like substances, 328 BRUISE OF THE ABDOMEN. may be arrested in the vermiform process of the coecum, and cause abscess of the abdominal parietes ; so effecting their own escape. Tumours of the Abdominal Parietes. These demand also early attention, lest, by long continuance and enlargement, they become unfavourably connected with the deepest portion of the parietal layers. The adipose is, perhaps, more common than any other form of tumoiu' in this situation. In dissecting it out, the preliminary incisions should penetrate quite into the substance of the fatty matter ; thereby facilitating extraction, and avoiding unne- cessary depth and extent of incision. Bruise of the Abdomen. This is always important ; on account of risk of injury to the abdominal contents. Dangerous hemorrhage may at once occur by lesion of these, or formidable inflammatory action may be kindled subsequently. And, in treatment, both of these contingencies must be regarded. Absolute rest and quietude are enjoined; and the simplest ingesta are given most sparingly. Thus, extravasation of blood from a torn part is not favoured ; neither is escape of contents from any ruptured viscus promoted — on the contrary. On the first rising of the pulse beyond the limits of moderate reaction, on the accession of increased pain, with vomiting or other sign of disorder of the system — in other words, so soon as there is any indication of inflammatory action having begun — the lancet is employed freely, and is followed by calomel and opium, as circumstances may demand. And here the opium may be administered in a larger proportion than usual (Prin- ciples, p. 170); it being the only available opponent of the intense and exhausting pain which attends on such action ; and it besides being of good service, in injury of the intestines more especially, by exerting a sedative effect on the muscular coat of the bowels. Very obviously, pui'ging is not to be dreamt of, in the early treatment. Subsequently, when it is necessary to move the bowels, the gentlest remedies are to be selected ; and even they are used Avith caution. The first effect of bruise, attended with serious injury of the in- ternal organs, is to produce a marked state of shock, or depression, in the system. And a very common error in practice is, at once to attempt removal of this. The same evil consequences follow, as in the analogous case of injury done to the cranial contents (p. 17). Let the patient alone ; and ere reaction occurs, with its quickened and full circulation, a torn liver or spleen may have had its vessels closed by Nature's hemostatics, and a ruptured portion of intestine may be so WOUNDS OF THE ABDOMEN. 329 circumstanced by position and exudation, as to render fatal escape of its contents into the peritoneal cavity at least less probable. But, stimulate unwisely ; and then premature reaction is established ; the returning blood finds the mouths of vessels still open, and intestinal extravasation is quite unopposed. In one case, only, are we to inter- fere ; and that is, when the shock is extreme iu both intensity and duration, and threatens to prove directly fatal. Then we stimulate, to save life from immediate loss ; and yet we stimulate very cautiously, lest saving from one hazard we engender another at least as great. A remote consequence of abdominal bruise may be such atrophy of the muscles at the injured part as shall cause permanent weakness there, with consequent liability to hernial protrusion.* Wounds of the Abdomen. Wounds penetrating the abdominal parietes, and implicating the viscera within, are necessarily fraught with much danger. From lesion of the liver, a formidable hemorrhage can hardly fail to occur ; wound of the urinaiy bladder causes infiltration of the contents, almost invariably fatal ; from wound of the gall-bladder, acrid bile will escape, kindling intense peritonitis ; both acrid extravasation and dangerous loss of blood are likely to follow wound of the kidneys ; wounds of the spleen, like those of the liver, are dangerous mainly on account of the risk of hemorrhage ; from injured intestines, ftecal extravasation is likely to take place, causing an extent and amount of inflammatory action which is seldom if ever recovered from. Such severe injuries are invariably attended with a grave amount of shock, which serves the double purpose of warning the attendant of the importance of the case, and giving an opportunity for the comi^letion of Nature's measures for obviating hemorrhage and extravasation. This state, as formerly observed, is not to be rashly interfered with by the practitioner ; its progress is watched ; reaction is rather delayed than hastened ; and when this, no longer repressible, advances to excess, anti^^hlogistics are employed actively. Wound of the Bowel — suspected when discharge of blood by the mouth or by the anus accompanies the attendant shock — is not neces- sarily followed by extravasation. A mere puncture is closed by Nature's efforts. The mucous coat is protruded outwards, and plugs the orifice ; the abdominal viscera exert a constant equable pressure on each other at every point, and this tends obviously to counteract escape of contents ; and these two temporary means of arrest are duly followed by another which is permanent — namely, exudation of plastic lymph on the exterior of the wound, whereby union of the opposed * G UTHKiE, Lancet, No. 1441, p. 397. 330 WOUNDS OF THE ABDOMEN. surfaces of peritoneum, and a safe circumvallation of the injured part, are effected. As in natural hemostatics (Principles, p. 347), the tem- porary means are by plug and pressure, the permanent by plastic exudation. A moment's consideration_of the nature of this process wiU explain how mischievous must be the imprudent exhibition of stimuli, or indeed of ingesta of any kind, at the outset of the case. Protimsion of the Bowel. — If through a penetrating parietal wound a portion of intestine, or other viscus, protrudes entire, it is to be simply replaced ; with all gentleness, so as not to endanger an aggra- vation of inflammatory accession ; and yet with all accuracy — the finger following the retreating viscus closely, so as to ensure its being replaced wholly within the abdominal cavity, and thus avoiding the serious risk of obscure strangulation, which is so prone to follow partial reduction. The wound is carefully approximated — by suture, if need be ; and by moderate bandaging such pressure is made without, as is calculated to prevent reprotrusion. In subsequent treatment an anxious prophylaxis is maintained, with a preparation for suitable antiphlogistics on the shoi'test notice. If the protruded part be found to have sustained mere puncture, it may be simply replaced, as if intact ; trusting to Nature's means of closure. If a larger wound exist — incised, of no great extent, and con- sequently deemed capable of adhesion — it is to be brought accurately together by the glovers' suture (Principles, p. 645). And, in applying this, it is well to turn in the edges of the wounded part gently, so that the ap- proximated surfaces shall be peritoneal ; that structure being well known to be much more capable of the required plastic exudation, than are the mucous or middle coats of the bowel. The punctures of the needle should not be more than a line apart ; and the fingers of an assistant should accurately retain the inverted condition of the wound during the manipula- tion. It is well to take the first stitch from within outwards ; and the placing of a large knot here is supposed to favour the inward escape of the thread ; which in time ulcerates its way into the cavity of the bowel, and is thence discharged. The suture having been duly arranged, the part is gently replaced ; in the hope that it may become safely covered up by plastic exudation. K the portion of bowel be bruised, or otherwise so extensively injured as to render the occurrence of adhesion obviously impossible, it were folly to effect mechanical union and replacement of the part. Fig. 120. The glovers'j or continued suture; in wound of the bowel. AETIFICIAL ANUS. 331 After sucli procedure, the wound must necessarily inflame and open, fgeculent extravasation is inevitable, and death is almost certain. The wounded part should be retained at the surface ; and, with this vdew, the peritoneal coat is united with the integument, at the lip of the wound, at one or more points by suture ; and then through the upper orifice of the wounded part the fgeculent contents discharge themselves innocuously. The condition of Artificial Anus is established ; a state of much dis- comfort, and not altogether devoid of danger ; but infinitely preferable to fatal peritonitis by fseculent escape within the cavity of the abdomen. Thus, the local treatment differs according to the nature of each case. But in all, the constitutional treatment is the same ; rest and quietude ; starvation ; free venesection or leeching, or both, on the first onset of over-action ; then calomel and opium — the latter in large doses. Artificial Anus. By this term is meant an unnatural outward opening of the intestinal canal, whence fascal contents are more or less copiously discharged. It may be the result of wound, of abscess and ulceration, or of sloughing consequent on strangulated heniia. By plastic exudation the open portion of bowel is retained in contact with the abdominal parietes ; and the following condition of parts becomes established. The orifice of the upper or gastric portion remains abundantly patent, and not unfi-e- queutly troublesome prolapsus of its lining membrane occurs ; the orifice of the lower or rectal portion contracts, is not patulous, and recedes from the external surface ; the two portions have a dense septum interposed between them — composed mainly of the two con- tiguous portions of the coats of the bowel ; and this becomes more and more solid, and more and more opposed to restoration of the normal flow of the intestinal contents. Outwardly the abdominal parietes are usually distended into a funnel-shaped cavity, whose apex is at the integument, whose base surrounds the intestinal breach, and within whose cavity faeculent matter tends to accumulate. The integumental opening is red, everted, prominent, and surrounded by excoriation. The dangers and difficulties of such cases depend very much on the site and extent of the intestinal opening. If this be large and near the upper part of the tube, death by inanition can scarcely fail to occur ; chyle running so much to waste. If, on the contrary, the opening be in the large bowel, nutrition may be sufficiently maintained, and the result will probably be one more of annoyance than of danger. Treatment is in the first instance palliative. Such food is taken as is easily digested ; and the bowels, by diet, and medicine, if need be, are kept "soft and easy." By external support — by compress and bandage, or by the adaptation of a suitable truss — outward escape from 332 AUTIFICIAL ANUS. the upper orifice is moderated, if not altogether prevented, and pro- trusion of the mucous membrane is opposed. And the ordinary means are employed, to obviate excoriation of the surrounding integument. The outer opening may contract and heal, the funnel-shaped cavity may close, and the normal flow may be restored. But much more frequently such is not the case ; and further interference by our art is required. The tAvo main obstacles to cure plainly are — projection of the septum, and retraction and contraction of the lower intestinal orifice. The latter state is to be opposed by the occasional introduction of tubes or tents, gradually enlarged, whereby the normal calibre may be restored. The septum is to be got rid of, by the gradual process of ulceration. Dupuytren's forceps may be employed for this purpose ; — one blade passed into each orifice, the instrument closed and locked, and the degree of pressure regulated by the screw at the handle. The pressure is at first applied lightly and temporarily ; lest over-action ensue, and the surrounding parts be implicated so as to establish either enteritis or. peritonitis. And throughout the whole period of the instrument's use, the effects must be closely watched, lest at any time over-action threaten to occur. By thus gradually destroying the septum — inducing ulceration of it by pressure, and I'egulating that pressure so that the inflammatory process it creates shall not go beyond ulceration in the part, nor extend thence to the neighbouring textures — by dilating and bringing forward the lower orifice, and by main- taining the external pressure at all times when the forceps and tent are not in use, we hope to restore the normal flow, and eflfect per- manent closure of the aperture. But not only must this use of the forceps be cautiously conducted ; it must also be warily begun. Weeks or even months should elapse before it is employed. For, an early application is plainly in favour of the occurrence of the following risks ; a fold of bowel interposed between the two orifices, on account of the septum not being yet fully developed, may be grasped by the instrument, and fatal enteritis may ensue ; or the yet recent, tender, and imperfect adhesions of the bowel to the parietes may be broken up, the former may recede, fasculent extravasation then takes place, and life is soon ended miserably by peritonitis ; or, simply on account of the still unquiet parts having no tolerance of a newly excited action, immature use of the forceps may be speedily followed by enteritis ; or the pressure may caiTse ulceration of an asthenic kind — not attended by plastic exudation around — the abdominal cavity may consequently become exposed, and faeculent extravasation may occur therein. The projecting septum, or eperon, may be repressed simply by the pressure of tents ; or the ingenious, though somewhat complicated instrument of Mr. Trant * may be used instead of that of Dupuytren. * Dublin Med. Press, vol. xiii. p. 305 ; and Brit, and For. Med. Chir. Eev. Jan. 1847, p. 28. PELVIC ABSCESS. 333 Such pressure, causing replacement and absorption of the projecting obstacle, is obviously more safe than that which produces destructive ulceration. An artificial anus is sometimes established, designedly, by the surgeon ; when the natural anus is imperforate ; or when, from any cause, the rectum has become insuperably obstructed. These pro- ceedings will be considered, in connexion with aifections of the lower bowel. FcEcal Fistula. "When an artificial anus has contracted to a narrow sinus, with a papillary orifice through which intestinal contents occasionally escape, it is termed a Faical Fistula. A similar state may also result from parietal abscess (p. 327) ; whose cavity has opened, by ulceration, into a portion of adherent bowel, either before or after external evacuation. The opening of communication is usually small ; the cavity of the abscess contracts ; and the condition of fistula is soon established. The methods of treatment are simple. Accurate and firm pressure is applied to the part, so as to prevent faaculent escape, and favour consolidation of the entire track. This may succeed, after patient continuance for some time, along with due attention to the state of the bowels. If it fail, then the actual cautery may be applied, so as by contraction of the burn to obtain closure (Principles, p. 226). And if this do not succeed, then by autoplasty the chasm may be filled up and permanently consolidated ; a suitable portion of integument being transplanted from a neighbouring part. Pelvic Abscess. The sub-peritoneal areolar tissue, in the pelvic region, is liable to be the seat of suppurative inflammatory action ; sometimes in con- nexion with the puerperal state, but often wholly independent of this. Occasionally it is induced, on the right side, by irritation extended from the caput ccecum — forming the perityphlitis of Burns and others ; on the left side it may originate in impaction or other disorder of the lower bowel. It has followed operative interference with the uterus or its appendages — as well as with the penis and bladder — not unfre- quently ; sometimes it is traced by the patient to a chill ; sometimes it can be connected with no assignable cause. The disease is more frequent in the female than in the male. Exudation may be both rapid and copious ; and at first is either serous or lymphous. In this state it is amenable to absorption ; and under suitable treatment may disappear rapidly. When suppuration has fairly taken place, evacuation is to 334 RETRO-UTEEINE SANGUINEOUS TUMOURS. be looked for, either spontaneously or by the hand of the surgeon. In the former case the point of exit varies ; at the hypogastrium, by pointing in the ordinary way ; in the groin, by the bowel, through the vagina, into the bladder; or into the general abdominal cavity. Fortunately, the last mentioned casualty is comparatively rare ; the peritoneum, from its fibrous nature, long resisting the ulcerative action of the accummulating pus (Principles, p. 208). Sometimes, instead of suppurating, the tissue becomes loaded with a dense plasma, partially incorporated and organized. The symptoms are often ushered in by rigor. There are pain and tendei'ness of the part, with dulness on percussion. The rectum and bladder, being compressed, and involved in sympathy, have their func- tions more or less disturbed ; and the uterus, too, is liable to displace- ment. On examining by the vagina or rectum, a hard dense swelling is perceived ; determined to be non-uterine, if need be, by the use of the probe ; and, unlike other pelvic tumours, having very firm con- nexion and continuity with the bony walls of the pelvis. In doubt, an exploratory thrust may be made by the small trocar — through the abdominal parietes, by the vagina, or by the rectum, according as the site of the swelling may determine. On outward pointing taking- place, the nature of the case becomes abundantly plain. At an early period, the treatment consists of leeching, followed by counter -irritation, and mercury pushed to ptyalism. Iodine may be painted over the abdominal parietes ; or it may be administered in the form of ointment, by the vagina. Under such treatment, with rest, and attention to the general health, many formidable effusions satisfactorily disappear ; perhaps leading an inexperienced observer to suppose that an ovarian or other tumour has been discussed. When matter has formed, it should be early evacuated, by means of the bistoury or trocar, at the point which circumstances may indicate as most suitable; by the vagina, by the rectum, or through the abdominal walls. Betro-utei'ine Sanguineous Tumours. There is another class of swellings in this situation, which may be mistaken for the inflammatory pelvic tumour, in the female. They are caused by extravasation of blood into the sub-peritoneal areolar tissue of the cul de sac between the uterus and rectum ; and in their pathology resemble the thrombus, which is not unfrequently found situated in the vagina or vulva. The affection may, in fact, be described as a throm- bus of the roof of the vagina. Attention has been recently directed to this subject by some late discussions in the Surgical Society of Paris ; and Dr. Montgomery of Dublin has published cases of thrombus in this situation, occurring during or after labour. OVAEIAN DEOPSY AND TUMOUES. 335 The blood is infiltrated into the areolar tissue, around the cervix uteri, and may spread thence into the areolar tissue surrounding the rectum, or into that involved betvpeen the folds of the broad ligaments. These tumours are liable to occur chiefly in cases where there is much venous congestion, and especially if there is a varicose and diseased condition of the vessels. They are caused by pov^^erful straining efforts, as in labour, venereal excesses, &c. They may also, as M. Huguier points out, be produced by the escape of blood from a uterus over dis- tended by retained menstrual secretion. On examination, the roof of the vagina will present a hard resist- ing surface, without pain on pressure ; or, if recent, tender to the touch in a much less degree than the real inflammatory pelvic tumour. The uterus will be found generally somewhat elevated, and pressed to the pubes. If they are small, these tumours require no special treatment. Eest in the recumbent position, and the antiphlogistic regimen, are necessary as precautionary measures. If the extravasation is very ex- tensive, there will be constitutional disturbance ; and local excitement may be produced, perhaps terminating in true inflammation. In this case treatment must be conducted as in the common inflammatory pelvic tumour. Ovarian Dropsy and Tumours. Of abdominal tumours, the ovarian are those which most attract the attention of the surgeon. Occasionally fibrous tumours, or masses of the different forms of the ordinary malignant tumour, are found affecting the ovary, either alone or in combination with the cystic disease of the organ — which latter very far surpasses all others in the frequency of its occurrence, and is generally known as ovarian dropsy. These cystic tumours are multilocular more frequently than monolocular. They may occur only on one side, or on both at the same time ; they may be attached by a narrow pedicle to the broad ligament, or by a broad base ; they may be moveable, or fixed in the cavity of the abdomen — this generally depending on their size, which varies extremely ; they may be free, or more or less adherent to the surrounding organs, or connected with the abdominal walls. On dissection the ovary of the affected side may be undiscoverable ; or it may be either entire, or partly incorporated with the tumour. The disease is believed by numerous pathologists always to originate in the Graafian vesicles ; and there is good reason to attribute certain of these productions to this source ; but it is equally well ascertained that the multilocular formation does not always acknowledge such an origin. The disease may affect a woman at any time of her menstrual life, 336 OVARIAN DEOPST AND TUMOURS. and is found occurring most frequently at that period when the repro- ductive functions are in greatest activity — namely, between the ages of twenty and forty. It attacks the virgin as well as the married woman. Of course it is found more frequently in married than in unmarried women, but there is no evidence for a common statement of authors that the former are more liable to it than the latter. Many causes connected with menstruation, marriage, and parturi- tion, have been assigned to ovarian dropsy, but this part of the history of the disease is necessarily very difficult of investigation. These affec- tions may be mere precedents, and not causes. The disease may attain a large development, without giving rise to any symptoms except such as are referrible to the displacements effected by its bulk. It may be accompanied by irregularity of the menstrual function, by menorrhagia, or by amenorrhoea. At its com- mencement there may be much complaint of pain and tenderness in either side, or a deep-seated pelvic pain may exist, or there may be other modifications of pain and tenderness too varied to demand de- scription. The tumour may press on the sacral nerves, and cause numbness and a feeling of powerlessness in one limb ; or venous con- gestion and oedema of it, by obstructing the circulation. There may be pain and difficulty in defsecation. Piles, and a varicose state of the veins of the legs, are often found. In diagnosis, our reliance must be placed almost entirely on the physical signs. Much obscurity is often produced by distension of the abdomen, with tlatulence, when the disease is in an early stage ; and the evidence of its nature is derived chiefly from the circumstances of its position, its mobility, or its connexions. At a later period, when it is distending the abdo- minal walls, we trust to its own physical characters, the nature of its contents, and the history of its origin and progress. Careful manipulation usually shows the swelling not to be so uniform or soft as in ascites, but more or less broken up in its outline, as well as of various hardness. Attention is also given to the follow- ing points : — In ascites, the fluid always occupies the most dependent parts, while the small intestines, floated by their contained air, corres- pond generally to the umbilical region ; and the arch of the colon and the stomach occupy the epigastrium. Percussion, therefore, elicits a dull sound over the hypogastric and lumbar regions, and a clear one in the umbilical and gastric ; whereas, in a large encysted dropsy, no tympa- nitic sound exists in these regions. The intestines, pushed back by the cyst which is developed anteriorly, may, however, produce a resonance laterally and posteriorly. Fluctuation is generally more easily and dis- tinctly detected in ascites. If the ovarian fluid is of great viscidity, or if the anterior cysts of the mass are numerous and small, fluctuation may be scarcely perceptible ; while, on the other hand, if the disease OVAEIAN DEOPSY AND TUMOURS. 337 be monolocular, fluctuation may be very apparent. Sometimes, in the multilocular variety, the larger cysts can be made out separately by the facility and distinctness of the fluctuation, when both hands are over the same cyst ; and by its indistinctness or absence when one hand is on one cyst, and the other on a different one. In encysted dropsy, the general health is often comparatively undisturbed, while in ascites the reverse is almost always found to be the case. Along with ascites, there is generally anasarca of the lower extremities, while in ovarian dropsy this is rarely observed. In the latter affection, however, we frequently find a varicose state of the vessels, and puffi- ness of the limbs. It is also to be remembered that ascites and ovarian disease frequently co-exist ; the ascitic fluid being of the ordinary kind ; or, as has been observed by Dr. Bennett and others, derived from an ovarian cyst by passing through foramina in its walls. When these diseases co-exist, fluctuation, if light and superficial, may deceive ; but if the fingers are pressed more deeply, a peculiar diagnostic mark is obtained by the stroke of the fingers against the ovarian cyst — after displacing the overlying ascitic effiision. If there is still doubt, we may in some cases be justified in drawing off" a few drops of the fluid by a small trocar, and ascertaining its nature by proper tests. Dulness on percussion over the hypogastric regions is more decided in ovarian dropsy than in ascites. If, however, the pedicle be long, and the tumour only moderately large and not distending the abdominal walls, but rather floating in the cavity, there may be some resonance above the pubes. In some rare cases this mark is of importance, in distinguishing the ovarian di'opsy from preg- nancy ; — in both cases we may find on auscultation a murmur resem- bling the placental souffle; and in ovarian disease, especially if recent, the equivocal signs of pregnancy may be present. From pregnancy it is further distinguished by absence of the foetal heart's pulsation, by the absence of ballottement,* by the drawing up of the uterus and vagina so that the cervix is with difficulty reached, by the hardness and length of the cervix, by the anteverted or retroverted state of the organ, by the commencement of the disease on one side, by more or less complete absence of the ordinary constitutional signs of the pregnant state, and by the duration and history of the complaint. Let the sur- geon, however, never forget that with ovarian disease (at least of one side) there may co-exist an impregnated womb. There is occasionally great difficulty in distinguishing a multi- locular ovarian dropsy from fibrous or other tumour of the uterus. The * A modified ballottement may be discovered in a case of ovarian tiimoui', if it is of moderate size and floating in ascitic fluid. z 338 OVARIAN DROPSY AND TUMOURS. tension of the cysts, their small size, and the viscidity of their contents, may be such as to destroy all signs of fluidity in the ovarian mass, and the uterus may be so fixed in the pelvis by compression between it and the tumour, or by adhesions, as to render the signs derivable from a vaginal examination also nugatory. The history of ovariotomy too truly shews that the diseases may be mistaken for one another by the most experienced and able physicians. The chief distinctive marks are the following: — A fibrous tumour is often observed first in the centre of the hypogastrium — an ovarian tumour generally at one side ; a fibrous tumour grows more slowly than an ovarian ; it has no fluc- tuation, and is generally much less moveable and harder than a diseased ovary ; it is more frequently accompanied by menorrhagia and leu- corrhoea ; the uterus is generally somewhat prolapsed, especially if the tumour is not of gi'eat size ; the uterus feels heavy, and cannot be moved without moving the tumour ; the cavity of the uterus is also often elongated ; sometimes it is shortened ; frequently the shape and plurality of the tumours are distinctive. In illustration and proof of the great difficulties which attend the diagnosis of ovarian disease, and of the errors liable to be made, even when the growth is so developed as to appear to demand an operation, we may cite the following fact in regard to 162 cases in which incision of the ovary was attempted. In 60 of these there was either no ovarian disease at all, or its removal was found imprac- ticable.* The management of ovarian dropsy is either palliative or radical. Besides the ordinary treatment for intercurrent attacks of inflammation, derangements of the functions of the stomach, bowels, kidneys, and bladder, the most important palliative measures are tapping and pressure. Recourse to the former has been recommended early in this aifection ; but it is a very questionable proceeding, and one, besides, which we rarely have an opportunity of trying, as women seldom complain till the disease is far advanced. Tapping is not advisable, except under rare circumstances, till the accumulation has become intolerable to the patient, from its large size impeding respiration and progression, and causing much local pain and sufi'ering ; perhaps producing vomiting, or suppression of urine, by pressure on the stomach or kidneys. It is a very simple operation, and the danger supposed to attend it in ordinary cases has probably been exaggerated, in the statistical tables of Southam, Safford Lee, Atlee, and others ; which, embracing all cases, do no doubt include many in which it was resorted to in despair, or as a mere palliative — the patient's strength being already worn out by the disease, or compro- * Lancet, Dec. 6, 1851. PARACENTESIS ABDOMINIS. 339 mised by some other affection. The clangers chiefly to be apprehended are syncope, the lighting up of suppurative inflammation in the lining of the cyst or cysts, and the supervention of peritonitis. It is j)erformed thus : — The patient having been seated on the side of a bed, or on a chair, has the abdomen tightly girded by a sheet or flannel bandage ; the ends of which are held by two assistants, directed to pull steadily and firmly as the fluid escapes — so as to maintain equable pressure on the abdominal contents, and obviate the sudden loss of support to these, which might otherwise occur, and from which serious hemorrhage might ensue by the giving way of one or more abdominal veins suddenly deprived of their ordinary support. Or, independently of rupture, alarming syncope might take place, from great or sudden accumulation of blood within the abdominal veins. It is well to ascertain that the bladder is empty. An aperture having been made in the bandage, an incision is made through the skin and fascia by a lancet or scalpel ; and then perforation is completed by a large trocar and canula. The trocar having been withdrawn, the canula remains, and through this the fluid escapes ; thin and albumin- ous, or viscid, ropy, and variously discoloured. Fluid having ceased to come, the canula is withdrawn, the wound is covered by a compress, and the general bandage of the abdomen is drawn tightly and secured. This cure by tapping is an excellent instance of the surgeon taking a lesson from the plans sometimes adopted spontaneously by Nature. Examples of the simple cyst, and more rarely of the multilocular, have been cured by spontaneous discharge of the contained fluid fi-om open- ings through the umbilicus, or some other part of the abdominal wall, or by discharge of the fluid per vaginam or per rectum. The point usually selected for the opening is in the linea alba, about midway between the umbilicus and symphysis pubis. But it may be made in the linea semilunaris, if the bulging of the ovarian cyst render that locality preferable. By the use of pressure after tapping, the walls of the cyst are made to collapse, and the mass comes to form a comparatively small firm tumour in one side of the pelvis. When such pressure is resorted to, it should be kept up for some months ; as these tumours have been known to refill, after they have» lain in the pelvic cavity for a long time collapsed and causing no inconvenience. The use of pressure, if it can be borne, and be regularly conducted, is decidedly of service in impeding growth of the tumour, and refilling of the sac after tap- ping. Some very interesting cases are recorded, where inflamma- tory action, attacking the cyst and its serous investment, has induced such induration, and caused the formation of adhesions so strong, as to resist further progress of the tumour ; curing the disease by mechanically arresting its progress. But the cysto-sarcomatous z2 340 OVARIOTOMY. tumours, the fibrous, and the malignant masses, which are not unfre- quently found in this situation, either alone or along with the multi- locular cyst, are, of course, not amenable to any method of discussion. As auxiliaries to tapping and pressure, the only remedies to be recommended are iodine and diuretics. The former may be used both externally and internally. That they may be of some service, we have evidence in the fact occasionally observed, that the rapidity of the growth or refilling of an ovarian tumour keeps pace with the dimi- nution of the urinary secretion. The remarkable increase of this secretion often observed for some days after tapping, is sometimes accompanied by progressive diminution of the tumour, which recom- mences to fill only when the urine again diminishes.* In general, after tapping, the cyst speedily refills and the operation is repeated as before, the cyst usually filling more rapidly after every repetition of the operation. The second tapping may not be required till after several months ; but subsequently the interval may diminish to a few weeks. This process generally exhausts the patient after some years, or an intercurrent attack of inflammation in the cyst, or in the peritoneum, may prove speedily fatal. Sometimes, however, patients survive to have the tapping very often repeated, and almost incredible quantities of fluid have thus been drawn off from the same woman. f These tumours may be dealt with heroically. Attempts may be made at extirpation. The operation is very simple. The patient having been suitably arranged in a room of elevated temperature, a wound is made through the parietes of such an extent as may be necessary. There is no good reason for incising the whole abdomen in all cases, from the ensiform cartilage to the symphysis pubis. The external incision should be proportioned to the bulk of the tumour. The dissection is to be carefully conducted till the tumour be brought into view, attention being directed to arrest as fiir as pos- * Many authors of note entirely discredit the efficacy of all internal remedies. Burns says they have an equal effect " over the configuration of the patient's nose." Hamilton, as is well known, used the solution of muriate of lime internally as a discutient, and placed great confidence in it. t Dr. Mead's patient, whose endurance is celebrated in the following epitaph, has now unfortunately been frequently surpassed. , " Here lies Dame Mary Page, Relict of Sir Gregory Page, Bart., Who departed this life March 21st, 1728, In the 56th year of her age. In 67 months she was tapped 66 times, Had taken away 240 gallons of water, Without ever repining at her case, Or even fearing the operation." Dr. Martineau of Norwich tapped a patient 80 different times, and drewofif 6832 pints of fluid. OVAEIOTOMY. 341 sible all bleeding from the wound. The tumour, its state as to adhesions, and its pedicle, are now to be examined ; and, if deemed advisable, the operation is continued. Unless the adhesions are very strong and extensive, they do not form an insuperable obstacle. The tumour is to be turned out of the abdomen ; the pedicle is tied, and then divided. The wound and the surrounding viscera are sponged clean, and the wound closed. If unfortunately the bowels cannot be kept within the abdomen during the operation, means must be taken to maintain in them their natural heat till they are replaced ; they may be immersed in water at blood heat, or in fine linen moistened with tepid water. The ligature of the pedicle is brought out at the lowest part of the incision ; and, last of all, the wound is closed by the interrupted suture, in such a manner as to expose as little as possible to the surface of the bowels beneath. This is effected by passing the needle close to the peritoneal surface of the wound. The interrupted quilled suture may sometimes be of service. In conducting the first step of the operation, the plan proposed by Dr. Frederick Bird, to avoid mischances, may be resorted to — namely, to make at first only a small wound into the peritoneum, and to explore the tumour with the finger and probe ; so ascertain- ing, to some extent at least, the feasibility of completing the operation before the patient is compromised by further proceedings. At present, great hostility to all such operations is declared by a large body of the profession. There are cases, however, which may cer- tainly render a duly conducted attempt quite warrantable ; when the tumour is non-malignant, single, moveable, and connected with a narrow pedicle ; when the patient is apparently free from other disease ; when the effects of this tumour are such as to threaten death by exhaustion at no distant period, unless relief be obtained ; when the ordinary palliative treatment, after due persistence, has failed to give relief; and when the patient, having been made fully aware of the risk, is resolved and wishful to undergo the operation. Modern experience has certainly demonstrated, that free incision of the abdomen, with exposure and manipulation of the peritoneum, is a less hazardous procedure than was generally supposed. But there are extreme dangers necessarily attendant upon this operation — from its site and its nature, from the necessity of leaving in the wound a long cord attached to the pedicle, from the danger of the ligatures bursting, or the wound in the parietes partially opening, in consequence of distension of the bowels or efforts in coughing, and from the risk of strangulation of the bowel either in the wound or by the puckering of deep cicatrices. And, besides, the following unavoidable difficulties at present stand in the way of a general recommendation of the opera- tion ; namely, the confessed difficulty of diagnosis — as to the existence 342 FIBROUS TUMOURS OP THE UTERUS. of extensive adhesions, as to the presence of malignant disease in the tumour or in the pedicle, and as to the large size of the pedicle render- ing deligation difficult. Sometimes cure is attempted by a minor proceeding ; making an opening in the abdominal parietes, only a few inches in length ; punc- turing the cyst, and drawing it out as the contents escape ; and then cutting off the attachment, after deligation. Such an operation, how- ever, has not been found more successful than the more direct and open procedure; and certainly it is not more easy of performance. The danger of some fluid from the cyst escaping, and finding its vs^ay into the peritoneal cavity — the impossibility of cleaning out the wound with the necessary care — the imperfect deligation of the pedicle, &c., are obvious objections to this mode of treatment. The statistics of ovarian operation give a mortality of about one death in every three cases. Its dangers, then, ai'e very great. On the other hand, hopes of relief from ordinary treatment of the tumour can- not be sanguine. Most women are carried off by the disease in less than four yeai\s. Very few have the good fortune to be cured, and only a small number live beyond the four years. But it will always be a difficult and anxious matter for the surgeon to propose that a woman suffering, it may be, very little from this disease, should subject her- self to the risk of almost immediate death, in order to obtain the chance of getting rid of that which might possibly permit several years of comfortable existence. The general treatment of ovarian disease is still an open question ; and we entertain strong and confident hope that the great attention drawn towards it will, some day, attain to the discovery of a method of cure, or of a plan of palliation tantamount to cure. But vre do not purpose to mention here any of the numerous methods now pro- posed for these objects. As yet, they have mostly proved even more fatal than ovariotomy, and have many additional objections. None have received the sanction of the profession. Fibrous Tumours of the Uterus May be found in any part of the organ. They may be single, but more frequently there are several present together. They may vary in size from a pea to a man's head. They rarely occur befoi*e the age of twenty, and are most frequently observed about the age of forty.*" They do not prevent conception, but cause great risk of abortion during pregnancy, and in delivery may obstruct the advance of the child, also favouring hemorrhage and subsequent * Bayle states that in women above thirty-five years of age, fibrous tumoui's are found in one out of every five. FIBROUS TUMOUES OF THE UTERUS. 343 inflammation. The tumours themselves are liable to congestion, inflammation, and suppuration ; in course of time, they may be- come calcified in whole or in part ; forming the uterine calculi of old authors. They may be developed in any part of the uterine wall ; the nearer to the mucous membrane, the greater is the hypertrophy of the uterine tissue. When the tumour is situated near to the peri- toneal or to the mucous surface of the uterus, it may be protruded from the wall of the organ in a polypoid form ; and, the pedicle gradually diminishing in size, the tumour may drop off into the peritoneal cavity in the one case, and in the other may be expelled per vaginam. When the tumour is near to the mucous surface it is sometimes spontaneously discharged in another way, as has been observed to occur even in large tumours ; and not unfrequently this result has followed the irritation and pressure caused by the efforts of delivery, on the tissues interposed between the cavity of the uterus and the tumour. By ulceration or sloughing, an opening is formed in these textures, and the substance of the tumour is exposed ; disorganization ensues in the loose areolar tissue connecting the tumour to the uterus ; contractions of the hyperti'ophied uterine tissue super- vene ; and expulsion of the tumour, in mass, or more gradually in parts, is the fortunate result. This may be called spontaneous enu- cleation ; a process which has been imitated by art in some cases. If the tumour becomes polypoid, dilating the cervix or lying in the vagina, it may be treated as an ordinary uterine polypus. But it is to be remarked that more danger of uterine phlebitis attends the removal of this form of tumour, than of the ordinary uterine polypus. The symptoms attending the presence of these tumours are neither constant nor diagnostic. Physical examination alone can detect their presence and decide upon their nature (p. 338). They are generally accompanied by feelings of weight, pain, or uneasiness in the hypo- gastrium, and pain in the back, in the side, or in the thighs — disorder of the functions of urination and defsecation, &c. ; but sometimes no symptoms at all exist. Often there is an increased amount of vaginal secretion and discharge, which may be checked by a mild astringent injection. Menorrhagia not unfrequently occurs, and may require the ordinary treatment, if severe ; it is generally a sign of proximity of the tumour to the mucous membrane. Occasionally, but rarely, there is amenorrhoea. If the tumours become congested and inflamed, ordi- nary antiphlogistic treatment is necessary — especial attention being paid to maintenance of the recumbent position. If the tumours are large, prominent, heavy, or moveable, an abdominal bandage or binder may be useful to support and fix them, and to afford the patient a feeling of security. Nothing can be done in the wav of discussing these OTOwths. 344 GASTROSTOMY AND GASTROTOMY. Discutient remedies, as iodine used externally and internally, counter- irritants, rest, tlie occasional local abstraction of small quantities of blood by leeching or cupping, have often a beneficial effect in removing disao-reeable symptoms, and sometimes seem to arrest growth, or even cause a diminution in size — probably by removing the surrounding swelling and engorgement. Gastrostomy.* In the case of insuperable obstruction of the pharynx, oesophagus, or cardia, it has been proposed to open the stomach by direct incision ; attaching the edges of the opening in the stomach to the integumental wound; and thus constituting a permanent aperture, for the intro- duction of food, similar to what occurred accidentally in Alexis St. Martin. The operation is feasible in theory, and simple in perfor- mance. But its extension to cases of hopeless malignant disease seems scarcely expedient-! Gastrotomy. ^Yhen the bowels are obstructed from an internal cause, beyond reach fi-om the outlet, a question arises as to the expediency of per- forming gastrotomy, with a hope of relieving the obstruction. If that depend on bands of lymph, or on intussusception, a simple manipula- tion might suffice to liberate the afiected part. But the difficulty of diagnosis, and chance of failure, besides the danger of the operation, conspire to enforce great caution in resolving on such serious procedure. At the same time, when all ordinary means have failed, when several days have elapsed, and when the case is otherwise certainly hopeless, the doubtful chance of the operation may be afforded ; more especially when pain, and other symptoms, point someAvhat plainly to some part of the abdomen as the probable site of obstruction. At that part the incisions are made ; with the precautions abeady spoken of. It may be happily in our power simply to disentangle and relieve ; or, at the worst, the distended bowel may be evacuated by puncture, and an attempt made at establishing the condition of artificial anus. Of twenty-seven patients operated on, J\L-. Phillips mentions thirteen, whose lives have been preserved.! * From yatrrtip, stomacli ; and aro[i,ce,, mouth. f Sedillot, Gazette Medicate de Paris, Jan. 1847 ; and Monthly .Journal, April 1848, Retrospect, p. 68. \ Phillips, Med. Chir. Transact, vol. xxxi. Lend. 1848 ; also Brit, and For. Rev. Apiil 1849, p. 433. AFFECTIONS OF THE DIAPHEAGM. 345 Affections of the Diaphragm. Surgically, the diaphragm may be affected by penetrating icound. This may prove formidable by hemorrhage, or by inflammatory action, and has to be treated accordingly (p. 329) ; or, those dangers avoided, an imperfect closure or weak cicatrix may invite protrusion of the abdominal contents at the w^eak point,* more especially when that happens to be on the left side ; and this may be followed by a sudden crisis induced by sti'angulation of a diaphragmatic hernia ; or, from simple misplacement, the thoracic organs may suffer chronic disorder, not without a risk of ultimate asphyxia. Rupture of the diaphragm may be produced by external injury or violent muscular effort. The risks by consequent misplacement of the abdominal organs are as in the former case. Such malposition is usually indicated by an anxious expression of countenance, a sunk empty state of the abdomen, corresponding fulness in the chest, thoracic percussion unusually clear or unusually dull, auscultation affording borborygmi rather than respiratory murmur, with obscuration of the sounds of the heart. In treatment but little is in our power. Should paralysis of the diaphragm co-exist with ascites, obviously great care is specially necessary in withdrawing the fluid by paracen- tesis, lest dangerous collapse occur (p. 339). f Travers, Inqviiry into the Process of Nature in Repairing Injuries of the Intestines, &c. Lond. 1812. Scarpa, on Hernia, by Wishart, Edin. ISli. Lizars, Observa- tions on Extraction of Diseased Ovaries, Edin. 18"25.i- Fingerhuth, Dissertatio de Vulnerum in Intestinis Sutura, Bonn, 1827. Weber, de Curandis Intestinorum Vulneribus. Eeybard, Memoires sur le Traitement des Anus Artificiels, &c. Paris, 1827. Jobert, Traite des Maladies Chii-urgicales dir Canal Intestinal, Paris, 1829. Yelpeau, Memoire sur I'Anus Centre Nature, &c. Paris, 1836. Dupuytren, de I'.Vnus Centre Nature, &c. Lecons Orales, &c. vol. ii. p. 193. Lawrence on Euptures, Lond. 1838. Teale, Cyclop, of Practical Surgeiy, article Intestinal Fistula, Lond. 1841. Phillips, Med. Chir. Trans, vol. xxxi. Clay, Cases of Peritoneal Section for the Extu-pation of Diseased Ovaria, &c. Medical Times, vol. vii. pp. 43, 59, 67, 83, 99, 139, 153, 270. Phillips, Med. Chir. Trans, vol. xxvii. p. 473, 1844. Lee, on Tumom-s of the Uterus and its Appendages, Lond. 1847. Bright, Guy's Hospital Eeports. Boivin and Duges. Diseases of the Uterus, &c. Curveilhier, Anat. Pathol. li\Tais, 5, &c. Seymour, on Diseases of the Ovaria. Nauche, Malad. Propr. aux Femmes. Lee, Cyclop, of Pract. Medic, art. Liiseases of the Ovary. Simpson, Library of Medicine, vol. iv. * Mr. Guthrie is of opinion that a wound made in the diaphragm never heals by closing. f Von C. W. Mehliss, die Krankheiten der Zwerchfells des Menschen, Eisleben, 1845 ; also British and Foreign Med. Rev. July 1847, p. 166. 346 CHAPTER XXVIII. HEENIA. By Hernia is understood a protrusion from witliin an internal cavity, of part of the contents of that cavity. But the term is usually limited to the most frequent form of such protrusion — namely, that from the cavity of the abdomen. And of this Hernia there are varieties, according to the site of the protrusion : Inguinal and Ventro-inguiual, Femoral, Umbilical, Ventral, Phrenic, Perineal, Vaginal, Labial, Obturatorial, Ischiatic. These, again, may vary according to the anatomical relation of their parts — Congenital, Infantile ; and accord- ing to the parts protruded — Enterocele, Epiplocele, Entero-epiplocele, Hernia Litrica. And, further, other varieties depend on the patho- logical condition of parts — Reducible, Irreducible, Incarcerated, Stran- gulated. The Causes of Heiuiia are predisposing and exciting. Whatever vs'^eakens the abdominal parietes at any point, predisposes to protrusion at that point ; — natural w^ant of closeness of development, as at the groin and navel ; rupture of muscle and fascia, at any part, as in par- turition ; atroj)hy of muscle, following bruise ; penetrating -wound. Again, whatever tends to propel the abdominal contents with unusual force against such weakened or predisposed parts, directly excites or causes the protrusion ; as violent coughing, straining at stool, or severe muscular exertion of any kind. And, further, the predisposing and exciting cause may be the same. Cough, straining, or habitual exer- tion of the abdominal muscles in any way, when long continued, tend to weaken and enlarge the natural outlets of the cavity, by constantly propelling the abdominal contents against the parietes — and thus prove predisposing. And then some sudden cough or strain eifects protrusion, and proves the exciting cause. Hence it is, that old men with coughs and urinary complaints, sailors, gymnasts, &c., are especially subject to the ordinary forms of this disease. The component 2Jcit'ts of the tumour vary according to the nature of the protrusion. But, generally, they may be stated to consist of Coverings, Sac, and Contents. The Coverings are far from uniform ; differing in the varieties of Hernia, and being seldom exactly the same in any two cases. In HEENIA. 347 inguinal and femoral hernia, for example, the coverings differ widely ; and in each of these affections, the density, thickness, and even num- ber of the investing layers, depend very much on accidental circum- stances. In opei'ating it is vain to look for an unvarying sameness in this part of the tumour. In all cases of ordinary hernia, how^ever, there is first the usual integument, and then one or more layers of fasciae. These will be enumerated, in the separate consideration of the varieties of hernia. The Sac is the portion of parietal peritoneum which is pushed before the protruding viscus, and which forms its immediate envelope. Some- times it is wanting ; as in hernia following directly upon wound, and in the congenital form of the disease. In the great majority of cases, we are to count upon its presence — adherent or not to the extra- abdominal parts with which it is in abnormal contact, according to the duration of its presence there, and the occurrence or not of plastic exu- dation on its exterior. We ordinarily speak of the neck and body of the sac, as we do of the neck and body of the genei'al tumour ; the neck being that portion, of smaller calibre, which is at and near the aper- ture of protrusion, and the body being understood to be the more globular swelling beyond. If the tumour have been long protruded, without reduction, and otherwise but little altered in its circumstances, the neck of the sac is apt to become dense and unyielding in struc- ture, and the calibre in consequence is at that part of a fixed nature. When, under the application of a fresh exciting cause, a new protru- sion takes place, there is an extension in the sac, corresponding to the increased bulk of its contents ; but, not improbably, the propelled ori- ginal neck of the sac does not change, except in its position only ; and, remaining of its contracted dimensions, it may become the seat of stricture in the case of strangulation — the new neck proving compara- tively free and accommodating. This circumstance has obviously an important bearing on the operation for relief of strangulation. The Hernial Contents are various, inasmuch as every abdominal viscus is liable to protrusion ; but the most frequently affected, by far, are the intestines and omentum ; one or other, or both. If intestine alone is protruded, the tumour is said to be an Enterocele ; Epiplocele implying descent of omentum ; and Entero-epiplocele, descent of both. Sometimes only a redundant portion of bowel escapes, in the form of a diverticulum ; and this is termed a Hernia Litrica. The Diagnosis of hernia is a practical subject obviously of the high- est importance. Ordinarily, a hernia is found to be a soft tumour, at the site of an abdominal aperture, receiving an impulse on coughing, and tending to enlargement under exertion of the abdominal muscles 348 HEENIA. in any way, gurgling under pressure if containing bowel, and capable of being replaced, by pressure, within the abdominal cavity. There are certain affections for which such tumours are especially liable to be mistaken. 1. Hydrocele simvla,tes the oblique inguinal hernia; but is to be distinguished thus : — Hydrocele is generally more or less translucent, and hernia is almost always opaque ; the exception being, when in a large hernia, invested by thin integument, a fold of bowel alone descends, capacious, and filled only with gaseous contents. Hydrocele is a constant tumour, unaffected by pressure; hernia is ever varying by accidental circumstances, and is usually capable of being diminished by pressure, if not made wholly to disappear. The apex of the pyi-iform swelling, in hydrocele, simulates the neck of the hernia ; but, on careful manipulation, it is found to terminate beneath the abdominal outlet, leaving always some part of the cord clear ; and the cord is never at any part clear in unreduced hei-nia. The hydro- cele, unless congenital, has no impulse, and evinces no tendency to enlargement, on coughing, or other exertion of the abdominal muscles. The testicle is felt obscurely, if at all, in hydrocele ; in scrotal hernia it is usually found, distinct and separate, at the lower part of the scro- tum. The history of the case, too, is widely different ; the hernial tumour appears suddenly, and proceeds in development fi'om above downwards ; the hydrocele is of gradual formation, and its progi'ess is from below upwards. Not unfrequently, however, be it remembered. Hydrocele and Hernia co-exist. 2. Hijdrocele of the Cord. — This is usually a circumscribed swelling, leaving a portion of the cord clear, above and below, as may be ascertained by careful manipulation ; it is not reducible ; and it evinces the ordinary negative signs on coughing or other exertion. When the portion of cord within the inguinal canal is affected by circumscribed sei'ous accumulation, however, the diagnosis may become of great difficulty, as can readily be understood — resting mainly on the reducibility or irreducibility of the tumour. 3. Cirso- cele. — Ordinary varix of the spermatic veins, and veins of the scrotum, can scarcely be mistaken for hernia ; the cord is comparatively clear, the feel of the veins is marked and characteristic. Like hernia, there is diminution of the swelling during recumbency, and on pressure ; but, vmlike hernia, there is return of swelling, on resumption of the erect posture, and on abdominal exertion, though the thumb be kept accu- rately and firmly placed on the abdominal outlet. When there is a swelling, however, at the upper part of the cord, partly within the inguinal canal, and consisting of enlarged veins — perhaps with some serous accumulation — diagnosis is difficult ; for the form and bistory of the tumour are very like those of hei'nia, and there is an impulse on coughing. We trust to non-reducibility of the entire swelling, and its characteristic feel ; on pinching it, the veins roll like earth-worms REDUCIBLE HERNIA. 349 between the finger and thumb, and the touch of the experienced is usually able to detect the absence of all abdominal descent. This swelling, however, often paves the way for hernia by dilating the canal, and thereby facilitating protrusion. 4. Buho. — The history, progress, form, and feel of bubo must obviously differ very much from those of hernia. The two may be combined, however; a patient afflicted with inguinal hernia, or femoral hernia, may have enlarge- ment of the inguinal glands. 5. Descent of the Testicle. — The testicle, descending at an unusually late period, may be arrested in the ingui- nal canal, causing a painful swelling there very similar to hernia. It is known, by absence of the testicle in that side of the scrotum, by the feel of the tumour, and by the characteristic pain which is experienced on pressure being made on the part. Like the high form of Cirsocele, it may be the precursor of hernia ; a portion of bowel or omentum slipping down behind the testicle, through the abnormally dilated canal. 6. Sarcocele. — This is readily distinguished by the history and pro- gress of the tumour, its feel and form, and its negative signs on cough- ing ; the cord too is free, except in some cases of malignant disease. 7. Psoas abscess is distinguished from femoral hernia ; by the evidences of spinal disease, by the history of the case, by distinct fluctuation in the swelling, and by the progress of "pointing;" and most frequently the site of the abscess is exterior to that of hernial protrusion. 8. Varix of the femoral vein. — A bulging varix of the femoral vein, project- ing through the saphenic opening, may very readily be mistaken for femoral hernia. The test is simple. Reduce the swelling by pressure in the recumbent posture, and then press firmly on the abdominal out- let ; if the case be one of hernia, there is no reproduction of tumour ; if it be varix, the swelling quickly reappears. Reducible Hernia. At some part of the abdominal parietes, a swelling forms ; pain- ful ; sudden, usually after some unwonted exertion ; at first slightly tense, and tender ; afterwards soft, compressible and tolerant of mani- pulation ; increased by the erect posture and by abdominal exertion — and then, too, sustaining an impulse, when held ; capable of being reduced, by pressure made in the direction of the outlet through which it has come ; often disappearing spontaneously, on recumbency being assumed. An enterocele is smooth, elastic, and more or less globular in form ; it gurgles on pressure, and flatulent noises may be emitted spontaneously ; reduction, under pressure, is preceded by gurgling, and is often abrupt — taking place ^jer saltum. Epiplocele is doughy, and more irregular in form ; it emits no noise ; and reduction is slow and gradual. 350 REDUCIBLE HERNIA. The treatment of reducible hernia may be regarded as analogous to that of dislocation ; consisting of prevention, reduction, and reten- tion (Principles, p. 732). Not unfrequently there are premonitory- symptoms of protrusion, and then Prevention is in our power. Pain and slight fulness appear at an abdominal outlet, after unusual exertion. Hernia is about to form. In order to avert it, the exciting cause is removed, by discontinuing all abdominal exertion, as much as possible. And the predisposing cause is met, by a well fitted, lightly springed truss being worn on the part, so as to strengthen what is weak in the parietes, while at the same time a mechanical obstacle is directly opposed to protrusion. Should hernia actually form, replacement, or Reduction, cannot be too soon effected ; inasmuch as the parts protruded are ever liable, from apparently but slight causes, to the supervention of strangulation — a state fraught with the utmost danger to life. To leave a hernia unreduced, and at the same time to continue any laborious avocation, or even to be exposed to but occasional abdominal exertion — ^is to con- vert a comparatively unimportant disease into one of a grave character, and to render a life, otherwise good, dependent on a very slender tenure. In life insurance for example, an applicant affected with a slight but well trussed hernia is admitted, if in other respects suitable, with only a trifling addition of premium ; while he who, with as simple a hernia, and of equally good health in other respects, neither wears a truss, nor otherwise provides against descent, is unhesitatingly rejected. Reduction is effected by placing the patient recumbent, slightly elevating the trunk, removing all outward pressure from the abdomen, and in short taking every means to relax the abdominal parietes ; then gentle and steady retropellent pressure is made with the hand, in the direction whence the descent has come. Such manipulation is termed the Taxis. Betention is effected by continued and suitable pressure at the site of protrusion ; and this pressure is best made by means of a truss ; a steel spring, with a compressing pad at the extremity. Of these instru- ments many varieties have been constructed ; but, of late, opinion seems to have inclined, very justly, towards a decided preference for the simple spring with its ordinary cork pad ; provided that the instru- ment is accurately adapted to each individual case ; the pad fitting nicely to the abdominal outlet, not too conical lest permanency of dila- tation should be so maintained, and yet not so flat as unnecessarily to diffuse the pressure ; the spring passing about two inches beneath the the crest of the ilium, grasping there firmly, and terminating a little way beyond the spinous processes of the lumbar vertebrae ; the spring not so strong as to gall the parts by inordinate pressure, and yet strong enough to shut up the opening effectually ; a thigh strap passing REDUCIBLE HERNIA. 351 from the back part of the spring to the pad, so as to prevent that from being displaced upwards ; and, to avoid chafing, a piece of folded lint or linen being interposed beneath the instrument, at the site or sites of pressure. At night, the truss may be removed, on the patient lying down in bed. In the morning it is the first article of dress to be ad- justed ; great care being always taken in regard to two points — 1. that the pad fits accurately; and 2. that there is no descent, how- ever slight or partial, during its application. Should at any time reprotrusion occur, the instrument must be instantly removed, and means as instantly taken for replacement and accurate readjustment. By careful and constant use of the truss, a radical cure is expected in the child. The predisposing cause is permanently removed ; for, descent being prevented, further dilatation of the outlet does not occur; and, during the general development of structure, the aperture or canal comes to acquire the normal proportion and capabilities. The period during which the truss requires to be worn, for attaining this end, is considerable ; from one to three, or more years. In the adult, so for- tunate an issue is not to be hoped for ; the outlet remains dilated, and predisposed to re-descent, on application of but a slight exciting cause ; usually the truss must be worn for life. And yet, a happy incident may occur, in favour of a better issue. Thus, we have seen a phleg- mon form under the pressure of a galling pad ; the abscess discharged, contracted, and healed ; and, on cicatrization, it was found that the extent and site of plastic exudation had been such as to consolidate the outlet, and render further use of the truss quite unnecessary. And even without such accidental aid, it sometimes, though rarely, happens that a slight hernia disappears under temporary use of the truss, and does not return. As, in the adult, the truss, however carefully and patiently worn, generally proves but a palliative, Radical Cures have naturally been sought for with some avidity. Of these, several have been applied to the inguinal hernia. What seems the best method is, to adopt the principle of subcutaneous puncture ; making several scarifications in the neck of the sac — the cord carefully protected — and then applying accurate pressure over the canal, so as to favour occlusion of its un- occupied part by plastic exudation. Another method is by invagina- tion ; pushing a fold of integument into the canal, after reduction of the tumour ; retaining the invagination by a suture, at the upper part ; and obtaining afterwards adhesion of the invaginated portion of integu- ment, by pressure, after excoriation by means of ammonia. This, however, is found to be both more uncertain, and more unsafe, than the former mode. And neither should be attempted, unless in extreme cases, and at the express desire of the patient ; seeing that neither is 352 IRREDUCIBLE HERNIA. quite fi'ee from risk by excess of inflammatory action. The application of iodine to the neck of the sac has been tried, by puncture and injec- tion ; but this method does not seem more promising of success than the other.* Irreducible Hernia. A hernia is said to be irreducible, which cannot be reduced, and is permanently fixed in its extra-abdominal position. This state may be caused — 1. By adhesion of the sac, on its external aspect, to the parts into which it has been protruded ; and by adhesion of its internal surface to the hernial contents. In a neglected hernia of any con- siderable duration, the former event seldom fails to take place ; and to constitute the second, plastic exudation has only to occur on the opposed surfaces. 2. By the nature of the protrusion. The caput CEecum coli is uncovered by peritoneum posteriorly. It may slide down through the parietes ; and, presenting at the groin, it may con- stitute an u-reducible tumour — as well as a hernia without a sac. The areolar adhesions of the displaced gut have been extended and shifted but not broken; and they may present an insuperable obstacle to replace- ment. But it has happened otherwise. The bowel may have a more extensive peritoneal investment than usual ; and, instead of merely descending with its fleshy connexions, may acquire a complete mesentery — so becoming easily reducible. "j" 3. By contraction of the abdominal cavity. When a lai'ge hernia has been long unreduced, it may become permanently irreducible, although no adhesion form between the con- tents and the sac. The abdominal cavity, having parted with a large proportion of its ordinary contents, contracts upon the remainder ; and then there is found to be no room for replacement of the extruded parts, even were circumstances quite favourable for such reduction. Irreducible hei'nise are predisposed to evil. The patient usually suffers from flatulence, indigestion, and constipation. The peristaltic movement of the protruded bowels is imperfect, and to other causes of incarceration and strangulation the part is constantly exposed. Such cases, therefore, require to be watched with unusual care. The bowels are to be carefully regulated ; all excitants of intestinal disorder are to be avoided, as well as unnecessary abdominal exertion ; and a bag truss must be constantly worn, so as both to support the protruded parts, and prevent the occurrence of further protrusion. No direct interference is warrantable, with a view to remove the obstacles to reduction. But, should strangulation occur, the ordinary operation is to be performed, for relief of the constriction. * BiGELOw, Boston Med. and Surg. Journal, Dec. 1850. t Lancet, 1235, p. 462. INCARCERATED HERNIA. 353 Incarcerated Hernia. This term denotes a temporary retention of the parts in their abnormal position, without obstruction to the fecal flow, and without the occurrence of inflammatory action. No urgent symptoms call for I'eduction ; but when this is attempted, it is found to be impracticable under existing circumstances. There may be — 1. An enlargement of the hernial contents. The gaseous matter may have become expanded ; the fluid and solid contents may have accumulated in unusual quantity ; or a portion of extruded omentum may have slowly expanded by in- creased deposit of adipose tissue ; and the tumour — thus enlarged — is too bulky to repass the outlet. Or, 2. While the tumour may be but little changed, the aperture through which it came may be temporarily contracted — preventing replacement, yet not causing constriction and strangulation ; and this state may depend on muscular spasm, or on swelling of the parts connected with one or other of the various stages of an advancing inflammatory process. Treatment depends plainly on the cause. Gaseous contents are diminished by the continued application of cold ; solid and fluid, as well as gaseous contents, may be favourably acted on by purgatives and enemata; a fatty omentum may be diminished by pressure and starvation ; and, then, the reduced tumour may be pushed back within the abdomen. Spasm is overcome by the warm bath, opium, chloro- form, or other antispasmodics ; inflammatory exudation is got rid of by antiphlogistics, followed by discutients ; and through the cleared outlet a comparatively unchanged protrusion may again be passed. Until this desirable event can be achieved, the part ought to be sup- ported by a bag-truss, or otherwise ; and every precavition should be taken to avert the occurrence of strangulation — to which such tumours are especially liable. Strangulated Hernia. Strangulation is said to have taken place, when faecal flow is arrested in the hernial tumour by tightness of constriction at the neck ; and when, usually from the same cause, circulation has been disturbed in the protruded parts, and the inflammatory process is begun. Or the condition may be otherwise defined to be : — incarceration, with interruption to both the f^cal and the vascular flow, and with an inflammatory process in the protruded parts either following or pre- ceding constriction. For this state of matters, the hernial contents are usually to blame. The constriction may depend on spasm, or other alteration in the abdominal outlet ; but much more frequently it is caused by sudden, or at least rapid and unusual, enlargement of the protruded parts — in consequence of which, the neck of the tumour 2 A 354 STRANGULATED HERNIA, becomes, as it were, jammed at the aperture of descent. A fresh protrusion takes place ; or fgeculent contents accumulate ; or gaseous contents become increased ; or an inflammatory process is begun in the protruded parts, causing both engorgement and serous eflFusion. Much more frequently, however, the inflammatory action is consequent to constriction — indeed caused by it. The symptoms of strangulation are very marked. The patient is annoyed by flatulence and general uneasiness. The bowels refuse to act ; the contents of the lower bowel may be evacuated, but no dejec- tion can be obtained from above the seat of stricture ; yet frequently there is a ti'oublesome and urgent desire to go to stool. The tumour is found incapable of reduction ; at first it may be flaccid, but it soon grows tense, and tension rapidly increases. Pain is felt in the part ; on the increase, and extending towards the abdomen. Sickness comes on, with retching. Then the stomach is emptied ; and, vomiting con- tinuing, the upper bowels also eject their contents ; the peristaltic movement comes to be wholly reversed, and the vomited matters are ster- coraceous. At fii-st, the pulse may have risen to the sthenic and inflam- matory character ; but now it becomes of another type — denoting the state of Constitutional Irritation, and tending fast to lapse into the typhoid character. The tumour becomes more and more tense and painful — perhaps intolerant of even the gentlest pressure. Great pain aifects the whole abdomen, with aggravation and twisting at the umbilicus. Nausea and vomiting continue ; the countenance is anxious, pale, pinched, and wet with clammy perspiration ; there is great restlessness, and distress is constant ; the pulse grows rapid and indistinct ; hiccoughing sets in ; the tumour becomes less intolerant of manipulation, less tense and painful, and feels dough}^ and crepi- tant on being handled. Gangrene has taken place. Then vomiting may cease, and sudden cessation of pain and discomfort may be experienced ; perhaps the bowels act imperfectly ; and the patient may express himself not only relieved but confident of recovery. Sinking, however, continues ; and the fatal issue is not long deferred. Such is the ordinary course of a strangulated hernia, unrelieved. But there may be another and less formidable termination. In the progress of the case, the integument and other envelopes of the tumour become involved in the inflammatory action ; at first they are bright red, tense, and very painful ; afterwards darker in hue ; less painful and tense, cold, phlyctenulous — in fact gangrened. The contents are in a similar condition. All slough. And, on separation of the mor- tified parts, copious fseculent discharge takes place ; relief follows immediately ; the urgency of the symptoms is over ; and gradual recovery may ensue, with the establishment of artificial anus. In the preceding enumeration of symptoms, we have first the STRANGULATED HERNIA. 355 signs of obstruction, and then tliose of inflammatory action, in the protruded parts. But this may be reversed. The inflammatory process may be the original affection ; caused, perhaps, by a blow — though a less direct and palpable exciting cause may suffice. The tumour is painful and red and swollen, even for some time, while as yet the abdomen is free from ailment, and the bowels are working naturally. The pain and tension are chiefly at the body of the tumour, in the first instance, instead of at the neck as in primary constriction. But, the inflammatory action continuing, engorgement with effusion takes place, the bulk of the whole tumour is increased, in consequence constriction occurs ; and then follow obstruction of the bowels, affec- tion of the abdomen, and aggravation of the local disorder. The rate of progress varies according to circumstances. When the tumour is small and recent, constriction is usually tight ; and, in a few hours, death of the parts, at least if unrelieved, is certain. Whereas, if the hernia be of some size and long standing, and if obstruction precede the inflammatory action, and neither prove urgent, days may elapse ere much mischief be done to either part or system. On the average, however, it is not by days but by hours and minutes, that the registration of time is made in cases of strangulated hernia. And, by the practical man, these minutes are invariably regarded as of vital importance. Many if not all of these symptoms may exist, independently of either hernia or strangulation. Whenever they do occur, however, hernia is invariably to be suspected, and the necessary inquiry and examination should be made under all circumstances. There may be no tumour found at the ordinary sites of protrusion, or at any other accessible part of the abdominal parietes ; then it is probable that the symptoms are independent of hernia — purely abdominal. If a hernia is discovered, of old standing and considerable size, not very tense or painful ; if the pain is not greater in the tumour than elsewhere — perhaps not so great ; if the bowels are acting, though perhaps imper- fectly ; if, on inquiry, it is ascertained that the abdominal and general symptoms plainly, and by some considerable time, preceded change in the tumour ; — then the probability is, that the affection is enteritic or peritonitic, originating in the general abdomen, affecting the tumour secondarily, and perhaps even in a minor degree. When, however, the signs of strangulation are found marked and acute, and the history plainly indicates precedence of the local and extra-abdominal signs of disorder, there need be no doubt that the case is of the ordinary kind — ^the urgency essentially dependent on strangulation of the hernia. Treatment of strangulated hernia necessarily varies according to the nature of the case. In general, it may be said that our object is to effect reduction as speedily as possible ; saving structure, by 2 A 2 356 TREATMENT OF STRANGULATED HERNIA, favouring decline of the inflammatory process ; restoring the normal passage of the intestinal contents ; and arresting the disastrous progress of constitutional disturbance. But it is not always good practice to have recourse to the manipulations for reduction immediately ; and, in regard to this practical point, the cases may be divided into two great classes ; those which are preceded by inflammatory action in the hernia, and those in which this action follows on constriction other- wise produced. The latter, doubtless, are the majority. In the former, it is the natural and proper course of procedure to remove the cause of constriction, if possible, in the first instance — provided the case is chronic enough to admit of this ; leeches are applied, and other suit- able antiphlogistics are enforced ; and when, by such means, the bulk of the tumour has diminished, and the parts have also acquired a better tolerance of manipulation, then reductive pressure is to be applied — without risk of doing harm, and with a good prospect of proving successful. The inflammatory action has caused constric- tion ; I'emove the cause, and the constriction is easily dealt with. But, in the other class of cases, the state of matters is reversed. The con- striction has caused inflammatory action ; and, only after removal of the former, can we expect to cope successfully with the latter. In employing leeches for the relief of hernia, it is well not to apply them to the tumour itself, but to its immediate vicinity ; otherwise, the slipperiness which is produced, by oozing of blood, may interfere seriously with the manipulations of the taxis. In applying the taxis, the patient is placed recumbent, and with the limbs and trunk so arranged as to relax the abdominal parietes to the fuU ;* it is well also to see that the bladder is empty, and that no bandage, belt, or other outward constriction is affecting the abdomen. The tumour is then grasped with the hands, firmly yet cautiously ; and while with one hand general pressure is made on the bulk and body of the tumour — forcing it in upon itself, as it were, and at the same time pushing it back in the direction whence it has been protruded — a kneading or pinching movement is made on the neck of the tumour by the fingers of the other hand, so as to disentangle and free the part most compacted and compressed. And this is steadily persevered in, for sonae time, provided the patient do not complain greatly of aggravation of pain and general uneasiness. Our wish is to push the hei-nial contents back, not in mass, but in detail ; those going first which were last pro- truded. The patient, if not chlorofoi-med, is kept in conversation, to * By some it is thought that much may be done by position alone ; flexing the thighs, rotating the limbs inwards (for inguinal and femoral hernise— especially the latter), raising the nates till the whole weight rests on the shoulders, retaining this position for a time, then lowering and raising again, the hand of the surgeon meanwhile making gentle pressure on the tumour. It is thought that the posturing tends to pull the contents out of their sac. — Brit, and For. Rev. April 1850, p. 491. AUXILIARIES TO THE TAXIS. 357 prevent him from straining his abdominal muscles in involuntary opposition to the operator. There is energy, yet no violence of force in the pressure ; and it is patiently and steadily maintained, yet not continued too long — that is, not after reasonable hope of its success has passed, and when its maintenance must inevitably tend to serious aggravation of the crescent inflammatory action.* Sometimes it is not applicable at all ; w^hen, for example, the case is acute, and has made great progress ere assistance is called ; when the parts are so obviously intolerant of pressure, as to convey to the practised hand and mind the apprehension of texture giving way by rupture under an attempted taxis ; also, when we are satisfied that inflammatory action has already gone so far as to render loss of substance, either by ulceration or by sloughing, inevitable in the constricted parts. Sometimes benefit accrues from an opposite direction of gentle force, previous to the reductive application of it ; bringing down the jammed neck from the abdominal aperture, and so favouring a clear- ance of the passage by an unravelling, as it were, of its contents ; causing, in fact, a slight increase of the descent, before the whole is attempted to be replaced. A bluff forcing of the fundus of the tumour on its neck is especially to be avoided, when replacement is intended ; for the efiect of this, in the case of protruded bowel, is not only to jam the parts yet more, but actually to favour formidable accession to the tumour's bulk by traction from the aperture downwards. Failing in the well applied taxis, we naturally look for Auxiliaries to it ; and we find a catalogue of these, analogous to the aids of reduc- tion in dislocation (Principles, p. 735). Some act on the contents of the tumour, tending to reduce bulk ; others affect the abdominal outlet, tending to enlarge space ; and the latter act well, not only in those cases in which spasm of the abdominal parietes is the cause of con- striction, but also in those in which the abdominal outlet may be of the ordinary dimensions, yet quite unfit for return of the impacted textures which it happens to contain ; in other words, they are of use in relaxing muscular fibre, not only in a spastic but also in a normal state — making easy room, either way, for replacement of the dislocated parts. And here it may be stated, that though in many cases the abdominal outlet is in the first instance free from change, and constric- tion depends on alteration in the contents ; yet, strangulation having occurred, the abdominal parietes at the site of the hernia become in- volved in perverted action, and sooner or later are irritated into spasm. And hence it is, that the most useful auxiliaries are such as tend to abdominal relaxation. 1 . Venesection is advisable in but a few cases ; — in the compara- tively young and robust, of inflammatory tendency, tolerant of loss of * For a sample of thu injuries done by imprudent taxis, see Teale on Hernia, p. 96. 358 AUXILIAPJES TO THE TAXIS. blood ; Avith a tight strangulation yet recent, marked signs of advanc- ing acute action in the parts, and the constitutional symptoms still evincing a sthenic type. In such cases, blood-letting — one copious and rapid abstraction, from the arm — is of use, by both combating this advancing action, and at the same time tending to cause complete prostration of the muscular system — the abdominal parietes of course included. 2. The Warm-hath has similar tendencies ; and is obviously more generally applicable, inducing temporary depression ; gaining the desired end, yet saving the system from actual loss. If there be time, this is one of the best means of assisting the taxis. The patient is placed recumbent in the bath, with the abdominal paxietes relaxed by posture ; and, when faintness is beginning to be complained -of, the taxis is resolutely applied. It may fail ; but the opportunity by the bath is not j%t over. Let the patient be replaced in bed ; in a few minutes he will be found deluged in perspiration, with a muscular system more prostrate than before ; and then the taxis is most likely to succeed. 3. Fomentation is inapplicable ; by rarefying the gaseous contents, and favouring exudation, it increases the bulk of the tumour; and it is too feeble and limited in its relaxing effect, to act favourably on the abdomen. 4. Antimony, as a nauseant and prostrating agent, is very inferior to the bath ; adding greatly, and in a dangerous degi-ee, to the irritability of the stomach, and to the downward tendency of the constitutional symptoms. It is inapplicable. 5. And, for a like reason, let Tobacco be used very warily, if at all. By other, less hazardous, and more manageable auxiliaries, our object may be as speedily obtained, 6. Opium is deservedly in much higher repute ; following blood-letting in the mai-ked cases of an infiammatoiy nature, given singly in others ; the dose a full one, not less than one or two grains — for the adult. The beneficial effect is twofold. Constitutionally, the system is rendered more tolerant of the depressing effects of strangulation ; the remedy being in fact equally useful here as in the case of intense abdominal inflamma- tion unconnected with hernia (Principles, p. 170). Locally, very great service is obtained by muscular prostration, so soon as the full narcotic effects of the drug have been established. This requires time, how- ever ; and consequently opium, like the warm bath, is not applicable to all cases — at least as an auxiliary of the taxis ; for, in all, there is not time to await the operation of the remedy. 7. Chloroform, as has else- where been stated (Principles, p. 795), is almost equally serviceable here as in dislocation ; producing thorough relaxation, not aggravating collapse, quickly passing ofi^, and leaving no unpleasant trace behind. 8. Olysters of acetate of lead, each containing ten grains dissolved in about six ounces of water, have been employed with success ; repeated, if necessary, every two hours.* 9. Purgatives are in all cases of stran- * Brit, and For. Eev. Jan. 1849, p. 271. AUXILIARIES TO THE TAXIS. 359 gulation most unwarrantable. The bowel is locked ; and the stimulus of purging, quite unable to undo the locking, acts but injuriously, in applying a stimulus which cannot be obeyed, and aggravating an already crescent inflammatory action. In the case of incarcera- tion, the wary use of purgatives is often serviceable, in unloading the protruded bowel ; but in the tighter degree of constriction, causing strangulation, they are never to be thought of. 10. Enemata., however, have a diiferent character. "When simple and bland, however freely and largely administered, they have not the pernicious properties of purgatives — more especially of those which are drastic and given by the mouth. Besides, they are positively of use, by disburthening the lower bowels of their contents, both solid and gaseous ; and so making- room within the abdominal cavity for reception of the extruded parts. And experiment would also lead us to suppose that they have a mechanical tendency to extricate, by exciting traction, from within, on the constricted and protruded bowel.* 11. The long elastic Rectum- tube is also both safe and useful, when passed high and cautiously, so as to reach the colon ; the object being to evacuate the gaseous con- tents of the lower bowels more thoroughly than enemata can do, and so to make room within the abdomen. But, obviously, such a proceed- ing is only applicable to those cases in which distension of the lower bowels exists. 12. Some auxiliaries affect the tumour mainly. Cer- tain cases, we have already seen, render it necessary that local blood-let- ting should precede the taxis. Fomentation has been thought of, but is found worse than useless. The application of Cold is sometimes of the greatest service. Applied indiscriminately, it will do harm ; but limit its use to those cases which are chronic in their progress, in which the signs of obstruction plainly precede those of inflammatory action, and in which the inflammatory process affecting the tumour is not only slight but scarcely begun — then the effect is often most favourable. The gaseous contents being condensed, bulk is diminished ; muscular energy is probably somewhat lowered, and space is gained ; and, per- haps by puckering the investments of the tumour, some little reductive pressure may be so exerted. But act as it may, there is no doubt that the local application of cold tends AvonderfuUy to assist the taxis, in the class of cases just described. It may be applied by sprinkling the tumour and surrounding parts with eether, and keeping up a con- tinuously rapid evaporation by directing a current of air uj)on the part. Should this fail, great care must be taken for some time not to apply heat suddenly to the part, by fomentation or bath, or otherwise to cause rapid exaltation of temperature, for very obvious reasons (Prin- ciples, pp. 152 and 285). Ice and freezing mixtures are less suitable ; being apt, by doing too much, to act injuriously on the hernia's con- tents. 13. Acu-puncture has been proposed, when the constricted bowel is * Lancet, Ko. 1035, p. 468. 360 AUXILIARIES TO THE TAXIS. obviously distended by gaseous contents. But the use of cold is likely to obtain the same end, as effectually, and more safely. 14. Posture may be rather considered as a part of the taxis, than as auxiliary to it; so invariably is it to be attended to. It necessarily varies, in details, according to the site of the protrusion. Its main object is ever the same ; to relax the parts through v^hich reduction has to be made. In hernia at the groin, as already stated, it has been thought that ele- vation of the pelvis, with a hanging position of the recumbent body, has been of use in exerting an extricating traction on the strictured parts (p. 356). The most available, and most generally used of these auxiliaries are : — blood-letting — local in all the inflammatory cases, and general in the few examples which admit of it ; the warm bath ; opium ; chlo- roform ; simple enemata, in large quantity ; perhaps the long tube ; in the chronic and uninflamed cases, always the local application of cold. If the taxis is to succeed, a yielding of the tumour is felt beneath the hands, the contents are plainly shifting ; then a gurgling noise is heard, denoting replacement of the gaseous contents — ahvays a wel- come sound ; and speedily thereafter the solid matters recede, some- times very gradually, often as it were ^?er saltum. A truss, or suitable compress and bandage, is instantly applied ; the patient is confined to bed, recumbent ; antiphlogistic regimen is strictly enforced ; after some hours, an enema may be given, if the bowels have not acted spontane- ously ; but not till after many hours should even the simplest purge be given by the mouth, it being well ascertained that the loop of bowel included in the stricture remains long in a paralytic state, and incap- able of obeying the pei'istaltic stimulus. There is, in short, the same serious objection to purgatives immediately after reduction, as during the existence of strangulation. Should peritonitic or enteritic symptoms threaten, the usual antiphlogistic treatment must be had recourse to, both early and with energy. Not unfrequently, after tight constric- tion, discharge of blood takes place per anum; this doubtless being furnished by the mucous coat of the lately strangled part. It may happen that under forcible application of the taxis, in a recent hernia, the tumour recedes suddenly, in mass. This is not desirable. For, it is not improbable that the untoward symptoms may continue, quite unchanged ; the reason being, that the sac and its con- tents have been reduced together with their relations unaltered, and that the neck of the sac continues to constrict the omentum or bowel, as before. In such a case, treatment becomes embarrassed. But most surgeons are of opinion that we are required to expose the abdominal outlet by operation, in search of the yet strangulated bowel ; aiding that search by making the patient cough, or otherwise exert himself, so as to favour re-descent of the hernia. An operation under such circumstances is much more promising of success than Gastrotomy on THE OPERATION FOE STRANGULATED HERNIA. 361 account of an undefined internal obstruction (p. 34:4). For in this case the cause of strangulation is plainly in the sac. and that is within reach at a fixed point, the parietal relations of the sac being likely to detain the reduced mass close to the site of protrusion.* The operation for strangulated hernia is unhesitatingly to be had recourse to, so soon as the taxis, with such auxiliary means as seem advisable, has been faMy tried, without success. The gi'eat majority of experienced surgeons agree, that in regard to this operation error is more frequent on the side of delay than of precipitancy. Two cfrcum- stances demand its instant performance ; a conviction that by no other means, than by the edge of the knife directly applied, can the abdo- minal outlet be so enlarged as to relieve constriction and admit of replacement ; also, a conviction that already inflammatory action has advanced so far, that either ulceration or sloughing is inevitable in the protruded parts. In the one case, we operate to relieve the stricture and effect replacement, hoping to arrest inflammatory action ; in the other, we operate to relieve the stricture, and, leaving the hernia unreduced, prevent fatal extravasation of intestinal contents within the abdomen — hoping also to limit inflammatory action to the directly implicated parts. The danger of strangulation is twofold ; formidable disturbance of the system, and untoward inflammatory progress in the tumour. Both dangers advance, in most cases, with rapidity. And if we wish to meet them successfully, the measures of relief must be not only suitable but early ; in other words, time, all valuable, must not be wasted in ineffectual attempts at the taxis, when the case at all partakes of an acute character. Large hernite are more hopeful of reduction than the small ; the inguinal protrusions are more hopeful than the femoral. It has been proposed to relieve the sti'icture by means of subcuta- neous section. But this proceeding is obviously so beset with danger and uncertainty as to be quite inapplicable. The seat of stricture is exposed by careful and regular dissection ; the incisions necessarily varying in their plan, according to the kind of tumour. Having cautiously divided the integuments and fascial envelopes, the sac is exposed, clear and glistening, resembhng very much the peritoneal coat of the bowel ; and there may be some diffi- culty in ascertaining whether it is the sac or bowel. By pinchino- it up, so as to show bowel separate beneath ; or by observing serum, fat, or a portion of omentum between, we arrive at a sure diagnosis. But, this ditficulty having been surpassed, another immediately arises. The sac having been exposed — or nearly so — are we to open it, examine the state of its contents, and divide the strictiu-e from within ; or ai-e we to attempt division of this from without, lea\'ing the peritoneum * Monthly Journal, Retrospect, Feb. lS=t9, p. 35. 362 THE OPEEA.TIOX FOR STRANGULATED HERNIA. intact, and so escaping the danger of peritonitis ? So long ago as 1720, Petit proposed this modification of the procedure — leaving the sac unopened ; and the proposal has met with a varied reception since — inclining to distrust rather than otherwise. Lately, however, it has been revived under better auspices ; and in suitable circumstances, it may be considered as the established and preferable practice. Were it applied indiscriminately, nothing could well be conceived more per- nicious ; bowel or omentum might be reduced when they ought not ; or, one stricture having been relieved, another might be left — this second existing in the sac, perhaps beloAv its pi'oper neck, and continu- ing to embrace the hernial contents with fatal tightness after reduc- tion. But, limit it to those recent cases of strangulation in which we are certain that the hernial contents are sound and reducible, and in which we are also certain that the only stricture is that which we pro- pose to divide — then, doubtless, the extra-peritoneal operation is by much to be preferred. It is also suitable in cases of irreducible her- nia, which have become strangulated ; and in which, from their large size, the exposure of peritoneum may reasonably be expected to prove especially hazardous.* If the case appear favourable for extra-peritoneal division, the investing textures are carefully divided at the neck of the tumour, so as to admit the point of the finger, or at least the finger's nail, within the tight orifice of the abdominal aperture ; and then on the finger's point, so introduced, a probe-pointed bistoury is passed, and by it the necessary enlargement is effected. If the stricture be in the neck of the sac itself, even that may perhaps be relieved extra-peritoneally, by care- fully scratching the outer part by the knife's point.t Then the taxis is applied ; the parts are reduced — the contents going first, and gi-adually, othervv'ise stricture might remain after reduction ; if the unopened sac be non-adherent, it is pushed back also ; the wound is bi'ought together ; and by suitable adaptation of compress and bandage, and avoidance of the ordinaiy exciting causes, reprotrusion is prevented. But if it be deemed expedient to proceed in the ordinary way, the sac is pinched up by forceps ; choosing a part where serum or fat inter- poses between it and the bowel — and that will generally be towards the fundus of small hernias. By the knife's edge, held horizontally, the raised fold is divided. Through this aperture the point of the fin- * Indiscriminate performance of the extra-peritoneal operation must often lead to serious and fatal error. Selection must always be carefully made. For objections to the operation, vide Haxcock, Observations on the operation for Strangulated Hernia, Lond. 1850. t According to Mr. Luke, the site of stricture may be ascertained previously to operation, by making impulse on the fundus of the tumour with one hand, while the other is placed on the neck. Wherever irapidse stops, there is the stricture. — Med. Chir. Trans, vol. xxxi. THE OPEEATION FOR STRANGULATED HEENIA. 363 ger is introduced ; and, on this, as the best director, dilatation of the opening is made to such an extent as may be deemed advisable. How- ever large the hernia, the opening of the sac need not be of greater extent than what is merely sufficient for ascertaining the state of the contents, and permitting the finger to reach the site of stricture. The point of the forefinger having been passed up to the abdominal aper- ture, the probe-pointed bistoury is slid flatly along it ; and, by the point's edge, pressed upon the stricture, this is divided to the necessary extent. Then the hernial contents, if sound and reducible, are replaced gently, portion by portion — the last protruded, first. Eecent and tender adhesions may be gently broken up with the finger, or touched with the edge of the knife ; but consoli- dated adhesions, if at all exten- sive, render the parts irreducible — they should not be interfei-ed with. When there is any con- siderable portion of omentum in the sac, it should be carefully rig. 121. examined, to ascertain whether or not it conceals — perhaps strangles — a knuckle of intestine. If the sac be not adherent, it is replaced as well as its contents, but not along Avith them ; for, reduction is found to be facilitated by an assistant's finger steadying and stretching the sac, while the contents are pushed upwards on its smooth and slippery surface. Reduction having been accomplished, the wound is brought together, and suitable pressure applied. Approximation by sutui'e should not be complete, however; for union by adhesion is not desirable, otherwise danger might accrue from the secretions in the deep wound finding their way into the peritoneal cavity. They should be allowed a free outward drain. When hernia is irreducible, we content ourselves with division of the stricture. If the contents are sound, the external wound is ap- proximated v/ith a view to adhesion. If the contents are found gan- grenous, or verging thereto, the wound is left open, to permit free discharge of the fceculent contents. If on exposing the contents of a reducible hernia, the bowel be found merely congested ; ruby-coloured, it may be ; perhaps spotted by points of ecchymosis, or showing one or more vesicles of the peritoneal coat — it is reduced unhesitatingly. If showing signs of Fig. 121. a a, The portion of bowel wbich has been protruded; constricted, dark, and engorged. At h, the upper, or cardiac portion, dilated, and of dark colour. At c, the lower portion, comparatively empty, flaccid, and pale. 364 THE OPERATION FOR STRANGULATED HERNIA. plastic exudation on its surface, it may still be reduced ; no structural change has taken place but what may be recovered fi'om. But if the bowel be dark-purple at some parts, gi'eenish at another, and perhaps ash-coloured at a third, friable, and evidently fast passing into gangrene — under no circumstances is it to be reduced ; else fatal fjeculent extravasation must ensue. And if omentum be found dark-red, emphy- sematous, and with its venous blood coagulated, it too must be left to slough in its outward site ; in either case, however, as much care being taken to free the neck of the tumour by division of the stricture, as if the whole were fit for reduction. In the case of gangrened bowel, it is also well to incise the sloughing part, so as to relieve by immediate and copious fseculent evacuation. Afterwards, the treatment is as already described for artificial anus (p. 331). In the case of gangrenous omen- tum, two modes of procedure are in our option. We may cut off the gangrened part — having previously satisfied ourselves that there is no portion of bowel within the mass — secure the vessels by fine ligatures, and return all within the abdomen. Or, having cut off the gangrened part, and secured the bleeding points, we may leave the rest still im- pacted in the abdominal outlet, with a view to its becoming per- manently fixed there, and so preventing all future tendency to pro- trusion. The former method — though not free from risk by bleeding and inflammatory exudation within the abdominal cavity — is usually preferred ; the latter being often followed by uneasy sensations in the part, and proneness to abdominal disorder. In all cases of doubt as to viability of the strangulated parts, reduction should at least be delayed. It is never to be forgotten, that notwithstanding relief and replacement, inflammatory action may still advance in the bowel, so as to cause loss of continuity by ulceration. And if this take place within the abdomen, and be followed by fasculent escape, the patient's doom is sealed. Sometimes, after opening the sac, stricture at the ordinary sites is sought for in vain. In such cases it is likely to be found in the hernial contents themselves ; a portion of omentum, for example, may encircle a portion of bowel. This is detected by careful manipulation ; and is to be gently undone by the fingers — perhaps aided by a touch of the knife. After successful reduction, by operation, the same treatment is required, as in the case of simple taxis ; rest ; recumbency ; anti- phlogistic regimen ; leeching and other antiphlogistics,* if inflam- matory symj)toms supervene ; hydrocyanic acid or creasote, if the stomach continue irritable ; bland enemata ; but no purge by the mouth, however simple, until many hours have elapsed — otherwise, as " Diffenbach is afraid of calomel ; supposing that it acts injuriously on the bowel, and is apt to induce an unhealthy state of the wound. — Vide his Operative Surgery, 1848. OBLIQUE INGUINAL HERNIA. 365 already stated (p. 360), dilatation with obstruction will take place above the palsied portion of intestine, and the patient will probably sink under symptoms of ileus. If intestine previous to reduction have shown an advanced stage of the inflammatory process, antiphlogistics are especially necessary, both local and general, in order to avert if possible ulceration or other dangerous structural change. When the case is of the obscure nature, already described (p. 355) — and it is difficult to say whether the hernia is to blame or not for occurrence and persistence of the untoward symptoms — let the operation for relief of stricture be performed. When the tumour itself is of an ambiguous character, when we are not certain whether it is a hernia or not, and yet the ordinary symptoms of strangulated hernia are present — again let the surgeon operate. It is well that he should approach error on the safer side. After operation, the greatest attention must be paid, for some days, to prevent reproduction of descent, by keeping the compress accurately applied, and avoiding the ordinary exciting causes. Should repro- trusion take place, by coughing, restlessness, or imprudence of the patient, the dressing must instantly be undone, and replacement effected, WTien the sac remains unreduced, simulation of re-descent is apt to take place, by serous accumulation within the sac ; — especially if the integumental incision be closed ; but this state is at once detected and remedied, on opening up the wound. After cicatrization, a well made truss must be worn, as in ordinary cases ; for it is seldom that the operation for relief of stricture effects a radical cure. Oblique Inguinal Hernia. This is by much the most common form of hernia, in the male. Descent takes place along the spermatic cord, through the inguinal canal ; the tumour shows itself external to the parietes, at the lower aperture ; and thence descends into the scrotum in the male — con- stituting an oscheocele, or scrotal hernia ; into the labium of the female, constituting labial hernia. The investments of the tumour are as follows : externally, the integument ; then the superficial fascia of the abdomen ; then the proper fascia, or fascia propria of Camper, consist- ing of fibres from the tendon of the external oblique ; then the fascia cremasterica, consisting of fibres from the cremaster muscle ; then the infuudibuliform, or transversalis fascia, consisting of a prolongation of the fascia transversalis abdominis ; lastly the sac. As the tumour is about to descend, a painful fulness is found opposite the upper abdominal aperture, increased by abdominal ex- ertion, and sustaining an impulse upon coughing. Then is the time for applying a truss carefully, and avoiding exciting causes, with a view to prevention of the hernia. The pad of the truss should com- 366 OBLIQUE INGUINAL HEIiNIA. press the superior abdominal aperture, not the lower ; otherwise there is room enough for hernia, and strangulated hernia too, within the abdominal parietes. To reduce this form of tumour, the pressure of the taxis is applied obliquely upwards and outwards, in the direction of the inguinal canal. In large tumours of old standing, however, it must be remembered that the canal becomes shortened as well as more direct, the two apertures coming to be almost opposite to each other ; and this is at- tended to in the taxis. The patient is laid recumbent, with the trunk raised, and the thighs flexed and approximated. In the operation for strangulation, a simple straight incision is made along the neck of the tumour ; beginning a little above the aperture of protrusion, and extending downwards on the tumour, as Fig. 122. far as may be deemed necessary. The deep cut, for relief of stricture, is made directly upwards ; in order to avoid the epigastric artery, which courses behind and to the inside of the hernia's neck. The spermatic cord is usually behind, and out of harm's way ; but some- times it is split up and scattered over the neck of the hernia — and then caution is required, to avoid the spermatic artery and duct. The stricture may exist at one of three points : in the margins of the lower abdominal apertui'e ; in the superior abdominal aperture ; in the neck of the sac itself Sometimes a double stricture exists ; each abdominal aperture being at fault. The ordinary site is at the lower outlet ; but if, after free division of this, reduction is still opposed, the superior site is at once to be suspected, and explored accordingly. Fig. 122. Plan of inguinal hernia; on the right side oblique; on the left direct, a, Tlie hernial sac ; I, the epigastric arterj'.— After Tiedemann. CONGENITAL AND INFANTILE HERNIA. 367 At this site, it is to be remembered, a small strangulated hernia may exist, with scarcely any perceptible swelling ; a minute portion of bowel being tightly embraced by the margins of the superior ab- dominal aperture. The symptoms are likely to be mainly those of enteritis, and attention may not be directed to the groin. In such cii'cumstances the patient has great risk of perishing; unless, by sloughing and abscess, outward discharge occur, with establishment of artificial anus. There are sub-varieties of inguinal hernia : — 1 . The intermuscular Hernia. — This is more liable to occur in females than in males ; the bowel meeting with obstruction in its ordinary descent. Having passed the internal aperture, it turns towards the ilium, and lodges between the abdominal muscular layers, above and exteriorly to its point of exit. On account of this unusual site, diagnosis may be some- what obscure.* 2. The Congenital Hernia. — This is a very simple deviation from the normal state of parts ; dependent on imperfect development. It is not likely to take place till after birth ; for not until after inflation of the lungs are the exciting causes applied. But so soon as the child is born, the exertion of crying brings down a portion of bowel or omentum along the open process of peritoneum, which exists in con- sequence of that which constitutes the tunica vaginalis testis having not been occluded. There is no sac, unless the tunica vaginalis be considered as such ; the bowel or omentum lies within the cavity of that tunic, in contact with the testicle — sometimes adherent to it, in which case the tumour is irreducible. Occasionally a portion of bowel contracts adhesions to the testicle while within the abdomen, and, descending with it at the usual time, constitutes this form of hernia before birth. Strangulation may occur at any time ; it has happened to an infant of but a fcAv days old, and required operation. This is per- formed as in the ordinary tumour. In the reducible cases, a carefully adjusted truss is worn constantly ; preventing protrusion ; tending to obliterate the peritoneal opening ; and so, speedily and surely, effecting a radical cure. 3. Hernia Infantilis. — This term is ap- plied to a more complicated state of parts, ^*s- '^~^- originating also in early life. The communication between the cavity * Luke, Medical Gazette, March 15, 1850. Fig. 12.",. Diagram illustrating the state of parts in hernia infantilis.— Liston. 368 VENTRO-INGUINAL HERNIA. of the tunica vaginalis and that of the abdomen is shut at its upper part ; but the former cavity is unusually spacious, and ascends high in the cord, containing more or less serous fluid. Behind this a hernia descends, invested by the ordinary peritoneal sac. In cutting down on such a tumour, we divide first the anterior portion of the tunica vaginalis, then the posterior ; and, after this, appear the sac and its contents — unless the former, as is not unlikely, be incorporated with, the posterior layer of the tunica vaginalis. This form is of rare occurrence. Ventro-inguinal Hernia. This is also called the Direct inguinal hernia. Descent is uncon- nected with the superior abdominal aperture ; and takes place through the abdominal parietes, immediately opposite the lower aperture — the common tendon of the internal oblique and ti'ansversalis muscles giv- ing way at that point. Sometimes, however, that tendon is pushed before the tumour, and forms one of its investing fasciae — protrusion in that case not being through the lower abdominal aperture, but near it. The ordinary coverings are similar to those of the oblique variety ; only, this descent being not directly connected with the cord— which is on its outer aspect — rthere is no cremasteric expansion. The course of the epigastric artery is external to the neck of the tumour (Fig. 122). And hence the general rule, in all cases of inguinal hernia, when stran- gulated, is to make the deep relieving incision directly upwards, paral- lel to the linea alba ; whether the descent be direct or oblique, the artery is safe. In the direct form, the pressure of the taxis is made directly upwards. Femoral Hernia. This is most frequent in females ; the greater space, in the normal state of the parts, obviously favouring protrusion. Descent takes place through the crural aperture, on the inside of the femoral vessels, and through the saphenic opening of the fascia lata. In the crural aperture the neck of the tumour is contained ; the fundus, I'esisted in its descent on the thigh, makes a sharp turn upwards, and lies on the lower part of the abdominal parietes ; the neck is beneath Poupart's ligament, the fundus may be above it. And this must be attended to in applying the taxis ; the tumour being invariably unbent, as it were, and made straight, ere the reductive pressure is applied. The tumour is usually of small size ; often not bigger than a pigeon's egg ; sometimes it is of even huge dimensions ; but its average bulk is much below that of the inguinal varieties. The coverings are, integument ; the superficial fascia of the thigh ; the fascia propria, obtained from the femoral sheath, and continuous with the PEMOEAL HERNIA. 369 fascia trans versalis and fascia iliaca ; lastly, a covering obtained from the textures which normally occupied and occluded the crural aper- ture. Very often the two last named coverings are matted together, into one dense fascia; and thus we may expect occasionally to meet with but two investing layers ; one the superficial fascia ; another beneath it, deep, dense, and strong. Not unfrequently the deep layer splits at its lower part ; and the fundus of the tumour, emerging through the aperture, may be covered only by the superficial fascia and integument. There are two peculiarities in applying the taxis to this tumour. The position of the patient is as for the inguinal ; but with the limb on the affected side bent much upwards, and at the same time carried across its fellow, so as to relax the crural arch, on which, and not on Poupart's ligament, constriction depends. The pelvis, too, may be alter- nately raised and depressed (p. 356). Also, as already stated, the neck of the tumour must be unbent and straight, befoi'e re- ductive pressure is made on the fundus ; in other words, the tumour is first pushed down on the thigh, and then upwards in- to the abdomen. After reduc- tion, a well made truss is ap- plied ; the pad resting on the outside of and beneath the spine of the OS pubis. Strangulation is both more common and more severe than in the inguinal forms of hernia; and conseqiiently operation is more frequently required. It is performed Fig. 124. Plan of femoral hernia, a, The sac ; h, the femoral vein ; c, the artery ; d, the abdominal ring ; e, section of the psoas and iliacus muscles ; f, the acetabulum. — From Dkuitt. Fig. 125. Femoral hernia ; of unusually large size. 2 B 370 FEMORAL HERNIA. thus : — The skin, having been pinched up, is divided by transfixion ; in order that there may be no risk of injury to the important parts beneath. The form of this integumental wound may be greatly varied ; an inverted T; an inverted Y; a Y; a simple oblique cut; or The investing textures are cautiously divided, by the forceps and knife — the latter held horizontally ; and the sac is ex- posed. In many cases, the opening of it cannot be avoided. And, this having been done, the forefinger of the left hand is passed up to the neck of the tumour. Here, as in the oblique inguinal hernia, there may be two strictures, a superficial and a deep. The former is con- siderably anterior to the ligament of Gimbernat, and independent of it ; formed by the inner and anterior part of the crescentic portion of the crural arch ; felt tight, on the inside of the tumour's neck, while the finger's point is yet at some distance from the actual brim of the pelvis. ^ig- 126. This resistance is divided by a probe- pointed bistoury — slid fiatly along the finger, and afterwards having its edge directed upwards and inwards. Dilatation is then made by the finger ; and, on withdrawing this, reduction may be effected, readily. If not, then the finger is re-introduced ; and, pushing it upwards, Gimbernat's ligament is felt tight and resisting, on a higher level than the former site of constriction. It is divided in a similar way, the bistoury's point being barely insinuated within the pelvis ; the least movement of its blade suffices ; a notch in the edge of the ligament is enough ; the finger, following, dilates. Were the deep incision to be made directly upwards, Poupart's ligament would be divided — an unnecessary act, that texture being unconnected with the constriction ; and, besides, the spermatic cord in the male, and the round ligament in the female, would be endangered. If the obturator artery arise by a common trunk with the epigastric, it is likely to encircle the neck of the sac within the pelvis. And were the bistoury, which divides the higher stricture, to be used rashly — without the guard of the finger, and with any part of its blade thrust over the brim of the pelvis — this vessel would doubtless run no slight risk of being wounded. But, with ordinary precaution — the fore-finger Fig. 126. Portion of bowel, not including its whole calibre, which was caught and strangled at the crural apertu^re ; the symptoms, though modified, proving fatal. During life no tumour could be discovered at the site of protrusion. — Liston. His Elements, p. 536. UMBILICAL HEENIA. 371 preceding the knife, and merely the bulbous point of the latter within the pelvic brim — the vessel is safe, whatever be its distribution.* In the extra-peritoneal operation, a smaller wound suffices than in the ordinary method. It is placed on the inside of the tumour, at its upper part ; and by means of it it may be in our power satisfactorily to relieve the stricture, without any interference with the hernial sac. Should this fail, and there be reason to suspect that the stricture is in the sac itself, it is necessary to enlarge the wound, disclosing the parts more thoroughly ; and then we may attempt relief by scratching through the faulty external fibres, as in inguinal hernia (p. 362). Fail- ing this, the sac is opened, and the operation completed in the usual way. The after treatment, is as for the inguinal operation. It is in femoral hernia that we are most liable to be puzzled, as to the exact nature of the tumour. But the safe general rule, as formerly stated (p. 365), is — when in doubt, operate. Umbilical Hernia. This is common in infants ; and in women who have borne many children, it is not unfrequent. In the former it vei-y readily occurs ; the exertion of crying forcing the bowel or omentum outwards, through the yet unconsolidated umbilicus ; forming a soft, impulsive tumour ; at first of small size, not larger than a button — commonly called " a starting of the navel." In women, unless congenital, it is seldom a true umbilical hernia ; protrusion having taken place near, not through, the navel — in consequence of a yielding of the abdominal parietes there, probably during parturition. Strangulation is comparatively unfre- quent. In the adult, the tumour may attain to an enormous size. In the child, treatment is both simple and effective. The exciting causes — especially crying — are averted, as much as possible. And compression is made by means of a conical pad — such as a piece of cork, covered with wadding or soft leather — which is made to occupy the space usually filled by the protrusion, and is retained in its place by strips of adhesive plaster ; the integument is closed over it in a fold ; and the whole may be secured by a large circular piece of soap- plaster spread on leather. This simple contrivance is more effectual than any truss or belt, being much less likely to slip ; and it has the equally important advantage of not acting as an excitant of protrusion elsewhere. Or the pad may be secured in its place by means of a belt of elastic material. In the course of a year or two — it may be of months only — the parts are found consolidated, and further use of the ■ compress is unnecessary. * For greater safety, it has been proposed to use a knife wholly blunt in the edge. This pressed upon the tight resisting fibres may dilate or tear them, while the elastic artery escapes all injury. 2 b2 372 THE OTHER VARIETIES OF HERNIA. In the adult, the case is not so easily managed. The tumour is larger and less repressible. A corresponding compress is necessary, secured either by a belt or by the spring of a truss. Its use is merely palliative. When strangulation occurs, relief is obtained in the ordi- nary way ; by taxis, or by operation. The external wound need not be of large dimensions ; most frequently, the hernial contents are found to have no coverings but the integument and the sac ; the deep incision for relief of constriction, made by a probe-pointed bistoury on the fore-finger, is placed in the mesial line, usually on the lower aspect of the swelling. The taxis is made directly backwards. The other varieties of Hernia. Ventral hernia is a protrusion at any part of the front and sides of the abdominal parietes, except the navel and groins ; the result of a giving way at some unusual point, in consequence of bruise, wound, abscess, or muscular rupture. There are no peculiarities in the tumour or its treatment ; excepting that, as in most cases of the last mentioned variety of hernia, but few fasciae need be expected to invest the sac. A Perineal hernia is said to exist, when bowel or omentum, with its sac, descends between the bladder and rectum, and presents itself as a swelling in the perineum. The term Vaginal is applied, when, in the female, the tumour does not reach the perineum, but bulges into the vagina. Descent has also taken place through rupture at the fundus of the uterus.* The Diaphragmatic or Phrenic (p. 345), and the Ischiatic forms of hernia — protrusions through the diaphragm and the ischiatic notch — are fortunately rare. They do not admit of accurate diagnosis in life ; and are not amenable to surgical treatment, if strangulated — unless the history of the case happen to be so unusually plain, as to warrant incision. t The Obturatorial Hernia — ^projecting through the foramen ovale — may be both discovered and relieved. In one case a painful elastic [tumour .^-^^^ over the foramen ovale was re- duced by the simple taxis, with complete relief to all the symp- toms of strangulated hernia. J The Hernia Litrica, as noticed by M. Littre, is said to exist when the protruded viscus is a diver- ticulum of bowel, not a portion The diverticulum may be con- * Lancet, No. 1276, p. 184. f Guthrie, Lancet, No. 1483, p. 114. X Monthly Journal, March 1847, p. 695. Fig. 127. Diverticulum of the intestine. Its protrusion constitutes the Hernia Litrica. Fig. 127. of the normal calibre of an intestine. HERNIA LITRICA. 373 genital; a mere prolongation of bowel, consisting of all the normal coats. Or it may be of recent occurrence, formed bv a protrusion of the mucous membrane of the intestine thi'ough its muscular coat, and consisting of the mucous and peritoneal coats alone. Both forms, the diverticulum acquisitum as well as the diverticulum congenitum, are liable to hernial protrusion ; the former found only at the crural aperture, and always of slow formation (Fig. 126). This form of diverticulum being made at the expense of the main bowel, the calibre of the latter is narrowed thereby ; and the traction caused by hernial descent also changes the line of direction in the bowel, forming a sharp angle at the origin of the diverticulum. Above the narrowed and somewhat obstructed part, dilatation takes place ; and a train of unpleasant symptoms result, independently of strangulation — costiveness, colicky pains, dyspepsia, flatulency, &c. The congenital fonn of diverticulum, on the other hand, may protrude without causing any such inconvenience. Stran- gulation occurring in either case is marked by the ordinary symptoms, follows the ordinary course, and requires the ordinary treatment. But, probably, the symptoms will partake more sparingly of the signs of obstruction, than in ordinary cases, at least in the first instance. * Littre, Memoires de I'Academie des Sciences, Paris, 1700. Pott, Chirurgical Works, by Earle, vol. ii. Lond. 1808. Scarpa on Hernia, by Wishart, Edin. 1814. Cloquet, Reserches Anatomiques sur les Hemies de I'Abdomen, Paris, 1817. Listen, Memoir on the Anatomy of Crm-al Hernia, Edin. 1819. Cooper, A., The Anatomy and Surgical Treatment of Abdominal Hernia, by C. A. Key, Lond. 1827. Key, C. A., on the Advan- tages and Practicability of Dividing the Stricture in Strangulated Hernia on the Outside of the Sac, Lond. 1833. Mayor, sur la Cure Radicale des Hernies, Paris, 1836. La-srrence, Treatise on Ruptures, Lond. 1838. O'Beirne on Defaecation; also, on Strangulated Hernia, Dub. Journal of Med. Science, Sept. 1, 1838. Bransby Cooper, Guy's Hospital Reports, Oct. 1840. Reid on Diaphragmatic Hernia, Edin. Med. and Surg. Journal, 1840. Malgaigne, Leoons CUniques sur les Hemies, &c. Paris, 1841. Thierry, des Diverses Methodes Operatoires pour la Cure Radicale des Hemies, Paris, 1841. Luke, Med. Chir. Trans, vol. xxvi. p. 159, Lond. 1843 ; also ibid. vol. xxxi. Teale, on Hernia, Lond. 1846. Gay, on Femoral Rupture, &c. Lond. 1848. Hancock, Observations on the Operation for Strangulated Hernia, Lond. 1850. Hewett, Med. Chir. Trans, vol. xxvii. Hilton, Med. Chir. Trans, vol. xxxi. p. 323. * See on this subject Brit, and Foreign Med. Rev. Oct. 1842, p. 360. 374 CHAPTER XXIX. AFFECTIONS OF THE EECTUM. Abscess Exterior to the Rectum. Abscess in the areolar tissue exterior to the rectum is almost always of an acute character, and most frequently affects adolescents, or young adults of a weakly system. There are two distinct varieties, according to the site. One is quite external in the nates, early pointing out- wards, attended with no great constitutional disturbance, not tending to burrow backwards on the bowel, and generally getting well under the simplest treatment. The other originates in a comparatively deep locality, by the side of the bowel, perhaps nearly two inches from the orifice. Pain, in the latter case, is great, and the constitutional disturbance severe; evacuation of the bowels is seriously impeded, and when attempted suffering is greatly increased ; at first no fluctu- ation is to be perceived, but hardness is felt on firm pressure with the finger by the side of the anus, and also when the finger is passed vsdthin the bowel ; throbbing pain continues, the hardness enlarges, and ultimately a softening may be detected in its centre ; matter forms rapidly and in quantity ; it may gradually and painfully reach the surface ; or, slow in its outward direction, the gut may give way by ulceration, and by this internal aperture the pus may be imperfectly discharged. In treatment, our main object is to procure early and outward escape ; attempts to prevent suppuration having previously failed. In the deep variety, the plunge of a bistoury, by the side of the bowel, so soon as softening has begun, is essential to prevent great constitu- tional disturbance and risk of the establishment of anal fistula. After evacuation, great attention to the general health will be required ; inasmuch as without considerable improvement in the tone of system it will be found difiicult to heal the wound, and equally difficult to prevent recurrence of the abscess. Not unfrequently a cachexy is met with, which bafiies aU remedial efforts — connected ^with phthisis of the lungs. In short, abscess exterior to the rectum is to be looked upon with suspicion, as regards both part and system — and treated accordingly. EECTITIS. 375 Rectiiis. The inflammatory process affects the rectum not unfrequently ; of idiopathic origin; or caused by external injury, lodgment of foreign matter, or exposure to cold ; or connected with an excited state of hemorrhoids ; or an extension of inflammatory action from a contigu- ous part. In acute cases, the symptoms are very severe. The part is somewhat swollen, and most exquisitely painful ; the sphincter acts spasmodically, and each movement of it aggravates pain to torture ; intense burning heat is complained of; a scalding discharge passes away ; or, in intense cases, the heat is at first dry as well as burning ; the constitution suffers severely, by fever. The urinary organs sym- pathize ; there is painful micturition, and not unfrequently strangury or even actual retention occurs. The progress and results vary. Resolution may take place, with copious mucous discharge — perhaps with, hemorrhage. Or the discharge is purulent, coming from the mucous coat ; and resolution is both slow and incomplete. Or ulce- ration may take place ; superficial and broad, limited to the mucous lining ; or circumscribed and perforating, causing an aperture into the areolar tissue without, where fresh abscess forms, and fistula results. Or, the action proving of a minor but persistent nature, plastic exuda- tion takes place in all the coats, but more especially beneath the mucous ; and simple organic stricture is established. Such being the risks of an advanced or obstinate inflammatory process in the rectum, treatment comes to be regarded as imj)ortant ; early and effectual, to anticipate evil. In the first instance, the cause is to be ascertained — and, if possible, removed; foreign bodies, for example, will be taken away, and ascarides expelled. The recumbent postm'e is enjoined, and blood taken away by leeching. No purga- tives are given — but gentle enemata, if necessary. To allay spasm, and to soothe the sympathetic irritation under which the urinary organs generally suffer, opium is useful ; in ordinary doses by the mouth ; and largely applied to the part, in the form of inunction, enema, or suppository. Fomentation can scarcely be applied too hot or too sedulously. Fistula in Ano. By this is understood a fistula, or sinus (Principles, pp. 224, 226) by the side of the rectum ; sometimes opening externally in the nates, but not communicating with the bowel, and then termed Blind External fistula ; more frequently communicating with the bowel, but not yet opening externally, then termed Blind Internal fistula ; usually having an apei'ture of discharge both externally and into the bowel, and then said to be Complete fistula. In the complete form — by far 376 FISTULA IN AXO. the most frequent — there is discharge of purulent matter by the fistu- lous track ; flatus also escapes, and faeculent matter. There is heat and much discomfort, often pain, increased by spasms of the sphincter ; not unfrequently aggravations take place by recurrence of inflamma- tory action ; and usually the general health is more or less undermined. Healing is prevented by at least three circumstances ; the fistulous condition of the cavity and aperture — obviously unfavourable to con- traction and consolidation ; the frequent, almost constant, passage of foreign matters along the ti'ack ; and fi-equent motion caused by the action of the levator and sphincter ani. The sinus may be mono- locular or multilocular ; that is, consisting of one simple track, or having more than one collateral sinus connected with the main and original one — the minor probably the result of intercurrent inflamma- tory attacks. The cavity may be "vvide within ; more frequently it is narrow — of the nature of true fistula ; it may extend high above the sphincter, more frequently its end is within two inches of it. The internal opening — to be found in the gi'eat majority of cases — is inva- riably within easy reach of the finger ; usually about an inch and a half from the orifice ; of various dimensions, sometimes so small as not to admit the end of a common probe, but seldom if ever so large as to allow the passing of a finger's point ; its size, circular form, and general character, denoting its origin to have been by perforating ulce- ration of the bowel. Such perforating ulceration is the proximate cause of complete fistula ; and it may come from without or from within. According to some authorities, the origin is always from Tvdthin ; rectitis produces perforation ; through the aperture, fseculent matter escapes into the areolar tissue without ; abscess forms there, which, only partially discharged by the internal and original opening, ultimately gains the surface, on the nates, and is thence mainly evacuated. That such is the state of matters in many cases, there seems no reason to doubt. But it cannot be denied that not a few may and do follow a different com'se. Abscess begins in the external areolar tissue, idiopathic, or caused by injiary, or following exposure to cold ; it slowly advances outwards, at the same time burrowing by the side of the bowel. The matter may escape externally, while the bowel's coats are yet intact; constituting blind external fistula. Much more frequently, there is the internal opening too ; of secondary formation, however, not pri- mary — caused by pressure from without, and beginning in the peri- toneal coat. And that this tunic is capable of taking the initiative in perforating ulcer, although less easily and more rarely than the mucous — even without so powerful an exciting cause as the pressure of an abscess — cases are not wanting to prove.* * London and Edinbiu-gh Monthly Journal, January 1844, p. 40. FISTULA IN AND. 377 Very frequently, fistula in ano is co-existent with pulmonary phthisis ; probably caused by it, and constituting but one of the symptoms and signs of that intractable malady. The frequent cough of the invalid, causing straining on the bowel, and the tendency to mucous ulceration in the great gut — so favourable to production of the initiatory perforation — readily explain how the anal and pulmo- nary affections should not unfrequently be in close connexion. The history of fistula is not complete till careful examination has been made, by means of the probe and finger. The latter having been introduced into the bowel, the probe — with a broad and bulky termi- nation to its handle, which renders it more obedient to the hand, and enables it to indicate with certainty the direction of the point when curved — is passed gently into the track, or tracks, so as to ascertain their number, position, and extent ; but most especially to ascertain the exact position of the internal aperture — that is, on what aspect of the bowel it has formed, for, as already stated, it is as to height almost always close to the sphincter. In order to facilitate the entrance and movements of the probe, it is sometimes necessary to dilate the external opening in the first instance. When there is no outward opening, the case being an example of the blind internal variety, there are usually plain enough indications of the site of the abscess — hardness, disco- loration, pointing, &c. ; and a plunge of a lancet or bistoury will at once change the case into the complete form. Or a probe, bent very much, may be introduced from the rectum into the internal opening ; and by pushing the handle on the opposite nates, its point may be made to project on the affected side, and being felt there may be cut upon. The treatment of fistula is simple — and, if the disease be merely local, usually quite effectual. The main obstacles to healing are the fistulous condition of the track, and the frequent motion by muscular action. By laying open the track, and at the same time dividing the sphincter, both are overcome. The patient is made to stoop over a bed or table, with the limbs unbent and somewhat apart ; if antesthesia be employed, he is recumbent with the legs raised. An assistant separates the nates to the full. The surgeon, seated, inserts the probe, taking especial care to lodge its extremity in the bowel through the ulcerated internal opening. The probe may be grooved, so as to admit of a curved, strong, probe-pointed bistoury being passed along it ; or, the probe having been withdi'awn, its place is occupied by the bistoury — used at first merely as a probe. The point is then met in the bowel by the fore-finger of the other hand — right or left, according to circumstances, for here ambidexterity is essential — and with the point pressing firmly on the finger, and with the edge moved in a gently sawing motion, both hands are brought down towards the operator, 378 FISTULA IN ANO. causing division of all that is within the concavity of the instrument. When this is of considerable thickness, or of almost cartilaginous density — as not unfrequently is the case — a particularly stout and well-tempered blade must be selected for the service, lest it give way. Fig. 128 It is unnecessary, however, to divide any great extent of parts, for the following reasons : — There is almost always an internal opening ; this is invariably situate almost immediately within the sphincter ; it is essential to make the line of division pass through this aperture ; but that having been done, there is in no case any necessity for passing the knife higher, however extensive the fistula may be. It is by no means uncommon to find the track passing higher than the internal opening ; yet in these cases the ordinary operation is all that is necessary ; the knife entering at the ulcerated opening, and no higher. One obvious advantage of this is, the avoidance of danger from loss of blood. A high wound might implicate arterial branches of considerable impor- tance. In the approved operation, only small branches will spring ; they are seen at the time of division, and can readily be secured by ligature, if need be — as, however, very seldom is the case. Should any superficial sinus exist — burrowing beneath the integuments — it should be laid freely open. In the external form, in progress of formation by abscess originating in the areolar tissue, it has been proposed to evacuate the abscess, and then at once to complete the operation for fistula ; hoping thus to save time and pain. It is better to evacuate, and delay ; permitting the abscess to contract, and to degenerate into the condition of fistula ; then operating for the cure of fistula. The wound is less painful and less extensive ; and the result is at least equally satisfactory. Similar caution is advisable in cases of old standing, in which abscess has repeatedly formed around the anus with burrowing ; it is well to evacuate and drain by opening and counter- opening, waiting till the suppurated space has contracted, and when much less extensive incision will consequently be required. Fig. 128. Plan of the operation of Fistula in ano, the finger and bistoiuy met in the i-ectum previously to division. FISTULA IN AND. 379 In the blind external form — that is, when we have searched care- fully for the internal opening, and found none — which -will seldom be the case — the bistoury, having been passed to the usual site of opening, has the edge of its point inclined towards the finger introduced within the bowel ; by a gentle rubbing motion perforation is effected ; and then the operation is completed in the usual way. The use of the anal speculum may assist in detecting the internal opening. And when this is found, the speculum may be retained as an auxiliary in the operation ; the parts yielding much more readily to the knife when put upon the stretch, as they are by lodgment of the open instrument. Immediately after withdrawing the knife, bleeding is attended to. If an artery spring, it is tied ; if there is oozing, at all formidable, pressure is applied by stuffing the wound moderately with lint. Usually, there is no necessity for any hemostatic ; and it is enough to interpose a small portion of lint, or other dressing, between the lips of the wound, so as to prevent premature closure of the superficial part ; our object plainly being, that the whole track shall inflame, granulate, and heal from the bottom. No cramming is necessary ; slight dressing is sufficient. Before operation, the bowels have been well cleared out by a purgative, aided by an enema if necessary. After the operation, a fuU opiate is given ; to lull the pain, and at the same time to prevent movement of the bowels — this not being contemplated for a day or two. At the end of the third or fourth day, a dose of castor oil, or other simple and bland aperient, is given ; and this, operating, brings away the contents of the rectum, including the dressing of the wound. Afterwards, it is enough to regulate the bowels ; to make sure, by examination from time to time, that the wound is not closing prema- turely, and that superficial sinuses are not forming ; to attend to cleanliness ; to apply water-dressing, by means of lint and oiled silk — retaining the dressing by a T bandage ; afterwards medicating this dressing by ordinary stimulants, as the state of the granulating sur- face may require. For obvious reasons, a close regard is paid to the system, throughout. If fistula in ano co-exist with e\ddent and advanced pulmonary phthisis, a question arises as to the propriety of operation. It may safely be answered in the negative. For, fii-st, the operation will fail in its local effect ; the wound, in all probability, will not heal. And secondly, supposing that it did heal, the result would probably be most injurious on the system ; the pulmonary disease advancing with fresh virulence, on the closing up of an outlet whence purulent and other products had long been habitually discharged ; in like manner as the temporarily and locally successful amputation of a strumous joint, may 380 FISSUEE OF THE ANUS. have the effect of greatly shortening the phthisical patient's term of existence (Principles, p. 522). Fissure and Ulcer of the Anus. m Fissures of the anus are extremely troublesome. They are most common in the adult ; but no age is exemjDt ; they have been observed in children at the breast. A chap or crack, analogous to what is observed on the lip, forms on the verge of the anus, in the mucous coat of the bowel ; and is the seat of much pain, often of intense agony, more especially when the bowels are moved ; then, too, spasm of the sphincter adds greatly to discomfort. Sometimes, indeed, the muscle is found to be in a state of almost perpetual spasm ; simulating most of the signs of stricture of the bowel ; and the existence of the fissure may be obscured, in consequence of the obstacle which such spasm affords to ocular examination. In looking for fissure, the nates are forcibly separated by an assistant, and downward traction is made upon the anus with the fingers of the surgeon, the patient meanwhile straining steadily as if at stool. Sometimes the assistance of a specu- lum may even be required. Almost invariably, this affection is found connected with previous disorder of the primes viee — perhaps a long continued dyspepsia. And, in treatment, this circumstance has an important bearing. For, no local management can be expected to prove fully successful, unless the cause be taken away ; that is, in most cases, the noxious matter lodg- ing in the bowels must be removed, and the functions of the mucous lining must also be amended. In such cases, a cautious dose of calo- mel will probably be found the most suitable prescription at first ; followed up, according to circumstances, by gentle aperients and altera- tives. The part may be touched freely with nitrate of silver, or with the fluid nitrate of mercury ; and relief of pain may be obtained by belladonna-ointment, or by chloroform made into the form of ointment, or by hot poultices medicated strongly with opium in solution. Very frequently, however, such local ti'eatment is resisted ; and then a simple and slight operation is required. By means of the fore-finger and a probe-pointed bistoury an incision is made through the mucous coat, including the fissure. And thus the irritable sore is at once converted into a simple wound, which first inflames, and then heals in the usual manner. But should this fail — as will not often be the case — the knife has again to be used ; pressing it more deeply, the sphincter ani is divided ; and the part, thus set at rest, quickly heals. Or by subcu- taneous puncture from without, the muscle may be divided, without interfering with the mucous membrane. To recapitulate ; in all cases, great and primary care of the stomach and bowels is necessary ; with HEMORRHOIDS. 381 this, some fissures heal under ordinary local treatment suitable to irrit- able sores ; others require simple incision ; and others, more obstinate, demand in addition division of the sphincter. Ulcers of the mucous membrane of the anus are liable to assume the irritable character, and then ar« productive of the same distressful symptoms as fissure. They require, and are subject to, similar treat- ment. Situated more internally, they are not ordinarily visible, even on the most careful examination. The finger, cautiously introduced, may detect them, by the peculiar feel which the ulcerated part conveys to the examiner, and by the great increase to the patient's suffering which is invariably produced by the finger's resting upon that part of the bowel. By means of the speculum their exact circumstances may be accurately surveyed. In those cases wliich evince no gi'eat irri- tability, tannin is often a most serviceable local application, in the form of ointment or suppository. Immediately in fi'ont of the coccyx — that is, at the back part of the anus — a broad and deep ulcer, capable of receiving the finger's point, is not unfrequently observed. For this, exposure by the speculum and the application of nitric acid, or nitrate of mercury, are usually neces- sary. Hemorrhoids. Hemorrhoids, or Piles, are divided into two kinds ; external and internal. They seldom occur before puberty, and are perhaps more common in females than in males ; certainly more troublesome to the higher than to the lower ranks of life. The predisposing causes are whatever tends to determine blood to the rectum, and to retard the return of blood from it ; habitual constipation, pregnancy, abdominal tumours of any kind, torpor of the liver, sedentary avocations with luxurious living. And the exciting causes are whatever acts on the bowel itself excitingly, as purging, bilious diarrhoea, exposure to cold and wet, &c. External piles are of but one structure ; a congeries of varicose veins, surrounded by hypertrophied areolar tissue, and covered partly by mucous membrane, partly by loose rugous integument. They may be undergoing the inflammatory process, or they may be indolent and quiet. At one or more points, ulceration may have exposed their inte- rior, and they bleed ; or they may be blind, as the phrase is — emitting no blood. The varicose veins may have their normal fluid contents ; or these, coagulated, may have caused condensation of the tumour, more or less complete. The tumour may be single ; usually more than one exists. Treatment is either palliative or radical. The latter consists in removing the morbid formation, by scissors or bistoury ; leaving the 382 HEMOREHOIDS. sore which remains to heal in the ordinary way. Palliation varies according to circumstances. If the part be inflaming, rest and the ordinary antiphlogistics are necessary. If it be in the indolent state, stimulants and astringents — iodine, galls, tannin, hellebore — are ap- plied, with the view of puckerin|> up the loose integument, obtaining discussion of the solid abnormal textures, and restoring the normal condition of the veins. The bowels are carefully regulated ; and, for this purpose, sulphur is the favourite medicine — usually combined, in the form of electuary, with pepper confection ; and sometimes, too, a proportion of copaiba is a good addition ; dosed so as to avoid over- action, while it insures a daily and sufficient passage of a semifluid stool. By some, linseed oil taken internally, is preferred as a soothing and safe laxative.* If any dyspeptic, or other disorder of the primse vise exist, that must be removed as speedily and thoroughly as possible. Very often the liver is to blame, and requires special treatment. Not unfrequently, a small, recent, tense pile presents itself, acutely inflamed, and exquisitely painful. A simple proceeding not only affords present relief, but also may effect radical cure. With a lancet or bistoury it is to be laid freely open, throughout its entire extent ; the coagulated blood rolls out, a salutary loss of fluid blood takes place, and in subsequent healing of the wound consolidation is effected. Internal piles are of different kinds. — 1. They may be of similar structure with the external ; varicose veins, surrounded by hyper- trophied areolar tissue, and covered by mucous membrane more or less altered ; open, or blind ; inflaming, or indolent. 2. They may be genuine tumours, of the nature of simple sarcoma ; more or less pen- dulous in their form. 3. They more frequently are of the nature of erectile tissue ; this abnormal development having taken place in the submucous areolar tissue, as well as in the membrane itself. The tumour usually presents a broad base of attachment ; and sometimes the surface resembles that of the strawberry. Internal piles are most commonly of the last variety. If large and numerous, they may constantly protrude more or less from the anus ; general relaxation of the mucous membrane of the rectum admitting of this. More frequently, they do not show themselves externally, ex- cept when the bowels are moved ; and then the straining causes them to descend. If not replaced, they may become constricted by the sphincter, and inflame. At each stool, it is common for blood to be lost ; small arterial jets taking place from one or more points of the tumour — more especially if constricted. Usually, the patient gets into the habit of replacing the prolapsed tumours, after each evacuation ; and, during the intervals, he may sustain no great inconvenience in the part. If the loss of blood, however, be habitual — even though * Brit, and For. RevT Oct. 18.50, p. .553. HEMORRHOIDS. 383 but a small quantity escape at each time — the system is certain to give way under it ; the patient becoming thin, weak, pale or sallow, dyspeptic, annoyed with tinnitus aurium, giddiness, and palpitations (Principles, p. 371). If the tumours are bulky, and often protruded, they are always in a more or less excited state ; there are pain, swel- ling, heat, and discomfort, discharge of mucous and puriform fluid ; and these, superadded to the effects of loss of blood, speedily under- mine the frame. In extreme cases, the whole bowel is relaxed ; and prolapsus ani accompanies and untowardly complicates the hemor- rhoidal state. At any time, the inflammatory process may extend from the abnormal structure, and seize the bowel — producing rectitis, probably of an aggravated form. Thence abscess and fistula may result ; or, under a minor degree of action, simple organic stricture may form. The urinary organs sympathize greatly, during rectal excitement connected with piles — whether these be external or in- ternal. To allow such an affection to follow its own course, is thus seen to be dangerous to both part and system. Treatment is general and local, palliative and radical. The general treatment is to be pursued in all cases ; regulating the bowels, looking to the liver, attending to regimen. Hemorrhage may be restrained by the internal exhibition of gallic acid, oil of turpentine, or other suitable astringent. If pal- liation only be intended, the local treatment will consist of careful reduction, after each evacuation of the bowel, and the occasional in- jection of some astringent fluid ; such as solutions of rhatany, zinc, sulphate of iron, matico, oak-bark, or tannin ; or the last named remedy may be very conveniently and efficiently applied in the form of suppository. If excitement occur, then come antiphlogistics, anodynes, and attention to the bladder. The radical treatment consists of re- moval by ligature. In the case of the solid genuine tumour, the knife may be used with impunity. But such formations constitute a small minority of internal piles. The overwhelming majority are vascular ; and the greater number of these consist of erectile tissue. To cut them out, were on each occasion to endanger life by hemorrhage ; not only because the parts are vascular in themselves ; but also because the interior of the rectum is favourable for continued oozing of blood, and ill adapted for the application of pressure or other direct hemo- statics. Consequently, deligation is preferred. The operation by ligature is thus accomplished. The patient having had the bowels freely opened, is placed as for the treatment of fistula. By previous straining at stool — renewed at the time of opera- tion, if necessary — the tumours are made to protrude to the full ; an assistant separating the nates. If the form be at all pendulous, it is well to seize the fundus by means of a large volsella, and over this to 384 HEMOEEHOIDS. apply a strong ligature, drawn very tightly around the neck of attach- ment. But if the base be broad, and the form of the swelling irregu- lar, it is necessary to transfix the base by means of a stout needle ; and, by tying separately the halves of the ligature, so to effect strangu- lation. Before tightening the second half of the knot, it is advisable to incise the livid fundus, permitting its fluid contents to escape ; for then the noose can be tightened more thoroughly ; and the tighter the constriction, the more rapid and less painful is the cure (Principles, p. 274 and 599). Deligation having been completed, the ends of the ligature are cut off close to each noose ; and, by gentle manipulation, the strangled parts are replaced within the sphincter. If an external hemorrhoid, or loose fold of skin be found, it is removed by the sweep of a knife or scissors ; and if an arterial twig of any importance spring, it is at once secured by ligature.* A full dose of morphia is given, to lull pain and prevent motion of the bowels. The bladder is watched ; and if strangury or threatened retention occur, warm fomentation is to be sedulously applied to the hypogastrium, along with the internal administration of henbane and sweet spirits of nitre, in small and repeated doses. By medicated poulticing, the pain in the anus may be somewhat assuaged. In a day or two, the sphacelated parts separate ; and the remaining sore is treated as its circumstances may demand. Foetor is subdued by the chlorides. After cicatrization nightly use of the tannin suppository is sometimes advisable, to promote and in- sure complete restoration of the normal calibre and tone of the bowel. As formerly stated (Principles, p. 786), anaesthesia may be used, without detriment to the facility or efficiency of the operation. And a subsequent minor use of chloroform is often of much service in assuaging the after pain. In the slighter cases, nitric acid has of late been employed with advantage; when the tumours are small, recent, and composed of altered mucous membrane — investing slightly varicose veins, or perhaps only hypertrophied areolar tissue — the disease being mainly resident in the membrane itself. The parts, having been made to protrude, are rubbed over with strong nitric acid, so as to produce an eschar ; and are then replaced within the sphincter, as in the case of deligation — carbonate of soda being freely applied so as to prevent unnecessary action of the escharotic. The eschar separates, removing the altered membrane ; the sthenic suppurative action, which attends on cicatrization, would seem to * This removal of loose skin is of great consequence, and should never be omitted ; otherwise the anus remains lax, and predisposes to further hemorrhoidal formation. Usually there is a packet of rugous skin connected with each internal hemorrhoid ; and the one is a very useful index of the other. Some surgeons think it sufficient to take away this outer defect, believing that the tight cicatrix will prevent reprotrusion, and that then the hemorrhoidally degenerated part will recover itself. But according to my experience, removal of both piles and skin is essential to a complete and permanent cure. POLYPUS OF THE EECTUM. 385 act restoratively on the textures around ; and the tightness of the cica- trix, when completed, may by its support prevent recurrence of varix beneath. By the potassa fusa, too, hemorrhoids may be \erj efficiently destroyed ; the neighbouring parts being carefully protected by use of vinegar. Patients of greatly deranged livers are subject to general fulness in the lining membrane of the rectum, perhaps with one or more internal hemorrhoids, accompanied by a febrile state of system. In such cases, we are not to operate in any way, until the liver has been restored to a healthy or at least quiet state, and the general excitement has been calmed — otherwise the result might be serious, by aggravation of the internal and constitutional disorder. In elderly, full-living patients, also, affected with disease of the heart, or showing a tendency to affection of the head, bleeding piles are not to be rashly interfered with ; else the sudden cessation of dis- charge, and subsequent plethora, may entail the most calamitous results. The operation, if had recourse to at all, is not performed till after due preparation of the system. And the after treatment is conducted with much care and caution. Similar precaution is requisite in the case of females, from whom blood escapes in large quantity and periodically, because vicarious. Such bleeding, however, is not always connected with piles. It may proceed from the lining membrane of the bowel, little if at all changed. In advanced cases of bleeding piles, it is sometimes difficult to determine whether the bruit, palpitation, and other signs of diseased heart are primary or secondary, dependent on an organic cause, or merely on anaemia. Diagnosis, in this respect, requires much caution ; and when in doubt, we may lean to the side of operation, ready with leeches, seton, or other compensating treatment, should troublesome consequences threaten. Polypus of the Rectum. Simple polypi are occasionally, yet seldom, found in the rectum ; most commonly in children ; and then may be mistaken for prolapsus. In the adult, the fundus may become hard, rough, and ulcerated, and prove troublesome by bleeding. There is frequent desire to go to stool, with discharge, uneasiness, and occasionally pain and swelling. At each evacuation, the growth is apt to be protruded, and usually requires replacement. Treatment is removal, by knife or ligature. Obviously, the preferable method is by deligation ; but, after the ligature has been secured on the neck of attachment, the main body may be safely cut away, in order to prevent tension and expedite the cure, 2c 386 PROLAPSUS ANI. Prolapsixs Ani. In consequence of relaxation, the rectum may become everted, on straining, and protrude beyond the anus ; and the protrusion may be either constant or occasional. Also, it may be either partial or complete ; that is, the protrusion may consist of the entire bowel — or, as is by some supposed, of rather the sigmoid flexure of the colon ; or it may be merely a descent of the mucous coat alone — a frequent concomitant, as has already been observed, of internal hemorrhoids. This partial prolapsus may occur at any age ; and is probably most common in the middle-aged ; but the complete form is an affection rig. 129. almost peculiar to the two extremes of life ; old age and childhood. The child is liable to irritation of the bowel, by ascarides, or by a perverted secretion from the general mucous coat ; and the habitual straining, which results, tends to the change in question. In the old man too, there is much straining ; by reason of enlarged prostrate, or debility of the muscular coat of the bladder. In the child there is much crying ; in the old man much coughing. Stone and stricture may induce prolapsus at any age. The tumour varies in size, from a mere annular border to the anus — as in the partial prolapsus — to a swelling as large as a child's head. The membrane, if habitually down and exposed, changes more and more to the cuticular character ; much discharge takes place, of a reddish jelly-looking substance ; inflammatory aggravations are liable to occur, causing much increase of distress ; and, at any time, the existence of descent is accompanied with painful uneasiness in the Fig. 129. Prolapsus Ani. PEOLAPSUS ANI. 387 part, and an oppressive general languor and debility — at least in the adult. In the child, the affection may generally be removed by riddance of its cause. At the same time, care is taken to replace the protrusion after each descent; the bowels are duly regulated, and evacuation should always be made in the recumbent posture ; crying should be avoided as much as possible ; astringents may be used both outwardly and within — that is, in the form of lotion, ointment, injection, or sup- pository ; and iron or other tonics are usually indicated, on account of laxity of the general system. If protrusion have been neglected, and have attained a large size, some difficulty may be experienced in effecting replacement. Pressure is applied, as in the taxis for hernia ; the parts having been previously lubricated. And it is well to make the reducing pressure chiefly during the straining or crying efforts of the patient, the verge of the anus then presenting a fixed point on which the reduction may be made. If the protruded part be found constricted, inflaming, and swollen, it is better not at once to attempt reduction ; but, in the first instance, to diminish the bulk and inordinate action, by leeching, rest, and ordinary antiphlogistic means. In the adult, there is the same necessity for removal of the cause, if possible ; but cure seldom follows so simply. The same attention to replacement is to be enforced ; and a pad may be worn, directly compressing the anus, so as to oppose reprotrusion. This pad — slightly conical in form, so as to fit into the anus — may be applied by means of the common T bandage ; or, what is better, is adapted to a spring, as in the truss for hernia. Astringents are used, the bowels are regu- lated ; and amendment, if not cure, is hoped for. It may be well, perhaps, to procure the daily stool at night ; so that afterwards the long recumbency of bed-time may prove favourable, in obviating the tendency to protrusion which is greatest after functional excitement of the part. Such is the palliative treatment. For a radical cure, other measures are required. One or more of the redundant folds of the mucous membrane may be removed, by knife or ligature ; in the hope that the contraction of healing may sustain the replaced parts in their normal relation. But it is better in most cases, while leaving the bowel intact, to take away the redundant integument externally ; hoping that the subsequently puckered cicatrix may effectually support the parts within, and prevent further protrusion. This removal of skin may be by knife or scissors, or by actual cautery. The latter agent is perhaps unnecessarily severe ; but, whichever is employed, the immediate pain may be safely abrogated by the use of chloroform. These means failing, another operation has been proposed ; an abbre- 2 c 2 388 STEICTURE OF THE RECTUM. viation of the sphincter. By incision, a portion of this muscle is removed ; and then the remainder, having been brought together, and got to adhere, is expected to constitute a more active and effectual guardian of the mucous outlet. The success of this proceeding, how- ever, has yet to be proved. And, in any such operation, especial care must be taken lest the task be overdone ; and an unnatural tightness of the orifice result. In the adult, accurate diagnosis is always important. Many a patient, during a long course of years, wears a painful truss for what is supposed to be prolapsus, but what is in truth mere looseness of the anal verge, with internal hemorrhoids — remediable, as we have seen, by a very simple operation. Stricture of the Rectum. Contractions here, as in other mucous canals, are of three kinds ; spasmodic ; organic and simple ; malignant. The Spasmodic does not frequently constitute a disease of itself; but is rather an accompani- ment of some other affection — as hemorrhoids, fissure, or ulcer of the anus. Its main symptoms are, painful tightness of the part, with difficulty and pain in voiding the fgeces. The site of constriction is at the orifice of the bowel ; and the immediate cause is spasmodic action of the sphincter muscle. If it be but an attendant of another disease, removal of the latter will ordinarily suffice for cure. In the few cases of its single occurrence, treatment consists in rectifying the primee vi«, which will invariably be found more or less deranged ; and in the occasional use of a short bougie, of metal or caoutchouc, passed just within the sphincter, and retained for a few minutes on each occasion. An obstinate case may render division of the sphincter expedient ; and in such circumstances the subcutaneous operation will probably be preferred. Belladonna may be used, in the form of ointment'. Simple organic stricture is the result of a chronic Eectitis, as already stated. The constriction depends partly on condensation and thicken- ing of the entire coats of the bowel ; but mainly on deposit in the submucous areolar tissue. The ordinary site is about two inches from the orifice ; and it is seldom indeed that this form of stricture is found beyond reach of the finger. The leading symptom is difficulty in defsecation, with slimy discharge ; the faeces passing in a flattened and attenuated form, like tape, when solid, and when fluid being liable to forcible ejection as if from a syringe. Derangement of the digestive organs, with impairment of the general health, is induced ; the abdo- men becomes swollen, perhaps tympanitic ; and the urinary organs are sympathetically involved. Above the stricture, dilatation takes place ; and there ulceration is apt to occur in the mucous membrane ; STEICTUEE OP THE RECTUM. 389 greatly aggravating the distressful symptoms, perhaps inducing fistula — and, in the aged, not unlikely to degenerate into malignancy. From the obstructed state of the bowels, enteritic symptoms are not unlikely to arise ; but, independently of sudden or casual aggravations, life is ultimately endangered by advancing emaciation and general disorder. Treatment consists in maintaining a gently open state of the bowels, Fig. 130. mitigating the painful symptoms in the part and neighbourhood by suitable remedies, and gradually obtaining dilatation of the bowel at the contracted part, by a cautious use of bougies ; not failing to remember that the cure is not by mechanical dilatation, nor by inflam- mation, but by gradual absorption of the submucous abnormal deposit. The best form of this instrument is that made of elastic material, pliable, smooth, yet dense enough to resist circular compression. Having been introduced gently, it is retained so long as the feelings of the patient permit ; and it is well that the lower part of the instrument should always be narrow, so as not to distend the sphincter and cause irrita- tion. Or the bougie may be so formed as to lodge wholly within the bowel ; an attached ligature or tape protruding, whereby it may be extracted. The portion of the instrument which is intended to pass and lodge in the stricture is gradually increased in size, until a full- sized bougie can be used without difficulty. Then dilatation may be deemed complete ; yet, to insure against relapse, an instrument should be passed occasionally for some time afterwards. Sometimes a tight callous stricture is found to resist the ordinary treatment. Then the knife's edge may be used with advantage ; the surgeon slightly notching the contracted ring at many points, by means of a probe-pointed bistoury introduced on the finger ; and afterwards proceeding with dilatation, in the ordinary way. Fig. 130. Rectum opened laterally; shewing stricture of the bowel at the ordinary site. 390 lEEITABLE RECTUM. Spasm of the anus may simulate organic stricture ; and many of its symptoms also attend on enlargement of the prostate. Conse- quently, an accux'ate diagnosis can never be attained without careful examination. By the frequent and forcible dejection of fluids, diar- rhoea may be simulated ; and a very erroneous treatment, by astrin- gents, might be enforced, were examination of the part neglected. In most cases, the stricture is within reach of the finger ; and in such, there is no difficulty ; the finger's exploration removing all doubt. Sometimes, however, the contraction is higher in the bowel. And then great caution is necessary in employing the exploratory bougie ; for a fold of mucous membrane, or the natural promontory of the sacrum, in a healthy bowel, may obstruct the point of the instrument for a time, more especially if this be rashly and unskilfully introduced. By disreputable empirics, indeed, such obstruction is made use of as a means of deceiving healthy patients into a belief of the existence of stricture. Malignant stricture, or Scirrho-contracted rectum, is by no means uncommon in the aged — and more especially in the female ; super- vening, usually, on some pre-existing affection of a simple kind ; as piles, or simple stricture. The symptoms are such as attend ordinary contraction, with the addition of copious, bloody, foetid, puriform dis- charge ; greater sympathy of the urinary organs ; greater difficulty and pain in defaecation ; and the ordinary constitutional cachexy which attends and characterizes malignant disease. When the verge of the anus only is affected, the diseased parts may be removed by the knife. But if the disease extend some way up the bowel, as it usually does, we must content ourselves with palliation ; assisting defaecation by enemata and laxatives ; and lulling pain by opiates, applied to both part and system. Death may take place by exhaustion. But more frequently the patient perishes under symptoms of ileus, the malignant deposit having advanced so as to cause complete occlusion of the bowel. Under such circumstances, the only hope of postponing death is by the formation of an artificial opening in the abdomen, for fgeculent evacuation ; a very doubtful proceeding — as will afterwards be stated. Medullary tumour sometimes forms between the bladder and rectum ; causing great distress ; interfering first with the functions of the rectum, and then with those of the bladder also. The treatment can only be palliative. Irritable Rectum. The lower bowel is liable to become the seat of Irritation, uncon- nected with any structural change ; causing pain, heat, itching, fre- quent desire to go to stool, spasm of the sphincter, and sympathy of the urinary organs. The soui'ce of irritation may be within the bowel HEMORRHAGE FROM THE RECTUM. 391 itself; ascarides. Or it may be contiguous ; stricture in the urethra, or stone in the bladder. Or it may be remote, yet continuous ; a depraved state of the mucous membrane of the stomach or upper bowels. Treatment is obviously to be begun by removal of the cause, if possible. Afterwards, opium, hydrocyanic acid, or other calmatives, may be applied directly to the part, by means of injection, suppository, or inunction. Itching of the Anus, an obstinate and distressing complaint — an irritation exterior to the bowel — is often the source of intense suffering to the patient. Generally, it is connected with a depraved state of the mucous membrane of the bowel ; and removal of this, by the suitable alteratives — as tar, copaiba, arsenic, &c. — may suffice for cure. Some- times it attends on piles or fissure ; and is removed along these ail- ments. Sometimes it is connected with a thickened and chapped state of the skin external to the anus ; and in these cases, as well as in those where no local cause is apparent, applications to the part are essential. Of these the most successful are hydrocyanic acid, tobacco infusion, and camphor powder. The last may be used alone, or in combination with starch, and preceded by the application of a calomel ointment, 5i — 5ii to the ounce. Hemorrhage from the Rectum. Bleeding from the lower bowel is usually an indication of piles, as has been seen ; of the internal, vascular pile, more especially ; and is almost always arterial. In females, however, it not unfrequently is found independent of prominent alteration in the bowel ; oozing from the lining membrane, merely congested ; and then usually pei'iodic and vicarious. Or it is frequent and exhausting, proceeding from a small vascular eminence on some part of the membrane, discernible only by the use of the speculum. The treatment is obvious ; according to the cause. Hemorrhoids are to be tied. The uterine function is to be restored, and the general frame amended. The vascular point is to be cauterised ; and astringents are at the same time given in- ternally — the best, perhaps, gallic acid. The tannin suppository may be used locally. In some way, the drain must be arrested (Principles, p. 371). Injuries of the Rectum. The anus is liable to wound and bruise, as other parts. The former may be formidable by hemorrhage ; the latter by inflammatory action, leading to deep-seated abscess. Treatment is accordingly. A dangerous form of injury used to occur in hospitals, when the old- fashioned metallic syringe for giving enemata was recklessly used 392 FOREIGN MATTER IN THE RECTUM. by ill-qualified administrators. The instrument's point, pushed rudely upwards, in a straight direction, is likely to lacerate the bowel. It may perforate ; and then the injection, perhaps stimulant and acrid, finds its way into the areolar tissue, causing extensive abscess, and sloughing, with violent constitutional disturbance. In such cases, the remedy is to make a free and early incision into the infiltrated parts. But the modern enema-syringe, intrusted only to trustworthy hands, is not likely to lead to any such casualty. Fceces and Foreign Bodies in the Rectum. In the elderly of both sexes, but especially in the female, with whom irregularity of the bowels is more habitual, the fseces may ac- cumulate mthin the sphincter, forming a tumour of large size, and occupying not only the whole rectum but also a portion of the sigmoid flexure. The symptoms are most distressing ; painful fulness in the part, bearing down, frequent desire to go to stool, thin and scanty fluid passed, the bladder irritable, sleep disturbed, the stomach dis- ordered, and more or less fever induced. "Without examination, the aflTection may be mistaken for diarrhoea or dysentery ; with an in- sufficient examination, the internal swelling may be supposed to be a malignant tumour. In cases of doubt, the finger's nail wall bring away a sufficiency to test the nature of the concretion. In the milder cases, repeated injections of oil, followed by cathartic enemata, may suffice to clear the bowel. In the more confirmed examples, it is necessary to introduce the finger or fingers, with a lithotomy scoop, so as to break down the mass ; afterwards clearing aU away by in- jection. And two or more such operations may be necessary, at dif- ferent times ; as the higher accumulations may descend, only after removal of those which occupied the lower bowel. Afterwards it is obviously of much importance to secure regular movement of the bowels ; with a view to avoid re-accumulation. Foreign substances may lodge in the lower bowel ; causing in- flammation, abscess, and ulceration there, if not removed timeously. They may be pushed upwards from without, by accident, or by ma- licious design. Or they may be arrested by the sphincter in their progress downwards, having entered by the mouth ; as fish bones, bones of poultry or other small animals, kernels of fruit, &c. Or they may have formed within the alimentary canal ; intestinal concretions. The smaller substances are readily removed by finger and forceps. Large bodies requii'e previous dilatation and lubrication of the bowel ; and an exploratory use of the speculum may be useful. In extreme cases of impaction, it may be necessary to divide the sphincter. In the case of rough or sharp substances, whose forcible extraction in the IMPEEFOEATE ANUS. 393 ordinary way might seriously injure the bowel, a speculum is first carefully introduced past the foreign body, so as to sheathe and pro- tect the mucous membrane. Imperforate Anus. Children are occasionally born with the anus closed. There are three kinds of this malformation. 1. The rectum may be fully de- veloped, and have its orifice shut by integumentary membrane only ; or the canal may be obstructed by a membranous septum, at some distance from the orifice — which latter may appear in all respects normal. 2. Or the bowel is imperfect ; ending in a blind cul-de-sac, at some distance from the integument of the perineum, in which there is a mere depression or vestige marking where the anus ought to be. 3. Or the rectum is almost or altogether deficient ; the sigmoid flexure of the colon terminating in a cul-de-sac, at the upper part of the pelvis. The first form is easily managed. An incision is made through the occluding membrane ; and for some days a piece of dressing is interposed, to prevent union. But often this precaution will be un- necessary ; the passage of meconium and feeces sufficing to keep the aperture patent. The second variety is more common, and more troublesome. Some thickness of parts intervenes between the operator and the bowel. And at first the latter may be felt but obscurely, if at all ; there being none of the bulging fluctuation which must soon be apparent in the former case. Under such circumstances, we wait until the meconium accumulates, and till the bowel in consequence descends and is distended. It may then aiFord some indication of its presence to the finger from without. To assist, let firm pressure be made in the left hypogastric region ; and such pressure should also be maintained, during the operation for relief. The cries of the child are of service. He is placed on the knee of a nurse or assistant, in a position as if for lithotomy. By means of a scalpel, an incision is made through the integument ; and, by cautious dissection, the bulg- ing cid-de-sac is sought for ; the finger always preceding the point of the knife ; the line of exploration following the natural curve of the bowel, in the hollow of the sacrum, lest the bladder or vagina should be wounded — not keeping too close upon the bone, lest the bowel be overpassed and be mistaken for the bladder — and not diverging to either side, lest the pelvic blood-vessels sustain injury. The cul-de-sac having been reached, is opened freely ; the meconium escapes ; and the wound is to be kept pervious by the careful and patient use of tents — or, what is perhaps better, by the constant wearing, for some time, of a tube such as is used after lithotomy. 394 FORMATION OF AN ARTIFICIAL ANUS. After even deep dissection, we may fail to meet the end of the bowel. Then it is quite warrantable, to pass a trocar and canula upwards, cautiously, in the direction in which the bowel ought to be ; and on withdrawing the trocar, we may have the satisfaction of seeing meconium follow. Sometimes the deficient rectum opens into the vagina or bladder ; constituting a cloaca ; irremediable. Of the existence of the third variety we are made aware, when, after waiting for days, not even the slightest indication of bulging or fulness can be detected in the perineum. A perineal wound and ex- ploration may be made ; but with scarcely a hope of success. And, failing in this, we have either to abandon the patient to its fate, or proceed to the establishment of an artificial anus. The Formation of an Artificial Anus. The question of artificially establishing an outlet for the contents of the intestinal canal, elsewhere than in the normal site, comes to be entertained, when the rectum is congenitally deficient, and also when it has become in any way insuperably obstructed, by simple stricture, or by carcinomatous and extensive degeneration, or by the impaction of an intestinal concretion or of some foreign substance from without. In the case of the child, probably the operation wiU seldom be deemed expedient; for when such a grave malformation exists — as entii'e deficiency of the boAvel — others usually accompany it, rendering the viability of the patient under any circumstances very questionable. It were better to leave such to perish, by the original obstruction of the bowels, than to force on them a more miserable and scarcely less brief period of existence. In the case of malignant disease of the rec- tum, also, practitioners may well hesitate, before having recourse to a difficult and serious operation, for the purpose of attempting but par- tial and temporary relief, in an affection which must at no distant period end fatally. In such a case, it would seem to be warrantable only under the following circumstances ; when the general strength is not yet greatly exhausted by malignant cachexy ; when the obstruc- tion in the bowel is complete, and plainly insuperable by any dkect treatment; when the patient — having had the danger of the operation, and the almost disgusting result of its success, plainly exhibited — himself decides on its performance, and is prepared to abide both the nuisance and the risk. On the other hand, when the rectum is imper- viously obstructed by the impaction of foreign matter from within or from without, or by disease not malignant nor necessarily and speedily fatal, and when such obstruction is otherwise insuperable — the expe- diency of the operation may be safely urged upon the patient. FOEMATION OF AN ARTIFICIAL ANUS. 395 The sigmoid flexure of the colon is plainly the part of the intestinal canal to be reached ; and it may be sought, either from before, or from behind. The former method, first proposed by M. Littre, is of easy performance ; being merely a direct incision upon the part through the abdominal parietes and peritoneum, above the left groin. The opera- tion, however, though most simple, is hazardous to life ; and, if suc- cessful, the anus is inconveniently situated, in one respect, the patient being the victim of discomfort to himself as w^ell as the source of annoyance to those around him. The site has its advantages, how- ever, too. The operation is easy, and its steps certain ; the anus, after a time, gets to possess something of a sphinctral power, from the mus- cular parietes ; and the offensive escape of its contents may be guarded against by wearing a well-fitted truss, the manipulation of which is easily within reach of the patient. The posterior operation, proposed by Callisen, and greatly improved by Amussat, is performed thus : — its object being to open the bowel on its posterior part, where it is uncovered by peritoneum, and which bare space may be expected to be considerable when the bowel is much distended by its contents. The patient is laid recumbent, with the trunk bent somewhat to the right side ; and with a pillow also placed beneath the abdomen, so as to make the left loin prominent. A transverse incision is made — about four inches long in the adult — midway between the last false rib and the crest of the ilium ; and if any considerable obesity exist, the posterior part of the wound is crossed by a second incision, parallel to the range of the spinous pro- cesses. The difierent layers of fat, fascia, and muscle, are carefully divided in succession, on the outside of the border of the sacro-lum- balis and longissimus dorsi ; and portions of fat, coming much in the way, may require to be removed altogether. Intestine having been exposed, some doubt may be felt as to its being the colon or not ; the bulging viscus at the bottom of the deep wound may be colon, or small intestine, or kidney. From the last, manipulation and percussion will readily enough distinguish intestine. And the great gut may be distin- guished from the small, by attention to the following circumstances : — the colon has its muscular fibres of greater development ; the small intestines sustain a motion of alternate ascent and descent — communi- cated by the diaphragm, and corresponding to expiration and inspira- tion — while the colon is stationary, being fi:sed to the loins by areolar tissue ; also, if two portions of bowel present themselves, that may naturally be expected to be the colon which is on the outer or spinal aspect, at the external border of the quadratus lumborum. Having become satisfied that the colon is exposed at the bottom of the wound, it is transfixed by a needle and ligature — at two points, above and below — so that it may not slip from its present relation to the wound. 396 FOKMATION OF AN AETIFICIAL ANUS. after an opening has been made and the contents have begun to escape. The bowel, stretched by the two ligatures drawn outwards, is divided freely between. Air and fluid contents at once pass out- wards ; but it may be necessary, by means of the finger, scoop, or for- ceps, to assist in extrusion of the solid matters. The margins of the opening in the bowel are then secured by ligature to the external wound, so that, by adhesion there, a permanent, safe, and efficient aperture may be constituted for faecal escape. The advantages of this operation, in contrast with that of Littre, are — the peritoneum is uninjured, fascal escape is not so directly in the way of sight, and touch, and smell; there is less risk of pro- lapsus of the bowel, and control of evacuation is moi-e complete ; indeed, a complete sphincter seems to form in the loins, rendering the occasional exhibition of aperients necessary. The objections are — this new sphincter is apt to exceed its office, rendering dilatation or fresh incision requisite to maintain patency of the opening ; and the site is not readily within reach of the patient, for managing the pad which requires to be worn carefully adjusted. Great cleanliness must be at all times observed. Copeland on the Principal Diseases of the Rectum and Anus, Lond. 1814. HowsMp, Practical Observations, &c., Lond. 1820. Eibes, Recherches sur la Situation de I'Orifice Interne de la Fistule a I'Anus, &c.. Revue Medicale, livr. i. p. 174, Paris, 1820. Calvert, Practical Treatise on Hemorrhoids, &c., Lond. 1824. Boyer, de la Fissure de I'Anus, &c., Paris, 1825. Bushe on the Malformations, Injuries, and Diseases of the Rectum and Anus, New York, 1827. Syme on Diseases of the Rectum, Edin. 1828. Salmon on Prolapsus of the Rectum, Lond. 1831. Dupuytren, Lecons Orales, Paris, 1831. Amussat, Memoire sur la Possibilite d'Etablir un Anus Artificiel dans la Region Lombaire, &c., Paris, 1832. Brodie on Diseases of the Rectum, Lond. Med. Gazette, vol. xv. p. 845, 1835; /Z/2'd vol. xviii. 1836. Hoiiston on the Treatment of Internal Hemorrhoids by Nitric Acid, Dub. Med. Journal, March 1843. Curling on Diseases of the Rectum, Lond. 1852. Morand, Collection des Plusieurs Observations Singulieres des Corps Etrangers .... dans le Fondement. Mem. de I'Acad. de Chirurg. vol. iii. p. 606. 397 CHAPTER XXX. CALCULOUS DISEASE. Urinary Calculi. Healthy urine is a straw-coloured or amber-coloured fluid, retain- ing all its elements in solution, with the exception of an almost in- finitesimal quantity of mucus, which may in most cases be seen to subside after an hour or two from the transparent fluid, forming a very slight cloud at the bottom of the vessel. In various states of disease, on the contrary, the solid matters contained in the urine are apt to be precipitated, either in consequence of simple increase in their quantity relatively to the fluids, or from more complicated changes in the consti- tution of the secretion. Such solid precipitates, especially if composed of saline or crystalline matters, may give rise to distressing symptoms by causing in the urinary passages the formation of gravel, and of stone or calculus ; the first term being applied to the finely granular form of de- posit, the two last to solid concretions of more considerable size. A stone, once formed, has always a tendency to increase in size by new accretions of foreign matter upon its surface ; and in consequence calculi, when they have acquired sufiicient size to be detained within the bladder or kidney, generally give rise to symptoms of increasing severity, and may, sooner or later, require surgical interference for their removal. Hence the study of urinary deposits is important in a surgical point of view ; although the constitutional conditions which lead to them fall, for the most part, within the province of the physician, like the other derangements of the urinary secretion. These conditions are com- monly called diatheses, and may be detected either by the occasional presence of gravelly deposit in the urine, or by such changes in its .chemical constitution, as are known to give a tendency to precipitation. The existence of any abnormal irritation in the urinary organs, should therefore in all cases lead to an examination of the urine, and parti- cularly to careful observation of its sediments, if present, with a view to ascertaining and correcting any calculous tendency. Here, as in all other cases, prevention is better than cure. The means necessary for the examination of urine in relation to surgical disease, are — a good microscope with a magnifying power of 398 CHARACTEES OF THE UEINE, at least 200 diameters, a urinometer for testing specific gravity, test- tubes, test-papers, and a few simple chemicals which wiU be mentioned immediately. By the conjoint employment of the microscope and of chemical analysis, after the manner so fully described of late years by Dr. Golding Bird and others, it is now within the power of every practitioner to detect even the earliest traces of calculous tendency ; and no one can now be excused for overlooking derangements of the urine, which a few years ago would inevitably have been allowed to proceed unchecked, until they ended in calculous formation, or at least in the minor evU of gravel. The normal urinary secretion usually yields, as above mentioned, a slight hazy cloud of mucous sediment, which forms its only precipitate in the state of absolute health. This cloud of mucus presents under the microscope only a very few rounded bodies, resembling closely the cells found in pus, and occasionally traces of epithelium cells from the bladder or some other part of the passages. Often, however, these are absent, or nearly so, and the sediment is altogether impalpable ; occasionally, on the other hand, the so-called mucus corpuscles are increased in number, and the mucous cloud which contains them is increased in bulk and opacity. This is the first grade of mucous irri- tation, and is often found in connection with various kinds of saline deposit. Under a further progress of this condition the urine may become highly impregnated with mucus and epithelium ; or the mucous cloud may be supplanted by a distinct deposit of pus. To the test-paper, healthy urine presents a tolerably distinct acid reaction ; this may be feeble, or the urine may even be occasionally neutral, without the presence of any serious derangement ; but any degree of persistent alkalinity must be regarded as distinctly abnormal, and requires correction by treatment, unless in the case of its having been induced by medicine or accidental dietetic conditions, which some- times render the urine temporarily alkaline. According to Dr. Bence Jones, the acidity of the urine undergoes constant changes in amount in healthy persons, according to the condition of digestion ; being inva- riably greatest immediately before meals, and falling to its minimum a few hours after breakfast and dinner ; appearing therefore to stand in an inverse relation to the acidity of the stomach. The source of the acid reaction of urine is not known with certainty ; it is supposed to be owing not to any free acid, but to the presence of some salt, such as the acid phosphate of soda. The specific gravity of the urine, and the proportion of solid matter contained in it, are likewise subject to considerable variation at different periods. After a meal and towards the close of digestion, the density of the urine (which has been called in these circumstances urina chyli) becomes greatest, and may exceed 1030, as tested by the LITHIC OE URIC DEPOSIT. 399 iirinometer. After drinking largely, on the other hand {urina potus), it may be reduced almost to the density of water ; while the urine passed in the morning (urina sanguinis), independently of the influence of food or drink, has usually a specific gi'avity of from 1015 to 1025. The absolute quantity of urine passed in twenty -four hours varies, as might be expected, with the amount of drink ; and has an inverse relation to the specific gravity, which is commonly high in proportion as the urine is scanty. About a quart (forty ounces) of urine may be assumed as an average quantity for an adult. The principal sediments occurring in the urine and tending to the formation of calculi are as follows : — 1st. Deposits of free uric acid, or urates of ammonia, lime, mag- nesia, and soda. (Lithi-ima) ; 2d. Deposits of oxalate of lime {Oxal- urid) ; dd. Earthy phosphatic deposits, consisting of phosphoric acid, with lime, magnesia, and ammonia (PJiosjjInuia) ; itJi. Deposits of a peculiar organic crystalline matter, termed cystin (Cystinurici) ; 5th. Deposits of another organic principle, scarcely crystalline, the uric oxide or xanthic oxide of Marcet (Xanthi-uria). Fibrin, carbonate of lime, and silica have also been mentioned as ingredients of calculi ; but the deposition of these substances from the urine is extremely rare, and does not appear to have been the result of any peculiar morbid diathesis or tendency, the knowledge of wliich can be of any important use to the practitioner. The Lithic or Uric Deposit. — This consists either of the uric acid. or of the urates, tinged with colouring matter ; and varies accordingly. 1. The most common is amorphous; consisting chiefly of the ui'ate of ammonia, more or less coloured ; of a yellow hue. when mixed with the colouring matter of the urine ; reddish, like brick dust, when com- bined with the purp urate of ammonia ; and when this latter ingi'edient is in much abundance, the sediment is of a pink colour. Such urine is unusually acid, when tested ; is of high density ; and has a small relative proportion of aqueous matter. When passed, it is clear ; but, on cooling, the sediment is deposited more or less abundantly. 2. The oystalline ; consisting of uric acid, variously tinged by admixture of colouring matter ; usually of a reddish hue — the crystals resembling particles of cayenne pepper ; and constituting the most ordinary form of gravel, or red sand. Examined under the microscope the amorphous deposit, or brick- dust sediment, appears either in the form of exceedingly minute mole- cules, sometimes aggregated together, sometimes dispersed over the field; or in that of larger globular masses, semi-opac[ue, brownish in colour, and sometimes either gi'ouped together or armed with project- ing spicula like stalactites. The last form is unusual, and has been considered by some observers as urate of soda. The crystalline 400 THE LITHIC DEPOSIT. deposit of uric acid assumes generally tlie form of rhombic prisms, but appears in various modifications of this primary type ; the most Kg. 131. usual is that in which the rhomboids or lozenges are very thick and rounded at the angles, so as to resemble, when placed upon their sides, Fig. 132. thick cylinders, for which they may readily be mistaken, especially if grouped together in masses, as frequently occurs. The uric acid Fig. 131. Urate of ammonia under the microscope. — From Donne. Fig. 132. Crystals of uric acid. — From Donne. THE LITHIC DEPOSIT. 401 crystals are generally coloured, and have, under the microscope, a peculiar deep amber tint, which is highly characteristic. All the deposits of either free or combined uric acid are highly soluble in caustic potash ; in soda they are less so. The urate of ammonia, which forms the principal part of the amorphous deposit, is tolerably soluble in water at the temperature of the body ; and hence is seldom deposited except on cooling of the urine after excre- tion. In some cases, however, especially when the urine contains an excess of acid, the urate of ammonia is deposited within the bladder. The uric acid deposit, on the contrary, which is thrown down by the addition of almost any acid to urine holding urate of ammonia in solu- tion, is soluble only to a very slight extent in water, even with the aid of heat ; and hence is a comparatively frequent deposit in the urine on emission, although much less common than the amorphous sediment as a result of cooling. Both deposits are decomposed by strong nitric acid with the aid of heat, and leave on evaporation a beautiful lake-coloured residue, which becomes purple in tint by the addition of ammonia (pui'purate of ammonia, murexide). Urine con- taining these sediments is usually rather high-coloured, of good or excessive specific gravity, highly acid, and often scanty. Not unfre- quently the amorphous deposit is not the result of any derangement of the system, but merely arises from deficiency of drink or abundant perspi- ration. This is never the case with the uric acid or crystalline sediment. Uric deposits may attend the slightest derangement of health, or the most serious ; they denote a sthenic state of system, more fre- quently than the opposite condition. A trifling disorder of digestion, as by casual error in diet, may cause a tolerably copious sediment ; the progress of hectic, and the decline of inflammatory fever, are accompanied by plentiful deposit of red powder — termed lateritious, from its resemblance to brick-dust. The gouty diathesis is marked by uric deposit. Habitual indulgence in much animal food, with deficiency of exercise, and neglect to maintain a clean and efficient state of the skin, will not fail to establish it. It is obviously connected with climate — at least with locality ; the inhabitants of certain places suifering much more than others. It is also connected with age ; prevailing most in childhood, and between the ages of forty and sixty. It is hereditary. It may follow injury of the kidney or its neighbour- hood ; congestion being produced in the secreting organ. It would seem to depend proximately, either on an excess of uric acid being generated in the system — by decay of the effete organism, or by mal- digestion of food ; or on the presence of a free acid — the muriatic, acetic, or lactic — which, combining with the base, frees the uric acid and so leads to its precipitation. Or the causes may be stated in another way, as by Dr. Gr. Bird : 1. Waste of tissues more rapid than 402 THE LITHIC DIATHESIS. the supply; as in fever, rheumatism, &c. 2. Supply of nitrogen in the food, greater than is required for the reparation of tissues ; as by excessive indulgence in animal food, and by too little exercise. 3. Digestion insufficient to assimilate an ordinary and normal supply of food; as in dyspepsia. 4. Obstruction to the cutaneous outlet for nitrogenized excretion; by skin diseases, or other cause. 6. Con- gestion of the kidneys; following injury of the organs, or disease wherein they are affected by sympathy. Plainly, the treatment must vary according to the cause. In the fevers already mentioned, the deposit ceases as the constitutional symptoms subside. In other cases, the treatment may be said to be twofold. By the exhibition of alkalies, with which the uric acid com- bines, soluble salts are formed, while at the same time — mainly per- haps by the vehicle in which the alkali is given — the aqueous portion of the urine is increased. And by attention to regimen, exercise, and skin — going more deeply into the matter — we seek to rectify the depraved state of the digestive organs, on which the evil in the great majority of cases primarily depends. Both methods are of service ; but the latter is obviously the more important. They are usually combined. Magnesia, soda, and potass may be given. The first may accumulate in the intestines ; and on this account is seldom prescribed, at least for any length of time. The phosphate of soda is both safe and useful. The carbonate is grateful, and quite efficient. But potass is usually preferred ; its urate being more soluble than that of soda. The bicarbonate is usually given, in half drachm doses ; largely diluted ; and it may be pleasantly combined with a few grains of citric acid. The best period for administration, probably, is about two hours after the principal meals — when alkalies are most wanted to neutralize the free acid of indigestion ; and when at the same time digestion is so far advanced as to render it unlikely that this process shall be interfered with by the alkali. There are also the borate, citrate, and tartrate of potass — all available. Simple though the alkaline remedies seem, let them never be per- severed with carelessly. Their over-sustained use may convert the sthenic state of system into the asthenic, inducing serious constitutional disorder, and causing an ammoniacal and phosphatic state of the urine. The test-paper must be used from time to time, and the state of the system must be carefully attended to. In those cases in which digestion is obviously weak and imperfect, preparations of iron are useful ; the citrate, in solution, may be given in moderate doses after each meal. Eegimen is carefully attended to ; food being regulated as to both quantity and quality. Nothing at all approaching to a surfeit should ever be indulged in ; animal food should be taken sparingly, if at all ; vegetables and farinaceous articles THE LITHIC DIATHESIS. 403 may be freely used, provided acidity be not produced ; malt liquors should be abstained from ; and wine, if taken at all, must be used with great moderation. The bowels require laxatives or alteratives. In most cases, a mercurial purge is a good beginning of the treatment ; and, if the sthenic constitutional symptoms amount to a febrile cha- racter, cupping may be also practised on the loins. The skin must be attended to ; by ablution, warm clothing, friction, and exercise ; and if any eruption exist, means must be taken to remedy that. Occa- sionally, gentle diuretics would seem to be of service. Colchicum, it is well known, is a powerful eliminator of uric acid ; and hence, pro- bably, the main reason of its success in gout and rheumatism. When congestion of the kidney is suspected, the treatment is by cupping, rest, and antiphlogistic regimen. The term ^^ gravel" is ordinarily applied to the passing of the uric acid deposit. It begins severely, and is liable to aggravations ; and these periods of intensity are termed "fits of the gravel" — cha- racterized by pain in the lumbar region, shooting down towards the groin, with pain and retraction of the testicle ; frequent micturition, hot and scalding ; uneasy sensations in the thighs, very frequently ; more or less febrile disturbance ; and always plain indications of great derangement of the digestive organs. It is in such cases that purging, antiphlogistic regimen, and sometimes local blood-letting, form so excellent a commencement to the remedial means. The ordinary treatment may be reduced to the following indica- tions : — 1. To diminish the uric formation; by moderate antiphlo- gistics ; regulation of diet and exercise ; and attention to the skin. 2. To increase the solvent power of the urine ; by diluents, given cold — yet not so as to discourage perspiration ; and by gentle diuretics, if necessaiy. 3. To increase the solubility of the deposit ; by prevent- ing or neutralizing the free acid, which, spoliative of the urate's base, causes precipitation of the uric acid ; and by presenting an alkali as a soluble base to the uric acid. 4. The fourth indication is one of no slight importance — to favour extrusion of the gravel ; by diuretics and diluents ; by warm bathing ; and by exercise. And, in regard to this, it is well to remember that the particles of uric gravel are especially prone to aggregation. The Oxalate of Lime Deposit. — The occurrence of oxalate of lime in the urine as a source of calculus has been long known ; but the frequency of this deposit was much underrated, until the careful re- searches of Dr. Golding Bird, who first investigated the form of its microscopic crystallization, and the symptoms connected with its oc- currence in the eai'ly stages. It constitutes a species of very minute crystalline gravel, which readily escapes observation by the naked eye, in consequence of the perfect transparency and absence of 2 D 2 404 THE OXALIC DIATHESIS. colour in the crystals. On careful observation, however, they may often be seen as minute glistening points floating in the urine, which usually contains a slight excess of mucus, but is often nearly or absolutely clear. The crystals are probably precipitated within the organism in most instances ; they may however be absent from the urine on emission, and be found in great abundance twenty-four hours after- wards. The mode in which they are retained in solution is not known, as the oxalate of lime is exceedingly insoluble in water. With the exception of a rather high specific gravity, which is usual, there is nothing very characteristic in the appearance of urine containing oxalate of lime. The amount of nrea is generally large ; often, also, uric acid and its salts are in excess, and sometimes they form deposits which co-exist or alternate with those of the oxalate. The earthy phosphates are likewise usually in excess in oxaluria, but are held in solution in consequence of the acidity of the secretion. The colour of the urine varies from a pale straw-colour to an amber tint, the latter being perhaps more common and characteristic. The urine in this disease generally, as already mentioned, deposits an ex- cess of mucus ; and along with this there are sometimes found minute quantities of seminal fluid, as indicated by the presence of spermatozoa under the microscope. The most usual form of the oxalate of lime as seen under the micro- ■^OTTo Fig. 133. scope is that of octohedral crystals, generally not more than -j^Vo ^^ of an inch in diameter, and often much less than this ; always perfectly transparent, colourless, and exceedingly sharp and well defined in their angles. Occasionally the crystals are " made up of a square prism, Fig. 133. Oxalate of lime under the microscope. — From Donne. THE OXALIC DIATHESIS. 405 with a four-sided pyramid at each end, forming a dodecahedron." Another form much more rare, and possibly not composed simply of oxalate of lime, is that of dumb-bell shaped or oval crystals, often re- sembling " two kidneys with their concavities opposed," and possessing a beautiful radiating structure in some cases, while in others they appear homogeneous. The crystals are insoluble in alkalies or in vegetable acids ; soluble in muriatic and nitric acid ; and on being subjected to a red heat are decomposed, leaving carbonate of lime, which dissolves with effervescence on the addition of acids. In re- gard to the pathological or physiological origin of oxalate of lime in the economy, many speculations exist ; but none of them are sufficiently precise or well founded to claim attention in a practical work. It is very probable that this deposit has some relation to the decomposition of the tissues, and is formed at the expense of urea or uric acid. The attendant constitutional symptoms are occasionally slight ; commonly, however, they are sufficiently characteristic and distressing to require attention and treatment. The patient is languid, weak, and thin ; often remarkably depressed in spirits ; usually pale, sometimes of a greenish hue in the face — more especially about the eyes and mouth ; pustular formations on the skin are common ; and so are scaly eruptions ; the slightest exertion induces great fatigue ; the temper is irritable ; the mind broods over the ailment, and desponds of recovery ; dyspepsia is present — troublesome, by flatulence and palpitation, more especially after taking food ; aching pain is com- plained of across the loins ; and the sexual power is usually much im- paired. Sometimes the symptoms of phthisis are simulated ; some- times those of heart disease. Not unfrequently, water is made with unusual frequency, and with heat and smarting. The ordinary causes of this affection are, over-exertion of mind or body, excess of venereal indulgence, habitual and gross errors of diet, exposure to cold, injuries done to the lower part of the spine. The oxalic acid would seem to be the product of faulty assimilation ; and it readily meets with its base. According to some, the acid may be introduced from Avithout ; it being supposed to be one of those substances which are capable of passing unchanged from the stomach to the kidneys. According to this view, the taking of rhubarb, sorrel, tomata, &c. as articles of food, along with the use of hard water as drink, may be deemed very favourable for the establishment of the oxalate of lime deposit. The treatment resembles that for the phosphatic diathesis. The general functions are looked to ; but more especially those of the stomach and skin. Diet is light and nourishing. Malt liquor is forbidden ; and a sparing allowance of brandy and water, with meals, is found preferable to wine. Sugar is abstained from. Warm clothing 406 THE PHOSPHATIC DEPOSIT, must be worn ; and by friction, exercise, and warm bathing, the pores are to be kept free. All sources of exhaustion, and all kinds of de- pletion are to be avoided. Medicinally, the mineral acids are found of much service ; especially the nitro-muriatic, exhibited in some bitter infusion. And, of the tonics, zinc and iron are to be preferred ; the sulphate of zinc more especially. Colchicum, too, may be found use- ful. It is well to remember that, in treatment, the oxalic often changes into the uric diathesis ; indeed it is probable that these two morbid states readily pass into each other — it costing the urea, as it were, but little effort to change into either the uric or the oxalic acids. When, under treatment, the uric deposit is observed to succeed the oxalic, the use of the acids must be abstained from, at least for a time. The Phosphatic Deposit. — Normal urine contains a considerable pro- portion of phosphoric acid, the greater part of which is in combination with alkaline bases, and forms salts which are highly soluble. The phosphates of lime and magnesia exist also in small but very variable quantity, and are held in solution, probably b}'- the acid of the urine, along with some of its saline constituents. These earthy phosphates are in greatest quantity after a meal, in healthy persons ; and in various diseases, especially those attended with emaciation, appear to increase in amount. They are precipitated and foi'm a slight cloudiness in the urine, on the addition of any caustic alkali or alkaline carbonate ; and when healthy urine passes into the state of decomposition, the earthy phosphates are also thrown down, owing to the evolution of carbonate of ammonia from decomposing urea. The precipitate may be either amor- Fig. 134. Crystals of the Ammoniaco-magnesian phosphate. — From Donne. THE PHOSPHATIC DIATHESIS. 407 plious or crystalline. The former generally consists of phosphate of lime; the other of the triple phosphate of ammonia and magnesia. This last, in a nearly neutral urine, crystallizes in triangular prisms bevelled at one or both ends, exceedingly transparent and colourless, like the prisms of crystal used in optical experiments. These crystals are very friable, and are consequently often observed irregularly splintered, or shivered into small fragments ; they are always perfectly colourless, and by this character are easily distinguished from uric acid. In a highly alkaline urine (whether spontaneously alkaline or decomposed after emission), the phosphate of ammonia and magnesia occurs under a variety of crystalline forms, corresponding to the basic varieties of the salt. " When rapidly formed, this salt generally appears in the form of six-rayed stars, each ray being serrated, or irregularly crenate, often runcinate, like the leaf of the taraxacum." There are, however, many varieties of star-shaped and foliaceous crystals, consisting of basic triple phosphate ; and generally these are mixed with the neutral salt in the ordinary prismatic form above described. All the forms may be readily produced artificially, by adding ammonia or its carbonate in different quantities to the urine. The phosphatic gravel is usually white or pale grey — whether amorphous or crystalline ; it may be precipitated in the form of plain gravel, or it may be either suspended or precipitated in a cloud resembling that of mucus, or it may form as a pellicle on the surface of the urine. The urine is pale and copious ; of low density ; occa- sionally alkalescent, when voided ; never more than very faintly acid ; often tui'bid, the last portion which is voided presenting a milky appearance — the phosphates being already precipitated ; sometimes it emits a heavy, sickening flavour, somewhat similar to that of weak broth ; not unfrequently it is ammoniacal from the first, dark-coloured, and loaded with mucus ; in all cases, it very soon putrefies, precipitat- ing the deposit copiously, and exhaling a very offensive odour. Very generally, an iridescent pellicle forms on its surface ; consisting of minute shining crystals of the ammoniaco-magnesian phosphate. The symptoms which attend the continuance of phosphatic deposit, are invariably of the asthenic type. The patient is pale, weak, nervous, irritable ; incapable of sustained exertion of either body or mind ; the bowels are flatulent and irregular ; and an oppressive, ex- hausting pain, or aching, is almost constantly complained of in the loins. The cause may be local or constitutional. "Whatever tends to ex- haust the general, and more especially the nervous system, tends to induce this deposit ; over-exertion, especially of mind ; insufficient food ; the habitual use of depressing medicines, as mercury, alkalies, saline purgatives. Also, this deposit is a frequent consequence of 408 THE CYSTINE DEPOSIT. injured kidney, and of injury to the spine ; and it is an almost invari- able attendant on confirmed disease — ^more especially if organic — in the bladder, kidney, ureter, or prostate. An occasional deposit of phosphates may follow a slight and transient cause ; as error in diet, or profuse perspiration under violent exercise. But continuance in- variably denotes broken health. The least formidable cases are those in which the ammoniaco-magnesian phosphate alone is found ; and the worst are usually those in which the deposit consists of a combination of this salt with the phosphate of lime. Happily, the phosphatic gravel is not prone to agglomerate within the bladder, unless a nucleus be present ; then, however, the cohesion of particles, around this, takes place rapidly. In treatment — as in that of the uric deposit — we have to du'ect attention both to the deposit, and to the causes which lead to its forma- tion. The mineral acids — as the muriatic, nitric, or a combination of both — exert a double influence ; they increase the solubility of the phosphates, and at the same time give tone to the primse via3 and general system. They are given in doses of a few drops, much diluted, and gradually increased. Regimen is carefuUy attended to. Food should be generous, yet light and moderate ; consisting chiefly of solids. Acescent vegetables, fruits, and drinks are injurious ; for, however useful the mineral acids, taken from without, may be, acids engendered within invariably betoken derangement of stomach, and that as invariably reacts most untowardly on the urinary organs. Wine may be taken sparingly. Over-exertion in any way is avoided ; free air and laxity of occupation are to be sought ; and the skin's func- tion must be well looked to. The bowels are regulated ; but mercury and saline purges do harm. Diuretics are not given ; neither are alkalies — unless indeed the acids of indigestion plainly are trouble- some, and then very small and occasional doses of alkali may be of service. Depletion, in any way, is not to be thought of. Opium is of much service ; by subduing the irritability of system. General tonics are plainly indicated. And the decoctions of the diosma crenata, pareira brava, and uva ursi, would seem to exert a beneficial influence specially on the urinary system. The Cystine or Cystic Oxide Deposit. — This deposit is rare ; but as it causes one of the most obstinate forms of the calculous diathesis, it is necessary to mention it here. Cystine is always crystalline, though to the naked eye it scarcely appears so, having more resemblance to the paler forms of lithate of ammonia. It forms a yellowish sediment, insoluble by heat, unaifected by vegetable acids, but dissolved by strong mineral acids and alkalies. Ammonia dissolves it very readily, and on evaporation deposits it unchanged in the crystalline form. Under the microscope, cystine appears in the form of hexagonal plates, often THE URIC OXIDE DEPOSIT. 409 overlapping each other so as to form rather a confused mass. The ammoniacal solution, sloAvly evaporated, gives crystals which can usually be distinguished from all others without difficulty. Urine containing cystine is usually of a more or less deep yellow colour, sometimes inclining to green. Dr. Golding Bird has even seen it o-rass-gTeen. Its odour is either aromatic like that of -sweet briar, or slightly foetid. The quantity of urea and of uric acid has generally been found below the average ; and it is not improbable, from the Jig. 135. chemical relations of cystine, that it is formed at the expense of these physiological products. Cystine contains a lai'ge proportion of sulphur (26 per cent.), and is therefore probably in some way related to the sulphur-extractive which is found in normal urine. Pathology has not yet succeeded in throwing any useful light upon the circumstances under which the cystine diathesis occurs ; the rarity of this deposit proving, fortunately, an obstacle to the extension of our knowledge in that direction. Its occurrence is occasionally hereditary ; and appears to be little subject to any therapeutical control. The Uric or Xanthic Oxide Deposit. — This is the rarest of all the urinary deposits; and was first described by Dr.Marcet, as the constituent of a calculus weighing eight grains. Neither its pathological history, nor its chemical properties and relations, have been so clearly ascer- tained as to demand notice in a practical work. It has chiefly been discovered in children, in the form of calculus. Dr. Douglas Maclagan lately found in the urine of a hysterical female ti-aces of what appeared to be uric oxide ; and his investigations led him to regard the sub- stance found in this case as identical with one of the normal colouring- Fia;. 135. Crvstals of rvstine. 410 UEINART CALCULI. matters of the urine, precipitated upon a basis of earthy phosphates. It showed under the microscope granular laminae, of irregular form, having the chemical characters described as those of cystine.* Formation and Varieties of Calculi. The persistent establishment of any of these deposits renders the patient more or less liable to the formation of calculi, and is therefore justly regarded as a calculous diathesis. A nucleus having formed in some part of the urinary passages, the particles of the prevailing deposit are aggregated around it, sometimes in a homogeneous manner, more generally in layers, Avhich may not unfrequently differ widely in composition. The nucleus may come from within or from without. A foreign substance introduced into the bladder, by the urethra, by wound, or by ulceration, and remaining in that viscus, soon becomes coated by calculous mattei*, even though previously no tendency to such deposit existed. Bai'ley-corns, straws, beans, portions of bougies, or bullets which have gradually worked their way inwards, may thus prove nuclei ; also portions of instruments, lint, or other matters, used in operations on the bladder ; or a portion of necrosed bone may find its way, by ulceration and abscess, into the viscus. By far the most common nucleus, however, is provided by the urinaiy organs them- selves. A few particles of uric acid, or of oxalate of lime — for these, the former more especially, are found to be most prone to formation in the kidney — become coherent immediately after secretion ; and by such aggregation a nucleus is at once formed, soliciting ftirther addi- tion. This addition may be made at the original site of aggregation, the kidney ; more frequently, however, descent takes place into the bladder ; and the small renal concretion then becomes the nucleus of a vesical calculus. Or blood, escaped from the kidney or mucous coat of the bladder, may afford a mass of fibrin, which in like manner may originate the formation ; all the more readily, of course, if a gravelish tendency previously exist. As the stone enlarges, the original nucleus usually retains its central position ; the stone moving loosely in the bladder, and receiving addition equally on all sides. Sometimes, how- ever, the stone is found to occupy a steady position, even when not encysted ; lying undisturbed behind an enlarged prostate, having one side in constant and immediate contact with the mucous membrane, and presenting only a part of its periphery to the source of additional deposit. In such cases, the nucleus will be found occupying a lateral position in the stone's section ; enlargement having taken place almost exclusively on that aspect which looked into the free interior of the viscus. * Monthly Joiu-ual, Aug. 1851, p. 131. URINARY CALCULI. 411 Stones vary in their nature according to the diathesis which pre- vails during their formation. The following are the varieties : — I. The Uric Calculus ; consisting chiefly of uric acid, but often con- taining a greater or less proportion of urate of ammonia. This is by far the most common class ; comprising probably about two-thirds of all calculi. The colour is brownish red, sometimes like that of mahogany ; the surface is either quite smooth, or finely tuberculated by crystals ; a section shows aggregation of the particles in a con- centric arrangement ; the form is generally oval ; and the size may vary from that of a pea to that of an orange. The tests are — solu- bility in caustic potass ; gradual consumption before the blow-pipe ; digestion in nitric acid, and gentle evaporation, producing a scai-let residue, which becomes purple on the addition of ammonia. II. Urate of Ammonia Calculus. — This salt, as just stated, enters more or less into the construction of the uric calculi. Sometimes, but rarely, it forms a concretion by itself. The surface is similar to that of the uric ; more frequently tuberculated than smooth ; it is of a clay colour ; Kg. 138. the fracture is fine and earthy ; and the layers are concentric. This comparatively rare calculus is peculiar to children. The tests are as for the preceding ; with this addition, that ammonia is evolved during solution in potass. III. The Oxalate of Lime, or Mulberry Calculus; not unlike a mul- berry in size, form, and colour. By no means unfrequent, especially in young people ; always of slow formation. The colour is dark brown ; density and weight are comparatively great ; the surface is almost always rudely tuberculated ; the texture is imperfectly lami- nated ; the size seldom exceeds that of a walnut ; and the stone is always single. The tests are : — solution in nitric acid ; the blow-pipe, con- Fig. 136. The triple phosphate surrounding a mulberry concretion. Fig. 137. Nucleus surrounded by oxalate of lime ; and this covered by concentric layers of urate of ammonia. From a child. Fig. 138. Oxalate of lime, or mulberry calculus. 412 URINARY CALCULI. suming the acid, leaves quick-lime in powder, which, if moistened, gives to turmeric paper a red stain. Small calculi of oxalate of lime, in size, form, and general appear- ance, very like hemp-seeds, sometimes form in the kidney. Descend- ing, they may be extruded with the urine ; but if one remain in the bladder, it becomes variously coated, according to the diathesis that prevails. If the oxalic diathesis continue, the hemp-seed sooner or later passes into the mulberry formation. IV. Phosphate of Lime Calculus. — Calculi seldom consist of this salt alone. When they do, the surface is smooth like that of porcelain ; the colour is a pale brown ; the texture is regularly laminated ; the form is spheroidal. The stone is friable, and usually of small size. The tests are ; solubility in nitric and muriatic acids, and precipitation by liquor ammonias ; resistance to the blow-pipe, unless at a very intense heat. V. The Ammoniaco-Magnesian Phosphate Calculus; commonly called the Triple Phosphate Calculus — although that term might with fully as much accuracy be applied to the next variety. This and the following seldom occur as composing stones entirely ; but rather as coatings or layers of others — the uric and oxalate of lime moi'e especially. The colour is nearly white ; the surface is covered with minute shining crystals; the texture is not laminated, or at least is imperfectly laminated ; the stone is soft. Fig. 139. easily broken and pulverised, andmayattain to alarge size. The tests are : solubility in acetic or muriatic acid ; evolution of ammonia, when treated with liquor potassse ; diminution and imperfect fusion under the blow-pipe, exhaling an ammoniacal odour. VI. The Fusible Calculus; composed of the ammoniaco-magnesian phosphate, conjoined with phosphate of lime ; is white and friable, like chalk ; and may stain the finger when touched ; the size and form are very various. The test is, its remarkable fusibility before the blow-pipe . VII. The Carbonate of Lime Calculus, is common in the lower animals, but rare in man. It is white, spherical, smooth, and very friable ; and dissolves in muriatic acid, with effervescence. VIII. The Cystic Oxide Calculus is also rare ;* of a yellowish-white colour ; the surface smooth, but of a crystallized appearance ; not laminated in texture, but presenting the appearance of a confusedly crystallized mass ; the fracture exhibits a peculiar shining lustre ; small fragments are semi-transparent. The bloAv-pipe elicits a pecu- * I had occasion to remove a calculus of this nature, successfully, from a patient on whom Mr. Liston had removed a like stone fifteen years before. — Monthly Journal, 1849, pp. 791 and 886. Fig. 139. The triple phosphate surrounding a centre of uric acid. URINARY CALCULI. 413 liar odour, like that of sulphuret of carbon ; and there is a ready solu- bility in alkalies and mineral acids. IX. The Uric or Xanthic Oxide Calculus is still more rare than either of the preceding. The texture is compact, hard, and laminated ; the sur- face is smooth, the shape ovoid, the colour cinnamon-brown. The tests are, consumption before the blow-pipe, leaving a white ash, and exhaling a peculiar foetid odour ; solubility in acids and alkalies — more readily in the latter ; the residue of solution in nitric acid, evaporated to dryness, of a bright lemon-yellow colour — whence the name. X. The Lithate of Soda sometimes enters into the composition of calculi ; but very rarely constitutes a calculus, of itself. The mass is white, friable, and soft, like what is seen in the tophous concretions of gout, in the neighbourhood of joints. The tests are ; solubility in caustic potash, with the aid of heat ; in treatment with dilute sulphuric or muriatic acids, the soda is separated, while the uric acid remains, and may be obtained by filtration and washing. XI. The Fibrinous Calculus, like the xanthic oxide, occurs with extreme rarity. And, perhaps, the term calculus is scarcely applicable to the almost solitary case on record ; in which small concretions were passed, of the size of peas, yellow, like Avax, and composed of fibrin — probably the result of a bloody clot, in either the kidney or bladder. Such formations, however, as already stated, may not unfrequently constitute nuclei of the ordinary calculi. XII. The Alternating Calculus, though last in the arrangement, is not the least frequent in occurrence. Few large cal- culi, indeed, fail to present more or less of the alternating character ; the nucleus consisting of uric acid or oxalate of lime ; variously coated or alternated ; the last covering invariably phosphatic, and most frequently of the nature of fusible cal- culus. The mulberry or uric calculus, having formed, creates much irritation in the urinary organs, and causes changes also in the general system for the worse ; the urinary secretion becomes more and more depraved ; and at last that derangement is produced which is favourable to the formation of the ammoniaco-magnesian phosphate ; this is deposited on the growing stone, and, uniting with phosphate of lime now furnished by the diseased mucous membrane of the bladder, constitutes the fusible formation. Such are the varieties of Urinary Calculi. Those ordinarily Fig. 140. Section of an alternating calculus ; chiefly composed of lu'ic acid. I'iff. liO. 414 UEINAEY CALCULI. occurring are, the uric, mulberry, phosphatic, and alternating. Form- ing in the kidney, and remaining there, a calculus is said to be Eenal ; originating in the bladder, or growing there after descent from the kidney, it is said to be Vesical ; originating in the urethra, or arrested there in its passage outwards from the bladder, it is said to be Urethral ; formed in the prostatic ducts, it is said to be Prostatic. Stone is most common in temperate climates, and in early years ; of adults, the old are more frequently attacked than the young. The sedentary ai-e more liable than the active, the luxurious than the tem- perate, the males than the females. Certain districts are remarkably prolific in stone : Norfolk, for example ; and the east coast of Scotland. The disease is doubtless hereditary, like its kindred affection, gout ; and this circumstance may obviously be made somewhat subservient to the explanation of prevalence in certain localities. Frequency of occurrence leads to skilful practitioners and the flocking of patients ; the patients recover, and raise a breed of men of like tendencies with themselves. Where the disease is rare, on the other hand, the treat- ment is less skilful ; the affected migrate, and the chance of reproduc- tion from those who remain is but slight. Injuries of the spine obviously favour alkaline formations ; causing perversion of function in the kidney, and in the lining membrane of the bladder, with want of expulsive or self-cleaning power in the latter viscus. An injury done to the kidney itself also favours stone ; by disordering secretion, and at the same time furnishing coagula as nuclei for the formation. Long-continued strictures, and affection of the prostate, are obviously predisposing causes ; deteriorating the secretion of urine — through disorder of the general health, and pro- longation of irritation from the original seat of disease, upwards to the kidney ; at the same time opposing satisfactory expulsion of the bladder's contents. Some children seem born with stone ; afflicted with a con- genital calculous diathesis. The treatment of calculous disease plainly resolves itself into the following indications : — 1. To' prevent the formation of stone, by cor- rection of the calculous diathesis. 2. To favour spontaneous expulsion of the stone, when formed. 3. To diminish suffering, and delay pro- gress of the disease. 4. To remove the stone by operation, when cir- cumstances are favourable. 5. Unfortunately we are not yet warranted in filling up as a fifth indication, removal of the stone by lithontriptics, or other means independent of instruments. Renal Calculi. Renal calculi at first consist either of uric acid, or of oxalate of lime ; most frequently the former. Particles cohere, either simply to RENAL CALCULI. 415 each other, or round a nucleus of fibrin or other animal substance. And a beginning having been made, however slight, addition speedily takes place, provided the calculous diathesis continue — as is not unlikely, seeing that the irritation of the calculus reacts unfavourably on the kidney, causing continuance or even mcrease of depraved secretion. Mere sand may remain in the tubuli ; but calculi lodge in the infundi- bula ; and thence may descend to the pelvis of the kidney. And if a calculus continue in any of these cavities for some time, a peculiarity of shape is acquired — diagnostic of such formations — dependent on the form of the cavity ; in fact, the stone — though at first small, oval, and smooth, like uric calculi in general — may often be said to be an accu- rate cast of the pelvis and infundibula. This happens when the calculus continues to be renal ; more frequently, however, it descends by the ■ ureter to the bladder ; thence to be expelled by the urethra, or to enlarge into a vesical calculus. If it remain in the kidney, serious changes take place in that organ. The cavity or cavities are com- pletely occupied ; then, the size increasing, encroachment by pressure is made on the texture of the gland, until this may come to consist of little more than a mere cyst within which the large stone is contained. Sometimes active inflammatory action is kindled ; the kidney suppu- rates ; the matter, obeying the general rule of seeking the external surface, may point posteriorly ; and, evacuation having taken place, the stone may be felt by the probe or finger. The symptoms of stone in the kidney are generally as follows : — A dull aching, with a sensation of weight, is felt in the loins ; with a sharp pricking feeling in the region of the kidney. Sometimes there is pain in the scrobiculus cordis ; sometimes there are fits of vomiting ; generally the stomach is irritable. The urine, from time to time, shows an admixture of blood, more especially after exercise ; and this, when rude and violent, aggravates all the symptoms. Water is made often, and with pain and heat ; the testicles are painful and retracted. Numbness, pain, and cramp in the corresponding thigh are very com- mon. Febrile aggravations are liable to occur, the kidney becoming the subject of intercurrent seizures of an inflammatory nature. Purulent matter may descend from the pelvis, and be voided with the urine ; and by continuance of such discharge, by the htematuria, by the pain and general disorder, serious exhaustion may ensue. Generally, irritation descends ; and the bladder ultimately sympathises more or less, by functional or organic disorder. Large calculi, occupying the whole gland, may sometimes be felt by external manipulation ; and, in the open suppurated condition, a very accurate diagnosis may be arrived at, as already stated. Generally the stone, at no long period after its first formation, 416 EENAL CALCULI. descends by the ureter ; this movement being induced by its own weight, and by the flow of urine. Sometimes, however, it is arrested in the passage ; an event towards which the irregular form of the calculus is manifestly favourable. The ureter may be, in consequence, either wholly or partially obstructed. Usually the form of the calculus is such as to favour the urine's escape by its side ; but still even such partial obstruction, if long continued, may lead to very serious results ; dilatation of the ureter above, of the kidney's pelvis, and of the infundi- bula ; absorption of the proper structure of the kidney ; and conse- quent interruption to the function of that important organ. Indeed, under such circumstances, the parts have been found reduced to the condition of a chronic abscess ; the distended pelvis and infundibula being coated with a false membrane, and secreting much puriform fluid. And other dangers attend on the arrest ; inflammatory action, kindled in the obstructed part, may extend to the parts adjoining, and may involve the abdomen in peritonitis ; or ulceration may take place, with perforation ; and through the aperture fatal urinary extravasa- tion may occur. Complete obstruction by the arrest is fraught with utmost peril; distension of the pelvis and infundibula, rapid and great, is likely to cause suppression of urine — always most hazardous ; there is a greater risk of inflammation and ulceration than in the partial case ; and the over-distended ureter may even give way by bursting. In the case of partial obstruction there is a chance — though a remote one — of ulceration proving chronic and sthenic ; preceded and accom- panied by plastic exudation, and consequent consolidation of tissues ; advancing towards the surface ; and ultimately discharging the offend- ing body externally. Or the calculus may remain in the ureter, with partial obstruction ; as it enlarges, it usually assumes the form of an hour-glass, the increase of deposit taking place chiefly at either extre- mity ; and sooner or later death is the result. Not unfrequentlyj a descending stone is arrested in the termination of the ureter ; one part within the ureter, partially obstructing it; the other projecting into the cavity of the bladder, and receiving increase there ; constituting a troublesome variety of vesical calculus. A small, smooth calculus may glide down the ureter imperceptibly. More frequently, descent is marked by symptoms. The patient is sick and vomits ; he is alarmed, feeling a change, and afraid of the result ; he is attacked by cold chills and shivering ; the pain shifts from the kidney, shoots downwards in the course of the ureter, and often down the corresponding thigh — intense, and sometimes almost insupportable ; the testicle is retracted and painful — the seat of neuralgia, or irritation ; sometimes the irritation induces the inflammatory process, and acute orchitis results. The pulse is comparatively little affected, but fever EENAL CALCULI. 417 may at any time supervene, in consequence of inflammatory seizure in the ureter, kidney, bladder, or testicle. If arrest and obstruction take place, all the symptoms are much aggravated. The treatment of renal calculus consists in favouring descent, and palliating the urgency of the symptoms. The warm bath relaxes ; opium does the same, and assuages pain ; purgatives and diuretics favour descent. Smart exercise is also of service. In the first instance, antiphlogistics are not demanded ; they are held in readiness for the threatening of inflammatory action. Not the least important part of the treatment is the adoption and maintenance of such means as are best suited for overcoming the diathesis on which the existence of the stone depends. Should there be reason to apprehend arrest in the ureter, with complete or even great obstruction, diuretics and diluents will of course be refrained from. When, however, descent has been completed, and the bladder is reached, diluents can hardly be plied too actively, so as to favour complete expulsion of the foreign body. When a large stone lodges in the kidney, and its presence can be made out with tolerable certainty, nephrotomy has been proposed ; cutting into the gland from behind, and extracting the stone. This is not warrantable, however, except in those cases in which Nature has effected the greater part of the procedure ; when suppuration has taken place ; when the textures intervening between the stone and the surface are matted together and consolidated ; when the stone has be- come superficial ; and when, in short, there is no risk of injui-y being done to the abdominal cavity. Then the pointing abscess may be opened, or the apertui'e already existing may be enlarged, and the stone may be seized and removed. Such cases, however, are very rare, as can readily be understood. Vesical Calculus. As already stated, vesical calculus may originate in the bladder, formed on a nucleus there. More frequently, it may be said to be a continuation of the renal concretion. On descent having been com- pleted, the sufferings which accompanied it generally cease; the patient enjoys a period of comfort ; and he is apt to imagine himself rid of the malady. Uneasiness, however, returns ; and in no long time the symptoms of stone in the bladder become marked and characteristic. The water is passed with unusual frequency, and with more or less pain. Desire to evacuate the bladder is not only frequent, but sudden and irresistible ; and the evacuation does not bring relief. On the contrary, the pain, which existed during micturitionj is ag- gravated when the bladder is empty, and when spasmodic contraction 2 E 418 VESICAL CALCULUS. of the middle coat brings the morbidly sensitive mucous membrane into direct and rude contact with the calculus. The pain is referred chiefly to the point of the penis, with a sensation as if something lodged there ; and, in consequence, the prepuce and end of the glans are liable to be pinched and pulled by the patient involuntarily. This especially takes place in children ; and in them it is common to ob- serve the forefinger and thumb pale and sodden in their points, like those- of a washerwoman. "We may find elongation and oedema of the prepuce, from the same cause. A slight change of posture may induce the desire for micturition. It is sure to be induced and ag- gravated, as well as the pain, bj exercise ; more especially, by being roughly jolted in a cart or other carriage ; and then, too, we may expect the urine which is passed to be more or less bloody. A stoop- ing posture is usually adopted during micturition ; sometimes the patient rests on his knees and elbows ; sometimes he leans over and rests on his head ; the object being to avert pain, by removing the calculus from the most sensitive part of the bladder — the trigone. The water at first may flow in full stream, and then it may stop suddenly ; the stone having moved to the posterior orifice of the urethra, and tem- porarily occluded it, causing aggravation of pain. By change of posture, the stone is dislodged, and the flow restored. The stone, acting constantly as a source of irritation to the lining membrane of the bladder, induces congestion there ; increase and change in the secretion result ; mucus coming in greater quantity, and more viscid than usual ; — a wise provision, the tenacious mucus adhering to the mem- brane from which it was secreted, and protecting it, to some extent, from injurious contact with the calculus ; what is redundant is discharged with the urine. And hence a common symptom of stone is, the presence of such mucus in the urine ; settling down in the bottom of the pot, and often showing itself there in great quantity, on the water being carefully poured ofi". If a chronic inflammatory process have been lit up in the inner coat, the mucus degenerates still farther, and resembles purulent matter. If true inflammation have occurred, and the membrane have ulcerated, the bladder will contain more or less of true pus. And under such circumstances, the urine vdll generally be found dark-coloured, turbid, alkaline, and foetid. The rectum sym- pathizes, more especially in children ; the bowel becomes irritable ; or hemorrhoids form ; or prolapsus ani occurs. Frequently there is sympathetic uneasiness elsewhere ; the testicles may be tender and retracted, from time to time ; pain often shoots down the thighs ; and unpleasant heat is sometimes complained of in the soles of the feet. The symptoms are not uniformly severe, but are liable to remissions and exacerbations ; the latter, termed " fits of the stone," are attended with gi'eat agony — as the self-performed operations of the blacksmith VESICAL CALCULUS. 419 of Amsterdam and the cooper of Konigsberg abundantly testify.* These aggravations are induced by exercise, error in diet, or constitu- tional disorder ; and the greater part of the suffering, it is probable, is directly dependent on spasm of the muscular coat of the bladder. The symptoms also vary according to peculiarity of constitution. One patient may suffer intensely, enjoying scarcely a moment's ease ; while another complains but little, and follows his usual avocations, little disturbed ; and yet the local circumstances may be very similar in both. And again, a variety in suffering is found to depend very much on the nature of the stone and the diathesis. The mulberry occasions more uneasiness than the smooth uric concretion ; the rough and sharp no- dules of the former coming into frequent and injurious contact with the lining membrane of the bladder. And the phosphatic stone will probably occasion more suffering than either ; the general system be- ing more deranged, as well as the mucous membrane ; and both being consequently prone to resent the stone's stimulus ; in other words, both the general and the local sensibility are morbidly increased. Also, with a varying diathesis, the intensity of the symptoms will vary. The uric concretion at first gives little trouble ; but it becomes coated with oxalate of lime, and increase of pain may come with the forma- tion of nodules ; again the uric diathesis prevails, the rough eminences are levelled by the new deposit, the surface once more is smooth, or at least even, and a remission in the symptoms is experienced. But then the phosphatic diathesis ensues ; both kidneys and bladder are advancing untowardly in disease ; a layer is forming of the ammoniaco- magnesian phosphate, or of the fusible calculus ; and the symptoms are more severe than they have yet been. For not only is the aggra- vation of the symptoms local ; the constitution also suffers, and that seriously. By supervention of enlargement of the prostate, the symptoms may be either mitigated or increased. If the gland simply increase in bulk, the former result may take place ; the swelling coming to occupy the most sensitive part of the bladder, and consequently saving that from contact with the stone. But if the gland be ulcerated towards the bladder, and the stone rest in contact with the ulcerated surface, suffer- ing will be greatly aggravated. The most ordinary and diagnostic signs of stone are : frequent, sudden, irresistible, unrelieved desire to make water ; pain at the point of the penis, after the bladder is empty ; mucous urine, occasionally bloody ; occasional stopping of the flow of urine, and restoration of the flow by change of posture. These fully warrant the surgeon in sus- pecting the existence of vesical calculus, and in adopting the necessary * Goaded on by torture to the desperate effort of ridding themselves from the stone bj' their own hands. 2 e2 420 VESICAL CALCULUS. means to detect it ; but of themselves, they never prove the existence of stone. The general symptoms of stone — and even these, the most pointed of them — may be very closely simulated by other affections ; by organic disease of the kidney, by renal calculus, by irritation or organic disease in the rectum, by disease of the coats of the bladder, by prostatic aflFection, by stricture of the urethra. Certainty can never be arrived at without the use of the sound. The continued irritation, by the stone's presence, induces serious change in the coats of the bladder. The mucous membrane, as al- ready seen, becomes congested, and sustains perversion, of its secretion ; the mucus is at first viscid and clear, afterwards discoloured and phosphatic. By a chronic inflammatory process the membrane may be thickened ; by true inflammation it may ulcerate, discharging pus copiously. The muscular coat, under frequent stimulus to contract, and frequent obedience to that stimulus by violent and spasmodic con- traction, becomes hypertrophied ; after death, the fasciculi are seen coursing in their interlacements, salient and strong, with depressions between. The cavity of the viscus is contracted ; and such diminution in capacity is usually proportioned to the increase of bulk in the muscular fibre. Between the fasciculi, the depressions get deeper and deeper ; and frequently the mucous coat becomes protruded outwards, so as to form pouches or sacs, of greater or less size ; within which a calculus may become embayed, or a fresh concretion may form. Ab- scess may occur between the coats ; usually discharging itself into the viscus ; sometimes opening outwards, by perforation, into the cavity of the peritoneum, or into the deep areolar tissue of the pelvis — either event most hazardous — or into the rectum. And thus, in three ways, a cavity may be produced for the encystment of calculus ; by internal opening of a parietal abscess ; by hernial protrusion of the mucous coat, outwards, through the muscular ; by deepening and enlargement of a depression between the hypertrophied fasciculi. The inflam- matory process may invade the whole coats ; chronic or acute. Gan- grene has sometimes occurred ; ulceration and abscess are not unfre- quent. In the aged, chronic cystitis is almost inevitable ; then the phosphatic mucus, which attends this afiection, increases the growth of the stone ; and phosphatic deposit, becoming entangled in the viscid mucus which adheres to the lining membrane, may lay the foundation of other concretions, or constitute a broad adherent layer of calculous matter. The prostate sooner or later becomes enlarged, in those advanced in years. The kidneys suffer more and more by derange- ment of function ; ultimately organic disease is not improbably pro- duced. And under such advancement in disease and sufiering, it need not surprise us that the issue of the malady is death. At the same time it is not to be forgotten, that many a patient, with large stone, VESICAL CALCULUS. 421 bulky prostate, and diseased bladder, lives for years, and may die of an ailment with which the stone is unconnected. The effects of time on the stone itself are important. The most obvious is enlargement ; slow, in the case of the mulberry ; in the uric, seldom rapid ; in the phosphatic, rapid and untoward. And be it remembered, that whatever the nature of the original concretion be, its ultimate coatings will be phosphatic, if it remain long ; its irritation never failing to induce the phosphatic depravity of secretion, in the kidney and in the mucous coat of the bladder. By sacculation of the bladder's walls, an opportunity is afforded for encystment. And if this take place, the symptoms are all mitigated — may, indeed, wholly dis- appear. But the stone slowly receives addition within the pouch ; and probably will come to project through the aperture of communication. On such projecting portion, deposit takes place with greater rapidity ; and then we may expect the symptoms of stone to be revived more or less intensely. Occasionally, the stone undei^goes spontaneous disrup- tion ; sometimes after unusual violence of exercise, sometimes in con- nection with no assignable cause. In such cases, the stone is usually phosphatic ; the particles being more loosely aggregated than in the uric or mulberry concretions. The event is generally to be regarded as untoward, when the stone is of any considerable size.* Indeed, unless speedy relief be afforded by our art, the issue is almost certainly fatal. The sharp irregular fragments inflict great injuiy on the urin- ary organs ; some may obstruct the urethra, causing retention of urine, with its various calamitous results ; the rest excite cystitis, acute and intense ; the bladder becomes filled with coagulated blood, and from this cause a formidable retention of urine may result ; the kidneys sympathize ; and, under a complication of disorders, the system is apt * A small stone, spontaneously disintegrated, may be expelled by the urethra, without much suffering, and ■\vith no danger. Fig. 141. Bladder containing a calculus in fragments. Spontaneously disrupted . Termination fatal ; by inflammatory action. — Liston. Elements, p. 633. 422 TREATMENT OF STONE IN THE BLADDEE. to be overborne. Lately a case occurred under my observation, in which the immediate perils of retention by coagula in the bladder were got over, as also the first brunt of the cystitis ; but at the end of the third week, the patient perished by abdominal peritonitis, found to result from extravasation of urine through perforating ulcer of the bladder. In a few very rare cases, ulceration of the coats of the bladder has had the happy effect of permitting spontaneous exti'usion of the stone ; through the abdominal parietes, in the hypogasti'ic region ; into the rectum ; or into the vagina. But such a result, so rare, hazardous, and improbable, manifestly cannot be taken into account in considera- tion of ordinary treatment. Treatment of Stone in the Bladder. No treatment can be adopted Avith propriety, until an absolute assurance has been obtained of the existence of stone. And this can only be secured, as already stated, by Sounding ; a simple operation, yet one requiring tact and care in its performance. The introduction of an instrument by the urethra, and its movement in the bladder during perquisition, must always be attended with more or less suffer- ing — unless an£esthesia by chloroform be employed ; and there must always be a gi-eater or less risk of undue excitement following. It can readily be understood how the careless and rude use of a sound in an irritable bladder and patient — had recourse to after walking, or travel- ling in any way, and not protected by rest and suitable treatment afterwards — may induce a most serious cystitis, with implication of the kidney ; and it is salutary to remember that a cystitis thus caused has once and again proved fatal. A patient — say from the country, and just arrived — presenting himself with the ordinary symptoms of stone, is not at once to be sounded, and at once dismissed. We should first ascer- tain that pulse, kidney, and bladder are sufficiently quiet to admit of this operation being practised Avith impunity ; and, after its performance, rest should certainly be enjoined for some time, perhaps with sedative, or even antiphlogistic treatment. It is in itself an important operation, and should be regarded as such. In children, and in irritable adults, it is well to use chloroform, as formerly stated fPrinciples, p. 793). The instrument is of steel, of medium size, straight tiU within two inches of the extremity — where it is sharply curved — and furnished vnth. a broad and smooth steel handle. Of steel, and broad in the handle, so that its impingement on the calculus may be the more dis- tinctly felt ; and of a sharp, short curve at its end, so that the straight portion being in the urethra, while the whole of the curve is within the bladder, the end may be moved about in that viscus freely, and in all directions ; of medium size — not so large as to be gi'asped tightly by SOUNDING. 423 the urethra, and so be limited in its movements — and yet large enough to afford a steady grasp to the operator, with surface enough for readily striking the stone. The bladder should be as much dis- tended by retained urine as the patient can conveniently bear ; so as to afford room for the instrument's play. The patient is placed recumbent ; and, the sound having been gently introduced, the convexity of its curve is pressed in the direction of the ordinary site of stone — at the most dependent part of the Fig. 142.^^^==^ " bladder, behind the prostate. There, a hard substance being felt, the instrument is moved sharply, with a gentle striking movement ; and, in addition to the rub which was at first conveyed to the operator's hand, a distinct elide will be heard, while a more defined and vivid impression of impingement on a foreign body will be felt. And without this combined indication of touch and hear- ing, the surgeon should never be satisfied of the existence of stone. If nothing be found in the ordinary site, the instrument's point must then be moved carefully and inquiringly in every direction ; groping at first, as a probe ; and, on finding resistance, moved with a sharp yet gentle stroke. Of four sources of fallacy we must be constantly on our guard ; the rub of the end of thesound on fasciculi of the bladder;* the grating of it on calculous matter entangled in the mucous lining ; the rub of a rough and enlarged prostate ; and the rub and grating of calculous matter in the prostatic or membranous portions of the urethra. If nothing is found in the ordinary site and in the ordinary way, posture is changed, and the search renewed ; first in the erect posture, and then with the patient stooping much forward. The space above the pubes, in the latter position, is particularly explored. The stethoscope may possibly be of service, applied over the region of the bladder ; but it is difficult to repress the thought, that wherever a stone actually is, the signs emitted by the sound's use will be sufficiently distinct, without the aid of mediate auscultation. Change of posture having failed to detect stone, change in the state of the bladder may next be tried. The urine may be allowed to dribble away by the side of the sound ; and, as the bladder contracts, the sound is moved gently in various directions, so as to favour distinctness in the sensation of con- * In using the catheter for retention of urine in the aged, a fasciculated portion of the tluckened bladder sometimes comes suddenlj' in contact with the end of the instrument, interrupting the urine's flo-vv, and giving the sensation of stroke or rub to the operator's hand. This, to the unwary, may simulate the presence of stone; and has to be guarded against accordingly. — Vide Adams on Diseases of the Prostate, pp. 76, 77. Fig. 112. Sounding. The stone in its ordinary position. 424 SOUNDING. tact should the stone descend upon it. Or a catheter, shaped like the sound, may be substituted; and, during rapid contraction of the bladder, contact may be ascertained. After failure by all the ordinary means, success has followed the use of an elastic catheter in this way : — With the bladder full, the patient, erect, makes water in a fuU stream through the instrument; and, as the last drops escape, the stone falls on the point of the catheter and is felt. Whenever difficulty is experienced in detecting a stone, in a case of plain symptoms, it is better to repeat gentle exploration at intervals, than by one continuous and prolonged perquisition to endanger the occurrence of cystitis and sympathy of the kidney — perhaps peritonitis by extension, and death. In children, the prudent surgeon is not satisfied with any obscurity ; the click and rub must both be very dis- tinct ; the restlessness and crying of the patient being otherwise apt to lead to deception. It is chiefly in such cases that blank lithotomy has been performed. And to guard against this, it is in such cases that the use of chloroform is especially serviceable (Principles, p. 793). But, by the sound's use, we may ascertain some of the characters of the stone, as well as its existence. Moving the point over the stone's surface, we may be able to estimate the smoothness or rough- ness of it. Passing it over, and on all sides of the stone, we may obtain some idea of its form and bulk ; and, by the finger of the other hand in the rectum, we may sometimes be greatly assisted in this con- clusion, by feeling its weight, as it were, while at the same time its diameter, at least in one direction, is made apparent.* Moving the sound in the bladder, we may have a distinct sensation of one stone being left, while another is encountered by the instrument ; or plura- lity of stones may be indicated by another circumstance, the stroke of the instrument eliciting different sounds at different parts of the blad- der — the sounds differing as to clearness, and as to pitch or tone. Also, a large stone is at once detected ; a small one may long elude the sound. And again, while the rub and grating imparted by a large stone are most distinct, the click of a small stone is more clear and defined ; and the following practical inference may be almost arrived at — the smaller the stone the sharper and more distinct the click ; the larger the stone the more palpable the feel. Further, when the symp- toms have been of long duration, we may expect a large stone ; and vice versa. Also, phosphatic formations are apt to be larger than those of any other kind. Having, by sounding, ascertained the existence of Vesical Calcu- lus, the treatment of it naturally resolves itself into the following indi- cations : — * It is right to remember, however, that, in the adult, stone may not be felt by the finger in the bowel. NATUEAL EXPULSION OF STONE. 425 I. Assist Nature's effort to expel the offending hody. — This, obviously, is applicable only to calculi of small size ; those, for example, which have recently descended from the kidney. Their natural progress is outward, with the current of urine. And in females this is usually effected readily ; the urethra being short, straight, capacious, with its current impetuous ; and hence one reason why vesical calculus in the female is rare. In males, however, there are many obstacles. The urethra is both long and tortuous, it is comparatively narrow besides, and its current is proportionally defective in expulsive force ; spasm, too, is liable to interfere. And yet, judiciously assisting Nature, small stones may be thus got rid of; by dilatation of the urethra, diluents, and forcible voidance of the urine. By the occasional introduction of bougies the urethra is brought to more than the normal dimensions, while its irritability is also diminished;* and by the use of diluents the flow of bland urine is considerably increased. It is well, also, to accustom the bladder to considerable distension by its contents. Then, with the bladder full, and the urethra occupied by a full-sized bougie, the patient stands stooping ; and, the bougie having been suddenly withdrawn, evacuation is made in as full and forcible a stream as possible. In the case of enlarged prostate, the main obstacle to the escape of a smaU stone by the urethra is at the lower or posterior part of the outlet ; it is well, therefore, under such circumstances, that the patient expel his urine in a recumbent and prostrate posture. The only objection to this mode of treatment, is the risk of arrest in the urethra, inducing retention of urine with its many dangers. II. Attempt Disintegration, medicinally. — Attempts at expulsion hav- ing failed, or being deemed inadvisable, the following other modes of removal may be thought of: solution within the bladder, forcible abduction by the urethra, disintegration by mechanical means, exci- sion. The first of these indications may be attempted in two ways : by medicines given by the mouth ; and by injections into the bladder. Of the former class of remedies, the alkalies are the most prominent ; especially the carbonates of soda and potass, given in small doses very copiously diluted — imitations of the natural waters of Vichy, of repute in calculous disorders. The oxalate of lime calculus resists their influ- ence. But the uric formations may be benefited in two ways ; alka- lies thus given tend to correct the diathesis whereby the calculus has arisen, and at the same time have undoubtedly a sedative and correc- tive effect on the urinary oi'gans — improving the secretion of the kid- neys, and assuaging the irritability and disorder of the mucous coat of the bladder. They arrest gi'ov^'th, and palliate the symptoms of stone ; and experience would seem to say, that a slow and uncertain dimi- nution of the stone occurs during their sustained use. Further, the * It has beeu proposed to introduce belladonna into the rectum, so that the neck of the bladder may be relaxed and dilated — like the iris. 426 MEDICINAL DISINTEGRATION OF STONE. voice of experience certainly conveys the fact, that their continued use — provided it be in small doses, greatly diluted — has no injurious consequences either on the renal secretion or on the general health. In the case of phosphatic formations, large doses of alkalies must prove prejudicial ; but doses such as already mentioned fail to do harm, and at the same time seem to have the eifect of favouring gradual disintegration of the stone, by solution of the animal matter whereby the calculous particles cohere. Further experience in the use of these simple lithontriptics is much to be desired. But it is to be feared that the long continued use which is essential, and the uncertainty of the issue, will prevent any general employment of, or confidence in them. No doubt, however, they are of much value, in a subsidiary place ; as means of delaying the increase of uric formations ; favouring disintegration of phosphatic calculi — as a prelude to Lithotripsy, for example ; in all cases of stone, improving the state of the urine and of the lining membrane of the bladder, and so mitigating the distressing train of symptoms.* Solvent injections into the bladder have been in use since 1792 ; with various degrees of expectation. As yet, unfortunately, their suc- cess is far from great ; and we dare only place them in the same sub- sidiary rank as internal lithontriptics. The agents employed have naturally been alkalies and acids ; the one in uric formations, the other in phosphatic ; introduced by means of a syringe operating on a double canula, whereby a constant stream may be kept in play on the calculus within the bladder. The objections are the same as before ; delay in treatment, and uncertainty in effect. The acid injec- tions, however, may be not without their efficacy, as palliatives of the symptoms attendant on phosphatic calculus ; employed weak, as cor- rectives ; not strong, as solvents. Of late, the carbonate of lithia has been supposed a promising solvent for uric concretions ; and the salts of lead have been proposed, as suitable for injection in the case of the phosphatic. III. A method of Snaring has sometimes proved successful, in the case of small calculi. It having been observed that, in removing catheters used on account of retention, small calculi were occasionally found entangled in their eyelets, or lodged in the tube — it was thought that in cases of calculus, this, when small, might so be ensnared and withdrawn. M. Bourguenod was the first to adopt the practice ; and he met with a few imitators. But success depends evidently too much on chance, and that chance is too remote, to admit of the procedure being favourably entertained by the practical surgeon. IV. Forcible Evulsion may be attempted, by the urethra. By the * At all times, however, even the most cautiously sustained use of alkalies must be ■watched, lest serious injury accrue to the system by its over-saturation ivith tlieni. — Vide Lancet, No. 1177, p. 818. LITHOTEIPSY. 427 forceps of Cooper, for example, a small stone may be seized and with- di'awn. But all such proceedings have been justly superseded by Lithotripsy. The perquisition was painful and tedious ; in seizing the stone, the lining membrane of the bladder was liable to receive injury ; and, after seizure, it was not improbable that the attempt at extraction might prove abortive — the stone perhaps becoming im- pacted in the urethi-a, and locked at the same time most inconveniently in the jaws of the instrument. V. The Calculus may he Disintegrated by Instruments. — In fulfilment of this indication there are two methods ; Lithotrity, and Lithoti'ipsy ; the latter the more modern, and preferable. Lithotrity signifies a boring or rubbing of the calculus, in the hope of its becoming pulverized. This was first put in practice — at all events in modern times* — in 1800, by General Martin ; who operated on himself, with partial success, by means of a file. In 1813, Gruithuisen proposed the use of a canula, through which, by means of a wire, the calculus was to be noosed, and then attacked by a borer. In 1819, Elderton invented a more feasible instrument. But neither of these were used in practice. In the same year, Dr. Arnott did good service, in illustrating the capabilities of the urethra and bladder, for the re- ception and play of suitable apparatus. In 1822, Amussat and Le Hoy busied themselves in this department ; the latter most ingeniously. And in 1823, M. Civiale, availing himself of the labours of his pre- decessors, invented a three-branched boring apparatus ; well adapted for drilling stones when caught — equally apt, however, to seize the coats of the bladder, and not very well adapted for disposing of the stone effectually. Its success in practice proved but indifferent. And, now, all such implements have been superseded by the crushing ap- paratus — more simple, safe, and effectual — whose use constitutes Lithotripsy. Lithotripsy. To remove calculus by crushing is a more modern idea than that of boring or drilling. Various instruments have been proposed and used ; some with screws, some with hammers. At present, the voice of the profession apparently j^refers the former ; on the principle of the instrument originally invented by Mr. Weiss in 1824 ; composed of two blades, abruptly curved at the extremity — the one sliding on the other, and propelled by means of a screw. A stone having resisted all endeavours towards its spontaneous expulsion by the urethra — and after, perhaps, a vain attempt has been made towards disintegration by medicinal means — has but two ways * Albucasis and Sanctorius had notions of bruising stones, and invented instru- ments for the purpose. 428 LITHOTEIPSY. of being efficiently dealt with — Lithotripsy, and Excision. Some years ago, a hot controversy was waged between the supporters of these operations ; each party maintaining their adopted procedure to be the best, and applicable to all cases of stone in the bladder ; one party attempting to grind or crush every stone that presented itself, the other using the knife indiscriminately. Fortunately, a better state of things now exists. The well-educated surgeon, finding himself equally well qualified to perform either operation, is in a position to consider, calmly and impartially, the bearings of each case that comes under his care. Some he finds suitable for Lithotripsy, others not ; and so some stones he attempts to crush, and others he at once sets aside for excision. And therein he does well. The one operation does not, and cannot, wholly supersede the other ; and yet there is every reason to believe that often the crushing operation is by much to be preferred ; not less formidable in all cases of stone ; but certainly less formidable in those whose circumstances we recognise as adapted to its use. The indiscriminate employment of the operation, however, has been fully established as somewhat more fatal than the indis- criminate performance of Lithotomy. The cases favourable to Lithotripsy are of the following character: — The urethra must be free from stricture ; the prostate must not be large ; the bladder must be not much diminished in capacity, compa- ratively free from irritability, and not sacculated ; the kidneys must be organically sound. Otherwise, the instruments will not have room for safe and efficient play ; the risk of cystitis will be gi-eat; aggravation of renal disease will be certain ; and fragments, being received into sacculi, will be placed temporarily beyond the reach of treatment, and will enlarge into fresh calculi. The stone itself must be of no great size, and of no great toughness. The mulberry calculus is usually dense and firm enough to resist all the pressure which may be exerted safely ; stones of large size — say of uric formation — are obviously not amenable to the grasp of the instrument ; and, even if they were, the number of rough fragments, and the many seizures which would be required for their pulverization, would obviously tend to serious mischief in the bladder. Further, it were well that no great amount of viscid mucus were secreted from the bladder ; for this, entangling part of the debris, is likely to retain more than one nucleus for the reproduction of stone. Such are the cases favourable for Lithotripsy ; Avhen the urethra and kidneys are organically sound, and the bladder and prostate are but little altered ; the stone small and soft ; the system not irritable. At one time it Avas supposed that the operation should be limited to adults ; the parts of the child being too limited for free and safe use of the instruments. Experience has proved, however, that such objection does not hold good ; and that Avith suitable instruments, carefully and LITHOTEIPSY, 429 skilfully used, Lithotripsy is quite as applicable to the adolescent as to the adult. Even in the favourable cases, Lithotripsy is not w^ithout its risks and disadvantages. In the hands of the most expert, the stone is not always readily and at once caught ; and perquisition may consequently be tedious and hurtful. The fragments must irritate the bladder more or less ; entailing at least some of the hazard which attends on spon- taneous disruption (p. 421). Fragments passing by the urethra create much irritation there, and may induce serious inflammatory action, extending to the bladder; or a fragment maybe arrested in its outward passage, and cause perilous retention of urine. Small portions may remain behind, eluding the sound, and becoming sure nuclei for repro- duction — loose in the bladder, entangled in adherent mucus, embraced by a fold of membrane, or embayed in a sacculated cavity. One ope- ration is seldom sufficient ; repetition is necessary, perhaps once and again ; and, under this, serious constitutional disorder may arise, pro- minently connected with renal disease. It has been well remarked by Dr. Willis, that even the successful cases may present the following degenerate class of symptoms. Although the stone is gone, " the man is not quite well ; irritability of bladder to a greater or less degree remains behind ; this irritability increases ; the constant services of the medical attendant again become necessary. The patient is next tormented with ceaseless pain in the region of the bladder, which by and by extends up the loins, and settles in the back. The urine has never been healthy in its character, or it has altered at an early period of these untoward symptoms ; by and by it becomes like turbid whey; it has a faint, sickly smell ; it coagulates on the addition of nitric acid and when exposed to heat ; the patient loses flesh and strength ; his stomach fails him ; he becomes sick and vomits ; he begins to dose ; and then he falls into a state of coma from which he never awakes ; or he is seized with convulsions in which he expires."* Such, then, we hold to be the true position of lithotripsy ; appli- cable to certain cases of stone ; for these less hazardous than lithotomy, and therefore to be preferred ; always, however, liable to the objections of long time — comparatively — consumed in treatment, risk by repe- tition of the operation, and the danger of exciting or aggravating renal disease. When a favourable case presents itself, the operation is not at once performed ; a certain period of preparation is essential. The general functions must be placed in a healthy state ; tongue clean, pulse natural, bowels open, skin acting well, &c. ; all phlogistic tendency must be overcome, by a certain amount of antiphlogistic regimen ; the urethra — if need be — must be dilated, and deprived of morbid irrita- * Willis on Stone, p. 108, 430 LITHOTRIPSY. bility, by the occasional use of a bougie ; the bladder, too, must be accustomed to tolerable distension. A weak solution of the bicarbonate of potass or soda may also be given ; with the double view of amending the secretion of urine, and assuaging both renal and vesical irritability — especially the latter — at the same time favouring disintegration, by loosening cohesion of the calculous particles (p. 425). Circumstances being deemed favourable, the patient is placed recumbent, on a convenient table, bed, or couch ; Avith the pelvis ele- vated on a cushion — so as to throw the stone into the fundus of the bladder, away from the neck ; and with the bladder as full of urine as possible, in order to admit of seizure, retention, and crushing of the stone taking place within the cavity, at a safe distance from the coats. And if there be any doubt as to the quantity of urine retained for this purpose, let a sufficiency of tejjid water be slowly injected by means of a syringe and catheter. Then the lithonti'iptor, having been intro- duced — with its curved portion of the fixed blade hollow, so as to prevent inconvenient impaction of fragments — is used first as a sound ; Fig. 143. and the stone is usually struck where it is to be expected, at the then most dependent part of the viscus. On the mucous coat of the bladder at this point, the convexity of the instrument is made to press, while at the sametime the thumb of the right hand moves the sliding blade backwards ; then a slight wriggling movement is made with the wrist ; and the stone, tumbling into the depression made by the dovmward pressure of the instrument, is felt between its jaws and secured. The direction of the lithontriptor— ;-now holding the stone firmly — is then changed, so as to bring the stone into the supposed centre of the viscus ; away from the mucous coats, and with urine all around. Then the Fig. 143. Plan of lithotripsy. The stone caught, and the insti-ument in a suitable position for crushing. LITHOTEIPSY. 431 screw is applied, and the work of crushing proceeded with. But if there be any doubt as to the instrument being free of the lining mem- brane, it must, in the first instance, be moved from side to side, or turned round, so as to make sure of this essential point. A small friable stone may be pulverised at one seizure. Usually, fragments are made ; which in their turn require separate seizure and crushing. And for this latter work, a form of lithontriptor is preferable, whose fixed blade is not hollow at the curve ; there is now less chance of clogging such an instrument, and, when imperforate, it is more efiicient in dealing with small fragments, which might in a great measure elude the force of the weapon first used. Enough having been done — and to estimate this, we must consider not only the amount of crushing, but also the patient's tolerance of the proceedings — a full-sized catheter is introduced, shaped like the lithontriptor ; on opening its jaws, urine with the finer of the detritus freely escapes ; and this extrusion — harmless and painless, because passing through the metallic instru- ment — may be favoured by once and again injecting the bladder with tepid water, by means of a syringe fitted to the catheter ; but only pro- vided the feelings of the patient admit of this. The patient is put to bed ; absolute rest is enjoined ; opiates are freely administered, by both mouth and rectum, if need be ; diluents are given ; and antiphlogistic regimen is enjoined. Should excitement threaten, local loss of blood and hip-baths may be required. During some days, fragments and sand continue to pass, with more or less sufifering ; and, by and by, again the urine becomes clear and free. The bladder and system recover from their disorder ; a tolerance of the operation is again established ; and repetition may consequently be proceeded with, with all due caution. When, after one or more sittings, we have reason to suppose that the stone has been completely crushed and passed, careful perquisition is to be made with the ordinary sound, used carefully, while urine is escaping from the recumbent patient ; and repeating this search after injection of the bladder with tepid water. Should such careful searching fail to detect any lurking fragment, the patient may be relie-ved from treatment ; much care being expedient for some considerable time, however, lest either renal or vesical disorder — espe- cially the former — ensue. It has b^en a question whether chloroform should be used or not in this operation ; the objection being that the patient's feelings are useful to determine whether or not injury to the bladder's coats is avoided, and that in deep stupor the urine is apt to dribble away in- voluntarily, perhaps emptying the bladder ere the operation is well begun. The former evil may be escaped by care and skill in handling the instruments, the latter by pressure of the fingers, or the use of a jugum penis. The advantages of anassthesia are evident ; especially 432 LITHOTOMY. in relaxing all spasm, as well as voluntary effort, which might impede manipulation. Lithotomy. This operation is very suitable to children. It is preferable to lithotripsy in adults when the stone is large, and when it consists of the oxalate of lime ; also when the bladder is intolerant of perquisition and distension. There are various modes of performance ; the lateral and bilateral ; the high operation, or supra-pubal ; the recto-vesical. For ordinary cases, the lateral is much to be preferred. As early as the year 318 B.C., the ancients cut out stones, by incising the perineum freely, the stone having been made prominent there by fingers introduced within the rectum ; and this operation — "cutting on the gripe" — continued in use till the sixteenth century. In 1525, Johannes de Romanis, of Cremona, incised the bulb on a sound, prolonging the wound into the membranous portion of the urethra ; the neck of the bladder he then dilated by male and female conductors, until the wound was deemed sufficiently wide for the introduction of forceps and removal of the stone. This operation — termed, from its complexity, the method by the "apparatus major," or the Marian method, from the name of an especially eloquent advocate of its superiority to all others — continued in vogue until 1697; pro- ductive, however, of only indifferent success. In that year, Frere Jacques appeared; the advocate of incision, as preferable to laceration ; at first cutting recklessly and ignorantly into the perineum, by an instrument very like a dagger ; afterwards operating with a common scalpel, and incising the prostate and neck of the bladder with scientific precision — having specially studied anatomy under Duverney at Ver- sailles. This was the foundation of the lateral method; afterwards practised with much success by Raw in Holland, and subsequently by Cheselden in this' counti'y — but not successfully by the latter surgeon, until he had recovered fii'om mistakes into which he had been led, by the disreputably mj'-sterious use which Raw had made of the know- ledge which he obtained from the honest Friar. We shall describe the lateral operation as ordinarily performed by modern surgeons ; and more especially as we were taught it by the late Mr. Liston. From his high authority, in one point onVy would we venture to dissent. He was opposed to much preparation of the patient ; conceiving that delayed expectation of the event operates injuriously on the mind, and disposes to sinking, or at least to asthenic results. On the contrary, we think preparation quite as essential here as in the case of lithotripsy. We hold that it is necessary to subdue phlogistic tendency, to rectify general function, to quiet the bladder and system, and to amend the state of the urine — before the LITHOTOMY. 433 operation can be performed under auspicious circumstances ; and that such preparation ought invariably to be completed, whether the time occupied be of weeks or days. Among other items of management, the carbonates of soda or potash, in weak solution, not only may be expected to produce the good effects on the bladder formerly mentioned (p. 425) ; but besides, the urine, by their use become less acrid than usual, will prove less hazardous in the event of infiltration in the wound.* The patient is placed on a firm table, of convenient height ; and is bound securely, hand to foot, by stout tapes. In no operation is anaesthesia by chloroform more suitable or safe (Principles, p. 794). It is well to clear the lower bowel, the evening before, by an enema, or by castor oil ; and the bladder should be moderately full of urine. A staff is passed, of as large a size as the urethra will conveniently bear ; gi'ooved deeply on the convexity, a little to the left side.f It will be more readily introduced before than after deligation ; and the surgeon should be satisfied, before he proceeds a step further, that it impinges on a stone. If in doubt on this point, let him withdraw the staff, and introduce a sound. It is essential that the stone be felt immediately before the operation. Deligation over, and the staff satis- factorily passed, the patient's nates are brought to project a short dis- tance over the end of the table ; and there he is to be secured by assis- tants ; one placed behind, with a hand on each shoulder, ready to oppose any involuntary movement away from the operator ; and one to each limb, holding them apart, and pressing each femur firmly down into the acetabulum, so as to fix the pelvis and at the same time fully expose the perineum. To the principal assistant, the staff is intrusted ; to be held very steady, in a vertical position, and hooked up against the pubes — as much space as possible being thus made between the mem- branous portion of the urethra and the rectum ; and the same assis- tant keeps the scrotum elevated. The surgeon, seated in front, at such a height as to bring his hand conveniently on a level with the perineum — and with all the instruments he is likely to require spread on a towel or tray on the floor by his side, so as to be within easy reach when wanted — introduces his left forefinger into the rectum, to make sure of its being empty, and to stimulate it to contraction. The knife — ^longer than the common scalpel, especially in the handle, and with the posterior two-thirds of the edge blunt — is then entered in the perineum — previously well shaved — about an inch in front of the * An American surgeon, of great repute as a lithotomist, attributes his success not to any peculiarity in the mode of operating, but solely to his long-continued and careful preparation of the patient. f The late Mr. Key used a straight staff. — (Treatise on Section of the Prostate in Lithotomy, London, 1824). Dr. A. Buchanan uses and recommends a rectangular staff. —(Monthly Journal, Feb. 1848, p. 554). 2 i- 434 LITHOTOMY. anus, on the left side ; and is carried downwards beyond the anus, passing about midway between that orifice and the tuberosity of the ischium, through the skin, fat, and superficial fascia. The forefinger of the left hand is then placed in the wound, and directed upwards and onwards ; with the double object of keeping the bowel out of harm's way, and dilating the space — pushing aside areolar tissue, but not tearing muscular fibre. With the knife's edge, the fibres of the transverse muscle of the perineum — if it exist — are divided, along with such fibres of the levator of the anus as resist the free onward passage of the finger. The groove of the staff is now sought for ; and the finger I'ig. 144. is moved freely, so as to dilate the outward wound sufiiciently — a touch of the knife's point being applied, warily, to any resisting part. Behind the triangular ligament, and in front of the prostate, the finger nail is lodged in the groove ; and over it the knife's point is made to perforate. The knife, felt distinctly on the staff, is then pushed onwards in the groove, obliquely downwards and backwards ; so as to divide the portion of the urethra which intervenes between the point of the knife's entrance and the prostate gland, and also the anterior part of the pros- tatic portion of the urethra. In other words, space enough is made for introduction of the finger, which follows the knife ; and the base of the prostate gland is left intact. The finger, introduced and moved freely, increases the space considerably ; the substance of the prostate being very capable of dilatation. And this dilatation of the wound is preferable to free incision ; there being much risk in cutting through the reflection of the ileo-vesical fascia, which is situate at the base of the Fig. 144. Plan of the lateral operation of Lithotomy. The knife entering the urethra. LITHOTOMY. 435 prostate, and which serves as an important boundary between the deep and superficial areolar tissue. By leaving this entire, the principal danger by urinary infiltration is shunned. And by dilatation of such a limited wound as now described, ample space is afforded for the introduction and play of forceps, and for the extraction of ordinary calculi.* Large stones require particular expedients, to be afterwards explained. In fact, the rule in this lateral operation is, to have a free external wound, and a small internal one ; the latter, when dilated, extending from the point of puncture in the membranous portion of the urethra, to near the base of the prostate ; the former varying in extent according to circumstances ; always large and free, and largest when either a deep perineum or a bulky stone is expected to be encountered ; for, the yielding of the surface both gives room and diminishes depth, in the work of extraction, as well as in the formation of the deep wound. In withdrawing the knife, some little care is necessary, lest the edge should inadvertently come too near the ramus of the ischium, and endanger the pudic artery. The making of the deep wound requires deliberation and care ; and it is expedient that the points of the finger and of the knife should move together, in order to secure exactness. In athletic adults, naturally of a deep perineum, and who are not in a state of anaesthesia, difficulty may be experienced at this stage by straining of the muscles, whereby the bladder is elevated in the pelvis, and the parts conse- quently removed from the control of the finger. Under such circum- stances, it were rash to proceed with the knife alone. The operator must withdraw the knife ; and, keeping his finger in the deep wound, he should wait patiently until the straining or spasm has ceased ; establishing the full influence of the chloroform ; or reasoning with the patient on the propriety of his being as passive as possible — if he be not anaesthetized ; and resuming the operation, when the parts to be incised are again found to be within his finger's reach. While the forefinger dilates the deep wound, the urine escapes more or less rapidly ; and we expect that the stone, descending in consequence, will be distinctly felt. Then the staff is gently with- drawn ; by means of the finger moving in contact, a more precise idea of the nature of the stone or stones is obtained — as to size, number, shape, and position ; and to the circumstances thus ascertained, the subsequent proceedings are adapted. If, for example, the stone be found of larger size than what the surgeon knows will pass readily through the aperture he has already made, an addition of space may be gained, without tearing, and without the division of any parts * Too sparing a wound of the prostate is also to be avoided ; otherwise sufficient space can be obtained only by tearing. A dense unyielding structure, demonstrated by Liston and others, at the posterior part of the gland must be divided, in order to admit of easy dilatation. Vide Listen's Pract. Surgery, last edition, p. 510. 2 F 2 436 LITHOTOMY. which it is expedient to retain entire — by passing a straight probe- pointed bistoury over the forefinger retained in the wound, dividing the prostatic region of the urethra on the right side, to the same extent as on the left, and then renewing dilatation. When the stone is ex- pected to be of considerable size, the surgeon should be prepai*ed to adopt this bilateral incision from the first. The wound being deemed sufficient, and the finger being in contact with a stone of ordinary character, forceps are introduced, for seizure and extraction. These should be, in length of handle and capacity of blades, proportioned to the size of the stone ; the object being, that the blades shall embrace the calculus at as many points as pos- sible, and that the handles shall be long enough to give a full power in extraction. The blades are partly lined with calico, so as to diminish the chance of the stone slipping from their grasp. An instrument, suited to the stone, having been selected, is passed over the finger to the deep wound ; and, as the finger recedes from this, the forceps enter and come in contact with the stone. If this is not at once felt, the handles should be elevated, so as to depress the blades to the part of the bladder where the stone is most likely to be. The blades are opened, and, by a catching movement of the instrument, seizure is effected. If any suspicion exist that a portion of the bladder may have been included along with the stone, the instrument is turned round so as to test this ; freedom of movement implying freedom of the bladder. Seizure having been accomplished, the axis of the forceps is changed ; the point is raised, and the handles are depressed. The forefinger is then re-introduced by the side of the instrument, and between the blades, to ascertain in what direction the stone is placed, and to rectify the position if necessary. For example, if an oval uric calculus have been seized in the transverse direction, it will not pass through the deep wound without much violence, if at all. The jaws of the instrument are slightly relaxed ; and with the forefinger's point the stone is gradually and carefully shifted, until the long diameter presents to the wound. Then the extracting force is applied ; press- ing the handles to each other as much as is necessary to prevent slipping of the stone, and not so much as to endanger its being broken ; directing the handles, and consequently the extracting force, according to the axis of the pelvis — obliquely downwards — not jamming the blades beneath the arch of the pubes ; and moving the forceps antero- posteriorly, so as to gain room by further dilatation. By pressure of the finger, the bladder is prevented from descending along with the stone ; or, in other words, counter-extension is made to the extension of the forceps, fixing the bladder, and allowing extraction to be made more effectually than it otherwise would be. After having passed the prostatic wound, resistance may be offered by fibres of the levator of LITHOTOMY. 437 the anus — insufficiently divided by the indsions; this obstacle may be overcome by the finger also ; or it may be necessary to notch the resisting fibres by the edge of a probe-pointed bistoury. In the case of a number of small stones, the metallic scoop will be found generally preferable to forceps. The instrument is first used as a sound, passed through the wound ; the stone, having been found, is moved towards the opening in the bladder ; and then — if not before — being brought in contact with the point of the forefinger, is with- drawn — steadied on the scoop by the finger's pressure. Sometimes the stone is lodged above the pubes, and refuses to de- scend. In such a case, curved forceps are of use ; but the difficulty is of rare occurrence. Bent forceps may also be useful, when, in an old man, the stone is lodged in a deep pouch of the bladder, behind a prostate very much enlarged. The stone may be encysted ; a part only projecting into the bladder. The forceps seizing the projection may bring the whole away ; if not, it may be necessary — when the part is within reach of the finger's point — to dilate the cyst's orifice slightly, by a probe- pointed bistoury. If the stone be firmly impacted, and not to be loosened safely by the bistoury's edge, the operator must have recourse to expectancy. The wound is occupied by a full-sized tube ; and, during the suppurative stage that follows, it is hoped that the textures may relax, and the stone be disengaged. Then it may be removed in the ordinary way — as has been experienced. Fortunately, however, such a complication is of rare occurrence. On one occasion, in contending with an encysted or sacculated stone, it was found impossible to seize the stone otherwise than with the coats of the bladder in which it was held. Retaining it thus by the forceps, bringing all down within reach of the finger, and with this pushing back the soft parts gently while the forceps yet kept their hold, the stone was extracted.* Should the calculus break and crumble under the forceps, the scoop will be found well adapted for removing the fragments. And in such cases, to make sure that nothing is left behind, it is well to wash out the bladder. This may be done in two ways ; by means of an ordinary enema-syringe, the tube being introduced by the wound ; or, by means of a syringe and catheter — the latter introduced by the urethra — a powerful stream being made to issue by the wound, while the patient is placed in a sitting posture. The stone, or stones — readily felt, by the finger, forceps, or scoop — having been removed, the Searcher is introduced — a metallic sound, with a large bulbous extremity ; and by this each part of the bladder is carefully explored, in order to make sure that no stone or other foreign body remains behind. It is also useful to examine the stones * Monthly Joiinialj Feb. 1848, p. 574. 438 LITHOTOMY. themselves ; if one be removed, and found smooth, or hollowed, at one or more points, we may be tolerably certain that there is at least another in the bladder ; if, on the contrary, a stone is found rough and unrubbed at all aspects, we may conclude that it is solitary. Then a gum-elastic tube is introduced, and retained by tapes fastened to a bandage round the belly ; the tube being of length sufficient to admit of one extremity projecting from the outer wound, while the other is lodged in the bladder ; and of diameter sufficient to afford a free escape to both blood and urine. The nates having been sponged and wiped, the patient is unbound and lifted into bed ; and is there placed with the shoulders elevated, so as to favour outward passage of urine, by sloping the track of the wound. The knees are elevated, and placed slightly apart — supported in the ham, if need be, by a pillow ; and an oil-cloth and sponge are comfortably an'anged for the reception of urine and protection of the bed-clothes. If much pain is complained of, an anodyne is given ; and henbane is preferable to opium, being less likely to interfere unfavourably with secretion of urine. The regimen is antiphlogistic for some days ; and plenty of diluents are given, so as to favour diuresis ; barley water, for example, is taken ad libitum ; and it may not be amiss to medicate it slightly with the alkaline carbonate, so as to ensure the urine being bland as well as plentiful. Copious " wetting " is always a favourable sign ; denoting a healthy condition of the kidneys, absence of febrile disturb- ance, and but slight risk of dangerous infiltration. The tube is retained, until there is reason to believe that the margins of the wound have become " water proof," by consolidation and glazing consequent on plastic exudation (Principles, p. 636); the object of this instrument being two-fold — the prevention both of urin- ary infiltration, and of accumulation of blood within the bladder. It is also useful in the event of hemorrhage from the deep wound, as will be stated immediately. During the first few hours, an assistant should frequently introduce a quill, or other suitable instrument, for the pur- pose of preventing occlusion of the tube by coagulated blood ; but when the urine is coming clear, this precaution may be dispensed with. No dressing of the wound is necessary until the tube is out ; and then simple water-dressing, afterwards medicated as circumstances indicate, is all that is required. When we wish to remove the tube, it is sufii- cient to cut the retaining tapes ; and this may be done after twenty- four hours in the young, but not tiU nearly twice that time has elapsed in the aged — the plastic process being much more speedy and perfect in the one case than in the other. After withdrawal of the tube, the wound contracts by the ordinary process of healing. And, after about eight days — sometimes sooner, sometimes later — uneasy sensations are begun to be complained of in the urethra, betokening restoration of its function as to the passage EISKS OF LITHOTOMY. 439 of urine. The first flow by the natural^ channel is partial, and accompanied with pain ; day by day, less and less comes by the wound, and the uneasy sensations in the urethra disappear. Ultimately the wound heals, and all is normally re-established. If any unusual delay occur, it may be necessary to pass a catheter gently ; in order to ascertain the state of the tirethra, and clear away obstruction if necessary ; at the same time inviting the flow to its original course. During the after part of the treatment, diet is gradually amended, as circumstances indicate ; the erect posture is resumed, and the patient may be permitted to move about a little, even before the external wound has quite contracted. Such medical treatment, by hygiene, will be continued, as is suited to prevent recurrence of the diathesis on which the stone's formation depended. The operation, in many cases, seems to have the effect, not easily explained, of changing the system wholly in this respect — reproduction of stone, after Avell-per- formed lithotomy, being by no means common ; yet it is well in all cases, by maintenance of due prophylaxis, to leave no means untried of preventing so unpleasant a relapse. Such is the usual result of an ordinary and successful case of litho- tomy. But there are risks and casualties which now fall to be con- sidered. I. Hemorrhage. — If there be a transverse artery of the perineum, of any considerable size, it may be troublesome by bleeding ; it cannot be avoided in the incisions ; but it can very readily be ^^secured by ligature. By attending to the following circumstances, wound of the artery of the bulb will be avoided, when that vessel follows its ordinary course ; making the free external incision of no greater depth than the superficial fascia ; cutting afterwards on a low level — sloping the main wound obliquely upwards, from the level of the anus to the membranous portion of the urethra ; never using the knife but with its back directed upwards ; using the finger, to dilate, more freely than the knife to cut, in making the deep wound of the perineum ; taking care to enter the knife's point, in the groove of the staff, behind the bulb ; and, at this part of the operation, invariably moving the knife from the operator, with its back towards him. If the artery follow an unusual course, it may, perhaps, be detected and avoided ; when the operator adopts the safe and good practice, of invariably preceding and accompanying his knife's point with his finger. When the vessel is wounded, three courses are open ; to attempt deligation at the cut point — difiicult, but not impracticable ; to pass an aneurism needle round the trunk of the pudic, on the inside of the ramus of the ischium, securing it by ligature there — also difficult, yet possible ; or simply to apply pressure to the vessel in the latter situation, by an assistant's finger placed either in the wound or in the rectum — main- 440 RISKS OF LITHOTOMY. taining such pressure by a relay of assistance, until bleeding has ceased. Veins or small arteries may bleed to excess, in the neigh- bourhood of the prostate — especially in the aged. This form of hemorrhage is readily restrained by pressure ; pledgets of lint being introduced firmly into the deep wound, along the tube — and retained, if need be, by a T bandage. This is one of the important uses of the tube ; its presence, as an open conduit for the urine, admitting of such plugging being made, with perfect safety as to the chance of urinary obstruction and infiltration.* Arnott's fluid dilator is well calculated to be a successful compressing agent in such bleeding ; the open tube occupying the centre of the apparatus, and the compressing fluid con- sisting of cold water. By cold and pressure it is doubly hemostatic. Secondary hemorrhage sometimes occurs in the aged, in conse- quence of asthenic ulceration in the deep wound ; this requires ordinary hemostatic treatment by general means (Principles, p. 364). II. Peritonitis. — This is the result of inflammation in the deep wound, extending thence to the coats of the bladder, and from the outer coat passing to the general peritoneum. Or it may be occasioned by violence directly done to the bladder, by forceps or scoop. It is accom- panied by its ordinary signs and symptoms ; and is amenable to the ordinary treatment — ^leeching or venesection, calomel and opium, &c. It is obviated by taking care, in dilating the deep wound, not to tear ; by not bruising or tearing the vesical coats in any part, through inad- vertent seizure by the forceps or scoop ; and by never operating while the bladder is in an irritable or excited condition. III. Urinary Infiltration is the most serious risk in lithotomy ; and the one of most frequent occurrence. To obviate it, the following points are of essential importance : Maintain the reflexion of the ileo- vesical fascia entire, at the base of the prostate ; that gland being not divided throughout its whole extent, by the knife — but rather first notched deeply,f and then dilated by the finger and forceps. Make the general wound conical in form ; the base at the integument of the perineum ; the truncated apex at the prostate. Make the general wound also sloping in form, its fall being from the prostate obliquely downwards — cutting obliquely up to the bladder, not directly into it ; also arranging the patient's trunk in bed, so as to favour this sloping form, obviously so well calculated for the ready draining away of the urine. In using the finger in dilatation, avoid all laceration ; torn * For obvious reasons, however, it is well to avoid such plugging if possible. The tube, no doubt, averts risk by urinary infiltration ; but the track of wound, and especially the neck of the bladder, is not likely to heal so kindly as if no such rough manipulation had been employed. Plugging for hemorrhage always affects the prognosis vintowardly. t The notch requires to be tolerably deep, to make sure of dividing the dense inelastic part of the gland, which will not dilate, and the non-division of which would lead to tearing (p. 435). EISKS OF LITHOTOMY. 441 parts being but ill-disposed for rapid plastic exudation. Retain the tube for the necessary number of hours ; and keep it clear from coagulum, or other source of obstruction. Further, the risk by infil- tration is certainly diminished, by not operating unless the urinary organs and general system are free from excitement, the kidney acting healthily, and the urine in a satisfactory condition ; and also by main- taining, after the operation, a supply of urine which is bland as well as copious — mainly aqueous, and containing but a sparing amount of saline matter. For, if infiltration do occur to some extent, it will be less hazardous to part and system under such circumstances, than if the infiltrated fluid were the acrid and scanty urine of fever or of renal disease. Urinary infiltration is indicated by the foUoAving symptoms : — A hot pain is felt in the site of the deep wound, thence creeping up the left hypogastric region, which by and by becomes tender on pressure ; the pulse grows rapid and weak — denoting constitutional irritation, not inflammatory fever ; the skin is hot and dry ; the tongue and lips are parched and dark-coloured ; the wound is dry and glazed in its edges, afterwards emitting a foetid sanies ; and the secretion of urine is in great measure arrested. Ultimately hiccough comes on, the abdomen grows tympanitic, and the patient is carried ofi^in typhoid prostration. The local changes are — sloughing of the infiltrated areolar tissue, under an asthenic inflammatory process ; with thin, foetid discharge. Treatment is by the ordinary means, adapted to bear the system through the irritation dependent on such a cause. And if the wound do not seem free and sloping enough, that defect may be remedied by enlargement of the external wound at its lower part. On the first rising of the asthenic action, we may be for some time uncertain Avhether the case is one of this nature, or peritonitis ; and then a sparing application of leeches over the tender hypogastrium is expe- dient. After infiltration is declared, however, further spoliation or depression is quite unwarrantable. By some it has been thought ad- visable to enlarge the wound, and to divide the rectum at the same time, by the sweep of a curved bistoury ; on the principle of freely incising the infiltrated parts, and permitting the noxious fluids a ready outlet. rV^. Urinary Infiltration and Peritonitis may occur together ; an un- happy combination — known, or at least suspected, by a blending of the signs and symptoms of each. In treatment, it is perplexing to determine whether the one disease shall be more considered than the other. But it is, perhaps, a safe general rule, to award pre-eminence to infiltration ; treating it much in the ordinary way ; in other words, endeavouring to support the system at all hazards, and hoping to afford it an opportunity of struggling through the inflammatory action. 442 EISKS OP LITHOTOMY. V. The Wound may Inflame untowardly ; suppurating copiously ; perhaps sloughing. This is dangerous to a weak frame, by reason of the grave amount of constitutional disorder which attends, more espe- cially when the deep part of the wound is much affected; the patient may sink under inflammatory fever; or he may afterwards succumb to hectic. The inflammation is obviated by care in the use of the finger and forceps while operating — neither tearing nor bruising ; and it is treated by ordinary aittiphlogistic means — cautiously, with a view to the coming chance of hectic tendency under a long open and discharging wound. For, the sloughs must separate ; enlarging the wound, and necessarily delaying greatly the process of cure. VI. Cystitis is to be obviated, by operating only in a quiet state of the bladder ; by avoiding bruise of the prostatic wound ; and by using the forceps and scoop with all gentleness, in reference to the coats of the viscus. VII. Aggravation of Renal Disease. — Plain indication of organic disease in the kidney is in most cases held sufficient to contra-indicate the operation. But the symptoms of this, obscure and masked, may have deceived the surgeon. In such circumstances, the aggravation following on the operation will be subdued with difficulty ; the patient will in all likelihood perish. But there is another source and chance of escape — by chloroform, as elsewhere stated (Principles, p. 794). VIII. Constitutional Irritation may prove dangerous in one of two forms: — 1. As a Shock; the immediate consequence of the operation. This may occur to a grave extent, as after other severe operations ; and the patient may never rally — death taking place within twenty- four hours, by sinking. And here again chloroform is useful as a means to avert such a casualty (Principles, p. 769). Or Hectic may ensue; in consequence of the wound remaining long open, and emitting a copious discharge ; as is apt to occur after inflammation of its track in a weakly patient. Then we have to invite restoration of the urethral flow, by cautious use of a catheter ; to favour closure of the wound, and diminution of the discharge, by suitably stimulant dressing ; and to maintain the powers of the system, by the general treatment adapted for hectic. Sometimes, this state of matters has been found dependent on the presence of another stone within the bladder, preventing closure of the internal wound ; overlooked in the operation ; or, perhaps, since descended from the kidney. Under such circumstances, it is our duty to dilate the wound, and to obtain extrusion of the stone by the scoop or forceps. IX. Erysipelas may occur ; extending from the wound to the nates and thighs, as well as to the perineum and abdominal parietes. It is obviated, by not operating unless the primae vi^e are in a satisfactory condition, and by great attention to cleanliness ; maintaining a proper KISKS OF LITHOTOMY. 443 staff of attendants, who keep the patient dry, clean, and as comfortable as circumstances will allow. X. The Wound may become Fistulous. — It may contract to a certain extent, and then remain stationary ; a portion of the urine continuing to pass through the fistulous track. This remote result is more trouble- some than dangerous. The urethra will most probably be found at fault — obstructed in some part of its course by former stricture, or by recent swelling ; and the catheter or bougie has to be used accordingly. After due clearance of this canal, the perineal fistula will probably close. If not, it is to be treated as obstinate fistulas usually are ; by application of a hot wire, at long intervals (Principles, p. 226). Rectal Fistula sometimes results, by wound of the bowel at the time of the operation ; or it may be caused more remotely by ulcer- ation. The aperture may close, with the rest of the wound. But not improbably it remains open ; faeces finding their way upwards into the track of the general wound, and urine passing into the rectum. Such a casualty is obviated by care, during the operation, in inter- posing the left fore-finger between the knife and the bowel, and always using the former most cautiously. Treatment consists in dividing the coats of the bowel up to the aperture, as in fistula in ano ; but this is not done at once ; an opportunity is first afforded for spontaneous closure. Such are the more important and ordinary dangers and difficulties which attend this operation. We are constantly liable to meet with others, however, which can scarcely be brought under any categorical arrangement ; and yet for them the surgeon must be at all times pre- pared.* The operation of lithotomy, in itself difficult, beset with many dangers, and implicating important parts, cannot be expected to prove very highly successful, even in the most skilful hands. The average proportion of deaths, hitherto — in the general practice of surgery — may perhaps be stated at one in five or six. But as our science and art advance, it is to be hoped that the result will rise propor- tionally. Some individual operators have attained to pre-eminent success in this department ; a pre-eminence apparently due, partly to operative dexterity and skill, partly to careful and judicious treatment both before and after the operation, partly to a wise selection of cases. The age of the patient has much to do with the prognosis. In child- hood, recovery is the rule, death the exception. And the hale old * I had occasion to operate in a case tlius complicated ; tlie outlet of the pelvis was naiTow; the perineum was deep; a cyst existed on the lateral exterior of the prostate; at least two round and distinct medullary tumours projected from the neck of the bladder into its interior ; the stone proved large, weighing six ounces and a drachm, and measur- ing nine inches and a quarter in its largest circumference. The patient sank on the fifth day, under symptoms of infiltration. The deep wound was more free and uncertain than I could have wished : and the operation was necessarily tedious. 444 VARIETIES IN LITHOTOMY. man is more favoui'ably situated than the robust and young adult. As a general rule, however, the chances of recovery diminish "v\4th increase of age — as well as with increase of size in the stone.* Varieties in Liiliotomy. In young children, the operation may be done with a common scalpel. And it is essential to remember that in them the bladder rises comparatively high. The rectum is then the predominant -^iscus of the pelvis; and gi'eat care must be taken accordingly, not to injure it by the knife. The patient may be exempted from deligation ; held firmly on an assistant's knee. The Bilateral Operation. — When the stone is known or suspected to be of large size — too large to pass through the ordinary single wound of the prostate, but not too large to pass through the outlet of the pelvis easily — the wound is made bilateral, as has already been explained (p. 434). But such bilateral section seems quite imneces- sary in ordinary cases. If, unfortunately, the surgeon have been deceived as to the bulk of the stone ; and, after having made his bilateral section with perineal Avound, finds that the stone is too bulky to pass, even were it out of the bladder — he must either proceed to the high opei'ation, or attempt to break the stone, and extract it piecemeal through the perineum. The crushing instruments, necessai-y in such circumstances, need not be described. They are to be found in cutlers' shops, and in the armamentaria of most lithotomists ; but, fortunately, are seldom if ever called into exercise. The simplest form of instrument is probably the best ; strong forceps, the blades armed with teeth, and the handles approximated by a powerful screw. The operation a deux temjjs — cutting into the bladder one day, and attempting to extract the stone on another, during suppurative relaxation — is Mdsely abandoned ; unless in the case of obstinately encysted stone, ah-eady alluded to (p. 437). In no other circumstances is such a plan of operation voluntarily adopted ; but it may be thrust upon an operator by the stern force of circumstances. The Gorget, too, is but little used in the present day. For the blunt gorget, the operator's forefinger of the left hand is a very supe- rior substitute, as a guide and conductor of forceps into the bladder. And the cutting gorget, however modified, can never be so certain or so safe, as a knife's point guided and controlled as we have endeavoured to describe.f In the hands of the careless or inexperienced, a cutting * Vide Monthly Journal, Nov. 1S47, pp. 325 and 326. f Gorget-like knives have been invented, for the purpose of rendeiing the prostatic wound very exact in its limits. But after tiial they have been laid aside, as inferior to the ordinarv knife guided bv the tinger. VARIETIES IN LITHOTOMY. 445 gorget may be the cause of frightful accident. Pushed recklessly on, it is as likely to be out of the bladder as in it. It may pass — has passed — between the bladder and os pubis, pushing up, bruising, detaching, or tearing the peritoneum ; or between the bladder and rectum — as has more frequently been the case ; in either way, favouring the most hazardous infiltration, and perhaps combining this with peritonitis. It has happened, indeed, that by a more heroic thrust, the bladder has been completely perforated, the intestines have protruded, and after death the lobulus Spigelii in the liver has been found wounded ! The Recto-vesical operation is also out of date. It was supposed that, by cutting through the rectum, and thence reaching the posterior part of the bladder uncovered by peritoneum, less hazard would be incurred of peritonitis, hemorrhage, or infiltration. But the misery and even danger of a foul fascal fistula remaining, was found by much to outweigh the supposed safety of the procedure. Under certain cir- cumstances, however, such an operation may be thrust upon us ; as in the case narrated by Mr. Liston, where a large stone was found encysted in the posterior part of the bladder, and bulging into the rectum. In that case after the ordinary opening had been made into the bladder, it was found impossible to dislodge the stone without division of the anterior wall of the cyst ; and that could not be accom- plished, without incising the corresponding portion of bowel. Then the stone was readily extruded.* The High Operation. — When a stone is deemed too large to pass with safety through the outlet of the pelvis, by the perineum, it is to be sought for above the pubes. By a blunt staff, introduced along the urethra, the fundus of the bladder is elevated as much as possible in the pelvis, so as to enlarge the space uncovered by peritoneum on the lower and anterior aspect. A suitable wound is made through the abdominal parietes ; entering the knife immediately above the symphysis pubis, and carrying it upwards as far as seems necessary ; cutting layer after layer, cautiously, until the vesical coats are reached. At the lowest part of the wound, these are punctured ; and, the finger having been introduced into the bladder, the aperture is enlarged to the requisite extent. The stone is seized by forceps, and removed. The wound is brought together, having a short tube — or a slip of lint, syphon-like — at the lower part, by which the urine may pass readily away, and infiltration be avoided. To aid in this indication, the patient is laid on his side ; and perhaps a flexible catheter may also be passed by the urethra, and retained. But with every care, it is difficult to prevent this grave accident — so likely to occur from the non-dependent nature of the wound. And, consequently, the results of this operation are not found to be very encouraging. * Liston's Principles of Surgery, 2d edition, p. 657. 446 PALLIATION OF VESICAL CALCULUS. Recently, an important modification has been suggested ; the pre- mising of a perineal puncture ; a track of wound resembling that of lateral lithotomy, but on a smaller scale ; the internal opening impli- cating the membranous portion of the urethra only. Through this puncture the elevating blunt staff is introduced, and may be worked more efficiently than from the urethra. After removal of the stone, a common lithotomy tube occupies the place of the staff in the perineal wound, and is retained for some days, the urine passing readily through it — the patient's trunk being slightly raised to assist in this. The supra-pubal wound is brought accurately together throughout its whole extent, and union by the first intention hoped for. And thus the operation may be not only simplified in performance, but also the great danger by infiltration may be effectually avoided. Liihectasy. — Another recent proposal is the substitution of Uthectasy for lithotomy ; that is, wound of the membranous portion of the urethra, and gradual dilatation of this — for wound of both this and the prostatic portion, dilatation and extraction following immediately. The operation is simple, and probably safe. Lithotomy is performed on a small scale ; or a puncture is made in the central space of the perineum, above the anus. The membranous portion of the urethra is reached and opened. No attempt is then made to reach the bladder and stone by the finger, but the wound is occupied by sponge-tent, or by Arnott's fluid dilator ; and thereby dilatation is effected more or less rapidly. In the course of twenty-four hours, the space may be expected to be suitable for introduction of instruments, and for removal of a small stone — the neck of the bladder being left undivided, and the great hazard by infiltration being almost certainly avoided.* But the manifest objection to this proceeding is, its slowness and uncer- tainty. Under tedious and painful dilatation the patient is very liable to suffer serious irritation, both mental and bodily ; and a susceptible frame may be irreparably injured thereby. Also, after the allotted period of painful probation has passed, the space may be found insuf- ficient ; the dilator has to be resumed, or the knife is employed ; and, in any way, danger is incurred. Further experience is yet required, ere the merits of this operation can be finally determined. But at present one naturally inclines to think, that it can be applicable only to smaU stones; and that these maybe better dealt with by lithotripsy. Palliation of Vesical Calculus. We are called upon to palliate the symptoms of stone, irrespective of any operation, when the patient refuses to submit to this, or when the circumstances of the case obviously contra-indicate its performance. * Willis on Stone, p. 160. URETHRAL CALCULUS. 447 If the patient is very far advanced in years, and suffers comparatively little from the stone, we decline to operate. When the patient is aged, and afflicted with great enlargement of the prostate — perhaps malig- nant — we cannot expect a successful issue ; and the operation can scarcely be looked upon as a likely means towards Euthanasia. When the kidneys evince organic disease, by albuminuria, renal pain, consti- tutional disorder, purulent urine, &c., we cannot expect but that the operation will cause renal aggravation and death. In these cases, therefore, and such like, we content ourselves with palliating what we cannot cure. All violence and imprudence in exercise and regimen are avoided ; the bowels are gently regulated ; by alkaline or acid remedies internally, the condition of the urine and of the bladder is hoped to be amended ; and by opiates, by the mouth or anus, pain is assuaged. When the phosphatic diathesis is not strongly marked, nothing proves more efficacious than weak doses of the alkaline car- bonates much diluted. Urethral Calculus. Calculus in the urethra is sometimes original ; foreign matter having been in some way introduced from without, and calculous deposit concreting on this as a nucleus. Much more frequently, how- ever, it is secondary ; a vesical calculus having been arrested in its progress outwards. It may be simply impacted in the canal, which dilates behind it ; or it may become imbedded in a cyst or cavity — sometimes formed of the urethral parietes, sometimes of condensed areolar tissue exterior to these. In the latter case, the symptoms may be slight ; there being little obstruction to the flow of urine. Impac- tion in the canal, on the other hand, causes much distress, by pain, frequent desire to make water, and imperfect ability to obey the call. If obstruction is complete, serious danger by retention of urine ensues. The calculus, when situated anteriorly, may be felt by manipulation in the course of the urethra. Treatment varies according to circumstances. 1. If the stone be of considerable bulk, and arrested at the posterior part of the canal — and more especially if retention of urine exist — a catheter is to be introd\iced, by which the stone is dislodged, and pushed back into the bladder. There it can be afterwards dealt with by Lithotripsy. 2. If the stone be small, and situated anteriorly, it is to be brought to the orifice of the urethra, and thence extruded. Such forward movement may be effected by the fingers simply. Or a loop of wire may be insinuated past and behind the stone ; and thus it may be extracted, like a cork out of a bottle. Or it may be seized by small dressing forceps ; or — more readily — by Hunter's forceps. Or a bent probe 448 PREPUTIAL CALCULUS. may be passed behind, and by it extrusion may be effected, as in the case of foreign bodies lodged in the nose or ear. 3. But the stone may be fixed, and not inclined to move in any direction. Then it is to be cut out. If situate in the prostatic or membranous portions, the operation of lithotomy on the gi'ipe may be had recourse to (p. 431). The fingers of the left hand, passed into the rectum, push the stone forwards on the perineum ; and there, through a semilunar incision made across the raphe, above the anus, it may be extracted. Or, lateral lithotomy may be performed on a small scale. And in having recourse to this latter operation, for a stone of some size, lodged in the prostatic portion of the urethra, and long resident there, it is well to remember that considerable alteration may have taken place in the bladder. It may have contracted completely on the stone ; the ends of the ureters abutting on this, and there being no cavity beyond ; the urine coming away constantly, by stillicidium. If a stone be found already in the perineal portion of the urethra, it is to be removed through a direct incision, made in the centre of the raphe. If one present itself anterior to the scrotum, it is well not to excise it there ; for, wounds in that situation are slow to heal, and apt to degenerate into troublesome fistula3. By manipulation let it be brought behind the scrotum — if it refuse to advance to the orifice — and there let it be excised, through a deeper but more manageable wound. Not unfrequently a calculus, after having passed all the rest of the urethra, with more or less suffering to the patient, is arrested at the orifice. Thence forceps, or a bent probe, may remove it. But if such difficulty be experienced in the attempt, as to threaten laceration of the parts, let an incision be made to dilate the orifice, by means of a narrow probe-pointed bistoury ; and then extrusion will be simple and imme- diate. 4. Sometimes a calculus, lodged in the urethra, works its way out by ulceration and abscess ; presenting itself in the perineum or scrotum ; — a tedious and unsatisfactory process, not to be wished for, or trusted to in treatment. Pi^ejmtial Calculus. — When the prepuce is congenitally long, and of tight orifice, and when the patient labours under calculous diathesis, a concretion may form exteriorly to the urethra, within the cavity of the prepuce ; the urine being in some proportion retained there, after micturition, and having opportunity thus afforded for deposit. The symptoms are most manifest ; painful and frequent micturition ; con- gestion of the parts ; the stone to be felt by manipulation, and also on introduction of a probe through the narrow preputial orifice. Treat- ment is simple. By a curved bistoury the prepuce is divided on its lower aspect ; and by this simple incision two evils are at once reme- died : the stone is dislodged, and the condition of phymosis is removed. CALCULUS IN THE FEMALE. 449 Prostatic Calculus. The term Prostatic is not applied to a vesical calculus, which, in its passage outwards, has been arrested in the prostatic portion of the urethra ; but is properly limited to those concretions which form in the ducts of the prostate gland. They are of small size, brown, smooth, and sometimes numerous ; and consist of phosphate of lime, some- times mixed with carbonate of lime, deposited from the secretion of the ducts. They produce more or less irritation at the neck of the bladder ; especially after the bladder has been emptied. When they project into the canal, a sensation of rubbing may be felt when a sound passes over them. And, if in numbers, they may be felt sliding on each other, by a finger introduced into the rectum, and pressing upon the part. Whatever tends to vitiate and retain the secretion of the ducts, tends to the formation of such concretions. Hence they are generally met with in cases of tight stricture of the posterior part of the urethra. The ordinary result is one of two events. The calculus, reaching the oi'ifice of the duct, drops back into the bladder, and may be either extruded thence, or remaining may constitute the nucleus of a vesical concretion. Or the stone or stones remain in the substance of the gland ; perhaps leading to abscess and disorganization. In the case of small projecting calculi, they may be dislodged by the end of a catheter ; to be afterwards passed by the ui'ethra, or to be ground by lithotripsy. And in the great majority of cases they may be passed readily enough, if no unnatural obstruction exist in the urethra. When numerous calculi lodge in the gland, a small lithotomy may be had recourse to — an operation, however, which is very seldom required. Calculus in the Female. As already stated, urinary concretions are comparatively rare in the female ; for two reasons ; because the calculous diathesis is less common ; and because, the urethra being short, capacious, straight, and well-flooded, extrusion of renal formations is more probable than their retention. Nuclei are not unfrequently afforded, however, by the introduction of foreign matter from without ; and these substances may be of bulk and form not favourable to extrusion under any circum- stances ; bodkins, pencils, glass stoppers, coal, sandstone, &c. When a stone does form, and remains, the symptoms it occasions are quite analogous to those in the male. Perquisition is made by a short, straight, steel staff, slightly curved at the extremity. And a stone, having been found, may generally be got rid of without incision. The urethra admits of great dilatation ; and if this be done gradually, but little pain is caused. Sponge-tent, Weiss's metallic dilator, or 2 a 450 CALCULUS IN THE FEMALE. Arnott's fluid dilator, may be employed. And a sufficiency of space having been so obtained, forceps or a scoop are introduced, and the stone removed. The risk is, that, in consequence of the dilatation, povyer of retention may be seriously impaired, and more or less incon- venience by incontinence of urine may result. Lithotripsy was at one time supposed unsuitable to the female ; but experience has shewn that it is fully as applicable as to the male — the shortness and amplitude of the urethra favouring, indeed, the in- troduction and efficient play of the instruments. Subsequent expulsion of the fragments, too, is more easy and safe.* If the stone be found of larger size than to pass by dilatation alone, and if lithotripsy should not be considered advisable, the knife is to be used — sparingly. A straight staff is introduced ; on it a probe-pointed straight bistoury is passed ; and the urethra is notched, upwards and outwards, on each side — the knife's edge being chiefly applied at the neck of the bladder. Dilatation is then resumed; and extraction effected. A stone has made its spontaneous exit from the female bladder, into the vagina, by ulceration. Sometimes calculous matter collects at the lower part of the orifice of the female urethra ; forming a concretion of greater or less size, which becomes imbedded in a partial dilatation of the canal — bulging into the vagina. The urine passes over it, freely but painfully ; it may produce most of the ordinary symptoms of stone ; yet, fi'om its lateral and sacculated position, it may be overlooked in the introduction of a sound. It is a good rule, therefore, in cases of suspected stone in the female, to direct our attention to this part, after the bladder has been explored unsuccessfully. Wollaston on Cystic Oxide, &c., Phil. Tr. vol. c. p. 223, Lond. 1810. Mai-cet on the Chemical History and Medical Treatment of Calculous Disorders, Lond. 1817. Sanson, Des Moyens de Parveuir a la Vessie par le Eectmn, &c., Paris, 1817. Prout on the Nature and Treatment of Gravel, &c., Lond. 1818. Arnott, Essay on the Different Modes of Extracting Stone, &c., Lond. 1821. Key on Section of the Prostatic Gland in Lithotomy, Lond. 1824. Dupuj'tren, sur I'Operation de la Taille, Paris, 1826. Deschamps, Traite Historique et Dogmatique de I'Operation de la Taille, Paris, 1826 ; Dupuytren, Sur une Maniere Nouvelle de Pratiquer I'Operation de la Pierre, par Sanson et Begin, Paris, 1836. Souberbielle, Observations sur les Operations de Cystotomie Suspubienne, &c., Paris 1828. Heurteloup, Principles of Lithotrity, &c., Lond. 1831. King, Lithotomy and Lithotrity Compared, Lond. 1 832. Crosse on the Formation, Constituents, and Extrac- tion'of the Urinary Calculus, Lond. 1835. Willis on Urinary Diseases and their Treat- ment, Lond. 1838. Civiale, Traite de 1' Affection Calculeuse, Pai-is, 1838 ; also Traite Pratique et Historique de la Lithotritie, Paris, 1847. Brodie, Lectures on Diseases of the Urinary Organs, Lond. 1842. Bence Jones on Gravel, Calculus, &c., Lond. 1842 ; also Animal Chemistry in its Application to Stomach and Renal Diseases, 1850. Scharling on the Chemical Discrimination of Vesical Calculi, translated by Hoskins, 1842. Garrod, Lectures in the Lancet, 1849. Prout on the Nature and Treatment of Stomach and Renal Diseases, &c., Lond. 1849. Golding Bu-d on Urinary Deposits, Lond. 1851. • CiviAi.E, Traite Pratiqup et Historique de la Lithotritie, Paris, 1847. 451 CHAPTER XXXI. AFFECTIONS OF THE BLADDER. Cystitis. The inflammatory process, attacking the bladder, may be acute or chronic; and either form constitutes a formidable disease. Acute Cystitis may be the result of direct injury ; as in Lithotripsy or Litho- tomy. Or it may be a continuation, or a metastasis, of inflammatory action elsewhere ; as in gonorrhoea. Or it may be of idiopathic origin. Or it may follow the use of internal irritants ; as cantharides. Most frequently it is the consequence of virulent and ill-treated gonorrhoea. The symptoms are : pain in the region of the bladder, and also referred to the perineum and saci'um, sometimes stinging along the urethra ; tenderness over the pubes ; the urine voided very frequently, with great pain and straining — the pain being greatest after the bladder has been emptied ; the urine at first clouded with mucus, afterwards puri- form in character ; sometimes, after the urine has passed, a small quantity of puriform matter is expelled with much suffering ; often the urine is mixed with blood ; sometimes, after scanty and turbid urine has passed, pure blood escapes, in drops or other small quantity. The system is involved in smart sympathetic fever. The action may extend by the external coat of the viscus, and general peritonitis result. Spasm may simulate most of the symptoms ; but is known by absence of inflammatory fever, and by the character of the pain — which, in spasm, is sudden in its accession, not gravescent, rapid in its disappearance, and may be intermittent (Principles, p. 117). In the treatment of acute cystitis, antiphlogistics are to be plied actively. Blood is drawn from part and system ; fomentations and the hip-bath are used ; antimony, and if need be, calomel and opium are given ; opium, by the mouth and rectum, is usually indispensable — after bleeding — to subdue pain ; and the recumbent posture must be rigidly enjoined. This last indication is indeed imperative, in the treatment of all inflammatory affections of the bladder ; the erect and semi-erect postures tending obviously to favour determination of blood 2 g2 452 CHEONIC CYSTITIS. to the pelvic organs. The bowels ai^e to be relieved by enemata, aided by the gentlest possible laxatives ; so as to avoid straining. During convalescence, the urine will probably require a special treatment ; varying, according as that fluid evinces an acid or an alkaline character. Chronic Cystitis, or Catarrhus Vesicce, is generally symptomatic of some other affection ; of gleet ; of stricture ; of enlarged prostate ; of stone in the bladder ; of hemorrhoids, or other disease of the rectum ; of renal irritation. Sometimes, however, it is idiopathic. Micturition is frequent and painful, and the urine contains much viscid mucus. Often the recipient vessel seems almost entirely filled with mucus, thick, glutinous, and very adherent to the bottom. At first, it is greyish and streaked ; the streaks dependent on phosphate of lime ; afterwards it becomes brown, ammoniacal, and intensely foetid. Not un frequently there is admixture of pus ; sometimes of blood. The mucous membrane is thickened and congested ; it may ulcerate ; the muscular coat is hypertrophied, and may sacculate ; the kidneys are sooner or later involved. By ulceration, it has happened that a com- munication between the bladder and rectum has been formed. Also, the fundus has become perforated into the sigmoid flexure of the colon ; constituting an entero-vesical fistula. The system is always affected more or less. And this is the diagnostic between catarrh, and mere irritability of the bladder. In the latter, the system is free ; in the former it is always involved, and in general seriously. In treatment little benefit need be looked for, unless the obvious cause, when it exists, be removed. Stricture must be cured ; stone must be taken away ; the rectum must be restored to a healthy state. Disease of the kidney and of the prostate may be palliated, but are not always curable. For the disease itself, opium is of great service ; allaying irritation, and lulling inordinate action. The buchu, pareira, and uva ursi, with mineral acids, are useful, as in alkaline urine from other causes. Regimen is generous, rather than otherwise ; to support the system. There is no tolerance of either purging or blood-letting. Iron often is of great use; and perhaps the best form is the tincture of the muriate. From a combination of benzoic acid with copaiba relief sometimes results. And counter-irritation is often of the greatest service ; on the hypogastrium, or over the sacrum — the latter the preferable situation — unless, indeed, there be already too much irrita- tion there, in the form of bed-sore. In severe cases, the actual cautery may be warrantable ; to a very limited extent, however ; there being no tolerance in the system of the exhaustion and irritation of a large suppurating surface. The following are some of the principal remedies : — Opium in full doses, and repeated, so as to overcome pain and irritation. If opium disagi'ee, hyoscyamus may be substituted. Of the mineral acids, the IRRITABLE BLADDER. 453 dilute muriatic and nitric are usually preferred ; in doses of eight or ten drops, gradually increased. The pareira is given in decoction. Half an ounce of the root, in three pints of water, is boiled down to one pint ; and of this from eight to twelve ounces may be taken daily ; or it may be given in the form of extract, to the extent of twenty or thirty grains daily. Of the buchu and uva ursi, in the form of strong infusion, ounce doses are given three or four times a-day. The tincture of the muriate of iron is administered, in doses of from eight to fifteen drops twice daily. A drachm of benzoic acid, with half an ounce of copaiba, made into an emulsion with camphor mixture, may be taken in ounce doses, in the course of forty-eight hours. The milder cases yield to such remedies. The more severe pro- bably do not. In them, other measures must be had recourse to ; and the most promising is injection of the bladder — never to be employed, however, except in aggravated cases, and after ordinary means have failed ; otherwise it may itself prove the source of no inconsiderable injury. It is also essential that no acute or subacute exacerbation be present; the disease must be thoroughly chronic. The injection is at first detergent and soothing ; water, or a decoction of poppies. Then a mixture of ten minims of dilute nitric acid with two ounces of distilled water is thrown in, and allowed to remain about thirty seconds. In two days the injection is repeated, and the dose of acid is gradually increased ; by and by the injection may be given daily — not often er. * In exti'emely chronic cases, the bladder may be thoroughly washed out by means of a double catheter, to the main orifice of which a small enema-syringe is adapted, and by means of which apparatus a strong and continuous current is established in the viscus. Should at any time pain or even uneasiness follow the use of this means, however, the practice must be discontinued. In very obstinate cases, it may perhaps be allowable to make a cautious trial of the application of nitrate of silver, in substance, to the mucous coat, as proposed by M. Lallemand. The bladder having been emptied, the porte-caustique is passed ; and the stilette having been pushed forwards, a momentary contact of the nitrate of silver with the lining membrane is permitted. The instrument is then with- drawn ; and a portion of the caustic, dissolved in mucus, pervades the viscus. This is to be done very warily ; and the after consequences must be anxiously watched, lest over-action ensue. Irritable Bladder, In healthy states of the urine and bladder, the stimulus of the former operates on the latter only according to quantity; a certain *Foi' further details of the lotura veskm, see Montlily Journal, May 1850, p. 482. 454 IRRITABLE BLADDER, amount of fluid having accumulated, an uneasy sensation is felt, and the bladder contracts in obedience to that stimulus, seeking relief thereby. If the urine be abnormally acrid, however ; if the mucous membrane of the bladder be morbidly sensitive ; or, more particularly, if both these states exist together — the ordinary stimulus of the urine is found to be intolerable, and frequent, uneasy micturition results, constituting the affection termed Ii'ritable Bladder. Patholo- gically, it differs from any form of cystitis, in depending on irritation, and not on the inflammatory process ; there is not necessaiily any structural change in the coats of the bladder. Pi'actically it is known by the absence of grave constitutional disorder, as well as by the absence of profuse secretion of vitiated mucus — the prominent charac- teristics of Catarrhus Vesicse. No doubt; however, these affections may and do, not unfrequently, coalesce ; the irritation inducing inflammatory action, and becoming merged therein. Concussion and compression of the brain are often associated, yet are regarded as dis- tinct affections (p. 25) : and so here. The symptoms of Ii-ritable Bladder are — frequent micturition, with uneasiness rather than actual pain ; the desire is almost constant, the slightest quantity of accumulated urine proving an unnatural stimulus to the irritable mucous coat; and relief is obtained, on evacuation being completed. The pulse and general system are comparatively unaffected. The urine may be limpid and cleai*; frequently it is clouded by mucus ; not unfrequently it furnishes deposit of the urates. The cavity of the bladder is contracted ; but not necessarily vsdth structiu-al change. In some cases, the coats have been found thinner than in health. The som'ce of irritation may be in the mucous coat itself. More frequently it is elsewhere ; affection of the kidney — in phosphatic or oxalic diathesis, for example ; ascarides, hemorrhoids, or other disease of the rectum ; calculus, or other irritation in the urethra ; in children, it not unfrequently depends on a contracted state of the preputial orifice. Most frequently, the affection is found to originate in derangement of the kidney and of the general health ; and this at once gives the two component parts ; the acridity of urine, and perverted sensibility in the mucous coat. Indeed, these morbid states very seldom are separate; for if irritation commence in the bladder, it is thence extended to the uro-poietic system, and derange- ment of secretion necessarily follows. Treatment consists in looking for a cause, and in removing it, if possible; amending the stomach, bowels, and general health; and restoring the urethra, rectum, and other parts to a sound state. By anodynes, given by both mouth and anus — but especially in the latter way — the irritation is subdued. And, throughout, a constant regard is had to the state of the urine. The small doses of alkali, largely HiEMATUEIA. 455 diluted (p. 425), are often found very serviceable. Recumbency is advisable ; at all events in cases of severity. And should these simple means fail, recourse is had to smart counter-irritation ; by blistering above the pubes, or over the sacrum. Mental anxiety induces a temporary simulation of this disease ; or, perhaps, it may be said to cause a variety of it. The mucous coat is increased in sensibility, and the whole frame is in unwonted excite- ment. The urine is not acrid ; on the contrary, it is copious, pale, aqueous, and bland ; and stimulates by quantity, rather than by quality. In this case, hyoscyamus and other direct sedatives are all powerful ; together with attention to the manifest cause of the disorder. Hcematwia. By this term is understood spontaneous discharge of blood from the urethra. It may proceed from different sources. 1. From the Kidney. — Stone in the kidney is often accompanied by discharge of blood from the mucous membrane in contact with the stone ; more especially after violent exercise, error in diet, or other source of aggra- vation in gravel. Blows on the renal region cause hgematuria ; the blood in such a case sometimes passing in large quantity. Occasionally the occurrence takes place without any assignable exciting cause, in cases of structural disease of the organ. The renal source of the hemorrhage is known, by the blood being diffused equably thi'ough the urine ; by the expelled fluid containing cylindrical portions of fibrin, like small worms, the result of coagula in the ureter — sometimes colourless, sometimes of a pale pink hue ; by the appearance of blood being preceded and accompanied by pain and heat in the loins, and other renal symptoms ; — and more especially when such symptoms are present on one side only. Treatment consists in such means as are best calculated to remove the cause. In the case of external injury, rest, fomentation, low diet, leeching if necessary. In the case of stone, the palliative or more thoroughly remedial measures, which we have already seen to be suit- able in this disease. In the idiopathic hemorrhage, connected with a generally relaxed state of system, and threatening exhaustion by con- tinuance, such remedies as are useful for passive hemorrhage — more especially rest, local application of cold, and internal use of gallic acid. 2. From the Bladder. — This is the most frequent variety ; as already seen, a very constant attendant on vesical calculus ; and then liable to be aggravated by circumstances. It may also proceed from a congested or inflamed state of the mucous membrane, unconnected with the pre- sence of any foreign body. More or less, it is common in cystitis. From ulceration of the mucous coat it cannot fail to occur. But per- 456 H^MATUEIA. haps the most frequent source, next to that of calculus, is enlarged and ulcerated prostate. And if this state co-exist with calculus, the loss of blood is likely to be both large and frequent. Malignant tumour of the bladder, as it ulcerates, must furnish blood ; and a large amount may flow from injury done to the coats of the viscus, by ill managed catheters, bougies, or lithontriptors. Worms lodge in the bladder ; sometimes, though rarely ; and they have been known to occasion profuse and even fatal loss of blood. Vesical hemorrhage may be so profuse as to furnish blood tolerably pure from the urethra. And, in general, this variety of haematuria may be known, by the blood not being mixed with the urine ; the latter fluid passes off first, tolerably pure ; and the blood comes last, more or less changed by mixture with the residue of the urine. It is also known by the absence of renal symptoms ; and by the presence of undoubted signs of stone in the bladder, or other disease of that viscus, or of affection of the prostate. In the case of direct injury done to the bladder by instruments, there need be no room for doubt. Treatment, varying according to the cause, is plain and obvious, and need not be particularized. Sometimes blood escapes in large quantity — in the case of stone, or enlarged prostate — and accumulates in the bladder ; coagulating, and causing retention of urine. A hard tumour is felt in the hypogastrium ; the ordinary distressful signs of retention are all present ; on introduc- ing the catheter, only a small quantity of bloody urine passes off; the fibrinous clot may be felt plainly enough, on moving the instrument's point ; and, on withdrawing the catheter, it is found more or less ob- structed by coagulum. If the symptoms be not urgent, we may con- tent ourselves with occasional introduction of the catheter, to remove what loose fluid there is ; the coagulum gradually dissolves in the urine, and comes away. If urgency exist, however, it is advisable to inject a small quantity of warm Avater ; and then, by the exhaustion of a powerful and well-fitting syringe, to endeavour to break doMoi and remove at least some of the clot. In the case of spontaneous disrup- tion of stone, attended with such complication, it is expedient to have instant recourse to lithotomy, provided the state of system be found sufiiciently tolerant of such a severe proceeding (p. 421). 3. From the Urethra. — In this case there is absence of both renal and vesical symptoms ; the blood passes pure, irrespective of any desire to evacuate the bladder ; and there is usually some plain cause for the accident — as injury, inflammatory action, erection in chordee, or ex- cessive venereal excitement. The application of cold, with recum- bency, usually suflBces for arrest. In extreme cases, following chordee, pressure may be made on or near the orifice, and at the perineum ; so as to include the source of bleeding between the two compressed points INCONTINENCE OF UllINE. 457 — preventing escape in either direction, and converting the effused blood into its own hemostatic. In the case of wound, the ordinary principles of surgery are put in force. Enuresis, or Incontinence of Urine. Practically, this affection may be divided into that which affects the adult and the aged, and that which occurs in children. In the former, one of two events has taken place. Retention of urine has occurred ; the bladder has become greatly distended ; and the re- cently secreted urine, finding no room in that viscus, dribbles away slowly and involuntarily by the penis. In other words, incontinence in this case is but a symptom of a more serious affection — retention of urine. Or, as more frequently happens in the aged, the parts have simply lost their tone ; the expelling power is small, while the retaining power is almost or wholly gone ; and the urethi*a is little more than a passive tube, through which the urine floAvs outwards, shortly after secretion. In the former case, treatment is by the use of the catheter ; directing our attention to the true disease — retention.* The other form is regarded as but one of the many signs of senile decay, and treated accordingly. Temporary relief may in some cases be afforded, by the internal use of nux vomica or strychnine ; a degree of tone being restored to the parts for a time. But, in general, we have to content ourselves with attention to comfort and cleanliness, by the wearing of urinals adapted to the circumstances of the case. In the adult, incontinence of urine sometimes follows rheumatic or other fevers; it may also result from injury of the spine ; and it is an ordinary symptom of the slow degeneration of the spinal cord formerly spoken of (p. 298). Nux vomica or strychnia, cantharides, and tinc- ture of the muriate of iron, with blistering over the sacrum, are the most likely means of benefit. In some cases, the application of elec- tricity to the parts affected has been of service. The remedies are plainly of that class which tend to restore muscular and nervous energy. Enuresis in children is extremely common ; very much allied to irritable bladder ; but differing in this, that while, in the latter affec- tion, evacuation of the bladder is voluntary, in this case it is involun- tary. During the day, the child makes water with unusual frequency, perhaps; at night the urine is passed involuntarily; and this unpleas- ant habit may continue in adolescence. Corporeal discipline may still be the favourite remedj^ among nurses, and with some parents ; but it is as ill-judged, as it is cruel and unnatural ; the child might as well * CaUed to a case of incontinence in the adult, the existence of distended bladder should always be suspected, and examination made accordingly. 458 INCONTINENCE OF URINE. be punished for club-foot or the measles. The involuntary escape of urine is the result of a morbid state, and requires curative treatment. Usually, the general system will be found out of tone ; and this is to be obviated by the ordinary remedies ; more especially by cold bathing, and by small doses of the tincture of the muriate of iron. At certain stated hours, during night, the child should be awakened for the pur- pose of emptying the bladder ; and, if possible, he should be prevented from sleeping on his back, and from so exposing the most sensitive part of the bladder to contact with the urine. The bowels must be kept in good order ; and the state of the rectum should be especially attended to. Ascarides may probably be found there ; if so, they must be expelled. Certain means are supposed to have a special eifect on the bladder. The nux vomica, or strychnia, is certainly of use ; perhaps by allaying irritation, as well as by increasing tone at the neck of the viscus. The niti-ate of potass has proved serviceable ; and, in such cases, it is probable that the urine was scanty, acidd, and conse- quently unusually stimulant. In other cases, the more ordinary means having failed, benefit has accrued from cantharides internally ; and in such cases, probably, there was a sluggish condition of the neck of the bladder and adjacent parts. The effect of this remedy has also been explained, by supposing that, acting as an irritant on the lining mem- brane of the urethra, especially at its posterior part, it produces turges- cence there, so rendering the potential canal less easily opened up. Amendment has not unfrequently followed the application of a large blister over the sacrum ; but whether by the principle of counter-irrita- tion, or from sleeping on the back being thus effectually prevented, it is not easy to determine. Mechanical means — as the jugum penis — are not to be thought of. It may happen that a boy, ashamed of his infirmity, and perhaps impelled by desire to escape corporeal punishment, voluntarily has recourse to mechanical aid ; and, at bed-time, constricts the penis by a ligature, or a curtain ring, or other suitable means which may occur to him. In the morning, he finds the parts swollen and painful ; he is unable to remove the jugum ; and, afraid of the consequences of a disclosure, he suffers in silence. The swelling increases ; ulceration takes place ; the foreign body becomes imbedded in the inflamed tissues ; the penis may be gradually cut through ; and, the urethra having been at length reached, a calculus begins to be constructed there. Such cases have been recorded by Liston, Helot, and others. Contrary to expectation, the erectile capabilities of the organ do not seem to have been impaired by the gradual transverse section.* * Lately, in operating on a little boy, on account of chronic paraphymosis, with pre- ternatural opening of the urethra behind the glans, I found a tight piece of packthread deeply imbedded in the penis, and constituting the true stricture. RETENTION OF URINE. 459 If called to such a case, after some clays, with the constricting agent sunk in inflamed parts, a free incision is to be made upon the offending body; which, having been exposed, is to be divided — by knife or pliers, according to its nature — and removed. If called early, a tight ring may be taken off, as from the finger, thus : pass the end of a stout and long thread beneath it, leaving the pubal end loose and prehensible ; roll the rest of the thread tightly and closely round the penis, in front of the constricted part, so as to invest it wholly ; then gradually unrol, from the pubal end ; and the ring is shuflied forwards, as the thread is made to uncoil. Retention of Urine. This serious calamity may arise from a variety of causes ; and treatment varies accordingly. The symptoms are : inability to eva- cuate any urine, while desire to do so is great, constant, and frequently aggravated — with straining, pain, and much distress. The bladder, rising in the pelvis, is felt above the pubes, and also by the finger introduced into the rectum ; pressure above the pubes causes great pain, and percussion is dull there ; in extreme cases, the bladder may become an abdominal tumour almost as large and distinct as the gravid uterus — oval, tense, and fluctuating. If the bladder have been previously contracted in cavity and thickened in its coats, the ordinary symptoms of retention may be occasioned by the incarceration of but a small quantity of fluid ; and then the tumour can be felt only by the rectum or vagina. In other cases, the bladder distends readily ; and the tumour may be both large and high in the abdomen, before unpleasant feelings are complained of. As the case proceeds, pain and straining, with sickness, become more and more unbearable ; the pulse rises, the skin grows hot, the tongue is dry ; breath and perspiration may evince an urinous odour; — "urinous fever" is established; absorption of the vesical contents has begun. By and by the ureters become distended, as well as the bladder ; increasing pressure is thus made upon the kidneys ; their secretion is arrested in consequence ; and suppression of urine, supervening on and caused by the retention, tends to produce coma and death. If the bladder be relieved, the urgent symptoms disappear speedily; the patient passes from torment to Elysium ; and under no circum- stances will he be found more eloquently and sincerely grateful. He must be seen again soon, however, otherwise the unpleasant symptoms may be speedily restored. The kidneys, compressed by the enlarged and full ureters, had for some time been secreting little ; on removal of that pressure, the secretion is renewed copiously, and the bladder may be soon refilled. 460 EETENTION OF URINE. If no relief be afforded, a serious local accident is likely to occur, before the sjstem has become fatally prostrate. The bladder or the urethra gives way ; either by ulceration, or by actual tearing under strong action of the detrusor ; and extravasation of urine takes place — of urine, be it observed, deprived of much of its aqueous part, intensely saline and acrid. The inevitable result is sloughing of the infiltrated parts ; too generally followed by rapid sinking of the patient. Obvi- ously, therefore, it is of the utmost importance to afford early and effectual aid in this affection. 1. Retention from Stricture of the Urethra. — In this case, perhaps the most common, danger is especially great ; the thickened and powerful middle coat of the bladder labouring hard to overcome the obstacle to evacuation, and consequently rendering solution of continuity all the more imminent. The patient has long been in the habit of making water tardily and ill ; at last the passage seems effectually closed ; and the ordinary distress of retention supervenes. Probably an exciting cause may be found; indiscretion at the dinner-table, injudicious use of a bougie or catheter, exposure to cold or wet, or an attack of piles. The previously narrowed canal has become occluded by congestion, or by the swelling attendant on an active inflammatory process, in the affected part ; and, no doubt, there is also spasm. If the history of the case and its symptoms be such, as to lead us to suppose that the strictured urethra is inflaming or inflamed, the catheter must be withheld ; unless indeed the case be far advanced, and the safety of the parts from extravasation already endangered. Leeches are applied to the perineum, in clusters ; or cupping is had recourse to ; the patient is seated in a warm hip-bath — and this bath need not be delayed till leeching is over, as the animals will not be disturbed by comfortable immersion. A full opiate is given, by the mouth or by the anus ; or in both ways. Very probably, such relax- ation occurs as to obviate all necessity for the catheter; urine dribbling away in the bath, and then perhaps coming in a tiny stream, sufiicient to relieve all urgency of symptoms. In the event of failure, however, after a reasonable time and trial, the bladder must be relieved at all hazards. In those cases where we have no reason to suspect inflammatory ^- -■ action, the catheter is used at once; 'of small size, steadily jet gently f'.' persevered with; the patient under chloroform. Sometimes the silver instrument refuses to pass, while a gum-elastic one, straight, and deprived of its stilet, enters the bladder with comparative ease. Some- times it happens, that after the end of a silver catheter has been pressed steadily for some time on the stricture, and withdi-awn, the urine begins to follow. In no case is force or violence to be employed. RETENTION OF URINE. 461 But, Avhen unsuccessful with the catheter and the auxiliary means already noticed, the bladder must be relieved at all hazards — through the perineum, or by the rectum, as will afterwards be stated. 2. Retention from Urethritis. — The inflammatory process may attack the urethra, independently of previous stricture ; causing turgescence and occlusion. This may be the result of gonorrhoea, or of direct injury. Retention supervenes gradually ; and there is time for anti- phlogistic treatment. To this we trust ; leeches, fomentation, hip- bath, antimony, &c. ; withholding the catheter, if possible ; inasmuch as its use, even though successful in relieving the bladder, must aggravate the inflammatory action, and tend to repetition in a worse form. 3. Retention from Irritation and Spasm at the Nedc of the Bladder. — This may take place, irrespective of inflammatory action, or of organic change. In the dissipated, it is no uncommon result of a late carousal, calls to evacuate the bladder, it is probable, having been imprudently neglected. A hip-bath, with an anodyne — opium or hyoscyamus, by the rectum or by the mouth — will usually give relief. If not, a full- sized catheter is to be passed, gently. 4. Retention from Priapism. — Priapism is a common result of spinal fracture ; and sometimes it occurs in connexion with venereal excess. In the former case, when retention takes place, v/e cannot expect benefit from direct treatment of the cause ; and we must use the catheter. In the latter, by opium and camphor, and antimony ; by the warm bath ; by an opiate enema or suppository ; and by leeches to the part, if need be — we may overcome the erection, and avert the use of instruments. 5. Retention from Aiscess in the Perineum. — Abscess forming here — in connexion with stricture, or as a result of direct injury — may bulge internally, so as temporarily to occlude the urethra. Catheterism would be very painful, and not unlikely to cause rupture of the abscess into the urethra, whereby urinous extravasation might occur. The knife supersedes the catheter ; the abscess is opened from without ; instant relief follows ; retention is overcome, and the morbid state which caused it is at the same time removed. Similar treatment may be required, on account of an abscess forming in the body of the penis, as a remote result of venereal disease. 6. Retention fro7n Pelvic Abscess. — Pelvic abscess (p. 333), bulging on the neck of the bladder, may cause retention of urine.* Treatment is conducted on the same principles as in the case of perineal abscess ; withholding the catheter, or using it very warily ; and puncturing the abscess, so as to at once remove both retention and its cause. Retention may be simulated. The abscess may so compress the * A case is narrated in the Lancet, No. 1431, p. 118. 462 RETENTION OF URINE. bladder as to prevent its distension ; and consequently urine is almost constantly passing away in small quantity, fiom a collapsed viscus ; while the abscess, forming a large, dull, hypogastric swelling, may be mistaken for the bladder largely distended. In one such case I thrust the catheter through the walls of the abscess, which was consequently evacuated through the urethra. The patient made a good recoveiy. 7. Retention from Urethral Calculus. — This occurrence has been already alluded to (p. 447) ; impaction of a calculus taking place in such a way as quite to occlude the canal. Three courses of procedure are open to us : "We may by the catheter push back the calculus into the bladder, treating it afterwards by lithotripsy. Or we may at once remove it by direct incision. Or we may bring it to the orifice of the urethra, and thence extract it — by dilatation if necessary. K the stone is small, moveable, and situate anteriorly, we prefer the last mode ; if it is impacted in the prostatic portion of the canal, we pro- bably prefer the first. If it is of some considerable size, firmly im- pacted, and beyond the prostatic portion, we have recourse to excision. 8. Retention from Injury of the Perineum. — 1. Extensive bruise of the perineum may cause retention, irrespective of any injury done to the urethra ; the extravasated blood bulging inwards on the canal. In such a case, the catheter must be used, until by absorption the compressing agent has been diminished or taken away. 2. Again, injury of the perineum may induce inflammatory action, either in the urethra itself, or in the parts exteidor to it ; and, in the latter situation, abscess may form. The treatment advisable under such circumstances has already been stated (p. 461). 3. When the urethra has been torn or cut, there is no room for delay ; retention must not be waited for ; the catheter cannot be too soon introduced. For, if the patient have made an efibrt to evacuate the bladder, before such introduction, urine will certainly have escaped at the injured part, causing all the deadly results of extravasation. And only by early introduction of the catheter — retaining it until consolidation shall have taken place at thq injured part — can extravasation be avoided.* If the urethra have been completely torn across, there may be difficulty in passing the instrument ; nay, not improbably, the surgeon may be altogether foiled in his attempt to penetrate the vesical orifice — shrunk, retracted, and displaced. Under such circumstances, a free perineal incision must be made so as to expose the part; and then the catheter is passed through and retained. It is surely much better to make a limited * It is a good general rule, in all cases of serious injury done to the perineum, to pass the catheter very cautiously, immediately on being called to the patient. If urine come away clear, it is a good omen, and a point is gained both in diagnosis and treatment. RETENTION OF URINE. 463 incision, with the view of preventing extravasation, than to be com- pelled to incise largely afterwards, for the escape of sanies and sloughs, after urinary infiltration has occurred, 9. Retention from Parlaysis. — A paralytic state of the detrusor may be the result of accidental over-distension merely ; of spinal injury ; of general debility, as in fever ; or of senile decay. The ordinary call to evacuate the bladder having again and again been neglected, under circumstances of restraint, the suflPerer, when liberated from these, will probably find no urine coming in obedience to his utmost eflbrts at expulsion. The muscular fibre of the detrusor has been over-stretched, and, for the time, is paralyzed. The catheter cannot be used too soon ; and its introduction is to be repeated from time to time, never allowing any considerable quantity of urine to collect; so that the normal dimensions of the bladder, and the wonted functions of its muscular coat, may be speedily restored. Should the return of con- tractility be slow and imperfect, strychnine or nux vomica may be given, or electricity may be employed.* In the case of spinal injury, the circumstances are very distressful; for, in addition to retention being ever liable to occur, there is phos- phatic degeneration of the urine, with more or less change in the lin- ing membrane of the bladder (p. 300). The prominent symptoms of retention, however, are probably less urgent than in other cases ; there being usually diminished sensation in the viscus, as well as impaired muscular power. Occasional relief, too, may come, by partial escape of urine; for, the abdominal parietes may act on the bladder when greatly distended and risen ; taking on themselves, in some measure, the lost function of the detrusor. Also, as the bladder changes in its coats, the middle coat, becoming hypertrophied, may acquire an increase of power, so as to effect a partial evacuation ; " the muscular coat, which is not excited to contraction so long as the mucous coat is in a healthy condition, acquires a degree of abnormal contractility." In such cases, treatment is mainly spinal. The catheter is used from time to time ; the usual means are taken to correct the depraved state of the uro-poietic system ; and, during convalescence, recovery of power in the muscular coat may perhaps be pi'omoted. In protracted fever, retention is not uncommon, often with incon- tinence. It is obviously of much importance to detect this condition, and by catheterism to prevent it ; otherwise a most injurious influence will be exerted on the afready oppressed system, by absorption of the confined urine within the bladder. * Probably the most effectual way of applying this agent is to introduce a silver catheter into the bladder, and a female catheter into the rectum, with its point resting on the rectovesical parietes ; and to connect each of these catheters with one of the poles of the electric machine. — (Monthly Journal, Aug. 1850. p. 174). 464 EETENTION OF UEINE. In the aged, tlie detrusor, as other muscles, grows feeble ; and, by reason of this, retention may occur. Relief is got by the catheter ; and something may be done in amending muscular energy — at least for a time. 10. Retention from Diseased Prostate ; it may be, from either an acute or a chronic enlargement of the gland. In gonorrhcea, the prostate is liable to the occurrence of acute swelling, with or without the forma- tion of matter ; and this may be to such an extent as to shut up the posterior part of the urethra. Treatment is by antiphlogistics ; with- holding the catheter, if possible. If abscess have formed, it must be evacuated externally, by incision ; as in the case of similar affection of the perineum (p. 461). In chronic enlargement of the prostate, peculiar to advanced years, relief can be had only by the catheter. And an insti'ument must be employed of large curve, and at least two inches longer than that in ordinary use ; for, by the prostatic enlai'ge- ment, as well as by elevation of the bladder when distended, very con- siderable elongation of the urethra takes place, and an ordinary instru- ment must necessarily fail to reach the bladder — as will afterwards be more fully explained. It is in this form of retention that incontinence of urine is so apt to show itself as a symptom. For years, perhaps, the bladder has been imperfectly evacuated ; a certain amount of residuary water has always lodged in that viscus ; and the amount increases ; at last, the bladder becomes completely distended, and the urine which comes fresh from the ureters — as surface water — dribbles over and is involun- tarily discharged. Very frequently, the kidneys become diseased. In such a case, the catheter must be used cautiously. Were it to be passed at regular periods daily, fully evacuating the bladder on each occasion, it is probable that the kidneys, thus deprived repeatedly, suddenly, and completely of the circumstances which had so long tended to restrain their secretion, would become untowardly excited, and fatal aggrava- tion of the renal disease might ensue. 11. Betention from Blood in the Bladder. — If this occur in connection with spontaneous disruption of a vesical calculus, lithotomy is pro- bably the best remedy, as already stated (pp. 421 and 456). In other circumstances, we have recourse to a full-sized catheter, with large eyelets ; and aid its action, if need be, by an exhausting syringe. The ordinary hemostatic means are at the same time had recourse to, to prevent continuance of internal hemorrhage. 12. Retention from Malignant Disease of the Penis. — As carcinoma or cancer advances in destruction of the penis, secondary glandular enlargements occur, both without and Avithin the pelvis ; and, in con- sequence, the outlet of the bladder may come to be completely RETENTION OF URINE IN THE FEMALE. 465 obstructed. In sucli retention, we can only hope to palliate, and briefly to extend the now closely meted term of existence. The bladder is relieved by puncture above the pubes, and the aperture is kept pervious. 13. Retention from Imperforate Urethra. — This is a state of matters analogous to retention of the meconium by an imperforate condition of the anus (p. 393). The perforation necessary to complete the canal cannot be too soon accomplished. Retention of Urine in the Female. The most ordinary causes of this affection are — pregnancy, tumours, paralysis, and hysteria. The gi-avid uterus is likely to compress the urethra ; more especially about the fourth month, when the tumour is considerable, and not yet risen out of the pelvis. Eelief is by the flat catheter. Other tumours may compress and obstruct the urethra ; uterine, ovarian, vaginal. Here again, as well as in the case of paralysis — of frequent occurrence after delivery — the catheter is employed. But, in hysteria, this instrument ought generally to be refrained from. Hysterical women very often labour under retention of urine, simply because they refuse the effort of volition necessary for expulsion of the bladder's contents. Use the catheter, and repetition of the retention speedily occurs, the cause remaining the same. But refuse the catheter, and allow distension to proceed, until the stimulus thereby occasioned becomes such as to compel the detrusor to its function ; and then, by an effect pai-tly moral and partly physical, the patient wiU find her; self permanently relieved. There are obstinate cases, however, which resist this mode of cure ; and, in them, care must be taken not to endanger the bladder, by an excessive withholding of the instrument. Puncture of the Bladder. This operation becomes necessary, when urgent retention of urine exists, and when by the catheter we have failed to afford relief. It may be performed in a variety of ways ; by the perineum, by the rectum, or above the pubes. 1. By the Perineum. — This is preferable in all cases of obstinate retention caused by impassable stricture, or other obstruction of the urethra ; the bladder is safely relieved, and the cause is at the same time effectually dealt with. The patient is placed in the position of lithotomy ; a catheter of medium size is passed down to the constricted part, and its point is cut upon by direct incision, in the central raphe ; behind the end of the instrument, we expect to find a bulging dilatation of the urethra on the vesical aspect of the stricture ; this is pierced by the knife; and urine. rushes out, 466 PUNCTURE OF THE BLADDER. affording complete relief to the bladder. Then the knife is carried forwards, so as to divide the constricted part of the urethra, as accu- rately and thoroughly as possible. That having been laid open, the catheter is passed on and retained ; and thus a most effectual begin- ning is made towards permanent removal of the stricture. The opera- tion is avowedly difficult — ^the dilated portion behind being not always easily found, and it requiring great care to make sure that the inci- sions at the constricted part lay open the canal of the urethra ; but when rightly performed, it is thoroughly sound in both its principle and results. It is rarely, however, that any such procedure is demanded of the experienced surgeon ; generally, he succeeds by the catheter and its auxiliaries — chloroform seldom omitted. But this may be said to be puncture of the urethra, rather than puncture of the bladder ; and so it is. In strict accuracy, jjerineal puncture of the bladder may be held to denote the reaching of the neck of that viscus, by the thrust of a trocar and canula, or by means of a small lithotomy wound — an operation which is very seldom performed for mere retention. 2. By the Rectum. — This is a simple and safe operation ; but is apt to leave a troublesome fistulous communication between the bladder and bowel. We have recourse to it, when foiled in the use of the catheter, and when the method by perineal incision is not considered advisable — or when that has failed ; and, indeed, it may be performed in any case, by a surgeon who prefers it, except when the prostate is much enlarged. The patient is placed recum- bent, with the limbs raised. The fore and middle fingers of the surgeon's left hand are introduced, well oiled, into the rectum ; and their points are rested on the central space immediately behind the prostate. A long curved trocar is introduced by the right hand, with its stilet withdra"\vn within the canula ; the ex- tremity of the latter is fixed on the trigone, between the points of the fingers resting there ; and, the stilet being then pushed forward, both Fig. 145. the trocar and its canula are lodged in the bladder. The trocar is withdrawn, and the canula is retained. If there be good prospect of speedily removing the cause of retention, Fig. 145. Trocar for puncture of the bladder by the rectum. EXTKAVASATION OF URINE. 467 the canula may be very soon taken out. Otherwise, it should be re- tained for some days, so as to prevent premature closure of the wound. 3. Above the Puhes. — This is our last resource ; when both the other methods are deemed impracticable. The operation is similar to supra- pubal lithotomy (p. 44,5). A small incision is made through the parietes, immediately above the symphysis; and through this the bladder is punctured at its lowest part, by means of a short trocar and canula — similar to what is used in ascites — directing the point of the instrument obliquely backwards, towards the promontory of the sacrum. The canula is left ; or a portion of elastic catheter ; or a short lithotomy tube. And the patient is laid on his side, so as to favour outward escape of the urine. These methods of operation have been enumerated, according to what is conceived to be their merit. All are rare, in actual practice ; and deservedly so ; for none are of a favourable character. But any one of them is much preferable, at any time, to postponement of relief, and consequent disaster by extravasation ; and all, too, are preferable to pushing a metallic catheter by sheer force through an impassably strictured urethra. Extravasation of Urine. This may be either vesical or urethral. The Vesical, as we have already seen, may follow wound, ulceration, or tearing of the viscus. 1. After the wound of lithotomy, it is too common ; 2. Cystitis may lead to perforating ulcer ; 3. Retention of urine may be relieved only by a bursting of the bladder, or by a more gradual giving way by ulceration. Actual laceration, however, is not uncommon ; and it is not difficult to understand why. Cohesion of the parts has been pre- viously diminished, by the inflammatory process occurring in them ; and, themselves unusually lacerable, they are powerfully acted on not only by a hypertrophied detrusor, but also by the muscles of the abdominal parietes and the diaphragm. 4. The bladder may be lacerated by external injury ; as by blows, or falls on hard substances, more especially when the viscus happens to be distended (p. 469). The nature and treatment of the first form has already been considered (p. 441). The second is hopeless ; the patient will necessarily perish, by peritonitis, or by areolar infiltration and sloughing, according to the site of the urinous escape. In the third form — that occurring by unre- lieved retention — there is but little hope ; yet there is some room for treatment. During violent effort to overcome the obstacle to expulsion of urine, something is felt to yield, and relief is experienced and ex- pressed ; yet — probably to the patient's surprise — no urine is seen to come by the penis. By and by, the sense of relief and comfort passes off; burning heat is felt in the infiltrated part; and the constitutional 2 II 2 468 EXTRAVASATION OP UEINE. symptoms attendant on asthenic inflammation and gangrene, which must follow, declare themselves in their most formidable shape, rapidly becoming more and more typhoid, and soon ending in fatal collapse. Or, if the viscus have fortunately given way at its most anterior part, the local mischief may advance outwardly, and perhaps evacuation by the perineum may occur, with more or less relief. Treatment obviously consists in reaching the infiltrated part, if possible, by early, free, and dependent incision ; and in maintaining the powers of the system, under the strong depressing agent so busily at work, by every means in our power. No case, in which an outward and efiicient opening has been afforded, is to be considered too desperate. Nourishment and stimuli must be steadily administered. Unexpected and wonderful recoveries have rewarded perseverance. Urethral Extravasation is more common, as a consequence of stric- ture. The urethra gives way, by ulceration, at some part of its course ; and the bladder remains entire. There may not be the same sensation of something having yielded during straining ; but there is, generally, the same temporary feeling of relief having been obtained. Soon, however, there is a painful undeceiving ; the infiltrated parts become hot, swollen, red, black, dead ; a urinous odour seems to exhale from the whole body, but more especially from the parts affected ; and the ordinary typhoid irritation of system becomes more and more de- veloped — low and rapid pulse, black tongue and mouth, sunk and anxious features, cold clammy skin, hiccough, muttering, delirium. The site and amount of local mischief depend on the part of the urethra which has given way. Not unfrequently, it is behind the bulb ; and the urine, restrained, at least for a time, by the deep fascia, burrows deeply. In such a case, the local signs may be obscure ; the scrotum being uninvolved, and the perineal swelling and discoloration at first indistinct. Should the glans penis be found swollen, hard, and blackening, it is a sign of the corpus spongiosum being infiltrated and an omen of most sinister import. In such cases, an early and free incision, in the centre of the perineum, affords the only chance of relief and safety — the knife being pushed determinedly down, so as not merely to expose the surface of the infiltrated parts, but also to lay bare the source of extravasation. When the giving way has occurred at a point anterior to the deep fascia, the case is more plain and less hazardous. The scrotum, and the integument of the penis, sometimes the inside of the thighs, and the lower part of the abdominal parietes — not always the perineum — become rapidly swollen, and of a dark red hue ; then the integument blackens, crepitates, and sloughs ; and, as the sloughs separate, urine and foetid sanies flow away. Long before this open state, however, the olfactoiy organs alone are sufficient for diagnosis. In this case. INJURIES OF THE BLADDER. 469 the incisions do not require to extend so deeply, but are more nume- rous and extensive ; leaving no part of the infiltrated textures without a free outward opening. Poultice and fomentation follow the knife ; usually with active support of the system. In a day or two the poul- tice is superseded by water-dressing ; and this again is medicated by the chlorides. Immediate hazard having been got over, and the parts having passed from excitement, means are taken to overcome the cause of the accident, and to restore the urethra to its normal condi- tion. In the great majority of cases, a tight stricture is found anterior to the site of ulceration. But urinous irruption does not always take place dii'ectly from the urethra ; urinous abscess may have formed, as the first result of the stricture ; and then, the parietes of this abscess having yielded, extra- vasation takes place outwardly. The consequences and treatment are the same as in the direct and ordinary variety. Injunes of the Bladder. This viscus may suffer in various ways, by the hand of the sur- geon. In lithotomy it may be unnecessarily cut, or bruised and torn by the forceps or scoop. In lithotripsy, it may be pinched, bruised, or torn, by a rash and inexperienced operator. By the catheter, too, it may sustain hurt. The risks are hemorrhage, and inflammatory action ; to be obviated by the means already considered. Not unfrequently, the bladder suffers by accident. The pelvis is broken; and a spicvilum of bone, projecting inwards, is liable to pene- trate the viscus, more especially if it happen to be distended with urine. Urinary infiltration can scarcely fail to occur ; and probably to such an extent as to prove rapidly fatal. Or laceration may take place, in consequence of a blow or bruise ; and it is well to remember, that this result may follow an application of violence apparently by no means great, if the bladder happen to be at the time fuU of urine. Blows, kicks, falls have often proved thus fatal ; and in the female it has occurred, from merely the superincumbent weight of another per- son. Ordinarily, however, the force applied is considerable. And unfortunately, the portion of the viscus which is most apt to give way, is where it is covered by peritoneum, near its fundus ; the outer coat, less extensile than the rest, is most apt to tear ; and, besides, the force is likely to jam this part of the bladder on the promontory of the sacrum. There is great pain in the region ; only a small quantity of urine comes by the urethra, and that is more or less mixed with blood ; no tumour of distended bladder can be felt by the rectum or vagina ; the catheter draws off but little fluid, and that is bloody ; by and by the ordinary signs of urinary inflltration are declared. 470 TUMOURS OF THE BLADDEE. K the tear has been extra-peritoneal, on the anterior aspect of the bladder, there is hope in the treatment. The urine may, in its infil- tration, approach the surface in a somewhat limited way ; timeous and free incision of the abdominal parietes may evacuate it, with sloughed areolar tissue ; and the patient may be saved — even with complete return of the urine to its natural channel.* When the injury affects that part of the bladder invested by peri- toneum, the urine passes at once into the peritoneal cavity ; and escape from death is hardly to be looked for. StiU there is room for treat- ment. The catheter is introduced ; no water wiU probably come, unless there has been penetration through the aperture in the bladder ; but the instrument should be retained, with its point just within the neck of the bladder, so as to afford an outlet to what may be after- wards secreted. Should the patient survive for a day or two, it is possible — as dissection has shewn — that by inflammatory agglutination of the abdominal contents, the general cavity of the abdominal perito- neum may be shut off from that of the pelvis ; the latter becoming coated with lymph, like an abscess, and the urine confined there. Under such circumstances, it has been proposed to tap this cavity from the rectum, by means of the long and curved trocar (p. 466).f In the parturient female the distended bladder is apt to suffer. By instruments in extraction of the foetus, it may be torn ; by long-con- tinued pressure of the head of an impacted foetus, it may be induced to slough or ulcerate ; and vesico-vaginal fistula is the result — provided the patient recover. Tumours of the Bladder. Fortunately this is a rare affection. The interior of the viscus, however, is occasionally the seat of tumours ; and these are of two kinds. Simple mucous polypi may form there, in considerable num- bers ; simulating the ordinary symptoms of stone. The sound finds no calculus, but may be felt impinging on a soft and moveable sub- stance, obviously exti'aneous to the bladder's coat. It has been pro- posed to deal with this by means of the lithontriptor ; but the pros- pect of success does not seem very inviting. Malignant tumours may form ; medullary ; growing from the coats of the viscus — usually near its neck, in apparent connexion with the prostate — and occupying the cavity to a greater or less extent. Mic- turition is frequent and painful ; and the pain is greatest immediately after the effort ; the urine is bloody and foetid, and often contains flaky substances, or masses of the disorganized tumour; by impaction of these, occasional retention may occur ; dull weight is felt in the loins ; * Syme, Contributions to Surgery, p. 332. f Lancet, No. 1386, p. 352. DISPLACEMENT OF THE BLADDER. 471 and the pain of micturition is much more pelvic, and more extensive there, than in the case of stone ; also the sound, on encountering the foreign body, imparts quite a diflPerent sensation. There is no remedy for this disease. We can only hope to palliate, by opiates, and the recumbent posture. Sometimes the tumour, expanding, may cause retention which is not capable of being relieved by the catheter ; and, in such circumstances, we are called upon to protract existence, by puncturing the bladder above the pubes. Cancerous disease may extend from the rectum to the bladder, involving all in one large and loathsome sore. Malignant tumours also form between the two viscera, as formerly stated (p. 390). There is for such cases no cure. Displacement of the Bladder. It has been already stated, that sometimes, though rarely, the blad- der is protruded, so as to constitute the contents of a hernial tumour. And displacements, too, of this organ, by pelvic abscess and tumours, are alluded to elsewhere. Miserable cases are not very unfrequent, in which the anterior half of the bladder is congenitally defective, as well as the correspond- ing part of the abdominal walls ; the mucous surface of the viscus be- coming consequently protruded to constitute a red moist swelling, from which the ureters may be seen throwing out their fluid.* These admit of mere palliation, by wearing mechanical contrivances adapted for protection and comfort. If the patient live to old age, the mucous coat is apt to become covered with vegetations, which, assuming malignancy, may fungate and bleed, and prove fatal. It has also happened, in the female, that the bladder has been in- verted and protruded through the urethra, forming a vascular looking tumour between the labia, f Were this removed, under careless diagnosis, by knife or ligature, the most serious consequences must ensue. The true nature of the case may be ascertained by discover- ing the orifices of the ureters, and finding the whole tumour to be reducible within the pelvis. Sometimes it is irreducible. Laroche, Dissertation sur I'Hematurie, Paris, 1814. Chopart, Traite des Maladies des Voies Urinaires, Paris, 1821. C. Bell on Diseases of the Urethra, Bladder, &c., Lond. 1822. Howship on Diseases of the Urine and the Urinary Organs, Lond. 1823. Foot on Diseases of the Urethra and Bladder, Lond. 1826. Begin and Lallemand, Diet, de Med. Prat. (art. Hematurie) t. ix., Paris, 1833. Coulson on Diseases of the Bladder and Prostate Gland, Lond. 1842. Guthrie on the Anatomy and Diseases of the Urinary Organs, Lond. 1843. Brodie, Lectures on Diseases of the Urinary Organs, Lond. 1849. * Handyside, Edin. Medical and Surgical Journal. f Ckosse, Trans, of Provincial Med. and Surg. Assoc, vol. ii. 1846 ; and Brit, and For. Rev. Oct. 1846, p. 319. 472 CHAPTER XXXII. AFFECTIONS OF THE PROSTATE. Prostatitis. * The prostate is liable to be affected by an acute inflammatory process, during the progress of -virulent gonorrhoea. And tbis may also be excited by direct injury of the part — as by a blow on tbe perineum, or rasb usage of instruments introduced by tbe urethra ; by excessive venereal indulgence; by imprudent exposure to cold and wet; by sympathetic influence from affections of the rectum ; by the internal use of cantharides, or other irritants. Heat and pain are complained of in the perineum, near the anus, and there is tenderness on pressure there ; water is made frequently, and with pain ; and pain is greatest as the accelerator muscles exert themselves to expel the last drops ; there is a sensation of weight in the rectum ; and that bowel is evacuated with both difficulty and pain ; the finger introduced into the rectum ascertains the prostate to be large, hot, and tender on pressure ; and an attempt to pass a catheter into the bladder is difficult and painful — the difficulty and pain occurring when the instrument's point has reached the prostatic region. Not improbably, the action extends to the bladder, and then the ordinary symptoms of cystitis are added to those already described. Treatment is by rigid confinement to the recumbent posture, leeching of the perineum, hip-bath, fomentation, and opiate enemata or suppositories. Sometimes relief is obtained from large, warm, and emollient enemata, which may be supposed to act as a poultice applied directly to the part. Direct leeching has been proposed, by means of a tube, or speculum, introduced by the rectum ; but it is probable that the irritation attendant on the applica- tion, will more than counterbalance the benefit obtained by such ab- straction of blood. Ahseess of the Prostate. When the above symptoms sustain sudden aggravation, with rigor, increase of swelling and tenderness in the perineum, greater difficulty of micturition, and greater swelling and tenderness on examination by SIMPLE ENLARGEMENT OF THE PEOSTATE. 473 the rectum, it may be presumed that matter is forming in the gland. Careful examination is made, in order to arrive at correct diagnosis ; and as soon as fluctuation can be discovered, however obscurely, a direct incision is made by the perineum, to procure outward evacua- tion. If an artificial opening be delayed, the abscess may open into the urethra — favouring the formation of urinous abscess ; or into the rectum, estabUshing a troublesome recto-vesical fistula ; or outwardly by the perineum, after much injury has been done to the intervening tissues. Spontaneous evacuation into the urethra is indicated by copious purulent discharge from the penis. And then it is advisable to use a catheter, gently introduced, as often as may be necessary to empty the bladder — for some days — so as to prevent, if possible, un- toward entrance of urine by the ulcerated aperture ; or a soft elastic catheter may be passed and retained. Chronic suppuration of the prostate has been observed, causing much distress, with discharge of muco-purulent urine. On examina- tion by the rectum, a soft point has been felt in the gland ; and, on pressing it, matter has escaped by the urethra. The plunge of a lan- cet or trocar, into the soft point, has given relief; and troublesome fistula has not followed. Simple Enlargement of the Prostate. Simple enlargement of the prostate is of two kinds ; one the result of chronic prostatitis ; the other hypertrophy, independent of the in- flammatory process ; the one not uncommon in the adult of middle age, the other peculiar to advanced years. The former variety is de- pendent on stricture, or gleet, or affection of the rectum, or injury of the perineum by habitual horse exercise ; and disappears, usually, on removal of its cause. If not, recumbency is to be maintained, a few leeches are applied to the perineum, these are followed by smart coun- ter-irritation, and, at the same time, internal use of the iodide of potas- sium may be of great service. The bowels are kept gently open, by simple laxatives and enemata. In obstinate cases, an alterative course of mercury is expedient ; and, under this, amendment is sometimes both rapid and satisfactory. Hypertrophy of the gland is usually regarded as but one of the many signs of senile degeneracy in the frame. As the eyes groAV dim, the trunk bends, the cartilages ossify, and the arteries change in their coats — so the prostate is supposed to grow large and hard. The en- largement may be uniform, the whole gland seeming to expand equally; displacing the urethra as well as compressing it, and consequently interfering with its function in regard to the urine. Or the central portion may enlarge, with much greater rapidity than the rest of the 474 ENLARGED PROSTATE. gland ; rising like a mammillary process ; projecting backwards into the bladder ; but, ever and anon, liable to move forwards, and so to act as an occluding valve to the outlet of the cavity. In general, the lateral lobes enlarge unequally ; and consequently a twist is given to the prostatic portion of the urethra, in the lateral as well as in the vertical direction. The symptoms of this simple hypertrophy are — increas- ing slowness and difficulty in making water, uneasiness and difficulty in emptying the rectum, with a sensation of weight in that bowel and in the perineum ; sometimes the fceces are passed flattened, as in stricture of the rectum. On introducing a catheter, some difficulty is likely to be met with in passing the region of the prostate ; and when a finger in the rectum is made to press upwards on the catheter, the enlarged pros- tate is plainly felt between. "Without the use of the catheter or bougie, tactile examination is never certain. As the tumour enlarges, calls to empty the bladder are more fre- quent, and the act is less perfectly accomplished ; as formerly stated, a portion of residuary water remains, cooped up be- hind the enlargement (p. 464). The bladder sympathizes ; it may become irritable ; more frequently, a degree of chronic cystitis is excited. The urine changes, in consequence ; be- coming dark-coloured, foetid, and full of mucus. The vesical aspect of the projection may. ulcerate, giving rise to hsema- turia, purulent urine, and aggravation of all the distress. The difficulty in micturition increases ; and at last — some casualty acting as an exciting cause — retention occurs. Generally, this has not existed long, before the " surface water" comes to dribble away; and, by the establishment of incontinence, the retention is partially re- lieved, as formerly stated (p. 457). It may happen, however, that the obstruction is complete ; and by retention the patient may perish. Or, the whole urinary system hav- ing become involved in disease, death takes Kg. 146. place by gradual exhaustion. Treatment is but palliative. We can scarcely hope to retard, much less to remove the enlargement. Every excess and imprudence is avoided, in diet and exercise ; and the recumbent posture is main- tained as much as possible. The bowels are regulated by enemata and simple aperients. Opiates are given occasionally ; and acids, iron, buchu, &c., are exhibited, as the complication by chronic cystitis may seem to demand (p. 452). To avert distension of the bladder, Fig. 146. The ordinary catheter; of half size. ENLARGED PROSTATE. 475 the catheter is used as often as may seem necessary. Excision of the gland has been talked of; but scarcely in sober earnest. When retention has occurred, the catheter requires a ^ peculiarity of management. As already stated, the urethra is considerably elongated ; and the catheter must be of a pro- portional length. The prostatic portion of the urethra almost invariably has a bend given to it, antero-posteriorly — that is, the convexity is towards the rectum, the concavity tow^ards the pubes ; and, to suit this peculiarity of form, the instrument should have a large curve. Very frequently, the central en- largement — or " third lobe," as it is usually called — exists ; and, to surmount it, it is vrell to have at least one instrument in the prostatic set, vphose point makes a sharper curve upon the general bend. It is introduced carefully ; and, to assist the point onw^ards, the handle is freely depressed after pass- ing the triangular ligament; w^hile, at the same time, the point is elevated by means of the finger in the rectum. If the silver catheter, thus made and managed, refuse to enter, one of elastic-gum may be tried ; bent to the proper shape, and introduced vpith the stilet. On reaching the prostatic ob- struction, the stilet is gently vnthdravs'n, while the catheter is pushed steadily on, and the consequent elevation of the point may perhaps lead it over the obstruction. Or, the stilet be- ing held steady, the tube is passed on, and the same effect is produced — the catheter's point curving round that of the stilet, as it were. There is another peculiarity. As the prostate enlarges, not only is the prostatic portion of the urethra unusually ex- tended and curved ; it is also very considerably enlarged, by dilatation of the prostatic sinuses on each side of the veru- montanum.* In retention, this dilatation is usually full of urine ; in fact may be considered as a small fictitious bladder in front of the real one. On the catheter reaching it, a spoon- ful or two of ui'ine may be discharged, and the surgeon may in consequence be led to suppose that he has reached the bladder and emptied it — the i-emaining swelling consisting of abscess ; the plunge of a trocar may follow ; or the patient may be left to his fate, unrelieved. But by invariably using the long ca- Fig. 147. theter, in such cases, and never resting satisfied unless this instru- * Deschamps, Traite de la Taille, torn. i. p. 222. Fig. 147. The prostatic catheter ; of half size. 476 MALIGNANT DISEASE OF THE PEOSTATE. ment be passed terms capulo — unless, indeed, water flow freely, without such extreme insertion — the surgeon is safe from all such serious error. Perhaps the prostatic obstruction proves insurmountable. Then the bladder must be relieved at all hazards; and one or other of the follow- ing methods may be adopted: — The catheter may be forced through the obstruction ; guided in a good direction by the finger in the rectum. Or a trocar and canula may be used, instead of the catheter. Or the bladder may be punctured above the pubes. The operation by the rec- tum is obviously unsuitable. Of these proceedings, perforation of the prostatic obstruction is the most advisable, by means of a suitable trocar and canula ; the latter of the same length and calibre as a fuU-sized prostatic catheter, but considerably less curved. It is passed carefully on to the obstruction, with its trocar withdrawn, and with its extremity temporarily occupied with a bulbous wire ; and, when satisfied by the finger in the rectum, that the instrument is duly directed towards the bladder, the bulbous wire is removed, the trocar is inserted and protruded, and the whole is pushed on. The trocar is then wholly withdrawn ; and the canula is retained for some days. When the retention has been of long dura- tion, and there is reason to believe that the kidneys are organically diseased, the urine is to be withdrawn gradually, for the reasons for- merly adduced (p. 464). Malignant Disease of the Prostate. The gland is sometimes, though rarely, the seat of scirrhns. More frequently it is afiected by medullary formation, which enlarges ra- pidly, ulcerates, bleeds, and follows the usual course of such tumours. The disease is not peculiar to the aged. It may occur in children, as medullary tumours in other sites so frequently do. The symptoms are similar to those of mere ordinary enlargement, with the addition of those of tumours in the bladder (p. 470), as well as of those which attend and characterize all malignant formations. The disease is incurable. By opiates, the catheter, enemata, and rest, we may hope to palliate and protract. Deschamp, Traite sur la Taille, torn. i. Paris, 1796. Home, Everard, Practical Ob- servations on the Diseases of the Prostate Gland, Lond. 1811. Lawrence, Lectures in the Lancet, 1829-30, vol. ii. Coulson on Diseases of the Bladder and Prostate Gland, Lond. 1842. Brodie on Diseases of the Urinary Organs, Load. 1849. Adams on the Anatomy and Diseases of the Prostate Gland, Lond. 1851. 477 CHAPTEE XXXIII. THE VENEEEAL DISEASE. The history of the venereal disease is involved in some ohscurity. Hovpever, it seems extremely probable — if not, indeed, quite certain — that affections of the genital organs, dependent on licentious venereal intercourse, have existed from the earliest ages ; that they have pre- vailed in various degrees of frequency and intensity, at different times and places ; that they were not directly imported from America to Europe, by Columbus' followers, in the end of the fifteenth century; but that, between the years 1493 and 1495 — at the time of the siege of Naples — they experienced an aggravation in Europe, and consequently attracted much more prominently the attention of the profession. They are usually spoken of under the general term of " The Venereal Disease ;" and this again is divided into Gonorrhoea and Syphilis ; both the result of the application of animal virus, engen- dered by illicit intercourse — or at least communicated thereby ; the former an inflammatory affection of the urethra ; the latter a con- tamination of the whole system, preceded by the formation of pustular ulceration on some part of the penis, or other part of the body. By some, it is still maintained that the poisons are the same ; that what produces gonorrhoea is capable of exciting syphilis, and vice versa. The weight of authority, however, preponderates largely in favour of an opposite opinion ; admitting, perhaps, that gonorrhoeal virus is capable of causing the simplest form, only, of venereal ulcer ; and even that concession is by many not granted. Gonorrhcea. An acute inflammatory process seizes on the lining membrane of the anterior part of the urethra ; caused by the application of gonorrhoeal matter, from a second party ; and this application usually made during sexual intercourse. There is a period of incubation, of uncertain extent ; discharge may show itself within not many hours after connection ; or it may not be till after many days have elapsed. About the fifth day may be taken as the average period of accession. 478 GONOEEHCEA. Heat and itching are felt in the glans, which seems fuller and more deeply coloured than usual ; the urethral orifice is uneasy, red, and swollen ; urine is passed in a small stream, sometimes forked, and with increasing heat and smarting ; the orifice of the urethra shows an increased secretion ; then it becomes dry, more red and swollen, and painful ; the stream of urine is more diminished, and the pain which accompanies it is intense; then discharge returns — no longer limpid, but turbid and puriform — becoming more and more pro- fuse, and ultimately seeming to consist of true pus ; and if the action prove intense, there may be a considerable admixture of blood. Some- times smart fever affects the system ; sometimes there is but little con- stitutional disturbance. The thighs, loins, and testicles, sympathise in a dull aching sensation. Such are the ordinary symptoms at the onset of the disease. But, in the course of its progress, serious additions may be made. 1. Chordee may occur ; that is, abnormal erection may take place ; the penis becoming bent like a bow — forming an arc of which the urethra is the chord — the convexity on the dorsal aspect — probably on account of exudation having taken place into the corpus spongiosum, so as to pre- vent uniform expansion of the erectile apparatus. Such erection is intensely painful, and tends to aggravate the disease ; it is also liable to induce profuse hemorrhage, probably by laceration of the mucous membrane. The tendency to chordee is greatest during sleep ; while the patient is warm in bed, and perhaps excited by voluptuous dreams. Sometimes, its proximate cause would seem to be other than plastic exudation ; normal and abnormal erections alternating with each other. 2, The glans may become excoriated, furnishing a profuse discharge ; establishing what is termed Spurious Gonorrhoea. 3. The prepuce may become cedematous; inducing the condition of Phymosis, when the swollen prepuce maintains its ordinary relation to the glans ; causing Paraphymosis, when it is reflected behind the glans, and allowed to remain there. The former state aggravates the disease, by retaining discharge, and increasing the tendency to affection of the glans ; the latter leads to strangulation of the glans, and consequently to intense exacerbation there. 4. The lymphatics may suffer ; becoming painful, red, and swollen, on the dorsum of the penis ; or, without such indica- tion, inflammatory enlargement may take place in the inguinal glands, constituting what is termed Sympathetic Bubo. 5. Abscess may form in the penis ; on the dorsum ; or beneath, opposite to the lacuna maxima. The latter is the more frequent site. A main residence of the inflam- matory action — which, in the first instance, does not extend beyond two inches from the orifice — seems to be in this lacuna ; which swells and becomes hard ; filled with accumulated secretion internally, and externally invested by plastic exudation. In this exterior true inflam- ACCIDENTS OF GONOERHCEA. 479 mation may occur, causing abscess of greater or less extent. 6. Or abscess forms in the perineum, at a distance from the original site of action — a less frequent complication ; threatening retention of urine by compression of the urethra, and urinous abscess by opening inter- nally (p. 469J. 7. Or prostatitis ensues; sometimes by continuous extension of the inflammatory process along the membrane ; more fre- quently, perhaps, by metastasis. And in severe cases — either originally and innately so, or become urgent in consequence of either mal-practice, or imprudence on the part of the patient — abscess may form in the prostate ; usually superficial, as regards the urethra ; temporarily causing retention of urine ; early emptying itself internally, and ren- dering urinous abscess not improbable (p. 473). 8. Or, the inflam- matory process extends still further, and more untowardly — either by continuity, or by metastasis ; and acute cystitis results ; aggravating all the local symptoms, and, by urgent disorder of the system, bringing even life into peril. From the bladder — with or without abscess of that organ — inflammation has extended to the peritoneum, and proved fatal. 9. Acute rheumatism may supervene ; the joints of the limbs becoming painful and swollen, and the system suffering under inflam- matory fever. The knee and ankle-joints are those most frequently and prominently involved. The supervention sometimes takes place during the acute stage, sometimes during the decline ; occasionally the rheumatic symptoms are coeval with those of the gonorrhoea. Or gouty symptoms may be excited, in those of the better ranks, and of advanced years. 10. Very often, in protracted cases, orchitis takes place ; the inflammatory action sometimes seeming to be transferred to the testicle by metastasis, sometimes seeming to creep along from the pos- terior part of the urethra to the vas deferens, and thence to be extended to the epididymis and testicle — becoming mainly resident in the former. During the acute stage of such orchitis, urethral discharge diminishes, and may wholly disappear ; not necessarily proving a metastasis, but explicable quite on the principle of relief by counter-irritation. As the orchitis declines, discharge usually reappears. Orchitis may be caused at any period of the case, by a blow on the part, or by imprudence in exercise. If spontaneous in its accession, it usually occurs in the chronic stage ; weeks, perhaps, after the first appearance of discharge. Gonorrhoea is one of those affections which are capable of self-cure. The intensity of the symptoms gradually subsides ; the complications which may have occurred are recovered from ; and the discharge becomes less copious, and somewhat restored to the mucous character. This state is termed a Gleet — embers of the previous burning. There is little or no pain, swelling, or redness ; thin discharge is the prominent symptom ; with, perhaps, some trouble in micturition. In a patient 480 TREATMENT OF GONORRHCEA. wlio has suffered from previous claps, a greater or less degree of con- traction in the urethra probably exists ; but, in primary attacks, the gleet need not be suspected of such complication. In any case, it is not to be considered that the gonori'hoea has finally ceased — ^becoming merged in an affection of a different name and kind ; for, from but a slight cause — as unusual exercise, imprudence in diet, or such like — reaccession of the inflammatory process may take place ; and the gonorrhcea may be revived in even more than its pristine severity. The Treatment of gonorrhoea varies, according to the stage of advancement. At the first onset, what is termed the ectrotic or abor- tive treatment may be attempted ; vs^hile the inflammatory process is still nascent, and has not reached the suppurative crisis. The nitrate of silver is used, as in similar affections of the surface ; vpith the view of procui'ing rapid resolution (Principles, p. 178). It is applied, in the form of strong solution, to the affected part of the mucous mem- brane — carefully, by means of a glass syringe, so as to pervade the whole diseased surface. Some prefer the form of ointment.* A coagulated film is produced, which, adhering, protects the villous surface beneath during the passing of urine ; besides, the purely anti- phlogistic effect of the remedy may be obtained, here, as in erythema ; and, not improbably, a third beneficial indication may be fulfilled — the virus may be chemically acted on and neutralized. Such injection or application is made once or twice — at an interval of twelve or twenty-four hours ; and strict rest, with antiphlogistic regimen, is observed.f The action may be arrested, resolution may rapidly follow, the virus may be destroyed, and the disease may thus be cut short in its outset. Obviously, however, such treatment is applicable only to the very earliest stage — ^which is seldom brought under the cognizance of the surgeon ; in irritable habits it is not likely to succeed ; and, under even the most favourable circumstances, there is always a risk of failure, with consequent aggravation of the original disease. Failing the ectrotic attempt — or, no opportunity having occurred for its practice — the acute or inflammatory stage is met by ordinary antiphlogistic means. And it is well to remember, in reference to this, that the first attack of gonorrhcea is generally the most severe. Rest is enjoined; but, for obvious reasons, this all-important indica- tion is but seldom fulfilled — and hence one cause of this affection often proving tedious and troublesome in its cure. Diet is low ; the part is fomented, and by a handkerchief or bandage it is suspended ; antimony * 3! to §i of lard. The strength of the injection may vary from fifteen to thirty grains in the ounce of distilled water. f Some employ the nitrate of silver in another way, for ectrosis ; using a weak solu- tion—say two grains to eight ounces of water — and injecting this once every four hours, for ten or twelve times. We would put more faith in the concentrated and less frequent form of application. TREATMENT OF GONORRH(EA. 481 is given in nauseating doses ; the bowels are gently moved ; drastic purging doe^s harm, by irritating the rectum, and involving the urethra in sympathy ; leeches may be applied to the perineum ; and, if uneasy feelings pervade the hips, loins, and thighs, the hip-bath will be found useful. In extreme cases, it may be necessary even to abstract blood from the arm. To mitigate the ardor urinae, bland fluids are drunk, abundantly ; as linseed tea, a solution of mucilage, &c. To render the urine less acrid, saline draughts are useful ; as, a scruple of bicar- bonate of soda, with a drachm of Rochelle salt, dissolved in tepid water, and then mixed with soda water ; taken three or four times daily. Bland enemata are useful, in regulating the bowels ; and, in the case of a sympathizing prostate, they are of service as a fomentation or poultice to that part. The antimony is of use, not only as anti- phlogistic, but also as antiaphrodisiac ; and this latter indication is to be assisted by suitable moral treatment on the part of the patient. Camphor, too, and lupulin, are useful in the same way. Should painful erections occur, opiates are given, especially at bed-time ; a pill of opium, hyoscyamus, and camphor, is found to be very suitable ; repeated as circumstances may demand. And the patient should lie cool at night, with few bed-clothes. Sometimes full doses of colchi- cum are of service, in relieving chordee — especially in those cases which possess the rheumatic complication. Leeching of the affected part is not advisable ; the leech bites are likely to cause swelling, partly by ecchymosis, partly by oedema ; and such swelling tends to complication by phymosis or paraphymosis ; besides, the wounds are liable to be inoculated by the virus, and troublesome sores may be the consequence. At this stage, ectrotic treatment is not to be thought of. We would not seek for sudden suppression of discharge, were this in our power. If it do occur, it is an untoward event ; sure to be followed either by aggravation of the original disorder, or by implication of the prostate, bladder, or testicle, through metastasis. Strong injection, therefore, is not suitable. No doubt, it may temporarily arrest the discharge ; but only because such exacerbation of the inflammatory process has taken place, as checks all secretion ; pain, swelling, and redness are greater than before ; and discharge soon reappears in increased quantity. The inflammatory crisis having passed over, the sternness of the antiphlogistic treatment is gradually departed from. And certain remedies are given,* which by experience are found to exert a specific * These remedies act on the part ; as is shewn by experiment. If a patient with fistula in perineo have contracted gonorrhoea, and if the whole urine be permitted to pass through the fistula, no benefit will accrue fi-om any dosing with cubebs or copaiba. But when, by shutting up the abnormal aperture temporarily, the urine is made to pass over the whole urethra, amendment is at once observed. 2 I 482 TREATMENT OF GONORRHCEA. influence on the urethra ; copaiba and cubehs ; the former the more suitable at first ; given in cautious doses, lest a deleterious amount of stimulus be imparted to the membrane. As the case becomes chronic, antiphlogistics are gradually aban- doned. And, for the state of congestion which remains in the mem- brane, the direct application of gentle stimuli is found useful. Pressure may be applied, by a compress over the corpus spongiosum ; but this is found irksome, and difl&cult of management. The method of injec- tion is preferable. A glass syringe, with blunt point, and long narrow nozzle, is employed; by means of which — inserted fully into the urethra — application of the injected fluid may be made accurately to the whole diseased surface. BackAvard extension to the bladder need not be apprehended, the natural collapsed condition of the canal being a sufficient obstacle to this. The fluid injected is at first weak ; and its strength is gradually increased, according to circumstances. In nothing is there more room for variety. Some use an infusion of green tea, or other vegetable astringent. Sulphate of zinc is perhaps most commonly employed; or the acetate of zinc; or sulphate of copper; or the salts of iron; or the nitrate of silver; or alum; or strychnine. A favourite injection is the acetate of zinc, with a pro- portion of opium. Water is passed befoi'e injecting, so that the fluid may reach the membrane directly ; and, on withdrawing the syringe, the point of the penis is held erect for some time, so as to keep the fluid in contact with the affected part. The operation may be repeated three or four times in the day ; but should over-excitement ensue, injection must be wholly discontinued for a time ; and when resumed, it must be very cautiously. As already stated, the strength of the injection is gradually increased ; and, if it seem to have lost its influ- ence, it is better to change to a different kind, than to increase the first to a strength at all formidable. In fact, the principle of stimu- lation is conducted as in the use of lotions to a weak sore on the surface of the body (Principles, p. 242). In obstinate cases, benefit may be derived from nitrate of silver rubbed on the perineum, so as to act as a smart counter-irritant. In the truly chronic stage, large doses of cubebs may be given vsdth advantage ; regard always being had to the kidneys, lest over- stimulation occur there. And sometimes rapid amendment may be obtained by cubebs combined with copaiba in the form of paste, given in wafer paper — an admirable remedy for the chronic cases, but usually much too stimulant for the early stage. These internal reme- dies may be employed along with injection. Or they may be alternated. But, in no case, should injection be long and continuously persevered with ; otherwise a discharge of the stimulant's own pro- duction may be maintained, keeping up a state of congestion in the TEEATMENT OF GONOREHCEA. 483 membrane, delaying the cure, and rendering the occurrence of stricture very probable. Sometimes the affection is chronic from the first ; passive congestion furnishing the discharge. This is liable to occur in patients of slug- gish temperament, who have had many attacks of the disease. In such cases, antiphlogistics are never suitable ; and the stimulant mode of treatment is adopted from the first. The casualties of the disease are met as they occur. Chordee requires cool covering of the parts at night, a suitable moral ti'eatment, and sedatives (p. 481). The attack, when spasmodic, may be mode- rated by immersion of the organ in cold water. Hemorrhage often requires no treatment, being regarded as a salutary occurrence, auxiliary in the treatment; if excessive, it maybe restrained by the application of cold, or by pressure, as already described (p. 456). (Edema is relieved by fomentation and poultices. Bubo requires fomentation and rest ; and, its first acuteness over, external application of iodine is likely to obtain resolution. Abscess threatening in the penis, or in the perineum, is opposed by increased and concentrated antiphlogistics; if matter have formed, an incision cannot be made too early for evacuation. Affections of the prostate and bladder require their suitable treatment, already noticed (p. 451, &c.) Small cold enemata, containing a moderate quantity of laudanum, are some- times very useful. And it is well to avoid these attacks, by doing nothing heroically, in the way of injection, after the gonorrhoea is fairly esta- blished. With some, no doubt, strong injections are still in vogue, even at an advanced period of the case. But, in our opinion, they are war- rantable only at the very first, as already stated ; and then should consist only of nitrate of silver — which alone seems capable of exerting a purely antiphlogistic influence on skin and mucous membrane. It is used here, as in inflammatory affection of the mucous membrane of the throat ; it forms a protecting crust, allays irritability, and resolves the inflammatory action. The same strength of sulphate of zinc would prove merely stimulant, and would not fail to cause aggravation. Gout and rheumatism are met by their peculiar treatment. And, obviously, it is important to remove the tendency to uric deposit as speedily as possible ; otherwise the passing of this cannot fail to main- tain, and probably to increase the urethral excitement. Thus, according to the ordinary principles of surgery, would we treat gonorrhoea ; and with a good hope of success ; if the indications regarding regimen and rest be fully carried out — a difilculty in many cases, as already stated. But there is no disguising the fact, that not unfrequently the disease proves quite intractable ; as if determined to run its own course, regardless of the means employed — unchecked, 2i2 484 TREATMENT OP GONORRHCEA. almost unmitigated and unmodified. In such cases, some peculiarity of constitution will generally be discovered ; scrofula, gout, or extreme irritability of system. And, for such difficulties, no general rules of treatment can be laid do"\vn. Each must be met by what seems most suitable under the circumstances ; always avoiding undue activity of practice ; and preferring rather that the disease should run its own course, than that by unfortunate interference more serious affections of the prostate, bladder, testicle, or general system, should be induced.* In general a tonic treatment is required ; specially the preparations of iron and quinine ; with the latter, nus vomica has been successfully combined. I Bougies are by some recommended ; but we would move them altogether from gonorrhoea to gleet. Their use in the former affec- tion is extremely apt to over-stimulate, causing reaccession of the disease. In gleet, however, they are very serviceable, by obviating any tendency to contraction in the urethra, and removing the con- gested state of the lining membrane ; and sometimes by means of a bougie, the citrine or some other stimulant ointment may be benefici- ally applied to the anterior part of the membrane. In obstinate cases, with irritability of the posterior part of the canal, nitrate of silver may be applied — cautiously — by means of Lallemand's porte-caustique. In some cases of obstinate gleet, the discharge seems to be kept up by chronic prostatitis, and to come from the follicles of the gland. Under such circumstances, chian turpentine, in five grain doses, often arrests the secretion ; seeming to have a special action on these parts. | After discharge has ceased, and uneasy sensations have almost whoUy disappeared, great care is still necessary on the part of the patient. Cure is not yet complete. A hearty meal, a debauch in wine, venereal indulgence, a long walk or ride, may reinduce the dis- charge and pain. Avoidance of all such re-exciting causes, therefore, must be scrupulously observed, until at least a week has elapsed. As to the period when contagion ceases, opinions differ. Probably, the discharge is most virulent when first displayed — as yet non-puru- lent in character. Perhaps, as the purulent character is declared, virulence may decrease, and soon disappear. Possibly, the creamy thick discharge may be not different, in any respect, from the ordinary product of simple inflammation. But such matters are, as yet, not fully removed from uncertainty ; and it is well always to approach * The length of time during which an obstinate gonorrhoea may persist is sometimes great ; but scarcely so extreme as that mentioned by one eminent modem authority, ■who gravely tells us of claps contracted at the peace of Amiens in 1800, being still running in 1840!— Lancet, No. 1263, p. 510. t Brit, and For. Rev. July 1850, p. 226. I Adams on Diseases of the Prostate, p. 35. GONOERHCEA PE^PUTIALIS. 485 error on the safer side ; holding, for practical purposes, that so long as there is discharge, there is at least a possibility of communicating infection thereby. Sometimes the eyes suffer by gonorrhoea ; and one of two affec- tions may occur. Gonorrhoeal Ophthalmia includes Conjunctivitis and Iritis. Gonorrhoeal Conjunctivitis, as formerly noticed (p. 94), is usually the result of direct contagion ; virulent gonorrhoeal matter having been applied from a second party. The inflammatory process is rapid and intense ; and the most active measures are necessary, to prevent serious structural change. Gonorrhoeal Iritis, on the other hand, is a remote constitutional result of the virus within the patient himself ; occurring as a secondary symptom ; usually mild in its cha- racter, and demanding no severity of treatment. It most frequently occurs in those of a rheumatic habit ; and is not unlikely to be associ- ated with affections of the joints. Often it is accompanied with cor- neitis. Secondary symptoms, of any kind, are rare. Sometimes, how- ever, a febrile disturbance is followed by papular eruption ; and Gonorrhoeal Lichen is said to be established. This, too, is mild. Under anti-febrile measures, the precursory disorder soon yields ; and the eruption will not resist simple and ordinary treatment. Like the primary affection, it is capable of self-cure ; and may often be medicinally disregarded. Mercury is never necessary. The virus of gonorrhoea is comparatively mild ; its seat would seem to be much more in the part than in the system ; and when the latter is involved, it is but slightly. In some constitutions, there is intolerance of copaiba ; its use being followed by the appearance of an eruption, of the nature of urti- caria, preceded and accompanied by smart constitutional disturbance. Discontinuance of the remedy, with antiphlogistic regimen, is enough. Gonorrhoea Prcejjutialis, sometimes termed Spurious Gonorrhcea, but more correctly Balanitis, denotes a condition of the preputial membrane and investment of the glans, similar to that of the urethral lining in gonorrhoea. The disease may be an accession to gonorrhoea ; or it may occur independently of this, from the same cause. Or it may be altogether simple in its origin ; resulting from accumulation of acrid secretion, from retention of calculous matter, or from external injury. The part is red, swollen, partially abraded by superficial ulceration, and discharges a profuse puriform secretion. The prepuce is oedema- tous ; and there is more or less trouble in micturition. Treatment is simple. An ectrotic result by nitrate of silver is almost always in our power. The glans, having been exposed, is pencilled lightly over by nitrate of silver in substance, or, what is better, by a strong solution of it. Within four-and-twenty hours, the intensity of inflammatory 486 GONOEEHCEA IN THE FEMALE. action, and the amount of secretion, will be found greatly diminished. And, very probably, another application vnYi complete the cure. Of course, rest and antiphlogistic regimen are not neglected. Warts are a frequent concomitant of the foregoing affection ; or they may form independently of it. They are usually clustered round the corona glandis, and on the fr^num (Principles, p. 405). The best method of removing them is to take away the projecting portions by knife or scissors, and then to touch the stools with an escharotic ; the nitrate of silver, firmly applied, may prove sufficiently power- ful ; or some one of the other suitable destructives may be used — as bichloride of mercury, dissolved in alcohol, ^i to ^^^- ^*®' gi ; equal parts of savine powder, and burnt alum ; acetic acid ; or a strong infusion of tormentilla officinalis. A more genuine form of Spurious Gonorrhoea occurs, when, from some cause, other than the application of gonorrhceal matter, inflam- matory action is kindled in the anterior part of the urethra, and fur- nishes discharge. The inflammatory process is common ; not specific. The symptoms are comparatively mild ; and their duration is short. Ordinary antiphlogistics suffice for cure. The more common exciting causes of such an affection are — the internal use of cantharides, or other irritants ; the application of acrid female secretions, in marital in- tercourse; injury done by instruments, or by the passing of calculous fragments; external injury of any kind ; sympathy with the rectum. Gonorrhcea in the Female. The female suffers comparatively little from Gonorrhcea. For a fe\v days only the acute symptoms persist ; and the chronic stage is attended with but little discomfort. The parts affected are the urethra, as in the male, the vulva and exterior of the vagina, and the os uteri ; the last mentioned part frequently becoming affected by superficial ulceration. Sometimes the inguinal glands enlarge sympathetically. The prominent symptoms are — discharge, painful micturition, pain and swelling in the vulva, cedema of the prgeputium clitoridis, uneasiness in sitting and walking ; at first, some constitutional disturbance ; often an aching in the back and loins. Treatment is simple. At the out- set, an ectrotic result may be obtained ; the vulva being painted over by nitrate of silver. Failing this — during the short acute stage, recum- Fig. 148. Warts on the penis. SYPHILIS. 487 bency is enjoined, with antiphlogistic regimen ; the parts are diligently fomented ; and, if need be, demulcents are given freely. Afterwards injections are to be used, of greater strength than in the male — the pelvis being elevated during, and for some time after injection, so as to prevent premature escape of the fluid ; and a piece of lint, soaked in the stimulant solution, may be kept constantly retained in the vulva. Gallic acid may be useful, internally. And, ultimately, a tonic system of general treatment may be expedient. Young girls are liable to suifer from a spurious gonorrhoea, caused by some intestinal, rectal, vesical, or general irritation ; and consisting of an excited and perhaps excoriated state of the vulva and orifice of the vagina, with discharge. It yields readily to removal of the cause, followed by the simplest local treatment. A knowledge of its nature and origin is obviously of much importance, in a medico-legal point of view. The true gonorrhoea is apt to be confounded with Leucorrhoea ; but may generally be distinguished, by attention to the history of the case, and its accompaniments ; also remembering that in gonorrhoea there is vesical and urethral disorder, with tendency to glandular irritation in the groins, while in leucorrhoea these affections are com- paratively uncommon. Syphilis. This includes, as a general term, all the diseased states, local and constitutional, primary and subsequent, which follow, and are caused by, the inoculation of venereal poison. The action of poisons has already been considered (Principles, p. 652) ; as well as the probability that there is here a double process of zymosis. The virus, settling on and in the part, accumulates there, and at the same time excites an inflammatory process, soon ending in true inflammation ; and this always causes suppuration and ulceration — sometimes sloughing. This constitutes the Primary or Local symptoms. From the specific sore, thus produced, absorption takes place, after the acute crisis of inflam- mation has passed (Principles, pp. 110 and 144). And, by absorp- tion, the virus enters the system, through the circulation ; more or less rapidly, and in greater or less quantity. In the system, a second zymotic process is established ; the poison is multiplied ; and, acting , perniciously on the frame, it declares itself by fever and eruption — these constituting the Secondary or Constitutional symptoms. By such an outbreak, the poison may be fully eliminated; and, if so, then the disease is at an end. If, however, elimination is incomplete, then other affections — of bone, skin, and mucous membrane — make their ap- pearance at a still more remote date ; and these are termed Tertiary symptoms. 488 SYPHILIS. The venereal ulcers, or primary sores, are of different kinds ; and these different kinds are liable to be followed by corresponding variety in the secondary symptoms. Hence it has been inferred, that there are varieties in the originating virus — that there is a plurality of poisons. At present, the question is involved in much uncertainty. But for practical purposes, it is sufficient for us to know, that all venereal sores are not alike in their characters, progress, and results ; that at least four different varieties exist, and can readily be discri- minated ; and that each of these requires peculiarity of treatment. But, in the first place, it is important to observe, that all sores of the penis are not venereal ; and, further, that all sores of the penis, caused by impure sexual intercourse, are not necessarily of this nature — the product of a specific virus. The penis is as liable as other parts to ordinary causes of the common inflammatory process ; and common sores may result. Again, it is liable to be excoriated during coition ; and a sore may form in consequence, quite unconnected with inoculation of any virus. And, also, the part is liable to herpetic eruptions, of quite a simple nature. Herpes of the penis usually occurs on the integuments of the body of the organ ; sometimes it forms on the preputial lining, behind the glans. It may be caused by the contact of acrid female secretions — not virulent; or its accession may be altogether unconnected with sexual intercourse. It is known by the character of the vesicles ; their plurality, form, speedy formation, and early disappearance. Rest, cooling medicine, and some simple soothing application, constitute the necessary treatment. Patients once affected by it are very liable to its recurrence. Simj^le Abrasion is known by its immediate appearance, by absence of the preliminary inflammatory process and pustular formation, by its superficial extent and irregularity of form, by the absence of true ulceration, and by speedy assumption of the healing process. It heals under ordinary simple means. Common sores are knoAvn by the history of their production, and by absence of the characteristics of the venereal ulcer. If any doubt exist, it is expedient to treat the sore, locally, as if it were really vene- real. Thus all risk, by mistake, is averted from the patient. And, if it be considered of importance to arrive at certainty on the subject, the test by inoculation may be had recourse to. A portion of discharge from the sore is inserted, by the point of a lancet, in the inside of the thigh ; if the virus be present, a succession of results will occur as in the case of other inoculations ; active congestion will form, then pustular formation, and then ulcer. By the third day, the charac- teristics will be sufficiently plain* And then, by freely rooting out * For detail of the results of venereal inoculation, see Ricord, Lancet, No. 1278, p. 225. SIMPLE VENEREAL ULCER, 489 the forming pustule by means of an escharotic, propagation of the disease is prevented. I. — The Simple Venereal Ulcer. If previous excoriation, or other breach of surface exist, the sore may declare itself at once ; the incipient inflammatory process becom- ing apparent almost immediately after connexion. More frequently, the virus has to find its way through entire skin or mucous membrane. And a day or two, consequently, may be occupied by a period of in- cubation — ^ranging from one to ten, or more.* Then the inflammatory process, causing pustular formation and ulcer, advances, as already stated ; ulceration being generally established by the sixth day from the time of infection. The progress may be conveniently divided into three stages. — First, that of inflammatory action and pustular forma- tion. Redness forms, with itching and heat ; in the centre of the red- ness, vesication takes place ; the contents of the vesicle become puru- lent, constituting a pustule ; this breaks, with or without scabbing, and discloses an acute ulcer beneath. The second period is that of ulcera- tion ; occupying, also, it may be said, from three to ten days. The advancing sore is usually of a circular or oval form, excavated, of pale surface, surrounded by a bright inflammatory areola, and furnishing a thin ichorous discharge. This is the period of infection, inoculation, and arrest by cauterization. The thin ichorous discharge, not yet truly purulent, is certainly most charged with the virus, and conse- quently most likely to propagate the disease by contagion. It is now that the most favourable opportunity exists for attempting the test by inoculation — ^if such be desired. And it is only at the early part of this period, that we have it in our power, by converting all into an instant slough, to extirpate the disease while it is yet wholly local. The third stage is that of reparation ; the sore speedily showing the characters of the weak class (Principles, p. 241). Tall, pale, and flabby gi'anulations sprout up, above the level of the surrounding parts ; and the vascular areola diminishes, in both extent and intensity. In this state, the sore may remain stationary for many days. But, on the healing process being begun, ii, fourth stage may be said to be in progress — that of cicatrization. | * There seems good reason to suppose, that in general the virus begins to act very soon after its application ; within a few hours, in most cases ; and that the examples of apparently protracted incubation depend, chiefly, on the circumstance of the poison having been temporarily intercepted, as it were, by a hair follicle, a hardened portion of cuticle, or other obstruction. f On the glans there is little or no reparative action by organization of new material, whatever kind of sore exist; consequentlj' there the cicatrix is always depressed, and loss of substance is permanent. 490 SIMPLE VENEREAL ULCEE. The negative signs by which this sore is distinguished, are : the absence of surrounding induration, no elevation of the edges, and no tendency to phagedsena. Its ordinai-y site is on the prepuce, and in the sulcus behind the corona glandis ; often by the side of the frsenum ; occurring, in short, in the parts most susceptible of, and most exposed to contagion, and where the virus is most likely to nestle, overlooked. All sores near the frsenum are unfavourably situated. The second stage is of long duration, and ulceration is acute ; the sore continues to enlarge ; often it bun-ows beneath the fr^num, causing perforation ; and reparation seldom advances, until the frsenum has been wholly destroyed. In all such cases, therefore, it is well to abbreviate the process, by division of the frsenum at once ; care being taken that troublesome hemorrhage do not ensue, from the small but active artery which generally shows itself at the time of incision. In treatment, early application is of the greatest importance. For it is only during the first few days, that we can be certain of success in the ectrotic attempt. Some authorities extend the favourable op- portunity to the sixth day, from the first symptom of infection ; and some include the whole period of the second or ulcei'ative stage. All seem agreed that, within the first three or four days fi'om the applica- tion of the exciting cause,* it is certainly in our power to root out the disease ; " punching it out," as it were ; converting the poisoned ulcer into a simple sore ; and preserving the system quite untainted. For this purpose, an escharotic is freely applied ; nitrate of silver — oi*, what is more certain, the potassa fusa — pointed, inserted accurately within the sore, and pressed there firmly ; the fluid exudation being wiped up, as it threatens to overflow. Water-dressing is applied, until the eschar separates ; and then the surface beneath is anxiously scanned. K it present the characters of a simple and healthy sore, water-dressing is continued, and healing advances. If, however, the tawny surface and angry appearance of a still virulent ulcer show themselves, the escha- rotic is re-applied. And such repetition is carried out, from time to time, until a satisfactory clearing has been obtained. If profuse and offensive discharge exist, it may be well to medicate the water-dress- ing, from the first, by one or other of the chlorides. The healing process having begun, simple water- dressing should not be long continued ; for, sores on the penis, even of a simple nature, tend speedily to the characters of the weak sore. Early medication, by zinc or otherwise, is accordingly required. If, notwithstanding, the granulations threaten exuberance, there is no better plan than to touch the elevated surface, every second day, -with the nitrate of silver, lightly ; applying water-dressing intermediately. During the treatment, * Ricord guarantees immunity if ectrotic treatment have been thoroughly applied within the first four dajB from the application of the vims. SIMPLE VENEEEAL ULCEE. 491 rest is of the gi'eatest importance ; and the organ should also be sus- pended, by a handkerchief or bandage. If the case be seen too late to admit of ectrotic treatment, the sore being in the third or reparative stage, the application of nitrate of silver is still useful ; by subduing the exuberant granulations, and ex- pediting the healing process. We cannot now save the system from contamination ; absorption having already been busy. But we may diminish the amount of taint, by shortening the period during which absorption takes place ; and, besides, the nitrate may probably act decomposingly on the remaining local virus. Experience teUs us, that the more speedily the sore is healed, the less is the likelihood of the occurrence of secondary symptoms. Warts are not an unfrequent complication. They are subject to the same treatment, and are of the same nature, as those which attend on gonorrhoea (p. 486). The secondary symptoms which occur, at a period of from three to six weeks after infection, — if the ectrotic attempt have failed, or have not been practised, — are usually either exanthematous or papular ; venereal roseola, or venereal lichen. The eruption is preceded by fever, and is accompanied by an affection of the throat, similar to what attends other eruptions of the same class. The tonsils, and fauces in general, are red, raw, swollen, and painful ; sometimes invested by an aphthous coating ; sometimes superficially abraded. The eruption is chiefly situated on the trunk, more especially on the back and belly ; but the face and limbs are not exempt. Sometimes there is mere discoloration of the skin, in numerous faint spots. A patient having begun to complain, at the ordinary time of acces- sion, of such symptoms of general disorder as usually usher in the secondary symptoms, it is our object to favour an early and full ap- pearance of the eruption ; for, thus the febrile condition will be re- lieved, and what seems the natural effort towards extrusion of the poison from the system will be assisted. To check the skin affection, were as unwise as to attempt repression of the eruptions of measles, small-pox, or scarlatina. The bowels are gently acted on, and a warm bath is given. Regimen is antiphlogistic, and confinement to the house is enjoined. Antimony is given, with more than one object in view; it tends to moderate fevei*, at the same time determining to the skin ; and there is good reason to believe, that it is also an auxiliary of no mean power in elimination of the virus. The eruption, having attained its acme, gradually fades. At the same time, the affection of the throat recedes ; but, in general, amendment here may be expedited by use of the nitrate of silver. By warm bathing, restriction of diet, avoidance of exposure, and general attention to the skin — ^iodide of potassium, sarsaparilla, or other alteratives, being given if necessary — 492 ULCER WITH ELEVATED EDGES. purity of the surface is restored ; and the cure is complete. It is sel- dom that the more decided but more dangerous alterative, mercury, requires to be had recourse to. Its sparing exhibition — only as an alterative — is expedient, how^ever, vphen the eruption either proves obstinate in its first attack, or tends to sundry recurrences, under the ordinary treatment. Tertiary symptoms need not be dreaded. II. — Tlie Ulcer with Elevated Edges. In this — a compound of the irritable and inflamed sores, of the general surface (Principles, pp. 253 and 255) — the reparative stage is late ; not occurring until at least tvro or three vv^eeks have elapsed. The excavated surface is of a brovv^nish hue ; and the edges are elevated, not only above this raw surface, but also above the surrounding parts. There is no surrounding induration, and there is no phagedena ; but, sometimes, the ulceration is acute and rapid ; destroying the parts, by persistence of acute inflammatory action, almost as formidably as if by phagedena — more especially if the sore be situated near the fr^enum. Treatment is the same as for the former class of sore. But, if the healing process be obstinately deferred — in cases too late for ectrotic treatment — mercury may be cautiously administei-ed ; a blue pill, or a pill of iodide of mercury, being given, night and morning, until the characters of the sore show amendment. Even this cautious dose, however, is not expedient, until the more simple and safe means have been fairly ti-ied and found ineffectual. The partially irritable is liable to pass into the thoroughly inflamed sore, here as elsewhere. In such circumstances, all escharotic or other- wise irritant applications must be abstained from, until, by the ordinary means, inordinate inflammatory action has been subdued. In the irritable condition, the oxide of silver is sometimes of use, in the form of ointment. If the ectrotic attempt have failed, the occurrence of secondary symptoms is extremely probable. Antecedent febrile disturbance is more considerable than in the first class of cases ; and the eruption is usually of either the papular or pustular character — more frequently the latter. The pustules are chiefly situated on the chest, back, and face ; occasionally they degenerate into irritable sores ; but the majority fade, and heal by incrustation. Their site is marked by brownish discoloration, sometimes of obstinate persistence. Bubo is not unlikely to occur, more especially if the patient fail to observe recumbency ; the lymphatic enlargement not, in general, dependent on a common inflammatory process, excited by simple irritation on the penis — as in the case of gonorrhoea, or simple abrasion, or herpes — but on a specific inflammatory process, caused by propagation of the virus from the HUNTERIAN OR TRUE CHANCRE. 493 original site, and lodgment of it in the ganglia. Iritis, too, may occur, constituting a serious complication. Affection of the throat is tolerably severe ; and the tonsils may display extensive aphthous ulceration. The secondary eruptions require the same general treatment, as those which follow the first class of sore. Bubo is treated by rest, fomentation, &c. — perhaps by leeching. Iritis demands its own pecu- liar management, formerly detailed (p. 111). Only in the slightest forms, dare mercury be withheld. Its exhibition here is not anti- syphilitic, but antiphlogistic ; and it is managed accordingly. The throat requires soothing by inhalation, in the first instance ; afterwards, the nitrate of silver, in substance or in strong solution, applied every second day, will remove irritability in the breach of surface, and expedite cicatrization. If either the throat or the skin affection prove chronic and obstinate ; or if, after deceptive disappearance, re-acces- sion occurs — mercury may be given, sparingly ; rather, however, as a last resource, than as an ordinary part of the treatment. Antimony and the iodide of potassium, with attention to hygiene, prove sufiicient in the greater number of cases. A troublesome sore sometimes forms on the orifice of the urethra ; and it generally is of this class. Constantly exposed to irritation, by the passing of urine, it is slow to heal ; it may, by persistence of ulceration, cause considerable loss of substance ; and then cicatrization cannot occur, without producing more or less contraction of the urethra at that part. Hence, it is obviously of great importance to detect its presence early, and to make sure of the ectrotic treatment. During the subsequent healing, light application of the nitrate of silver is very suitable ; this forming an adherent incrustation, protective of the parts beneath. And this protection may be further aided, by the temporary application of an oiled piece of lint, on each margin of the orifice during micturition. Sores sometimes form more within the urethra ; causing much trouble, by pain, swelling, discharge, and liability to constitutional sequelae ; and rendering the occurrence of troublesome stricture all but inevitable.* They are treated by injections, carefully introduced so as to ensure their application to the sore ; and of such a ' kind as would be applied to the ulcer in an ordinary site. After cicatrization, the occasional use of a bougie is expedient, to obviate the tendency to contraction of the canal. in. — The Hunterian, or True Chancre. This belongs to the indolent class of sores ; but, unlike those on * The presence of such concealed sores in connexion with gonorrhoea, probably, gave rise to the belief that gonorrhoeal matter had the power of producing syphilis. 494 HUNTERIAN OR TRUE CHANCRE, the general surface of the body, is usually indurated from the first. The antecedent inflammatory process is chronic, accompanied by copious plastic exudation, around and beneath the forming sore; giving an almost cartilaginous hardness to its base and margin, which feel as if a split pea had been inserted into the textures. The sore is circular, and excavated ; the surface of a tawny or brown- ish hue, seems as if recently scooped out by an instrument; reparative action is faint, and long- delayed ; sometimes, the site of granulation is occu- pied by a thin, ash-coloured, adherent pellicle. Fig. 149. There is no surrounding vascular areola, after the sore has fairly formed. The ordinary sites are the glans penis, the preputial reflexion, and the integument of the body of the organ ; the first the most frequent, and showing greatest induration. While other kinds of sore may occur in one or two places, this form is in general solitary. Treatment is based on the same principles as that of the preceding varieties. Not only the sore, but also the caUous induration around and beneath — in which, it is probable, the virus mainly resides — must be destroyed ; and for this purpose no weaker caustic than the potassa fusa is necessary — freely applied, perhaps with repetition. Neither is it enough merely to obtain cicatrization, leaving the hardened base and margin but little altered, if at all. These, constituting essential parts of the disease, must be got rid of. And if, after repeated use of the escharotic, hai'dness still remain, then removal by discussion is to be sought ; by internal means — mercury, or the iodide of potassium ; and also by the local application of these substances. It is better that some further contamination of the system, by rapid and final absorption, should be risked, than that the part should remain a constant zymotic source of propagation. And discussion may be expedited by the application of pressure, when the sore is so situate as to admit of this ; a piece of folded lint being placed over the part, and retained by an elastic band.* It may happen, that early and free use of the potass thoroughly succeeds in obtaining the ectrotic result ; the sore completely changing its character, and healing up, without risk of secondary symptoms. More frequently, however, we fail in this ; probably from being too late in our interference ; and the sore refuses to change under local means alone. Then mercury is necessary"; given with more freedom than in * Acton, Lancet, No. 1226, p. 220. Fig. 149. A venereal sore on a common site. The characters are chiefly those of the Hunterian chancre. — After Actox. HUNTERIAN OR TEUE CHANCRE. 495 any of the former cases, though still with caution ; never pushing it to excess of ptyalism, and always ceasing from the administration, at least for a time, so soon as amendment seems fairly begun in the sore. It is invariably our object to accomplish the desired end, at as little cost of the mineral as possible. When the ectrotic attempt fails, as is not unlikely, secondary symptoms are almost certain to occur. The eruption is scarcely pre- ceded by fever, and is unaccompanied by it. Faint, brownish spots, or macules, appear — chiefly on the trunk ; or, as more frequently happens, an eruption of copper-coloured blotches occurs, and these subsequently become scaly — evincing the characters either of lepra or of psoriasis. As the primary sore is considered the true Chancre, so the constitutional affection may be termed true Syphilis or Pox* The throat is involved ; but, as in the other symptoms, this shows but a dull amount of inflammatory action. One or both tonsils are found occupied by deep ulceration ; often there is a sore on each, of charac- ters very similar to those of the primary ulcer. For such affections of the system, there is no remedy equal to mercury ; and it seems generally agreed that, when true syphilis has declared itself, the cautious use of that mineral should be immediately begun. No heroic dosings are necessary, however ; an alterative course is still all that is required ; continued till amendment appear ; and perhaps revived, at intervals, until final clearance of the poison has been effected. Bubo and iritis, if they occur, are met by their appropriate treatment ; in the latter affection, mercurialization may be conducted with especial freedomi — for a marked tolerance of the remedy will certainly be found. If the primary and secondary symptoms have not been actively and conclusively dealt with, tertiary symptoms are extremely probable ; showing themselves after the lapse of some months. The periosteum of the bones which are most exposed — tibias, ulnse, clavicles, cranium, sternum — suffers by a chronic inflammatory process ; and the bones themselves are similarly involved ; creating the condition of Node (Principles, p. 415), sometimes circumscribed and acute, more fre- quently chronic and diffuse. The joints, too, are affected with chronic swelling and pain. Foetid, ill-conditioned sores may form between the toes. Condylomata may appear on the nates and perineum. Irritable sores may form on various parts of the general surface. The glands of the neck may be chronically enlarged ; especially behind the ears. The testicles may swell ; either solid, or with serum in the tunica vaginalis. The throat may again' become attacked by ulceration — * By many the term " chancre " is employed to denote all kinds of venereal sore ; as " cancer " is often made to comprehend all kinds of malignant disease. When a special meaning is intended to be affixed to " chancre," however, it is understood to include only this fourth class of sore. 496 THE PHAGEDENIC ULCER. of a more diffuse and acute character ; the palate may be involved, and exfoliation may ensue. And one or both groins may be occupied by indolent bubo. The more ordinary of the tertiary symptons, however, vphen mercury has not been abused, are the ostitic and periostitic affections. And for these, as well as for the tertiary symptoms in general, iodide of potassium is found to be the preferable remedy;, begun in full doses, and regulated according to the effects produced. Eight grains, thrice daily, in solution, is a justly favourite form of exhibition ; diminished when the physiological effects are threatened to be produced. There is a modification of this class of sore, consisting of induration merely, A callosity forms, after impure intercourse ; and it may, or may not ulcerate, at a late period. It is equally prone to contaminate the system as the true chancre ; and requires precisely similar treat- ment. Cure is not complete, so long as any degree of hardness remains. It is not to be forgotten that this form of disease may be simulated, by sores unconnected with venereal virus. From accidental circum- stances, induration may occur here as elsewhere ; indolent characters superseding the weak in an ordinary breach of surface. Or, again, a venereal sore, originally of the first or simple class, may become indurated, in consequence of frequent and unnecessary use of caustic, or from other sources of irritation. Such simulations, of course, warrant neither the prognosis nor the treatment of true chancre. rV". — The Phagedcenic Ulcer, the Sloughing Ulcer, and the Sloughing Phagedcena. Phagedsena, here, as elsewhere, may be either acute or chronic. The latter is not very formidable ; being as it were, only a degree more troublesome than the worst forms of the second class of sore. Its most common site is the root of the glans ; but, not unfrequently, it burrows from this, beneath the fascia of the penis, producing much induration and swelling of the organ, with copious foetid discharge ; advancing unseen and unchecked, till much mischief is done ; probably opening into the urethra, at one or more points ; at all events, laying the foundation of tedious sinus, with perhaps a permanently enfeebled and abnormal state of the organ. Sometimes, also, this form of sore attacks the posterior part of the dorsum of the penis, and burrows beneath the pubes. Acute phagedaena, the sloughing sore, and the sloughing phagedaena, present the same characters here, as elsewhere (Principles, p. 256, et seq.) ; attacking the glans and prepuce indiscriminately ; and in a short time effecting the most destructive ravages. The accession and THE SLOUGHING AND PHAGEDENIC ULCEES. 497 progress of the sore, or sores, are accompanied with marked constitu- tional disturbance, of the natui'e of irritative fever, tending manifestly to prostration. The sinister characters may declare themselves from the first ; or, for a day or two, the sore may seem but an unusually foul and active sample of the second class, attended with an unusual amount of constitutional disturbance ; and then, without any apparent exciting cause, rapid aggravation takes place, in both the local and constitutional symptoms ; constituting what is ordinarily termed the " black pox." Sometimes such aggravation would seem to be accele- /S- Tig. 150. Mg. 151. Fig. 152. rated, if not caused, by imprudent administration of mercury. And sometimes mercurialism would seem to have the effect of converting an originally simple sore, of the first or second class, into a tolerably close imitation of this of the fourth. It is important, however, to dis- criminate between the sore originally of a bad kind, and that which, by casualty, has become temporarily occupied by a slough, from over- action ; for, the suitable treatment is very different. Active and painful local management is required in the one ; rest and simple antiphlogistics are sufficient for the other. As the disease advances, constitutional disturbance increases pro- portionally ; and this, becoming decidedly typhoid, may prove fatal. Or it may be assisted by hemorrhage. Moderate loss of blood, how- ever, may have an opposite effect, in the less urgent cases ; occurring in quantity sufficient to affect the part, resolutively ; and not to such an extent as to affect the system, depressingly. In most cases, a fatal result may be avoided ; but, in many, serious mutilation is inevitable. The disease, fortunately, is comparatively rare ; and is chiefly found in maritime towns, where by sailors and the lower class of prostitutes sexual vice is extravagantly perpetrated.* * " Most of the young creatures who are brought from that genteel place, Swan-alley, Fig. 150. The sloughing sore, as affecting the penis. The prepuce almost gone ; the glans going. — Acton. Fig. 151. Acute phagedsena, burrowing beneath the integuments of the penis. — Acton. Fig. 152. Chronic phagedsena ; with surrounding hardness, almost equal to that of true chancre. — Acton. ■2k 498 THE SLOUGHING AND PHAGEDJSNIC ULCERS- To change the character of chronic phagedeena, no local applica- tion is so powerful as the fluid nitrate of mercury ; diluted, so as to have an alterative rather than an escharotic effect. The primge vi£e are attended to ; regimen is antiphlogistic ; warm bathing is useful ; and strict rest is enjoined. Acute phagedfena, the sloughing phagedsena, and the sloughing sore, require the active treatment, locally and generally, suitable to this form of disease (Principles, p. 260) ; the clearing out of the primee vise, followed by sedatives and anodynes ; the stern use of an active escharotic, the characteristic moisture of the sore having first been removed ; strict rest, and an antiphlogistic regimen ; but, at the same time, a careful watching of the constitutional symptoms, lest typhoid tendency suddenly supervene, and stimulants become indispensable. Cover the part in a poultice, treating the case expectantly, as is the manner of some ; and serious mutilation will be the probable result. In the outset of an urgent case, one is tempted to imitate nature, and abstract blood. But, generally speaking, the experiment is a rash one ; it may irreparably depress the system. While, however, bleed- ing from the system is unwarrantable, abstraction of blood may some- times be made from the part, safely and well. A pendulous, half-dead portion of prepuce, soon about to slough wholly, may be cut off by the stroke of a bistoury ; and bleeding from the wound may be en- couraged, to such an extent as may be deemed suitable and safe. Sometimes paraphymosis occurs ; as can be readily understood, on account of the swollen state of the parts. This must be instantly remedied by replacement, if possible ; if not, a free, liberating incision should be made on the dorsum of the penis, at the constricted part ; otherwise, the progress of destruction cannot fail to be frightfully ag- gravated. After the acute stage is over, the internal use of iron may sometimes be employed with much benefit. After cicatrization has been completed, it may be in our power partially to remedy the damage done, by closing abnormal apertures in the urethra by means of autoplasty. Mercury is never advisable. Persistence of the febrile disturbance is itself a sufficient contra-indication. Besides, experience plainly tells us, that its local effect is to accelerate sloughing and phagedena; seeming to favour the softening and undoing of organized structure, afflicted with phagedsenic ulceration, have had very little wholesome food ; they are generally kept by Jews and Jewesses, who give them plenty of gin, though but Httle proper nourishment ; they are half-starved, and, more or less, in a continued state of excitement and intoxication, having connection with lascars, and other dirty foreign seamen, as many times in the day as there are hours. In this manner, their constitutions must soon get into a very disadvantageous state for the favourable progress of any dis- ease whatever ; and we cannot wonder that their impaired, and imperfectly developed frames, their course of life, and uncleanliness, should promote phagedenic ulceration, and give it an unusually severe character." — S. Cooper. TREATMENT OF SL0UGHINC4 AND PHAGEDENIC ULCEES, 499 and so fitting it for ulceration, while tendency to this is already excessive. Obviously, in such cases, ectrotic treatment is not always within our power. The local disease may spread too rapidly to permit isola- tion of the virus, with extirpation of the affected part ; at the same time, however, the very acuteness of the inflammation is unfavourable to absorption ; and, consequently, the occurrence of secondary symp- toms is not so frequent as might otherwise have been expected. When they do occur, their accession is preceded by serious constitutional dis- turbance, similar to what attended on the local symptoms, but generally less urgent. The eruption may be pustular ; the pustules large rather than numerous, giving way, crusting, and degenerating into foul sores of either the inflamed or irritable characters. Or it may be vesicular ; large flat bullae forming, Avith contents at first serous, but afterwards purulent ; giving way, crusting, and forming unhealthy sores beneath. Or it may be tubercular ; broad tubercles forming, which enlarge and suppurate slowly, ultimately degenerating into loathsome and extensive sores. The throat is the seat of asthenic inflammatory action ; ulcera- tion quickly forms, and spreads both in width and depth — by sloughing, by phagedasna, or by both. One or other of the large vessels in the neighbourhood of the tonsil may be opened into, and fatal hemorrhage may ensue. The larynx may be involved ; ulceration actually extend- ing to it ; or oedema, preceding the ulceration, may cause most urgent symptoms. Either event may prove fatal. Bubo is seldom absent, at some period of the case. And when, by suppuration, an opening has taken place, this is apt to assume the same characters as the primary sore ; by this time, perhaps, the gland being itself the residence of the same poison — by absorption and zymosis. The treatment of these symptoms is fraught with much anxiety. Still mercury is withheld. It would but aggravate. Regimen is anti- phlogistic ; and antimony is given guardedly — so as not to prostrate ; in many cases, it is well to combine it with gentle opiates. Warm bathing is grateful, and may relieve the febrile disturbance. Evacuants are obviously calculated to be of service ; acting on skin, bowels, and kidneys ; yet still not so as to cause prostration. The sores on the surface are cleaned and calmed, by poultice or water-dressing ; after- wards they are dressed with nitrate of silver, chloride of soda, or other lotion. The fauces are diligently fomented by inhalation ; the sores are touched with nitrate of silver in substance, or with the fluid nitrate of mercury slightly diluted ;* and, after the acute stage has * In touching the throat with nitric acid, or fluid nitrate of mercuiy, of any strength, great care must be taken to avoid redundancy of liquid in the sponge or lint with which the application is made ; otherwise, a drop may fall down, and, alighting on or in the glottis, may cause the most alarming dyspncsa. 2 k2 500 TEEATMENT OF THE PHAGEDENIC FOEM. passed, benefit will accrue fi'om moderate counter-irritation. Then diet is gi'adually amended ; and yvhen all has passed into the chronic stage, much advantage may result from judicious use of the iodide of potassium. Should iritis occur, a serious difficulty is engendered. We wish to give mercury to save the eye ; and we at the same time wish to withhold it, to save the constitution. At first we trust, there- fore, to smart loss of blood from the neighbourhood of the part, and to the substitution of turpentine for mercury as the specific internal remedy (p. 111). Only after this has failed, are we driven to a cautious use of the mineral. The tertiary symptoms which may follow this form of disease, are of a formidable character ; more especially, if mercury have been given. Bones are liable to ostitis, and its highest results ; abscess, ulcer, caries, necrosis. Tubercles form on the skin, larger, more pain- ful, and degenerating into worse sores than those of the secondary class ; often crusting prominently, and assuming the characters of Rupia. Obstinate sarcoceles and hydrosarcoceles form. The throat is liable to be again attacked ; in a more chronic, but very obstinate ulceration ; with the same risk by hemorrhage ; and with the ad- ditional risk of ghastly deformity, by involvement of the bones of the palate and nose. It is in this form, associated with a strumous tendency of system, and maltreated by the false mineral specific, that deformity and death are most likely to occur.. But, happily, both of these untoward events are now-a-days rare. Modern treatment does not aggravate, if it fail to cure. It consists in ordinary attention to the general functions, ■with careful regimen — not low but temperate ; and in the administration of sarsaparilla, guaiac, or other simple alteratives, so long as febrile excitement, or stomachic and intestinal derangement, may remain. The primae vias having rallied, and febrile disorder having ceased, the iodide of potassium is brought into play, internally ; and is patiently persevered with — hygiene, meanwhile, being not neglected. In obstinate cases, the " liquor hydriodatis arsenici et hydrargyri " may be of service. Condyloma. Condylomata are excrescences of the integument ; sometimes white, sometimes of a mucous appearance ; sometimes diy, sometimes exhal- ing a thin discharge ; forming on the nates, around the anus, in the folds of the thighs, on the perineum, on the scrotum — in the female on the labia. They occupy a doubtful place in the arrangement of primary, secondary, and tertiary symptoms. And there seems little doubt that they are occasionally to be found, pertaining to all the three classes. Discharge trickling from primary sores — more CONDYLOMA. 501 especially from the true chancre — and accumulating filthily in the neighbouring folds of integument, doubtless produces such irritation, and probably inoculation, as may lead to condylomatous formation ; and this may then be regarded, as partly of a secondary and partly of a primary chai'acter. Condylomata may also show themselves along with ordinary secondary symptoms ; though this is rare. Again — months after the primary attack, and after a secondary train of symp- toms, too, have run their course — condylomata may appear, for the first time, among the tertiary symptoms ; and this is most frequently observed after true chancre. Besides, there is no reason to doubt that, not unfrequently, condyloma forms as the primary and only form of infection ; whether communicated by a distinct variety of poison, or not, we are not at present in a position to determine. To the primary condyloma a peculiar kind of constitutional affec- tion succeeds. An " exanthematous eruption of a mottled appearance, and of a red or brownish colour, occurs ; sometimes preceded by vesication or scaliness, but never by pustules ; sometimes elevated," and approaching to the tubercular character. The throat is raw and painful ; and, on the mucous surface of the lips, cheeks, palatine arches, and tonsils, " peculiar, Avhite, elevated patches are found ; having the appearance of parts touched with the nitrate of silver, or coated with milk ; irregular in form, and presenting occasionally superficial ulcera- tions on their surface."* By some it is supposed, that this affection is identical with " sibbens ;" which at one time used to prevail much in this country. * Skae, Northern Journal of Medicine, April 1844. Fig. 153. Condylomata. — Acton. 502 BUBO. The treatment of condyloma consists in repeated applications of sulphate of copper, nitrate of silver, or more active escharotics, until the excrescences disappear ;* in rectification of the primae vise ; and in the internal use of iodide of potassium. The affection of the throat and mouth is treated with nitrate of silver, in substance or solution, applied every second day. The internal remedies — it is to be under- stood — are required only for the constitutional symptoms. Primary condyloma is removable by local treatment — ^perhaps ectrotic — in the same way as any primary sore. Bubo. Venereal Bubo, like Condyloma, is with difficulty appropriated to a class ; for it, too, may be found of primary, secondary, and tertiary occurrence. It is a question, whether or not bubo may be truly a primary form of syphilis ; occurring without the formation of sores, of any kind, on any part of the penis ; capable of producing venereal sores, by inoculation of the matter which forms by its earliest sup- puration ; and liable to be followed by constitutional pox. The pro- bability is that bubo is never thus " d'emUee ;" and that it is always the result, more or less remote, of venereal ulcer ; the consequence, sometimes, of simple extension of the inflammatory process along the lymphatics ; more frequently arising from angeioleucitis, not only in- duced but maintained by the virus — which may become resident and accumulated within the affected glands. In gonorrhoea, sympathetic bubo is probably the consequence of simple excitement. Inguinal swelling may, indeed, precede the appearance of discharge ; the very first part of the inflammatory process having proved a sufficient stimulus to the lymphatics. True bubo, as it may be termed, is the product of virus proceed- ing from a venereal sore ; and usually occurs after the ulcerative stage of the sore has ceased, when absorption is busily resumed. But at any period bubo may occur, through exercise, debauchery in drink, or other folly on the part of the patient ; occasioned then — if at an early period of the case — by mere extension of the inflammatory process ; at a remote period, partly by this, and partly by evil working of the absorbed poison. Bubo of the Penis is said to exist, when the lymphatics on the dorsum are continuously affected by inflammatory action ; and when — usually about the middle of the organ — painful swelling takes place, Avith much induration ; the inflammatory process having thrown out a large amount of plastic deposit, and threatening to advance to central suppuration. Pus generally forms ; and may be at once evacuated * Sometimes dusting with calomel is of service. BUBO. 503 externally, or may burrow extensively beneath the fascia. Treatment is by rest, leeching and fomentation, in acute cases. Subacute swell- ing may be discussed, by external application of the iodide of potas- sium in solution. When suppuration has taken place, early evacuation is practised ; more especially if retention of urine have threatened to occur (p. 461). Inguinal Bubo affects the upper cluster of glands ; and this is a prominent characteristic of venereal affection, in contra-distinction to inguinal enlargement in consequence of common sores, or other source of simple irritation, on the thigh, leg, or toes ; in which latter case, the swelling will be found beneath Poupart's ligament. The tumour may be small or great ; chronic, subacute, or acute ; indolent, or has- tening to suppuration. The acute varieties, prone to suppurate, are those which follow directly on the primary sore ; the chronic and indolent range themselves rather with the secondary and tertiary symptoms ; the acute form often affects but one ganglion ; the chronic frequently implicates the whole cluster ; in suppuration of the acute, matter generally is first formed in the areolar tissue exterior to the gland ; if the chronic slowly come to matter, gradual softening and suppuration take place in the interior, and may originate at more points than one. To such swellings, the ordinary pi'inciples of surgery are applied ; not always, however, with a satisfactory result. "Were the acute bubo dependent on simple excitement, or on mere extension of a simple inflammatory process, it would doubtless often yield readily to rest, leeching, and fomentation. But such is not the case ; leech- ing is found to have but little effect in retarding the onward progi'ess ; and this is to be explained, by the active presence of venereal virus within the part itself — just as antiphlogistics would have but little effect, in retarding the formation of the primary pustule and sore. Loss of blood, therefore, may in most cases be abstained from ; rest, fomentation, poultice, and antimonials ai"e employed ; and, when matter forms, this is evacuated. And perhaps it is well that suppura- tion and evacuation should occur ; there being a tendency thereby towards elimination of virus. Should matter form only between the enlarged gland and the skin, it is advisable to insure suppuration of the former, by penetrating its interior by potass introduced through the external wound — after the acute stage is over ; otherwise, the cure will be tedious and imperfect, and, obviously, little or nothing will be done towards elimination. Under subsequent poultice and water- dressing, the swelling may only partially subside ; and in such circum- stances discussion of the indolent tumour is to be obtained, by the application of pressure by means of a compress and bandage. Some- times matter is secreted at different times, and in different sites ; and, in consequence, sinuses are apt to form. Then a sufficient opening 504 A GENERAL VIEW OP THE SUBJECT. is afforded to each collection, and pressure is applied ; if this fail, the sinuses are to be laid open by the bistoury. Very frequently, how- ever, pressure, good diet, and the iodide of potassium internally, sufl&ce. If, along with bubo, the primary sores still exist, it is obviously an indispensable duty to soothe these, and obtain cicatrization as soon as possible. An open bubo, attacked by sloughing or phagedasna, receives the ordinary treatment applicable to such a state. The subacute bubo may be discussed ; by rest, low diet, and external use of the iodide of potassium, followed by gradually increased pressure. Or, if this fail, a blister may be applied, in the hope of thereby either promoting resolution, or accelerating a satisfactory sup- puration. The indolent bubo may almost always be discussed ; by pressure or blistering — the former usually preferable — rest, good diet, and internal use of the iodide. If an undoubted connexion exist with the third class of sore, a powerful alterative is necessary; mercury, in moderate doses. If matter form, it does so slowly and imperfectly ; and blistering may be useful, in hastening the general disorganization of the swelling which is then desirable. Often, to complete this, free use of potass is necessary ; destroying undermined integument, and breaking up obstinate indui'ations of the glands. Special modes of treatment have been thought advisable in vene- real bubo ; as, for example, by the local use of corrosive sublimate, and severe pressure. The preponderating weight of authority, how- ever, would seem to be in favour of but little departure from the ordi- nary rules of simple sui-gery. In taking a general view of the Venereal Disease, it is obviously resolvable into two great divisions — Local and Constitutional Pox. I. Local or Primai^ Syphilis. — This consists of some variety of sore ; sometimes of condyloma. It is transmissible to a second party, by contact and by inoculation ; chiefly, if not only, during the ulcera- tive stage — in the case of a sore ; and the earlier the secretion, the more impregnated is it, probably, with the virus. In treatment, an ectrotic result is to be obtained, by timeous and decided use of an escharotic ; which, converting all the poisoned textures into an instant slough, removes the disease — yet local and circumscribed ; at the same time, probably, acting destructively, as a chemical, on the poison. Afterwards, management of the sore is simple ; by medicated water- dressing. If, however, the sore be not seen by the surgeon until it has attained an advanced stage, acutely inflamed, red, swollen, and very painful, perhaps with affection of lymphatics in the penis and groin. CONSTITUTIONAL SYPHILIS. 505 escharotics must be withheld. The inflammatory action is to be sub- dued by ordinary means ; and, meanwhile, perhaps, something may be done towards decomposing and limiting the poison, by applying solutions of the chlorides. When ectrotics fail, mercury is given — alteratively — in addition to the ordinary local treatment ; in the third class of sore, and in obstinate samples of the second. During the local treatment of all cases in which ectrosis fails, it is well to stimulate the organs of excretion ; by attending to the bowels, promoting the flow of urine by diluents aud gentle diuretics, and determining to the skin. Anti- mony is most useful with this view ; the object of such treatment being to favour elimination of the virus, by exaltation of ordinary means ; in the hope that it may be excreted from the system, as fast as it is conveyed thither by absorption from the primary affection ; and that thus systemic zymosis may be prevented. II. Constitutional Syphilis consists of secondary and tertiary symp- toms. 1. Those which follow speedily after the primary affection, within a few weeks or months ; usually during the second month ; consisting chiefly of general cutaneous eruption, and affection of the throat ; ushered in by febrile excitement, and, generally, by more or less change in the complexion, dryness of the hair, rheumatic pains in the ends of the long bones, and violent nervous headach, particu- larly in the forehead — aggravated at night, or rather by the recumbent posture.* 2. Those which occur more remotely, after six months or more have elapsed, and after the secondary train has already run its course ; their most prominent and characteristic part being, affections of the skeleton, of glands, and of the superficial areolar tissue. It is generally supposed that constitutional syphilis, having once occurred, is not so likely to return, or at least in a severe form, in the same patient, after venereal contact or inoculation. And some even imagine that the system once affected obtains complete immunity from return of the disease, as in the case of small pox. On this latter sup- position has been grounded an infamous proposal to inoculate as a preventive from syphilis ;f a pi'oposal only mentioned here for the purpose of characterizing it in words of disgust and indignation. 1. The Secondary eruptions — which are seldom itchy like those of nonspecific origin — are of different kinds. Exanthematous ; roseola ; following the simple sore, often at an early period. Not unfrequently it precedes the appearance of other forms of eruption ; seeming to be the basis on which they subsequently form. Papular; lichen; the ordinary result of the first class of sore. Pustular ; ecthyma ; more frequently following the second class of sore than any other. Tuber- cular ; prone to ulcerate untowardly ; following the fourth class of * RicoRD, Lancet, No. 1284, p. 384. f Brit, and For. Rev., Jan. 1850, p. 261. 506 , SECONDARY SYMPTOMS. sores. Vesicular ; rare ; large bullae, surrounded by a copper-coloured areola ; becoming purulent, crusting, and tending to rupia prominens ; sometimes following tbe second, but more frequently found after the fourth class of sore. Scali/ ; lepra or psoriasis ; usually the result of the third class of sore ; true syphilis. Sometimes condylomata form, contemporaneously with the eruption. Such is the general arrangement ; but, in practice, occasional con- fusion of the sequences need not excite surprise. Very frequently, the hair loosens, and comes away ; threatening baldness. The throat is variously affected ; by inflammatory process, aphthae, or ulcer. Iritis not unfrequently occurs ; and may foUow any form of sore ; it is more frequently found associated with the papular eruption, however, than with any other. Sometimes periostitis shows itself, on one or both shins. A question here arises ; are sores on the penis ever of a secondary character? No doubt they are. Eruptions degenerate into sores, very frequently, on the general surface ; and there is no reason why the penis should be exempt from the general liability. Secondary sores there are known by their history ; appearing at a long date after exposure to contagion. Arid they are also distinguished by absence of the ordinary characteristics of primary sores ; usually superficial, inflamed, and of a peculiar hue ; resembling aphthous ulceration of a mucous surface. Secondary symptoms are shown, by experience, to be transmissible from father to child, from child to mother ;* the blood being tainted with the virus, which has become multiplied by general zymosis ; and the virus being communicated through the medium of tainted secretion. As yet, it is doubtful whether they are communicable by direct contact or inoculation. f It has still to be shown that the early, ichorous, non- purulent secretion of a secondary sore has not the power of propagating the disease. In the papular form of eruption, and in many cases of the pustular, mercury is seldom necessary ; in the tubercular, it is often hurtful. Antimony, sarsaparilla, guaiac, and the iodide of potassium, are powerful enough alteratives and eliminators ; and, along with atten- tion to the general health, sufiice for cure. In the scaly form, how- ever, mercury is always given ; yet warily ; never pushed to extreme * The husband procreates an infected child, which may then propagate the secondary- poison to the mother. Where there are no children, the mother does not suffer. — Ricokd, Lancet, No. 1284, p. 384. A mother affected with secondary sj'philis, after primary sores in herself, however, may be expected to communicate the disease to her offspring. A father affected after conception has taken place, does not taint the child then in utero. T Some maintain that the husband has the power of communicating syphilis, in the secondary form, to the wife, dnectly through the semen ; and that then the female may produce an infected fcetus. See Whitehead on Hereditary Transmission ; and Brit, and For. M. C. Rev., April 1852, p. 323. TERTIARY SYMPTOMS. . 507 ptyalism ; and always ceased from, at least for a time, on amendment being begun. In the constitutional symptoms following on the slough- ing sore, the phagedgenic sore, or the sloughing phagedsena, mercury is studiously abstained from ; experience having amply demonstrated its inefficiency as a means of cure, and the certainty with which it tends to ultimate aggravation. It is never our object to repress the eruption in its first onset ; on the contrary, its full appearance is solicited. Obstinate persistence, and repeated recurrence, however, we seek to overcome. And the object of our constitutional treatment is, simply to assist Nature in a full, early, and complete elimination of the poison ; by acting on the skin, kidneys, bowels, and other organs of excretion. The throat is steamed, fomented, touched with nitrate of silver, or blistered externally ; according as it is the seat of active congestion, inflammation, ulcer, chronic inflammatory action, or passive conges- tion. Ii-itis has its own appropriate treatment, except when the sequel of the fourth class of primary disease ; and then mercury is withheld, if possible — turpentine being substituted (p. 111). Coming baldness is anticipated, by shaving the head ; and it is well to keep it closely shaved, for months, long after the other signs of constitutional disorder have whoUy disappeared. 2. Tertiary symptoms seldom occur, except after the third and foiu-th classes of sores, and the worst examples of the second ; unless when mercury has been profusely and rashly administered. In any case, they are seldom urgent, when the result of venereal poison alone. It is only w^hen this has been associated in the system with the mer- curial poison, that severity is declared. In the milder cases, the bones and periosteum are aflFected by a chronic inflammatory process ; those suffering most which are most exposed. In the more severe cases, suppuration takes place ; sometimes superficial, between the bone and periosteum ; sometimes in the interior of the bone ; sometimes involv- ing the whole girth of the bone ; and resulting in ulceration, caries, or necrosis. Sometimes the skeleton is affected symmetrically ; cor- responding bones suffering at corresponding points ; but it may happen tbat the whole of one side is free, while scarcely a bone of the op- posite side of the skeleton is not more or less affected. The joints are liable to pain, stiffness, and chronic enlargement ; similar to chronic rheumatic affections of these parts. The skin is subject to be attacked — more especially after the fourth class of sores — by tubercular forma- tions, which assume the characters of rupia prominens, and degenerate into foul irritable sores ; sometimes the initiative is by vesicular for- mation ; sometimes the sore at once is formed by sloughing, followed by acute ulceration. The mucous membrane of the alimentary canal is liable to suffer at either extremity, but especially in the fauces — bv 508 . TERTIARY SYMPTOMS. congestion, and troublesome ulceration, usually of a chronic yet in tractable kind; the anus may be the seat of aphthous ulceration, fissures, and condylomata. The tongue may become generally swollen ; indurated at several points ; at the edges and tip superficially ulcerated — the sores irritable and obstinate, sometimes spreading as if by chronic phagedsena ; and the mucous surface of the cheeks, and gums, as well as beneath the tongue, may be similarly affected. Chronic enlarge- ment of the lymphatic glands on the upper and back part of the neck is common. Deafness is no unfrequent occurrence ; probably from congestion of the mucous lining of the ear. Iritis and bubo some- times occur, in this class ; the latter usually indolent ; and the former tending less to severity than when a secondary symptom. The testicles not unfx'equently undergo chronic and simple enlargement, with or without accumulation of serum in the tunica vaginalis. Tertiary symptoms are not transmissible in any way.* Parents affected by them, however, impart scrofula to their children. Whatever their connexion, mercury is generally superseded, in treatment, by the iodide of potassium ; and this is assisted by attention to the general health — more especially as regards warm bathing, clothing, and regimen — and by other alteratives, if need be. In ostitic affections, obstinate, and attended with much nocturnal exacerbation, opiates are essential ; and it may be that, ordinary means failing, we may be driven to small doses of corrosive sublimate. In obstinate affections of the skin and throat, too, the " liquor hydriodatis arsenici et hydrargyri " may be of service. And besides this constitutional management, the local affec- tions of bones, joints, testicles, glands, are treated according to the general principles of surgery. In tertiary symptoms following the fourth class of sores, the general rule still obtains as to the propriety of avoiding the use of mercury. There are cases, however, of occasional occurrence, which compel its exhibition. When the face or other part of the surface, is covered with ulcerating tubercles, when the tonsils are ever and anon the seat of bad ulceration, and when the tongue and cheeks are affected with a constant succession of painful ulcers, surrounded by induration, and extremely slow to heal ; when such symptoms have resisted the ordinary non-mercurial treatment, and the patient is obviously declin- ing in health — in such cases, an alterative course of arsenic is some- times of much service. But, if it fail, mercury is had recourse to ; in combination with small doses of the iodide of potassium ; and usually with the very best effect. Iodide of potassium is of great use in the treatment of all venereal affections ; as an eliminator, probably, of the virus, as well as an alterative of the system. It is best given in the form of solution ; * Whitehead and others are of a contrary opinion. See reference in footnote, p. 506. THE USE OP MERCURY IN SYPHILIS. 509 beginning with a dose of two or three grains, given thrice daily ; and gradually increasing it to half a drachm, or more, according as it is borne. It is not always necessary to induce the physiological effects. Some have a strong prejudice in favour of eight grains thrice daily, in camphor mixture ; and adhere to that dose, throughout the whole period of exhibition ; seldom finding any decided intolerance mani- fested by the system. Again, if a primary sore is slow to change, and to assume the healing process, this medicine is useful ; provided there be no inflammatory excitement in either part or system — for that pro- vision is always essential to its proper administration. In many of the secondary symptoms, it supersedes the use of mercury, in the chronic stage.* And, in tertiary symptoms of every kind and compli- cation, it is pre-eminent and paramount. Sarsaparilla and guaiac, in the form of the compound decoction, are also not unimportant auxi- liaries. Some affect to believe them quite inert ; but we beg humbly to vouch for their possession of an important though minor virtue. In cases of intolerance of the iodide, by reason of idiosyncrasy, they often prove most valuable and efficient substitutes. The use of Mercury in Syphilis. That mercury is a specific — indispensable as well as infallible — for the venereal disease in all forms, is a maxim which, happily for man- kind, is fast falling into desuetude. It is now abundantly established that many forms of the disease — nay the greater number of cases — are capable of cure without the use of this mineral; that, with simple means — that is, non-mercurial — the cure is shorter, the symp- toms prove less grave, and immunity from future calamity — connected with the attack, its progress, or its mode of cure — is much more cer- tain. In other words, the system is cleared quite effectually of the venereal poison ; and it is saved from the pernicious effects of the mercurial poison — perhaps not the less formidable of the two. There are certain cases, however, in which it has been shown by experience, that a satisfactory issue cannot be obtained without recourse to mer- cury. And, in those cases, its judicious employment seldom leaves any deleterious impression on the system ; there being then a decided tolerance of its administration (Principles, p. 3 54). Its modus operandi is involved in uncertainty. Many, especially of the old school, still believe that it has a specific and destructive influ- * As a general rule, the place of mercury is as an opponent of secondary symptoms, that of the iodide to deal with the tertiary. And practical observation would seem to warrant another broad statement ; namely, that obstinate secondaiy sjTnptoms, for which mercury has been given, are always benefited by iodide of potassium ; while obstinate secondary symptoms, for which no mercury has been given, usually require mercury. 510 THE ABUSE OF MERCURY IN SYPHILIS. ence on the venereal virus ; that the two poisons meet in the circula- tion, and that a destructive influence is exercised there by the mercury on its antagonist. This may in part be true ; but it seems reasonable to conclude that its beneficial operation mainly depends, like that of other constitutional remedies, on its alterative influence on the general system, and on its power of stimulating secretion and excretion, so favouring elimination of what is noxious. Long ago, it seemed the general belief that such elimination was mainly to be achieved through the action of the salivary glands ; that the poison, overcome in the blood, was to be excreted from it in the form of tainted saliva ; and that the more speedily it was thrust out by the mouth, the more rapid and satisfactory would be the cure. Mercury, accordingly, was pushed invariably to profuse salivation ; either in the belief that such was necessary for satisfactory elimination ; or holding that copious ptyalism was the only sure sign of the mineral having been so thoroughly introduced into the system as to afford a good prospect of the poison's annihilation. In the beginning of the sixteenth, and end of the fif- teenth centuries, when the venereal disease experienced such an aggra- vation as to alarm all Europe, the antidote was plied with a blind, empirical, and desperate profusion ; and there is no doubt that, to this circumstance, rather than to any unusual virulence in the disease itself, its frightful ravages at that period are to be attributed. The primary symptoms were bad ; but the secondary and tertiary symptoms were far worse ; under the last, the most frightful deformities and mutilations occurred — by affections of the bones of the face and cranium, and destruction of the soft parts of the nose, mouth, and throat — and death was no unfrequent tei'mination of the hideous misery. Now-a-days, we find no such severities, except when mercury has been heedlessly and unnecessarily given — perhaps in a strumous habit. And the un- doubted rarity of mutilation, deformity, and death, by any part of the venereal disease, in the present day, is reasonably to be attributed to a greater prudence in the treatment of the affection, more especially in the primary symptoms. Mercury is withheld in many cases, if not in most ; when administered, it is given in moderation, and with a reluctant hand ; alteratively, not cumulatively ; frequently stopping short of ptyalism ; never going beyond mere touching of the gums. Formerly, the ordeal of salivation was such as must have proved to many frames quite intolerable. Even Boerhaave, in the eighteenth century, laid down the following " axioms :" " If there is four pounds of saliva spat every twenty-four hours, it is sufficient !" " the saliva- tion is to be continued until the symptoms of the disease vanish, which generally takes up six-and-thirty days ! !" and " a small dose of mer- cury must be taken for six-and-thirty days more, to keep up a gentle salivation ! ! !" No wonder that patients died ; and no wonder that THE USE OP MEECURY IN SYPHILIS. 511 some were found to prefer death to such a mode of cure !* And yet, while in Europe suffering humanity was thus outraged by the profes- sion, the natives in the West Indies, by the aid of guaiac alone, were showing an infinitely more favourable result. And among the former too, there were not wanting some who became alive to the folly and danger of indiscriminate and extreme mercurialization ; some driven to a better mode of reasoning and practice, by the stern rod of personal experience. Ulric de Hutten had himself been salivated eleven times, and thereafter became a zealous apostle of a treatment opposed to that of the majority of his fellow-practitioners. But, while it is contended that mercury and the venereal disease are not inseparable — that a patient affected with the one is not inevitably to be affected by the other — it is yet to be admitted, gratefully, that this mineral is in not a few cases a most important remedial agent ; used, however, much more sparingly than in former times ; and, in consequence, not only more efiicient as a means of cure, but also less likely to peril the future durability and soundness of the frame. By reference to statistics, it has been found that mercury, indiscriminately given in all cases, does not accelerate, but that on the contrary it re- tards, the ordinary healing of primary sores ; that it does not prevent secondary symptoms, but that these coming after its exhibition are generally severe ; and that the tertiary symptoms are both most fre- quent and most severe, when mercury has been profusely given in the previous stages. On the other hand, an indiscriminate withholding of mercury, in all cases, will present a much less favourable general re- sult, than when mercury is judiciously exhibited in those examples of the disease in which it is found by experience to be not only useful, but in a great measure absolutely necessary to full and satisfactory elimination of the poison. If ectrotic treatment of the primary sore have been successfully achieved, of course no mercury will ever be required ; there is no poison in the system, with which it is required to contend. But, fail- ing this, it is given — 1. In the second class of primary sore, when it proves obstinate. 2. In the third class of primary sore, always. 3. In the papular and exanthematous secondary eruptions, only when they prove obstinate and recurrent. 4. In the pustular secondary eruption, if it prove obstinate ; but not if it be consequent upon the fourth class of sore. 5. In the scaly secondary eruption, following the third class of sore, always. 6. In iritis, actively, unless when the affection results from the fourth class of sore. 7. In ostitic affections, of tertiaiy occur- * Omnibus certe exulcerebantur fauces, lingua, et palatum ; intumebant gingivae, dentes vacillabant, sputum per ova sine intermissione profluebat, unde et labia sic contacta ulcus trahebant, et intus buccEe vulnerabantur. Foetebat omnis circa habitatio, atque adeo durum erat hoc curationis genus, ut perire morbo complures quam sic levari mallent." — Ulric dk Hutten, 1519. 512 THE USE OP MERCURY IN SYPHILIS. rence, when other means have failed to procure rest, alleviation of pain, and decadence of the constitutional irritation. 8, In tertiary- affections of the skin and throat, of whatever origin, which have ob- stinately refused to yield otherwise. 9. Experience also shows it to be essential to the removal of that secondary taint of system, whereby a parent conveys syphilitic suffering to the child. It is never given — 1. In any case, during acute inflammation iu the primary sore ; otherwise, ulcerative action will certainly sustain aggravation ; and sloughing, or phagedena, may be induced. 2. Nor in any case, during persistence of febrile excitement in the system ; otherwise, cure will be delayed, and the symptoms aggravated. 3. Nor in any form of disease connected with the fourth class of sores — excepting the rare cases of a tertiary character already specified (p. 508) — otherwise, such aggravation is to be dreaded as will either end fatally, or fix the deleterious poisons permanently in the frame. 4. It is well to avoid mercury, also, if possible, whenever the active presence of scrofula is plainly and prominently indicated. The mode of exhibition varies according to circumstances : 1. It may be given in the form of calomel and opium ; in the ordinary way. 2. Or blue pill may be given, in such doses as the cure demands ; combined with opium or hyoscyamus, if pain or purging be occasioned ; if mere griping occur, it may be enough to let each dose follow closely on a meal. 3. Either of these forms disagreeing, hydrargyrum cum creta will probably be found suitable ; and this is the preferable form for children. 4. The corrosive sublimate, in very small doses, in pill or solution, is generally preferred in obstinate ostitic affections. And in such cases, also, it is sometimes of use to combine the mercurial with a tonic, or with small doses of the iodide of potassium. 5. In habits suspected of struma, the iodide of mercury is a suitable form ; or a combination with iron may be given, in the " ferruginated " blue pill. 6. Inunction is useful, as an adjuvant to the internal exhibition, when speedy affection of the system is desirable; in iritis, for example, mercurial ointment is rubbed on the forehead and temple, while calo- mel and. opium are given internally (p. 110). It is also used alone, in cases which exhibit intolerance of the remedy given internally, in any form ; then it is rubbed in, night and morning, in the axillae, or on the inside of the thighs, 7. Fumigation, also, is sometimes employed; when other forms seem to disagree. The fumes are obtained from the red sulphuret, put on a heated iron; and they are applied to the system, by inhalation ; to a part, by means of an oiled-silk tube or bag. Fumigation, however, is seldom used, except in cases of obsti- nate chronic affection of the throat, and tertiary enlargements of the testicle. In the primary affections, amendment often shows itself before the ERETHISMUS. 513 mineral has given any other evidence of having affected the system. In secondary affections, the yielding is seldom so rapid ; such continu- ance is usually necessary as touches the gums ; and then the remedy is no longer pushed; but a minor dosing is maintained; the object being not to increase, but simply to maintain, the approach to ptyalism, until decadence begin to appear satisfactorily. Then the remedy is altogether withdrawn ; although, it may be, that persistence or recur- rence of the symptoms may afterwards require its resumption. In tertiary symptoms, also, it is generally necessary to attain to the evi- dence of systemic seizui'e ; maintaining this, if need be, with the same niggard caution and economy. Certain idiosyncrasies require consideration, in regard to the exhi- bition of this medicine. 1. Some patients are slow to shoAV ptyalism, even under great and sustained doses. In them, it is not necessary to push the medicine until ptyalism is produced. 2. Others have their mouths touched — perhaps severely — with but a few grains. And, in their case, the dosing must be both minute and guarded. 3. Some suffer by pain and purging, in whatever form the mercury is given internally. In these, careful inunction is to be made trial of. 4. Some are actually poisoned by the mineral ; the condition termed Eretliismus being induced.* To such patients mercury can never be given, in any form ; for the symptoms induced are such as imminently to endanger life. The patient is anxious, under an apprehension of great and impending evil ; his muscular system is prostrate ; he trembles, walks with difficulty and uncertainty, and his heart's action is weak and fluttering ; breathing is difficult ; an unpleasant sensation of weight or tightness is felt at the praecordia ; both mind and body are incapacitated for all exertion ; and, during some ordinary effort, he may expire by syncope. Such symptoms require instant discontinu- ance of the mercury, removal to a better and freer air, cautious use of stimuli, friction of the chest, generous diet, and avoidance of all exer- tion and excitement. 5. The system may not suffer, but the surface may ; a very troublesome eruption occurring ; vesicular, the Eczema mercuriale. This may be the result of either external or internal exhi- bition ; when the former, it usually occurs in and around the part on which the ointment or plaster has been applied ; when the latter, the first appearance is usually in the axillae, or on the inside of the thighs, and thence the eruption may extend over the trunk. The vesicles soon break ; and, instead of healing, are apt to degenerate into pain- ful excoriations. Sometimes there is smart attendant constitutional disturbance. Treatment is by instant removal of the cause, and by exhi- bition of the soothing remedies which are suitable to such eruptions in * For Pearson's own description of Erethismus, see his work on Lues Venerea, 2d edit., p. 154. 2l 514 EFFECTS OF MEECUET. general ; the pain may be assuaged by opiate applications, the itching by an aqueous dilution of hydrocyanic acid. Liability to such an eruption does not forbid the use of mercury; but requires that it should be administered, when essential, in small doses, and with unusual caution. Its external use is certainly contra-indicated. 6. Some systems evince their intolerance of the remedy, by gradual loss of flesh, strength, and spirits — an asthenic state, partly anemic and partly hectic, becoming established. In such circumstances, mercury is to be discontinued ; generous diet, with iron or other tonics, is given ; and cure of the venei-eal affection must be sought by other than mer- curial means. Violent salivation may be caused by imprudent and excessive dosing, and by sudden exposure to cold during use of the medicine ; or it may depend on an idiosyncrasy of system. The mercury must be discontinued ; diet should be low ; cool and pure air is to be breathed ; and the mouth is rinsed, and the throat gargled, with weak brandy and water, or with solutions of the chlorides. If this prove insufficient, leeches may be applied over the angle of the jaw, followed by fomentation ; so that a directly sedative effect on the salivary glands may be obtained. Chlorate of potass, given internally, has been found useful. After the febrile excitement has abated, diet is improved ; and superficial ulcerations, in the mucous membrane of the mouth and throat, are touched occasionally with the nitrate of silver. Of the remote evil consequences of mercury on the system, much might be said. Of itself, sakelessly given, it may cause the most obstinate and serious affections of the skeleton. Associated untowardly with the venereal poison, its evil results show themselves as tertiary symptoms — even at a very remote period — and may be most formid- able : — nodes, ulcer, caries, necrosis of bones ; intractable ulcerations of throat, tongue, cheeks, and gums ; exfoliation of the hard palate, and of the nasal bones ; lupous ulceration of the nostrils, lip, or face ; hideous deformity by loss of the nose and palate ; caries of the skull, perhaps implicating the interior by perforation ; ulcers and tubercular formations in the skin and areolar tissue ; pain, misery, deformity, and death. Such calamities, happily, are now rare ; but our museums can speak to their frequent occurrence in times not long bygone. The worst evils occur, when the mercurio-syphilitic cachexy is aggravated by association with the strumous. In treatment, we have not much in our power ; and we may well plume ourselves more on prevention than on cure. The iodide of potassium and sarsaparilla are perhaps the only remedies which deserve a special mention, as antagonists of this depraved state of system ; the rest is done by general treatment and hygiene. SYPHILIS IN THE CHILD AND FEMALE. 515 Syphilis in the Child. A father, labouring under secondary syphilis, may transmit the taint to his child (p. 506). Or a mother, herself affected with secon- dary syphilis, may communicate the disease to the foetus. Or a mother, labouring under genital sores, may give direct contagion to the child during parturition. Or the child may be infected, at a more remote period, by suckling a female possessed of secondary syphilis ; the milk coming from tainted blood, and charged Avith the virus accordingly. Thus, in one or other, or in all of these ways, disease may be commu- nicated at the earliest age. Sometimes the child is born labouring under the symptoms ; more frequently, they show themselves after birth. The more prominent are — hoarseness of cry ; a shrivelled, lean state of body ; an anxious expression of face, often senile ; chaps at the flexures of the limbs, and on the nates ; a copper-coloured eruption, sometimes studded with pustules, more frequently scaly ; discharge from the nostrils ; excoriation of the mouth and throat. When the mother is syphilitic at an early period of pregnancy, the child often does not arrive at maturity, but comes away dead and putrid, as an abortion ; and this may happen repeatedly, until complete elimination of the poison from the parent's system has been obtained. For this purpose, a mercurial course is generally necessary — as can be readily understood, seeing that it is generally the true syphilis, or scaly eruption proceeding from the true chancre, which is communicated in this way. For a like reason, mercury is generally necessary in the child. It may be given indirectly through the nurse ; or directly — as is to be preferred in most cases — by inunction, or by guarded doses of the hydrargyrum c creta internally. Or mercurial ointment may be spread on flannel, and bound round the trunk, once a day, until the symptoms yield. In nursing, precaution is necessary ; as it is thought that a healthy nurse may have constitutional syphilis communicated in this way ; the excoriated or ulcerated lips of the child producing a similar condition of the mammilla, and the ordinary class of secondary symp- toms following. In such cases tubercles are apt to form about the anus and vulva of the nurse ; and these may be the means of infecting her husband. It is possible, that in some cases the sores on the child's mouth may be primary, caused by lodgment of virus there during parturition — the unfortunate mother labouring under primary disease at the time. Syphilis in the Female. In the female, syphilis is peculiar only as regards the primary affections ; and their peculiarity is chiefly as to their site ; their 2l2 516 PSEUDO-SYPHILIS. general character, progress, and results, being very similar to the occurrences in the male. Females are more subject to condyloma ; and, if cleanliness be neglected, warts are very liable to form, sometimes attaining to large size, and involving the labia in hyper- trophy. Sores are usually situated on the inner surface of the nymph se, and in the orifice of the vagina ; but they are also found in all parts of the vagina, on the os uteri, and sometimes in the urethral orifice ; sometimes they affect the anus. Treatment is as in the male. Warty formations occasionally are of such size, as to require a regular dis- section for removal of the hypertrophied mass (Principles, p. 405). Pseudo-syphilis. Certain diseases, not supposed to be of venereal origin, resemble some of the forms of constitutional syphilis more or less closely ; the Radesyge in Norway ; the Button-scurvy in Ireland ; the Yaws in America ; the Sibbens in Scotland — this, however, is lately supposed to be identical with the constitutional disorder consequent on condy- loma (p. 500). These affections belong to the province of the phy- sician. Astruc, de Morbis Venereis, Venet. 1760. Hunter, John, A Treatise on the Venereal Disease, Lond. 1786. Bell, Benjamin, a Treatise on Gonorrhoea and Lues Venerea, Edin. 1793. Pearson, Observations on Various Articles in the Cure of Lues Venerea, Lond. 1807. Carmichael on the Sj^mptoms and Distinctions of Venereal Diseases, Lond. 1818 ; Ihid, on Venereal Diseases, and the Uses and Abuses of Mercury in their Treat- ment, Lond. 1825. Devergie, Clinique de la Maladie Syphilitique, avec un Atlas colorie, Paris, 1826. Bacot, Treatise on Syphilis, &c., Lond. 1829. Travers, Observations on the Pathology of Venereal Affections, Lond. 1830. Lawrence on the Venereal Diseases of the Eye, Lond. 1830. Titley, Practical Treatise on Diseases of the Genitals of the Male, &c., Lond. 1831. Wallace, a Treatise on the Venereal Disease and its Varieties, Lond. 1833. Judd, a Practical Treatise on Urethritis and Syphilis, Lond. 1836. Colles, Practical Observations on the Venereal Disease, and on the Use of Mercurj'-, Lond. 1837. Ricord, Traite Pratique des Maladies Veneriennes, &c. Paris, 1838. Mayo on Syphilis, Lond. 1840. Acton, Treatise on Venereal Diseases, Lond. 1841. Guthrie on the Treatment of Syphilis without Mercury, Med. Chir. Trans, vol. viii. Lane, Lectures in the Lancet, 1841 and 1842. Skey on Venereal Diseases, Lond. 1841. Cazenave and Schedel, on Diseases of the Skin, by Burgess, Lond. 1842. Parker, A Safe and Successful Method of Treating Secondary, Constitutional, and Confirmed Syphilis, &c. Lond. 1850. White- head on the Transmission, from Parent to Offspring, of some Forms of Disease, &c. Lond. 1851. Wilson, Erasmus, on Syphilis, Constitutional and Hereditary, Lond. 1852, 517 CHAPTEE XXXIV. AFFECTIONS OF THE URETHRA. Stricture. Contraction of the ui*ethra may depend on one of three different causes. 1. There may be Spasm of the muscles connected with the membranous portion of the urethra, causing temporary diminution of calibre at that part, as well as resistance to instruments attempted to be introduced; and there is good reason to believe that a similar result is sometimes occasioned, in the anterior portion of the urethra, by spasmodic action of the muscular fibres which have lately been shewn to form part of the normal structure of the urethra, and to extend throughout its whole length — continuous posteriorly with the muscular coat of the bladder.* These conditions are liable to be suddenly induced, by ordinary exciting causes; and they generally disappear readily — often rapidly — under ordinary treatment ; hip-bath, fomentation, opiate enema or suppository, perhaps a sedative by the mouth, rest, quietude, and antiphlogistic regimen. 2. Inflammatory action, by its attendant swelling, may cause contraction. It may affect the lining membrane itself; either at one point, as in consequence of injury ; or over a considerable space, as in severe gonorrhcea — one of the symptoms of which, as we have seen, is an obvious diminution of the stream of urine, dependent on the contracted state of the canal. Or the inflammatory process may be exterior to the urethra ; in the substance of the prostate, in the areolar tissue of the perineum, or by the side of the rectum ; and the bulging of the phlegmon, or abscess, may not only diminish the calibre of the urethra, at the affected part, but may even shut it up altogether, causing retention of urine. The treatment of such a case has already been considered (p. 461) ; it is by antiphlogistics ; withholding the catheter as long as possible, and using the bistoury for evacuation of matter at the earliest practicable period. 3. The canal may be narrowed by chronic structural change, occurring in the urethra itself ; and this constitutes true Stricture; a condition which is ever liable to aggravation by the two preceding * H^\ncocK, Lancet, No. 1486, p. 187. 518 STEICTURE OF THE URETHKA, causes of contraction — spasm and inflammatory action. And it is well to limit the use of terms thus : understanding " spasmodic stric- ture " and " inflamed stricture " to be aggravations of true organic stricture in one or other of these ways ; understanding the terms "spasm of the urethra" and "urethritis," to include the condition of temporary narrowing of the canal by spasm and the inflammatory pro- cess ; and understanding by " stricture," an organic change in the urethra, causing a narrowing of the canal, which may be altogether independent both of spasm and of existing inflammatory action. But stricture results from the inflammatory process, in and near the urethra ; and this, as we have seen, may be excited in various ways. 1. It may follow the application of specific virus, as in gonor- rhoea ; and this is perhaps the most frequent cause of stricture. Clap is of common occurrence ; the inflammatory process is often of long duration, as well as of such a kind as to favour plastic exudation ; and treatment by injection is not unlikely to be so misconducted, as to cause maintenance or aggravation of such action. 2. Stricture may follow a chronic inflammatory process, always of a minor grade — never reaching beyond active congestion — occasioned by constant excitement of the canal; as by excess in venereal indulgence, or by an acrid state of the urine. The latter is no uncommon cause ; the urine may be simply acid, in excess ; or it may hold more or less deposit ; the bladder is emptied frequently ; and, on each occasion, the urethra smarts under the passage of the urine. At length, a continued state of congestion is induced ; and that brings not only discharge from the free surface of the mucous membrane, but also a certain amount of plastic exudation which remains. 3. External injury may be the exciting cause; lighting up an active inflammatory process in and around the injured part, and tending much to solid deposit — not always easily removed by absorption. Hence, blows and kicks on the perineum are found to produce the worst forms of the affection. A less amount of violence, often repeated, may induce gradual formation of stricture ; as by contusion of the perineum on the saddle, in dragoons, or others much employed on horseback. Also, there is good ground for fearing, that the disease not unfrequently originates in the unskilful and unnecessary use of bougies, lithontriptors, and other instruments. 4. Ulceration of the urethra cannot well heal, without causing more or less contraction of the canal ; and this ulceration may be the pro- duct either of a common or of a specific inflammatory process. There is no more troublesome stricture than contraction of the orifice, in con- sequence of venereal ulceration there. The proximate cause of stricture is plastic deposit, and consequent structural change, both in the substance of the lining membrane of the urethra, and also in the submucous areolar tissue ; and it is impor- STRICTUEE OF THE URETHRA. 519 tant to remember, that it is in the latter situation chiefly that the deposit takes place. The ordinary sites of stricture are — at the orifice ; at the neck of the glans, about an inch from the orifice ; at the natural bend of the penis, from the suspensory ligament, between three and four inches from the orifice ; and in front of the membranous portion of the urethi-a, between six and seven inches from the orifice.* The most frequent are the two last named. But it is seldom that a tight stricture is found at the posterior part of the urethra, without more or less contraction also at the ordinary sites in front ; in other words, in cases of bad stricture, a plurality of contractions may generally be expected. When the aff'ection results from external injury, the site obviously depends on the application of this. The extent and degree of contraction vary. Sometimes a shred of plastic deposit passes across the canal ; and this rare form is termed the bridle-stricture. Sometimes the stricture is tight, but very limited, seeming as if a thread had been tied tightly on the part. More fre- quently, the contraction is of greater extent ; from a quarter of an inch to an inch; sometimes involving several inches of the canal. And the degree of contraction varies, according to the duration and treatment of the disease, from the slightest narrowing of the canal to its complete occlusion. Behind the constricted point, dilatation takes place. Anteriorly to the actual stricture, there are collapse and contraction. The dila- tation may be to such an extent as to hold more than one ounce of urine ; and the mucous lining of the dilated part becomes prone to ulceration. Calculous matter may be retained there ; and a stone may form, occupying the whole space. The mucous lining of the entire canal sympathizes more or less. From the strictured part, and also from the general surface of the membrane, an abnormal discharge proceeds ; usually clear, sometimes puriform ; and liable to be increased by casual excitement — this inducing aggravation of the congestion. Chronic prostatitis is apt to be induced ; increasing the dischai-ge. The lining membrane of the bladder becomes aifected ; the muscular coat too is changed, becoming hypertrophied ; and, in consequence, both fasciculation and sacculation of the viscus may take place. The enlarged muscular fibres, arranged in fasciculi, act strongly on the urine ; and the urine, not getting freely away through the strictured urethra, reacts on the mucous membrane, causing pro- trusion of this through the interspaces of the fasciculi. Cysts, thus formed, receive gradual additions to their parietes, and may attain to a large size — rivalling the bladder itself in magnitude. Chronic cystitis may follow. And morbid sympathy does not end with the * The researches of Sur C. Bell, and others, have demonstrated that seldom, if ever, does contraction of the urethra occur posterior to the last named site. 520 SYMPTOMS OF STEICTUEE. bladder ; the kidneys are in many cases involved ; first in irritation, causing functional derangement only ; afterwards in organic disease. The pelvis of the kidney, and the ureters, are often enormously dilated, their lining membrane furnishing much puriform discharge. The formation of stone, too, is favoured, as was formerly remarked ; derange- ment of the kidney's secretion leads to calculous deposit, and this is obstructed in its outward passage by the urethral change. The symptoms of stricture are of gradual invasion, and may for some time escape the patient's notice. The urine is passed in an attenuated stream, sometimes twisted, sometimes scattered ; the act is both frequent and tedious ; and sometimes it is accompanied by pain and uneasiness in the bladder and penis, which abate on the bladder being emptied. After the patient supposes evacuation com- plete, a few drops — in some cases, a considerable quantity — pass away involuntarily ; coming from the dilatation behind the stricture. In consequence, the clothes are usually soiled and stained. The increased frequency of micturition is most observed at night. Dis- charge comes from the urethra, as already stated ; and excess in diet or exercise may induce aggravation, resembling an attack of gonorrhoea, and very probably implicating the bladder. Pain is complained of in the loins and thighs, and in the perineum ; often erection is painful. In tight strictures, the urine may pass only guttatim ; and then, too, there may be no escape of semen in emission — this fluid passing backwards into the bladder, to be afterAvards discharged in an altered state along with the urine. The testicles are liable to enlargement ; and the rectum frequently sympathizes — becoming prolapsed, or inflamed, or fissured, or ulcerated, or affected with hemorrhoids ; sometimes strictures of the urethra and of the bowel are found to co-exist. The straining, in bad cases, is such as to empty the rectum as readily as the bladder ; and in consequence the water-closet has to be used, instead of the chamber-pot. Often hernia is induced. The prostate is liable to become not only excited but enlarged ; and if this enlargement be chronic and simple, relief from the symptoms of stricture may be experienced; the prostatic tumour acting as a breakwater, in favour of the part originally affected. But if ulceration or abscess affect the gland, then aggravation must necessarily ensue. As the kidneys suffer, their secretion becomes more and more changed ; and the acrid urine, passing frequently along the urethra, reacts unfavourably on the urethral disease. The complications of ague and gout are by no means unfrequent, in those advanced in years, and who have lived freely. Retention of urine is at any time liable to occur; the degree of constriction being suddenly increased by spasm, or by inflammatory action, or by both. From this cause, extravasation of urine may follow ; urinous abscess, however, ending TREATMENT OF STRICTUEE. 521 probably in the formation of fistula in perineo, is more common — generally producing mitigation of the symptoms, at least for a time, as will afterwards be explained. In severe and protracted cases, the general health suffers materially — independently of all accident ; the flesh and strength fail, the digestive organs are impaired, the face is sallow, and the features wear an expression of anxiety almost pathog- nomonic of the disease. Constitutional irritation sets in ; the symp- toms denoting organic disease of the kidneys become more and more marked ; purulent, mucous, ammoniacal urine passes often, in small quantities, and with much distress ; febrile exacerbations recur with greater force and frequency ; emaciation advances ; the appetite and digestion fail more and more completely ; at length coma may super- vene ; and the patient perishes. Treatment is conducted on simple principles; but a satisfactory cure is often of very difficult attainment. Our object plainly is, to get rid of the redundant deposit which causes the contraction ; and this may be effected in one of two ways : 1 . By simply procuring absorption, under the stimulus of pressure ; 2. By so managing the application of pressure, as to establish a temporary and active con- gestion in the part, which, on its resolution, may induce rapid dimi- nution of the deposit — somewhat in the same way as the injection of a hydrocele removes a redundancy of serum (Principles, p. 193). Advance of such action to a high grade is obviously to be avoided ; true inflammation will cause further deposit around ; and ulceration — at the time perhaps widening the canal — is likely ultimately to lead to renewed and probably aggravated contraction, by puckering of the cicatrix. Besides, ulceration, to prove effectual on the submucous deposit — the true cause of the stricture — must flrst penetrate and destroy the mucous membrane ; an event never desirable ; 3. In bad cases, the knife may be necessary to free the contracted part ; not, however, as a sole means of cure ; but to assist the bougie in after- wards establishing the normal condition of the part. To obtain the curative result, in ordinary cases, cautious manage- ment of the metallic bougie is now universally acknowledged to be the most suitable means. But, in the first instance, exploration is neces- sary ; to ascertain whether a stricture exists or not, as also its nature and extent. A metallic instrument may be used for this purpose ; but one of wax is sometimes preferred, as less formidable to the patient, and capable of conveying very explicit information as to the state of the urethra. A large one is not suitable obviously ; neither is one of small size — for it is liable to catch a lacuna, and so to indicate stric- ture when there is none ; or, passing through a stricture of no great tightness, it may lead to the belief that the canal is clear, while con- traction really does exist. One of a medium size is selected ; and, 522 USE OF THE BOUGIE. having been warmed gently, and made pliable, by the hand, is intro- duced cautiously. If obstructed, it is gently withdrawn a little, and then pushed on again ; a fold of the urethra may have been in the way. If, however, still opposed, the existence of stricture may be fairly. presumed ; and its site is noted, by observing the extent to which the instrument has passed. To elicit further information, the bougie is pushed steadily onwards, so as to fix its point in the stricture ; and, on withdrawing it, a tolerably accurate idea may sometimes be obtained of the extent and character of the contraction, by observing the marking of the instrument's point. The wax bougie is then laid aside; its ofiice is exploration;* and now, for the cure, one of metal is taken up, of such a size as is likely to pass without much difficulty. The most convenient kind of bougie is that manufactured of Berlin silver ; hollow, and consequently light, yet firm enough ; and always possessing a smooth surface. The curve should be gradual and slight — a segment of a large circle ; and the set of instruments are arranged in a gradually ascending scale, from the smallest wire-like form, to what is likely to fill the average canal in its normal state. The selected instrument, oiled, or smeared with cold cream — sad mis- chief has happened from croton oil having been mistaken for the bland fluid — is passed down to the seat of stricture, and steadily pressed onward, with intent to pass through it. Having succeeded in this, the instrument is permitted to remain, from a minute to half an hour, according as the patient's feelings may indicate. If sickness occur ; or if much pain be felt, and on the increase ; or if the patient express a decided wish for removal of the instrument, stating his belief that it is "hurting" him — it should be withdrawn; remembering that our object is, to excite not inflammation, but absorption only. Rest and temperance are essential, for that day. On the second or third day, we expect the uneasiness occasioned by the former introduction to have passed away ; and the operation is repeated ; introducing the same instrument as before, then immediately withdrawing it, and sub- stituting a size larger. And this is repeated, at longer or shorter intervals, until the full size is passed readily. This last is repeatedly introduced at the ordinary intervals, until aU obstruction has fairly disappeared ; and then the stricture may be regarded as cured — though not finally disposed of. A tendency to recontraction remains. And, to obviate this, an occasional bougie is required — sometimes termed the protesting bougie — at a gradually increasing interval ; the first introduction taking place at the end of a fortnight, then after a month, then after two months, and so on ; until, after introduction at an * Many surgeons never use the wax bougie, even for exploration. No doubt, the metallic instrument is quite capable of fulfilling all ordinary indications in this way. But if a wax instrument is to be used at all, this seems its proper place. USE OF THE BOUGIE. 523 interval of six months, all is found normal. Thus only can immunity from relapse be secured. Such is the ordinary course of events, in a plain and simple case ; but many circumstances require attention besides. And, in the first place, in commencing the treatment of stricture, it is essential to have regard to the general health, and especially to the state of the urine. If an acrid fluid be frequently passing over the canal, little or no pro- gress can possibly be made ; the disease need not be expected to give way, while a cause of maintenance, if not of origin, is in constant ope- ration. It is also very important that regimen should be strictly regu- lated ; and that walking exercise should be indulged in as little as possible. Horseback exercise must be absolutely prohibited. The instrument is held lightly in the hand, and is never pressed onwards with much force. Force of propulsion, and tightness of grasp, may tear the urethra, pushing the unentered stricture before the instru- ment's point — if this be kept straight ; or, if any divergence be made from the true direction of the canal, the parietes are perforated, and a false passage is established. Lightness of grasp, and gentleness of propulsion, permit the instrument to be restrained by the walls of the urethra ; and all such hazards are avoided. The point is pressed steadily on the stricture for a short time ; and then, withdrawing the hand, we observe whether the instrument resiles, or remains fixed in its place ; if the former event occur, it is a sign that no penetration of the stricture has taken place ; the latter is a token of the instrument's point being lodged in the contracted part. And according to the evi- dence thus afforded, either a smaller instrument is selected, or the onward pressure is steadily maintained. In the latter case, our chief care is to avoid the use of force, and to exert the steadily maintained pressure not on the sides of the canal, but on the obstruction in its direct course ; and, to assist in this, when the stricture is behind the scrotum, the fore-finger in the rectum is often of use. An obstacle may be felt at the bougie's point, near the neck of the bladder ; and yet it may not depend on stricture. The canal may be of its normal calibre throughout; but made tortuous, by unequal enlargement of the lobes of the prostate. In such a case, a flexible instrument is more likely to pass than one of metal ; the passage is to be traversed, not forced — " arte, non vi " — and much assistance is derived from the finger in ano. Another obstacle, not connected with stricture, may be occasioned by osseous deposit on the rami of the ossa pubis, or upon their symphysis; the result of injury, or of idiopathic ostitis. It is of rare occurrence. A cautious turning of the instru- ment's point to a side will probably elude such obstruction. A stricture, at first wholly resistful of the instrument's point, may in a short time yield to it. Instead of attempting at once to pene- 524 FALSE PASSAaES. trate, therefore, steady pressure is kept up ; and, after a few minutes, we may expect such an amount of relaxation to take place as may admit either of the instrument passing completely, or of its becoming lodged in the strictured part. It is not essential to the cure, that penetration should be complete at first ; and this undoubted fact has an obvious and important bear- ing on practice. Having found a tight and unyielding stricture, which will not, without force, permit penetration, even by a very small instrument ; and if there be no threatening of retention, or other urgency ; — we lay aside small bougies, and the determination to pene- trate, and, selecting an instrument of medium size, pass it down to the stricture, and retain it there — on the stricture, rather than in it — as long as the patient's feelings will allow. This is repeated, at the usual intervals. And, after several such introductions, relaxation will be found gradually advancing, so as to admit first of partial lodg- ment, and afterwards of complete penetration. No time is lost ; and no risk is incurred. The principle of cure is obviously the same as that of the ordinary use of the instrument.* Should, at any time, over-excitement — as evidenced by tendency to bleeding, pain, spasm, and discharge — occur in the part, from over-use of the bougie, exposure to wet, fatigue, intemperance — all instrumenta- tion must be desisted from, for a time ; until, by rest, and antiphlo- gistic regimen, a quiet and tractable condition of the canal has been restored. In receiving the bougie, the patient may be either erect or recum- bent. If it be his first experience of such an operation, the latter posture is preferred ; lest faintness occur, as is apt to be the case. After one or more repetitions, such tendency ceases ; and then the erect posture is more convenient for both parties. The surgeon, seated in front, passes the instrument with its convexity directed towards the abdomen, down to the suspensory ligament ; and then, gently depress- ing the handle, while the instrument is slowly turned half round, this natural obstruction is overpassed. To avoid injury to the canal here, it is well to move the point mainly on the upper surface of the urethra. K an opposite course be followed, a fold of the membrane is almost certain to be caught ; then rash pressure cannot fail to cause abnor- mal penetration — and a False Passage is begun. The evidences of a false passage being formed are : — the conscious- ness of having used an unusual and unwarrantable degree of force ; an uncertainty as to the point having been in the true direction ; a want of the ordinary sensation of being grasped, as the pressure is * To this mode of procedure the term " tunnelling " has sometimes been applied ; portion after portion of the stricture being excavated, as it were, until a clear " driftway " has been established. I can vouch for its safety and efficiency. FALSE PASSAGES. 525 continued ; a sensation of something having suddenly yielded ; when pressure is then continued, a feeling of roughness and rubbing on the instrument's point — and the bougie is then apt to advance, not smoothly, but per saltum ; a complaint from the patient of unusual pain — perhaps vpith a start, and then faintness ensuing ; blood welling out, in greater or less quantity, by the side of the instrument. Yery frequently, the patient decidedly corroborates our own aj^prehensions, by declaring his conviction that the normal canal has been departed from. Such things ought not to be ; the risk is great. And they need not be ; for, by avoidance of force, and by the exercise of ordinary caution and skill, all such accidents are rendered more than unlikely. The only circumstances in which force is at all excusable, are those of urgent retention. Then the bladder must be relieved, as we have seen (p. 460). But, of all the methods of affording relief, forcing the stricture is probably the worst. If there be time and indication, leeches, fomentation, hot-bath, sedatives, and antispasmodics are tried ; and, failing these, the obstruction is overcome by incision. The risks of false passage are: — 1. Escape of urine, and conse- quent sloughing or abscess, according to the extent and manner of the infiltration. If the false passage be incomplete, opening into the urethra only on the distal side, urine does not enter so readily as when the perforation is complete — having both a distal and a proximal opening. The incomplete form, consequently, is more likely to cause urinous abscess ; the complete, urinary infiltration. 2. Hemorrhage may be considerable. 3. Inflammatory action may seriously affect the part, causing softening and ulceration ; and healing cannot take place, without contraction — worse, probably, than the original stric- ture. And, besides, during the persistence of inflammatory action, constitutional disturbance is likely to be severe, bearing hard on a system already enfeebled. 4. Or, in the especially feeble, a formid- able amount of constitutional irritation may occur, irrespective of local inflammation. A false passage having been formed, it is with difficulty avoided in subsequent introductions of the instrument. For some days, nothing should be passed along the canal ; an opportunity being thus afforded for closure of the track ; or, at least, for such diminution of it as may render entanglement of the instrument less likely. And when this is again used, it must be with a very lively caution ; the hand being alert, as it were, to notice the first and slightest deviation from the normal path. In some patients, there is an especial ii-ritability, which tends to baulk the bougie; perineal spasm supervening on the introduction being attempted, and receiving obstructive aid, probably, from a turges- cent state of the lining membrane. Such a difficulty may be partially 526 TREATMENT BY THE CATHETER. or altogether avoided, by the exhibition of a moderate opiate, by the rectum or mouth, about half an hour before the attempt at introduc- tion — or by the employment of aneesthesia. Other patients are liable to suffer from agueish attacks, after use of the bougie. Such are generally elderly persons, who have lived freely and been abroad. They benefit greatly by the use of quinine. Hitherto, yve have been speaking only of the ordinary cases which require the ordinary application of instruments, in expectation of the ordinary result — disappearance of the redundant deposit, by absorp- tion ; this absorption being excited, simply and directly, by pressure. We now come to another class of cases, requiring another effect of the instrument — the second which we formerly noticed ; excitement of an active congestion, whose resolution may carry with it removal of not only its own effusion and exudation, but also of the deposit of former times. These are tight and unyielding strictures, of considerable ex- tent, and long duration. A very small instrument may be insinuated into or through them ; but no progress is made ; on each introduction, there is the same difficulty to be overcome. In such cases, the treat- ment requires a modification ; a higher result is to be obtained from the instrument's use. A firm silver catheter is carefully passed through the stricture ; and is retained by tapes, which are appended to the rings of the instrument, and secured, like the lithotomy tube, to a bandage round the waist. The orifice of the instrument is shut by a plug of wood or cork, which is to be removed, from time to time, for evacuation of the urine. At first, the catheter is felt tightly fixed ; and, after some time, the embrace is found to become more and more close, in consequence of the crescent infiammatory process, and its attendant swelling. The foreign body's presence is resented, in the usual way ; and an effort is made for its extrusion. The temporary lodgment of a smooth metallic substance in an open mucous canal, however, does not inevitably cause true inflammation ; and, accord- ingly, the action is generally found to fall short of this, and to follow the ordinary course of acute congestion — resolving itself by copious discharge. This occurring, relaxation and widening of the canal take place ; absorption, and exhalation on the free surface, both busily con- ducing to this desired result ; and then the instrument — before, fixed and firm, as in a vice — will be found loose and movable. It is now withdrawn ; and a bougie, of comparatively large dimensions, may be passed in its stead. This is permitted but a brief stay ; and then the ordinary instrumentation is proceeded with, as in other cases. This method of treatment, it is obvious, requires great care ; there being always a risk of over-action locally, as well as of untoward con- stitutional disturbance. And the case must be watched accordingly. There is always considerable uneasiness in the part, during the instru- TREATMENT BY THE KNIFE. 527 ment's stay ; and some excitement of the system may seldom be avoided. It is only when either proceeds to excess, that the instrument has to be prematurely withdrawn. In some patients, it may be safely re- tained for twenty, thirty, or forty hours ; in others, that time must be greatly abridged. Opiates are of service, in allaying the pain and irritation. And if by their use, all untoward symptoms are averted, we need not regulate the catheter's stay by any fixed limit of hours ; but may regard its thorough loosening, as the first sign of the propriety of its removal. It is seldom, however, that a retention of more than twenty-four hours is required. And, in that short space of time, if the case proceed favourably, we may expect threefold more progress than under the ordinary system of management. This method, how- ever, though rapid, is doubtless attended with some risk, which the other method wants ; and therefore is wisely held applicable only to the severer forms of stricture, on which ordinary means may have produced, or are likely to produce, but little effect. But there are worse strictures still, to which even this treatment is unsuitable — because of their extreme tightness, and unyielding nature. An instrument cannot be made to penetrate ; and it is difficult perma- nently to retain one but partially introduced. In these cases, we must be content with the treatment already noticed, of passing down a bougie, of medium size, at the ordinary intervals, and retaining it in contact Avith the stricture for some time ; expecting that, in this way, the desired diminution of deposit by absorption may advance. But, if excitement occur, the case becomes urgent by retention of urine ; and then we are forced to relieve the bladder. The stricture must be got through. A firm instrument, of suitable size, is patiently and gently used — re- membering that, by the inflammatory process, the parts have had their lacerability much increased. With the aid of sedatives and antispas- modics, we may succeed. But, if baffled in this legitimate use of the instrument, we are not warranted in having recourse to force. It is better to cut th£fti to bruise and tear ; it is better to make a clean wound through which urine may discharge itself innocuously, then to leave a bruised and torn sinus in which infiltration can hardly fail to occur, with all its lamentable results. The patient, under chloro- form, is put into the position suitable for Lithotomy ; and an incision is made in the central raphe, as foi'merly described (p. 465). The bladder having been relieved, and the stricture cut through, a catheter of medium size is passed from the orifice of the urethra to beyond the seat of stricture, and is retained as long as the feelings of the patient will permit. Then it is removed ; but on excitement having passed oflT, it is re-introduced ; and thus we endeavour to retain the canal of con- siderable width, while the external wound slowly closes. On cicatriza- tion being nearly completed, the size of the catheter or bougie is gradu- 528 TREATMENT BY INCISION. ally increased ; and instrumentation is continued, in the ordinary way, until full dilatation shall have been completed. This is the treatment of extreme cases — complicated with the crisis of retention. To such only is it applicable. And of the skilful surgeon it is comparatively seldom re- quired. It has lately been proposed to extend the principle of subcutaneous incision to the treatment of stricture. But a fatal objection to such proceedings is the liability to urinous infiltration ; free and direct incision coming soon to be required, and that too late to save the part from loss of substance, and the system from grave disorder. Ac- cordingly, it is understood that the practical experience of this method has proved far from satisfactory ; and, in all probability, ftirther repetition of the experiment will scarcely be thought advisable. The risk is least, when fistula in perineo exists behind the stricture ; and when, consequently, the urine has an opportunity of draining away through the perineal opening, without coming in contact with the incised urethra situate anteriorly. A safer method of incision is from within the canal, by the em- ployment of lancetted catheters. But these are dangerous weapons, very obviously, in the hands of the inexperienced; and the most skilful must have difiiculty in using them with safety, in the case of stricture posterior to the scrotum. There can be no certainty of the incision being made in the true direction ; the walls of the canal may be injured ; and then infiltration of urine can hardly fail to ensue. For very tight and unyielding contractions anterior to the suspensory ligament, however, the method is not unsuitable. The straight instru- ment of jMr. Staffbrd can be passed dovra, and held directly on the diseased part ; and the operator can make sure of pushing onwards the cutting stilet in the right direction. After this, a common bougie may find itself but little opposed, and may pass readily on to the blad- der. But even then there is always some risk of accident by escape of urine into the cut parts. And, accordingly, we would limit the use of the straight and short cutting catheter, to those cases of anterior strictm'e which resist the ordinary means ; and would dissuade from the use of the long and curved cutting catheter, under any circum- stances whatever. It is but seldom that even the former will be re- quired. Orificial stricture — tight, callous, unyielding, sometimes admitting the most delicate probe with difficulty — is usually the result of cicatri- zation ; and the sore has probably been of venereal origin. By probes, or short bougies, occasionally introduced, a cure by dilatation may sometimes be procured in the ordinary way. But, very frequently, it is found necessary to expedite the process by incision. A narrow probe-pointed bistoury is introduced ; and, by its edge, the contracted TREATMENT BY CAUSTIC. 529 part is notched all round. A bougie is passed immediately afterwards, of such a size as will penetrate without force. And repetition is made daily, in an ascending scale ; a less interval than usual sufficing here, in consequence of there being less irritability than in the deeper-seated portions of the canal. Sometimes, it may be found necessary to lay the contracted part entirely open by incision, introducing the bougie afterwards through the wound ; and seeking for a cure of the stricture, at the cost of establishing an imperfect state of the urethra, similar to the congenital malformation termed Hypospadias. It is easy to understand how spontaneous alleviation of stricture may occur ; either by absorption, or by ulceration. But it is probable that such an occurrence is actually very rare ; and, certainly, it is not to be trusted to in practice. Eelief by the latter mode, indeed, is scarcely desirable ; inasmuch as the cicatrix of the ulcer is likely to reproduce contraction, perhaps in an aggravated form. For a like reason, the caustic bougie has fallen into comparative desuetude. To prove successful as an escharotic, in clearing away obstruction, the mucous membrane must first be sacrificed ; and though, for a time, ample space may be thus obtained, yet in the end recon- traction is obviously inevitable ; partly by reason of the plastic deposit Avhich surrounds ulceration, and partly by reason of the contraction which invariably attends on cicatrization of a sore — unless, indeed, reproduction of the urethra's wall, by new tissue, be considered possible, during the cure. The best use of the " caustic bougie " is, not as an escharotic, but as a corrector of irritability. If a peculiarly irritable stricture resist the ordinary means, already alluded to, decided benefit may be obtained by the application of nitrate of silver to the contracted part and its vicinity. This may be accomplished, either by the porte- caustique, recommended by M. Lallemand ; or by means of the old- fashioned instrument — a wax bougie, in whose hollowed point a portion of the nitrate is imbedded. For a stricture at all penetrable, the former is the preferable instrument ; but a tight contraction can be directly reached, only by the latter mode of conveyance. Instead of nitrate of silver, caustic potass is used by some ; not as an escharotic, but as an " alterative "* A small portion — from a grain to the eighth of a grain — having been inserted in a hole made in the point of a soft bougie, is passed rapidly down to the stricture, and held there for one, two, or three minutes ; and repetition is made in four or five days, after irritation has passed away. It is probable that what are termed " elastic " strictures — strictures which dilate under the ordinary treatment, but speedily relapse, and become tight as before — often depend on an unusual irritability of the canal ; and that they will be more appropriately treated by the * Wade on Stricture, Lond. 1849. 2m 530 UEINOUS ABSCESS. occasional application of nitrate of silver — in conjunction with the ordinary use of the bougie, and suitable general treatment — than by the employment of cutting instruments. Lately another mode of external incision has been adopted ;* namely, passing a small grooved staff through the stricture, and cut- ting into the groove at the contracted part, by perineal w^ound. To avoid hemorrhage, the incision is placed carefully in the perineal raphe ; and on v^^ithdrawing the staff, a catheter is introduced and re- tained as after the old operation. Until this is done, it is well to have the patient deep in anaesthesia, with a view to avoid urinary infiltration by voluntary action of the bladder. By subsequent use of the bougie, in the ordinary way, permanent as well as rapid dilatation of the canal may in many cases be obtained. The advantages of this procedure are, accurac)'- of division, and rapid approach to cure. The disadvantages are, the ordinary risks of such operative procedure, and the uncertainty of being able in all cases to insinuate (not force) a small instrument through the contracted part. Some few strictures, we believe, are really " impenetrable ;" and are consequently to be treated ordinarily by the " tunnelling method " (p. 524) — in the crisis of retention by perineal incision ac- cording to the old way (p. 465). The great majority of " penetrable " strictures, on the other hand, are capable of safe and satisfactory cure, without the use of cutting instruments. But to some few of those which refuse to yield to ordinary treatment, and in whom great irritability of system prevails,- this mode of operation seems very suitable — an operation whose proper character will probably be fixed hereafter, as neither so safe nor so generally applicable as its promoter at first imagined, nor yet so dangerous or disappointing as some of its op- ponents have declared-! Another mode of treating obstinate stricture — recently devised — is by tubular dilatation ; introducing a small bougie or director through the stricture, and on that passing down tubes of increasing size ; the object of the apparatus being to secure accurate introduction and rapid dilatation. I Time is yet wanting to warrant a decided opinion of the merits of this proposal ; but facts, as far as they go, speak in its favour, as being both suitable and safe. Urinous Abscess. This consists in the condition of abscess, complicated with a com- munication with the bladder or urethra, and consequently having a * Syme on Treatment of Stricture by Perineal Incision, Edin. 1849. t Lancet, March 22, 1851. X Wakley, Lancet, No. 1438, March 1851 ; and ibid, No. 1484, p. 144. URINOUS ABSCESS. 531 greater or less admixture of urine in its contents. The formation may occur in one of two ways; from without or from within. 1. An abscess may form exteriorly to the urinary passages — excited by injury, or by the irritation of stricture or stone; and, in its progress by enlargement, it may open into the urethra, or bladder — according to its site. Then, through the ulcerated aperture, urine enters. Its stimulus, within the purulent cyst, necessarily kindles a fresh amount of inflammatory action. If this advance rapidly to ulceration of the tissues composing the limits of the original abscess, urinous infiltration takes place, with sloughing of the affected parts. But if the pyogenic membrane remain entire — perhaps strengthened by a renewed and plastic exudation — then the escaped urine remains limited within the suppurated space, and the state of urinous abscess is established. The collection may assume quite a chronic character ; but, in general, it extends more rapidly than an ordinary acute abscess, has- tening to the surface, and discharging thin, dark-coloured, and foetid contents. 2. Or, as more frequently happens, the affection originates in ulceration of the lining membrane of the urethra or bladder. Acute ulceration, and also direct laceration, of the mucous membrane is liable to occur, as we have seen in the case of retention of urine (p. 460) ; then rapid escape of that fluid takes place, under powerful action of the hypertrophied muscle of the bladder ; and the most for- midable extravasation results. But, unconnected with any such crisis, a more gradual giving way may take place ;' the urine, escaping first in a few drops, may excite an inflammatory process of a sthenic type ; the abscess formed has all the ordinary characters — the impor- tant limiting barrier of plastic exudation not excepted ; and, as it enlarges, these are not destroyed. Before the actual ulceration, too, it is probable that an inflammatory process has been slowly advancing in the tissue exterior ; which has thus become in some measure consoli- dated, before any urine has had an opportunity of entrance. Or, as has already been stated, the commencement may not be by ulceration, but by wound or tear — inflicted by an unskilful use of catheters, bougies, or other instruments (p. 525). But the term " Urinous, or Urinaiy Abscess," is generally under- stood to refer to the urethra. Its origin is commonly from within ; and the usual exciting cause is stricture. The urethral ulceration may be either immediately behind the stricture, or at some distance posteriorly. The ordinary site is in the perineum. There a hard swelling is dis- covered, on pressure ; the ordinary symptoms of stricture undergo aggravation ; shivering and febrile disturbance occur ; and, perhaps, by the pressure of the abscess, retention of urine may be occasioned. Treatment consists in making a free external incision, for the evacuation 2 M 2 532 ' FISTULA IN PERINEO. of matter and urine ; afterwards removing the cause, the stricture, in the ordinary way. Urinary Fistula. This may follow wound in the perineum, implicating the urethra. More frequently, it is the result of urinous abscess. The collection has opened spontaneously in the perineum, temporarily relieving the symptoms, both of abscess, and of stricture ; but, by persistence of the latter, closure and cicatrization of the abscess are prevented ; the irri- tation of the stricture maintains a morbid degree of excitement, and the obstruction which it occasions forces the urine into the abnormal channel. The abscess consequently does not close ; but partially con- Kg. 154. tracting, degenerates into the condition of fistula. There may be but one fistula, or several ; in the perineum, or traversing the scrotum, or anterior to the sci'otum, or on the nates. Sometimes abscess burrows beneath the fascia of the penis, and opens near the glans ; sometimes the opening is on the dorsum of the penis. Also, one abscess, having more than one external outlet, may lead to the establishment of more than one fistula ; or, each fistula may be connected with a separate abscess. The discharge is thin and gleety ; often copious. Sometimes a constant dribbling of urine exists ; in other cases, urine escapes only during an expulsive eflFort. The surrounding parts are tender and excoriated ; the patient is in a constant state of discomfort ; and very frequently his general health suffers seriously. Treatment is simple ; directed to the stricture, not to the fistula — at least in the first instance. The stricture having been thoroughly dilated, the urine comes again by the normal channel ; the fistula contracts and dries ; and, in many cases, it wholly closes, without any direct treatment having been received. Should contraction prove tedious and Fig. 154. Example of Fistula in perineo. LACERATION OF THE UEETHKA. 533 incomplete, the hot wire may be used ; applied not to the mere orifice, but deep in the track — lest premature closure of the external part might take place ; not repeated frequently, but at long intervals — it being our object to obtain the benefit of the healing process which follows remotely on the burn, not the destructive and infiammatory effects which are its primary result (p. 162). If sinuses communicate with fistulee, it will probably be necessary to lay them open with the bistoury. In cases long neglected, in which the whole urine has for years been passing by the perineum, the urethra anterior to the open- ing contracts greatly, and may be almost completely obliterated. Dilatation is then effected with great difficulty ; and recourse to the method by incision will probably be expedient. Sometimes the abscess opens, not in the perineum, but into the rectum ; and fistula forms in the bowel. Urine passes per anum, and air, or even faeces, may escape by the urethra. Treatment is the same as for the more common varieties ; the speculum ani being used to protect the bowel, when it is necessary to employ the cautery. Laceration of the Urethra. This has been already spoken of (p. 462). The first object is to prevent infiltration of urine ; and that can be accomplished only by early introduction of the catheter, which should be retained until a sufficient time for consolidation of the injured parts has transpired. If a catheter cannot be passed, incision must be had recourse to, as already explained. But extravasation of urine is not the only risk that demands our regard. That over, the risk by inflammatory action remains ; a minor amount is likely to cause stricture ; true inflamma- tion will cause abscess ; and this, communicating with the urethra, will degenerate into perineal fistula. Leeching, fomentation, rest, and antiphlogistic regimen, are therefore very essential after the injury. Neglect a severe kick or blow of the perineum, and stricture, abscess, .and fistula, are almost sure to follow. Everard Home, Practical Observations on the Treatment of Strictures in the Urethra, &c. Lond. 1805. Arnott, Treatise on Strictures of the Urethra, &c. Lond. 1819. Charles Bell, Treatise on Diseases of tlie Urethra, &c. by Shaw, Lond. 1822. Ducamp, Traites des Eetentions d'Urine Cause'es par le Eetrecissement de I'Uretre, &c. Paris, 1822. Lisfranc, des Eetrecissements de I'Uretre, Paris, 1824. ilacilwain on Stricture of the Urethra, Lond. 1830. Araussat, Legons sur les Retentions d'Urine Causees par le Eetrecissement du Canal de I'Uretre, &c. Paris, 1832. Stafford on Strictures of the Urethra, Lond. 1836. Brodie, Lectm-es on Diseases of the Urinary Organs, Lond. 1842. Wade on Stricture of the Urethra, &c. Lond. 1849. Sjine on Treatment of Stricture by Perineal Incision, Edin. 1849. Lizars on Stricture of the Urethra, &c. Edin. 1851. Waklej', Lancet, 1851. 534 CHAPTEE XXXV. AFFECTIONS OF THE TESTICLE. Orchitis. The inflammatory process affecting the testicle may be acute or chronic; original, as following external injury; or secondary, the consequence or attendant of gonorrhoea. Sometimes it is an accompaniment of Mumps — inflammatory enlargement of the glands in the upper part of the neck ; not improbably depending then on metastasis. Secondary gonorrhoeal orchitis is usually acute, and is the most frequent form of the affection. It is also known as Hernia humoralis. There being an increased susceptibility in all the genital system, during the existence of gonorrhcea, orchitis may be lighted up at any time, by the application of a slight exciting cause ; a squeeze, excess in walking or diet, exposure to cold and wet, or premature use of strong injection. But, without any apparent exciting cause, the attack is liable to occur ; and then seldom until some time has elapsed — usually in the third week of the gonorrhoea. It may be the result of metastasis ; more frequently the action extends by continuity of tissue, descending along the vas deferens ; seizing on the epididymis, and chiefly residing, there. In fact, the affection may in strict language be designated as an Epididymitis ; although the whole testicle seems to swell, yet the epididymis is the true seat of disorder, and the general swelling depends chiefly on acute effusion of serum into the tunica vaginalis. Pain and a sense of weight are felt in the cord and testicle, the skin reddens, and uneasiness is felt in the groin and loins. The swelling Fig. 155. Acute orchitis ; attendant on gonorrhoea. ACUTE ORCHITIS. 535 and pain increase, often becoming excruciating ; and then sensation in the loins is as if the back were sawn across. Discharge from the urethra diminishes, and ceases — an example, generally, not of metas- tasis, but of the effect of counter-irritation. The scrotal swelling becomes tense, red, glistening, and intolerant of the slightest pressure ; the cord, too, is swollen, red, and painful. Febrile disturbance is con- siderable ; and vomiting is both a common and distressing symptom. Sometimes such pain is complained of, in the lower part of the abdo- men, as to lead to a simulation of enteritis — and for this the complaint has actually been mistaken. Treatment requires, to be decidedly antiphlogistic ; leeching, rest, fomentation, low diet, antimony. Recumbency is essential ; and the weight of the tumour must be taken off" the cord, by suspen- sion, or by the arrangement of a pillow between the thighs. Opiates, too, are of much service ; in full doses, and of frequent repetition. When the body of the testicle is undoubtedly involved in acute action, the antiphlogistic use of mercury is both warrantable and expedient ; to save, if possible, the delicate structure of the gland. If tension be great, it is well to open a vein in the scrotum ; at the same time per- forating the tunica vaginalis with the lancet, so as to evacuate the accumulated serum. French surgeons have advised that the puncture should implicate the testis ; but this does not seem necessary, the testis seldom being so affected as to require wound for the relief of tension ; and it is inexpedient also, on account of the risk of exciting or aggra- vating intense inflammatory action there, from which the patient might otherwise have been exempt. As the action subsides, resolution may be hastened by stimulants to absorption ; a solution of the iodide of potassium, with iodine, may be painted on the surface, and pushed to vesication ; at a more advanced period, a gum and mercurial plaster may be applied ; or pressure may be made by means of adhesive plaster, cut in strips, and applied as if to a limb — the testicle being separated from its fellow, and made to protrude, so as to admit of such application. By some, it is proposed to apply this pressure from the first ; but, surely, its proper place is only after the chronic stage has been fairly established. In the acute stage, pressure, however care- fully applied, must prove intolerable, or at least must cause aggrava- tion, if the action be I'esident in the testicle itself. In the case of epididymitis, there may be a greater tolerance of the application ; but still its usefulness as an antiphlogistic is more than doubtful. As the complaint yields, discharge may be expected to reappear at the orifice of the urethra. Very frequently, resolution is incomplete ; hardness and swelling remaining in the epididymis. These require active perseverance in the employment of local discutients ; and the iodide of potassium may be useful internally. In some eases, resolu- 536 CHRONIC ORCHITIS. tive absorption is not only rapid but excessive. The gland, after re- gaining the normal size, continues to diminish, and may ultimately dwindle down to a mere shred, wholly destitute of the peculiar function. Sometimes Abscess forms; but seldom, in gonorrhoeal orchitis, un- less some casualty or mismanagement have occurred, so as to involve the testis in true inflammation. In simple orchitis, however, the re- sult of direct injury, the occurrence is not so rare. It is attended with much suffering; and the tubular structure of the organ is endangered. An incision must be made as soon as matter has formed ; and, in the after treatment, care must be taken to obviate the tendency to fungous protrusion which the substance of the testicle usually manifests. Chronic Orchitis, and Fungus of tJie Testicle. Chronic orchitis may be the result of an acute attack, imperfectly resolved ; or — as more frequently happens — the action may be chronic from the first ; it also may be either primaiy or secondary — that is, oc- curring as an independent affection, or as a consequence of gonorrhoea. Very frequently, it depends on stricture of the urethra ; not unfre- quently it is of syphilitic origin. The body of the testicle is completely involved, as well as the epididymis — though the latter is usually first affected. The swelling, at first irregulai', extends from the lower part of the epididymis, and involves the whole organ in a firm, inelastic, uniform tumour, usually of an oval form, and seldom exceeding twice or three times the bulk of the healthy gland. The attendant uneasi- ness is slight ; and, after some time, the characteristic sensibility of the organ under pressure is in a great measure lost. The enlargement is found to depend in part on the deposit of a yellow, cheesy, fibrinous exudation, condensed non-vascular — intra- tubular, as well as in the interposed areolar tissue. On making a section of the tumour, after removal, this deposit and its peculiar characters are very apparent. Slow softening of this deposit may take place ; matter is formed ; the swelling increases, with subacute exacerbation; the integument thins, and gives way by ulceration ; and through the opening the tubular structure protrudes, in the form of a hard, firm, light-coloured, comparatively painless, and slowly increasing fungus. The softening, in such a case, is but partial, and the amount of suppuration slight. Not unfrequently, opening and protrusion take place apparently with- out the intervention of any such action ; the tunica albuginea gives way, under gradual increase of deposit ; the tunica vaginalis becomes adherent, and ulcerates at this point ; and then the integument soon yields also. If the opening be small, the protrusion may be propor- tionally trifling. But, sometimes, almost the whole of the organ pro- SYPHILITIC TESTICLE. 537 jects ; its surface studded with granulations, from which a copious thin secretion is discharged. Chronic orchitis requires the ordinary discussive means for its arrest and removal ; and abstraction of the cause, when practicable, is not to be omitted. Simple enlargements of the testicle always lead to a suspicion of stricture in the urethra ; and that canal is examined accordingly. If stricture be found, it must be removed, before any amendment can be expected fi^om treatment directed towards the testicle. When syphilis is the originating cause — indicated by the history of the case, large size, and slow progress of the tumour, the concurrence of other syphilitic signs, and nocturnal exacerbations of pain in the testicle — that taint must be combated by the appropriate means ; and cautious mercurialism may be required.* In the open condition, when fungus has formed, a slight operation is necessary ; the object being to reclaim the fungus — producing absorption of the abnormal dej)osit, reducing the swelling, and clearing the tubuli. The thickened integument around, constituting the closely adherent margin of the ulcerated opening, is loosened by dissection ; and, having been brought completely over the protrusion, is secured by suture. Consolidation takes place ; partly by the first, but mainly * Authors speak of two forms of syphilitic orchitis : simple and tubercular; the former seldom suppurating, and usually requiring mercury for its cure ; the latter often becoming disorganized, and better treated by a combination of iodide of potassium, with gentle mercurials. Mr. Hamilton thus describes these affections : — " In the simple syphilitic sarcocele the testicle will be found enlarged to the size of a lemon or turkey- egg, of an ovoid or pyriform shape, sometimes flattened at the sides ; either uniform on the surface, or with the epididymis distinguishable as an irregular ridge along the back; hard, particularly in the situation of the epididymis ; heavy, with the integuments of the scrotum of a dusky red ; generally neither tender nor painful, except that the hanging weight causes a feeling of uneasiness in the loins and inside of the thighs. In this respect it differs remarkably from gonorrhceal orchitis, where the tenderness is so exqui- site and the pain usually so great." " The tubercular syphilitic sarcocele is much more common, and differs materially, both in local and constitutional symptoms, from the simple form. The testicle is enlarged from two to four times its natural size, but the increase of size is generally not remarkable ; of very irregular shape, so that the ordinary form of the testicle is often eatirely lost, presenting, instead, an uneven, hard, knotty mass, in which it is impossible to distinguish the body from the epididymis. At other times the irregularity is seen to arise from the enlarged and indurated epididymis, which gets of a great size compared to the body of the testicle ; that remains but little altered, and readily distinguishable from it. In the gonorrhceal orchitis we well know that the inferior globus of the epididymis is usually the part most enlarged and hard, and often keeps so long after the testicle has recovered ; whereas in the tubercular syphilitic sar- cocele, I have more frequently met with enlargement of the upper globus of the epidi- dymis, sometimes excessive and disproportioned to the other parts of the testicle. The reason of this may be, that in gonorrhceal orchitis the inflammation extends from the vas deferens at the inferior part of the epididymis to the cellular tissue external to it, with effusion of lymph, causing swelling and induration ; whereas in the tubercular syphilitic sarcocele, the swelling of the superior globus of the epididymis depends on the presence of a tubercle imbedded among the vasa efferentia of which it is constituted."— Hamilton, Essays on Syphilis, Dublin, 1849 ; see also Lancet, No. 1188, p. 620. 538 FUNGUS OF THE TESTICLE. by the second intention (Principles, p. 640) ; tendency to protrusion is repressed ; and, by the contraction incidental to cicatrization, such pressure is exerted by the integument on the parts beneath, as leads to gradual removal, at least in part, of the abnormal structure. After cicatrization, such pressure may be supposed to continue, in some de- gree, for a time ; and is then to be aided by the discussive means ap- plicable to occult chronic enlargements. This is infinitely preferable to the old method of shaving off the fungus from time to time, and treating the remaining wound as an ordinary ulcer. The cure was tedious ; and, besides, frequent use of the knife in this way was tantamount to castration. By the new method — for which the profession is chiefly indebted to Mr, Syme* — cure is accelerated, and the function of the testicle is preserved. A question, however, still remains to be settled : whether the whole of the protruded part is capable of being reclaimed ; whether the intra- tubular deposit will wholly disappear, and the tubes everywhere re- cover their normal state and function. The probability is that, in the outward part of the fungus, disorganization has often advanced too far to admit of this ; and that, therefore, this portion — seldom more than a thin slice — may be removed by the knife, before the rest is covered in by raised integument, without sacrificing any recoverable virile power, and with the effect of still further expediting the cure. Often, the operation cannot be performed immediately on the patient's pre- senting himself ; some days of preparatory treatment are usually necessary, that the part may be brought to a clean, granulating, and quiet condition — favourable to adhesive results. Central suppuration may occur in chronic orchitis. The matter may slowly reach the surface, and be discharged. Sometimes, it remains long stationary, in the condition of chronic abscess. Then the fluid portion of the matter may be absorbed, while the solid part remains in a concrete mass, resembling tubercular deposit ; but dis- tinguished from it, by being confined within a distinct cyst — ^what was the pyogenic membrane. Scrofulous Testicle. Tubercular deposit is not uncommon in the testicle ; occurring either in aggregated masses, or difiused in the tubular structure, which becomes atrophied under the pressure of accumulation. Such affection is termed ^^ Scrofulous Testicle." The swelling is gradual and very indolent ; little pain or uneasiness is felt ; the tumour seldom attains to a large size ; and the tubercular diathesis is usually indicated by strumous affections in other parts of the body. After a time, one of * Contributions to Surgery, p. 204, Edin. 1848. SCROFULOUS TESTICLE. 539 the prominences enlarges, reddens, and becomes painful ; softening and suppuration have occurred there ; the integument gives way, and pus and tubercular matter are discharged. The sore presents the ordinary appearances consequent on tubercular softening (Principles, p. 243). Other parts may soften, point, and break ; and sinuses communicate one with another. After a time, the greater part of the tubercular matter may be discharged ; then the swelling diminishes, and the sores assume a healing tendency. Should any considerable part of the tubular structure have remained entire, it may protrude and form a fungus, as in the case of simple chronic orchitis. This fungus may be repressed in the ordinary way ; and solid and perma- nent cicatrization may occur. But, sometimes, a fistulous opening remains, discharging thin pus, with occasionally also the secretion of the tubuli ; and then the condition of Spermatic Fistula is said to be established. Treatment varies according to the stage of advancement. In the indolent state, discussives are employed, along with antistrumous con- stitutional treatment; and gradual subsidence of the swelling may result. In the softened state, incision is suitable ; for evacuation. If then the amount of deposit and suppuration seem slight, cicatrization is to be attempted. If, however, as is more frequently the case, sup- puration and deposit are extensive, it is well to favour speedy disin- tegration and discharge of the abnormal mass, by free use of the caustic potass. Afterwards, pressure, by strapping, is of much use in favouring closure and cure. Sometimes, the tubercular matter protrudes slightly ; but this fungus is readily distinguished from that which is composed of the substance of the gland, by being of less size, soft, crumbling, varying, and tempoi'ary. For the one, preser- vation is suitable ; the other requires destructive use of an escharotic. Sometimes the extent of suppuration and disorganization in the part, and the degree of disturbance in the constitution, are such as to call for more summary procedure ; and, to save the system, the part has to be sacrificed, by castration. In the indolent stage of scrofulous testicle, and during the progress of simple enlargement dependent on chronic orchitis, it is not un- common for serum to accumulate in greater or less quantity ; masking the character of the tumour, and increasing its apparent bulk. It is detected by softness, translucency, and fluctuation. If the accumu- lation prove considerable, occasional removal by tapping is of use ; permitting the discussive applications to act more eflliciently on the solid enlargement. Tumours of the Testicle. These were wont to be included under the general term Sarcocele. 540 IRRITABLE TESTICLE. The most common is the simple enlargement dependent on chronic oi'chitis. The scrofulous tumour is not uncommon. Occasionally the fibrous tumour is found. Cystic sarcoma is as frequently formed here as in any other situation. Cai'cinoma and cancer are not of frequent occurrence. Cephaloma has no more frequent site ; sometimes, though rarely, it is combined with melanosis ; and sometimes the open medullary tumour degenerates into the condition of Fungus Hsema- todes. These tumours present the ordinary characters, and require the ordinary treatment (Principles, p. 302, et seq.) The simple enlarge- ments are capable of discussion. The strumous tumours may be either discussed or disintegrated. The rest can be removed only by castration. Prognosis, in the case of malignant formations, may be more favourable here, than at any other site. Irintdble Testicle. This term is usually made to include mere increase of the sensi- bility of the organ, as vpell as decided neuralgia. The former is^almost always dependent on some affection of the urethra, bladder, or kidney, or on disorder of the genei'al system ; and is to be remedied accord- ingly. But it may — like the tumid and sensitive breast of the female — be the temporary consequence of change at puberty ; and it may also follow mere excess in venereal excitement. The latter is a formidable disease ; inasmuch as it is attended with great suffering, and is but little amenable to any treatment. Uneasi- ness is almost constant, the part is tender to the touch, and violent pain comes in paroxysms. There is little or no enlargement, or other morbid indication, in the organ ; in general, it is intolerant of pressure and mani- pulation ; and, during the paroxysm, it is retracted close upon the groin. The patients most liable to suffer from such affections are the weak, nervous, and dyspeptic ; more especially if they have indulged in vene- real excess. Occasionally the affection is combined with cirsocele ; and seems to depend on that morbid condition of the veins. But, in general, the origin of the affection is equally obscure as in most other cases of neuralgia. The treatment is such as is generally applicable to this disease (Principles, p. 628). Among the more successful local appli- cations, aconite, belladonna, and nitrate of silver may be mentioned ; among those used internally, iron, and the liquor arsenicalis. Fre- quently but little improvement follows the most skilful management ; and the patient may be driven by his sufferings to demand castration. This request is seldom if ever to be complied with, however ; inasmuch as the neuralgia is likely to return, in the cord ; being not dependent on any local cause capable of being removed by the operation. HYDROCELE. 541 Atrophy of the Testicle. Gradual wasting of the testicle may follow acute orchitis, as already noticed; and a blow or squeeze may result in this, with the intervention of a slight inflammatory process.* It is not uncommon for atrophy of the testicle to supervene on cirsocele. The pressure of hydrocele, too, would appear, in some few cases, to cause diminution of the gland ; and the same result has followed the pressure of fatty or other tumours. Continence, and the prolonged use of iodine inter- nally, are supposed to tend to atrophy ; but the truth of the supposi- tion seems more than doubtful. Suppuration of the testicle may cause disorganization of part of the tubular structure, with obstruction and consequent absorption of the remainder. Atrophy of one or both organs, it has been supposed, has followed injuries of the head. Occa- sionally, examples of the affection occur while no exciting cause can be assigned. Obviously, but little is in our power in the way of treatment ; except by removal of the cause, when that is practicable. In the case of cirsocele, for example, if we succeed in curing this, wasting of the testicle may be expected to cease. Restoration of the normal bulk, however, is scarcely probable. Hydrocele. The term denotes chronic accumulation of serum, in connexion with the genital organs ; and this may occur in more than one site ; in the tunica vaginalis, in the cord, or in the sac of a hernia. I. Hydrocele of the Tunica Vaginalis Testis. — There is no more com- mon disease. It may follow on injury, and a minor amount of orchitis ; sometimes it is attributed by the patient to a strain ; very frequently there is no assignable cause. Swelling takes place slowly, and with little or no uneasiness ; ascending from the lower part of the scrotum upwards. The tumour may ultimately attain to a large size, encroach- ing closely on the groin. It is of pyriform shape, except when much distended ; and then the narrowness of the upper part is undone by expansion there. It is translucent, unless the coverings be preter- naturally thickened. Fluctuation can be felt, unless distension is great. The testicle usually occupies the back of the cavity, near the middle — nearer the lower than the upper part ; and seldom can be felt distinctly. On grasping the tumour firmly at that part, however, a hard substance may be felt ; and the patient experiences the pecu- lig,r sensation which compression of the testicle is calculated to pro- * Squeezing of the testicles is a mode of castration in oriental courts ; complete atrophy- being found to result. And the same method is applied to the lower animals ; bucks for example. 542 HYDROCELE. duce. However translucent the rest of the swelling, at that part it is opaque. Sometimes the testicle is situate in front ; and then can be felt distinctly. It is never found at the lower part of the scrotum, and separate from the general swelling, as in hernia. The finger and thumb can always be carried above the tumour, at its neck ; and the spermatic cord can be felt free. The tumour has no impulse afforded to it, on coughing, or during any other exertion of the abdominal muscles ; unless there be a communication between the cavity of the tunica vaginalis, and that of the abdominal peritoneum — as in the case of congenital hernia. The accumulation generally consists of a straw- coloured serum ; and sometimes loose solid bodies are found, as in serous cysts elsewhere. The tunica vaginalis is, in general, merely distended ; sometimes it is thickened ; sometimes it is intersected, so as to constitute minor cysts. In simple hydrocele, the testicle and epi- didymis are structurally sound. Not unfrequently, however, they are the subject of chronic enlargement ; and then the disease is technically termed Hydro-sarcocele (p. 539). The treatment of hydrocele is either palliative or radical. The former consists in simply withdrawing the fluid, by tapping ; the swelling and uneasiness ai'e removed for a time ; but they return, and sometimes rapidly. The latter treatment consists in withdrawing the serum, and injecting a stimulant fluid instead, whereby an acute con- gestion may be established, whose resolution, when complete, shall have the effect of restoring the noi-mal balance between exhalation and absorption (Principles, p. 193). Simple tapping may be performed by the thrust of a lancet ; the flat end of a probe being afterwards used to keep the wound open, during the flow of serum, if necessary. Or a flat trocar and canula may be employed. When injection is contemplated, a round trocar and canula are to be preferred. The patient is placed erect. The surgeon, grasping the tumour firmly behind, with his left hand, renders it tense and pro- minent in front ; then the instrument is entered, perpendicularly ; afterwards it is passed obliquely upwards, so as to avoid wound of the testicle, and yet 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 serum having been withdrawn, a caoutchouc bottle, with stopcock and nozzle, is adapted to the canula — or a syringe is employed; and the cavity is partially filled with some stimulant fluid. Port wine, undiluted, or a solution of the sulphate of zinc, used to be much employed. Now, the favourite injection is iodine, in solution; one part of the tincture to three of water. Or, a small quantity of pure tincture of iodine having been thrown in, may be permitted to remain permanently in the sac — disappearing ultimately by absorption. If the dilute injection be used, three or four ounces are injected; and are temporai-ily retained, by withdrawing the bottle or syringe, and turn- HYDROCELE. 543 ing the stopcock of its nozzle — which is left pendent from the canula. After waiting a few minutes, the patient will begin to feel pain in the testicle, shooting up the cord into the loins ; and a sensation of faint- Fig-. 156. 7m- 157. ness will probably come upon him. Then the stopcock is opened, and the fluid drains away. The patient is put to bed, with the scrotum suppoi-ted. If subsequent action threaten to be excessive, fomentation is applied, and antimony may be given internally. The tumour re-forms quickly, with heat and pain ; sometimes the acute accumula- tion seeming greater than the first. By and by, recession in the action gradually occurs ; the tumour subsides ; the pain ceases ; and, in eight or ten days, we may expect to find the parts restored, pei'ma- nently, to their normal state. It has been proposed to retap, for eva- cuation of the acutely effused serum, and thus to abridge the period of cure ; but this seems to be, in most cases, unnecessary. It is very seldom that the operation fails. Should it do so, it is to be repeated, with a stronger stimulant. The method by pure tinc- ture of iodine, allowed to remain, is then specially suitable. Before injecting any stimulant, it is most necessary that the sur- geon satisfy himself that the point of the canula is fully within the cavity of the tunica vaginalis ; otherwise, injection of the areolar tissue of the scrotum may take place, followed by sloughing, and severe con- stitutional disturbance. Fig. 156. Operation of tapping hydrocele ; the trocar entering. Fig. 157. Diagram shewing the du-ection of the trocar; a, the direction of perforating, to avoid splitting of the parietes ; the direction afterwards changed to b, to avoid wound of the testicle. 544 CONGENITAL HYDROCELE. A case of hydrocele presenting itself, injection cannot at once be determined on. It is first necessary to ascertain wliether the testicle is sound or not ; and this cannot be done until the serum has been discharged. If the organ be then found in its normal state, injection may at once be proceeded with. Otherwise, it must be delayed ; we are first to turn our attention to cure of the chronic enlargement; and, after that has been accomplished, the radical operation may then be undertaken. When the testicle is diseased, the accumulation of serum is but a symptom of this afiection, and is to be treated accord- ingly. The palpable cause of the redundant secretion must be removed ; otherwise, reproduction can scarcely fail to occur. Fpr, the radical cure, by injection, is not effected by glueing the serous surfaces together, and obliterating the cavity of the tunica vaginalis, as was at one time supposed. The excited action seldom advances to plastic exudation ; and the cure is simply by restoring normal function in the membrane. A hydrocele of large size is not at once to be injected, though the testicle be sound. It is simply tapped ; and when, by reaccumulation, an average bulk has been attained, then the radical cure is to be pro- ceeded with. The painful operations by seton, caustic, and incision, are now fallen into complete desuetude. Of late, it has been proposed to operate by acupuncture ; making small openings with a needle, through which the serum may gradually escape, partly externally, but chiefly into the areolar tissue — thence to be absorbed. The mode is tedious and uncertain ; but being safe, and little painful, it may be had recourse to, when the patient decidedly objects to the ordinary treatment by injection. Children are liable to hydrocele. And in them, treatment is very simple. We may succeed in dispelling the fluid, by discutient lotions — such as a solution of the muriate of ammonia ; or by the external application of iodine, used cautiously. Failing in this, the serum is to be evacuated by the simple puncture of a lancet. And this, in the great majority of cases, is sufficient to effect a radical cure. The part swells, reddens, and is painful, as after injection in the adult ; and, on resolution being completed, the parts are found in a normal state. By the term Congenital Hydrocele, is usually understood a condition of parts such as leads to congenital hernia (p. 367) ; the vaginal pro- cess of peritoneum not having become obliterated. The fluid conse- quently communicates with the cavity of the peritoneum, usually by a small aperture ; and may be made to disappear gradually from the scrotum, by pressure upwards. In treatment, the first object is to shut up the vaginal process ; and this may in general be effected, by ENCYSTED HYDEOCELE. 545 the constant pressure of a truss. In the child, this may suffice for the whole cure ; absorption of the fluid being afterwards hastened by dis- cutient applications. In the adult, the ordinary treatment may be necessary ; but never is injection to be had recourse to, until we are satisfied that all communication with the peritoneum has been com- pletely obliterated. To obtain this result, use of the truss is also im- portant in another point of view. The testicle is liable to injury; by slight injuries the inflammatory process may, at any time, be lighted up in the tunica vaginalis ; and, from thence, extension to the ab- dominal peritoneum will be easy and direct, unless the communication have been closed. By Encysted Hydrocele is understood, an accumulation of serous fluid within a cyst, or cysts, independent of the cavity of the tunica vaginalis. Such adventitious formations are usually found connected with that portion of the tunica vaginalis which covers the epididymis ; but they may arise in connexion with any part, either of that mem- brane or of the tunica albuginea. The growth is more irregular than in common hydrocele, and the tumour seldom attains to a large size ; the testicle is situated sometimes in front, sometimes on the lateral aspect ; sometimes at the bottom ; seldom on the back part, as in the common form ; and the fluid is generally paler and less albuminous, than that which is found in the tunica vaginalis. When the bulk is such as to occasion inconvenience, tapping is had recourse to ; and, if nothing contra-indicate, injection may be practised. Should this fail — as is not unlikely, in the case of a plurality of cysts — a seton may be introduced, and retained until consolidation has occurred. The tunica vaginalis has been found the site of much calcareous deposit, and filled with turbid fluid containing cholesterine. In such a case, cure can result from nothing short of free incision ; and, after all, castration may not improbably be required. Spermatozoa are sometimes observed in fluid withdrawn from hydrocele ; and such fluid is usually of a milky appearance. It seems uncertain whether these have escaped from an accidental wound or giving way of the tubular structure, either of the testicle or of the epididymis ; or whether the cyst, from which they are derived, has been formed by dilatation of a part of the tubular structure — as takes place in lacteal tumour of the breast, and in ranula. Whatever their origin, their presence is not found to contra-indicate the ordinary cure by injection. Hydrocele and hernia may co-exist ; and, as the former enlarges, the cord and abdominal aperture may come to be so occupied and compressed as to prevent hernial descent. A hydrocele, thus enacting the part of a truss, need not be interfered with, unless productive of much inconvenience by its weight and bulk. 2 N 546 HYDROCELE OF THE CORD. II. Hydrocele of the Cord. — This may be either diffuse or encysted. The Diffuse form is comparatively rare. A serous fluid accumulates in the areolar tissue of the cord, and is enclosed in a distinct sheath ; this again is covered by the cremasteric expansion. The swelling is seldom of large size ; uniform, and somewhat pyramidal ; of slow formation ; and not attended with any considerable uneasiness. The base rests on the point where the spermatic vessels join the testicle, and is separated from the tunica vaginalis by a dense septum ; hence, the testicle is felt, distinct, in its ordinary site. If the abdominal aperture be not encroached upon, there can be no difficulty in diagnosis ; but, when the swelling extends within this, it is apt to be mistaken for omental hernia. The chief points of difference are, the complete- ness in reduction of the hernia, the clearness of the cord after reduction, and the impulse given upon coughing ; in the hydrocele, also, fluctu- ation is in general tolerably distinct. The fluid has been found re- ducible within the abdomen, but not into the abdominal cavity ; passing up along the spermatic cord — probably in its areolar tissue — and, when past the abdominal ring, forming a distinct tumour in the abdominal parietes. Unless the swelling prove large and inconvenient, it need not be interfered with. The best mode of cure, probably, is acupuncture, aided by local discutients. The punctures are made at the lower part of the tumour, and need not be numerous ; for the fluid readily escapes from space to space ; and, not unfrequently, these are broken down into larger compartments. Encysted hydrocele of the cord is the more common variety. The serous fluid is contained within a distinct cyst ; sometimes of ad- ventitious formation ; sometimes formed of an unobliterated portion of the vaginal process of peritoneum. Growth is slow and painless. The tumour is circiimscribed, oval, tense, and fluctuating ; often plainly translucent ; always movable on the cord. The testis is felt distinctly separate. And no difficulty in diagnosis exists, unless, as sometimes happens, the swelling extend within the abdominal parietes. In general, however, the tumour can be pulled down from the abdominal aperture, permitting the cord to be felt free above ; and, besides, the tumour can never be wholly reduced within the abdomen — a certain degree of tense fulness always remaining in the upper part of the canal. In the child, this affection wiU disappear under discutients. In the adult, it seldom demands interference. If it should, it may be got rid of by tapping and injection ; or a seton may be temporarily applied. in. Hernial Hydrocele. — When a scrotal hernia has been reduced, and the neck happily becomes obliterated, the sac, remaining, may be filled by serous accumulation. A pyramidal, fluctuating, and trans- HiEMATOCELE. 547 lucent tumour will result ; of easy diagnosis ; and amenable to the same treatment as an ordinary hydrocele. The affection is of rare occurrence. IV. Hydrocele in the Female. — The term Hydrocele is applied to an cedematous state of the round ligament ; analogous to diffuse hydrocele of the cord in the male. Also, a prolongation of peritoneum, along the round ligament of the uterus, may remain in communication with the abdominal cavity, by means of a narrow aperture at its neck ; and this pouch may become the seat of serous accumulation, consti- tuting a tumour analogous to congenital hydrocele of the male. Besides, the round ligament is liable to be the seat of cystic forma- tion ; analogous to encysted hydrocele of the cord in the male. The affections are rare ; and seldom require active treatment. Hoematocele. This may be the consequence of external injury ; or it may be of spontaneous occurrence. By the term is understood an accumulation of blood, in one of three localities : the areolar tissue of the scrotum, the areolar tissue of the cord, and the tunica vaginalis. 1. Hcematocele of the Scrotum is the result of bruise, or oblique wound ; and is analogous to an ordinary bruise, both in nature and in treatment. The scrotum swells, and is discoloured ; the hue is blackish, like that of urinous infiltra- tion ; but the diagnosis is easy, by attention to the history of the case — also noting that there are none of the signs of gangrene present, and that the system is comparatively unaffected. The treatment consists in ar- resting inflammatory action, and afterwards favouring absorption of the extravasated blood by local sorbefacients. Incision is withheld, unless suppuration have unfortu- nately occurred. ^^°' ^^®" 2. Hcematocele of the Cord. — A spermatic vein may give way, under external injury, or great bodily exertion ; and extravasation into the areolar tissue will result, forming a tense, discoloured tumour there. The treatment is as for the preceding variety. 3. Hcematocele of the Tunica Vaginalis is the most common form ; and to it, in strict accuracy, the term may be limited. The blood is extravasated into the cavity of the tunic ; and may be associated, or not, with hydrocele. By wound of the testicle, in tapping — or by a Fig. 158. Hsematocele of the scrotum. 2 n2 548 CIRSOCELE. blow or other external injury, or by the spontaneous giving way of a blood-vessel — a hydrocele may at any time be converted into haema- tocele. The tumour suddenly increases in size, and is the seat of pain ; and, when handled, is found heavier, and less fluctuating than be- fore. The blood, if in small quantity, becomes dilFused in the serous fluid ; when copious, a portion coagulates, and assumes the fibrinous arrangement. This, acting as a foreign substance, may excite inflam- matory action ; and suppuration may take place, with much increase of swelling and pain. Very frequently the affection is associated with chronic enlargement of the testicle — H^emato-sarcocele. When hgematocele is unconnected with hydi'ocele, the treatment is as for other simple extravasations — antiphlogistic and sorbefacient ; the formation of matter being the only indication which requires use of the knife. When the extravasation supervenes on hydrocele, simple tapping is in the first instance to be had recourse to. To inject then, however, would be productive of no good result ; and, very probably, would cause over-action and suppuration. The fluid is allowed to collect again ; and tapping is repeated. After several withdrawals, the fluid may be found once more of the same character as in simple hydrocele ; and then injection may be proceeded with, not only in safety, but with a good prospect of success — provided the testicle is sound. In the confirmed cases — and more especially when suppura- tion is already threatened — the only mode of obtaining a radical cure is by free incision ; laying the cavity fully open, turning out the coa- gula, and obtaining closure of the gap by granulation ; care being taken to avoid wound of the testicle. If the tunica vaginalis be found thickened, and otherwise much altered, the greater portion may be cut away ; as thus the amount of suppuration, and the period of cure, will be materially abridged. Cirsocele. A varicose condition of the veins of the spermatic cord is termed Cirsocele, or Varicocele. The pendent nature of the part predisposes to this affection. And the ordinary causes are such as favour varix in general (Principles, p. 612) ; especially constipation, and laborious exertion in the erect posture ; as also tumours, trusses, and whatever causes obstruction to upward flow in the cord. The left side is much more frequently affected than the right ; the left testicle usually hang- ing lower than the right ; and the left spermatic vein being not only longer in its course, but also more exposed to compression by fgecal accumulation in the sigmoid flexure of the colon. The swelling is usually pyriform ; with its base on the testicle, its apex upwards ; and, on manipulation, the veins can be distinctly felt rolling under the fin- gers, like cords or earth-worms. There is a sensation of weight and CIESOCELE. 549 uneasiness in the part ; the testicle may be the seat of neuralgia, some- times it becomes atrophied. An aching sensation in the groin and loins is not unfrequent. Sometimes the swelling proves very incon- venient, from its mere pendulousness and bulk ; as in saddlers and others, who require close approximation of the thighs in their voca- tional labour — and in those who are much on horseback. Occasion- ally, a mental despondency is observed, greater than the bodily ail- ment would seem to warrant. Treatment is palliative or radical. The former consists in avoid- ing or removing the more obvious causes of the affection, keeping the testicle well supported by a bandage, and bathing the parts frequently in cold water. When the integuments of the scrotum are very redun- dant, the testicle may be retained in close contact with the groin, by invagination of the loose integument through a padded metallic ring. Or such trussing may be more effectually maintained, by removing the redundant skin by incision ; support of the testicle being then in- trusted to the cicatrix. "VYhen the testicle is suffering either by neuralgia or by atrophy, or when much uneasiness and discomfort are experienced, eradication of the disease is naturally sought for. With this view, the varix may be treated here as elsewhere — by obliteration of the veins. 1. The actual cautery may be used ; a heated wire being applied to the veins, isolated and fixed between the finger and thumb. The practice is safe and effectual, but the formidable nature of the application is a serious objection. 2. The veins may be compressed by suture, applied on needles passed beneath them by transfixion ; as in ordinary varix (Principles, p. 615); care being taken to exclude the vas deferens and the spermatic artery. Obstruction of the duct is tantamount to castra- tion, and obliteration of the artery can hardly fail to be followed by atrophy of the testicle. 3. The operation of M. Vidal may be per- formed. The varicose veins, having been separated from the rest of the cord, are placed betAveen two silver wires, passed by the transfixion of needles, and emerging at the same openings. By twisting together the ends of the wires, the interposed veins are compressed ; and, by a continuance of the twisting, they are rolled up round the wires, while at the same time the testicle is somewhat elevated. The ends are then secured, on a roll of bandage placed on the integument. By further twisting of the united ends, by means of a turnstick, the compression and twisting of the veins are gradually increased ; and this is con- tinued, until the wires free themselves by ulceration — thus declaring section and obliteration of the veins to be complete. 4. Obliterative pressure may be maintained on the veins at the groin, by means of a spring truss. But this, for obvious reasons, is not advisable. Mode- rate pressure there, however, is found very serviceable, not merely 550 TUMOUHS OF THE CORD. palliating, but sometimes obtaining cure ; probably by affording sup- port to the veins, while they are at the same time relieved from the superincumbent weight of blood. Such moderate pressure is best applied by a light and accurately fitted truss.* One great advantage of such treatment is its simplicity, and freedom from risk by phlebitis. A variety of varicocele occasionally occurs, affecting the veins within the inguinal canal, and at the groin ; while those of the scrotum ai-e comparatively free. It is very liable to be mistaken for hernia, as formerly noticed (p. 348). The best test is the peculiar sensation imparted to the finger and thumb when the part is pinched and rubbed. Palliative treatment usually suffices. But should a radical cure be sought, the preferable means is the application of pressure by a truss. Tumours of the Cord. Occasionally, adipose tumours form in the areolar tissue of the spermatic cord. Their bulk is inconvenient, and their pressure may cause atrophy of the testicle. They are to be removed by incision. Fibrous tumours and osseous formations have also been found here ; but are rare. The testicle, arrested at the groin, in its descent, may become affected by tumour ; and in that situation may require removal by operation. f Castration, This severe and painful mutilation is seldom required, except for tumours of the testicle ; malignant, or such as, though simple, are not amenable to either discussion or disintegration. In neuralgia of the testis, and in cirsocele, it is sometimes demanded by the patient ; but in neither case is the surgeon warranted in acceding to the wish. All hair having been removed from the scrotum and groin, the patient is placed recumbent. By grasping the tumour behind, the skin is made tense. The bistoury is entered at the neck of the swelling, and carried to its fundus ; diverging over the body of the tumour, so as to include a sufficiency of skin within an elliptical incision. This form of wound is especially necessary, when a fungus, ulcer, or other involve- ment of the skin requires to be taken away. A simple rectilinear Avound would suffice for removal of the tumour ; but a redundancy of skin would be left, constituting a pouch for untoward accumulation of blood or pus. On the other hand, it is very necessary to avoid excessive removal of the skin, lest, on contraction, a bare sufiiciency be found for effectually covering the remaining organ. And, in con- * Curling on the Testicle; and Thomson, Monthly Journal, Nov. 1848, p. 295. " Evans' moc-main lever truss " is very suitable, t Lancet, No. 1214, p. 617. CASTEATION. 551 nexion with this, it is important to remember that the covering of a large sarcocele is borrowed from the adjoining parts ; and that, con- sequently, after incision, a great degree of resilience in the integument is certain to occur. The dissection is advanced, first at the upper part of the wound, so as to expose the cord ; this, having been iso- lated, is intrusted to the firm grasp of an assistant, to prevent retrac- tion within the abdominal aperture ; and then it is cut across. The apex of the tumour being now everted, dissection is rapidly proceeded with — a dissection rendered comparatively painless and bloodless, by early section of the cord. Care is taken not to wound the septum, and thus to expose the sound testicle. The arteries of the cord are then tied. And, should they have slipped from the fingers of the assistant, an upward enlargement of the superficial wound may be required. The scrotal vessels are secured with especial care ; expe- rience warning us that, otherwise, troublesome bleeding after reaction is almost certain to occur. The wound is brought together, and treated in the ordinary way. The lower part seldom heals but by granulation ; and, therefore, need not be closely approximated. The cord requires to be carefully watched ; diffuse suppuration being apt to occur there ; and should this threaten, early incision must be had recourse to. But, by suitable antiphlogistic precautions, all necessity for i-esumed use of the knife may generally be avoided. It is important to remember that, like hydrocele, sarcocele may co-exist with hernia ; and that the latter may be temporarily restrained by the bulk of the tumour of the testicle. On removal of this, how- ever, the hernia, descending during the cries or straining of the patient, may appear at the wound. Impotence. This may depend on imperfect development of the testis ; but not on imperfect descent. The organs are as efficient, functionally, in the abdomen as in the scrotum. Ablation and atrophy of both organs cause impotence; but either testicle may be lost with comparative impunity. The oxalic diathesis, and diabetes, diminish the sexual appetite and power ; and so does the phosphatic diathesis, to a less degree. The pressure of hydrocele may cause impotence, even without g,trophy of the testicle. Affections of the brain are sometimes followed by it. In the newly married, a temporary loss of power is sometimes caused by mere predominance of mental emotion. Excessive venery, inducing an irritable state of the whole genital system, is perhaps the most frequent cause. Effete roues thus " read their sin in their punishment." Cure can be expected, only in those cases which are unconnected with structural change in the testicles. The cause having been 552 SPERMATOREHCEA. removed, certain medicines are supposed to have a tendency to restore this animal function, and are hence termed Aphrodisiacs. Of these, the most important are, Indian hemp, conium, and phosphorus ; the two former most suitable in cases of irritability ; the latter given, in very guarded doses, for the more chronic examples. Musk, cantha- rides, steel, and other tonics, may also be of service ; and diet should be generous. The mental cases may be left to work their own cure. Spermatorrhoea. An irritable state of the testicles, seminal vesicles, bladder, and urethra, with a turgid and especially irritable condition of the prostatic portion of the urethra, leads to involuntary and frequent emission of the seminal fluid. By much the most frequent cause of this morbid state is masturbation ; and, next in order, comes excess in vene- real indulgence. Stricture, prostatic diseases, and irritation commu- nicated from diseased rectum, are common causes of minor forms of the affection. In consequence of the irritability, an impression much infei-ior to the normal stimulus suffices for production of seminal dis- charge. Slight venereal excitement, by day or night, causes emission ; and semen is also discharged during straining at stool, and by the effort of evacuating the last drops of urine in micturition. The testicles are soft, and hang low in the scrotum, which is loose and flabby. Impotence results ; by incapacity of erection, as well as by reason of preternatural haste in emission, and by the vitiated character of the secretion itself. The digestive organs become deranged ; the general health fails ; many anomalous sensations are felt, and many serious diseases are simulated ; a dejected expression of countenance is acquired ; and the air and bearing are those of a poltroon. The principles of treatment are obvious. Chastity in thought, word, and deed ; cold bathing, and a tonic system of treatment ; regu- lation of bowels, but avoidance of purgatives, or other sources of local irritation and general exhaustion ; early rising, cheerful society, and healthful occupation of body and mind. If the irritability continue, nitrate of silver may be applied to the posterior part of the urethra, by means of the porte-caustique of Lallemand.* This instrument * This instrument " consists of a straight or curved platina canula, or tube, rather smaller than a middle-sized catheter, through whicli plays a caustic bolder ; in the further extremity of which there is a narrow groove, eleven lines in length, for the purpose of holding the caustic. After filling the groove with the nitrate of silver, by fusing it over a spirit lamp, it becomes so securely fixed, that there is no longer any danger of it escaping. At the other end there is a sliding screw or stop, by which the action of the remedy may be limited to any extent less than the groove which contains it. Another sliding stop affixed to the canula serves, after the distance of the orifice from the part to be cauterized has been ascertained, to prevent the instrument passing farther into the canal. SPEEMATOEEHCEA. 553 having arrived at the tender part — which is at once indicated by the feelings of the patient — has the stilet projected, so as to expose the caustic ; and, by gently turning the instrument, an efficiency of appli- cation is insured. Afterguards, strict rest, with antiphlogistic regimen, should be maintained for a day or two ; and, if need be, sedatives are given, either by the mouth or by the rectum. Repetition may be required, after a considerable interval. In mild cases, the occasional introduction of a common metallic bougie may succeed in removing the irritability ; rendering recourse to the more painful and hazardous cauterization unnecessary. Cold enemata, and counter-irritation in the perineum, may be of service. Compression of the urethra, by a pad applied to the perineum, has also been found useful.* This obscure and distasteful class of cases are still much in the hands of unprincipled practitioners and quacks. This is no reason, however, for leaving the unfortunate victims in such a predicament, or for denying the existence of such affections. Acknowledging the disease, it seems plainly the duty of our science and art to afford what assistance may be in our power ; at the same time remembering, that without strict purity of conduct on the part of the patient, all treatment will prove of little avail. * Banking's Eetrospect, vol. ii. p. 118. See also, on this subject, Lallejiand, des pertes seminales involuntaires, Paris, 1842. Brit, and Foreign Review, April 1843, p. 346. Phillips, Med. Gazette, Jan. 1843. Civiale, Memoire sur I'Emploi des Caustiques dans quelques Maladies de TUretre, Paris, 1842. On Diseases of the Testicle, see Warner, An Account of the Testicles, their Cover- ings and Diseases, Lond. 1774. Pott, A Treatise on the Hydrocele, &c. in his Chirur- gical Works, vol. ii. Lond. 1783. Benjamin Bell, A Treatise on Hydrocele, &c. Edin. 1794. Earle, A Treatise on Hydrocele, Lond. 1796. Eamsden, Practical Observations on the Sclerocele, &c. Lond. 1811. Astley Cooper on the Structure and Diseases of the Testis, Lond. 1830. Eussell, Observations on the Testicles, Edin. 1833. Curling, A Practical Treatise on Diseases of the Testis, &c. Lond. 1843. 554 CHAPTEE XXXVI. AFFECTIONS OF THE SCROTUM AND PENIS. Erysipelas of the Scrotum. Erysipelas not unfi-equently attacks the scrotum, in a distinct and marked form ; peculiarly asthenic in its type ; partaking much of the characters of diffuse areolar infiltration. It occurs in adults of weak and broken down system, given to drink and other dissipation ; and usually follows a kick, blow, or other injury. Swelling is great and rapid ; with marked symptoms of constitutional irritation from the commencement. Thin, unwholesome matter speedily forms, and is diffused into the areolar tissue. The skin — at first, red, tense, and glistening — blackens, or assumes a tawny hue, shrivels, and becomes cold and foetid. Sloughing is begun and advancing. Very frequently, the groins are involved; and the mischief extends upwards in the abdominal parietes. The constitutional symptoms soon pass from the irritative into the typhoid type ; and fatal sinking follows. Local and general safety can be obtained, only by early and active inter- ference ; free incision, and constitutional support (Principles, p. 229). Erythema may occur at any time in the scrotum, under the ordinary exciting causes. It follows the ordinary course, and requires the ordinary treatment. The areolar tissue of the scrotum is very liable to oedema ; occur- ring sometimes as a distinct affection ; much more frequently a con- comitant of general anasarca. When excessive, relief and diminution may be obtained from a few dependent punctures ; made cautiously, however, lest asthenic and diffuse inflammatory action ensue. JElephantiasis of the Scrotum. The scrotum is liable to chronic enlargement by hypertrophy; forming a large, simple tumour, within which the genital organs come to be altogether concealed ; the prepuce alone remaining visible, at the ELEPHANTIASIS OF THE SCROTUM. 555 lower part of the swelling, thickened, and warty ; and from this point the urine is discharged in a scattered stream. The affection is much more frequent in hot climates than in this country. There is no cure, but by use of the knife. When the tumour is of no vast size, the incisions may be planned so as to save the penis and testicles ; and dissection is conducted cautiously with this vieAv.* In the case of a Fig. 159. large tumour, however, such an attempt may be hazardous ; the patient being apt to undergo fatal exhaustion, under the tedious and painful operation, and the copious loss of blood. It is then better, probably, to sacrifice every thing ; and to effect removal, at once, by a few rapid strokes of a long bistoury. Before proceeding to any opera- tion, however — and more especially to summary ablation — it is most necessary to ascertain whether or not sci'otal hernia exist. If such be found, the incisions must be planned and conducted with peculiar care. * Further details of this affection, and of the operative treatment required, with dia- grams, will be found given by Dr. Beett, Lancet, No. 1174, p. 241. Fig. 159. Hypertrophy, or elephantiasis of the scrotum, in a Hindoo. 556 chimney-sweepers' cancer. Chimney -Sweepers^ Cancer. The integuments of the scrotum are liable to malignant ulceration ; more frequently found in chimney-sweepers than in others — probably on account of the irritation of soot, and habits of uncleanliness ; but not limited to that peculiar vocation. The ulcer begins in the form of a wart; and frequently is surrounded by warty formations. It may spread rapidly. Cure is by excision, or by thorough destruction by means of chloride of zinc paste ; and certainty of success is to be hoped for only at an early stage — when the disease is as yet limited to the integument, and when no great amount of even this tissue is involved. At a more ad- ^'='^^°' vanced period, when the testicle is exposed, and probably contaminated, a chance may yet be afforded by castration ; provided the groins are free from secondary enlargement, and the constitution is not much broken down. Priapism. Permanent erection of the penis occurs in three forms. 1. From injury of the spine. This has been already noticed, as a distressing symptom of spinal fracture (p. 300). 2. From vascular and nervous excitement, induced by excessive venereal stimulus. The turgescence may be such as temporarily to occlude the urethra, causing retention of urine ; and this is to be treated by antiphlogistics and anti-spas- modics, as formerly noticed (p. 461). 3. A more formidable variety may occur, from the same cause as the preceding ; dependent on extra- vasation of blood into the corpora cavernosa — a vessel of some size having given way. In a case of urgency, it may be necessary to evacuate the extravasated blood by incision ; but, in general, it is better to treat the case according to the general principles applicable to bruise ; averting inflammatory action, and favouring absorption. If incision be made, there is great risk of troublesome suppuration fol- lowing ; incapacitating the organ afterwards for normal erection. Sometimes chronic deposit, of a plastic kind, and probably of inflammatory origin, takes place in the corpus cavernosum ; producing thickening, perhaps with enlargement of the part, and more or less Fig. 160. An aggravated example of chimney-sweepers' cancer; much superficial texture destroj-ed. PHYMOSIS. 557 obliteration of the erectile tissue. Erection, consequently, is imperfect and painful. Treatment will mainly consist of counter-irritation and sorbefacients to the part, with alteratives internally. Should stricture co-exist, that must be removed in the ordinary way.* Phymosis. Phymosis and Paraphymosis both depend on preternatural con- traction of the pi-eputial orifice ; the difference being, that in the one case the contracted portion occupies its normal position in front of the glans ; in the other it is reflected behind the glans, and acts as a constriction there on the body of the penis. Phymosis may be congenital ; an original malformation. In this case, if the contraction be great, the child is apt to suffer much. The urine escapes imperfectly; and, in con- sequence, chronic balanitis may ensue, or a calculous concretion may form. In after life, the preputial contraction may have the same effect as a tight stricture of the urethra ; causing first irritability of the genito-urinary system, afterwards organic change — stricture of the urethra, alteration in the coats of the bladder, dila- tation of the ureters, and finally renal disease. Should these dangers pass by, °' and an advanced age be reached by the patient, ulceration is apt to take place at the contracted part; and, very frequently, the ulcer assumes ultimately a malignant action, and extends so as to involve the glans and body of the penis. It is important, therefore — on many accounts — to remove this source of evil as early as possible. Acquired phymosis may be acute or chronic. The former is the result of an acute inflammatory process ; following external injury ; or sympathetic with gonorrhoea, balanitis, or venereal sores. The areolar tissue becomes infiltrated with serum ; the swelling, thus caused, pre- vents the glans from being uncovered in the usual way ; and discharge, accumulating, aggravates the disorder. The main treatment is by rest, fomentation, poultice, and general antiphlogistics. And, under this management, swelling may more or less rapidly disappear, and the normal state be regained. Failing this, and if there be urgency for exposure of sores — which may be extending rapidly, and may require activity in direct applications — incision is necessary. It may be that the urgency is such as to demand incision very early in the * H. J. Johnson, Lancet, No. 1473, p. 481. Fig. 161. Phymosis. 558 PHYMOSIS. case, while the sores are yet fully impregnated with virus ; and then there is risk of the disease being much extended, by contamination of the recently made wound. Such risk may be hi a great measure obviated, however ; by applying an active escharotic immediately to the sore, so as to annihilate both the local poison and the poisoned part ; and by touching the wound slightly with the nitrate of silver, so as to make a protecting crust on the raw surface. In general, the operation is to be delayed, until the sores are of such a date as to render impregnation of the wound at least improbable — the reparative stage having been reached, when discharge probably ceases to be virulent (p. 489). The chronic form of acquired phymosis may result from gradual increase of original mal-formation, or from cicatrization of ulcer or wound. Like the congenital form, it is to be relieved only by operation. And this may be performed in various ways. 1. A simple and very suitable mode consists of inserting a director into the preputial cavity, retaining it by the side of the frsenum, intro- ducing on it a sharp-pointed curved bistoury, and by this transfixing and dividing the prepuce at its lower aspect. The director's point must in the first instance be moved about freely, to make sure that it is in the preputial cavity, and not in the urethra. The site of the incision is chosen, for obvious reasons. If placed on the dorsum, two unseemly flaps are formed, and the glans is left permanently uncovered. By the side of the frgenum, a less amount of wound suffices ; the glans is equally well exposed ; and, after cicatrization, no unseemliness results, nor is thei'e any departure from the normal relative position of the parts. To prevent resilience of the integument from the mucous membrane, and thereby to prevent an unnecessary extent of raw surface, a fine suture on each side is required ; and this is retained, until spontaneously freed by ulceration, or until consolidation has taken place by plastic exudation — whereby the natural resilience is obviated. 2. When the prepuce is redundant in front of the glans, the following operation is suitable. The prepuce having been stretched, so as to clear the glans, the mere orifice is taken away, by the stroke of scissors or a knife. Circumcision, in fact, is performed ; to a limited extent. The skin is found free enough, but the mucous membrane is still tight ; and this is slit up, by scissors, at two or more points. The end of each flap of mucous membrane is then secured, by a fine suture, to a cori'esponding portion of the integument. This mode of procedure is weU suited to those cases, which are connected with a cluster of venereal sores on the very verge of the prepuce ; both diseases being got rid of at once. It is also advisable when, in any case, the end of a long prepuce is much indurated, or otherwise permanently altered in structure. PARAPHYMOSIS. 559 Paraphymosis. A tight preputial orifice, reflected beliind the glans, and permitted to remain there, constricts the body of the organ, and gives rise to very unpleasant consequences. The superficial areolar tissue swells greatly, on each aspect of the stricture ; the glans swells too ; and an acute inflammatory process is kindledj under unfavourable circum- stances — the strangulated parts being obviously ill provided with the power of resistance or control. There is the same necessity for relief, as in the case of strangulated hernia, so far as the preservation of structure is concei'ned ; and relief is sought in the same way. Reduc- tion generally is practicable, in recent cases. The patient's trunk having been steadied, and the parts well oiled, the surgeon grasps the glans with the fingers of the right hand, and makes steady pressure thereon, also pushing it steadily from him ; at the same time, with the fingers of the left hand, he draws forward the constricting orifice ; the object being to push the glans, diminished by pressure, through the narrow preputial orifice. Failing in this, and there being no marked urgency, another mode of reduction may be attempted. The penis is placed erect, and on the glans a stream of cold water is maintained for some time. This may have the effect of so diminishing the bulk of the formerly turgid part, as to admit of its being replaced without much difficulty within its preputial covering. But should these attempts at simple reduction fail, or should the case be already so far advanced as not to warrant their being practised, incision is required. And little more than a scratch suffices, if rightly placed. The general bulge behind the glans is not to be widely laid open ; but it is separated, by means of the fingers, into its two component parts. In the depth between these, the constriction is found, as a narrow band or thread ; and that alone requires division. After reduction, the wound seems a mere notch in the preputial verge. If neglected, the glans may slough, or ulcer- ate very destructively ; or, the glans remaining ^'^- ^^^• merely congested, the stricture may cause ulceration of the body of the penis, opening the urethra, and producing urinary fistula. Oper- ating lately on a case of this kind, in a boy, after the paraphymosis had existed unreduced for three months, I divided a piece of thread Fig. 162. Paraphymosis ; the dark portion is the lining of the prepuce, reflected; the preputial orifice, the seat of stricture, is behind, between the two swellings. 560 HYPOSPADIAS. wliicli encircled the penis — deeply imbedded in it — and which had been secretly applied as a jugum, to prevent punishment on account of enuresis (p. 458). When paraphymosis and venereal ulcer of the glans co-exist, there is an especial necessity for immediate relief; otherwise, acute phagedaena, or sloughing, cannot fail to supervene. It may happen that the con- striction has been slight, and of old standing ; and that, in consequence, even after extensive incision on the dorsum of the penis, reduction is found impracticable ; the parts being firmly glued to their abnormal site by plastic exudation. Under these circumstances, we must be contented with simple relief of the stricture, by suitable incision ; leaving restoration of normal relative position to be effected, when resolution of the inflammatory action has become complete. Hypospadias. This term denotes an imperfect condition of the urethra, at or near its orifice ; the result sometimes of accident or disease, but usually a congenital malformation. There may be a vestige of the normal opening at the apex of the glans, the urethra terminating somewhere behind this ; or, as more frequently happens, the anterior portion of the canal — to the extent of an inch or more — appears as if slit up, the margins of the wound having become rounded off; in other words, the lower part of the wall of the canal is deficient. In extreme cases, the whole antepubal part of the urethra may be thus imperfect. The inconveniences of the affection are, a scattered and ill-projected stream of urine, perhaps inefficient emission of the seminal fluid, and a raw, congested state of the exposed mucous membrane. When there is rather a slitting up, than a deficiency of parts, the edges may be pared and brought together over a catheter. When the parts are actually deficient, autoplasty must be had recourse to ; a portion of integument being borrowed from the neighbouring perineum or scrotum, and engrafted into the hiatus. In the minor cases, however, which con- stitute a decided majority, no interference is necessary ; the inconve- niences, if any, being slight. Hyperspadias or Epispadias. This is an analagous, but opposite state; the splitting up — or rather the non-development — having taken place on the dorsal aspect. The chasm may extend from the glans to the symphysis pubis. In general, there is a sufficiency of parts to admit of paring the edges, and approximating them by suture over a catheter. Immediate union MALIGNANT DISEASE OF THE PENIS. 561 is not likely to occur at every part; but permanent closure may ultimately be obtained, either by repetition of the operation at the unclosed points, or by occasional application of the heated wire. Imperforate Urethra. A congenital malformation, in this respect, is obviously to be remedied in but one way ; by the plunge of a round trocar and canula, in the proper direction ; and by keeping the artificially constructed canal pervious, by the lodgment of a catheter — changed occasionally to prevent calculous deposit. Malignant Disease of the Penis. This is found only in the aged ; and frequently, as already stated, it may be traced to the irritation of congenital phymosis ; beginning in the preputial orifice, by ulceration, and extending thence to the body of the organ — or, it may be, beginning in the glans itself. The glans is enlarged and indurated ; angry ulcers penetrate it in various places ; the body of the penis suffers likewise ; the lymphatics on the dorsum swell and harden ; the glands of the groin are involved ; reten- tion of urine may ensue, by pressure of the secondary tumours on the neck of the bladder ; the cachexy advances ; and the patient perishes — his end perhaps hastened by hemorrhage from the open and deep cancer. Nothing but the knife can afibrd a chance of cure. When the prepuce alone is affected, its removal is sufficient. Sometimes a malignant ulcer attacks the integument of the body of the penis, origi- nating there ; it may be long and successfully resisted in its advance, by the dense fibrous fascia which invests the organ subintegumentally ; and, in such a case, removal of the affected surface by dissection may suffice. When the glans and body are involved, nothing short of amputation of the entire thickness affords a prospect of cure — cutting in sound parts, between the disease and the symphysis pubis ; and the attempt is warrantable, only when as yet the lymphatics show no sign of implication. When the glands are already enlarged, there is nothing left in our power but palliation ; and, as formerly stated, punc- ture of the bladder above the pubes may be required, towards the close of the case, on account of retention of urine (p. 464), I lately met with an affection which strongly simulated malig- nancy. In a gentleman of middle age, one half of the lining membrane of the prepuce was occupied by a flat growth ; partly warty and hard, partly smooth and villous, in every part highly vascular. This was the seat of intense irritation ; the least touch was agony; frequently pain 2 o 562 AMPUTATION OF THE PENIS. shot violently down the thigh ; sleep was denied at night ; the general health was wasted ; and the patient professed himself, as he seemed, most miserable. The corresponding part of the glans was red and excoriated. The disease was removed freely by the knife ; and per- fect cure resulted. Amputation of the Penis. This is had recourse to on account of malignant disease, affecting the body of the organ ; but only when there is a sufficient space of sound texture between the disease and the pubes, and when the glands yet show no sign of contamination. The ordinary mode of perform- ance is exceedingly simple. The organ, stretched by the left hand pulling it outwards, is lopped off by one sweep of an ordinary ampu- tating knife — laid upon the part, and moved rapidly across from point to heel or conversely. The integument is encouraged to contract towards the pubes ; so that, during the puckering of cicatrization, it may not overlap and interfere with the orifice of the urethra. And this is kept of the normal calibre, by a suitable use of bougies. Ricord's method of operating is preferable, however, being well calculated to obviate the principal difficulty — namely, tendency to con- traction in the orifice of the urethra. Rapid healing of the wound is also promoted ; and, at the same time, a sufficient covering is pro- vided for the corpora cavernosa. The procedure is conducted thus : After amputation in the ordinary way — enough skin being left to cover the corpora cavernosa, and no more — the surgeon seizes with forceps the mucous membrane of the urethra, and with a pair of scissors makes four slight incisions, so as to form four equal flaps ; then, using a fine needle, which carries 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 membrane ; and these textures become continuous — a condition analogous to what is observed at the other natural outlets of the body. The cicatrix then contract- ing — instead of operating prejudicially, as in the old method — tends to open the urethra, by pulling its lining membrane outwards. When, in the case of a short stump, inconvenience results from inability to direct the stream of urine in a sufficiently outward jet, the deficiency of the organ may be temporainly compensated, when the patient makes water, by a mechanical adaptation — a funnel-shaped canula, of sufficient length, its base resting on the pubes. Travers on Phymosis and Paraphymosis, Lond. 1818. Earle and Travers on Chim- ney-Sweeper's Cancer, Med. Chir. Trans, vol. xii. Larrey, Mem. de la Chir. Militaire, torn. ii. p. 110. Titley, Med. Chir. Trans, vol. vi. p. 71. Listou, Edin. Med. and Surg. Journal, vol. xix. p. 566, 1823. Key, Case of Hoo Loo, Med. Gazette, vol. viii. p. 93, 1831. Bergson, Die Beschneidung vom Historichen, &c. Berlin, 1844. 563 CHAPTER XXXVIL AFFECTIONS OF THE FEMALE GENITAL ORGANS. The affections included in this chapter are considered very briefly, the great majority belonging to the exclusive province of the obstetric practitioner. Infiammation of the Vulva Occurs at all ages. In the adult it presents no marked peculiarity in its history or treatment. In the child it forms the disease generally called infantile gonor- rhoea, or infantile leucorrhoea. This affection, which vi^as long mis- taken for the result of attempted impure connexion, may occur at any period of adolescence. It is most frequently seen in delicate, unhealthy children ; and more among the children of the lower than of the higher classes. Not unfrequently it comes on during convalescence from the eruptive fevers, or during teething (p. 487). Sometimes no cause can be assigned ; or it may be induced by worms or other rectal irritation, by want of cleanliness, or by exposure of the parts to damp and cold. The symptoms ai'e, constant irritation and pain, so that the child is frequently moving its hand towards the part ; pain and scalding in making water, to which the calls are sometimes inordinately frequent ; and, in addition, the ordinary signs of slight febrile excitement. On inspecting the pudenda, they are found bathed in pus ; the whole surface of the vulva is swollen, red, and tender ; and there is frequently, on and around the vulva, an eruption of a few red and in- flamed spots, which may either disappear, or go on to form small pustules. Treatment is simple. In mild cases, nothing but cleanliness may be required. In the more severe, it is necessary to exhibit laxative and alterative medicine, to keep the patient in bed, to allay feverish irrita- tion by hot bathing, to apply locally hot fomentations at the outset, and subsequently to use various washes — as a weak solution of nitrate of silver, or of sulphate of zinc. The decoction of popies is often useful to remove irritation. If the skin is broken, care must be taken, dur- ing the healing, to prevent cohesion of the labia. 2 2 564 ABSCESS OF THE VULVA. Sometimes the disease affects cliildren along with a low form of fever ; and the inflammation may go on to sloughing. The vulva is also sometimes the seat of extensive and unhealthy ulceration, and of noma, with accompanying fever of a low typhoid character. Abscess of the Vulva May be the result of mechanical violence, or the secondary conse- quence of sanguineous extravasation into the subcutaneous or sub- mucous areolar tissue. It may follow erysipelas, or acute phlegmonous inflammation of the glandules of the areolar tissue of the part, arising Avithout assignable cause. Occasionally there is a succession of such abscesses in the vulva ; apparently induced by inflammation or irrita- tion of the vagina, or of the deeper-seated organs. It is a common affection of prostitutes ; and in them frequently ends by forming fistulse. When the disease is a consequence of sanguineous extravasation, it also sometimes ends in fistula ; the purulent deposit extending, like the sanguineous, from the vulva upwards along the walls of the vagina — or in other directions, as towards the anus. The origin and progress of abscess in this situation does not materially differ in any respect from its history as originating else- where. Generally, the accompanying pain is severe ; but if the abscess has followed extravasation of blood, the pain and constitutional symptoms may be comparatively slight. The affection is distinguished from thrombus by the presence of more or less fever, by the acuteness of the pain and tenderness, by gradual progress of the swelling, and by the colour of the integument over it ; from varicose veins of the vulva, by its sensibility on pressure, by its tension, and by not disappearing when the patient lies down ; from hernia, by the absence of impulse on coughing, its histoiy, pro- gress, &c. There is no special point to be attended to in the treatment. The abscess should be opened early ; and, in preference, from the skin, not from the mucous membrane. Every attention must be paid to the encouragement of speedy healing, in order to avert the danger of the formation of fistula. If, in spite of all care, a, fistula vagincB does form, and proves tedious, it must be dealt with in the same way as fistula in ano (p. 378). Thrombus of the Vulva May be in either labium, or in both. It is most frequently caused by the efforts of parturition ; but may also follow external violence, efibrts at stool, &c. Persons affected Avith varicocele of the labia are predis- posed to the affection. The thrombus may attain to very large size, so as, in the case of parturition, to prove an obstruction. In such cir- WARTY EXOEESCENCES OF THE VULVA. 565 cumstances, the treatment consists in making a free incision, evacuat- ing the blood and coagula, and restraining hemorrhage by pressure ; with or without stuffing of the wound. In the case of accidental wound risk by hemorrhage is great. If the tumour is small, it may cause no uneasiness ; and requires no treatment, except the use of cooling and discutient lotions, with rest. Warty Excrescences of the Vulva May be situated on the labia, nymphae or vestibulum ; or all these parts may at the same time be affected. The gTowths may be of con- siderable size ; and when numerous they distend the vulva. They may be of syphilitic origin, or may arise from other causes. They are the soux'ce of much pain, irritation, and annoyance ; and may pro- duce a quantity of muco-purulent discharge, especially if seated on the mucous membrane. K small and recent, the application of nitrate of silver may disperse them ; or they may be powdered with calomel and chalk. The larger may be removed by strong caustics, as potass, or the acids ; but in most cases it is better to cut them off by scissors — subse- quent hemorrhage being checked by cold and styptics. The bulky growths, as already stated, may require a regular dissection for their removal (p. 516). Oozi?ig Tumour of the Labium Is a rare disease. One or both labia may be affected. The part — hard, sulcated, and discharging a watery acrid fluid — is the seat of much pain and itching; and the neighbouring parts are ii'ritated. Local treatment by caustics, iodine, astringent lotions, &c., combined with the use of laxative and alterative medicine, may be effectual in curing the complaint ; if not, the affected textures must be removed by the knife. But after all this, the disease is apt to recur. Pruritus of the Vulva Is a frequent accompaniment of pregnancy, and of disease in the rec- tum or vagina — especially leucorrhoea. It is more common in advanced life than in youth ; and is a cause of very great suffering. To some women it renders life absolutely miserable. The skin of the parts is generally dry, and often has a rough and cracked appearance ; sometimes it is indurated, and more than usually callous in ordinary sensation. Not unfrequently there is a rush of small, inflamed, and excessively irritable papulae over the affected parts ; or there may be spots of chronic eczema, especially on the labia, or aphthous incrusta-' tion of the nymphje and vestibule. 566 MALIGNANT ULCER OF EXTERNAL PARTS. If there is any marked exciting cause, its removal will do much towards effecting a cure ; and permanence of the relief may be esta- blished. But under other circumstances, the disease generally proves very intractable, especially in those of advanced years. If the patient labours under irritable bowels from any cause, that must be remedied : if worms are present, they must be expelled ; if there are piles, they must be cut or tied ; if leucorrhoea exist, its cause is to be enquired into and removed ; if there are pediculi they must be destroyed and cleanliness enjoined. In general, some laxative and alterative medicine is beneficial. Numerous local applications are of service. Among these are — camphor and chalk powder in equal parts ; or calomel ; to dust on the part. Simple iced water ; or very warm water ; or infusion of tobacco, with borax or carbonate of soda added ; or Groulard's lotion ; or decoc- tion of poppies, with sugar of lead ; or a weak solution of nitrate of silver; or camphor mixture, with carbonate of soda; or diluted hy- drocyanic acid, or solution of borax with sulphate of morphia — as lotions. Among ointments, the diluted citrine, the mercurial, the hydrocyanic, the sugar of lead, are recommended; as also borax and honey. Malignant Ulcer of External Parts Occasionally shews itself. It is recognized by the ordinary cha- racters of malignant ulceration, and demands the ordinary treatment. Early and wide removal is the only remedy. Sometimes the labia are found enlarged, and more or less exten- sively and deeply ulcerated ; forming a disease which, from its intrac- tability, may well be called malignant ; although it has no other character of a cancerous sore. Strong caustics may succeed in pro- ducing healing action ; but if not, the knife must be resorted to. Tumours of the Labia. In the Labium, fatty tumours are the most common ; easily remov- able by the knife. Simple enlargement sometimes takes place in one labium, or in both ; constituting a tumour analogous to the Elephan- tiasis Scroti of the male (p. 555). Encysted tumours occasionally form ; when of small size, remov- able by incision, and evulsion of the cyst ; when large, to be dealt ■svith by regular dissection. Hernial tumours, be it remembered, are also met with in the labium ; recognizable by the ordinary signs, and amenable to the ordinary treatment. Varicocele is also common in this situation (p. 564). LACERATION OF THE PERINEUM. 567 Hypertrophy of the Clitoris and NymphoE. These parts are liable to simple enlargement. Ordinary cases require no remedial interference. But it may happen, that the swell- ings are not only inconvenient by their bulk, but also of a suspicious character as regards malignancy ; and, in such circumstances, removal by the knife may become necessary. A Bed Fleshy Excrescence in the Orifice of the Urethra Is productive of intense suffering, on account of the part's extreme sensibility to the urine, and to all external influences. It is easily made to bleed, and is generally about the size of a pea ; sometimes as large as a small hazel-nut; usually at the verge of the canal, partially projecting, but sometimes also prolonged upwards into the urethra; and sometimes it forms a complete circle surrounding it. The only remedy is by excision ; or by simple ablation, followed by the use of an escharotic to repress growth. During healing of the wound, the nitrate of silver is of much use in restraining inordinate sensibility ; applied lightly, every alternate day. But the growth is apt to reappear ; again demanding treatment. Laceration of the Perineum. This is a casualty of parturition ; the parts tearing down towards the anus — perhaps with implication of the bowel. The wound is kept clean, and approximation is effected and maintained by adduction of the thighs. By and by, the healing process is stimulated by medicated water-dressing. If necessary, the unclosed portion, having had its edges made raw by the bistoury, is brought together by means of the quilled suture — the form of suture found most suitable, in almost all cases of solution of continuity in these parts. Suture in the recent state of the injury is quite improper ; and should in fact be long delayed, as natui'e generally makes sufficient reparation. Vaginal Fistida. Of this there are three varieties : Vesico-vaginal, Urethro-vaginal, and Recto-vaginal ; all the result, usually, of accident in parturition. By an unskilful use of instruments, the parts are torn ; or, they are subjected to prolonged and severe pressure by the child's head, and sloughing consequently ensues. Vesico-vaginal Fistida denotes an abnormal communication between the vagina and bladder. During parturition, the parts suffer irrecover- 568 TREATMENT OF VAGINAL FISTULA. able injury. Shortly afterwards a slough may separate ; if the urine have not been previously discharged, a gush follows ; and afterwards, a draining away of that fluid remains ; or there may be a discharge of urine, per vaginam, from the first. The patient is in constant discom- fort and suffering. In spite of every attention, congestion and excoria- tion of the external parts ensue ; and if constant diligence is not applied to maintain cleanliness both of person and dress, the patient's proximity may be noisome to others. As the chasm closes, the discharge dimi- nishes. In some rare cases, spontaneous closure may be complete. In the great majority, an aperture remains ; sometimes such as will barely admit a common director ; sometimes a loathsome chasm, admittino- several fingers. The aperture usually is in the mesial aspect behind the origin of the urethra. It can be felt by the finger; and may be disclosed by the bivalve speculum ; or flat copper spatulge may be used to hold aside the walls of the vagina. In consequence of this canal having suffered other injuries, it may become distorted and irregular ; and the discovery of the fistula, if small, may in consequence be very difficult. Detection is effected by placing a metallic catheter in the bladder, and examining the septum upon the catheter by a finger introduced per vaginam ; or a probe may be passed from the vagina through any sinus, till it come in contact with the catheter. The existence of this abnormal state does not necessarily prevent re-impregnation. Treatment, palliative or radical, should be commenced as soon as possible after the discovery of the disease. The former consists in taking measures calculated to prevent the constant and involuntary discharge of urine ; the latter implies an attempt to close the abnormal aperture of communication. It is quite possible to dilate the vagina ; to expose the inj ured parts ; to pare the edges of the opening by a bistoury in situ, or after bringing them externally by traction with the volsella ; to effect approximation by suture, by means of such instru- ments as are employed in staphyloraphe ; and to leave a catheter in the urethra, so as to conduct off the urine before it distends the bladder. Sometimes, however, the catheter cannot be tolerated ; and then the prospect is less hopeful. All this can be done, with difficulty to the ope- rator, and pain to the patient ; but a successful issue is extremely impro- bable. The ligatures may remain in situ even for two or three weeks, and all the urine be naturally discharged for that time, without adhesion of the edges of the wound having been effected. And so discouraging has been the result of such attempts hitherto, that many surgeons are agreed in the propriety of treating most cases of severe Vesico-vaginal Fistula by palliative means alone. The minor cases are remediable by simpler procedure ; the occasional use of heated iron. The part is exposed by means of curved wooden spatula, or by an ivory specu- lum Avith an aperture in its side. If a metallic speculum is used, the TREATMENT OF VAGINAL FISTULA. 569 cautery must be handled with care, so as not to touch the instrument. The iron, at a white heat, is accurately applied to the aperture ; and, at long intervals, the application is repeated. The judicious operator, who wisely seeks only the remote, cicatrizing, and pucker- ing effect of the burn, will seldom, if ever, make the interval shorter than three weeks ; and often a much longer period may be found advisable. At the same time, all avoidable exertion is abstained from, the recum- bent posture is maintained as much as possible, the vagina is tempo- rarily occupied by a sponge or other plug, cleanliness is much attended to, and the marital use of the parts must, of course, be utterly abstained from. Mere fistulge are quite curable in this way. And in the case of any opening, not of larger size than what is barely sufficient to admit the end of the little finger, cure may be thus attempted. In small fistul^e, the application of lunar caustic every three or four days is occasionally effectual. Palliative treatment consists in the use of the adjuvant means just mentioned ; occupying the vagina by a restraining plug ; attend- ing to cleanliness ; preventing filth, foetor, and excoriation. Probably the best means of occupying the vagina is by a piece of sponge, repeatedly changed ; or by a pyriform caoutchouc-bottle, of moderate size ; enveloped in a piece of oiled silk ; introduced in a state of collapse, and then inflated by means of a nozzle and stop-cock — or by means of such a valve as is used in air-tight cushions. Thus accurate compres- sion is made on the aperture, so as to prevent escape of urine ; and both comfort and cleanliness are obtained. The bottle is v/ithdrawn daily, the air being previously permitted to escape ; at the same time, the vagina may be cleared of accumulated secretion by means of a syringe, and fcetor may be removed by a solution of the chlorides. The bottle, having been cleaned, is replaced. Immediately after the occurrence of the accident, something may be done to favour spontaneous contraction of the aperture, and perhaps spontaneous cure. The patient is directed to lie as much as possible on her face ; a catheter is constantly retained — being removed only for the purpose of being cleaned ; a sponge, or some dressing, which must be changed with great gentleness, is placed in the vagina, of sufficient s\ze to exert a moderate closing pressure on the injured part — so as to prevent cohesion of the wound to the walls of the vagina, with consequent complication of the case. Unfortunately, however, the catheter cannot, in all cases, be tolerated, and consequently the benefit of this plan of treatment is lost. The bowels are kept gently open, so as to preclude the necessity of straining. TJrethro-vaginal Fistula denotes a preternatural communication between the vagina and the urethra ; caused, probably, by the impru- dent use of instruments. In general, the same disagreeable results 570 STEICTUEE OF THE VAGINA. occur as in the former case. Sometimes there is power of retention ; but, in evacuating the urine, it trickles through the vagina, and over the limbs. The treatment is the same, but more frequently successful. Recto-vaginal Fistula. — Laceration of the septum between the vagina and the bowel takes place, by the rash use of instruments, or by tear- ing in the natural efforts of parturition, or as a consequence of slough- ino- from pressure. In the latter case, the perineum usually suffers laceration also. The parts are to be kept clean and quiet ; and sponta- neous diminution of the chasm is favoured by every possible means. When the fistulous condition has been arrived at — that is, when the margins of the tear have healed, and contraction has ceased — the parts are exposed, by means of a speculum, if necessary ; the edges are made raw by paring, and approximation is effected by means of ihe quilled suture (Principles, p. 644). The parts, in this case, being compara- tively superficial, the operation is performed not only with comparative ease, but also with a good prospect of success. If the aperture is small it may be treated by caustic or cautery, like the vesico-vaginal fistula. In the advanced stages of cancer of the female organs, these fistula frequently are produced by malignant ulcei-ation of the septa. Of course, in such cases, no surgical treatment is admissible. Stricture of the Vagina. This may be the result of previous inflammation, indurating the mucous and submucous tissues of a part of the vagina ; or it may follow on the healing of a wound received during artificial delivery, or otherwise ; or it may be consequent on ulceration produced by a badly arranged pessary. Finally it may be the result of cancerous deposit. Under ordinary circumstances, it is amenable to the same treatment, by gradual dilatation, as conti^actions of other mucous canals. But the surgeon's aid is seldom called for, except during the crisis of parturition ; the progress of the child having become obstructed, by an unyielding contraction of the vagina — usually situated at the upper part of the canal, and usually the result of a previous unfortunate labour. The duty of the surgeon is, by a probe-pointed bistoury, introduced on the finger, to notch the contracted part at various points ; and then, by progress of the child's head, or by the finger of the operator, dilatation is effected. Obliteration of the Vagina^ To a greater or less extent, is occasionally met with ; arising from the same causes as stricture. Then much constitutional disorder must result, from arrest of the uterine discharges ; and it is desirable to IMPERFOKATE VAGINA. 571 restore the canal, at least to such an extent as to admit of a due per- formance of the excretory functions of the organ. The knife, or the trocar, is used, guided in a normal direction by the finger in the rectum ; and the passage made is kept dilated, by means of tents or bougies. If the patient has ceased to menstruate, no operation may be required. Imperforate Vagina or Hymen. The vagina may seem well formed externally ; but, on examina- tion, may be found terminating in a blind cul de sac, at no gi'eat dis- tance from the orifice. In such a case, no exploratory incision is warrantable, in search of the uterus, in the adult ; unless, on careful examination, by the rectum and otherwise, there is a tolerable cer- tainty of that organ being present. A more frequent imperfection occurs at the orifice ; the other part of the canal being well developed, and in a normal state. The mem- brane of the hymen may be excessive, and imperforate ; or the vagina itself may be shut up, by a more solid and fleshy structure. Interfer- ence is not necessary, and, indeed, the malformation may not be dis- covered, until about the time of puberty ; and then, on account of non-appearance of the menstrual discharge, and the persistence of uneasy sensations in the pelvis and parts affected, attention is directed to the state of the genital organs. The obstructed fluid may be found bulging through a thin membranous septum ; or there may be but a vestige of the normal opening, and solid flesh beneath, devoid of bulge or fluctuation. In the one case, simple division of the membrane suffices to establish the normal state. In the other, careful incision is required, as in the case of imperforate anus ; and the same necessity exists, for afterwards maintaining the proper calibre of the part by suitable means. Immediately after incision, it is well to insure thorough evacuation of the pent-up fluid ; washing out the vagina with tepid water, by means of a syringe. In cases of this kind, the accumulated menstrual fluid may fill and dilate not only the vagina but also the uterus, expanding the latter as in pregnancy, and causing even some of the equivocal symptoms of that state. The operation of evacuation is not without danger, espe- cially if performed in hospitals ; the dangers being by purulent fever and phlebitis. The fluid evacuated is generally dark red, or mahogany coloured, very viscid and grumous ; but these characters vary. Sometimes, adhesion of the nymphse takes place in children ; the opposed surfaces having become raw, on account of neglect of cleanliness, or in consequence of these parts suffering in sympathy with disorder elsewhere, and a purulent discharge having become established (p. .563). In general the cohesion is slight, and easily 572 PEOLAPSUS OF THE VAGINA. broken up by means of the flat end of a probe. For some days, inter- position of dressing is necessary, to prevent reunion. Foreign Bodies in the Vagina. These may be introduced by the patient herself, under some morbid excitement ; or, violently and criminally, by a second party. And they may be of such bulk, or so impacted, as to resist the ordinary means of extraction. By dilatation and lubrication of the passage, and by the judicious use of forceps or lever, dislodgment may be effected, without injury of the parts. In difficult cases, division of the impacted substance, or, if that is impracticable, of the sphincter, may be necessary, as in the analogous case of the rectum (p. 392). Prolapsus of the Vagina May exist in various degrees ; the dislocated part still remaining in the vaginal cavity, or protruding fi'om it at the vulva. It may be partial or complete. Partial prolapsus consists in the falling dovv^n of a part of the vagina ; generally either of the anterior (vaginal cysto- cele), or of the posterior wall (vaginal rectocele). Complete prolapsus resembles prolapse of the bowel per auum ; the whole circumference of the vaginal tube descending. It is distinguished from prolapsus of the uterus, by the anatomical characters of the mucous membrane of the vagina, and by reaching the os uteri with the finger passed through and above the swelling. It is generally accompanied by a feeling of much weight and uneasi- ness ; and often there is considerable irritation with discharge. The functions of the bladder and rectum are more or less impeded or deranged ; and if the dislocation has been suddenly produced, there may be obstinate constipation and strangury. It is a complaint extremely obnoxious to the female ; not only causing uneasiness or pain in sitting or walking, but often exciting unjustifiable alarm. The affection is most common in women who have borne many children, or suflTered frequent abortions, or who labour under menor- rhagia or aggravated leucorrhoea. In short, anything which tends to relax the parts involved, favours its occurrence; not forgetting the influence of deranged general health, and feeble constitution. It may be caused suddenly and kept up by any violent effort, as in coughing, sneezing, laughing, lifting a heavy weight, or straining at stool. Sometimes removal of the exciting cause — with or without the use of cold and astringent lotions and general tonics — is sufficient to efiTect a cure. The wearing of an understrap is often beneficial. Sometimes a pessary, in shape adapted to the parts, is enough. But if the case THE PASSING OF THE FEMALE CATHETER, 573 pi-ove incurable and cause much annoyance, it may be dealt with by the knife, as in prolapsus ani — special care being previously taken to ascertain the relations of the bladder and rectum to the parts to be excised. If either of these organs come in the way of the incisions required, of course no cutting is at all admissible. The 2ycissing of the Female Catheter. In this operation, much delicacy is required. When, from prolapsus uteri, or other causes, there is much relaxation or change of relative position, ocular inspection may be necessary. But, in ordinary cases, all is done by touch alone, under the dress or bed clothes. The patient should be in the recumbent position, with the nearer thigh flexed. If the surgeon is at the left side of his patient, the fore-finger of the left hand, if on the I'ight side the fore-finger of the right hand, is passed to the upper part of the orifice of the vagina, which is distinguished from the vestibulum by its rugosity ; the catheter is placed about an inch over this — and, by moving the point downwards, in the mesial line, it slips into the orifice of the urethra. Or, the finger is moved in search of the urethral oi'ifice ; which is recognized by feeling a depres- sion, with an elevation on its vaginal aspect ; and, along the finger, the catheter is then directly introduced. When there is displacement of the parts, a common elastic catheter may be found more suitable than the silver instrument ; as then there may be both twisting and elongation of the canal. The ordinary silver catheter should be flat, very slightly curved, about six inches in length, and having some pro- jection or knob on its outer orifice, to prevent its slipping into the canal altogether. Plugging of the Vagina Is a most useful and important operation, as a hemostatic, when flood- ing (not post partum) has to be arrested. In every form of hemorrhage from the vagina, it may be of the greatest service ; and often is in fact the means of saving life. The simplest and most convenient method of plugging is to use pieces of sponge, or lint, or linen ; placing them in the vagina one after the other, every piece being lodged as high as possible. When the bleeding is passive, not many pieces may be required ; but if vessels have been opened by operation, the plugging must be done very efficiently ; the vagina being well crammed, and a T bandage applied to support the pledgets, which may be previously saturated with vinegar, or solution of matico, or other astringent and styptic lotion. Great care must be paid to watch against return or persistence of the discharge ; and the plug should be carefully removed at the end of about twelve hours ; to be replaced, if necessary, with new materials. 574 LEUCOREHOEA. Another plan, not so easy of execution, is to pass the centre of a napkin into the vagina ; thus making a blind pouch there open from without, and into which the necessary amount of stuffing may be passed. Or, a bladder may be passed and inflated with air, or with refrigerant solutions. Or the same may be done with bags of vul- canised caoutchouc ; and some ingenious instruments have been constructed for the purpose. Leucorrhoea Is a nosological term, used to indicate a state of disease having dis- charge of a mucous or muco-purulent character from the vagina as its most prominent phenomenon. Apart from its occurrence as a symptom of almost all the more serious uterine affections, it is the most common of female diseases ; and occurs in a great variety of forms. The discharge commonly called " Whites" may exist without any defined disease in the vagina or uterus, and may be the result of general debility and relaxation of system, especially if in a scrofulous consti- tution ; or it may occur during amenorrhoea. Occasionally it super- venes after the manner of a common catarrh. Often, also, it is a per- sistent excess oi SBQ,v&tion post j^aftum. In such a case, if examination be made by the speculum, no organic lesion may be discovered. Sometimes, however, the mucous mem- brane of the cervix is found red and injected, or slightly abraded — especially if the case has been neglected, and allowed to run a pro- tracted course. In this, as well as in all other forms of leucorrhoea, the symptoms complained of by the patient may be either few or numerous. They are a class of symptoms common to all uterine affections ; viz., disorders of the menstrual function ; pain in the back and loins, in the hypochondria, across the hypogastrium, and down the limbs ; feelings of bearing down and unnatural weight in the perineum ; besides the ordinary accompaniments of disordered stomach and bowels. In most such cases, no local treatment is required. On the contrary, by causing excitement and irritation, it would probably aggravate the complaint. Cold sponging, or the cold hipbath, with attention to the general health, will suffice. The tincture of cantha- rides, and the various preparations of iron taken internally, often seem to have a good effect in diminishing the discharge. If the case be one of vaginitis, simple or specific, there will, in addition to the other symptoms already mentioned, be those of febrile accession, along with much local pain, irritation of bladder, ardor urin», pain in defecation and in walking. The discharge will not be white and mucous, but muco-pui'ulent. In such circumstances,- vaginal exa- INFLAMMATOEY AFFECTIONS OF THE CERVIX UTERI. 575 mination will reveal a preternaturally red colour of the mucous mem- brane, with much tenderness ; and in addition there may be more or less excoriation or superficial ulceration of the cervix. Treatment consists in maintaining the horizontal position, fomenting or poulticing the parts externally, and internally using a bland or sedative injection ; besides employing purgatives and all the ordinary treatment of gonor- rhcea (see p. 487). After an attack of vaginitis, a disagreeable muco-purulent discharge may continue ; or by neglect a simple white discharge may be aggra- vated to this character. But the most frequent cause of these leu- corrhoeal complaints, when they come to demand local treatment, is an inflamed and ulcerated, or otherivise morbid state of the cervix uteri. The disease may occur in an acute form, but is more frequently met with as a chronic complaint. The symptoms are severer than in the case of " whites," and the general health suffers severely. The dis- charge may vary much in quantity, it may also be of various consis- tence, it may be muco-purulent, or almost pure pus, and it may, or may not be tinged with blood. If of long continuance and profuse, it often causes much irritation of the labia externally. Sometimes it is complicated with displacement of the womb, or with chronic inflam- mation, or engorgement and hypertrophy of the whole organ ; and these circumstances much retard the progress of cure. All women are liable to such complaints ; but the married and child-bearing suffer both most frequently and most severely. In this brief sketch it is expedient to treat of the numerous, morbid, non-malignant states of the cervix together ; more especially when we consider that they cannot in any way be distinguished from each other, without a tactile and visual examination of the implicated parts ; and further, that the treatment, in its general features, is similar in all. Passing over with simple mention, the aphthous, her- petic, and other forms of integumental disease, rarely observed, we notice the simply inflamed and idcerated cervix. All the signs of inflam- mation are present; but the pain and tenderness may not be very severe. The part may be more or less indurated; and the degree of swelling varies. Sometimes the cervix acquires considerable bulk, is hard and somewhat nodulated, and may cause some difficulty in diagnosis from cancer ; the more especially as the weak, pallid, and cachectic appear- ance of the patient often appears to favour the notion of malignancy. It happens very rarely, however, that carcinoma of the uterine neck is actually mistaken for hypertrophy ; for it is generally found, even on a first examination, to be in an advanced state. At the same time, it is to be remembered that hypertrophy is not unfrequently mistaken for carcinoma ; and sometimes even the most experienced find a difficulty 576 ULCERATION OF THE CERVIX UTERI. in diagnosis, till the result of treatment has been ascertained. The following points are distinctive in most cases. In carcinoma, there is the peculiar cachexy of system ; and the morbid deposit may extend from the cervix more or less over the roof of the vagina, rendering the uterus fixed in the pelvis. There is generally gi'eat induration ; and if there be ulceration, the indurated points pi'ojecting into it are friable under the finger ; the ulceration is deep and irregular in form ; and the discharge is frequently foetid, and sometimes mixed with blood. In inflammation of the cervix, the accompanying ulceration most frequently attacks the postei'ior lip. The ulceration may be of various kinds; simple or healthy, indolent, irritable, or weak (Principles, p. 241). The cervix uteri is also liable to a granular form of inflammation. The part is tender, red, and having the mucous membrane abraded or superficially ulcerated ; and bears numerous red points on its surface. Generally, it is also somewhat enlarged ; and frequently, in this case, the vagina is irritated, or more or less inflamed, around the cervix. Sometimes, also, the cervix is found with small nodulatiojis over its surface, apparently the result of inflammation in the glands of the part. Wlien the ulceration is healthy, and there exists no complication, it is easy to effect a cure, by enjoining rest of the parts, and using any simple detergent or mild astringent lotion. If it is protracted in dura- tion, or unhealthy in its character, the lunar caustic may be used through the speculum, every third or fourth day ; care being taken to secure its proper application, by cleansing the parts with a small sponge, or dossil of lint, previously. In all forms of inflammation of the cervix with ulceration, this is one of our most useful resources ; and in most cases, along with proper regulations as to rest of the parts, and attention to the general health, it is successful. If the ulcera- tion prove obstinate, however, other means may be tried ; as the sulphate of copper, nitric acid, the acid nitrate of mercury, or even the cautery. After the ulceration has been healed, it is generally necessary to continue the adjuvant treatment for a considerable time ; and to check the leucorrhoea which may persist, a variety of astrin- gent lotions may be used, as circumstances demand. Among these may be mentioned the simple douche of cold water, injected into the vagina for a few minutes, once or twice a day ; the use of strong infusion of green tea, with some borax added — eight or ten ounces being injected morning and evening ; the use of decoction of oak bark in the same way, or of weak solutions of sulphate of zinc, alum, acetate of lead, chloride of zinc, or nitrate of silver in small quantity. Sometimes the application of leeches internally, by means of a tube, is useful to dispel inflammation, and to remove local congestion. INVEESION OP THE UTERUS. 577 And the application of iodine in tincture through the speculum, or its use in the form of iodide of lead ointment introduced into the vagina, is often advantageous in dispelling engorgement. The most intractable cases are those where the disease is chronic, and where there is more or less enlargement of the cervix. In these, there is frequently a degree of hypertrophy of the whole uterus, also often displacement of the organ ; and although reduction of the size of the cervix, and arrest of the leucorrhoea, frequently remove the entire aiFection, there constantly recur cases where this does not happen and the symptoms of uterine disease persist. In such circumstances, the progress to cure is often tedious, and treatment must be directed to the engorgement and hypertrophy of the womb, and to the general health, simultaneously. In reducing the enlarged cervix, it is sometimes necessary, in addition to the means already described for the cm-e of ulceration, to resort to more heroic means. After destroying a part of the diseased tissues by means of strong caustics, absorption and disappearance of the remaining portion are induced. For this, various plans have been recommended ; such as the careful application, through an ivory speculum, of a cautery at white heat. Thus a slough is pro- duced, and a healthy ulceration may follow; the application after- wards being repeated or not, according to circumstances. The appli- cation of potassa cum calce has also been advised ; but a more efficient and satisfactory plan is to apply freely to the most indurated part the potassa fusa, through a glass speculum ; guarding the neighbouring parts by irrigating them immediately and abundantly with dilute acetic acid strongly injected. Inversion of the Uterus Is the turning of the organ inside out ; and it may happen in various degrees. It has been observed to occur idiopathically even in the virgin ; and in a minor degree is probably a not unfrequent conco- mitant of polypus springing from the body or fundus of the womb. But the great majority of cases occur soon after delivery, in conse- quence of improper treatment after the birth of the child ; and occa- sionally it happens spontaneously at this time. Into these details this is not the place to enter. It is sufficient to state that if the organ be not reduced very soon after the displacement has occurred, it will speedily become irreducible. If death do not quickly follow, the case becomes one of chronic inversion, which, inducing as it does large losses of blood, exhausting discharge, with rectal and vesical irrita- tion, is the cause of constitutional disorder so serious as to suggest the propriety of completely removing the inverted organ. The statistics of the operation are not sufficient to found a decided opinion upon ; 2p 578 INVERSION OP THE UTERUS. but they are encouraging, when we consider the gravity of the com- plaint. The surgeon has to decide whether his patient's best chance lies in tolerating the disease and combating its effects, or in submitting to the risk of operation. On the one side, there is a grave disorder which frequently proves fatal, by exhausting the patient — if not more directly ; and on the other, we have the favourable experience of numerous surgeons who have practised extirpation of the organ. It is sometimes difficult to diagnose this affection from polypus ; but in general it can be made out with great certainty. In inver- sion, we observe the absence of the body of the uterus from its natural position ; a state of matters as easy to determine in the thin and relaxed female, as it is difficult under the reverse condition. There is a tumour in the vagina, sensible or even tender, and the handling of which is liable to induce sickness ; it is rough on the surface, dark in colour, easily made to bleed, regularly rounded in form, and with the base larger than any other part ; or only moderately constricted, by the cervix ; having little mobility ; and occasionally, if prolapsed, shoAving the openings of the Fallopian tubes, into which a stilet may be introduced. If the finger is passed above the inverted parts, it first reaches the cervix, more or less completely encircling the base of the tumour ; and the finger or bougie introduced between the cervix and the tumour quickly reaches a cul-de-sac all round the latter. Fur- ther, the history of the case is peculiar. The revei'se of almost all these points is predicable of a polypus ; and some of them, if certainly made out, are quite distinctive. When inversion is partial and the result of polypus, it will pro- bably disappear spontaneously on removal of the cause. In an ordinary case of chronic postpartum inversion, an attempt should be made to reduce it by direct pressure ; premising the use of warm baths, local bleedings, purgatives, &c. If this fail, and extirpation of the organ is recommended, it is sufficiently easy of execution. The womb is drawn down between the labia by forceps, and a very tight ligature is applied around it below the cervix, care being taken that no intestine, has descended into the inverted organ. Or the mass may be transfixed by a double ligature, and tied in two parts. Or a metallic ligature may be thrown around the mass ; and by the aid of Gooch's double canula, or other similar instrument, this may be gradually tightened till it cuts its way through and separates the mass. It occasionally happens that the already existing constriction at the neck of the womb is such as to cause sloughing without surgical assistance. Prolapsus of the Uterus May be partial or complete ; the former term indicating an abnoi'mal PEOLAPSUS OF THE UTEEUS. 579 approximation of the uterus to the os externum vaginae ; the latter denoting that the organ lies in part, or in whole, without the os externum, forming a tumour between the patient's thighs. The affection may occur at any age ; but increases in frequency with the advance of life, as well as according to the number of labours. Small tumours in the uterus, or the pressure of large tumours upon it, menorrhagia and leucorrhoea, are local predisposing causes ; as also relaxation of the vagina, from whatever cause, and largeness of pelvis. It is met with in every rank of life ; but when in a very aggravated state, is most frequent in the lower classes — especially in those unfortunate women whose avocations require much straining and effort — which not only predispose to the disease, but also aggravate it when it exists. It may occur at any stage of pregnancy, or through it all ; and even during delivery at the full time — but this rarely. This condition is easily distinguished by finding the os and cervix, and ascertaining that the former leads into the cavity of the organ. Partial prolapsus is extremely frequent in its occurrence, is easily re- placed in most cases, and seldom causes any serious disturbance. In complete prolapsus, also, the tumour is often easy of replacement ; some- times, indeed, it resumes its natural position spontaneously, when the patient lies down. But in aggravated cases, replacement may be a matter of difficulty from various causes. Of these, congestion and in- flammation, with their consequences, are the most important. In some cases this latter has been so intense as to end in gangrene and separation of the parts ; resulting in either death or cure of the patient. When the prolapsus is large and of long standing, it may be quite impossible to replace it. The uterus, carrying with it the bladder and rectum, becomes swollen and condensed ; and forms a large pouch, containing other viscera prolapsed into it ; in this state resembling an old and large hernia, the contents of which can with difficulty, if at all, find room for return to the abdominal cavity. In such cases, the protruded parts generally present large and unhealthy patches of ulceration ; and the corresponding portions of the thighs are more or less irritated and excoriated. Prolapsus of the uterus is generally the cause of much unde- fined suffering in the region of the pelvis. Patients complain of distressing feelings of bearing down, weight in the perineum, dragging in the loins ; and there may be much disturbance, or even tempo- rary arrest of the functions of the bladder and rectum. Often there is difficulty in walking. In cases of complete descent, great uneasiness is of course produced by friction of the thighs upon the tumour ; and the irritation caused by urine passing over the exposed raucous surface is extreme — often ending in unhealthy ulcerations. 2p2 580 TREATMENT OF PROLAPSUS OF THE UTERUS. There is also generally much derangement of the functions of the stomach. The complaint is sometimes complicated by hypertrophy or tumours of the uterus, or of the ovaries, by ascites, by polypus of the uterus, by leucorrhoea, by menorrhagia, or by calculus in the bladder. The objects of ti'eatment are three-fold, 1, To replace the organ ; 2, to retain it in its proper situation ; and 3, to protect and support it when it is irreducible. The replacement, as already remarked, is frequently effected with- out aid, on the patient assuming the recumbent posture ; or, it may be done with more or less force directed against the tumour, always in the direction of that axis of the pelvis through which it is at the time passing. If any difficulty is apprehended, care must be taken to secure complete evacuation of the bladder and rectum before the at- tempt is made. Sometimes, from the causes already enumerated, it is for the time at least irreducible. But continued maintenance of the horizontal position, and the use of local antiphlogistics if necessary, will generally restore reducibility. In some rare cases of long standing, the reduction, although easily enough effected, cannot be tolerated by the patient ; and in others reduction remains altogether impossible. When the case is recent, and produced by violence, simple reduction, with maintenance of the horizontal position for a few days, will be sufficient. In some examples, it is necessary, in addition to this, to use means to restore the tonicity and contraction of the relaxed and extensile vagina. For this purpose, frequent irrigation of the canal, with cold water, or continued use of astringent ointments and lotions, are very serviceable. Attention must be at the same time paid to heal up ulceration, and to remove leucorrhoea. In most cases, however, the use of a pessary is required. It may be either worn constantly, except when removed for the sake of cleanliness for a few minutes ; or it may be laid aside during the night. It should always be as small as is consistent with efficiency; the size ranging according to the conditions of the case. If the perineum is much injured, a bandage may be necessary to retain the pessary. And this must be kept clean, by removing and replacing it ; -with a frequency varied according to the material of which the pessary is made. A great deal has been written concerning the material of the pessary, and its shape. Different practitioners are in the habit of using different forms, and it not unfrequently happens that after trying several, the patient herself is the best judge of what is most suitable. The ball pessary of boxwood is one of the most useful ; the ring pessary is often recom- mended to married women, but requires particular watching lest the cervix uteri pass through the ring and become strangulated there. Pessaries more or less cup-shaped, and having a stem attached, are DISPLACEMENTS OF THE UTERUS. 581 particularly applicable to those cases where the destruction of the peri- neum renders a bandage necessary. In some cases the wearing of the instrument eventually effects a cure; but in others, dependent on relaxation, it may prevent that result ; and in these it should not be used till other remedies have been tried in vain. In all cases, the utero-abdominal supporter of Hull, or some of its numerous modifications, is very useful ; if no special cause exist to prevent the patient wearing it. By supporting partly the weight of the bowels, it lightens the pressure upon the womb ; the padded under- strap counteracts the j)rolapse from below; and the machine gives general support and a feeling of security to the patient. Operative interference has been resorted to in aggravated cases, and not without some success; it is most applicable to those not exposed to the risk of childbearing. The labia have been made raw, and adhesion between them effected, so as to occlude the vagina, excepting a small passage for the vaginal excretions. Episoraphy has also been successful ; it consists in carefully paring off longitudinal slips of the mucous membrane of the vagina, and uniting the edges of the wounds by the necessary number of interrupted sutures. Caute- rization by the hot iron, or the mineral acids, has also been resorted to for the same purpose. When the knife is used, great care must be taken to arrest bleeding timeously. Finally, if reduction is impossible, a protecting and supporting truss must be adapted to the case, after the manner of a suspensory bandage. Displacements of the Uterus. This organ is frequently found lying in an abnormal position. It may be dislocated en masse, or its body may be displaced in regard to the cervix ; and the most common malpositions are either backwards or forwards, forming, in the one case, an antiversion or a retroversion, and in the other an antiflexion or a retroflexion. The flexions, espe- pecially the retroflexion, are sometimes congenital. These changes may be simple or complicated. Frequently they coexist with tumours, chronic metritis, hypertrophy of the womb, leucorrhoea, or ovarian irritation. "When uncomplicated, they may cause no painful symptom whatever ; but sometimes they produce great difficulty in standing or walking for even a short time, disturbance of the functions of the bladder or of the rectum, a feeling of weight and bearing down, a sense of pressure at the anus, pain on going to stool, as well as many of those numerous neuralgic and other symptoms Avhich accompany all the chronic uterine affections. On passing the finger to the roof of the vagina, the cervix uteri is 582 STRICTURE OF THE CERVIX UTERI. found more or less displaced from its natural position ; and a hard, often tender, rounded tumour is felt through the vagina. This is found to move with the cervix, and may sometimes be traced to be continuous with it. In thin and relaxed women, it is possible during examination, by placing the free hand over the hypogastrium, and using the necessary palpation and pressure, to feel the position and relations of the entire organ. The affection is diagnosed by introducing a bougie or probe into the cavity of the organ, and ascertaining its entrance into the tumour felt through the roof of the vagina. Generally, by means of the probe, it can be depressed or removed from the finger by replacement. Treatment consists in removing all local congestion and inflamma- tion, combating uterine hypertrophy and engorgement, arresting leu- corrhcea ; in short removing, as far as possible, everything which can be regarded as a cause of the production or continuance of dis- placement. Maintenance of the horizontal posture, for a length of time, is often of great service, as an adjuvant. In some cases, the vaginal, and in others the intra-uterine pessaries of Dr. Simpson may be tried with caution. Stricture of the Cervix Uteri May be congenital, or may result from inflammatory engorgement and induration. The stricture, if congenital, is generally at the os externum, or at the os internum. If acquired, it may be found at any part of the cervix, or may partially close up some extent of it. It is not of frequent occurrence ; but when present is often the cause of dysmenorrhoea, and sometimes it prevents conception. It is discovered by the symptoms of dysmenorrhoea ; or, physically, by the dilEculty of passing even a small probe through. Every case, however, where a probe cannot be easily passed, is not therefore to be considered a case of stricture. There may be obstacles to passing a probe into the cavity of the uterus, from many other causes ; as flexion or version of the uterus, the presence of tumours, and difiiculty of adjusting the probe to the direction of the long axis of the neck and cavity of the organ. Treatment consists in dilating the cervical canal. This may be effected by a succession of bougies, or of small pessaries with an intra- uterine stem, as is done in stricture of the urethra or rectum. The instrument, however, may be safely left much longer in situ than in the cognate affections. In fact, it may often be left for days with safety. If the disease is inflammatory in its origin, however, the pessaries would merely irritate, without producing benefit. In such cases, espe- cially if there is any engorgement, it is often better to use the bistouri- cache, ortheuterotome of Dr. Simpson — a similar instrument, adapted UTERINE POLYPUS. o83 to this particular case. By means of this, the stricture is divided from within outwards ; the blade being made to project only to a small extent. J£ the neck is small, the incision must be proportionally diminished ; as there is danger from dividing the vascular trunks which lie on the peritoneal aspect of the proper tissue of the cervix. Uterine Polypus. Uterine Polypi may be of various structure (Principles, p. 410). Before their removal we can in some cases determine their patho- logical nature by their consistence, by theii* seat of insertion, by their size, by their history, and by the concomitant symptoms. The size of the polypus may vary from that of a miUet-seed, to that of a child's head. In fact, their growth is limited only by the capacity of the pelvis. The largest tumours are generally fibrous in their structure. The mucous vary much in size ; the smallest being generally vesicular or cellular in structure. Some- times, the mucous polypus is so small and sessile, as to be with difficulty discovered. The insertion of these tumours may be at any point on the internal surfac§ or os of the uterus. Very rarely, they are found implanted in the vaginal walls ; either having originally sprung from that part, or, as still more seldom happens, having formed a second insertion by adhesion. Polypi have sometimes been observed growing by two roots from the uterine walls ; the roots having an identity of struc- ture ; and sometimes the second root is merely the accidental result of adhesion. A polypus may be inserted by a pedicle or stalk ; or it may be sessile. The pedicle may be of any thickness ; it may be several inches long ; or its length may be inappreciable. Sometimes polypi are found projecting from the vagina, suspended from the uterus by a long slender pedicle. These have been designated by French authors " polypes a pendule ;" and are generally observed in women considerably advanced in life, in whom the polypus has grown without occasioning much if any annoyance. The vesicular, mucous, and cellular polypi may spring from any part of the internal surface of the uterus. Not unfrequently several may be met with at the same time in the cervix, or adhering to the OS. The fibrous polypus generally grows from some part of the body of the uterus. The most urgent symptom of the affection is loss of blood. This is the chief source of the mischief the tumours produce ; and the consideration of its arrest is generally what leads to their discovery. It rarely happens that a woman dies directly of loss of blood from this 584 UTERINK POLYPUS. cause ; but tliere frequently results an extreme state of anemia, leading ultimately to a fatal termination. Violent, and sometimes fatal post partum hemorrhages are occasionally connected with this as a cause. Bleeding may take place at the monthly periods, or at irregular intervals. It is frequently brought on by long continuance in the erect posture, by exertion in walking, or by jumping from a height ; or it may occur without any assignable cause. It may in its flow resemble the ordinary menstrual discharge ; or the blood may issue in a continuous stream from the vagina. The quantity lost has no con- stant relation to the size of the tumour. The fibrous polypus is gene- rally believed to be the most frequent cause of serious hemorrhages ; but these may occur with polypi of any kind, even the smallest. Further, in some cases, there may be no bleeding at all ; there may even be amenorrhoea. In the intervals of hemorrhage, there may be no discharge from the vagina. Generally, however, there is a mucous or muco-purulent secretion ; and in cases of large polypi, this is often abundant. Some- times it is mixed with blood ; occasionally it is very foetid, especially if the polypus is ulcerated or breaking up. When the growth is intra- uterine, the blood may sometimes be observed distilling from between the lips of the cervix. The other symptoms accompanying polypus need no particular description. They are those common to all affections of the uterus. Occasionally, one of these symptoms is very prominently complained of ; as pain in the hips, verging to sciatica ; also pains in the mamma. Examination with the finger generally discovers the growth. If, however, it be very small, care may be required. Sometimes a smooth, soft, and easily movable polypus, with small pedicle, remains undis- covered, although of considerable size ; the finger always pushing the growth before it, instead of passing round it, as in general is easily done. If the tumours are small, and lodged in the cervix, they may be better exposed after dilatation of this, by means of a sponge tent. By the same means, an intra-uterine polypus may be detected. The speculum also may be used to expose a polypus for examination by the eye. But, it may be added, that these growths not unfrequently cause no inconvenience whatever ; and are discovered only by accident. Polypus is distinguished from cauliflower excrescence, by the latter having a broad attachment to the cervix, by its free bleeding when touched, by its profuse watery discharge, by its rough granular surface, by its accompanying cancerous cachexia, and lastly, by the results of treatment. Polypus is also liable to be mistaken for inversion of the womb (p. 577). The treatment of uterine polypus consists simply in effecting its removal. Bleeding has the same treatment as other forms of uterine TREATMENT OF UTERINE POLYPUS. 585 hemorrhage unconnected with labour. If violent, and proving dan- gerous, it may be commanded by the plug. If slighter, it may be arrested by placing the patient in the horizontal posture, keeping her cool, applying cold locally over the vulva and hypogastrium, adminis- tering cold enemata, or, in some cases, cold and astringent vaginal injections, cautiously, and using internally the common astringent and refrigerant medicines. As in many other hemorrhages, opium is of service (Principles, p. 364). Removal may be effected in various w^ays. The quickest, and in most cases the best plan, is the direct use of the knife or scissors, through the speculum — or without it, using the finger, or fingers, as a guard. When the polypus is large, and can be well seized by a volsella, it may be dragged down to the vulva, and its stalk divided there by knife or scissors. If the growth be very bulky, it may be necessary to enlarge the vaginal opening by incisions. When the stalk or base is large and broad, it is safer to cut near the tumour, rather than near its insertion ; on account of the danger of incisions implicating the uterine walls. If difficulty is felt as to the proper site of the incisions, it is preferable to use some of the slower, but in this instance safer methods of removal. And in all cases it is to be remembered that it is not necessary to take away the whole pedicle ; for the part left after separation of the polypus quickly disappears. After removal there is rarely any alarming hemorrhage ; but it must be carefully watched for, and early ai'rested, A ligature of whip cord, or silver wire, may be thrown around the pedicle, by means of Gooch's well-known double canula (p. 578), or by any of the numerous modifications of it, which best suits the operator's fancy. The ligature is to be daily tightened, till it cuts its way through the stalk ; when both polypus and instrument are to be removed. But the direct use of the knife is perhaps, upon the whole, the safest method ; as the other modes are tedious, and on account of conti- nuance of foetid discharges from the half separated and decaying polypus, as well as fi-om the irritation of the ligature, there is risk of untoward inflammation being excited — especially phlebitis. It may happen that a polypus of moderate or small size may be difficult to deal with, either by ligature or cutting instrument ; and under such circumstances, it is sometimes possible to destroy it by com- pression, or by bruising with strong forceps ; as a stone is crushed by a lithontriptor. It may then be either left to slough away ; or, if soft and easily lacerable, it may be twisted ofi" and brought out with the instrument. Small, sessile, mucous polypi may often be conveniently destroyed by nitrate of silver ; or a stronger caustic may be used, if necessary. 586 EXTIRPATION OF THE CERVIX UTERI. Extirpation of the Cervix Uteri Is performed chiefly in cases of malignant disease stUl confined to this part, and when the peculiarities of its site, and its prominence into the vagina, render complete removal feasible. The operation is sufiicientlj simple ; the only point requiring particular care being to keep the incisions in the cervix below the peritoneal reflections — at the same time removing as much as can safely be done. The patient is laid on her back, in the position for lithotomy ; or flat on her face, with the hips raised, and the legs dependent. The cervix is seized by strong hooked forceps, and gently but determinedly dragged downwards, tiU it appear at the os vaginge, through which it is at length drawn. If the patient has never borne children, or if the OS vaginte be small and contracted, it may be dilated by one, two, or three small incisions, made either posteriorly or laterally. After the cervix has been drawn down, the insertion of the vagina is made out, in order to judge of the position of the peritoneal reflections, and to avoid including the bladder in the incisions. The necessary amount is then taken away, either by large and powerful scissors, or by the scalpel. Our chief confidence for the arrest of hemorrhage is to be placed in careful and thorough plugging of the vagina by lint (p. 573). The amount of bleeding may be inconsiderable ; or a large quan- tity may be lost. And it may happen that a case, otherwise adapted for the operation, may be unable to bear, without the greatest risk, even a small loss of blood. Under such circumstances, a modification of the operation may be resorted to. After dragging down and ex- posing the cervix, it may be encircled in a strong ligature ; or it may be transfixed, as often as may seem fit, by a needle armed with a double ligature ; the different parts being separately tied. And the part below the ligature may then be excised with safety. Malignant Disease of the Uterus May assume one of three principal forms ; the corroding ulcer, malig- nant ulceration without much interstitial cancerous dejDOsit ; the cauli- flower excrescence, springing from the cervix ; and the common cancer of the uterus, which may be scirrhous or encephaloid, very rarely colloid. The Corrodinrj Ulcer is not a common affection. It is distinguished from simple ulceration by its graniilated sm-face, by the fcetor and profuseness of the discharge, by the occurrence of hemorrhages, by the nature of the pain, which is generally severe and lancinating, by the unhealthy malignant local characters, and by the presence of the MALIGNANT DISEASE OF THE UTERUS. 587 malignant cachexia of system. From ordinary cancer of the womb it is easily known, by the want of extensive induration, by the mobility of the womb ; and often, though not always, want of tenderness to touch is also distinctive. As it advances, it consumes or corrodes the tissues ; spreading into the uterine cavity ; attacking and destroying the recto- vaginal, and vesico- vaginal septa. The disease is irremediable. But attempts have been made to arrest its progress while the cervix alone was implicated, by excising the part in the usual way. Frequently, the use of caustics seems to retard advance, to improve the nature of the discharges, and to diminish the tendency to repeated hemorrhage. For this purpose, the pencil of lunar caustic, and the actual cautery are of most service. The extreme fcetor of discharge is to be corrected by copious use of the chlorides upon the recipients of the discharge, and as a lotion ; used very gently internally, if there is little tendency to bleeding. A weak solution of the chloride of soda is suitable for this purpose. In addition, all the general rules for the palliation of cancerous disease are here applicable (Principles, p. 328). Cauliflower excrescence is also an unfrequent complaint. It consists in the projection of a malignant mass, which may be of various shapes, into the vagina. It springs from the cervix, and generally has a large base. It is covered by a number of small pedunculated bodies or granulations, which are often in bunches, and give the general appear- ance of a head of cauliflower. It is of a bright red colour, and easily made to bleed. The general symptoms are those of ordinary cancer of the uterus ; but the wateiy and bloody discharge is usually excessive in amount. On examination, a tumour is discovered, with the char- acters above stated ; it is felt to be moveable and polypoid ; and if the disease is in an early stage, the uterus also is not fixed. It is to be distinguished from the polypoid masses of encephaloid, which some- times grow from the interior of the cervix, but along with which there is much diffused cancerous infiltration. If the excrescence be the sole discoverable malignant afi^ection, and if there be every reason to think that it might be completely and favourably extirpated, the operation of excising the cervix should be performed. And during healing of the wound, care should be taken, by the use of caustics, to procure healthy cicatrization, and prevent, as long as may be, any tendency to repul- lulation of the growth. In numerous cases, the operation has been successful in procuring complete relief, and apparent cure — at least for a very considerable time. During the course of the disease, cold and astringent lotions are sometimes of service in checking the amount of discharge. Cancer of the Uterus occurs at all ages ; but increases in frequency from the period of puberty till the end of menstrual life. It presents 588 MALIGNANT DISEASE OF THE UTEEUS. itself most frequently in the form of scirrhous infiltration, and more rarely encephaloid. The scirrhous deposit generally commences in the neck, and spreads from thence ; the encephaloid more frequently attacks other parts of the organ first, and sometimes forms projecting and polypoid masses in the vagina, or on the cervix and body of the uterus ; it is softer to the touch, and probably gives rise to bleedings at an earlier period. "With encephaloid, too, there is more enlargement and hypertrophy of the non-cancerous parts of the organ, than with scirrhus. It sometimes but rarely happens that the vesico-vaginal or recto- vaginal septa are first affected with malignant deposit — the disease spreading from thence to the cervix uteri. At the outset, there is frequently much ill-defined derangement of the general health, Avhich proves but little amenable to treatment, and often distracts the attention of patient and practitioner from the real seat of disease. And even when the malady has made some pro- gress, but is still in an early stage, the distance of the severest pains from the womb, their lancinating and neuralgic character, and the small quantity, or even unusual absence, of discharge, may deceive. But as soon as ulceration is established, the nature of the discharges and their mixture with blood at once give the alarm. Patients frequently suffer from pain in the mamma, also in either the right or left hypogastric region, of a wearing kind, with frequent recurrences of stabbing and lancinating shoots ; also from fixed pain, often of a burning kind, in the region of the womb ; from pain in the back ; from pain and restlessness in the legs; from pruritus of the vulva, and irritation of the bladder ; also from constipation, and feeling of bearing down or pressure upon the anus. These sufferings may con- tinue during all the course of the disease, or may be at different times substituted the one for the other. Before active ulceration commences, there may be no discharge ; or there may be a secretion of thin, serous, acrid fluid. Sometimes, even when there is superficial and slowly progressive ulceration, there may be little or no discharge ; as is sometimes seen in cases of open scirrhus of the mamma. But, in general, as soon as ulceration com- mences, there appears a large quantity of muco-purulent secretion, which soon becomes foetid and mixed with dehris from the seat of disease. Hemorrhage also occurs ; either merely at times tinging the discharge more or less, or, if a considerable vessel has been ulcerated through, flowing in a continuous stream. On examination in an early stage of the disease, the cervix uteri is found enlarged, hard, irregularly nodulated, more or less tender to the touch ; the os much increased in size, and more or less dilated. On inspection, the cervix is seen to be generally of an unhealthy red MALIGNANT DISEASE OF THE UTERUS. 589 colour, and there may be excoriations in the sulci between the nodules ; the excoriations being of a deep red colour, and the nodules projecting and often shewing very little redness. Cancer of the uterus is generally of easy diagnosis ; patients gene- rally presenting themselves after ulceration with its accompanying dis- charges has commenced, and infiltration into the cervix and surround- ing tissues is considerably advanced. It is liable to be confounded with hypertrophy of the cervix, with fibrous tumour of the uterus, and with polypus ; and the grounds of distinction have already been given in treating of these subjects. The disease is incurable ; and treatment is confined to palliation. Sometimes the excessive watery discharge may be moderated by the use of astringent lotions, or the application of astringent ointments ; especially those having tannin in their composition. If there is much tendency to hemorrhage, no local application can be used with safety. Bleeding, when it occurs, must be arrested in the usual way — horizontal position, cold, styptics, astringents and opiates internally, and plug- ging if necessary. Foetor in the discharges is corrected by use of the chlorides. The pains in the hypogastrium and loins may be relieved for a time by blistering, or by cupping ; no blood, or a small quantity, being taken — according as there is little or much sharpness and fre- quency of pulse, or the reverse. The local application of ice, or of refrigerating mixtures, through the speculum, has sometimes been of service. But for the pains of this, as of all other forms of cancer, the great remedy is opium. When the disease is seen in an early stage, the cervix still mobile, and presenting only some prominent indurations — and if other circum- stances, as the general health and age of the patient, are propitious — an attempt may be justifiable to remove the part by excision, or by strong caustics used as already described, in speaking of the infiam- matory hypertrophy of the cervix, and of corroding ulcer. If this can- not be done, it is prudent to interfere with the parts as little as possible. If there is much cancerous deposit and induration, any violence, such as even introduction of the speculum, is liable to do much harm, by tear- ing or bursting the lacerable structures and inducing hemorrhage. Books on Midwifery, passim. — Leake, Astruc, Clarke, Dewees, Gooch, Boivin and Duges, Blundell, Meigs, Hamilton, Lee, Lever, Ashwell, Churchill, on Diseases of Women, or of Uterus. Dupuytren, Legons Orales. Nauche, Maladies propres aux Femmes. Lisfranc, Maladies de I'Uterus. Duparcque, Alterat. Organiques de I'Uterus. Siebold's Frauenzimmerkrankheiten. Meissner, Ueber die Polypen, &c. Bennett on Inflammation of Cervix Uteri. Locock, Art. Leucorrlicea, in Cycl. of Pract. Med. &c. Mackintosh's Practice of Physic. Whitehead on Abortion and Sterility. Waller, Art. Uterus, in Cycl. of Pract. Med. Safford Lee on Tumours of Uterus, &c. Ingleby, Facts and Cases in Obst. Med. Simpson, Dublin Journal, Nov, 1846, also May 1848; also various articles in Edinburgh Monthly Journal. Newnham on Inversion of the Uterus. Deneux, Tumeurs sang, de la Vulve. Jobert, Traits de Chir. Plastique. Walshe on Cancer, &c. &c. &c. 590 CHAPTEE XXXVIII. OPEBATIONS ON THE BLOOD-VESSELS OF THE LOWEE EXTEEMITY. The Aorta. Compression of the Aorta may often be of service in cases of pelvic hemorrhage ; assisting both Nature and the surgeon in their hemostatic means. And it can be readily effected by direct compression of the vessel against the vertebral column — a little above, and to the left side of the umbilicus — w^hen obesity, abdominal tumour, or intestinal distension, do not interfere. Deligation of the Aorta is very seldom required of the surgeon. Spontaneous obstruction of the vessel, doubtless, has occurred, in a few cases, vyithout serious consequences ensuing. But this event is wholly different from the abrupt mechanical obstruction by ligature ; and, besides, the ligature cannot be applied without the infliction of a most hazardous wound. From the operation, a permanently successful result cannot be expected ; it must, we fear, be regarded as inevitably fatal. But cir- cumstances may, notwithstanding, occur, such as warrant its perfor- mance with the object of protracting existence for a few hours ; saving the patient, perhaps, from death by the direct effect of hemorrhage, and affording an opportunity for the arrangement of temporal affairs ; yet inspiring no rational hope of ultimate recovery. The vessel may be reached in one of two ways ; directly, by incision through the abdomen ; or indirectly, on the outside of the peritoneum, by extension of such a wound as is suitable for deligation of the common iliac. Were there a chance of successful issue, the latter method, though the more difficult, would certainly be preferred. But, as it is, the direct mode is likely to be adopted, by any one who may unfortunately find himself compelled, by a sense of duty, to undertake so unpromising and serious a procedure. The bowels having been opened by a warm purgative, so as to void both their gaseous and their solid contents, a suitable incision is made in the mesial line, commencing above the umbilicus, and terminating a little below it. The intestines are care- THE ILIACS. 591 fully pushed aside, the peritoneum is again cut through, the vessel is exposed, and a ligature applied. Aneurism of the Abdominal Aorta itself, is obviously remediable only by general treatment (Principles, p. 592). In the nervous, hyste- _ rical, dyspeptic, and anemic, the affection is simulated by great abnormal pulsation in the course of the vessel. It is known by distinct perception of a tumour, which is not moveable ; by observing that the tumour pulsates equally in all directions ; by pulsation and bruit being limited to this one part of the vessel, not diffused equally along its course ; by the bruit being equally distinct in the supine and in the erect postures ; and by the pulsation being constant, not occasional and intermittent. At the same time it is right to state, that the diag- nosis of abdominal aneurism, especially in its incipient state, is often very obscure ; solid tumours, in the neighbourhood of the artery, par- taking of the aneurismal characters very closely. The Iliacs. On account of inguinal aneurism, and aneurism affecting the common femoral artery — also on account of hemorrhage not otherwise repressible — the External Iliac may require deligation. Due systemic pi'eparation having been made, the patient is placed recumbent, with the abdominal parietes relaxed by position ; and the surgeon proceeds to operate, with the intention of securing the vessel without injury of the peritoneum. Many forms of incision have been proposed and followed. That of M. Lisfranc is exact, and suitable ; exposing the vessel readily enough ; not calculated unnecessai'ily to weaken the abdominal parietes ; and, at the same time, causing little risk to the spermatic cord and artery, or to the circumflex artery and vein. The knife is entered, two lines above, and an inch within, the anterior superior spinous process of the ilium ; and, being candied downwards, the incision is terminated at an inch above the level of the spine of the pubes, and about an inch and one third on its external aspect. By cautious dissection, the abdominal layers are divided ; the fibres of the transversalis muscle — pinched up with forceps — being cut with extreme caution. The transversalis fascia is then scratched through, with the point of the knife — near the upper abdominal aperture, where the cord enters the inguinal canal, and where this fascia may be expected to be especially distinct, as well as loosely connected ; and, the finger having been introduced through the aperture, on this the rest of the fascia is divided in safety. The peritoneum, separated from the fascia, is pushed aside ; and is held out of the way, either by the fingers of an assistant, or by means of a flat copper spatula. The inner border of the psoas muscle is traced with the finger ; and, by its pulsation there, the artery 592 DELIGATION OF THE EXTERNAL ILIAC. will be detected. The vein is found on the inner side, and is cau- tiously separated by the finger nail, or by the point of the knife ; the artery is then more fully isolated, by the same means ; and the aneu- Fig. 163. rism needle is passed on the inner side — being inserted between the artery and vein. The wound is managed in the ordinary way ; and, by position of the trunk and limbs, abdominal relaxation is main- tained. This operation is, in general, easily performed ; unless when great obesity is encountered ; and is, perhaps, the most successful of its class. In aneurism, the point for securing the vessel must necessarily vary, accoi'ding to the bulk and site of the tumour. The Internal Iliac may require deligation ; on account of aneurism of, or hemorrhage from, its branches. Bleeding from deep perineal wounds, for example, may not otherwise be restrained. And in false aneurism of the gluteal or ischiatic arteries, this operation is usually considered preferable to direct incision of the tumour. The securing of the vessel, however, is attended with a considerable amount of both Fig. 163. Ligature of the external iliac. The wound supposed to be held open, a, artery ; h, vein ; c, peritoneum ; d, spermatic cord. — Skey, p. 270. DELIGATION OP THE INTERNAL ILIAC. 593 difficulty and hazard ; and, fortunately, is but seldom required. The patient having been placed as before, an incision is begun over the upper abdominal aperture, and carried upv^ards, as in the line of the former incision, to the extent of three, four, or five inches ; the extent varying according to the contemplated depth of the vessel, and alvp^ays leaning rather to the side of unnecessary amplitude. The comparative length of the external wound, intrinsically, will have but little eflFect on the success of the operation ; and yet it has a most important bear- ing thereon, according as it facilitates, or impedes, the accomplishment of exposui'e and deligation. The abdominal muscular layers having been cautiously cut through, the transversalis fascia having been divided, and the peritoneum having been pushed aside, the sacro-iliac articulation is felt ; and there the vessel wiU be found pulsating, in close connection with its vein, and perhaps with the ureter also — both of which parts are to be avoided carefully. The origin of the vessel is nearly opposite the centre of a line, drawn from the anterior superior spinous process of the ilium to the umbilicus. Frequently, the ex- ternal iliac — first found — will prove the best guide to the internal. Fig. 164. Wound of the abdominal parietes ; supposed to be held aside, shewing the iliacs. a, a ligature round the internal iliac ; h, a ligature on the common iliac ; c, liga- ture of the external iliac. 2 Q 594 THE PEMORALS. Isolation is effected by the finger-nail, or by the end of the needle. It is not safe to use the knife's point at such a depth. The vein, situ- ated posteriorly, is especially cared for. The wound being then fully opened by assistants, the needle is passed, from within outwards ; taking care to avoid the ureter and peritoneum internally, and the ex- ternal iliac vessels externally ; and selecting the point of deligation at a suitable distance from the iliac bifurcation. The Common Iliac may requu'e deligation, on account of either aneurism or hemorrhage implicating the external and internal iliac arteries ; or on account of secondary hemorrhage after high amputa- tion in the thigh. It is reached by an incision similar to that just described ; and is, perhaps, as easy and promising an operation as the preceding. The vein is found on the inner and posterior aspect of the artery, on the left side ; behind and external to the artery, on the right. A similar incision, extended upwards, may serve, as already stated, for deligation of the Aorta (p. 590). The Femorals. Aneurism of the Common Femoral, as formerly observed, requires deligation of the external iliac. False aneurism may form in the superficial femoral ; and, for this, the ordinary operation for such an accident is requisite; namely, incision of the sac, and deligation of the artery above and below the wounded part. Aneurismal varix, too, is occasionally met with here, of traumatic origin ; a penetrating wound having been inflicted by the grasping of a knife, or other sharp- pointed instrument, between the thighs. It may prove but little troublesome, and demand no other treatment than support of the part by bandaging. The Popliteal is probably the most common of all external aneurisms ; and, hitherto, the Hunterian application of ligature, to the superficial femoral, has been the only approved mode of treatment. Latterly, however, as elsewhere explained (Principles, p. 580), the application of pressure, instead of the ligature, has been employed. And ex- perience is, almost daily, giving direct and undoubted testimony to the efficacy of the practice. There are some patients, doubtless, who may prove intolerant of pressure ; and there may be others who prefer the apparent certainty of the knife and ligature, to the apparent un- certainty and delay of the compressor. But the greater number of cases are assuredly capable of cure by pressure properly applied ; vsdthout risk, with but little pain or inconvenience, and without any wearisome amount of privation or confinement. The skin, which is t-o bear the pressure of the instrument, is protected by a layer of thick PRESSUEE, IN POPLITEAL ANEUEISM. 595 soap-plaster ; and that, again, may be covered by leather. More than one compressor is used ; or, at least, pressure is made at different parts, at different times ; so that the burden of it may not all be thrown on one point, but, by being subdivided, may be rendered more tolerable.* Using several instruments, along the course of the vessel in the thigh — they may be slackened and tightened alternately ; or the same in- strument may be shifted in its site, with a like effect. It is never to be forgotten, that all severity of pressure is unnecessary ; and that it is not essential to arrest the arterial flow, at the compressed point. And it is also important to remember, that should this mode of treat- ment fail, it by no means interferes with subsequent performance of the ordinary operation ; but, on the contrary, the constitutional treatment suitable for pressure renders the success of subsequent deligation all the more probable. Those surgeons who obstinately adhere to the old operation may adduce, as their apology, a series of successful cases so treated. But this is very plainly a contracted view of the subject ; and as well might such practitioners prefer successful amputation of the hand to amputation of a finger, for a simple affection of the latter only. A surgeon of the olden time, who had succeeded in curing several successive cases of popliteal aneurism by amputation of the thigh, might very naturally entertain a distrust and dislike of the pro- posal to treat the same disease by ligature of the femoral ; but the naturalness of such an aversion to the minor and modern practice, would not render it one whit the more reasonable or praiseworthy. And an impartial observer will not consider any one justified, in sub- jecting his patient to serious risk of life, by hemorrhage, suppuration, and gangrene ; while he has it in his power to effect cure by a minor means, comparatively devoid of risk, and the failure of which will not militate against subsequent recourse to the major procedure — if ne- cessary. "Why should a mode of treatment, which causes little or no risk, always be passed by ; or why should an operation always be had recourse to, which may, and not unfrequently does, result in direct loss of life ? And the question comes in much force, if it be admitted — and statistics will scarcely warrant even feeble contradiction of this any longer — that the two methods are at least equally successful for the cure of aneurism. Recorded facts seem to prove the following conclusions — 1, That, in popliteal aneurism, skilful compression of the femoral is capable of * The mechanical means for compression are undergoing change, and are, doubtless, destined to become more simple and more perfect. Dr. Carte's instruments for making accurate and elastic pressure on the vessel at the groin, and in the upper part of the thigh, are efficient and ingenious, but complicated and expensive. Some have used com- mon leaden weights placed over the vessel, and have found them suiUble and satisfac- tory. For a detailed description of the different instruments, see Tufnell on the Treat- ment of Aneurism by compression, Dublin, 1851. 2 Q 2 596 DELiaATION OF THE SUPERFICIAL FEMORAL. curing the disease, and that with comparative, and almost absolute safety to life and limb ; 2, That the time expended in cure is, on an average, not greater than in the treatment by ligature ; 3, That failure by compression does not compromise subsequent recourse to deligation ; 4, And that consequently, compression, when skilfully employed, being equally certain, far more safe, and not more tedious than the ligature, should in the great majority of cases be preferred. The only dis- advantage of compression is the care and trouble necessary on the part of the attendant, with irksomeness and sometimes suffering on the part of the patient. The obvious and only advantage of deligation, on the other hand, is the facility and dispatch of its execution, with probable exemption from suffering afterwards by the patient, in the successful cases. The formidable disadvantage is, its proved risk to life and limb.* But should a case occur, suitable for deligation — on account of intolerance or failure of pressure, or on account of expressed wish and preference by the patient — the operation is performed as follows : — The patient is placed recumbent, with the upper part of the thigh suit- ably exposed. He is directed slightly to adduct and raise the thigh, so as to make the inner edge of the sartorius salient ; and, along this, the superficial femoral is traced. An incision of two or three inches in length is then made, in the course of the vessel ; so placed, that its centre may correspond to the part of the artery where it is intended to place the ligature. By cautious dissection, the common sheath is exposed ; and, very carefully, this is opened, and the arterial coats isolated, to the requisite extent. In the external wound, the saphena vein is avoided ; in the deep dissection, avoidance of the femoral vein cannot too prominently occupy our regard. The needle is passed very cautiously, so as to avoid all injury to the vein ; which is situated posteriorly, and may be partly seen bulging out on the inner aspect of the artery. The point usually chosen for deligation is where the ves- sel is crossed or concealed by the sartoi'ius ; sufficiently removed from the profunda, as a cross branch ; and not too distant from the aneu- rismal tumour. In performing this operation, the surgeon should always make sure that the tightening of his ligature has a satisfactory effect on the tumour ; for there is the same risk of a high division here, as in the case of the humeral artery (p. 263); and, consequently, two parallel vessels may require ligature. After deligation, a relaxed position of the limb is maintained, for obvious reasons. For aneurism affecting the lower part of the femoral artery, a similar operation may be required. For aneurism of the superficial * Vide Tufnell, op. cit. ; and Brit, and For. Med, Chir. Rev. Oct. 1851, p. 470. DELIGATION OF THE POPLITEAL. 597 femoral, in its upper part, the Common Femoral may be tied. But this vessel is obviously not favourably circumstanced for successful deliga- tion ; and, in consequence, the equally simple and greatly more cer- tain operation, on the external iliac, is to be preferred. In recent wound of the common femoral, however, with or without the forma- tion of false aneurism, the ordinary rules of surgery are to be upheld ; the part is cut directly into, and each orifice of the wounded vessel is secured. The femoral vein, here on the pubic side of the artery, is carefully avoided. The Popliteal. For aneurism, or for bleeding, in connexion with the posterior tibial, the Popliteal artery may be tied ; but ligature of the superficial femoral, below where it is crossed by the sartorius, is a preferable operation. For wound of the popliteal itself, however, ligature of that Fig. 165. vessel is necessary, according to the general principles of surgery. The patient having been secured in a prone posture, a free incision is made, traversing the popliteal space, and penetrating through the skin, areolar tissue, and fascia. The deep dissection is continued cautiously, along the borders of the semi-tendinosus and semi-membranosus muscles. On the edge of the latter muscle, the artery may be felt beating ; per- haps overlapped by it. The vein is superficial, and somewhat external to the artery. The nerve is both on a more superficial plane, and on Fig. 165. Ligature of the popliteal at its upper and lower parts, a, the popliteal vein; h, the popliteal artery; c, the posterior saphena vein. The sciatic nerve, on the outside of the artery, has been accidentally omitted in the diagram. 598 DELIGATION OF THE TIBIAL ARTEEIES. the exterior of the mesial line. The vessel is most readily exposed and secured in the upper part of its course. The Tibials. These vessels may require ligature, on account o£ recent wound, or on account of false aneurism formed at some part of their course. For secondary hemorrhage, ligature of the femoral is to be preferred ; when recourse to an operation of this kind is deemed expedient. Fig. 168. Ligature of the Posterior Tibial, at the upper part of the leg, is an operation of considerable difficulty. Tw^o methods are recommended. One consisting of a direct incision on the vessel, through the centre of the gastrocnemius and solseus ; the other reaching the vessel from the lateral aspect. The latter is usually preferred. The limb having been Fig. 166. Ligature of the posterior tibial, at various parts. The wounds are supposed to be held asunder. The ligature is under the vessel. DELIGATION OP THE TIBIAL ARTERIES. 599 placed on its outer side, a free incision is made between the edge of the tibia and the border of the gastrocnemius ; the tibial origin of the soljeus is then divided ; and, the deep fascia having been cut through, the artery will be found about an inch from the tibia, between the con- ^r^ '• Fig. 167. comitant veins, and with the nerve on its fibular side. Separation of the veins is made very carefuUy, while the edges of this deep wound are as much retracted as possible by means of copper spatulse ; the knee being bent, and the foot extended, so as to relax the muscles of the calf. The needle is passed from without inwards. At the lower part of the leg, the vessel is reached much more readily ; by making an incision on the inner side of, and parallel to, the tendo Achillis, through the two layers of fascia ; opening the Fig. 167. Ligature of the anterior tibial, at various parts. The -wounds are supposed to be held asunder. The ligature is under the vessel. 600 DELIGATION OF THE TIBIAL ARTERIES. sheath, separating the artery from its concomitant veins, and applying the ligature in the ordinary way. At the ankle, the operation is also simple. A semilunar incision is made on the inner side of the malleolus, about a finger's-breadth distant from it ; indeed, the finger, applied behind the malleolus, may be a sufficient guide to the knife. The fascia of the leg having been divided, a strong aponeurosis is exposed ; this having been cautiously cut through, the common sheath is found ; and, the vessel having been separated from its concomitant veins, the needle is passed from the heel towards the ankle, to avoid the nerve which is situated between the artery and the tendo Achillis. The Anterior Tibial may be tied, either at the upper or at the lower part of the leg. The superior operation is difiicult. A free incision is made between the extensor communis digitorum and tibialis anticus ; and it is well to make a slight transverse division of the investing fascia, at each extremity of the wound. The foot is flexed. The re- laxed muscles are separated down to the inter-osseous ligament ; and, on this, the artery will be found. In the middle of the leg, the artery is placed between the tibialis anticus and the extensor proprius pollicis. At the lowest part of the leg, a less incision is necessary; the vessel being much more superficial. The wound is made on the fibular side of the extensor proprius pollicis. The vense comites, and the anterior tibial nerve, are carefully excluded from the ligature. Should it seem necessary to secure the vessel on the instep, by regular dissection, it is found by an incision on the fibular side of the tendon of the extensor proprius pollicis. The Peroneal artery may be exposed, by a free incision on the pos- terior and tibial aspect of the fibula. It is found concealed under the inner edge of the flexor longus pollicis. Deligation of the arteries of the leg, however, being seldom if ever required except on account of recent wound, all rules for regular dissec- tion may be in a great measure dispensed with ; the extent and form of incision depending very much on those of the wound already existing, and the bleeding point being the best guide to the injured vessel. Manec on Ligature of Arteries, Paris, 1832. Harrison, Surgical Anatomy of the Arteries, Dublin, 1833. Knox, the Arteries, from Tiedemann, 1835. R. Quain, Anatomy of the Arteries, with large plates, London, 1840. Dermott, Illustrations of the Arteries connected with Aneurism, 1841. Tufnell on the Treatment of Aneurism by Compres- sion, Dublin, 1851. The bibliographical references to Chapters XIX. and XX. have been accidentally misplaced at p. 267. 601 CHAPTER XXXTX. AFFECTIONS OF THE JOINTS OF THE LOWER EXTREMITY. Morbus Goxarius. The hip-joint is liable to the common diseases of articulations ; but, from its position, the exciting causes of synovitis affect it but little, comparatively. It is a common seat of porcellanous deposit, inter- stitial absorption, adventitious deposit, and other chronic structural changes (Principles, p. 525, et seq.) It is sometimes affected by neuralgia, also ; and then is constituted the true Coxalgia — a term, which, like its analogue Omalgia, has been improperly applied to structural change. But the most important as well as the most com- mon affection to which this joint is liable, is chronic disorganization of the head of the bone ; to which the term Morbus Goxarius is applied. There is reason to believe that the moi'bid changes usually observe the following sequence. Interstitial absorption takes place in the can- cellated tissue of the neck of the bone ; perhaps with deposit of tuber- cular matter in the opening texture. After a time, a chronic inflam- matory process is kindled ; and softening and disintegration ensue, affecting chiefly that part which is immediately beneath the articulating cartilage. The cartilage is then involved ; partly by ulcerative erosion, partly by necrosis of patches. Matter is effused into the synovial capsule ; and acute disintegration is established. The cartilage perishes more and more ; the head of the bone crumbles down ; the acetabulum is secondarily involved in similar decay ; the joint fills, and is reduced to the condition of abscess ; the matter makes its way, more or less rapidly, and at one or more points, through the restraining textures ; cor- responding pointing takes place, followed by evacuation ; and then, either the work of disintegration may advance with a fresh and fatal energy, or a lull may be experienced, and anchylosis may ensue. Such we believe to be the ordinary course. But the diseased action may occa- sionally commence, or at least be cotemporaneous in the acetabulum. A more rapid and acute destruction .of the joint may follow inflam- matory action primarily affecting the synovial apparatus. But the 602 MORBUS COXARIUS. term morbus coxarius is, in strict accuracy, limited to the chronic and gradually nascent affection, which commences in the hard textures. The disease is conveniently divided into two stages. The first, the period which is occupied in the incipient change of structure ; Fig. 168. without such loss of substance as to cause change of form, and with the synovial capsule yet entire; denoted by apparent elongation of the limb. The second, corresponding to loss of substance, change of form, and destruction of the joint ; indicated by the limb's shortening and distortion. The affection is most common in the young, more especially in those of strumous habit; and it may, or may not, be connected with some external injury as its exciting cause. The primary symptoms are deceptive. They are such as may attend on dentition in childhood, or on general disorder of health in adolescence ; they may simulate rheumatism also ; and they are every Fig. 168. Articular caries, affecting the hip-joint. Fig. 169. Wasting of muscles shewn, with elongation of limb, in disease of the hip- joint. The muscular deficiency is but imperfectly represented; the change of natal fold, resulting from it, is however sufSciently apparent. MOEBUS COXARIUS. 603 day mistaken for primary affection of the knee. Obscure pains are felt in the knee and thigh, and occasionally in the hip. The limb is weak, and its weakness is complained of — increasing with exercise ; it is felt to be long as well as weak ; it is dragged, rather than moved, in walking ; in standing, it is somewhat advanced, while but little weight is borne on it ; and all these symptoms are most observable during fatigue consequent on exercise. An inspection, with the body naked from the waist, is essential. The knee, in which for some time gi'eat and almost constant pain has been complained of, may be quite of a normal appearance, and also tolerant of manipulation. The affected limb is decidedly thinner, softer, and more shrunk in appear- ance than the sound one, and somewhat advanced in position ; resting on the toes and ball of the foot, with the heel raised from the ground. To bring the two heels together requires an effort, with a suitable inclination of the pelvis ; and the effort usually causes aggravation of uneasiness. As, in the analogous affection of the humerus, the shoulder is flattened by wasting of the deltoid (p. 275) ; so here is found a flattening of the hip, by wasting of the glutei. The fold between the nates and thigh — deep and almost transverse in the normal state — is sloping, superficial, and sometimes almost effaced. Place the patient recumbent ; straighten the spine, and equalize the position of the pelvis as much as possible — and elongation of the limb will be observed ; the knees and heels by no means corresponding to each other. Part of this elongation, no doubt, is apparent only — from twisting of the spine and pelvis, which it is impossible altogether to undo ; but part of it is real — dependent on relaxation of the liga- mentous apparatus, and on increasing accumulation of fluid within the capsule, while as yet no change of form has occurred in the bone ; and also in part dependent on the comparative, or even actual, disuse of that limb, in bearing the weight of the body during the erect posture. The foregoing symptoms, however, may almost all be found in the delicate adolescent, without disease of the hip. And a further exa- mination is necessary for diagnosis ; by jarring the joint suspected. Forcible abduction of the thigh causes pain in the hip ; so does rota- tion of the limb ; and a still more distinct sensation follows concussion, applied either directly or indirectly — by striking the knee, or the sole of the foot, or the trochanter-major, smartly. There is also tenderness of the groin, and behind the trochanter. Thus far — the first stage — the disease is capable of complete cure ; the limb being left of its normal length, and restored to its normal form and capabilities. But, too frequently, the morbid process advances. Pain and tenderness increase ; swelling of the hip becomes more and more apparent ; and the thigh is increasingly flexed on the pelvis. A bulging is observable behind the trochanter ; and this bone 604 MORBUS COXi^EIUS. seems displaced somewhat backwards. Enlargement also may form over the groin ; and the swellings may be felt to fluctuate. Opening and evacuation ultimately take place ; with one of the two results already stated. In this, the second stage, shortening of the limb is observed ; the Fig. 170. Kg. 171. toes resting on the ground, without any advancement of the limb. As the shortening advances, the toes may not reach the ground at all ; but, turning inwards, may dangle over the opposite member, as in dislocation. Or the toes may be everted, as in fracture of the neck of the thigh bone. And it is supposed that comparative destruction of the acetabulum tends to inversion, while comparative destruction of the head of the bone favours eversion of the foot. This shortening is plainly symptomatic of organic change in the joint; destruction of hard tissues as well as soft, deepening of the acetabulum, and abridg- ment of the head of the femur. And towards such shortening, no doubt, a spastic action of the muscles of the hip contributes somewhat. The hip appears more and more broad and prominent ; though really flat and wasted ; apparent enlargement depending on atrophy of the rest of the limb, with twisting of the pelvis. As disorganization advances within, the joint becomes more and more loose ; and dislo- Fig. 170. Shortening, swelling, deformity, lameness ; the advanced stage of morbus coxarius. Fig. 171. Luxation of hip, in consequence of morbus coxarius. MORBUS COXAKIUS. 605 cation may occur, by muscular action alone — without the intervention of a fall or other injury. The dislocation is usually upwards, on the dorsum of the ilium ; and this event is of course followed by increase of shortening in the limb, and by a still greater and more marked deformity of the hip. Matter, in general, continues to form ; and is evacuated at various points ; at the groin, behind the trochanter, in the thigh. Not unfrequently, perforation of the acetabulum takes place ; and then the matter may accumulate within the pelvis, fatally ; or it may again make its way outwards, through the sciatic notch, and discharge itself at some part of the hip or thigh ; or evacuation may take place by the rectum. Structural change may advance from bad to worse ; the patient perishing of hectic. Or anchylosis may take place ; Fig. 172. the patient recovering with a stiff joint, and a shrunk and deformed limb. In the case of dislocation — by no means of frequent occurrence — it sometimes happens that morbid action ceases, and the head of the bone acquires a new recipient cavity on the dorsum of the ilium. More frequently, however, the head of the bone seems to act as a foreign body in its new site, and causes much inflammatory excitement. Acute affection of the synovial apparatus in the hip — by some termed the Acute form of Morbus Coxarius — shows the ordinary characters of synovial disease. There is rapid and uniform swelling of the hip, with acute pain in the hip, thigh, and knee, much increased by movement and pressure of the hip ; the thigh is bent upward, by spastic action of the muscles ; and, very often, an apparent shortening of the limb is to be observed, dependent on twisting of the pelvis ; acute fever attends ; walking and even the erect posture are imprac- ticable ; often the slightest movement, even during recumbency, is Fig. 172. Cuve (?) of morbus coxarius by anchylosis. 606 TEEATMENT OF MORBUS COXARIUS. attended with great agony. If the action be not speedily arrested, suppuration takes place; the matter is discharged, by one or more openings ; and extreme articular disorganization too frequently results, with corresponding disorder of the system. Such a case is met by the ordinary treatment adapted to acute synovitis (Principles, p. 493, et seq.) Not unfrequently, the affection is of rheumatic origin. The chronic disease, or true morbus coxarius, is also amenable to the general rules of practice. But, as already stated, it is only in the first stage that complete cure and restoration to health can be hoped for. The disease cannot be opposed too soon ; consequently, tact and expe- rience are of much value, in enabling the practitioner to detect with certainty the obscure and insidious commencement. The paramount indication is rest ; one, however, which it is often very difficult to main- tain efiectively. The patient must be wholly confined to the recumbent and sitting postures ; the weight of the body must not, for an instant, be felt by the affected limb. And the best way of accomplishing this, is to put the patient to bed, and keep him there ; the pai'ents and attendants having been previously enlisted in the cause, by having the importance of the privation fully explained to them. Should the patient prove refractory, a light splint may be applied, as for fi-acture of the neck of the bone. And by some, indeed, the wearing of this splint is recommended throughout the whole period of cure, in order to oppose the decided tendency to flexion of the thigh which invariably exists — increasing along with the disease. But, probably, relief is obtained by this spontaneous assumption of posture, as in analogous affections of the knee-joint ; and, to thwart Nature in this, were to denude ourselves of an important item of the means of cure. Encou- rage flexion, rather, until the disease has begun to subside ; and then undo it gradually, ere rigidity has occurred. A few leeches are applied over the hip — perhaps with repetition, should heat or pain seem to require this ; and then moderate counter- irritation is maintained, by inunction of croton oil, or tartar emetic. If the tubercular cachexy be suspected, the suitable opposing constitu- tional management is put in force — especially cod-liver oil. And by steady perseverance in such treatment, for some weeks, all symptoms of disease may subside ; the patient may rise, without any feeling of local ailment ; and, cautiously renewing the use of the limb, he may find, in due time, all its functions fully restored. But if the disease threaten to advance, recourse to a higher degree of counter-irritation is expedient ; the actual cautery may be applied behind the trochanter ; or a seton may be placed either there, or in the groin. Rest and moderate counter-irritation were enough, for the period of absorption ; but when structural change, by chronic inflammatory results, has fairly begun, the highest grade of counter-irritation is demanded. TREATMENT OF MOEBUS COXAEIUS. 607 In the advanced period of the second stage, all severity of treatment is inexpedient, there being then no longer any hope of saving struc- ture. When matter has formed, and is plainly discernible, seeking the surface, an early opening is advisable — here as elsewhere ; an opening must form sooner or later, and early evacuation may not only give relief, but may also limit disoi'ganization. Then we may hope only for a minor result of treatment — anchylosis ; or for gradual cessation of morbid action, leaving the joint crank, weak, yet movable, and a limb impaired in both its symmetry and function. To conduce towards such ends, we mainly trust to general treatment ; keeping the parts steady by means of splints. Now there can be no harm in undoing flexion completely, and keep- ing the limb straight. Tension of the joint is not likely to occur ; so much disorganization having taken place. And by maintaining the straight posture — by means of the long wooden splint, if necessary — dis- location is rendered less likely, and the position is made more favourable for usefulness after anchylosis. In open disorganization of the joint, the straight splint may not be tolerated ; then relief is obtained from the gum or leather splints, as elsewhere noticed (Principles, p. 517). When from synovitis, imperfectly resolved, stiffness of the hip remains, orthopaedic treatment may be applied with advantage ; friction, passive motion, and perhaps subcutaneous section of resisting muscles. But in the case of anchylosis following structural change in the joint, the result of morbus coxarius, all such attempts will be wisely desisted from ; we ought rather to content ourselves with possession of a partial cure, than incur the risk of return of the disease in an aggravated form. There are cases, however, in which the propriety of resection may be not unreasonably entertained ; when, in an open state of the joint, after spontaneous dislocation, the head of the bone seems to cause much excitement in its new site ; when there is good reason to suppose that the disease has all along been chiefly limited to the head of the bone, leaving the acetabulum comparatively uninjured ; and when it seems probable that, after removal of the head of the femur, quiet might be restored to the joint, and a certain degree of useful motion might be regained. Successful cases are already on the records of surgery.* The diagnosis of morbus coxarius from other diseases is important. It is simulated by sciatica, by enlargement of bursee, by lumbar dis- ease, by rheumatism, by interstitial absorption of the neck of the thigh bone in the aged, and by wasting of the limb consequent on general irritation in the young. 1. Sciatica is known by the pain following the course of the sciatic nerves ; the whole thigh is lame ; position of * Vide Lancet, No. 1285, p. 414. In the same Journal, the question of resection, as applicable to this joint, will be found well stated. No. 1283, p. 362. 608 DIAONOSIS OF MORBUS COXAEIUS. the trochanter, and the length of the limb, are unchanged. 2. Beneath the conjoint tendon of the psoas magnus and iliacus internus muscles, a bursa is interposed, where the tendon plays on the capsule of the hip-joint. And this bursa is liable to chronic enlargement ; causing pain in the hip and knee, flexion of the thigh, disuse and wasting of the member. The enlargement may be felt, and is painful on pres- sure ; succussion of the joint itself causes no pain ; abduction and rota- tion of the limb are not attended with inconvenience ; but forcible extension of the thigh and inversion of the foot cause pain, by stretch- ing the affected part ; and pain is also felt when the patient himself flexes the thigh, or everts the foot — the tendon then acting directly on the bursal swelling. 3. Disease of the lumbar vertebrae, inducing neuralgic pains in the hip and limb, and impeding progression, is sus- pected when there is absence of the positive signs of hip-joint disease, as well as of those of bursal affection ; and its existence may be ascer- tained by minute inquiry into the history of the case, with careful manipulation of the lumbar and sacral regions. 4. Young girls, about the time of puberty, or earlier, are apt to fall into a state of general disorder of system. Among other signs of this, lameness of one limb may occui', perhaps with occasional pain of the knee ; and, on exami- nation, the limb may be found smaller than its fellow, the muscles soft and flabby, and the hip, consequently, somewhat flattened. Abduc- tion, rotation, and succussion, however, are all well borne ; and on the affected limb the patient may hop round the room, with impunity. It were cruel, as well as futile, to confine that patient to constant recum- bency, to leech the hip, or to bring out crops of pustules over it. It is sufiicient to enjoin moderate exercise, sea-bathing, friction, and general tonic treatment. 5. The other affections mentioned, as liable to simulate hip-joint disease, are detected by ordinary care in diagnosis ; they require no special remarks. Resection of the Hip- Joint. Till lately, this operation has not had a place in surgery. And it is still begirt with difficulty and danger. As just stated, in a few cases of advanced morbus coxarius it may be deemed warrantable ; when the head of the femur is dislocated, and is causing continuance or aggravation of excitement ; Avhen the joint is open ; when the muscles are wasted, and the head of the bone, consequently, is covered with little else than skin and areolar tissue ; and when there is reason to believe that the acetabulum is comparatively free from disease. In connexion with this last point, it is well to remember that, after dislo- cation, the acetabulum may take on a healing action, and, instead of remaining ulcerated, become occupied by a fibrous tissue. Also, in CHANGE OF FORM IN THE HIP-JOINT. 609 gun-shot wounds and other similar injuries, involving the head and neck of the femur only, removal of these parts is preferable to am- putation of the w^hole limb ; and may be had recourse to unhesi- tatingly, with a good prospect of success. No decided rules can be laid down to guide the manipulations. The form and extent of the wound will depend, very much, on the nature of the openings which already Fig. 173. exist. A sufficiency of the diseased or injured bone having been removed, and the wound having been adjusted, the limb is placed straight, and retained in that position by means of the long splint suit- able for fracture. In the case of an anchylosed hip, the neck of the bone may be divided; with the view of forming a false articulation at the sawn part, and so restoring motion (Principles, p. 519). Success has already attended the experiment; its reputation for safety and expediency, however, is as yet by no means determined. Change of Form in the Hip- Joint. The chronic changes of form which frequently occur in the hip- joint, have been formerly treated of (Principles, p. 525). By osseous deposit, and porcellanous change — but especially by interstitial absorp- tion of the head and neck of the femur — most serious lameness occurs ; Fig. 173. Cure of morbus coxarius by anchylosis, bisected ; at a, section might be made, with a view to the formation of a false joint. 2 R 610 AFFECTIONS OF THE KNEE AND HAM. slowly, but steadily advancing, often under the cover of symptoms characteristic of chronic rheumatism in the part. Rest, gentle counter- Fig. 174. rig. 175. irritation, and constitutional alteratives — especially the iodide of potas- sium — constitute the treatment ; but too often are of little avail. Affections of the Knee and Ham. Affections of the knee are not so peculiar as to require separate consideration. This joint, it will be remem- bered, is especially subject to synovitis, chronic and acute ; to disease of the bone, and of the cartilages ; and to the formation of loose bodies within the synovial cavity. It is not suitable for the operation of Resection. HousemaicVs Knee — that is, enlargement of the bursa over the patella — is extremely com- mon in housemaids, shop-keepers, and others who habitually exert much pressure on this part. The affection is usually chronic ; some- times, however, the case is acute, and apt then to be associated with erysipelas. The ordinary treatment is required (Principles, p. 543). . ^ ^ ^ Kg. 176. Fig. 174. Head of femur and acetabulum much altered by chronic deposit ; causing shortening of the limb, and stiffness of the joint. Fig. 17.5. Femur bisected ; head atrophied and altered ; neck gone ; the result of interstitial absorption. Shortening and lameness inevitably gi-eat. " Fig. 176. Enlarged bursa over the patella ; the result of pressure. Housemaid's knee. TUMOURS OF THE HAM. 611 Abscess of the Ham is by no means unfrequent; and may be con- nected with exfoliation from the posterioi' part of the femur. When the portion of dead bone is large, considerable difficulty may be experienced in effecting its removal ; and free incision may be neces- sary. In such circumstances, caution is obviously required, lest injury be done to the artery, vein, or nerve. Tumours may form in the ham. As already stated, it is perhaps the most frequent site of external aneurism. G-anglionic and bursal enlargements form, producing more or less inconvenience ; and these may be treated by repeated puncture by means of a trocar and canula, or by puncture followed by injection as in hydrocele. Erectile, fatty, encysted, and fibrous tumours are also met with. The ordinary treatment is required. Removal should be early, before deep and inconvenient attachments have been formed. Tn addition to the ordinary authorities on diseases of the joints, see Coulson, on diseases of the hip-joint, London, 1841. Hugman, on Morbus Coxarius, &c., London 1850. 2 r2 612 CHAPTEE XL. INJUEIES OF THE LOWER EXTREMITIES. Fractures. Fractures of the Pelvis. The bones of the pelvis give way, only under great and crushing force ; a heavy weight, for example, passing over or falling on the part. There is but little displacement ; muscles not tending thereto. The great risk is from injury done to the important parts within. The bladder may be torn, or it may be punctured by a spiculum, as formerly noticed (p. 469) ; a portion of bowel may be ruptured ; or great extravasation of blood may occur. From such lesions of structure, immediate danger to life results. A risk somewhat more remote follows mere bruise of the interior ; inflammatory action being lighted up within, and advancing both rapidly and untowardly. Or, instead of union, abscess may form at the site of fracture. In treatment, little is to be done in the way of replacement ; the chief care must be directed towards avoidance of motion, and the averting of inordinate action. The application of a broad, firm bandage suffices for the former indication ; the latter is fulfilled in the ordinary way. 1 . A waggon wheel, rolling over the pelvis, may detach the Crest of the Illium from the body of the bone. The upper fragment is dis- placed inwards ; and replacement may be effected by the fingers, ere swelling has occurred. 2. From a heavy and high fall, fracture of the Sacrum may result. The fracture is usually longitudinal ; and there is no displacement. 3. A kick or fall may cause fracture of the Coccyx ; and there may be considerable displacement inwards. By means of the finger in the rectum, accurate readjustment may be effected ; and it is very obvious that, in the after treatment, both purgation and con- stipation are to be avoided. 4. The Os Pubis may give way in its horizontal body, or in its descending ramus. This fracture is especially hazardous, from the risk which displacement of the sharp fragments, inwards, entails upon the bladder. The necessary treatment was formerly considered (p. 470). 5. The ascending ramus of the Ischium FRACTURES 0¥ THE FEMUK. 613 is as frequently broken as any other part of the pelvis. Ci'epitus is readily felt by the finger in the rectum or vagina ; and, by the same means, readjustment of the fractured portions is to be effected. 6. The Acetabulum may be split ; and injury of the neck of the femur may be simulated. There is no shortening of the limb ; and ci'epitus is felt by the finger in the rectum or vagina — when the pelvis is moved, not during mei-e rotation of the thigh. Fractures of the Femur. I. Fracture of the Neck, toithin the Capsule. — This accident is almost peculiar to advanced years ; and occurs more frequently in women then in men. The external dense portion of the bone is atrophied, a mere thin shell enclosing the cancellous texture ; the neck tends to become rectangular, instead of being oblique, in relation to the shaft of the bone ; and there is, besides, the brittleness of the osseous texture peculiar to old age. The accident may be produced by direct violence, as by falls on the hip ; more frequently it is the re- sult of indirect violence, as by a slip or stumble, of comparatively trivial amount. The upper fragment remains in situ ; the lower fragment is drawn upwards by the muscles of the hip, and rests above and on the brim of the acetabulum — further elevation being resisted by the capsular ligament. Such displacement may not occur immediately, however ; not until spastic action of the muscles takes place — it may be, some hours after receipt of the injury ; and if the periosteal investment be not wholly torn through, the displacement after all may be but slight. "When shortening, to a marked extent, occurs suddenly after some hours, there is reason to infer that the periosteal investment, at first but partially torn, has then given away entirely. By muscular action, also, the lower fragment is everted ; the muscles inserted into the tro- chanteric fossa, inter-trochanteric line, and trochanter minor, especially conducing to this change. On examination — best conducted with the patient laid straight on his back — the following signs of the injury are observable : — There is shortening of the limb, from half an inch to nearly two inches ; but perhaps not immediate, as just explained. The toes are everted, and the eversion can be undone by the surgeon, though not without the infliction of much pain. Like the shortening, the eversion may at first be but slight. In some few cases, inversion is found ; but that position is accidental ; resulting from the nature and direction of the inflicting force, and from absence of the muscular action which ordin- arily determines the displacement, and which might have undone the position in which force had first placed the limb. The trochanter is higher and flatter than its fellow. Voluntary motion and power are greatly abridged ; forced motion is preternaturally extensive. On 614 FRACTUKES OF THE FEMUR. rotation of the limb, the hand or ear, placed over the trochanter or on the groin, perceives distinct crepitus ; but only when extension has previously been made, so as to bring the fragments into apposition. By gentle extension, the shortening may be undone, and the two heels may be brought together ; but on ceasing to extend, muscular action soon restores the shortening as before. On rotating both thighs, the trochanters will be found " moving in the arcs of different circles ; that on the injured side rolling on its own axis, while the healthy trochanter describes an arc of which the neck forms the radius." There is no great amount of swelling ; as can readily be understood, when the nature of the inj ui'ed parts is considered. It is possible that impaction may take place — the upper fragment being driven into the lower ; in which case the shortening and eversion will be slight, and crepitus will be absent unless impaction be undone by extension. TJnion of this fracture is quite possible, but yet improbable — especially when the bones are unimpacted. The following are the more important obstacles to such an occurrence : — 1. There is an obvious difficulty in maintaining accurate apposition ; restraining splints cannot be applied to the part itself, and it is difficult to main- Pig. 177. Fig. 178. tain uniform ascendancy over the retracting muscles. If the perios- teal investment remain partially entire, however, there may be little displacement, and proportionally slight shortening ; and, in such cu'- cumstances, a better issue may be looked for — as well as in the case of impaction. 2. There must be a want of pro\-isional callus ; there being Fig. 177. Fracture of the neck of the femui', within the capsule ; thoroughly and accurately reunited. From the collection of Sir A. Cooper. Fig. 178. The same. A section shewing the line of imion. FRACTURES OF THE FEMUR. 615 no structure from whicli it may be produced, aud in whicli it may be formed and sustained ; the synovial capsule is obviously bai-ren in this respect. The fractured ends may be said to be steeped in an increased secretion of synovia. 3. Also the definitive callus, which, if uninterrupted, might alone achieve consolidation — as happens in other fractures, when from any cause the provisional formation proves defective — is ever liable to accident, by even slight movement of the parts. 4. The upper fragment, or head of the bone, nourished only through the round ligament, must be of weak power, and ill able to execute the exalted nutritive action necessary for reparation. 5. The age of the patient, and the atrophied condition of the bone itself, are obviously unfavourable to reunion. • With such adverse complications, it is no wonder that examples of union in this fracture are most rare. And yet circumstances may occur, in which that result may be attempted and expected, with every reasonable prospect of success. When, for example, the patient is comparatively young ; when the shortening is slight, indicating but partial division of the periosteal investment ; or when, besides this, there is absence of crepitus, indicating impaction ; when the patient joins heartily with the surgeon in the use of means calculated to main- tain apposition, and to prevent all movement of the fragments ; and when neither become weary of the prolonged period of vigilance required — for, be it remembered, provisional callus is wanting, and the definitive must do all (Principles, p. 709). The ordinary result, how- ever, is the formation of a false joint ; the parts becoming accom- modated to each other by absorption, connected by new fibrous texture, and further restrained by a thickened state of the capsular ligament ; the limb remaining deformed, and comparatively powerless, yet admit- ting of tolerable comfort and usefulness, with the aid of a stick or crutch. In the extremely old, fatal sinking is probable ; under the shock of the injury, and the irritation of pain and confinement. In the last named class of patients, the use of splints and bandaging for retention of the fragments is not expedient. Success cannot re- sult ; the annoyance will but aggravate the general disorder ; and, not improbably, sloughs will form at the points where the splint exerts its pressure. It is sufficient to arrange the limb comfortably on pillows,' and by very gentle swathing or deligation to restrain motion. In the more hopeful cases, the long splint is to be applied as in treatment of the following injury. II. Fracture external to the Cainule, and above the Trochanter. — This is usually an impacted fracture ; the upper fragment being driven into the cancellated texture between the trochanters, and more or less firmly wedged there. In such circumstances, there is but little displacement ; crepitus, even, may be obscure ; and power of the limb, both as to FRACTURES OF THE FEMUR. motion and the sustaining of Aveight, may be wonderfully preserved — continuity in the bone having been restored by the impaction, immedi- ately after it had been dissolved by the fracture. Not unfrequently, however, impaction is not so complete as this ; and sometimes it neither does nor can occur, on account of comminution attending on the frac- ture ; and then the amount of displacement and shortening may be very considerable. This form of injury usually results from direct and severe violence, as by falls or heavy blows on the hip. It diiSers from the preceding; in the mode of occurrence, as just stated; in its liabi- lity to occur at any age ; in a greater amount of swelling and pain following — the fleshy textures being more or /^^^ less extensively implicated ; in a greater amount of constitutional sympathy being manifested — the injury being altogether more severe ; in there being usually a less amount of shortening and eversion, vsdth a greater amount of power and motion ; and in crepitus being very palpable, only when full extension, and consequent disen- tanglement, have been effected — obscure, or altogether wanting, until then. When impac- tion has not occurred, often the slightest motion causes very distinct crepitus ; there being com- paratively little retraction of the lower fragment. The degree of shortening may be said to vary from half-an-inch to an inch and a-half. A more important difference exists, in this fracture being capable of satisfactory union. The best mode of treatment is by application of the straight, light, wooden splint. It should extend from a little below the axilla, to a little beyond the ankle, when the patient is Fig. 180. Straight and recumbent ; and, having been well padded, more especi- ally at the points where pressure is likely to be greatest — at the tro- chanter, external condyle, and malleolus — it is made one with the limb, as it were, either by bandaging, or by the swathing of a broad linen sheet. Then a soft shawl, or other suitable band, is passed beneath the perineum, on the affected side ; and has both its ends tied on the upper end of the splint — there being two holes placed there for this purpose. A broad bandage or belt is also applied firmly round Fig. 179. Impacted fracture, through the trochanter.?, into the lovrer. Fig. 180. Splint, ready for api)lication. The upper fragment is wedged FEACTUEES OF THE FEMUE. 617 the pelvis, so as to bind the splint more securely on the limb, and Fig 181 keep the broken surfaces in apposition. By tightening the perineal band, from time to time, the splint is forced down- wards ; the splint, having been made of a piece with the limb, brings the latter with it; and thus such exten- sion is made, as is likely to prevent retraction by the muscles, and to maintain the limb of its proper length. Indeed, in practice, it is well to have the extension such as to make a seeming elongation on the affected side. On resumption of the erect posture, and use of the limb, such lengthening soon disappears. A method of treating fractured thigh has been re- cently explained to me, by Dr. Kimball, of Lowell, Massachusetts. Two long pieces of strong adhesive sti'ap are applied, one on each side of the limb, extend- ing from above the knee to the ankle ; and these are secured by a roller. The end of each strap is uncovered with adhesive matter ; and hangs loose jfrom the foot. The splint, as represented in the accompanying diagram, having been applied, the ends of each strap are secured to the cross-bar at the splint's extremity, and the limb is made one with the splint in the ordinary way. By turning the screw, the cross-bar is moved up or down, at will ; and extension consequently is regulated with both accuracy and power. The perineal band is em- ployed besides ; but should its pressure prove at any time galling, it may be temporai'ily discontinued with safety, the crutch of the splint being moved up into the axilla to supply its place. This splint is the joint in- vention of Dr. Kimball, and his nephew Dr. G. K. Sanborn. It seems a most efficient apparatus ; and the Fig. i&s. use of adhesive strap for extension — a method applicable to other frac- tures — is at once simple and successful.* * This method of dressing fractures has been more particularly brought into notice bv Dr. JosiAH Crosby, of New Hampshire, U. S. Fig. 181. The splint applied. Fig. 182. The American splint, a, The movable cmtch ; 5, the screw which tixes the crutch; c, the cross-bar, to which the ends of the strap are fastened ; d, the moving screw. 618 FRACTURES OF THE FEMUR. On discontinuing the splint, at the usual time — from four to six weeks — a considerable amount of osdematous swelling generally per- vades the whole limb ; removable by friction and bandaging. Weight should be ]Dlaced very gradually on the foot, especially in the aged, and in those of infirm health ; for in these, even slinging of the foot, in attempts to walk with crutches, has caused serious displacement of the fracture. Cases of complete impaction would require little or no treatment, were we content with a permanently shortened limb. But, in order to obtain a perfect cure, it is evident that the impaction must be undone by extension, and the normal length of the limb thus restored. III. Fracture through the Trochanters. — This is also the result of direct and severe violence. There is usually much displacement ; and, in consequence, crepitus may at first be obscure. On extension and rotation, the hand, placed over the trochanter, ascertains that the upper fragment is fixed, while the lower alone moves with the thigh. Treat- ment is by the long splint. IV. Fracture of the Trochanter Major. — This process may be broken off from the shaft of the bone. It is displaced upwards, by the action of the lesser glutei muscles ; and a hiatus can be felt between the two portions. The signs of solution of continuity in the shaft are absent. Accurate approximation and retention are effected with difficulty ; and, in consequence, union is generally by ligament. Splints are unnecessary ; it is sufficient to maintain recumbency, in such a posture as is likely to conduce to relaxation of the displacing muscles. V. Fracture helow the Trochanter Minor. — The indications of this accident are sufficiently plain. The end of the upper fragment is tilted much forwards, by the action of the psoas and iliacus muscles ; while, by the muscles of the thigh, the lower fragment is drawn upwards, and usually inwards — the action of the adductors preponderating. The consequent deformity and shortening are great. Extension and rotation cause distinct crepitus ; and the preternatural mobility of the part, with loss of continuity in the shaft, are very apparent. Adjust- ment having been made, by extension and coaptation, the limb may be secured to the long straight splint ; and sometimes it is expedient, in addition, to place pasteboard splints directly on the fractured part — one on the inside extending from near the perineum, one on the out- side extending from the trochanter major, and both reaching the knee. They are secured by bandaging, before the long splint is applied. But, in some cases, the double-inclined plane is preferable — Mac- Intyre's splint, simplified and improved by Liston (p. 623) ; the spon- taneous rising of the upper fragment being thus humoured, while the lower part of the limb is brought up to it. The trunk should also be somewhat elevated ; to relax the muscles of the minor trochanter. In children, it is well to varnish the bandaging ; and so to prevent FRACTUEES OF THE FEMUR. 619 the necessity for frequent renewal of dressings, on the score of clean- liness. VI. Fracture of the Shaft near its middle. — Here the signs of the injury are self evident, and need not be detailed. Displacement is usually great ; and unless this be undone, and permanently opposed, most serious deformity must ensue. The retentive apparatus will con- sist either of the sti-aight splint, or of the double-inclined plane; the latter bent to a tolerably acute angle. In ill-adjusted cases, not only is deformity great by shortening and bulging at the part ; the knee is apt to become weak and loose, the ligament of the patella proving altogether inert. VII. Fracture above the Condyles. — The lower fragment is usually displaced backwards, by the action of the popliteus and gastrocnemius. The upper fragment, pushed forwards, may penetrate muscles and skin, and so render the case compound. The signs of the injury are obvious and plain. Treatment is by the double-inclined plane, with the knee considerably bent. VIII. Diastasis, or separation of the shaft of the bone from its epiphysis, may take place in the adolescent ; simply, by direct violence ; or with more or less rotation of the detached part, the limb having been twisted by a w^heel, or in machinery. Retention is best effected in the straight position ; with the use of common splints, of wood or pasteboard; or laying the limb in Macin tyre's splint, fully extended. IX. Fracture of the Condyles may take place, ex- tending into the knee-joint. There is much swelling of the joint, and crepitus is felt on the slightest motion. This is also best treated in the straight position. But watchfulness and activity are especially requisite, to avert inflammatory action, which is apt to seize upon the synovial capsule, and to prove severe. After the first fortnight, to prevent stiffness, gentle passive motion of the joint is expedient ; provided the parts are quiet enough to admit of this. Li all fractures of the thigh, the limb's use must be resumed very gradually, crutches being used to bear weight at first, lest bending and shortening occur after ■^'=- ^^"■ apparent consolidation. And this precaution, indeed, is necessary in all fractures of the lower extremity — especially in those enfeebled by age or disease, as already stated. X. Compound Fractures of the thigh, especially at the upper part, are prone to an unfavourable issue ; by suppuz*ation and constitutional Fig. 183. Diastasis of femur. Reunited. 620 FRACTUEE OF THE PATELLA. disturbance. No peculiarities of treatment need be specified ; further tban that the patient's fate usually hinges on the prophylactic and antiphlogistic constitutional treatment of the first ten days (Principles, p. 717, &c.) Fracture of the Patella. Longitudinal fracture of this bone is the result of direct violence, and may be attended with comminution. Inflammatory action is liable to occur, implicating the joint; and active prophylaxis, in this respect, is in consequence essential. Bony union readily takes place, unless action prove excessive. No complicated apparatus is necessary ; it is sufficient to prevent motion, by a short splint under the ham, lightly retained by bandaging. Transverse fracture is common ; the result more frequently of muscular action than of direct injury — as when a person, in full exer- cise, endeavours suddenly to save himself from falling. In other words, when the knee is bent, and the extensor mass of muscles acts violently, the patella is apt to be broken across, over the condyloid surface of the femur. The lower fragment remains in situ. The upper portion is retracted upwards on the thigh, by the extensor mus- cles — Avhen the severance of fibrous as well as osseous texture is com- plete ; and a wide hiatus is left between, in which the condyloid surface of the femur may be plainly felt — and even seen. The limb is powerless, more especially when descent in progi"ession is attempted ; the extensor muscles proving impotent. Ti'eatment is usually simple ; position often being alone sufficient to effect reduction and retention. The limb is straightened and ele- vated, so as to relax the extensors on the thigh ; a bandage is applied, from the toes upwards, to prevent engorgement of the limb ; and, if coaptation be not quite complete, the bandaging may be arranged in the form of the figure 8, at the knee, so as to force the fragments gently into apposition. The trunk is also elevated, in a half-sitting posture. Accui'ate apposition and osseous reunion may be obtained ; but this result is not desirable ; the knee being apt to prove crank and limited in its movements, and recurrence of the fracture being by no means improbable, under the application of a comparatively slight cause. Short ligamentous union is preferable ; affording sufficient firmness and resistance for action of the muscles, leaving the play of the joint unfettered, and proving less liable to recurrence of a solution of continuity. As the consolidation advances, passive motion is gently begun ; otherwise the muscles may prove slow in recovering their function. Should peculiarities of the case render such simple treatment in- sufficient, and a ligamentous union of redundant lencrth be threatened. I FRACTURES OF THE LEG. 621 more coercive measures are necessary. A broad leather belt is passed round the limb above the patella, another below it ; by cross belts, tightened as circumstances require, the circular girths are brought together ; and their approximation includes that of the fragments of the patella. Or Lonsdale's appai'atus may be worn ; which has the advantage of avoiding constriction of the limb. In cases of non-union, the constant wearing of such an apparatus restores the limb to a great degree of usefulness. Lately a case occurred to me, in which it was found quite impossible to maintain satisfactory apposition of the frag- ments, on account of a large bulging in the thigh, caused by exuberant callus — the result of previous fracture, ill adjusted. Compound Fractures of the patella have generally an unfortunate issue ; the joint inflaming acutely, and becoming disorganized. Not unfrequently, amputation is required, to save life. Instead of the patella giving way, under intense muscular action, the combined tendon of the extensors of the thigh may be torn asun- der; causing a hiatus at the injured part, with pain, swelling, and lameness — the power of flexion being alone retained. Treatment is conducted on the same principles as in the case of transverse fracture of the patella. Fractures of the Leg. Fracture of the Head of the Tibia is the result of great and direct violence; the fracture extending into the knee-joint. Treatment is as for the analogous fracture of the femur, at its condyles. The limb is placed straight, so that the condyles may act as retaining splints on the fragments ; and the limb is also elevated, so as to relax the ex- tensor muscles, which, through the ligament of the patella, act on the lower fragment. Passive motion is expedient, so soon as consolida- tion has advanced so far as to admit of it. Fracture of the Tibia immediately below its Tubercle. — The peculiarity of this form of injury is, the tendency to rising in the upper fragment, through agency of the muscles acting by the ligamentum patellae. The rising is aggravated by flexion of the knee. The limb is there- fore placed and retained in the straight posture, and elevated. Fracture of the Tibia, at any lower point, is best treated on the double-inclined plane. When this bone suffers alone, there is usually but little displacement ; the fibula acting as a restraining splint. Fracture of the Fibula. — This bone most frequently gives way near its lower extremity, at a short distance above the external malleolus. When force is suddenly applied, so as to cause eversion of the foot — as in twisting the foot, on the side of a stone, or in a gutter — this eversion is resisted by the external malleolus ; but if the force be suffi- 622 FRACTUEES OF THE LEG. cient to overcome the resistance, the bone snaps at its weakest point — from two to three inches above the ankle-joint — and eversion of the foot is effected. There is immediate lameness, and the patient may be sensible of something having snapped in the leg ; the foot is found turned out ; and, if progression is attempted, the patient leans on the inside of the foot, so as to support himself on the tibia. A marked depression is observed on the outside of the limb, at the site of fracture ; and, on replacing the foot, and making rotatory move- ment of it, crepitus may be distinctly perceived. The deltoid liga- ment is ruptured ; and the end of the tibia is necessarily displaced, more or less, from the corresponding surface of the astragalus ; not unfrequently it is moved forwards on the dorsum of the foot. Treat- ment is by Dupuytren's splint ; a light piece of wood, in breadth pro- portioned to the limb, and of length sufficient to extend from the knee to a few inches beyond the ankle. It is applied on the inside of the limb ; provided with a pad — considerably thicker at the ankle than at the upper part. To a hole at the upper part of the splint a linen roller is attached; and application of this is begun at the ankle — the bandage being occasionally turned over notches made for this purpose in the distal extremity of the splint, so as to maintain com- plete inversion of the foot, and consequent apposition of the fragments. The more thoroughly the foot is turned in over the malleolar pad as a fulcrum, the more sure are we of accurate readjustment. In effect- ing reduction, the knee is flexed, so as to relax the muscles of the leg ; and care is taken that replacement of the tibia is effected not only in the lateral but also in the antero-posterior direction. Fracture of loth Bones of the Leg may be the result either of direct or of indirect violence ; a heavy weight falling on, or passing over the part ; or the patient falling, and alighting on his foot. In the former case, the fracture is usually transverse, and the bones give way at corresponding points. In the latter case, the fracture is usually oblique, and the bones give way each at its weakest point ; the tibia a little above the ankle, the fibula about two or three inches Fig. 184. Fracture of the fibula ; with the splint applied, inverted. The foot should be more FEACTURES OF THE LEG. 623 below its head. This latter form of injury is especially apt to occur, in falls or leaps from a vehicle in motion ; and one or other of the sharp fragments may protrude through the integument, renderino- the case compound. Treatment is best effected by the double inclined plane. Should pressure on the heel be much complained of, the limb may be laid on its outer side, incased in two pasteboard splints extending from the knee to beyond the ankle. To prevent such undue pressure — during the use of the double inclined plane — it is well always, when practicable, to suspend the heel and foot by means of a sock — the end of which is hung, by a piece of tape, on a nob placed for this purpose on the upper and outer part of the footboard. It is also well, in all cases, to have the limb, in its splint or splints, considerably elevated ; either by slinging, or otherwise. Compound Fractures of the leg require no special notice. They are, in general, best treated on the double inclined plane ; for the Fig. 186. wound, being usually either in front, or on a lateral aspect, may be completely exposed, and frequently inspected and dressed, without the limb being at all disturbed, or the retaining apparatus undone. Fig. 185. Listen's modification of Maclntyre's splint, a, The screw which increases or diminishes the angle of flexion ; at h, there should be a knob on the footboard, whereby the foot may be slung. The limb is arranged so as to shew the facility afforded for dressing the wound, in the case of compoimd fracture. Fig. 186. Compound and comminuted fracture of the leg. 624 DISLOCATION OF THE PELVIS. Fractures at the Ankle. The Internal Malleolus may be broken off, by twisting of the foot inwards. The fracture is oblique ; the displacement is marked and considerable. The foot is dislocated inwards ; presenting its outer edge to the ground. Sometimes, instead of only the malleolus being separated, the fracture includes the whole thickness of the lower end of the tibia ; passing obliquely upwards. Replacement having been effected, by manipulation, while the limb is flexed, Dupuytren's splint is applied on the fibular aspect of the limb. Tlie External Malleolus may be detached in a similar manner, by forcible eversion of the foot ; but, as already stated, the fibula is more likely to give way at a point somewhat higher — its weakest part. The same splint is employed as in the more ordinary fracture (p. 622). The Tarsal Bones are occasionally fractured ; usually by intense and direct violence. In general, disorganization is such as to leave no hope of recovery ; and primary amputation, consequently, is often required. The Astragalus, however, may be split and fissured, by a heavy fall received on the calcaneum ; there may be little or no dis- placement; and a satisfactory issue may ensue. The part is kept steady by lateral splints, or by means of the double-inclined plane. Sometimes the tuberosity of the Calcaneum is snapped, by the action of the sural muscles. The symptoms and treatment are the same as in the case of ruptured tendo Achillis. Fractures of the Foot. Fractures of the metatarsal bones, and phalanges, are seldom effected but by a crushing force. Their issue is rarely prosperous, especially when compound. The metatarsal bones, after readjustment, require no splints. It is sufficient to keep the foot at rest and elevated. The phalanges, if not demanding immediate amputation, are arranged and retained by small splints, as in the case of the analogous injuries of the superior extremity. Dislocations. Dislocation of the Pelvis. From heavy and high falls, it has occasionally happened that the Os Innominatum has been displaced upwards ; separated from the sacrum, at the sacro-iliac junction, and from its fellow at the sym- DISLOCATIONS OF THE HIP. 625 physis pubis. The following are the diagnostic marks of the injury : — The limb of the affected side is shortened and powerless ; yet the signs both of dislocation and of fracture of the thigh-bone are absent ; and the limbs, when each is measured from the anterior superior spinous process of the ilium, are quite of the same length. The spine and horizontal ramus of the os pubis are unusually elevated ; forming a hard ridge in the ordinary site of the iliac fossa. The anterior superior spinous process, and the crest of the ilium, are on a higher level than those of the opposite side. By examination from the rectum, the tuberosity of the ischium will be found raised, and nearer the mesial line ; and the descending ramus of the os pubis will pro- bably be on a plane considerably posterior to that of the sound side. The fold of the nates is higher than on the other side ; and, on the injured side of the sacrum, a depression will be felt, at the junction of that bone with the ilium. More or less difficulty may be experienced, in evacuating the bladder. Should the nature of the case be distinguished in time, moderate efforts may be made for re-adjustment; by extension of the limb, and forcing the ilium downwards with the hand. The bladder is relieved by the catheter, as often as circumstances may require ; and a flexible catheter is likely to pass more readily than the metallic instrument. The same attention to the state of the internal organs is required, as in the case of fracture of the pelvis. Indeed, fracture of the os pubis is not unlikely to be associated with such an accident. Prognosis is unfavourable. Separation of the Symphysis Pubis is said occasionally to occur, in difficult labour. It may also result from direct injury. Displacement is not great. By a broad belt the parts are kept unmoved, as well as in apposition. Dislocations of the Hip. The head of the femur may be displaced, in various directions. The displacing force is usually indirect ; but the accident occasionally results from direct blows or falls upon the hip. It may take place at any time of life ; but most frequently affects the young or middle- aged adult. In youth it is rare — except in the congenital form (Principles, p. 727) ; in old age, fracture of the neck of the femur is much more likely to occur. I. Dislocation upwards on the Dorsum of the Ilium. — This is by far the most frequent form of the injury ; usually resulting from a fall under a heavyweight. Examination is best made in the erect posture. The limb is shortened, from an inch and a half to two inches ; and is turned inwards, the toes resting on the opposite instep, with the knee advanced somewhat in front of its fellow. Motion is much abridged, 2 s 626 DISLOCATION ON THE DORSUM ILII. especially in an outward direction. The trochanter is less prominent than it should be, and is also preternaturally near to the anterior superior spinous process of the ilium. If there be not much swelling, the head of the bone may be felt rolling in its new site, during rotation Hg. 187. of the knee inwards. There is also diminution of roundness in the injured hip. Fracture of the neck of the femur is the injury most likely to be mistaken for this dislocation. Diagnosis rests on the following points : — In dislocation, the motions of the limb, both voluntary and forced, are abridged ; there is invariably inversion of the foot, and this inver- sion cannot be undone, until reduction has been effected ; the toes may be moved round forcibly, but the whole body turns with them ; on ex- tension being made, the normal length of the limb cannot be restored, until reduction has occurred; and then there -rtII be no recvu'rence of the shortening, unless fracture of the bi'im of the acetabulum exist. True crepitus is felt only in the case of fracture. The occurrence of dislo- cation is much more rare than that of fracture ; and, while dislocation may occur at any age, fracture within the capsule seldom if ever is found under the age of fifty. Fracture external to the capsule is at Fig. 187. Dislocation on the dorsum ilii. DISLOCATION ON THE DOESUM ILII. 627 once known, by the distinctness of the crepitus — when extension and rotation ai'e made, and when the trochanter is pressed inwards. Reduction is effected, with or without the aid of pulleys, and their auxiliaries ; according to the date of the inj ury, the robustness of the patient, and the other circumstances of the case (Principles, p. 735). The patient is placed recumbent on his back ; and extension is made obliquely across the opposite limb ; the thigh crossing its fellow a little above the knee. The laque, to which the pulleys are attached, is applied either above the knee, or at the ankle, as the surgeon may prefer (Principles, p. 734). Counter-extension is made, by means of a strong belt — well padded — passed beneath the perineum, and secured to a fixed point behind the patient. When extension has been made for some time, the limb is i-otated outwards. It is seldom that we shall find it expedient to forego the use of chloroform ; and when this is employed, no other mode of reduction need be tried than the simplest — that just stated. But, if anaesthesia from peculiar circumstances be not available, another method may be tried, if the first fail. The patient being placed erect — resting his weight on the sound limb, stooping over a firm table, and having his pelvis fixed securely thereon — the surgeon takes hold of the foot of the affected limb with one hand, and, flexing the leg on the thigh, presses steadily with the Fis. 188. other hand on the popliteal space, downwards. After extension has thus been applied for some time, sudden rotation is made on the hip ; and the bone may, thus simply, move at once into the acetabulum. After reduction, the patient is placed gently in bed; and no reten- tive means are necessary — unless the patient be careless, or violent, by delirium or otherwise. Then it is well to secure the two limbs together, by bandaging, at the knees and ankles ; pads being inter- posed at these points. If, as rarely happens, the upper edge of the acetabulum have been broken, retention is effected with difficulty ; Fig. 188. Mode of reducing dislocation shevvu. the laque attached to the thigh ; at c, the pulleys. 2 s 2 At (I, counter extension made; at b, 628 DISLOCATION OF THE HIP BACKWARDS, and it is necessary to maintain permanent extension of the limb, by means of a long splint with perineal band, as used in the case of fracture (p. 617). II. Dislocation baclcivards, into the Ischiatic Notch. — In point of fre- quency, this form may be placed next in order. " The head of the thigh-bone is placed on the pyriformis muscle ; between the edge of the bone which forms the upper part of the ischiatic notch, and the sacro-sciatic ligaments ; behind the acetabulum, and a little above the level of the middle of that cavity."* The accident results from the rig. 189. application of force, while the body is bent forward on the thigh, and the knee is pressed inwards. The signs bear a general resemblance to those of the preceding injmy ; but occur in a minor degree. The shortening is from half an inch to an inch. The foot is inverted, and the great toe rests on the ball of the great toe of the opposite foot. The trochanter is behind its usual place, and is slightly inclined towards the acetabulum. The head of the bone can seldom be felt distinctly. The joint is preternaturally fixed ; flexion and rotation, in any considerable degree, being quite impracticable. The whole * AsTLEY CooPEE Oil Dislocations. Fig. 189. Dislocation into the ischiatic notch. DISLOCATION OF THE HIP DOWNWARDS. 629 body cannot be straightened in the recumbent posture ; if the trunk be smoothed down, the thigh rises up ; and if the limb be forcibly and painfully straightened, the loins are found immediately and insupe- rably arched — and this characteristic will not cease, until reduction has been effected. Reduction is made with the patient recumbent, on his sound side ; and the affected limb is extended obliquely, so as to bring it across the middle of the sound thigh. After extension has been maintained for some time, the head of the bone is lifted over the margin of the ace- tabulum, by means of a towel placed under the upper part of the thigh ; extension in that direction being made, by passing the loop of the towel over an assistant's neck, while counter-extension is exerted by his hands resting firmly on the patient's pelvis. But it is not to be sup- posed that such movements ai'e to interfere with the main extending force ; the two are carried on consentaneously. Ill, Dislocation doivnwards, into the Foramen Ovale. — This — as well as the following variety — is comparatively rare. It is usually caused by a heavy weight falling on the pelvis, while the trunk is bent for- wards, and the thighs are separated from each other. The limb is elongated, to the extent of nearly two inches; and is advanced in front Fig. 190. Dislocation into tlie foramen ovale. 630 DISLOCATION OF THE HIP DOWNWARDS. of its fellow, the toes usually showing neither inversion nor eversion. The thigh is much abducted, and cannot be brought near its fellow. The trunk is bent forwai'ds, during maintenance of the erect posture ; and the tense ridge, formed on the inside of the thigh by the stretched psoas and iliacus muscles, can generally be both seen and felt. The trochanter is flattened and depressed. The head of the bone can be felt — only in thin patients, and in the absence of swelling — by pressure on the inner and upper part of the thigh towards the perineum. The position of the limb somewhat resembles that which attends on the first stage of morbus coxarius ; a mistake in diagnosis would be fraught Avith the most direful consequences ; but, with ordinary care, such a misfortune is not likely to occur. Elongation of the space between the anterior superior spinous process of the ilium and the trochanter major, is of itself a sufficient test of the dislocation. The patient is placed flatly recumbent ; and counter-extension is made across the pelvis, by means of a strong belt passed round it. Extension is applied in the opposite direction, at right angles to the pelvis ; the pulleys being attached by means of a loop passed under the upper part of the thigh, and with one portion of the loop passed over the belt whereby counter-extension is made. Extension is exerted gradually, until the head of the bone is felt moving from its abnormal site. The surgeon then, passing his hand behind the ankle of the sound limb, grasps the ankle of the dislocated member, and draws it inwards, towards the mesial line of the body. The foot should not be raised, lest the head of the bone slip into the ischiatic notch — a casualty, however, Avhich is far from being irreparable. Or, tlie patient having been placed recumbent, on the sound side, Fiw. 191. Rertuction of dislocation into the foramen ovale. DISLOCATION OP THE HIP FORWARDS. 631 and the apparatus arranged as before, extension is made directly upwards, while the knee and foot are pressed down. IV. Dislocation forwards on the Pubes. — This accident happens when a person, while walking, puts his foot into some unexpected hollow ; his body being at the moment bent backwards. The head of Fig. 193. the bone is then forced upwards and forwards, on the horizontal ramus of the OS pubis. The limb is shortened to the extent of an inch. The Fig. 192. Dislocation on the pubes. Fig. 193. Reduction of dislocation on the pubes. 632 Di^ knee and foot are turned outwards, and cannot be rotated inwards. The head of the bone may be distinctly felt and seen, forming a globu- lar tumour ; resting above the level of Poupart's ligament, on the outside of the femoral vessels ; and obedient to the motions of the thigh. The patient is placed flatly recumbent on a table, with the affected limb projecting over the edge. Counter-extension is made in the ordinary way, by the perineal band — secured behind, and a little above the level of the patient. Extension is made in a line behind the axis of the body, carrying the thigh downwards and backwards. After some time, the head of the bone is lifted over the margin of the acetabulum, by means of a towel placed under the upper part of the thigh. And rotation inwards is also likely to be of service. Anomalous dislocations of the Hip. — Besides the ordinary varieties of dislocation, the following have been observed : — 1. The head of the femur has been displaced, so as to rest on the anterior superior spinous process of the ilium — or rather on the space between the two spinous processes of that bone, the trochanter major lying on the dorsum ; such displacement having been determined by the direct effect of the force, and muscular action having, from some cause, failed to modify displacement in the usual way. 2. Or, in like manner, the head of the bone may rest on the anterior inferior spinous process of the ilium, the trochanter major lodging in the acetabulum. 3. The head of the bone has been found resting on the tuberosity of the ischium, and also upon the spinous process of that bone. Dislocations of the Knee. Dislocations of the knee-joint are caused only by great violence, and are rare. The displacement cannot occur without much dis- ruption of the retaining parts ; and, in consequence, replacement is generally effected without difficulty. The Tihia may be luxated from the femur, in four different directions : — 1. Bachwards, behind the condyles of the femur ; causing shortening of the limb, prominence of the condyles in front, depression of the ligament of the patella, and bending of the leg forwards. 2. Forwards. — The condyles are thrown back, and compress the popliteal vessels ; the tibia and patella are elevated in front ; the limb is shortened and slightly flexed. These dislocations are complete ; the other two are only partial. 3. Inioards. — The internal condyle of the femur rests upon the external semilunar cartilage ; and the tibia projects plainly on the inner side of the joint. 4. Outwards. — The external condyle rests on the inner semilunar cartilage ; and the projection is on the outside of the joint. DISLOCATIONS OF THE PATELLA. 633 Reduction is in general readily effected, by extension and coapta- tion. Antiphlogistics are required subsequently, to ward off or modify the intense inflammatory action, which is apt otherwise to ensue after so serious an injury. The compound luxations usually require im- mediate amputation. Gradual displacement of the knee, by muscular action, in the case of advanced structural change, has been already considered (Principles, p. 514). The Semilunar Cartilages are sometimes displaced, by twisting the joint ; as when a person in walking, with the foot everted, strikes the toes against an obstacle ; or when the foot, in walking, becomes sud- denly caught in a crevice or hole. Perhaps there is a predisposing cause in operation ; namely, unusual relaxation of the retaining liga- ments of these cartilages. The cartilages are pushed from their normal site, by the condyles of the femur, which then come in direct contact with the head of the tibia. The limb is immediately rendered stiff, and incapable of bearing weight ; and a sickening pain is felt. Extreme flexion of the joint, by disengaging the parts, usually sufiices for restoration of the normal state ; the cartilages, by their elasticity, seeking their own place, when free. The production of such flexion may require force, and is painful. After the joint has remained a little in that position, the limb is brought down again with a sudden movement. The knee remains weak and swollen for some consider- able time — perhaps the seat of rheumatic pains ; and the use of a knee-cap is expedient. If chronic structural change threaten to ensue, that must be opposed by the ordinary means. Dislocation of the head of the Fibula is a rare accident. It may take place, by violence, either backwards or forwards. Reduction is effected by direct coaptation ; and bandaging sufficiently effects retention. Should displacement depend on relaxation of the retaining ligament, the pressure of a knee-cap or bandage is necessary ; with stimulation of the part, to restore the normal state if possible. Dislocations of the Patella. The Patella is liable to be displaced, in various directions ; by ex- ternal violence, applied directly or indirectly. But such accidents are rare. 1. Outwards. — This is the most common ; and is apt to occur in persons who are knock-kneed. The bone is thrown outwards on the external condyle, and forms a manifest projection there ; the knee is incapable of flexion. 2. Inwards. — This is the result of direct injury ; the bone being struck on its outer side, while the foot is turned in- wards. The mal-position is the reverse of the preceding. Reduction in either case is effected by raising the leg, so as to relax the extensor 634 DISLOCATIONS OF THE ANKLE. muscles on the thigh, fuEy ; at the same time, with the hand, forcing the bone back to its place. 3. The patella may be displaced by Semirotatton ; one edge resting on the middle of the articular surface betn'een the condyles of the femur, while the other projects beneath the tense integument. Reduc- tion in this case is to be effected by flexing the knee to the utmost ; so as to free the bone, and admit of its being drawn into its normal position by the action of the extensor muscles. Should this means fail, it may be expedient to di^-ide the ligamentum patellae, by sub- cutaneous incision. 4. The bone can be displaced Upicards, only on division of the ligamentum patellfe. by wound or tear. The treatment is as for trans- verse fracture of the patella (p. 620). 5. Slight displacement, Down- wards, may follow rupture of the tendon of the rectus muscle. Dislocations of the Ankle. I. Dislocation of the Tibia inwards. — This, as already stated, usually coexists with fractui-e of the lower end of the fibula (p. 622). The foot is everted ; and the inte-i-nal malleolus projects greatly. Reduc- tion is effected by extension of the foot ; while the limb is bent at a right angle, so as to relax the gastrocnemii muscles. And this flexed position of the leg, be it remembered, is essential in the treatment of all luxations at the ankle. Replacement having been accomplished, Dupuytren's splint is applied on the inner side of the limb ; and shoidd it seem necessary, for complete retention, a minor sj)lint may be placed on the outer side also. II. Dislocation of the Tibia foru-ards. — This, too, attends on fracture of the fibula. It may also occur independently of fracture ; but then the fibula is usually displaced along with it ; and the case is one of luxation of both bones.* The tibia rests on the upper surfaces of the navicular and internal cuneiform bones, and on a small part of the anterior surface of the astragalus. The foot is fixed, and appears much shortened ; the heel is proportionately elongated : the toes are pointed downwards ; there is a marked depression in front of the tendo Achillis ; and the end of the tibia is felt to be resting on the middle of the tarsus. Treatment is as in the former case ; a splint being applied on each aspect of the limb. A minor form of the injury may occur ; the end of the tibia rest- ing partly on the navicular bone, and partly on the astragalus. HI. Dislocation of the Tibia outwards. — In this case, the fibula is associated in the displacement ; and both bones form a manifest pro- * I have seen the tibia displaced forwards and inwards — the dislocation all but com- pound, while the fibula remained not only in its place, Ijut entire. DISLOCATIONS OF THE ANKLE. 635 jection on the outei' aspect of the joint. The foot is turned inwards, its outer edge resting on the ground ; and the toes are pointed down- wards. The intei'nal malleolus is obliquely fractured and detached. Treatment is as in the other cases. But especial watchfulness is necessary, as to the consequences ; this form of injury being always the result of much violence, and untoward action being consequently apt to ensue. IV. Dislocation of the Tibia backwards is extremely rare. The end of the bone rests on the os calcis, in front of the insertion of the tendo Achillis ; the heel is shortened, and the foot is proportionately elongated. The foot has also been found forced upwards between the tibia and fibula ; these having separated. But this may be regarded as merely an aggravation of dislocation of the tibia inwards. The treatment is still by extension of the foot, during flexion of the leg ; and by the application of lateral splints. V. Compound Dislocation of the Anlde. — This is the most common of the compound dislocations of joints; and usually takes place inwards. The patient having fallen forcibly, with the foot everted, the end of the tibia is driven through the integuments on the inner aspect of the joint; and protrudes to a greater or less extent. Even in extreme cases, the posterior tibial artery generally escapes untorn. This acci- dent may occur to any one ; but is especially frequent in adults of advanced years and intemperate habits ; and, in these, but a slight amount of violence would seem to suffice for its infliction. The com- plication of delirium tremens is not unfrequent. Reduction is effected as in the simple form ; and subsequent treat- ment is conducted according to the general principles elsewhere stated (Principles, p. 739), Should anchylosis occur, motion and usefulness are considerably regained, by compensating increase of movement in the tarsus. According to the high authority of Sir Astley Cooper, immediate amputation will probably be expedient ; "when the ends of the tibia and fibula are very much shattered ; when, in addition to the compound dislocation of these bones, some of the tarsal bones are dis- placed and injured ; when one or other of the tibial arteries is divided, and cannot be secured without extensive enlargement of the wound, and disturbance of the soft parts ; when the common integuments, with the neighbouring tendons and muscles, are considerably torn ; when the protruded tibia cannot by any means be reduced ; and when the constitution of the patient is enfeebled at the time of the accident, and not likely to endure pain, discharge, or long confinement." The ampu- tation suitable is that of the ankle-joint. Secondary hemorrhage may ensue from the posterior tibial, in a case otherwise affording a chance of cure. In such circumstances. 636 DISLOCATIONS OF THE ASTRAGALUS. ligature of the superficial femoral may be performed, if all the other points of the case are favourable. But if thei'e be profusion of un- healthy discharge, manifest indication of ulceration in the joint, or signs of incipient gangrene in the wound and on the foot — then ampu- tation is to be performed, with as little delay as possible. Dislocations of the Tarsus. I. Of the Tarsal range of bones, the Astragalus is the most frequently displaced by violence. Its dislocation may be either complete or partial ; and it may take place in various directions. ] . Forwards. This is by far the most frequent form. When the ankle is fully ex- tended, a large amount of the upper articular surface of the bone is exposed ; and if, by a fall, a powerful shock should then be applied to the calcaneum, the astragalus is very apt to be loosened and displaced — forwards and inwards — coming to rest on the navicular bone. Some- times the displacement is forwards and outwards ; the bone resting on the OS cuboides. The nature of the accident is at once declared, by the manifest appearance of the astragalus in its abnormal site. Reduc- tion is to be attempted by persevering extension of the foot, with the leg flexed ; while the bone is pushed backwards to its place. And, with the aid of chloroform, we shall not despair of success in all recent cases (Pi-inciples, p. 790). If the luxation have been complete, and remain unreduced, tension of the integument will be such as to render sloughing inevitable at the tense part ; and the case so becomes compound. Then, three modes of procedure are open to the surgeon ; to retain the parts as they are, and endeavour to bring them through the risks of open suppuration ; to perform amputation at the ankle ; or to excise the displaced bone, and hope to save both the limb and the joint. The last is usually to be preferred. Primary amputation is unnecessarily severe ; and the first mode is declared by experience to be hopeless of a successful issue. When, therefore, the case is from the first compound, when it ulti- mately becomes so by sloughing or ulceration of the strained and bruised integument, and also when the circumstances are such as to render it plain that sloughing or ulceration must soon occur — the luxated bone is to be removed by incision, the limb is to be carefully adjusted, retention is to be maintained by the adaptation of suitable splints, and the case is then to be treated as a compound dislocation of the ankle joint. In partial displacement, no such severity is ever necessary ; in complete luxation, it may not be required ; but in a luxation which is both compound and complete, and in complete luxation which is certain to become compound, such treatment is certainly preferable to the greater severity of immediate amputation — DISLOCATIONS OF THE ASTRAGALUS.. 637 as well as to the perils of profuse suppuration, constitutional suffering, and the almost certain prospect of secondary amputation, Avhich must follow an attempt to retain the bone. 2. The astragalus may be dislocated Backwards ; becoming firmly wedged between the ten do Achillis and the posterior surface of the tibia. The bone is readily felt in its unnatural site ; it is seen pro- tubei-ant there ; and the end of the tibia is felt projecting in front. Reduction, for obvious reasons, must be difficult. In only one case, probably, has the attempt ever proved successful, without chloroform — one which occurred to Mr. Liston.* 3. The astragalus has been displaced Upwards ; wedged between the tibia and fibula. But this accident is extremely rare. 4. Dislocation has taken place Outwards ; and it has also taken place Inwards. Such injuries are usually not only compound, but also complicated with fracture of one or other malleolus. They may be so severe as to demand immediate amputation at the ankle ; or they may admit of replacement of the limb, in the hope of saving it, after the dislocated bone has been removed. II. The Os Calcis and Astragalus may be separated from the other bones of the Tarsus ; the foot becoming displaced inwards, as in TaHpes Varus. Reduction and retention are easy ; the former by extension * Lancet, July 6, 1839. Fig. 194. Compound dislocation of the astragalus. — Sir A. Cooper. 638 SPEAINS OP THE LOWER EXTREMITY. and coaptation ; the latter by placing the limb on the double-inclined plane, and securing the foot firmly on the foot-board. III. The Cuneiform bones may sustain displacement. Of these, the internal is most likely to suffer. The bone projects inwards ; and is also drawn upwards by the action of the tibialis anticus. Keduction will be difficult. But, after a time, the limb may become little less useful than before, even though the displacement remain unreduced. Dislocation of the Metatarsus. One or more of the metatarsal bones may be displaced upAvards on the front of the tarsus ; the foot having undergone a severe wrench, as by a fall from horseback while the foot is retained in the stirrup. Under chloroform, the parts are easily reduced ; and no retentive means are necessary. Leeching, with other antiphlogistics, will pro- bably be required, however ; such displacement not being likely to occur without the infliction of much violence. Dislocation of the Toes. Luxation of the phalanges of the toes is rare. Reduction is readily effected, by extension and coaptation. Compound luxations usually require amputation. Subluxations and Sprains of the Lower ExTREMrir. The hip is seldom sprained. The knee suffers not unfrequently. The twist is usually such as to strain the inner aspect of the joint; and there the ligamentous appai*atus may partially give way. Pain is great and sickening; much swelling ensues, perhaps involving the synovial capsule ; and the part is apt to remain weak, and prone to recurrence of the injuiy. In addition to the ordinary treatment suitable for sprain (Principles, p. 740), the wearing of a knee-cap is essential for some time, until the part, by consolidation, regain its power of resisting the more ordinary applications of force. Sprains of the ankle are extremely common ; by twisting the foot, by a fall, or by a " false step." The most ordinary sprain is caused by twisting the foot inwards ; and the consequent pain and swelling are on the outside of the foot — often great over the belly of the short extensor of the toes. Treatment is by rest, fomentation, leeching, &c. And an elastic bandage on the ankle is necessary, for some time, after walking has been resumed. RUPTURE OF THE TEXDO ACHILLIS. 639 Injuries of the Tendo Achillis, and GASTROCNE^ncs Muscle. Rupture of the Tench Achillis. — By sudden and violent exertion of the sural muscles, as in leaping, dancing, or running — more especially if the patient be muscular, advanced in years, and unaccustomed to such exercise — the tendo Achillis is apt to give way, close to or at its insertion into the 'calcaneum. There is immediate lameness ; the patient falls, and is quite unable to resume the ordinary erect posture ; much pain is complained of in the part ; and, on manipulation, a very palpable gap is fotmd at the site of injury. Usually there is. at the time of rupture, a sensation of something having given way ; some- times there is an audible snap ; not unfrequently the patient complains rig. 195. of having been struck at the injui'ed part, although no blow has been sustained there. Treatment is simple. Position, alone, suffices for replacement. The leg is bent, and the foot is extended, so as to relax the sural muscles completely, and favour approximation. This position is maintained by simple means. A slipper is placed on the foot ; to the heel of the slipper a stout cord or tape is attached ; and this is Fig. 195. Outline of limb, shewing the slipper and ligature useful for maintaining flexion m ruptured tendo Acliillis. UNUNITED TENDO ACHILLIS. fastened to the thigh, by means of a circular belt applied there — or to the loins, in a like manner — as tightly as is necessary for securing the requisite degree of flexion. Bending may be voluntarily increased by the patient ; and this does no harm. But extension is absolutely pre- vented. Eeparation is slow (Principles, p. 742) ; and the period of confinement requires to be extended, a Aveek or two, beyond that re- quired in the case of fracture. After consolidation, extension is made gradually, lest the uniting medium be over-extended, and disruption of it ensue. The patient, when first allowed to move about, Avith a crutch or stick, is provided with a high-heeled shoe ; and, every day or two, a thin slice is cut from this heel, so as to permit a gradual approach of the sole to full planting on the ground. Wound of the Tendon is managed in a similar way. Accidental wounds — as by a scythe, knife, or reaping-hook — are usually com- pound. And, in them, the cure may be facilitated by approximating the two portions of tendon by means of suture. Ununited Tendon. — Cases sometimes present themselves, in Avhich rupture of this tendon has not been repaired. The retracted portion has become rounded off; the calcaneous portion is similarly changed; and the space between is occupied by dense deposit, quite inefficient for restoring function to the muscles. The hiatus being considerable — perhaps to the extent of two inches, or more — the limb is quite use- less in progression. To remedy this state, an incision may be made, the rounded ends of the tendon may be cut off, and approximation may be effected by suture. But this is severe practice. I have lately applied, quite successfully, the principle of subcutaneous section (Principles, pp. 724 and 743) ; by a stout needle making raAv the ex- tremities of the tendon, and breaking up the intervening space com- pletely ; so restoring the parts to a resemblance of their condition immediately after the original injury ; applying the same simple, retentive, and approximating apparatus, as after recent rupture ; and, after consolidation, employing the same caution in permitting resumed use of the limb. Laceration of the Muscle. — Instead of tendon giving way, the mus- cular fibres of the gastrocnemius may yield. The laceration seldom implicates more than a few of the fibres ; and the site of injury is usually where the muscular fibre ceases and tendon begins. The causes are the same as those of the former injury; the symptoms are very similar, and the treatment is identical (Principles, p. 741). Sometimes, it is the plantaris which yields in either its muscle or tendon. For Bibliographical reference, see p. 297. 641 CHAPTER XLI. AFFECTIONS OF THE FOOT. Talipes. Br this term is understood, tlie deformity of Clubfoot; generally con- genital ; yet, not unfrequently, acquired. The original development of the bones is not faulty ; but displacement of these is gradually effected, by a predominance of action in certain muscles ; such pre- dominance being dependent, either on spasm of those which so act, or on want of action in those which ought to be their antagonists. There is no actual dislocation of the tarsal bones ; there is merely gradual change in their relative positions. A case is related by Delpech which well illustrates the mode of production. A soldier had " the external popliteal nerve injured by a shot ;" the peronei, the tibialis anticus, and the extensor muscles, became paralytic in consequence ; Pig. 196. and, from the unopposed action of the opponents of these muscles, club-foot resulted.* There are varieties of this deformity. * Lit ixe. Iiitroductionj p. 35. Fig. 196. Talipes equinus. •2 T 642 TALIPES. I. Talipes Equiniis. — The muscles of the calf are contracted ; the tendo Achillis is rigid ; the patient steps on the toes, -n-ithout bringing the heel to the ground ; the foot is in other respects well-formed ; but, Hg. 197. the extensor tendons being on the stretch, there is a turning up of the toes, independently of that -which is caused by pressure in progression. Fisr. 19S. n. Talipes Varus. — This is the most common variety ; consisting of extension, adduction, and rotation of the foot — the rotation being Fig. 197. Talipes equinus after di^dsion of the tendo AchiUis. Fig. 198. Talipes vanw. Fig. 199. The same dissected; shewing the altered relative position of the bones. TREATMENT OF TALIPES. 643 analogous to supination of the hand. The muscles of the calf and the adductors of the foot are contracted ; the heel is drawn up ; the toes turn inwards ; the outer edge of the foot rests on the ground ; and, in progression, weight is borne on the outside of the foot and on the outer ankle — where adventitious burs^ usually form, of some size. The toes are extended, as in the former case. m. Talipes Fa/g^wsis the reverse of the preceding. There are abduc- tion, rotation, and partial flexion of the foot; the rotation being analogous to pronation of the hand. The front of the foot is raised from the ground ; and the patient rests on the inside of the instep, and on the inner ankle. The tendons of the peronei muscles are chiefly to blame. IV. Talipes Calcaneus. — The muscles in front of the leg are con- tracted ; the foot is extremely flexed ; and, in progression, the heel alone touches the ground. One foot, or both, may be affected by Talipes. In the former case, the affected limb is found thinner and more flabby than the other; and, sometimes, by arrest of development, it is shortened as well as weak. The mode of progression is painful and imperfect. And, not unfre- quently, contraction takes place at the knee, to a greater or less extent. Spurious Talipes is said to occur, when displacement of the foot takes place by muscular change or integumental contraction, following on burns, extensive suppurations, ulcers, &c. Treatment of Talipes. In the minor cases, which occur in children, mechanical means — early employed, skilfully adapted, and duly persevered with — are alone sufficient to effect a normal relation of parts. Many such cases occur; and it is quite unnecessary to subject the little patients to the pain of tenotomy. When the deformity obviously depends on a paralytic condition of certain muscles — as is more likely to be the case in the acquired than in the congenital examples — attempts may be made to obviate this condition, by remedies directed both to the system and to the part. Attending to the nervous centres, to the chylopoietic viscera, and to the general functions — we may find the symptoms yield, as in the analogous affection of strabismus. And the local means most likely to be of service are, blistering, the endermic use of strychnine, galvanism, exercise, friction, and passive motion. Tenotomy is had recourse to, when structural shortening of muscle, of tendon, or of both, has occurred ; and when the obstacles to replace- ment cannot otherwise be overcome. A large number of cases are so circumstanced. The operations, however, are but part of the remedial means ; and will certainly fail, unless suitable apparatus be afterwards 2 T 2 644 TREATMENT OF TALIPES. employed, well and sedulously. Instead of waiting for reunion of the tendons, and then extending their new bond of union, painfully and slowly, it is better to effect the required change of relative position immediately after section ; leaving the interspace to be filled up by new matter. In the congenital form, the operation may be had recourse to about the twelfth or fourteenth month, when the patient is just beginning to walk ; the mechanical and general remedial means having been in use previously. Extreme cases in the elderly adult should be regarded as irremediable. Tenotomy will fail to effect a cure ; and may do harm, for a time at least, by impairing very seriously the acquired usefulness of the limbs. In Talipes Equinus, division of the tendo Achillis is usually suffi- cient. In Talipes Varus, division of this tendon may suffice, along with the use of mechanical aid. But, very frequently, it is necessary also to divide the tibialis posticus and flexor longus poUicis. In con- firmed cases, the tibialis anticus, and extensor proprius poUicis must be added to the list. In Talipes Valgus, the peronei are divided along Avith the tendo Achillis. In Talipes Calcaneus, the tibialis anticus is cut, along with the extensors of the toes. The tendo Achillis is divided a little above its insertion into the calcaneum. The patient having been placed in a prone position, the limb having been steadied, and the foot having been bent, a tenotomy knife or needle is introduced obliquely ; and, by bringing its edge or point on the rigid tendon, the fibres are cut from without inwards; an assistant flexing the foot forcibly, so as to assist in the disruption. This having been completed, the instrument is withdrawn, and a com- press is applied to the aperture. Or division may be reversed ; from within outwards ; but there is thus a risk of accidentally wounding the integument. The tibialis posticus may be divided, either above the ankle, or near its insertion in the navicular bone. The tibialis anticus is divided in front of the ankle ; from below outwards, so as to save the joint. The flexor longus pollicis is divided, where felt tense in the sole of the foot. Sometimes it is expedient to divide the plantar fascia also ; from below outwards, to save the important textures beneath. The peroneus longus and peroneus brevis may be divided above the external malleolus, or near their points of insertion ; — the rest, at such points as circumstances may render apparently the most suitable. As a general rule, in such operations, the knife is moved away from, not towards, arteries and nerves. It is not improbable that, occasionally, reunion of the divided ten- don does not take place ; but that a new attachment is formed. Obviously, section of tendon should be avoided within thecse ; as, in such a locality, there is but little capability of the expected plastic exudation. FLAT-FOOT. 645 The mechanical apparatus need not be described. Many varieties are in use ; the simplest usually the best. For the Talipes equinus, and the Talipes varus — the two most common varieties — the indica- tions are simple, and may be simply executed ; flexion of the foot, by acting on the ankle ; and restoration of the normal position of the foot, as regards rotation and abduction, by acting on the foot itself. Flat-foot. Young adolescents, of delicate health, and exposed to considerable exertion on the feet, are liable to serious lameness from sinking of the arch of the tarsus ; apparently in consequence of relaxation of the connecting ligaments. The arch of the foot is lost, the tibia projects inwards, the foot turns out, the ankle is apt to swell, and progression is slow, awkward, difficult, and painful. The deformity affects both sexes, and all classes; excited, in the poor, by overwork; in the rich, by absurd ever- sion of the feet, and overtask- ing of the limbs, in attempts to impart polite accomplish- ments to these oi'gans. In most cases, a state of system very similar to the strumous will be found. By discon- Fig. 200. tinuance of the exciting causes, by fi'iction, by bandaging and the wearing of a roborant plaster on the part, and by general tonic treat- ment, relief is obtained. It is well also to have the sole of the shoe, or boot, considerably thicker on the inner than on the outer side. And, if matters do not advance favourably, an apparatus may be worn, which will both support the ankle and invert the foot. Sometimes, the young patient, in the process of further development, recovers both symmetry and usefulness. In confirmed cases, both deformity and lameness are great. " The pei'onei and anterior muscles of the foot obtain a preponderance, and eversion of the foot becomes ultimately as considerable as in true talipes valgus. The preponderating muscles undergo structural shortening; the outer margin of the foot, and even sometimes the front of the foot generally, is raised from the ground ; and locomotion is effected to a considerable extent on the heel. The gastrocnemii then waste, and the gait becomes very unsightly." Such cases are to be treated as examples of Talipes. Tenotomy is required, with the subsequent use of rectifying apparatus. And the tendons which Fig. 200. Flat-foot. 646 PODELKOMA, require division are, the tibialis anticus, all the peronei, the extensor proprius poUicis, and the extensor longus digitorum. Podelkoma. This has been elsewhere described, as a form of multiple ulceration peculiar to the foot (Principles, p. 264). By others it has been noticed as morbus tuherculosus jiedis.* The milder forms may be remedied by pres- sure and constitutional alteratives ; the advanced cases generally result in amputation. Corns and Bunmis. These painful affections are the result of pressure, exerted by ill- constructed shoes and boots. They are more easily prevented than cured. 1. The shoe or boot should be large enough to contain the foot easily ; and an allowance should be made for the occasional swell- ing to which the part is liable by exercise, heat, and a dependent position. 2. The sole should be at least as broad as that of the foot. The outline of the foot — represented on a piece of paper, on which the patient leans in the erect posture — should be the measure of the sole of the boot or shoe. 3. The boot or shoe should be square, or, rather, rounded in front ; not sharp, with the point nearly in a central position. The point corresponding to the end of the great toe should be nearly in a line with the inside of the instep. And abundance of room should be given for each toe to occupy its own place, without any crowding, or overlaying of its fellows. Corns consist of two parts. A thickening of the cuticle ; and a hypertrophied and irritable condition of the corresponding papillse of the true skin. The inflammatory process may supervene. And then a small abscess may form ; very painful, because the matter is confined * Godfrey, Lancet, No. 1187, p. 593. Fig. 201. Podelkoma; or morbus tuberculosus pedis. «, The toes, much altered ; b, the outer side of the foot, in some parts shewing cicatrices ; c, the line of amputation, at the ankle; d, the astragalus. The swelling is often much greater than here represented. CORNS AND BUNIONS. 647 by the dense cuticle ; and frequently leading to smart erythema or erysipelas of the foot. Corns are also said to be Soft and Hard. The former situate on the outer points ; the latter placed between the toes, where there is naturally considerable moisture. Another division of corns is into the Laminated and Fibrous. In the former, hypertrophied cuticle is arranged in a laminated foi'm ; and there is uniform enlarge- ment of the papillae beneath. In the fibrous, the central papillae are much enlarged and project; each is surrounded by a sheath of epidermis; and, consequently, while the circumference of the corn is laminated, the central portion presents a fibrous appearance. And, in ordinary language, these projecting papillae are termed the "roots of the corn." The indications of cure are simple. 1. To remove the cause; by wearing suitable boots and shoes, or by leaving the part altogether unfettered for a time. 2. By careful dissection, to remove the hardened and hypertrophied cuticle ; and, by repetition, to prevent reproduction. 8. To remove the irritability, and to restore a normal state of the cutis vera ; by occasional application of the nitrate of silver. 4. If inflamnaation have occurred, poulticing, fomentation, and rest are suitable. And the subsequently open state of the parts is taken advantage of, so that a free and effectual use of the nitrate may be made. 5. Inveterate cases are palliated, by wearing roomy and soft shoes and boots ; also protecting the corns, by means of thick plasters, which are excavated opposite the tender points. And into the excavations, it may be well to insert, occasionally, extract of belladonna, or some other anodyne substance. Bunions are formed thus : — 1. Inordinate pressure has been habitu- ally made, by boot or shoe, on the ball of the great toe. The skin consequently becomes congested and tender ; and the part is red and swollen. This is one form of the affection ; remediable by abstraction of the cause, by rest and fomentation, and by a subsequent light use of the nitrate of silver, or of a solution of iodine. 2. Or an adven- titious bursa forms over the joint; and enlarges gradually. Occa- sionally, it may show an unusual size, by reason of bursitis. The remedies for this form are — abstraction of the cause, discutient appli- cations in the chronic stage, antiphlogistics in the acute. A thin caoutchouc envelope is sometimes of service, by equalizing the pressure of the shoe. 3. Or, in consequence of repeated attacks of bursitis, the cyst suppurates, and opens externally ; the aperture becomes fistulous ; the cyst contracts, but continues to discharge fluid, more or less ; and acute accessions are ever liable to occur. In this case, it is necessary to destroy the cyst, by inserting a piece of potass into the cavity. Afterwards, the granulating sore is brought to heal under the ordinary means — rest, and simple applications. 4. There is an aggravated class of cases, in which there is enlargement of the osseous texture. 648 AFFECTIONS OF THE TOES. Blistering and rest may make some favoui'able impression. By suitable adjustment of the shoe, palliation is obtained. 5. The joint may be partially displaced — in the rheumatic and gouty adult ; the toe riding over its fellows, and pointing to the outer side of the foot. This, too, can be but palliated. Onyxis and Onychia ; Exostosis ; and Contraction of the Toes. Onyxis and Onychia require the same treatment, as when affecting the fingers. The great toe is the especial site of Onyxis (p. 271). Exostosis of the Distal Phalanx of the Great Toe is a troublesome affection, not unfrequent in occurrence. Sometimes the growth takes rig. 202. place from the plantar aspect of the phalanx; but much more fre- quently from the dorsal ; elevating the nail, causing pain, and seriously interfering with progression. Excision is performed, by means of a strong knife, or by cutting pliers ; and, should any reproduction Fig. 203. threaten, during cure of the remaining wound, the chloride of zinc is applied. Should excision fail, amputation of the phalanx is had recourse to (Principles, p. 478). Conti^action of the Toes. — The toes — more especially the one next the great toe — are liable to extreme contraction, whereby considerable deformity is produced, the wearing of boots and shoes is rendered pain- ful, and the functions of the foot are interfei-ed with. Subcutaneous section of the extensor tendon usually permits sufficient restoration of the normal position. But it is not uncommon to find amputation of the offending toe expedient ; other means having proved unavailing, and the patient being himself anxious for a summary procedure. Fig. 202. Onyxis ; affecting the gi-eat toe. Fig. 203. Exostosis of distal phalanx of great toe. Little on the Nature and Cure of Clubfoot, (fee. London, 1839. Tamplin Nature and Treatment of Deformities, London, 1846. Bishop, Lectures in the Lancet, 1846. Weis, de Tenotomia Talipedibus applicata, Havniffi, 1844. Durlacher on Corns, Bunions, &c. London, 1845. 649 CHAPTER XLII. AMPUTATION. Mutilation by removal of a limb, or part of a limb, is the last I'esource of our art ; and ought never to be had recourse to, until it is evident that other means either have proved, or must prove, un- availing. The profession have reason to rejoice that necessities for the performance of amputation are much less frequent than in former times ; yet tlie circumstances are not few — and in all human proba- bility never will be few — in which nothing but the sacrifice of a part of the body will suffice for the retaining of existence. We are con- strained to amputate ; in spreading gangrene, as speedily as possible, if there be a sound space in which to make our incisions ; in chronic gangrene, when the line of separation has been formed, and is ad- vanced; in tumours which are of a malignant kind, and involve a bone or joint ; in diseases of the joints, which have baffled our skill, and have caused urgent hectic ; in cases of recent injury, when it is evident that the parts are so far mutilated as to render recovery im- possible ; and in cases of attempted preservation of limbs, after injury, Avhen it is plain that further continuance of the attempt must be attended with unwarrantable peril of life. Not unfrequently, also, a partially recovered limb proves so stiff, useless, and inconvenient, as to urge the possessor to seek its removal ; and such operations of " complaisance" are not always to be declined. In the case of injury, amputation is either primary or secondary ; the former, when done immediately, after the system has emerged from the state of shock, and before it has become involved in febrile excitement ; the latter, when performed after febrile accession has occurred, and when — it may be after some weeks — life is threatened by excessive suppuration, disease of bone, disease of joints, or slough- ing of the soft parts. The comparative merit of primary and secondary amputation is still, with some, a disputed point. The question has already been considered (Principles, pp. 678 and 686). For its decision, a mere comparison of statistical details is obviously insufficient ; for, in one class are necessarily included all the most severe cases, while the other contains many of a very minor character. 650 AMPUTATION. The two chief objections to the primary operations, are : — 1. Two shocks may overpower a patient, who might have rallied successfully from one. To this it is answered, that the operator must choose his time skilfully ; not bringing the two shocks into immediate contact ; but waiting until the former has wholly passed away ; and not ope- rating at all, unless a sufficient rally shall have taken place. It is seldom that a patient perishes of mere sinking, after amputation. And besides, by the use of chloroform — an agent which is seldom dispensed ■with in amputations now^-a-days — it is to be remembered that the shock is very much modified, and a positive tolerance of the opera- tion seems to be imparted to the system (Principles, pp. 769, 770). 2. It is alleged that a robust state of body — in which the patient may be, at the time of the accident — is less favourable to recovery than the comparatively reduced state Avhich obtains after subsidence of the inflammatory fever. This objection obviously can be removed, by judicious antiphlogistic treatment of the case. Not unfrequently, inflammatory fever, and its results, afford no opportunity to judge of the expected favourable condition for secondary operation ; the patient dying during the inflammatory period. But we would rather refrain fi'om the discussion in this place ; and would simply repeat the practical rule, on which the great majority of surgeons are agreed — That, when an injury has been sustained by a limb, of such a character as to render it impossible, in the opinion of the surgeon, that the part can be retained ; when, in other words, it is obvious that amputation must be performed at some period of the cure — it is better to amputate at once, so soon as the system has rallied from the primary shock; preferring to encounter the minor risk by rapid succession of a second shock, rather than to meet the more perilous invasion of intense inflammatory action, with its serious consequences to both part and system. Another question, scarcely yet arranged, is as to the comparative merits of the old circular method of operation, and of the modern operation by flaps. In this part of the country, the latter is tacitly preferred ; recourse to the circular method being quite the exception to the general rule of operating. And the obvious advantages are ; more rapid performance ; a cleaner cut ; a better covering to the end of the bone ; and a power of selection, as to what parts shall constitute the covering. The vessels are cut obliquely, no doubt; but, if the ligatures be applied carefully — as they always ought to be — there is no risk of secondary bleeding on this account (Principles, p. 361). Li temporarily restraining hemorrhage, during the incisions, the hands of an assistant are usually preferable to any tourniquet ; as has FLAP-AMPUTATION. 651 already been explained (Principles, pp. 354, 355). And pressure is not applied until the knife has begun to penetrate ; in order that no Fig. 304.. Fig. 205. unnecessary loss of blood may be occasioned, by venous congestion beneath the site of compression. In the Flap operation, the following are the more important points of detail. The patient is arranged comfortably recumbent, on a firm table, of convenient height for the operator ; who places himself on the left of the patient, so that his right hand may be used, freely, for the incisions. The sound limb is held steady, and out of the way, by an assistant ; or is secured by a towel — in the case of the lower limbs — to a leg of the table. Ordinary assistants are ready to control the motions of the patient, to reassure him, if need be, and to minister to his wants. An experienced administrator undertakes the whole charge of the chloroform, from the beginning to the end of the ope- ration ; never allowing himself to be distracted by the details of this from a close and uninterrupted watching of the patient. A trust- worthy assistant is ready to command the hemorrhage, by the pressure of his own fingers, or by that of a tourniquet. Another is prepared to retract the flaps, and to tie the arteries. A third is stationed to hand what things may be required ; and these are suitably arranged on an adjoining table — tourniquet, bandage, lint, ligatures, sutures, Fig. 204. The tourniquet, unapplied ; but with its two platforms as much separated, as if in actual use. Fig. 205. Signoroni's compressor, a, The point of counterpressure ; h, the pad which acts directly on the vessel. 652 FLAP-AMPUTATION, knives, saw, cutting-pliers, arteiy-forceps, sponges — cliloroform. If necessary, an assistant, seated in front of the patient, steadies and supports the limb to be removed. Fig. 206. Suppose that the thigh is to be amputated by double flaps. The surgeon grasps the flesh in front of the limb with his left hand, so as to raise it from the bone : thereby facilitating the making of a full flap anteriorly. As the knife's point is about to enter, pressure is applied to the femoral. Transfixion is made, by pushing the knife down to the centre of the bone, horizontally ; gently passing the point round the bone to the front ; then pushing across, so as to make the point of exit as nearly as possible opposite to that of entrance. Moving the knife downwards and outwards, with a gentle sawing motion, a suffi- cient flap is formed anteriorly, and this is retracted by the assistant ; or, rather, is simply elevated. The knife's point is then re-entered, about an inch beneath the site of former transfixion ; in order to avoid cross-cutting of the integument, which is otherwise apt to occur. And, the second transfixion having been effected, a second flap is formed posteriorly. This is quickly laid hold of by the assistant's other hand ; and he now retracts both flaps ; pulling steadily ; and keeping his own fingers out of the way. The surgeon, by circular sweeps of his knife, divides the soft parts completely, as high as the fleshy commissure of the flaps will permit ; effecting this leisurely and coolly, in order that it may be done thoroughly. Not even a shred of periosteum should be left at the point which is to be sawn ; and this should be as close Fig. 206. The flap-operation illustrated in the thigh. The sloping wounds, whence the flaps have been taken, shewn in the amputated part. Fig. 207. The corresponding stump ; intended to exhibit the comparatively small extent of wound tliat remains ; in contradistinction to Fig. 209. FLAP-AMPUTATION. 653 to the adherent cushion of muscle above, as the instrument can be made to go. The form of the wound — the flaps unretracted — is conical ; and the sawn end of the bone must occupy the very apex of the cone. The assistant continuing to keep the flaps out of harm's way, the saw is applied to the isolated portion of bone — the side of the instru- ment lying close upon the fleshy wall above. The saw is held perpen- dicularly, and is " grooved " by drawing it lightly from heel to point. By steady sweeps, section is effected ; the surgeon, meanwhile, con- trolling the lower limb with his left hand ; making sure that it is not held too high, so as to lock the saw by shutting it up in its own groove ; and taking equal care to prevent its being too much depressed so as to favour splintering of the bone when the section is nearly completed. During and after the use of the saw, the assistant takes care to apply no traction to the flaps, lest the periosteum be unnecessarily stripped upwards. Should this happen to any considerable extent, necrosis and exfoliation may scarcely fail to ensue. Should any roughness remain on the end of the bone ; either by splintering, or fi'om natural con- struction ; this is to be removed by means of the cutting pliers. Attention is now immediately directed to the arteries ; the largest being the first secured. Each is laid hold of with the artery-forceps, and, by being pulled outwards, is separated from all surrounding textures ; partly to insure deligation of the arterial coats only ; partly to secure application of the ligature beyond the oblique section of the vessel. By neglect of this, nerve and vein may be unnecessarily injured ; and the ligature's noose, traversing the oblique section, not going beyond it, may leave a part of the arterial mouth still open, and ready to afford a troublesome hemorrhage. So soon as the larger arteries have been secured, the assistant relaxes his pressure above, or altogether removes it. The smaller vessels can be quite commanded by the finger-points ; and, were the high pressure continued, venous loss of blood must necessarily ensue. Removal of the pressure, above, is usually sufiicient to arrest the venous flow. But, should this con- tinue, direct pressure is made ; either by the finger applied to the venous oi'ifices, or by shutting the flaps and pressing them firmly together, for a short time. Deligation of a vein is unwarrantable (Principles, p. 368). Bleeding having been satisfactorily arrested, the flaps are partially approximated by a few stitches ; and, a wet cloth having been applied to the line of wound, the patient is removed to bed. The subsequent treatment is conducted according to the principles formerly described (Principles, p. 635, et seq.) ; our object generally being to obtain adhesion ; yet, not unfrequently, preferring a moderate suppuration — as when the system has been long previously subjected to copious 654 CIRCULAE AMPUTATION. discharge, the sudden arrest of which might seriously endanger the internal organs (Principles, p. 523). The Circular amputation is performed thus ; again supposing the thigh to be the part concerned. An assistant, grasping the limb with both his hands, draws up the skin as far as possible. The surgeon, hold- ing the knife lightly, and with his arm at first placed under the thigh, Rg. 208. divides the skin and areolar tissue in one continuous sweep. The assistant now retracts the skin, more decidedly than before ; and he is assisted in this, by the surgeon touching the subcutaneous tissues at various points with the knife. Close to the retracted integument, the knife is again laid on ; and, by a second sweep, the superficial muscles are divided. These are pulled upwards by a retractor — a portion of linen or leather, slit at one end ; and, by a third sweep of the knife, laid on close to the retractor, the bone is made bare. Retraction is then applied to all the fleshy textures ; touches of the knife assisting to expose the bone at a higher point ; and, this having been reached, complete isolation of the bone is effected there. The saw is applied, while by the retractor the muscles are protected from injury. Bleed- ing having been arrested, the soft parts are let down, and are arranged so as to make the line of wound rectilinear. Fig. 208. Circular amputation, illustrated in the thigh. The terraced arrangement of the wound shewn in the amputated part. Fig. 209. The corresponding stump ; intended to exhibit the comparatively large ex- tent of wound that remains ; in contradistinction to Fig. 207. AMPUTATION OF THE FINGERS. 655 Amputation of the Fingers. Amputation at the Distal and Middle Joints is performed thus. An assistant controls bleeding, by grasping the wrist tightly. Another separates the fingers from that which is doomed ; at the same time steadying the hand in a pronated position. The surgeon lays hold of the finger, slightly bending the joint at which removal is to take place ; and the articulation is then laid open, by a sweep of a narrow straight bistoury. Division of the lateral ligaments is completed, if need be, by the point of the instrument ; and the joint is more flexed, to favour disarticulation. This having been effected, the knife's blade is placed Fig. 310. behind the head of the bone ; and, by cutting downwards and out- wards, a sufficient flap is formed on the palmar aspect. Previously to disarticulation, the surgeon lays hold of the part on its dorsal and palmar aspects ; in making the flap, his hold is lateral. Or the pro- cedure may be reversed. The hand being placed in a state of supin- ation, transfixion is made in front of the joint ; by cutting downwards and outwards, the flap is made in the first instance ; and then, by a sweep of the knife, disarticulation is effected, and the integuments on the dorsal aspect are divided. Usually, no hemostatics are required. The flap is turned over the joint ; and is I'etained in its place, by a single point of suture, or by bandage or strap alone. The Proximal phalanx, if not wholly involved in injury or disease, need not be entirely sacrificed. Amputation may be pei-formed near the middle of the bone ; in obedience to the general rule, of saving as much as possible of the organ of prehension. A stump of the fore- finger is especially useful. By transfixion, on the palmar aspect, a Fig. 210. Amputation of the finger, at the distal articulation. 656 AMPUTATION OF THE METACARPAL BONES. long flap is formed there ; and a small semilunar flap of integument is made on the dorsal aspect, by a subsequent sweep of the knife. Or corresponding flaps may be made on the sides of the finger ; in cases of external injury, when the palmar aspect is much mutilated. The bone, having been made bare at the upper part of the wound, is severed by cutting-pliers. And in using this instrument care is taken to place its smooth side always where the stump is to be ; otherwise splintering and irregularity are apt to occur. Hemorrhage having been arrested, the flaps are united and retained in the ordinary way. Amputation at the Metacarpal Joint may be performed in one of two ways. The hand is held pronated. 1. The finger, well separated from its fellows, is laid hold of by the surgeon, and pushed to one side. On the exposed and tense web, the bistoury is passed upwards, from point to heel, so as to expose .that side of the articulation ; at the same time, leaving on its outer side a flap of suitable dimensions. With the knife's point, disarticulation is effected ; the finger being pushed much across to facilitate the process. Were the blade to be used for this purpose, ragged wounding of the integument could not well be avoided. The head of the bone having been detached, the blade of the knife is placed behind it ; and, by cutting obliquely outwards, a second flap is formed, to suit the former — while at the same time, detachment of the finger is completed. 2. Or the knife's point is entered on the centre of the knuckle ; and, by one continuous move- ment, is carried round the finger, so as to make two equal, lateral, semilunar flaps, at the same time exposing the joint. Disarticulation is then completed, and the part removed. The digital arteries usually require ligature. Approximation is effected by bringing the two adjoining fingers together, and retaining them so by means of a slip of bandage. Cold pledgets of lint are applied ; and, otherwise, the wound is managed in the ordinary way (Principles, p. 635, et seq.) When operating on the fore and little fingers, it is well to extend the incisions a little upwards, to expose the head of the metacarpal bone, and to remove its articulating surface by means of the cutting- pliers. The stump is more rounded, and has a more seemly appear- ance after cicatrization, than when the end of the metacarpal bone is left projecting. But, in doing this, care must be taken not to injure the transverse ligament. Amputation of the Metacaipal Bones of the fingers is sometimes required ; in consequence of disease affecting one or more of them. The incisions vary, necessarily, according to the extent of the disease, and the site of the openings already existing. Disarticulation from the carpus requires both skill and caution. The fingers are taken with the metacarpal bones ; for, the former become useless appendages, when deprived of their support. If in amputating a finger and its AMPUTATION OF THE METACARPAL BONES. 657 metacarpal bone, the corresponding carpal surface be found in a carious state, by the use of a gouge the diseased parts may be removed ; and the progress of cure may prove most satisfactory. Disease or injury of three metacarpal bones, does not warrant removal of the vv^hole hand. The stump which i-esults from amputa- Fig. 211. tion of the affected parts only, is infinitely more serviceable than that which follows complete mutilation. When the lower part, only, of a metacarpal bone is affected, dis- articulation at the carpus is not attempted ; but section of the bone is made in its shaft, by means of the cutting-pliers. The knife is entered on the dorsal aspect, at the point where section is to be made, and is carried down in the mesial line, till the knuckle is reached ; there a divergence is made, on either side, as in amputation of the finger only ; but without passing the knife so deeply as to open the articulation. Then, by dissection, the diseased portion of the bone is isolated ; care being taken to leave the palm entire. Also, when a single metacarpal bone is removed entire, it is well to spare the palm ; the hand being afterwards both more useful and more seemly than it otherwise would be. Amputation of the Metacarpal Bone of the Little Finger is accomplished thus : — The finger is laid hold of, and separated from the others ; and the bistoury, laid on the stretched web, is carried up at once, along the inside of the metacarpal bone, to its articulation with the unciform bone of the carpus. The doomed part being much pushed outwards, disarticulation is effected with the point of the knife. And then, the blade having been placed behind the base of the bone, a suitable flap is formed on the outer side, by bringing the knife downwards and out- wards — causing it to emerge a little below the metacarpal articulation. Hemorrhage having been arrested, the flap is accurately adjusted to the raw metacarpal surface, and retained in the usual way. Fig. 211. Stump of the hand, in -which the thumb and little finger, ^vith their meta- carpal bones, were left, alone ; after amputation on account of injury by a printing machine. The thumb and finger acquired great mobility and power, and the stump proved most serviceable. 2 u 658 AMPUTATION OF THE THUMB. Or the flap may be made in the first instance ; by transfixing at the carpal articulation, and carrying the knife downwards and out- wards, as before ; or, by marking out the flap with the knife's point, and dissecting it up — cutting from without inwards. One obvious advantage of this mode of operating is — that should the base of the metacarpal bone be found not diseased, it may be saved ; instead of disarticulation, the bone is cut across by the pliers. Amputation of the Thumb. The phalanges of the thumb are removed in the same way as the phalanges of the fingers. Amputation of the Phalanges, with the Metacarpal Bone, may be effected in the same way as removal of the little finger and its meta- Fig. 212. carpal bone ; by placing the bistoury on the web between the thumb and forefinger, passing it up to the articulation with the trapezium, disarticulating there, and forming a suitable flap by bringing the knife down on the opposite side of the bone. Or, by transfixing at the articulation with the trapezium, and making the flap in the first instance ; afterwards effecting disarticulation, isolating the bone, and removing the member. Or the flap may be made by dissection up- wards. Or the bistoury may be entered over the trapezium, and carried down on the dorsum of the metacarpal bone ; having reached the distal extremity of this bone, it may be swerved to the inside ; thence it may be made to transfix the ball of the thumb, emerging where it fii*st entered ; and, by cutting outwards and downwards, the flap may be constructed. Fig. 212. Amputation of the thumb and its metacarpal bone. AMPUTATION OF THE WRIST. 659 Amputation of the Wrist. Hitherto, pressure on the wrist has sufficed temporarily to restrain hemorrhage. Now, compression of the humeral is expedient ; and is Fig. 213. best effected by the firm and steady grasp of an assistant — on the lower part of the arm — the nerves being excluded from pressure as much as possible. Hitherto, also, a narrow, straight, sharp-pointed bistoury has been the preferable instrument, for making the incisions. Now, a regular amputating knife is required. An exaggeration of the former instru- ment, in a fixed wooden handle ; straight, sharp-pointed, and of fine edge and temper ; light yet firm. The amputating case contains various sizes ; proportioned to the dimensions of the parts which may require their use. For the wrist, the shortest size will suffice ; the blade not much larger than that of a full-sized bistoury. The arm is steadied, with the hand in a state of pronation. The knife is laid on below the styloid process furthest from the operator — who stands on the patient's left — and is carried across the limb so as to form a semilunar wound on the dorsal aspect, whose centre extends as far as the second carpal range, and whose termination is below the styloid process on the side next the surgeon. An assistant retracts the flap thus formed. The wrist is bent, and disarticulation effected. The blade of the knife is then laid behind the carpus ; and, by cutting outwards and down- wards, a suitable flap is formed on the palmar aspect. In the last part of the proceeding, the pisiform bone is to be avoided ; and, in Fig. 213. Amputation of the wrist. 2 u 2 660 AMPUTATION OF THE FOREARM. endeavouring to escape fi'om it, care must be taken not to notch the corresponding portion of integument. The radial, ulnar, and inter- osseous arteries, require ligature. Amputation of the Forearm. Pressure being made on the humeral, the limb is steadied, with I'lg. 214. the hand in a state of pronation. Two flaps are formed ; one on the dorsal, the other on the palmar aspect. Below the middle of the fore- arm, it is not easy to obtain a sufficiency of fleshy covering. Yet — when circumstances will at all permit — the general rule is not to be rashly deviated from ; of removing as little as possible from the organs of prehension. And, besides, another practical axiom comes into play ; namely, that the further removed an amputation is from the trunk of the body, the less is the risk to life thereby. The flaps may be made either by transfixion, or by cutting from without inwards. The former mode is usually preferred. In the case of the left forearm, the surgeon with his left hand pinches up the cushion of flesh on the dorsal aspect, and enters his knife horizontally over the ulna, bringing it out at a corresponding point over the radius. The knife is again introduced, beneath the ulna, and pushed through on the palmar aspect of the bones ; not at the same point as the former Fig. 214. The ordinary tourniquet shewn in application to the brachial artery ; a bandage enacting the part of compress over the vessel — not very accurately placed. AMPUTATION OF THE ELBOW-JOINT. 661 transfixion, but about half an inch lower down — a precaution which is to be attended to in all double-flap amputations, as already stated (p. 652). An assistant retracts the flaps ; with a few circular sweeps of the knife the surgeon clears the bone of soft parts, at the very Fig. 315. upper part of the wound ; the interosseous space is freed, by the knife being passed between the bones ; and the saw is then applied. At least, the three principal vessels require ligature. The wound is then adjusted in the ordinary way. In transfixion, it is obvious that care must be taken to avoid passing the knife between the bones. On this account, the position of the limb here recommended is preferable to the middle state between pronation and supination ; and during the incisions, care must be taken that the position is maintained unaltered. Amputation of the Elbow-Joint. If space enough be left on the forearm, in extensive disease or injury of that part, the humerus need not be interfered with. An excellent operation may be done at the elbow ; making a single flap in front, The limb is steadied, with the hand in a state of supination. Transfixion is made, by passing the knife over the condyles, in front of the joint ; and, by cutting downwards and outwai'ds, a large and suitable flap- is constructed. With a circular sweep, the integuments behind are divided ; and disarticulation is then effected. The olecra- non may be sawn across ; or, extending the forearm, this process may be wholly removed, the attachment of the triceps having been severed. The flap is then suitably adjusted over the trochlea of the humerus. Fig. 215. Amputation of forearm. 662 AMPUTATION OF THE AEM. Amputation of the Arm. Pressure is made on the upper part of the humeral, or in the axilla. The surgeon with his left hand steadies the limb, below the point of incision ; an assistant, seated in front of the patient, supports the l-ig. 310. hand and forearm. The knife is entered, horizontally, over the bone near its centre, on the side of the limb nearest the surgeon ; the point, having touched the bone, is passed lightly round to its anterior surface, by depression of the handle ; then the handle is raised again to its former level, and transfixion is completed. By cutting downwards and outwards, an anterior flap is formed. The knife is re-entered on the opposite aspect of the bone, a little lower down ; and, after trans- fixion, is brought out so as to construct a corresponding flap posteriorly. The flaps having been retracted, the bone is bared, and the saw applied. Amputation of the Shoulder- Joint. Hemorrhage is restrained by pressure applied to the subclavian, above the clavicle ; by the fingers alone ; or by means of the handle of a key, well padded ; or by means of any other suitable compressing agent. The pressure is not made downwards merely ; but downwards and backwards, so as to jam the vessel between the compressing agent and the first rib. The patient may be either seated or recumbent. The former position is the more convenient for the operator, as well as for the compressor ; but, if it be adopted, it is necessary to secure the patient against changing his position, through fainting or restless- ness, by lashing him to the back of the chair by means of a sheet or towel, as well as by a suitable arrangement of supporting assistants. And now that chloroform is almost invariably employed, this posture is Fig. 216. Amputation of the arm. AMPUTATION OF THE SHOULDEU-JOINT. 663 generally superseded by that of recumbency. In cases of injury, the selection of flaps, as to position and form, may not be left to the surgeon's choice ; but may have been already indicated by the nature of the accident. When space and opportunity for selection are afforded, however, the operation may be accomplished in a variety of ways. The method by transfixion, and by the formation of an outer and inner flap, is so generally preferred and practised, that to it alone need attention be directed. The steps of the operation vary according to the limb opei'ated on. In the right shoulder, it is effected thus : — A long knife is entered on the toj) of the shoulder, about an inch below the acromion ; and, passing round the joint, on its exterior, is brought out immediately within the posterior border of the axilla. By cutting Fis- 217. outwards and downwards, a large outer flap is formed. The arm is then carried across the chest ; and the head of the bone, thus made prominent, is cut down upon by a sweep of the knife. The capsule is opened, and disarticulation effected ; and the blade of the knife, laid on the inside of the head of the bone, is carried rapidly inwards and downwards, so as to form an internal flap, considerably smaller than the other. The main artery is immediately secured by ligature ; and then pressure on the subclavian is removed, lest, by its continuance, venous hemorrhage should be favoured. On the left side, the knife, having been entered within the margin of the posterior border of the axilla, is made to emerge on the top of the shoulder, a little beneath the acromion ; and the outer flap is formed as before. The arm is then canned over the chest, disarticula- tion is effected, and an inner flap is formed. Or the outer flap may be marked out by a bistoury, and dissected up. After cicatrization, the stump requires artificial protection ; other- wise, the prominent acromion is apt to sustain injury. Fig. 217. Amputation of tlie shoulder. 664 AMPUTATION OF THE TOES. Amputation of the Scapula. Disease and injury sometimes, though rarely, render it necessary to take away the scapula along with the superior extremity. No fixed plan can be laid down for the incisions ; they must vary accord- ing to the circumstances of the case. When such extensive mutilation is required on account of injury, the greater part of the incisions will probably be found already made. Amputations of the Lowek Extremity. Amputation of the Toes. The Phalanges of the toes are removed in the same way as those of the fingers. The metatarsal articulation, however, lies consider- ably deeper than the corresponding joint of the superior extremity ; and the incisions require to be made accordingly. There is no necessity for removing the head of the metatarsal bone ; the more ample the base of support, the more efiicient is its function. The Metatarsal Bone of the Great Toe is not unfrequently diseased in the greater part of its extent. It may be disarticulated ; but it is better to divide it a little below its base, if possible, in order to leave the tendinous insertion there undisturbed. By a bistoury, such a flap is indicated as will efficiently cover the wound. The instrument is entered over the tarsal articulation, on the dorsum of the bone, and is carried down, along the dorsum, until the metatarsal joint is reached ; a sweep is theti made on the inner side of this — or rather a little below the joint ; and the incision is continued upwards, leaving an interspace of about an inch and a half between the returning line of wound and that which descended. The flap, thus indicated, is dissected up ; the bone, along with the corresponding toe, is isolated from its connexions, by a suitable use of the knife's point ; and is either disarticulated, or cut across by the pliers, according to circumstances. After removal of the diseased part, and arrest of hemorrhage, the flap is brought down and adjusted to the raw surface. The other Metatarsal Bones are liable to the same operations as the analogous bones of the superior extremity. A very useful foot may be left, after removal of even three of the toes with their metatarsal bones. In estimating the extent of incisions required, it is important to reraerabev the oblique direction of the metatarsal range. AMPUTATIONS OF THE FOOT. 665 Amputations of the Foot. All the Toes may require removal at their metatarsal articulations, on account of frost-bite. A transverse incision is made on the dorsal aspect ; sloping inwards, so as to make a short anterior flap. Disarti- culation is then effected, at each joint; and, the blade of the knife having been laid behind the heads of the phalanges, a suitable flap is made from the plantar aspect. In the case of more extensive disease or injury, similar flaps may be formed — the plantar being made by transfixion ; and then the meta- tarsal bones are divided by the bone-pliers. Hey\s Amputation. — The whole metatarsal range may be taken away, leaving the foot very useful. Hemorrhage is restrained by the pressure of an assistant at the ankle — mainly exerted on the posterior tibial. The patient is laid recumbent on a table, with the foot pro- jecting over the edge. The surgeon, with his left hand, steadies and commands the toes. On the right foot, the prominence of the base of the metatarsal bone of the little toe is felt for ; the knife's edge, laid on immediately above this, is carried across the dorsum of the foot in a semilunar direction, terminating at the articulation of the base of the metatarsal bone of the great toe with the internal cuneiform bone. The short anterior flap, thus indicated, is dissected up ; and disarticu- lation is effected at each joint ; the surgeon pressing heavily down- wards on the toes and metatarsal range, so as to favour this, by ren- dering the joints more open. The peculiarity of the relative position of the base of the second metatarsal bone has to be borne in mind ; and the point of the knife, only, should be used for its detachment. Should anchylosis have taken place there, the pliers or saw are to be employed ; dividing the bone on a line with the general range of arti- culation. Disarticulation having been effected, the blade of the knife is laid on behind, and a sufficient flap is made from the sole of the foot — longer on the inner than on the outer aspect. Or the flap may be fashioned, and dissected up, probably more accurately by cutting from without inwards. The bleeding vessels having been secured, the flaps are adjusted by suture and strap. In operating on the left foot, the dorsal incision is begun over the articulation of the metatarsal bone of the great toe with the internal cuneiform bone, and terminates behind the prominent head of the metatarsal bone of the little toe ; in other respects, the operation is the same. Chopart^s Operation. — Amputation may be performed still higher, leaving a useful stump. Disarticulation is effected between the astra- galus and the navicular bone ; all the bones of the foot and tarsus 666 RESECTION OF THE ANKLE. being removed, except the astragalus and calcaneum. The operation is conducted on the same principles as the preceding ; a short flap being made in front ; and the main flap being obtained from the sole of the foot. The marks for laying on the knife in its dorsal sweep are, the articulation of the navicular bone with the astragalus — behind the prominence of the navicular bone, in front of the inner ankle ; Fig. 318. and the articulation of the cuboid with the os calcis — about midway between the outer ankle, and the prominent base of the metatarsal bone of the little toe. Often, however, these marks cannot be dis- cerned, on account of swelling. After cicatrization, the remnant of the foot is not displaced back- wards, so as to bring the cicatrix in contact with the ground in walk- ing, as might have been expected, from preponderating action of the muscles of the calf. The muscles on the front of the leg, forming new attachments, seem to counteract this effectually. A third amputation of the foot — intermediate between the two preceding — may be performed, by disarticulating the cuneiform bones from the navicular, and sawing the cuboid bone across at a corres- ponding point. The general plan of the incisions is the same as in the two preceding cases. Resection of the Anlde, When disease is limited to the ankle-joint and upper part of the tarsus, it is a question whether or not excision of the diseased parts may not be performed, leaving the foot. On this principle, Mr. Wakley has removed the calcaneum and astragalus, at the same time sawing off the malleolar surfaces of the tibia and fibula.* Further experience of this operation, however, will probably be required, ere it be received as a substitute for that next described. * Lancet, No. 1296, p. 5. Fig. 218. Amputation of the foot. — Chopakt's. AMPUTATION OF THE ANKLE. 667 Amputation of the Ankle. When no part of the foot and tarsus can be saved, amputation is required either in the leg or at the ankle. The latter site is preferable on more than one account ; risk to life is less ; the mutilation is less ; and the stump is not only more useful in progression, but also less liable to neuralgia and exfoliation. Disease of the ankle-joint does not contra- indicate the operation, unless it extend beyond the ends of the bones. And, in most cases of diseased ankle, indeed, it were now unwarrantable to perform any other operation. For the revival and more general introduction of this procedure, the profession is indebted to Mr. Syme. The patient having been suitably arranged on a table, a tourniquet is applied, so as to compress the popliteal artery ; or the fingers of an assistant may be employed, as in amputation of the foot (p. 665). A semilunar incision, directed forwards, is made over the instep, with a strong bistoury or short amputating knife ; and a corres- ponding wound is made across the sole of the foot. " The foot being placed at a right angle to the leg, a line drawn from the centre of one malleolus to that of the other, directly across the sole of the foot, will shew the proper extent of the posterior flap. The knife should be entered close up to the fibular malleolus, and carried to a point on the same level of the opposite side, which will be a little below the tibial malleolus. The anterior incision should join the two points just mentioned at an angle of 45*^, to the sole of the foot, and long axis of the leg. In dissecting the posterior flap, the operator should place the fingers of his left hand upon the heel, while the thumb rests upon the edge of the integuments, and then cut between the nail of the thumb and tuberosity of the os calcis, so as to avoid lacerating the soft parts which he, at the same time, gently but steadily presses back until he exposes and divides the tendo Achillis. The foot should be disarticulated before the malleolar projections are removed, which Fig. 219. Amputation of the ankle. 668 AMPUTATION OF THE LEG. it is always proper to do, and whicli may be most easily effected by passing a knife round the exposed extremities of the bones, and then sawing off a thin slice of the tibia connecting the two processes."* In most cases, the operation will be most readily conducted by com- pletely opening the joint from the front, before dissecting off the soft parts from the calcaneum. Bleeding having been arrested, the flaps are brought together by suture ; and care must be taken, during the cure, to prevent accumulation of pus in the pouch which may be formed by the posterior flap. After cicatrization, a most efficient, round, callous stump is produced ; the patient resting on the integuments of the heel — well accustomed to pressure — and retaining a full use of the knee and leg. It has been said that division of the posterior tibial artery, before it divides into its plantar branches, should be avoided ; otherwise, partial sloughing of the flaps is apt to ensue. Usually, however, incision will not be found to interfere with the arterial trunk in question. And it is probable that in those cases in which sloughing has occurred, the accident was not wholly attributable to deficiency of arterial supply. Should circumstances not be suitable to the plan of incision as above described, lateral flaps may be made — leaving the integument of the heel as much entire as possible. The operation may be readily effected in this Avay ; but there is risk of a less convenient cicatrix resulting, and consequently of the stump proving less useful in pro- gression. Amputation of the Leg. This is not altogether superseded by the operation at the ankle. There are still not a few cases occurring, in which the latter procedure would prove quite insufficient. And in regard to some of these it is to be feared, that the natural preference for a new operation may lead to its performance in circumstances quite unsuitable. The affected parts of the leg-bones having not been sufficiently removed, sinuses and fistulge may form, communicating with caries ; long retarding complete cure ; rendex-ing the stump but little serviceable, perhaps, even when healed ; and, probably, at length, demanding a second amputation. Near the ankle, a fleshy stump is not to be obtained in thin per- sons ; and in these, consequently, we may be compelled to cut some- what higher than otherwise might have been necessary. On the other hand, there are stout limbs — their rotundity mainly caused by a solid oedema — in which it is desirable to amputate low down, in order to avoid redundancy of soft parts. Hemorrhage is restrained by pressure on the popliteal, either by a tourniquet, or by the fingers of an assistant ; or by the assistant's * Syme, Contributions to Surgery, p. 146 ; and Monthly Journal, Feb. 1850, p. 173. AMPUTATION OF THE LEG. 669 pressure on the femoral artery, as it passes over tlie brim of the pelvis. The patient is laid on a firm table, of convenient height, with the Fig. 320. limbs projecting over its edge ; the sound ankle is secured to the leg of the table by means of a towel — the work of an additional assistant being thus spared ; and the doomed limb is supported by an assistant seated in front. The surgeon, feeling the exact outline of the bones, transfixes ; passing his knife as closely as possible to their posterior surface ; and, by carrying it downwards and outwards, a long poste- rior flap is formed. The knife is then laid on at the upper margin of I'ig. 221 the wound ; by a sweep in front, in a semilunar direction, the integu- ment is divided ; this having been retracted, the interosseous space is cleared by the knife passed between the bones ; and the saw is then applied as close to the soft parts as possible. If the ridge of the tibia project, much and sharply, it may be rounded off by means of the Fig. 220. Malan's flat tourniquet, applied to the popliteal. Fig. 221. Amputation of the leg. 670 AMPUTATION OF THE LEG. bone-pliers. Bleeding having been arrested, the flap is brought up and secured. To facilitate transfixion, and guard against locking of the knife between the bones, it may be well to make a little alteration in the procedure. Supposing that the right leg is operated on, the knife is entered on the outside of the fibula, about an inch, or more, beneath the point where transfixion is contemplated ; with a sawing motion the instrument is carried upwards along the outside of the bone, until the site of transfixion is reached ; the blade is then applied in front, Fiff. 233. to form the anterior wound; and, the point having arrived at the inside of the tibia, transfixion is effected — the instrument emerging at the upper part of the wound formerly made on the outside of the fibula. In operating immediately below the knee, the fibula is sawn across, along with the tibia. Disarticulation of the head of the former bone may improve the appearance of the stump, at the time of its formation ; but experience has shown that the procedure is not warrantable, on account of the risk of subsequent inflammatory seizure in the knee-joint. A short stump having been made, the patient usually rests on the knee, with the stump bent at right angles ; and to the knee the arti- ficial limb is adapted. When the stump is long, however, the motions of the knee-joint are retained, and the false limb is adapted to the leg immediately above the cicatrix. When stout muscular men sustain such injury of the leg as requires amputation below the knee, a redundancy of flesh cannot fail to be obtained in the flap, by the ordinary mode of operation. And, accord- ingly, Mr. Liston has advised, in such cases, a modification of the cir- cular amputation. " Supposing the left leg to be injured : — Avith a Fig. 222. The forceps shewn at work. The arteiy fairly isolated, and made to project. Seldom it protrudes so far ; but when it does, the ligatm^e is applied close to the base, and scissors or knife amputates the redundant part. AMPUTATION OF THE KNEE-JOINT. 671 common amputating knife an anterior semilunar incision is made through the skin, commencing from the inner side of the tibia, about four fingers' breadth below its superior extremity, and passing over its anterior aspect. A similar semilunar incision is made at the posterior part of the leg, its extremities joining the horns of the previous inci- sion. The integument is then reflected upwards to a sufficient extent to cover the bones, and the operation is finished after the manner of the circular amputation." Amputation of the Knee-Joint. Latterly, this operation has also been revived ; when injury or disease extend no higher than the condyles of the femur, and involve these only to a superficial extent. A semilunar incision is made on the front of the limb, passing beneath the patella ; the integuments are dissected up, and transfixion is made behind ; by cutting downwards, a very long flap is made from the back part of the leg ; and, the soft parts having been all detached, section of the bone is made through the condyles. Bleeding having been arrested, the flaps are approxi- mated. The operation is easily enough accomplished, but experience seems to have unequivocally decided on this revival unfavourably. Amputation of the Thigh. The patient is arranged as for amputation below the knee, but V-t' Fig. 233. with the pelvis resting on the edge of the table. The femoral is corn- Fig. 223. Amputation of the thigh. 672 AMPUTATION OF THE HIP-JOINT. pressed by an assistant, as it passes over the horizontal ramus of the pubes. The operation is by double flaps. Low down in the thigh, a suitable amount and character of soft parts can be obtained only from the lateral aspects of the limb. Trans- fixion, accordingly, is made perpendicularly. On the upper part of the thigh, the tlaps are anterior and posterior (p. 652); transfixion is horizontal; and the operation is performed in the same way as the analogous procedure in the arm. The posterior flap should be considerably longer than that in front ; to compensate for the greater displacement upwards, by contraction, to which the muscles on the posterior part of the thigh are liable — and for the greater amount of permanent atrophy by absorption, which the pos- terior flap invariably undergoes. Immediately after section by the saw, the muscles inserted into the trochanter-minor project the end of the bone forwards; and, in consequence of this, protrusion at the upper angle of the wound would be apt to take place, were the flaps made laterally ; while, as it is, the more the bone is bent forwards, the more completely is its extremity covered by the anterior flap. Amputation of the Hip- Joint. Amputation at the hip-joint is seldom required. The operation is one of great severity, and eminently perilous to life ; yet, when cir- cumstances are urgent and decided, we need not shrink from its per- formance. There are abeady nearly thirty successful cases in the records of surgery.* For malignant disease of the femur, the opera- tion is unadvisable ; experience having shown that, even although the operation itself may be temporarily successful, return of disease in the interior will surely carry off the patient — probably at an earlier period, and more painfuUy, than if the tumour had been left undisturbed in its original site. The patient is placed on the table, with his pelvis projecting from the edge. A steady assistant compresses the femoral ; and is ready to follow the knife with his fingers, during formation of the anterior flap, so that he may grasp the end of the vessel almost as soon as it is divided. The knife is entered about midway between the trochanter major and the anterior superior spinous process of the ilium, and is made to emerge on the inside of the thigh, after having passed in a somewhat curved direction over the articulation ; the assistant, who supports the limb, gently rotating the thigh inwards. By cutting downwards, a suitable anterior flap is formed. The assistant, then abducting the thigh, presses it backAvards ; and by a determined sweep of the knife over the head of the bone thus made prominent, the joint * Brit, and For. Rev. No. 43, p. 112. AFFECTIONS OF STUMPS. 673 is cut into. With the point of the instrument, the round ligament is divided, and disarticulation effected. The blade of the knife is then placed behind the bone, and carried downwards and backwards, so as to form the posterior flap ; the assistant managing the limb so as to prevent locking of the instrument by the trochanter major. Or the posterior flap may be formed by cutting from without inwards. How- ever made, it is instantly covered by a sponge ; and the vessels there are rapidly secured. Afterwards, the assistant is relieved from his charge of the femoral. By some, the formation of lateral flaps is preferred. Not unfre- quently, in cases of injury, there may be no room for selection ; the extent of the accidental wound precluding all attempts at reo-ular operation, and compelling the surgeon to shape his flaps according to what may be, perhaps, quite an original mode of procedure. Affections of Stumps. Neuralgia of the stump is no unfrequent result of amputation, how- ever skilfully conducted (Principles, pp. 419 and 626). It is most commonly observed after amputation below the knee. If no change of structure in the nerve can be detected, the treatment must be such as is suitable for neuralgia in general ; and, of the remedies usually Fig. 224. Amputation of the hip-joiut. 2x 674 AFFECTIONS OF STUMPS. found most useful, iron internally, and the light application of nitrate of silver to the part, may be specially mentioned. If neuromata plainly exist, entangled with the dense cicatrix, they ought to be removed ; and, for this purpose, a repetition of the amputation on a minor scale is usually necessary ; care being taken, in the fashioning of the stump, and in the after-treatment of it, that the nerves be not again similarly circumstanced. Not unfrequently, however, notwith- standing every care, neuralgia returns — obviously dependent on a genei-al more than on a local cause (Principles, p. 631). The neu- ralgic part should not be pressed upon, in the adaptation of any arti- ficial limb. Exfoliation from the stump seldom follows a well-conducted flap- operation. It is most likely to occur, when section has been made in the dense part of a bone — as in the middle of the femur. The seques- trum may consist of a mere scale from the sawn surface ; or it may be of some length — involving the whole thickness of the bone at its lower part, and tapering, upwards, of a cancellous texture. Healing of the wound is necessarily delayed, until detachment and extrusion of the sequestrum have taken place. Sometimes, in an ill-formed stump, or when the soft parts have perished by sloughing, the end of the bone projects, uncovered, par- tially necrosed, and in part, perhaps, carious. In such a case, renewal of the amputation is necessary ; or the making of such incisions as may admit of the bone being sawn, at a point sufficiently high for subsequent fleshy covering. The accidents of exfoliation, and protrusion of the end of the bone, ought to be prevented ; by fashioning the flap, or flaps, so as to afford a full covei'ing for the end of the bone — allowance being always made Fig. 225. Neuromata of stump, after amputation of the arm. A large neuromatous mass at a; opposite b, the tumours are more defined. AFFECTIONS OF STUMPS. 675 for subsequent coutractiou and atrophy ; by sa'i^'ing the bone, care- fully, close to its connexion with tlie soft parts — not leaving any por- tion bare and projecting, stripped of botb flesli and periosteum, at the time of the operation ; by so conducting tlie cure as to prevent unto- ward accessions of intiammatorv action, "vvherebv ulcerfition. sloushuio'. or long gaping of the wound might occur ; by opposing excessive retraction of the muscles, if need be, by bandaging — in those cases in which the process of granulation is interrupted or tedious. The face of a well-formed stump is -fenced with firm skin, and no more liable to accident than a man's finger-ends," A Bursa usually forms over the end of the bone ; tending towards tolerance of pressure. A blow, or other injury, may induce painful enlargement of this ; and the fluctuation, and other characters of the swelling, may simulate the condition of acute abscess verv closely. Accuracy of diagnosis is obviously of importance ; as, in the one case, early incision is advisable ; while, in the other, rest and fomentation, with pei'haps leeching, prove suflicient. Hemorrhage. — Bleeding, taking place within a few hours after the operation — when the patient grows wai'm in bed, and recovers fully Fig. 226. Necrosis of the femur, after amputation. At a, the sequestrum in process of separation. At h, the parent bone enlarged, and undergoing inflammatory change, necessary for detachment and repair. Fig. 227. The sequestrum detached : at its lower part, (7, including the whole thick- ness of the bone ; but gradually shelving upvrards, as such sequestra usually do. 676 AFFECTIONS OF STUMPS. from the state of shock — usually requires an undoing of the partial approximation of the wound, and the application of ligatures to the open vessels. But if at the time of operation, due care have been taken to apply deligation accurately to each likely orifice, the occurrence of such a casualty need seldom be apprehended. Hemorrhage which occurs at a more remote period, in consequence of ulceration having attacked the stump, may, if slight, be restrained by pressure. But, in general, deligation of the arterial trunk is necessary ; for example, deligation of the femoral, after amputation below the knee ; deligation of the humeral, after amputation of the fore-arm (Principles, p. 366). Koux, Relation d'un Voyage fait d, Londres, Paris, 1814. Hammick on Amputations, Fractures, &c., Lond. 1830. Alcocli, Lectures on Aniputation, Lancet, 1840-41. Cox, Memoir on Amputation at the Hip-Joint, Lond. 1845. Maingault's Operative Surgery, by Cox, Lond. 1845. Liston's Practical Surgery, Lond. 1846. Malgaigne, Operative Surgery, by Brittan, Lond. 1846. Bourgeiy, Operative Surgery, Paris, 1846. Skey, Operative Surgery, Lond. 1850. Fergusson, Practical Surgery, Lond. 1852. Larrey, Memoire sur les Amputations, Mem. de Chir. Milit. vol. ii. INDEX. Abdomen, affections of, 327. Abdomen, bruise of, 328. Abdomen, wonnds of, 329. Abdominal aorta, aneurism of, 591. Abdominal parietes, abscess of, 837. Abdominal tumours, 328, Abscess of the abdominal parietes, 327. Abscess of the antrum, 153. Abscess of the brain, 32. Abscess of the cornea, 99. Abscess of the dura mater, 33. Abscess of the ear, 210. Abscess of the ham, 611. Abscess, lumbar, 309. Abscess of the mastoid cells, 212. Abscess of the neck, 219. Abscess of the pharynx, 197- Abscess, psoas, 309. Abscess exterior to the rectum, .374. Aljscess of the septum nariura, 14i. Abscess of the tonsil, 193. Abscess of the vulva, 564. Abscess, pelvic, 333. Abscess of prostate, 472. Abscess and ulcer of cranium, 59. Abscess, urinous, 530. Acetabiilum, fracture of, 613. Acliillis, tendo, injuries of, 639. Acids, swallowing of, 333. Accidents of venesection, 266. Accidental swallowing of irritant fluids, 233. Acromion, fracture of, 380. Albugo, 103. Amaui'osis, 118. Amputation, 649. Amputation of the ankle, 667. Amputation of the arm, 663. Amputation, circulai-, 654. Amputation of the elbow-joint, 661. Amputation of the fore-arm, 660. Amputation of the fingers, 655. Amputation of the foot, 665. Amputation of the hip-joint, 672. Amputation of the knee-joint, 671. Amputation of the leg, 668. Amputations of the lower extremity, 664. Amputation of the metacai^ial bones, 656. Amputation of the metacarpal bone of little finger. 657. ■ Amputation of the metatarsal bone of great toe, 664. Amputation of the metatarsiil bones, 664. Amputation of the penis, 563. Amputation of the shoulder-joint, 663. Amputation of the scapula, 664. Amputation of the thumb, 658. Amputation of the toes, 664. Amputation of the thigh, 671. Amputation of the wrist, 659. Amaurosis, 118. Amussat's operation for artificial anus, 395. Ammoniaco-raagnesian phosphate calculus, 412. Anal fistula, 375. Anal prolapsus, 386. Anchyloblepharon, 72. Anem-ism, false, 13. Aneurism, popliteal, 594. Aneurism of abdominal aorta, 591. Aneirrism of common femoral, 594. Ankle, amputation of, 667. Ankle, compound dislocation of, 635. Ankle, dislocation of, 634. Ankle, fracture of, 634. Ankle, resection of, 666. Anonyma, arteria, ligature of, 258. Anus, artificial, 331. Anus, fissure of, 380. .'i.nus, imperforate, 393. Anus, itching of, 391. Anus, ulcer of, 380. Anus, formation of artificial, 394. Anus, prolapsus of, 386. .Antrum, abscess of, 153. Antrum, collection of fluid in, 152. Antrum, polypus of the, 154. Anchylosis of the jaw, 185. Aorta, abdominal, aneurism of, 591. Aorta, compression of, 590. Aorta, deligation of, 590. Aquo-capsulitis, 99. Arcus senilis, 103. Arm, amputation of, 662. Arm, bend of the, affections of, 265. Arteria, anonyma, deligation of, 258. Arteries of "the neck and superior extremity, affections of the, 257. Arteries of the fore-arm, deligation of, 263. Arteriotomy, 12. Artery, anterior tibial, deligation of, 600. Artery, aorta, deligation of, 590. Artery, axillary, deligation of, 261. Artery, common carotid, deligation of, 257. Artery, common iliac, deligation of, 594. Artery, common femoral, deligation of, 594. Arteiy, external carotid, deligation of, 258. Artery, external iliac, deligation of, 591. Artery, humeral, deligation of, 262. Artery, internal iliac, deligation of, 592. Artery, popliteal, deligation of, 597. Artery, posterior tibial, deligation of, 598. Artery, peroneal, deligation of, 600. Artery, radial, deligation of, 263. Artery, superficial femoral, deligation of, 596. Artery, suljclavian, deligation of, 359. .Artery, temporal, false aneurism of, 13. Artery, temporal, wounds of, 13. Artery, ulnar, deligation of, 263. Artificial anus, 331. Artificial pupil, 114. Artificial pupil, operationB for, 115. 678 INDEX. Artificial anus, formation of, 394. Arteriotomy, ulceration after, 13. Astragalus, dislocation of, 636. Astragalus, fracture of, 634. Asphyxia, 333. Atrophy of the testicle, 541. Auricle, affections of, 308. Auricle, hypertrophy of the, 317. Axillary artery, dehgation of, 261. Auxiliaries to the taxis, 357. Balanitis, 485. Beer's knife, 133. Bend of the arm, affections of, 365. Biceps, displacement of tendon of, 393. Bladder, affections of, 451. Bladder, displacement of, 471. Bladder, lisematuria from the, 455. Bladder, inflamed, 471. Bladder, injuries of, 469. Bladder, irritable, 453. Bladder, puncture of, 465. Bladder, puncture of, hy perineum, 465. Bladder, puncture of, by rectum, 466. Bladder, puncture of, above pubes, 467. Bladder, stone in the, 417. Bladder, treatment of stone in the, 433. Bladder, tumours of, 470. Blepharitis, 68. Blepharoplastics, 79. Blood, extravasation of, affecting the brain, 36. Boiling water, swallowing of, 333. Bougie, caustic, 529. Bougie, protesting, 532. Bougies, use of, in stricture of urethra, 522. Bowel, protrusion of the, 330. Bowels, wounds of, 329. Brain, abscess of, 32. Brain, concussion of, treatment of, 16. Brain, concussion of, consequences of, 20. Brain, compression of, by extravasation of blood, 26. Brain, compression of, 22. Brain, concussion of, 14. Brain, foreign bodies in, 60. Brain, protrusion of, 51. Brain, puncture of, 52. Brain, wounds of, 49. Breast, female, affections of, 320. Breast, carcinoma of the, 324. Breast, pendulous, 322. Bronchocele, 351. Bronchotomy, 227. Bronchotomy, in what cases advisable, 337, 246. Bridle-strictm-e of urethra, 519. Bruise of the abdomen, 328. Bruise of the larynx, 233. Bruise of the scalp, 7- Bubo, 503. Bubo, inguinal, 503. Bubo, venereal, 502. Bunions, 647. Bursa over olecranon, affections of, 267. Bursa over patella, affections of, 610. Bursa, thyro-hyoid, enlargement of, 355. Bursae over stumps, 675. Calcaneum, fracture of, 624. Calculi, prostatic, 449. Calculi, urethral, 447. Calculous disease, 397- Calculous disease, treatment of, 414. Calculi, urinary, formation and varieties of, 41 0. Calculi, urinary, 397. Calculi, renal, 414. Calculus, alternating, 413. Calculus, ammoniaco-magnesia;i phosphate, 412. Calculus, carbonate of Ume, 412. Calculus, cystic oxide, 412. Calculus, oxalate of lime, 411. Calculus, fibrinous, 413. Calculus, fusible, 413. Calculus in the female, 449. Calculus, lithate of soda, 413. Calculus, mulberry, 411. Calculus, palliation of vesical, 446. Calculus, phosphate of Ume, 412. Calculus, preputial, 448. Calculus, urate of ammonia, 411. Calculus, ui'ic, 411. Calculus, uric or xanthic oxide, 413. Calculus, vesical, 417. Calvarium, tumoms of the, 63. Cancer, chimney-sweeper's, 556. Cancer of the eyelids, 71. Cancer of the uterus, 587. Cancrum oris, 167. Capitis paracentesis, 53. Capsular cataract, 120. Cauhflower excrescence of uterus, 587. Carotid artery, common, dehgation of, 257. Carotid artery, external, deligation of, 358. Caries of vertebrce, 307. Caries of the teeth, 174. Carbonate of lime calculus, 412. Carpus, dislocation of, 398. Carpus, fracture of, 288. Caries of the skull, 59. Caruncula laelirymalis, affections of, 86. Castration, 550. Cataract, 120. Cataract, breaking up of, 125. Cataract, capsular, 120. Cataract, capsulo-lenticular, 120. C itaract, couchin,' of, 134. Cataract, distinguished from glaucoma and amau- rosis, 131. Cataract, depression of, 134. Cataract, dissolution of, 135. Cataract, drilling for, 126. Cataract, extraction nf, 122. Cataract, false, 111, 121. Cataract, hard, 121. Cataract, lenticular, 120. Cataract, operations on, 122. Cataract, radiated, 121. Cataract, symptoms of, 120. Cataract, spm-ious, 121. Cataract, soft, 131. Catarrhus vesicfe, 453. Catheter, female, passing of, 573. Catoptrical test, 130. Caustic bougie, 529. Cerebri, hernia, 51. Cerumen in the ear, 213. Cervix uteri, extii'pation of, 586. Cervix uteri, inflammatory affections of, 575. Cervix uteri, stricture of, 582. Cervix uteri, ulceration of, 576. Ceruminous secretion, deficiency of, in the ear, 213. Cerrical vertebrse, disease of, 355. Cliancre, Hunterian, or true, 493. Cheiloplastics, 168. Cheek, sinus of the, 161. Cheek, tumours of the, 160. Chemosis, 91. Chest, affections of, 313. Chest, wounds of, 314. Child, syphilis in, 515. Chimney-sweeper's cancer, 556. Chopart's amputation of the foot, 665. Choroid coat, affections of, 108. Choroiditis, 108. Circular amputation, 654. Cirsocele, 548. Cii-socele, diagnosis of, 348. Clavicle, dislocation of, 389. Clavicle, fracture of, 279. Clitoris, hypertrophv of, 567. Cloaca, 394. Club-hand, 374. Club-foot, 641. INDEX. 679 Coat, choroid, aifections of, 108. Coat, sclerotic, affections of, 106. Coccyx, fracture of, 612. Colnmna nasi, formation of, 149. Compression of the brain bv depressed bone, 46. Compression of the brain by abscess, 32; treat- ment of, 34. Compression of the brain by extravasation, 26. Compression of the brain, 22. Compression of the spinal cord, 299. Compressor, Signoroui's, 651. Compression of aorta, 590. Componnd fractures of thigh, 619. Concussion of the brain, 14. Concussion and compression combined, 25. Concussion of the spinal cord, 298. Concussion of the brain, treatment of, 16. Concussion of the brain, consequences of, 20. Concussion and compression, distinction between, 25. Concretions, saUvaiy, 191. Condyloma, 500. Congenital hydrocele, 544. Congenital hernia, 367- Congenital occlusion of the meatus auditorius, 217. Conjunctiva, granular, 90, 95. Conjunctivitis, purulent, 90. Conjunctivitis, simple, 87. Conjunctivitis, strumous, 94. Conjunctiva, aifections of the, 87. Contraction of toes, 648. Contre-coup, 23. Coracoid process, fracture of, 281. Coretomia, 115. Corectomia, 116. Coredialysis, 116. Cord, spermatic, heematocele of, 547. Cord, spermatic, hydrocele of, 546. Cord, spermatic, tumours of, 550. Cord, spermatic, varix of, 548. Cornea, affections of the, 97- Cornea, abscess of, 99. Cornea, conical, 105. Cornea, hernia of, 101. Cornea, opacities of, 102. Cornea, over distension of, 106. Cornea, staphyloma of, 104. Cornea, ulcer "of, 100. Corneitis, 97. Comeitis, strumous, 98. Corns, 646. CoroDoid process, fracture of, 286. Corroding ulcer of uterus, 586. Couchins, 124. Coup, 28". Coxalgia, 601. Cramp, -wTiters', 272. Cranium, abscess and tilcer of the, 59. Cranium, affections of, 59. Crauiimi, depression of, 46. Cranium, exostosis of the, 62. Cranium, fissure of, 37. Cranium, fractures of, 36. Cranium, fractures of, at base, 38. Cranium, fissure at base of, 38. Cranium, fracture of, without displacement, 40. Cranium, fracture of, with displacement, 41. Cranium, fracture of external table of, alone, 45. Cranium, fracture of inner table of, alone, 45. Cranium, injuries of, 14. Cranium, ordinary fractures of, 36. Cranium, penetrating cuts of, 45. Cranium, punctured fractures of. 43. Croup, 237- Cut-throat, 223. Curvatures of spine, 303. Curvature, lateral, of spine, causes of, 303. Cynanche tonsillaris, 193. Cvstitis, 451. Cystitis, acute, 451. Cystitis, chronic, 453. Cystocele, vaginal, 572. Crystalline lens and capsule, affections of, 12o. Cysticercus telas ceUulosa, 129. Cystic oxide calculus, 412. Cuneiform bones, dislocation of, 6-38. Cynanche membranacea, 239. Cystine deposit, 408. Dacryolites, So. Dacryadenitis, 85. Deafness, 213. Deformities of hand, 274. Deformities of foot, 641. Deligation of carotid artery, 257. DeUgation of anonyma, 258. Deligation of subclanan, 259. DeUgation of avillary, 261. Deligation of humeral, 262. Dehgatiou of radial and ulnar, 263. Deligation of aorta, 590. Deligation of external Oiac, 591. Deligation of internal ihac, 592. Deligation of common iliac, 594. Deligation of common femoral, 597. Deligation of superficial femoral, 596. Deligation of popliteal, 597. Deligation of posterior tibial, 598. Deligation of anterior tibia], 600. Deligation of peroneal, 600. Delirium after injuries of the head, 16. Deposit, lithic, 399. Deposit, oxalate of hme, 403. Deposit, phosphatic, 406. Deposit, cysdne, 408. Deposit, uric, 409. Deposit, xanthic oxide, 409. Depressed fracture of the cranium, 46. Depression of cataract, 124. Diaphragm, affections of the, 345. Diaphragm, paralysis of the, 345. Diaphragm, rupture of the, 345. Diaphragmatic hernia, 372. Diastasis of the femur, 619. Diatheses, 397. Diathesis, lithic, 399. Diathesis, oxalic, 403. Diathesis, phosphatic, 406. Diphtheritis, 239. Diplopia, 119. Diseases of scalp and cranium, 55. Dislocations, 289. Dislocation of the carpus, 296. Dislocation of the lower jaw, 184. Dislocation of the clavicle, 239. Dislocation of the scapula, 290. Dislocation of the shoulder, 291. Dislocation of the elbow, 293. Dislocation of the ulna, 294. Dislocation of the raditis, 295. Dislocation of the wrist, 295. Dislocation of the fingers, 296. Dislocation of the thumb, 297. Dislocation of the spine, 302. Dislocation of the ribs, 313. Dislocation of the pelvis, 624. Dislocation of the hip, 625. Dislocation of the knee, 632. Dislocation of the patella, 633. Dislocation of the ankle, 634. Dislocation of the tarsus, 636. Dislocation of the toes, 638. Dislocation of tibia at the knee, 632. Dislocation of tibia at the ankle, 634. Dislocation, compound, of the ankle, 635. ' Dislocation of the head of fibula, 633. } Dislocation of the astragalus, 636. i Dislocation of the os calcis and astragalus, 637. Dislocation of the cuneiform bones, 638. Dislocation of the metatars\is, 60S. 680 INDEX. Displacement of the bladder, 471. Displacements of the uterus, 581. Distichiasis, 74. Distoma oculi, 129. Diverticulum of intestine, 347. Dropsy of the eve, 126. Dropsv, ovarian, 335. Duct, "nasal, obstruction of, 84. Duct, nasal, obliteration of, 85. Duct, nasal, absence of 85. Dura mater, abscess of, 33. Ear, affections of, 208. Ear, polypus of, 208. Ear, hemorrhage from, 216. Earache, 213. Ecchymosis of eye, 66. Ectropion, 77. Eczema mercuriale, 513. Elbow, amputation of, 661. Elbow, dislocation of, 293. Elbow-joint, resection of, 276. Elephantiasis of scrotum, 554. Emphysema, 317- Empyema, 318. Encauthis, 86. Encysted hydrocele, 545. Encysted tumours of scalp, 57. Encysted tumours of eyelids, 70. Enlargement of prostate, 473. Entozoa in the eyeball, 128. Entropion, 75. Entropion, Crampton's operation for, 76. Enuresis, 457. Enuresis in children, 457. Epididymitis, 534. Epiphora, 79. Epispadias, 560. Episoraphy, 581. Epistasis. 140. Epulis, 17S. Erectile tumours of orbit, 66. Erectile tumours of scalp, 58. Erectile ttmiour of tongue, 188. Erectile tumour of nose, 139. Erstliismus, 513. Erysipelas of face, 159. En'sipelas of scalp, 55. ErA'sipelas of scrotum, 544. Eustachian tube, affections of, 214. Exfoliation of skull, 61. Esfohation from stumps, 674. Exomphalos, 371. Exostosis of cranium, 62. Exostosis of great toe, 648. Exturpation of cenis uteri, 586. Extraction of cataract, 122. Extraction of teeth, 175. Extravasation of blood within cranium, 26. Extravasation of blood between bone and dura mater, 27 ; treatment of, 28. Extravasation of blood on or in brain, 28; treat- ment of, 29. Extravasation of urine, 467. Extravasation, vesical, of urine, 467. Extravasation, urethral, of urine, 46S. Extremity, superior, affections of arteries of, 257. Extremitv, superior, diseases of articulations of, 275. ■ Extremity, superior, injuries of, 279. Eye, dropsy of, 126. EyebaD, affections of, 87. Eyeball, congenital deficiency of, 130. Eyeball, entozoa in, 128. EyebaU, extirpation of, 129. EyebaD, tumours of, 129. Eyeball, wounds of, 128. Eyelid, hypertrophy of, 71. EyeUds, injuries of, 66. Eyelids, cancer of, 71. Eyelids, closure of, 71. Eyelids, foreign bodies in, 67. Eyehds, swellings of, 69. Eyelids, ttunours of, 70. Eyelids, warts on, 70. Eyelids, wounds of, 67. Face, affections of, 159. Face, erysipelas of, 159. Face, neuralgia of, 160. Face, spasm or", 159. Face, warts of, 159. Face, wounds of, 159. False aneurism, 13. False passages in urethra, 524. False cataract, 111. Fascia, palmar, contraction of, 271. Female, calculus in the, 449. Female, gonorrha?a in the, 4S6. Female, retention of urine in the, 465. Female, syphilis in the, 515. Femoral artery, compression of, 595. Femoral artery, deligation of, 596. Femoral artery, common, aneurism of, 594. Femoral hernia, 368. Femur, fractures of, 613. Femur, fracture of neck of, within capsule, 613. Femur, fracttire of, external to capsule, and abore ti-ochanter, 615. Femur, fracture of, through trochanters, 618. Femur, fracture of trochanter major of, 618. Femur, fracture of, below trochanter minor, 618. Femur, fracture of shaft of, 619. Femur, fracture of, above condyles, 619. Femur, fracture of condyles of," 619. Fibula, dislocation of head of, 633. Fibula, fracture of, 621. FUaria oculi humaui, 128. Fingers, amputation of, 655. Fingers, dislocation of, 296. Fingers, hypertrophy of, 274. Fingers, supernumerary, 274. Fingers, webbed, 274. Fissure at the base of cranium, 88. Fissure of the anus, 360. Fissure of the cranium, 37. Fissure, spinal, 301. Fistula after lithotomy. 443. Fisttila, fa-cal, 333. Fistula in ano, 375. Fistula in perineo, 532. Fistula lachrymalis, 82. Fistula, recto-vaginal, 570. Fistula, salivary, 161. Fistula, spermatic, 539. Fistula, tracheal, 244. FisttUa, urinary, 530. Fistula, urethro-vaginal, 569. Fistula, vaginal. 567. Fistula, vesi co-vaginal, 567. Flap-amputation, 651. Flat-foot, 645. Foot, affections of, 641, Foot, amputation of, 665. Fore-arm, amputation of, 660. Fore-arm, deligation of ai'teries of, 263. Foreign bodies in the brain, 50. Foreign bodies in the ear, 208. Foreign bodies in the eye, 67. Foreign bodies in the nostrils, 142. Foreign bodies in the oesophagus, 204. Foreign bodies in the phar\Tix, 200. Foreign bodies in the rectum, 393. Foreign bodies in the vagina, 572. Foreign bodies in the ■nnidpipe, 227. Fracture of acromion, 2S0. Fracture of astragalus, 624. Fracture of fibula, 621. Fracture of body of scapula, 280. Fracture of both tibia and fibula, 622. Fracture of botli radius and ulna, 288. INDEX. 681 lYacture of calcaneum, 624. Fracture of cranium, without displacement, 40. Fracture of cranium, witli displacement, 41. iVacture of external table of cranium alone, 45. Fractm-e of inner table of cranium alone, 45. Fracture, depressed, of cranium, 46. Fracture of carpal bones, 288. Fracture of clavicle, 279. Fracture of coracoid process, 281. Fracture of cranium, 36. Fracture of femur, 61-3. Fracture of humerus at its condyles, 285. Fracture of humerus at its neck, 282. Fracture of humerus at its shaft, 284. Fracture of leg:, 621. Fractiu-e of lower jaw, 183. Fracture of malar bone, 162. Fracture of malleoli, 624. Fracture of metacarpal bones, 288. Fracture of nasal bones, 134. I'racture of patella, 620. Fractiu-e of pelris, 612. Fracture of phalanges of fingers, 289. Fractm-e, punctured, of cranium, 43. Fracture of radius, 286. Fracture of ribs, 312. Fracture of scapula at its neck, 281. Fracture of spine, 900. Fracture of sternum, 313. Fracture of tarsal bones, 624. Fractui'e of ulna, 285. Fractures at ankle. 624. Fractures, compound, of leg, 623. Fractures, compound, of tlugh, 619. Fractures of foot, 624. Fractures of tibia, 621. Frsenum linguae, division of, 189. Frontal sinus, polypus of, 63. Fungus of testicle", 536. Fusible calculus, 412. Ganglia in fore-arm and wrist, 268. Galaotirrhoea, 321. Gastrocnemius muscle, rupture of, 539. Gastrocnemius muscle, laceration of, 640. Gastrostomy, 344. Gastrotomy, 344. Geuital organs, affections of female, 563. Gland, lachrymal, affections of, 85. Gland, lachrymal, atrophy of, 86. Gland, lachrymal, tumours of, 86. Gland, parotid, tumours of, 161. Gland, thyroid, affections of, 251. Gland, thyroid, tumours over the, 254. Glaucoma, 127. Glaucoma and amaui-osis distinguished from cataract, 121. Glandular enlargement of neck, 219. Glenoid cavity, fracture of, 281. Glossitis, 186" Glottis, spasm of, 234. Goitre, 251. Gonorrhcea, 477. Gonon'hcea, infantile, 563. Gonorrhcea in the female, 486. Gonorrhoea prteputialis, 485. Gonorrhoea spuria, 478. Gonon'haja, accidents of, 478. Gonorrhcea, treatment of, 480. Gonorrhoea] ophthalmia, 94, 485. Gonorrhocal lichen, 485. Gonorrhffial orchitis, 534. Gorget, 444. Grando, 70. Granular conjunctiva, 90, 95. Gravel, 403. Great toe, exostosis of, 648. Great toe, amputation of, 661. Gums, recession of, 176. Gums, tumours of. 192. Gumboil, 178. Hfematocele of neck, 220. Hfcmatocele of scrotum, 547. Hcematocele of spermatic cord, 647. Hematocele of tunica vaginalis, 547. Haemato-thorax, 316. Hsematurla, 455. Hfematuria from kidney, 455. Hsematurla from bladder, 455. Hematuria from urethra, 456. Ham, affections of, 610. Ham, abscess of, 611. Ham, tumours of 611. Hand, defonnities of, 274. Hand, affections of, 268. Hare-eye, 72. Harelip, 163. Harelip, single, 163. Harelip, double, 164. Harelip, complicated, 165. Heart, wounds of, 319. Hemorrhage after extraction of teeth, 176. Hemorrhage after lithotomy, 439. Hemorrhage from ear, 216. Hemorrhage from rectum, 391 . Hemorrhage from stumps, 675. Hemorrhoids, 381. Hemiopia, 119. Hernia, 349. Hernia bronchalis, 255. Hernia, causes of, 346. Hernia cerebri, 51 _: prevention of, 51 ; cure of, 51. Hernia, component parts of, 346. Hernia, congenital, 867. Hernia, coverings of, 346. Hernia, diagnosis of. 347. Hernia, diapliragmatic, 372. Hernia, direct inguinal, 368. Hernia, enterocele, 347. Hernia, epiplocele, 347. Hernia, entero-epiplocele, 347. Hernia, femoral, 368. Hernia humoraiis, 534. Hernia, incarcerated, 353. Hernia infantilis, 367- Hernia, intermuscular inguinal, 867. Hernia, irreducible, 352. Hernia, ischiatic, 372. Hernia litrica, 347, 372. Hernia of the lungs, 314. Hernia, obUque inguinal, 365. Hernia, obturatorial, 372. Hernia of the cornea, 101. Hernia, perineal, 372. Hernia, phrenic, 372. Hernia, radical cure of, 351. Hernia, reducible, 349. Hernia, scrotal, 365. Hernia, strangulated, 353. Hernia, strangulated, operation for, 361. Hernia, umbilical, 371. Hernia, vaginal, 372. Hernia, ventral, 372. Hernia, ventro-inguinal, 368. Hernial hydrocele, 546. Hernial contents, 347. Hernial sac, 347. Herpes of penis, 4SS. Hey's amputation of foot, 665. Hip, dislocation of, 625. Hip, dislocation of, upwards, 625. Hip, dislocation of, backwards, 628. Hip, dislocation of. downwards, 629. Hip, dislocation of, forwards, 6-31. Hip, anomalous dislocations of, 632, Hip-joint, aniputatiou of, 672. Hip-joint, change of fonn in, 609. Hip-joint, disease of, 601. Hip-joint, resection of, 608. Hordeolum, 69. Housemaid's knee, 610. Humeral artery, ligature of, 263. 682 INDEX. Humerus, condyles, fracture of, 285, Humerus, dislocation of the, at the shoulder, 291. Humerus, fracture of, 283. Humerus, fracture of neck of, 282. Humerus, fracture of shaft of, 284. Humours of eye, affections of, 126. Hunterian or "true chancre, 493. Hunter's forceps, 447. Hydrocele, 541. Hydrocele, congenital, 544. Hydrocele, diagnosis of, 541. Hydrocele, encysted, 545. Hydrocele, hernial, 546. Hydrocele in the female, 547. Hydrocele of the cord, 546. Hydrocele of the neck, 220. Hydrocele of tunica vaginalis, 541. Hydrophthalmia, 126. Hydrorachitis, 310. Hydrothora-x, 318. Hydro-sarcocele, .542. Hymen, imperforate, 571. Hyo-thyroid bursa, enlargement of, 255. Hyperspadias, 560. Hypertrophy of the auricle, 216. Hypertrophy of clitoris and nymphfe, 567. Hypertrophy of the eyehd, 71. Hypertrophy of the fingers, 274. Hypertropliy of the mamma, 322. Hypertrophy, partial, of tlie mamma, 323. Hypertrophy of the tongue, 187. Hj'pertrophy of the tonsils, 194. HypoEema, 111. HjTiopion, 111. Hypospadias, 560. Hiacs, deligation of, 591. Hiac, common, deligation of, 594. Iliac, external, deligation of, 591. Iliac, internal, deligation of, 591. Ilium, fractui-e of, 612. Imperforate anus, 393. Imperforate urethra, 561. Incarcerated hernia, 353. Incisions, mode of making, 3. Incontinence of urine, 457. Induration of the tongue, 188. Infantile hernia, 367. Inflammation, orbital, 63. Inguinal bubo, 503. Inguinal hernia, 365. Inguinal hernia, intermuscular, 367- Inguinal hernia, dii'cct, 368. Injuries of the cranium, 14. Imperforate vagina, or hymen, 571. Impotence, 551. Instruments, use of, 2. Intercostal artery, wound of, 315. Intestines, injuries of, 328. Inversion of uterus, 577. Iris, affections of, 109. Ijris, adhesions of the, 114. Iris, tremulous, 114. Iritis, 109. Iritis, rheumatic and artliritic, 112. Intis, strumous, 113. Iritis, sj^hilitic, 112. Irritable bladder, 453. Irritable mamma, 320. Irritable testicle, 540. Iscliiatic hernia, 372. Ischium, fracture of, 612. Itching of the anus, 391. Jaws, affections of, 178. Jaw, anchylosis of the, 185. Jaw, lower, caries and necrosis of, 183. Jaw, lower, dislocation of, 184. Jaw, lower, extirpation of, 180. Jaw, lower, fracture of, 183. Jaw, lower, tumours of, 179- Jaw, upper, extirpation of, 155. Jaw, upper, tumours of, 154. Jaw, upper, large osteosarcoma of, 154. Joints of lower extremity, affections of, 601. Jugular vein, external opening of the, 221. Knee, aft'ections of, 610. Knee-joLut, amputation of, 671. Knee, dislocations of, 632. Knee, housemaid's, 610. Kidney, hsematuria from the, 455. Knee, injuries of, 632. Labium, oozing tumour of, 565. Lachrymal apparatus, affections of, 79. Lachrymal fistula, 82. Laclu'ymal gland, affections of, 85. Lachrymal gland, atrophy of the, 86. Lachrymal gland, tumours of the, 86. Lachrymal sac, affections of, 80. LachrjTual sac, chronic affections of, 81. Lacteal enlargement in breast, 322. Lallemand, M., his porte-caustique, 529. LagophthaJmos, 72. Laryngeal ulceration, 242. Laryngismus stridulus, 234. Laryngotomy, 248. Laryngitis, acute, 235. Laryngitis, chronic, 240. Laryngitis, chronic, thickening of mucous mem- brane from, 240. Laryngitis fibrinosa, 237. LarjTigitis purulenta, 240. Laryngitis cedematosa, 235. Laryngitis simplex, 235. Lai-ynx, apoplexy of the, 233. Larynx, folhcular disease of the, 241. Larynx, formation of matter near the, 246. Larynx, diseased cartilage of, 243. Larynx, injury of, 282. Larynx, stricture of, 245. Larynx, ulceration of the, 242. Larynx, warts of, 244. Leg, amputation of, 668. Leg, fractures of, 621. Leg, compound fractures of, 623. Lens and capsule, affections of the crystalline, 120. Leucoma, 103. Leucorrhcea, diagnosis of, 574. Lipoma of the nose, 134. Lippitudo, 69. Lips, affections of, 163. Lips, ulcers of, 165. Lithate of soda calculus, 413. Lithectasy, 446. Litliic diathesis, 399. Lithic deposit, 399. Lithontriptics, 414. Lithotripsy, 427. Lithotritv, 427. Lithotomy, 432. Lithotomy, aggravation of renal disease by, 442. Lithotomy, bilateral, 444. Lithotomy, constitutional irritation after, 442. Lithotomy, cystitis to be obviated in, 442. Lithotomy, erysipelas after, 442. Lithotomy, hemorrhage after, 439. Lithotomy in children, 444. Lithotomy, lateral, 432. Lithotomy, a deux temps, 444. Lithotomy, peritonitis after, 440. Lithotomy, recto-vesical, 444. Lithotomy, rectal fistula after, 443. Lithotomy, risks of, 439. Lithotomy, supra-pubal, 444. Lithotomy, ru'tnarj' infiltratiou after, 44(). Lithotomy, urinary infiltration and peritonitis after, 441. Lithotomy, varieties in, 444. Little finger, amputationof metacarpalbone of, 657- Lower extremity, subluxations and sprains of, 63S. INDEX. 683 Lower extremities, injuries of the, 612. Lumbar abscess, 309. Lungs, wounds of, 315. Lungs, hernia of the, 314. Lupus, 145. Malar bone, fracture of, 163. Malleoli, fracture of, 624. Mamma, affections of, 320. Mamma, chronic abscess of, 321. Mamma, fungus heematodes of, 324. Mamma, extirpation of, 325. Mamma, hypertrophy of, 322. Mamma, irritable, 320. Mamma, lacteal tumour of, 323. Mamma, malignant tumours of, 323. Mamma, partial hypertrophy of, 323. Mamma, tumours of, 323. Mamma, tumours external to the, 325. Mammilla, affections of, 326. Mammitis, 320. Mammitis, acute, 320. Mammitis, chronic, 321. Mastoid cells, abscess of, 313. Maxilla, superior, affections of, 152. Maxilla, extirpation of superior, 155. Maxilla, tumours of the, 154. Meatus auditorius, congenital occlusion of the, 217. Medullary nasal polypi, 139. Membraua tympani, perforation of, 216. Meningeal artery, injury of, 26. Mercury, effects of, 513. Mercuric-syphilitic ulcers, 144. Mercury, use of, in syphilis, 509. Metacarpal bones, affections of, 272, 273. Metacarpal bones, amputation of, 656. Metacarpal bones, fractures of, 288. Metacarpal bone of little finger, amputation of, 657. Metacarpal bones, tumours of, 272. Metatarsal bone of great toe, amputation of, 664. Metatarsal bones, amputation of, 664. Metatarsus, dislocation of, 638. Milium, 70. Monostoma lentis, 129. Mons veneris, malignant disease of, 564. Morbus coxarius, 601. Morbus coxarius, diagnosis of, 607- Mulberry calculus, 411. Muscae volitantes, 109. Mydriasis, 113. Myocephalon, 102. Myosis, 113. Nail, diseased matrix of, 271, 648. Nasal bones, fracture of, 134. Nasal duct, absence of the, 85. Nasal duct, obUteration of, 85. Nasal duct, obstruction of, 84. Nasal polypus, 136. Nasal tubes, passing of, 143. Nebula, 103. Neck, abscess of, 219. Neck, affections of, 319. Neck, affections of the arteries of, 257. Neck, glandular enlargement of, 219. Neck, hydrocele of the, 220. Neck, suspension by the, 232. Neck, tumours of, 230. Neck, wounds of, 223. Necrosis of skull, 60. Neuralgia of the face, 160. Neuralgia of the ear, 213. Neuralgia of stumps, 673. Nipple, affections of, 326. Noli me tangere, 145. Noma, 564. Nose, affections of, 134. Nose, dense fibrous polypus of, 138. Nose, erectile tumour of, 139. Nose, lipoma of, 134. Nose, partial restoration of, 149. Nose, polypus of the, 136. Nostrils, foreign bodies in, 142. Nostrils, plugging of, 141. Nostrils, ulcers of, 144. Nymphse, hypertrophy of, 567. Oblique inguinal hernia, 365. Obliteration of vagina, 570. Occlusion of the pupO, 114 ; tlu'ee modes of ope- ration, 115. CEdema glottidis, 335. (Edema glottidis, chronic, 341. CEdema of the uvula, 193. OEsophagitis, 203. CEsophagotomy, 206. CEsophagus, affections of the, 203. (Esophagus, foreign bodies in, 204. CEsophagus, palsy of the, 307. CEsophagus, stricture of, 203. Olecranon, fracture of, 285. Olecranon, affections of bursa over, 367. Omalgia, 275. Onychia, 270, 648. Onyx, 99. Onyxis, 271, 648. Operations, 1. Ophthalmia, 87. Ophthalmia, gonorrhoeal, 94. Ophthalmia, neonatorum, 93. Ophthalmia, purulent, two varieties of, 93. Ophthalmia tarsi, 69. Ophthalmitis, 128. Orbit, affections of, 63. Orbit, tumours of, 64. Orbit, wounds of, 64. Orbital inflammation, 63. Orchitis, 534. Orchitis, acute, 534. Orchitis, chronic, 536. Os calcis, dislocation of, 637. Oscheocele, 365. Osteocephaloma, 154. Osteocystoma, 179. Osteoma, 180. Osteosarcoma, large, of upper iaw, 154. Otalgia, 213. Otitis, 209. Otitis, external and internal, 209. Otoplasties, 217. Otorrhoea, 210. Ovarian dropsy, 335. Ovarian tiunours, 335. Ovariotomy, 340. Oxalate of lime calculus, 411. OxaUc diathesis, 403. Ozaena, 144. Palate, affections of, 169. Palate, congenital deficiency of, 169. Palate, ulcer and exfoliation of, 172. Palmar arch, wounds of, 264. Palmar fascia, contraction of, 271. Palsy of tlie oesophagus, 207. Pannus, 97- Paracentesis abdominis, 339. Paracentesis capitis, 53. Paracentesis thoracis, 318. Paraphymosis, 559. Paralysis of the pharynx, 199. Paronychia, 268. Parotid, tumours of, 161. ParirUs, 178. Patella, compound fractures of, 621. Patella, dislocations of, 633. Patella, fractures of, 620. Patella, longitudinal fracture of, 620. Patella, transverse fracture of, 620. Pelvic abscess, 333. Pelvis, dislocation of, 634. Pelvis, fracture of, 612. 684 INDEX. Pendulous breast, 322. Penis, affections of, 554. Penis, amputation of, 562. Penis, bubo of, 502. Penis, berpes of the, 488. Penis, malignant disease of, 561. Penis, warts on the, 486. Perforation of membrana tympani, 216. Pericranitis, 58. Perineal fistula, 533. Perineal hernia, 372. Perineum, laceration of, 567. Peritonitis after lithotomy, 440. PerityphUtis, 333. Peroneal artery, deligation of, 600. Phagedaena, sloughing, 496. Pliagedsnic syphilis, 496. Phagedsenic ulcer, 496. Phalanges of fingers, affections of, 272. Phalanges of fingers, dislocations of, 296. Phalanges of fingers, fractures of, 289. Phalanges of fingers, tumours of, 272. Pharyngeal abscess, 197. Pharyngitis, 197. Pharynx, affections of the, 197. Pharynx, foreign bodies in, 200. Pharynx, paralysis of, 199. Phai7nx, passing of iustrumeuts in, 201. Pharynx, sacculated, 199. Pharynx, spasm of, 199. PharyiLx, stricture of, 198. Pharynx, tumours of, 199. Phosphatic diathesis, 406. Phosphate of lime calculus, 412. Phthisis laryngea, 243. PhjTnosis, 557. PUes, 381. Piles, blind, 381. Piles, external, 381. Piles, internal, 382. Pleura, wounds of, 315. Plugging of the nostrils, 141. Plugging of the vagina, 573. Pueumo-thorax, 317. Pneumocele, 314. Podelkoma, 646. Polypus of the antrum, 154. Polypus of the frontal sinus, 62. Polypus, dense fibrous, of nose, 138. Polj-pus of the ear, 208. Polj^pus of the nose, 136. Polypus of the rectum, 385. Polypus of the uterus and vagina, 583. Popliteal aneurism, 594. Popliteal artery, deligation of, 597. Preputial calculus, 448. Pressure in treatment of aneurism, 595. Priapism, 556. Probang, use of, 198, 201. Prolapsus ani, 386. Prolapsus uteri, 578. Prolapsus vaginje, 572. Prostate, affections of, 472. Prostate, abscess of, 472. Prostate, enlargement of, 473. Prostate, malignant tumours of, 476. Prostatic calculus, 449. Prostatitis, 472. Protesting bougie, 522. Pruritus of the vulva, 565 Pseudo-syphihs, 516. Psoas abscess, 309. Pterygium, 96. Ptosis, 73. Pubes, fracture of, 612. Puffy tumour of the scalp, 32. Puncture of the bladder, 465. Puncture of bladder by perineum, 465. Puncture of bladder by rectum, 466. Puncture of bladder above pubes, 467. Punctured fracture of the cranium, 42. Pupil, artificial, 114. Pupil, artificial, operations for, 115, Pupil, contraction of the, 113. Pupil and iris, changes in the, 113. Pupil, occlusion of, 114. PupQ, unusual dilatation of the, 113. Puriilent conjunctivitis, 90. Radius, dislocation of, 295. Radius, dislocation of, at the elbow, 295. Radius, dislocation of, at the wrist, 296. Radius and ulna, dislocation of, at the wrist, 295. Radius and ulna, dislocation of, at the elbow, 293. Radius and ulna, fracture of both, 288. Radius, fracture of, 286. Radial artery, ligature of, 263. RaraoUissement of spinal cord, 299. Ranula, 190. RecUnation of cataract, 125. Rectal fistula after lithotomy, 443. Rectitis, 375. Rectoceie, vaginal, 572. Recto-vaginal fistula, 570. Rectum, abscess exterior to, 374. Piectum, affections of, 374. Rectum, foreign bodies in, 392. Rectum, hemorrhage from, 391. Rectum, injuries of, 391. Rectum, irritable, 390. Rectum, itching of, 391. Rectum, malignant stricture of, 390. Rectum, medullary tumour of, 390. Rectum, polypus of, 385. Rectum, scirrlio-contracted, 390. Rectum, stricture of, 388. Rectum, simple organic stricture of, 388. Rectum, spasmodic stricture of, 388. Renal calculi, 414. Resection of ankle, 666. Resection of elbow-joint, 276. Resection of hip-joint, 608. Resection of shoulder-joint, 275 . Resection of the wrist, 278. Retention of urine, 459. Retention of irrine, from abscess in the peri- neum, 461. Retention of urine from pelvic abscess, 461. Retention of mine from blood in the bladder, 464. Retention of urine from calculus, 462. Retention of urine from diseased prostate, 464. Retention of urine from imperforate urethra, 465. Retention of urine from injury of perineum, 462. Retention of urine from malignant disease of penis, 464. Retention of urine from paralysis, 463. Retention of urine from priapism, 461. Retention of urine from spasm, 461. Retention of urine from stricture, 460. Retention of urine from urethritis, 461. Retention of urine in the female, 465. Retina, affections of, 117. Retinitis, 117. Retro-uterine sanguineous tumours, 334. Rheimiatic iritis, 112. UhinoUthes, 140. Rhinoplasties, 146. Ribs, caries and necrosis of, 313. Ribs, dislocation of, 313. Ribs, fracture of, 312. Ruspini's styptic, 141. Sacrum, fracture of, 612. Salivai-j' concretions, 191. Salivary fistula, 161. Sarcocele, 539. Sanguineous, retro-uterine, tumours, .334. Scalp, bruise of, 7. Seal,), erectile tumours of, 57. Scalp, erysipelas of 55. Scalp, contused and lacerated wounds of, 10. Scalp and cranium, 'diseases of, 55. INDEX. 685 Scalp, malignant tumours of, 57- Scalp, malignant ulcer of, 57. Scalp, punctured wounds of, 11. Scalp, simple incised wounds of, 9. Scalp, solid tumours of, 57. Scalp, tumours of, 57. Scalp, wounds of, 9. Scarpa's ueedle, 125. Scapula, amputation of, 664. Scapula, displacement of angle of, 290. Scapula, fracture of body of, 280. Scapula, fracture of neck of, 281. Sclmeideriaa membrane, simple ulceration of, 144. Schneiderian membrane, congestion of, 143. Scirrho-contracted rectum, 390. Sclerotic, staphyloma of, 107. Sclerotitis, 106. Sclerotic coat, affections of, 106. Scrofulous testicle, 538. Scrotal hernia, 365. Scrotum, affections of, 554. Scrotum, cancer of, 556. Scrotum, elephantiasis of, 554. Scrotum, erysipelas of, 554. Scrotum, hccmatocele of, 547. Secondary symptoms of syphilis, 487, 505. Semilunar cartilages, displacement of, 633. Septum narium, abscess of, 144. Searcher, 437. Shoulder, amputation of, 663. Shoulder, dislocation of, 291. Shoulder, subluxation of, 293. Shoulder-joint, disease of, 275. Shoulder-joint, resection of, 276. Signoroni's compressor, 651. Sinus, frontal, polypus of the, 62. Sinus of the cheek, 161. Skull, caries of the, 59. Skull, exfoliation of, 61. Skull, necrosis of the, 60. Sloughing phagedfena, 496. Sloughing ulcer, 496. Sounding, 432. Spasm of the face, 159. Spasm of the glottis, 234. Spasm of the phaiynx, 199. Spermatic cord, htematocele of, 547. Spermatic cord, tumours of, 550. Spermatic fistula, 539. Spermatorrhcea, 552. Spina ventosa, 179. Spine, affections of, 298. Spine, causes of lateral curvature of, 303. Spine, caries of, 307. Spine, curvature of, 303. Spine, dislocation of, 301. Spine, fracture of, 800. Spine, malignant disease of, 311. Spina bifida, 310. Spinal cord, compression of, 299. Spinal cord, concussion of, 298. Spinal cord, ramoUissement of, 299. Spinal cord, softening of, 298. Spinal fissure, 301. Split palate, 169. Sprains of lower extremity, 638. Squintmg, 130. Squinting, varieties of, 130 ; convergent, diver- gent, 131. Stammering, 192. Staphyloma of the cornea, 104. Staphyloma of the sclerotic, 107- Staphyloraphe, 169. Sterno-cleido-mastoid, division of, 221. Sternum, caries and necrosis of, 313. Sternum, fracture of, 313. Stilhcidium lachrymarum, 79. Stomach-pump, use of, 203. Stoue in the bladder, 417. Stone in the bladder, treatment of, 423. Stone, borinw of, 437. Stone, crushing of, 437, 444. Stone, disintegration of, medicinally, 435. Stone, evulsion of, 426. Stone, excision of, 432. Stone, natural expulsion of, 435. Stone, snaring of, 436. Strabismus, 130. Strabismus, congenital, 133. Strangulation of hernia, 353. Strangulated hernia, operation for, 361. Stricture of cervix uteri, 583. Stricture of the oesophagus, 203. Stricture of the pliai'ynx, 198. Stricture of the rectum, 388. Stricture of the urethra, symptoms of, 520. Stricture of the urethra, treatment of, 521. Stricture of the urethra, use of bougie in, 521. Stricture of the urethra, 517. Stricture of the vagina, 570. Stricture of the windpipe, 245. Strumous conjunctivitis, 94. Strumous iritis, 113. Stumps, affections of, 673. Stumps, bursse over, 675. Stumps, exfoliation from, 674. Stumps, hemorrhage from, 675. Stumps, neuralgia of, 673. Stye, 69. Styles in fistula lachrymalis, 82. Styloid, process of ulna, fracture of, 386. Subclavian artery, deligation of, 359. Subluxations of lower extremity, 638. Suicidal wounds of neck, 323. Suspension by the neck, 232. Swellings of eyelids, 69. Symblepharon, 72. Symphysis pubis, separation of, 625. Synechise, 114. Synchysis oculi, 127. Syphilis, 487. Syphilis, constitutional, 487, 505. Syphilis, common sores in, 488. Syphilis iu the child, 514. Syphilis in the female, 414. Syphilis, primary, 487, 504. Syphilis, secondary symptoms of, 505. Syphihs, simple abrasion in, 488. Syphilis, tertiary symptoms of, 507. Syphilis, use of mercury in, 509. Syphilitic iritis, 112. Syphilitic testicle, 537. Talipes, 641. Tahpes calcaneus, 643. Talipes equinus, 642. Talipes, spurious, 643. Talipes, treatment of, 643. Talipes valgus, 643. Talipes varus, 643. Tarsus, dislocation of, 636. Tarsus, fracture of, 634. Tartar on teeth, 176. Taxis, 350. Ta.xis, auxiliaries to the, 357. Teeth, affections of, 173. Teeth, caries of, 174. Teeth, crowded, 173. Teeth, extraction of, 175. Teeth, hemorrhage after extraction of, 176. Teeth, injuries of the, 177. Teeth, tartar on the, 176. Temporal artery, aueurism of, 12. Temporal artery, ulcer of, 13. Temporal artery, wounds of, 12. Teudo Achilhs, rupture of, 639. Tendo Achillis, ununited, 640. Tendo Achillis, wounds of, 640. Tendo Achillis, injmles of the, 639. Tertiary symptoms of syphilis, 505. Testicle, affections of, 534. 686 INDEX. Testicle, atrophy of, o-tl. Testicle, descent of, 349. Testicle, fungus of, 536. Testicle, irritable, 540. Testicle, removal of, 550. Testicle, scrofulous, 538. Testicle, syphilitic, 537. Testicle, tumours of, 539. Thigh, compound fractures of, 619. Thecal collections on wrist, 268. Thigh, amputation of, 671. Throat, wounds of, 233. Thrombus of the vulva, 564-. Thumb, amputation of, 658. Thumb, dislocation of, 297. Thumb, spastic flexion of, 272. Thyroid cartilage, ossified, fi-acture of, 333. Thyroid gland, affections of, 251. Thyroid gland, tumoui's over the, 254. Thyro-hyoid bursa, enlargement of, 255. Tibia, dislocation of, 632. Tibia, dislocation of, at the ankle, 634. Ti1)ia, fractures of, 621. Tibial artery, posterior, deligation of, 598. Tibial artery, anterior, deligation of, 600. Tic douloureux, 160. Toes, amputation of, 664. Toes, contraction of, 648. Toes, dislocation of, 638. Toes, exostosis of, 648. Tongue, affections of, 186. Tongue, erectile tumour of, 188. Tongue, encysted tumours beneath, 190. Tongue, fatty tumours beneath, 191. Tongue, hypertrophy of, 187. Tongue, induration of, 188. Tongue, removal of portions of, 188. Tongue-tie, 191. Tongue, tumours beneath, 190. Tongue, ulcers of, 187. Tongue, wounds of, 186. Tonsillitis, 193. Tonsils, abscess of, 193. Tonsils, hyperti'ophy of, 194. Tonsils, malignant disease of, 196. Tonsils, ulcers of, 194. Toothache, 174. TorticoUis, 221. Trachea, rupture of the, 233. Tracheal fistula, 244. Tracheotomy, 248. Tremulous iris, 114. Trephining, 46. Trichiasis, 73. Trochanters, fractuj'e of, 618. Truss, 350. Tumour, chronic mammary, of Cooper, 323. Tumour, lacteal, 322. Tumour, medullary, of rectum, 390. Tumour, oozing, of labium pudendum, 565. Tumours of the antrum, 154. Tumours of the bladder, 470. Tumours of the cheek, 160. Tumours of the eyeball, 129. Tumours of the ham, 611. Tumours of the labia, 565. Tumours of the lachrymal gland, 86. Tumours of the lower jaw, 179. Tumours of the mamma, 323. Tumours of the metacarpal bones and phalanges, 272. Tumours of the neck, 220. Tumours of the orbit, 64. Tumours of the pharynx, 199. Tumours of the scalp, 57. Tumours of the testicle, 539. Tumours of the tongue, 188. Tumours, solid, of the scalp, 57. Tumours, malignant, of the scalp, 58. Tumours, erectile, of the scalp, 58. Tumours of the calvarium, 62. Tumours, soft, of orbit, 65. Tumours, encysted, of the eyelids, 70. Tumours, erectile, of nose, 139. Tumours of superior maxilla, 154. Tumours of parotid gland, 161. Tumours over parotid gland, 161. Tumours, mahgnant, of mamma, 323. Tumours external to the mamma, 325. Tumours over thyroid gland, 254. Tumours of the abdominal parietes, 328. Tumours of the uterus, 334, 342. Tumours, fibrous, of the utenis, 342. Tumours of spermatic cord, 550. Tumour's, hard, of orbital parietes, 64. Tunica vaginalis testis, hydrocele of, 541. Tunica vaginalis, hsematocele of, 547. Tympanum, perforation of, 216. Ulcer of the anus, 381. Ulcer and exfoliation of the palate, 172. Ulcer, cancerous, of the nose, 146. Ulcer after arteriotomy, 13. Ulcer of the cornea, 100. Ulcer, malignant, of the scalp, 58. Ulcer, phagedsenic, 496. Ulcer, sloughing, 496. Ulcer, simple venereal, 489. Ulcer, venereal, with elevated edges, 493. Ulcers of the lips, 165. I leers of the Mps, malignant, 165. Ulcers, mercurio-syphihtic, 144. Ulcers of nostrUs, 144. Ulcers of the tonsils, 194. Ulcers of the tongue, 187. Ulceration of cervix uteiu, 576. Ulceration of the larynx, 242. Ulceration, sin)ple, of schneiderian membrane, 144. Ulceration, tubercular, of windpipe, 243. Ulna, dislocation of, 294. Ulna, dislocation of, at the elbow, 294. Ulna, dislocation of, at the wrist, 396. Ulna, fractm-e of, 385. Ulnar artery, deligation of, 263. Umbilical hernia, 371. Ununited tendo AchiUis, 640. Urethra, affections of, 517. Urethra, false passage in, 524. Uretlira, hEcmaturia from the, 456. Urethra, imperforate, 561. Urethra, laceration of, 533. Urethra, stricture of, 517. Urethra, vascular excrescence in, 567. Urethral calculus, 447. Urethral extravasation of urine, 468. Urethro-vaginal fistula, 569. Uric calculus, 413. Uric deposit, 399. Uric or xanthic oxide calcidus, 413. Uric diathesis, 409. Urinary calculi, 397. Urinary calculi, formation and varieties of, 410. Urinary deposits, tests of, 399. Urinary fistula, 532. Urinary infiltration after lithotomy, 440. Urine, characters of the, 397. Urine, extravasation of, 467. Urine, incontinence of, 457- Urine, mucous, 398. Urine, pathology of, 397. Urine, retention of, 459. Urine, retention of, in the female, 465. Urine, vesical extravasation of, 467. Urine, urethral extravasation of, 468. Urinous abscess, 530. Uterus, cancer of, 587- Uterus, cauliflower excrescence of, 587- Uterus, corroding ulcer of, 586. Uterus, displacements of, 581. Uterus, fibrous tumours of, 342. Uterus ;inversion of, 577- INDEX. 687 uterus, malignant disease of, 586. Uterus, removal of neck of, 586. Uterus, polypi of, 583. Uterus, proiapsua of, 578. Uvula, oedema of the, 192. Uvula, elongation of, 192. Uvula and tonsils, affections of the, 192. Vaginitis, 574. Vagina, foreign bodies in, 572. Vagina, imperforate, 571. Vagina, obliteration of, 570. Vagina, plugging of, 57.3. Vagina, polypi of, 583. Vagina, prolapsus of, 572. Vagina, stricture of, 570. Vaginal hernia, 372. Vaginal rectocele, 573. Vaginal cystocele, 572. Vaginal fistula, 567. Varicocele, 548. Vein, jugular, opening of, 221. Velosynthesis, 169. Venereal disease, 477. Venereal disease, general view of, 50-i. Venereal ulcer with elevated edges, 492. Venereal ulcer, simple, 489. Venesection at the bend of the arm, 265. Venesection, accidents of, 266. Venesection in the neck, 221. Ventral hernia, 872. Ventro-inguinal hernia, 368. Vertebrae, caries of the, 307. Vertebrse, cervical, disease of, 255. Vertebrfe, continuous absorption and simple ulceration in bodies of, 307. Vertebrae, diseases of, 806. Vertebra, iuterstitial absorption of bodies of, 306. Vesical extravasation of mine, 467- Vesical calculus, 417. Vesical calculus, paUiation of, 446. Vesical calculus, treatment of, 422. Vesico-vagiual fistula, 567. Vulva, abscess of, 564. Vulva, inflammation of, 563. Vulva, pruritus of, 565. Vulva, thrombus of, 564. Vulva, warty excrescences of, 565. Warts of the face, 159. Warts of the larynx, 244. Warts of the penis, 486, 491 . Wai'ts on the eyelids, 70. Water, boiling, swallowing of, 233. Webbed fingers, 274. Wens, 57. Whartonian ducts, concretions in, 191. Whites, 574. Whitlow, 268. Windpipe, diseases of, 235. Windpipe, foreign bodies in, 227. Windpipe, passing of tubes into the, 248. Windpipe, stricture of the, 245. Windpipe, tubercular ulceration of, 243. Wounds of the bowels, 329. Wounds of the brain, 49. Wounds of the chest, 314. Woivnds of the eyeball, 128. Wounds of the eyelids, 67. Wounds of the face, 159. Wounds of the lips, 163. Wounds of rhe lung, 315. Wounds of the neck, 223. Wounds of the orbit, 64. Wounds of the palmar arch, 264. Wounds of the pleura costalis, 315. Wounds of both pleurse and of lung, 315. Wounds of the heart, 319. Wounds of the abdomen, 329. Wounds of the scalp, 9. Wounds of the temporal artery, 12. Wounds of the tendo AchUUs, 640. Wounds of the throat, 223. Wounds of the tongue, 186. Wrist, amputation of, 659. Wrist and hand, affections of, 268. Wrist, dislocation of, 295. Wrist, resection of, 278. Writers' cramp, 272. Wry-neck, 221. Xanthic oxide deposit, 409. Xeroma, 80. EDINBnEGH : PETNTED BY E. AND E. CLAJRK. Now pvhUshing in Monthly Parts, at 8s., and in Volumes, 24s. THE ENCYCLOPAEDIA BRITANNICA EIGHTH EDITION GREATLY DIPEO'lTD AND EEOUGHT UP TO THE PRESENT TIME. EDITED BY THOMAS STEWART TRAILL, M.D. F.R.S.E. &c. 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BLACK'S TRAVELLING MAP OF ENGLAND AND WALES, Carefully compiled from the Maps of the Ordnance Surveys, and beautifully engraved by Sidney Hall ; with all the Roads, Railroads, and other Topographical Information required by the Tourist or Traveller on business. Size, thirty-two inches by twenty-two and one-half. In a neat portable case, coloured, 4s. 6d. cloth. " A beautifully-executed Map of England and Wales, which, after careful observation and reference, we can characterise as being among the most correct ever issued." — Mining Journal. BLACK'S TRAVELLING MAP OF SCOTLAND. Carefully constructed from the best authorities. With all the Roads and Railroads accu- rately laid down. Size, thirty-two inches by twenty-two and one-half. In a neat portable case, coloured, 4s. 6d. cloth. "A handsome-looking Map, of large dimensions, yet so well mounted that it folds up into the size of a pocket-book, and admits at the same time of a partial examination." — Spectator. *i^* Smaller Maps of England and Scotland, in pocket cases, price 2s. 6d. each. BLACK'S COUNTY MAPS OF SCOTLAND. In neat cloth cases, and coloured, price Is. each. BLACK'S TRAVELLING MAP OF IRELAND. Carefully constructed from the most recent authorities, with all the Roads, Railroads, &c. accurately laid down. Size, twenty by fourteen and a-half inches. In a neat portable case, coloured, 2s. 6d. cloth. BLACK'S MAP OF THE LAKE DISTRICT of Cumberland, Westmoreland, and Lancashire. Constructed by William Hughes, Professor of Geography in the College for Civil Engineers, from the Maps of the Ordnance Surveys, with all the heights of the principal mountains in feet attached to their names, and the Waterfalls, and Mountain Paths only to be traversed on foot, properly indicated ; with other topographical information required either by the Tourist or Traveller on business. Size, nineteen by fourteen inches. Beauti- fully engraved and coloured, 2s. 6d. in a neat portable case. BLACK'S MAPS OF NORTH AND SOUTH WALES. Compiled from the Maps of the Ordnance Surveys. Size, North Wales fourteen by eleven and a-half inches, and South Wales sixteen by eleven and a-half inches. Beautifully engraved and coloured, Is. 6d. each, in neat cloth cases. BLACK'S TRAVELLING MAP OF THE CONTINENT. Embracing Germany, Holland, Belgium, with parts of France and Switzerland; constructed by William Hughes, Professor of Geography in the Royal Collego for Civil Engineers, from the most recent authorities- With all the Roads, Railroads, Canals, and every other topographical information required by the Tourist or Traveller on business. Size, seventeen by twenty-four inches. Beautifully engraved and coloured, 4s. 6d. in a neat portable case. 10 CATALOGUE OF WORKS BLACK'S MAP OF INDIA. Constructed from the most recent authorities, and including the Punjaub, Cabool, Scinde, Tibet, and the islands of Ceylon and Singapore, &c. Size, twenty-three by seventeen and a-half inches. BeautifuUj' engraved and coloured, 3s. in portable case. BOW. — Treatise on Bracing, with its application to Bridges and other Structures of Wood or Iron, with numerous Plates. By Eobert Henry Bow, Civil Engineer. Eoyal 8vo, 3s. 6d. cloth. BEEWSTER — A Treatise on Magnetism. By Sir David Brewster, LL.D., F. E. S., Corresponding Member of the Eoyal Institute of France, &c. &c. Illustrated by upwards of 100 Engravings on Wood, and a Chart of Mag- netic Curves. Post 8vo, 3s. cloth. BROWN — Lectures on Ethics, or Moral Philosophy. By Dr. Thomas Brown. With a Preface by Dr. Chalmers. Post 8vo, 63. cloth. BROWN— Philosophy of the Mind. With a Memoir by Dr. Welsh. Seventeenth Edition, 8vo, 14s. cloth. BROWN — Philosophy of the Mind. Carefully revised with the original MS. ; with a Portrait, Index, and Memoir of the Author, by Dr. Welsh ; (all wanting in the previous Editions in 4 vols.) Sixteenth Edition. 4 vols. 8vo, £1 : 16s. cloth. "An inestimable book." — Db,. Parr. BROWN — Views of Canada and the Colonists : embracing the experience of an eight years' residence; views of the present State, Progi'e?s, and Prospects of the Colony ; with detailed and practical infonnation for intend- ing Emigrants. By James B. Brown. Second Edition, fcp. 8vo, 4s. 6d. cloth. BRYCE.— Elements of Algebra. By James Bryce, M.A., F.G.S., one of the Masters of the High School, Glasgow. Second Edition, 12mo, 4s. 6d. bound. BUCHANAN — A Comprehensive Atlas of Modern Geography, Consisting of Thirty Maps, correctly engraved from new Drawings, containing the latest Discoveries, and embodying in each Map a great variety of Statistical and other details. By Robert Buchanan, Teacher of Mathematics, Geography, &c. Quarto, coloured, 18s. bound. BURTON — Life and Correspondence of David Hume. From the Papers bequeathed by his Nephew to the Eoyal Society of Edinburgh, and other Original Sources. By John Hill Burton, Advocate. 2 vols. 8vo, with Por- traits, &c. 15s. cloth. Besides a large collection of Unpublished Letters by Hume, this work con- tains Diaries, Extracts from Note-Books, and other Original Papers ; including an Essay on the Authenticity of Ossian's Poems, Letters from Hume's Eminent Contemporaries— Gibbon, Adam Smith, Blair, Smollett, Montesquieu, D'Alem- bert, Diderot, &c. BURTON — The Law of Bankruptcy, Insolvency, and Mercantile Sequestration in Scotland. By John HUl Burton, Advocate. Two vols, royal 8vo, £1 : Is. cloth. " This work reflects credit on the Scottish bar. In fulness and lucidity of general proposition ; in vigour and accuracy of critical inquiry ; in scope of research and terse power of thought and expression, it stands in honourable contrast with the great herd of text- books." — Law Magazine. PUBLISHED BY ADAM AND CHAKLES BLACK. 11 CAIRD — The Poor Law Manual for Scotland. A new Edition, the Sixth of, by Alexander M'JSTeel Caird, Esq. 7s. 6d. cloth. To this Edition more than 150 pages of new matter have been added. The " Supplement" has been incorporated ; the " Principles" (as well as the rest of the Contents) have been carefully revised, and upwards of Fifty Decisions, pronounced in the Court of Session and the Justiciary and Sheriff Courts, since the issue of the fifth edition, have now been reported. *^* The former Edition was thus noticed : — " It is referred to by all the Judges iu the Supreme and Inferior Courts of Scotland, as an excellent authority on questions connected with the Scottish Poor Laws. We have derived much benefit from it in its former editions ; and we advise all those who have to do with the administration of the Poor Laws in Scotland to provide themselves with a copy." — Scottish Pook Law Journal. CARSON — Exercises in Attic Greek, for the Use of Schools and Colleges. By A. R. Carson, LL.D., F.R.S.E., &c., and late Rector of the High School of Edinburgh. 12mo, 4s. bound. CARSON — Phgedri Fabulse, Augusti Liberti Fabularum Aesopi- arum, quas oculis puerorum subjici fas est, libras quinque, cum Indice verborum phrasiumque difficiliorum Anglice redditorum. Edidit A. R. Carson, LL.D., Late Rector of the High School, Edinburgh. Editio Sexta. 18mo, 2s. bound. CHRISTISON'S DISPENSATORY; A Commentary on the Pharmacopoeias of Great Britain, comprising the Natural History, Description, Chemistry, Pharmacy, Actions, Uses, and Doses of the Articles of the Materia Medica. Bj"- Robert Christison, M.D., Professor of Materia Medica in the Uni- versity of Edinburgh. New and improved Edition, with a Supplement, con- taining the most important New Remedies whicli have come into general use since the publication of the last Edinburgh Pharmacopoeia in 1841. 8vo, 20s. cloth. "We eai-nestly recommend Dr. Christison's Dispensatory to all our readers, as an indispensable companion, not in the Study only, but in the 'Surgery' also." — Brit, and For. Med. IIeview. CHRISTISON — A Treatise on Poisons. In relation to Medical Jurisprudence, Physiology, and the Practice of Physic. By Robert Christison, M.D., Professor of Materia Medica in the University of Edinburgh, &c. &c. Fourth Edition, enlarged, corrected, and improved. 8vo, 20s. cloth. CHRISTISON — A Treatise on Granular Degeneration of the Kidneys, and its connection with Dropsj^, Inflammation, and other Diseases. By Robert Christison, M.D., Professor of Materia Medica in the University of Edin- burgh. Svo, 8s. cloth. " The illustrative cases, thirty-one iu number, are narrated with Dr. Cliristison's usual clearness, and, like the rest of the work, are higlily instructive. We strongly recommend this book to our readers." — London Medical Gazette. CLERK — Naval Tactics. A Systematical and Historical Essay in Four Parts. By John Clerk, Esq. of Eldin, F. R, S. E., &c. Third Edition, with Notes by Lord Rodney, an Introduction by a Naval Officer, and explana- tory Plates. 8vo, 25s. cloth. COCKBURN— Life of Lord Jeffrey. By Lord Cockburn, one of the Judges of the Court of Session. Second Edition. 2 vols. Svo, 25s. cloth. " Our expectations on taking up these volumes were very liigh, and they have not been disappointed. The book contains a variety of excellent matter, and the "letters of Lord Jeffrey will heighten the respect that attaches to his name." — Athenaeum. " Taken altogether, this is a most pleasing and satisfactory book." — Examiner. " One of the letters we would fain give entire, as not only one of the best in the volume but one of the happiest pieces of epistolaiy writing in the language." — Literarx Gazette.' 12 CATALOaUE OF WORKS COOPER — A Dictionary of Practical Surgery : Comprehending all the most interesting improvements from the earliest times downto the pre- sent period; an accouut of the Instruments and Eemedies employed in Surgery ; the etymology and signification of the principal Terms ; and numerous references to ancient and modern works, forming a catalogue of Surgical Literature, ar- ranged according to subjects. The Seventh Edition, revised, corrected, and enlarged. By Samuel Cooper, Senior Surgeon to the University College Hospi- tal, London, Professor of Sm-gery in the same College, Surgeon to the Queen's Bench, &c. &c; &c. 8vo, 30s. cloth. CRAIGrlE — Elements of General and Pathological Anatomy, Presenting a vie w of the present state of knowledge in these Branches of Science. By David Craigie, M.D., F.R.S.E., &c. &c. The Second Edition, enlarged, revised, and improved. 8vo, 24s. cloth. "A work of great value, aud one wliicli does great credit to the Author's erudition and laborious researcli." — London Medical Gazette. CRAIGIE — Elements of the Practice of Physic, Presenting a View of the present state of Special Pathology and Therapeutics. By David Craigie, M.D., F. R. S. E., Fellow of the Royal College of Physicians, Edinburgh, Phy- sician to the Royal Infirmary, Emeritus President and Extraordinary Member of the Royal Medical Society, &c. &c. &c. 2 vols. 8vo, 24s. cloth. "We are inclined to regard Dr. Craigie's Elements as the best we at present possess." — London Medical Gazette. CRAIGIE — Elements of Anatomy, General, Special, and Com- parative. By David Craigie, M.D., forming the article under that head in the Seventh Edition of the Encyclopedia Britannica. With Fourteen highly- finished Engravings, 4to, 12s. cloth. ""Without branching out into unnecessary details, the leading points of each division are placed before the reader in a clear and concise (though sufficiently comprehensive) man- ner, the whole forming a volume which may be jjerused with pleasure and advantage, both by the non-professional man of science and the practical anatomist." — Lancet. CREUZE — Shipbuilding. Being a Treatise on the Theory and Practice of Naval Architecture. By Augustine F. B. Creuze, Member of the late School of Naval Architecture ; "President of the Portsmouth Philosophical Society; and Editor of the " Papers on Naval Architecture." With 15 Engrav- ings on Steel, and numerous Woodcuts. 4to, 12s. cloth. "One of the best, because the clearest, and, at tlie same time, perfectly comprehensive disquisitions on Shipbuilding, is contained in the Encyclopaedia Britannica." — Livebpool Mail. DALGAIRNS — Practical Cookery carefully adapted to the pur- poses of everyday life, and containing plain dbections how to prepare in the best manner every dish at present in general use. By Mrs. Dalgaiens. Twelfth Edition. 1697 accm-ately tested Receipts. Price 6s. cloth. List of the Principal Subjects Treated. — Soups — Fish — Beef — Mutton — Lamb— Veal— Pork — Poultry— Curries— Game Gravies and Sauces — Vege- tables — Puddings, Pies, and Tarts — Creams, Custards, &c. — Cakes — Preserves — Vinegars and Pickles — Domestic Wines, &c. — The Poultry Yard — Dairy — Brewing — Kitchen Garden — Bees — Pigs, &c. " "We consider we have reason strongly to recommend Mrs. Dalgairns' as an economi- cal, useful, and practical system of Cookery, adapted to the wants of all families, from the tradesman to the country gentleman. It is not a gourmand's book, nor does it pretend to be ; and though we shall not put away Kundell and Kitchiner for Mrs. Dalgairns, she is far more copious than they are, far more various, and to us more novel." — Spectator. PUBLISHED BY ADAM AND CHAELES BLACK. 13 DAVIDSON — A Treatise on Biblical Criticism ; exhibiting a S3'stematic View of that Science. By Samuel Davidson, D.D. — Author of " Ecclesiastical Polity of the New Testament," 8vo ; " Introduction to the New Testament," 3 vols. 8vo ; " Sacred Hermeneutics Developed and Applied," 8vo, &c.— 2 vols. 8vo, 28s. cloth. "Any one desirous of becoming acquainted with the history of the text of our Scriptures, with the present state of Scripture criticism, and the difficulties tliat lie in the way of rectify- ing mistakes that have crept into the text — In short, with what criticism is, what it has done, what it expects yet to do, and the materials with which it has to work — to any one desirous of knowing these things, andwhat student of the Bible is not desirous of knowing something of them ? Dr. Davidson's Treatise on Biblical Criticism is just the work we would recom- mend. It is truly a systematic view of the science. One feature of the work, particularly valuable to young students, we must not omit to point out, namely, the mention of those departments where c-.ireful research may be expected to be productive of important results. Dr. Davidson has omitted no opportunity of helping those who may be honourably ambi- tious of adding something to the accumulation of facts on which is based the science of Biblical Criticism. We have much pleasure in commending these volumes to the notice of those for whose benefit they are intended and in expressing the hope that the author may be spared to do much more in this his favourite department." — Witness. " The student may thus the more appreciate the labours of Dr. Davidson in these volumes, which are a highly important contribution to the study of Biblical Criticism, containing, as they do, a careful statement of facts and results, such as is not to be found on the subject elsewhere in the English language." — Eclectic Review, March 1853. " Dr Davidson's work contains a great mass of highly valuable information, coUected and condensed with the care which marks the whole work. But we have said enough to accomplish our object, which is not to give an epitome of these volumes, but to do our best to recommend them to our readers." — Jouenal oe Saceed Liteeatuee, April 1853. DICK — The Nature and Office of the State. By Andrew Coventry- Dick. 8vo, price 7s. 6d. boards. DICKSON — The Breeding and Economy of Live Stock, Being the results of Forty years' Practical Experience in the Management and Dis- posal of Cattle, Horses, Sheep, and Pigs. By James Dickson. 12mo, Ss. 6d. boards. EDINBURGH MEDICAL AND SURGICAL JOURNAL, Exhibiting a concise View of the latest and most important Discoveries in Medicine, Surgery, and Pharmacy. Publishing in Quarterly Numbers, 6s. sewed. In every branch of Medical and Surgical Science, this work exhibits a va- luable compendious view of the progressive advancement of knowledge ; and to those who desire to keep pace with the improvements of the times, either in the theoretical departments of Medical Science, or in their practical application, the Edinburgh Medical and Surgical Journal is recommended, not only as a safe and judicious guide, but as an indispensable requisite. EDINBURGH NEW PHILOSOPHICAL JOURNAL, Exhibit- ing a View of the Progressive Discoveries and Improvements in the Sciences and the Arts. Conducted by Professor Jameson. Publishing in Quarterly Numbers, 7s. 6d. The Edinburgh New Philosophical Journal is now the only Journal of Science published out of London. Its plan embraces all the subjects regarded as most important by those engaged in scientific pursuits ; and for the benefit of the general reader, the information is conveyed in a form as popular as the na- ture of the subjects will admit of. The numbers will be found to contain many important articles illustrating the progress of discovery in Natural Philosophy, Geology, Chemistry, Natural History, Comparative Anatomy, Practical Me- chanics, Geography, Navigation, Statistics, Antiquities, and the" Fine and Useful Arts ; together with many interesting Biographies of Individuals eminent in the history of Science. *,^* A Complete Set from No. 1 to No. 107, £10. EDINBURGH PHARMACOPOEIA OF THE ROYAL COL- LEGE OF PHYSICIANS. Second Edition. 18mo, 5s. cloth. 14 CATALOGUE OF WOEKS ENCYCLOPEDIA BRITANNICA. Eiglith Edition. Vol. I., containing Preliminary Dissertations by Dugald Stewart, Sir James Macintosh, Richard Whately, D.D., Archbishop of Dublin, Professors Playfair, and Sir John Leslie. 4to, 24s. cloth. Now publishing in Parts Monthly, and Volumes Quarterly. FLEMESTG— Molluscous Animals — Including Shell-Fish; con- taining an Exposition of their Structure, Systematic Arrangement, Physical Distribution, and Dietetical Uses, with a reference to the Extinct races. By John Fleming, D.D., F.E.S.E., M.W.S., Professor of Natural Science in the New College, Edinburgh, &c. &c. &c. With Eighteen Plates, Post 8vo, 6s. cloth. FORBES — Travels through the Alps of Savoy, and other Parts of the Pennine Chain, with Observations on the Phenomena of Glaciers. By James D. Forbes, F.R.S., Sec. R.S.E., Corresponding Member of the Koyal Institute of France, Professor of Natural Philosophy in the Universitj' of Edinburgh, &c., &c. A New Edition, Revised and Enlarged. Illustrated by a large Map of the Mer de Glace of Chamouni, Lithographed Views and Plans, and Engravings on Wood. Imperial 8vo, 28s., or with the large Map coloured, in a case, 31s. 6d. cloth. "This elaborate and beautiftiUy-illustrated work."— Quakteklt Ketiew. " Pregnant with interest." — Edikbuugh Review. FORBES — ^Notes on Norway and its Glaciers, made on a Journey in 1851 — followed by Journals of Three Excursions in the High Alps of Dau- phine, Berne, and Savoy. By James D. Forbes, F.R.S., &c. &c., Professor of Natural Philosophy in the University of Edinburgh, and Author of "Travels through the Alps." With numerous Woodcuts and Coloured Lithographed Illustrations. Royal 8vo. In the Press. G-ALLOWAY— A Treatise on Probability. By Thomas Gallo- way, M.A., F.R.S., Secretary to the Royal Astronomical Society. Post 8vo, 6s. cloth. GARDNER — A Latin-English, English-Latin Dictionary. Founded on the Work of the late Mr. Leverett, and particularlj- adapted to the Classics usually studied preparatory to a Collegiate Course. By Francis Gardner, A.M., Instructor in the Public Latin School in Boston. 8vo, 10s. 6d. cloth. GILLY— Valdenses, Yaldo, and Vigilantius. By the Rev. W. S. Gilly, D.D., Author of " Waldensian Researches." Post 8vo, Is. 6d. "An eloquent account, from personal observation, of that small community of Protes- tants, who, in the secluded valleys of the Cottian Alps, have, for many centuries, main- tained the purity of their faith and worship, and kept up the fire of their vestal church, in the midst of privations and persecutions not yet extinguished." — Quarteslt Eeview. GLASSFORD — Italian Poets. Lyrical Compositions selected from the Italian Poets, with Translations. Ijy James Glassford, Esq. of Dougalston. Second Edition, greatly enlarged. Small 8vo, 7s. 6d. cloth. GRAHAM — Musical Composition. Being an Essay on its Theory and Practice, with an Appendix and Notes, being an extension of the article " Music." By G. F. Graham, Esq. With numerous Engravings and copious Musical Illustrations interspersed with the Text. 4to, 9s. boards. "A masterly and comprehensive Essay." — Athen^um. GRAY — Lectures on the Nature and Use of Money. By John Gray. 8vo, 7s. 6d. cloth. The sum and substance of the Author's doctrine may be given in these few words : — Without the slightest shadow or semblance of Association or Combina- tion of any kind — or, in other words, consistently with the most unbounded freedom of Indi-^ddual Competition between man and man— Production may be rendered the uniform and never-failing Cause of Demand ad infinitum; and that merely by the establishment of a properly-constituted National Bank. PUBLISHED BY ADAM AND CHAELES BLACK. 15 GUNN — Rudiments of the Latin Language. By tlie late William M. Gimn, LL.D Second Edition. 12mo, 2s. bound. HANSARD — Printing and Typefounding. Two Treatises by T. C. Hansard. Illustrated with Plates and "Woodcuts. Post Svo, 2s. 6d, cloth. HAYDON AND HAZLITT— Painting and the Fine Arts. By B. R. Haydon and William Hazlitt. Post Svo, 6s. cloth. " Mr. Hazlitt's clever little Treatise, written for the ' EncyclopEedia Britannica,' has come under our notice. We have read no work of that author with anything approaching to the same gratification." — Qdabtkely Review. HENDERSON — Astronomical Observations Made at the Royal Observatory, Edinburgh. By Thomas Henderson, F.E.S.E., and E.A.S., Pro- fessor of Practical Astronomy in the University of Edinburgh, and Her Majesty's Astronomer for Scotland. Published by order of Her Majestj^'s Government. Vols. 1, 2, 3, 4, 5, and 6. 4to, 12s. boards. HETHERINGTON— The History of Rome. By the Rev. W. M. Hetherington, M.A. With an Account of the Topography and Statistics of Modern Eome. By the Rev. J. Taylor, M.A. l2mo, with a Map of Ancient Rome. 3s. 6d. bound. *^* Without suppressing those traditionary legends which are blended with the earlier records of Eoman Historj', an attempt has been made in the present work to distinguish between Fact and Fable, and to make the latter subserve the important purpose of elucidating and of fixing in the Memory those real events from which the fabulous legends have arisen. HOSKING — Architecture with the Practice of Building. By William Hosking, F.S.A., Architect. To which are subjoined the Articles Ma- sonrj'. Joinery, and Cai-pentry. With Thirty-five Engravings. 4to, los. boards. IRVING— Lives of Scottish Writers. By David Irving, L.L.D. Post Svo, 5s. cloth. JAMIESON'S SCOTTISH DICTIONARY. Abridged by John Johnstone. Containing all the Words in the Dictionary and Supplement, in four vols. 4to, incorporated in one Alphabet; with the various meanings and the etj-mons ; and embodying the proverbial sayings, and a brief description of the usages and manners of Scotland. Svo, 12s. cloth. JEFFREY'S LIFE. By Lord Cockburn. 2 vols. 8vo, 25s. cloth. KELLAND — Elements of Algebra. By P. Kelland, A.M., F.R.SS.L. and E. &c. &c., late Fellow of the Queen's College, Cambridge, Pro- fessor of Mathematics in the University of Edinburgh. Svo, 9s. cloth. KELLAND — Demonstrative Mathematics. Being a Course of Lectures, by the Eev. Phillip Kelland, A.M.,F.E.SS.L. and E., Professor of Ma- thematics in the University of Edinburgh, late Fellow and Tutor of Queen's College, Cambridge. 12mo, 4s. 6d. cloth. 16 CATALOGUE OF WOEKS KITTO— A Cyclopedia of Biblical Literature. By John Kitto, D.D., F.S.'A., Editor of " The Pictorial Bible," &c. &c. Assisted by numerous able Scholars and Divines, British, Continental, and American, whose Initials are affixed to their respective contributions. Illustrated by Maps, Engravings on Steel, and 554 Engravings on Wood. In two thick volumes 8vo, £3, cloth. " It is not too much to say, that this Cyclopfedia surpasses every Biblical Dictionary which has preceded it, and that it leaves nothing to be desired in such a work, which can throw light on the criticism, interpretation, history, geography, archfeology, and physical science of the Bible. It is beautifully printed, aud is illustrated with fourteen engravings of maps and views, besides more than five hundred well- executed woodcuts of subjects cal- culated to elucidate the Holy Scriptures." — Horne's Introduction to the Ceitxcal Ana- lysis OF the Scriptukes, Ninth Edition, Vol. v. p. 437. " In the CyclopEedia before us, we recognise the closeness of the connection between the Scriptural and profane subjects of the ancient world ; the learning and ability with which the one class is made to tlirow light upon the other ; the industry with which obsolete usages are again restored to the knowledge of mankind ; the acute criticism which is made to bear on the most disputed forms and things of revelation ; and the extraordinary illus- tration which the most recondite subjects receive at the hands of the Contributors." — Athen^um. KITTO— A Popular Dictionary of the Bible. By John Kitto, D.D., F.S.A., &c., Editor of the Pictorial Bible. In a beautifully printed volume, Illustrated by 336 Engravings on Wood. 8vo, 10s. 6d. cloth or half-bound calf. KITTO'S ILLUSTRATED HISTORY OF PALESTINE. A New Edition, with Map and upwards of 200 Illustrations. Small 8vo 6s. cloth ; 6s. 6d. cloth, gilt edges. " Iv expense seems to have been spared in the getting up of this -volume, which will be found not only a most useful companion to the sacred volume, from the compactness and comprehensiveness of its numerous details, but an attractive as well as valuable present to the young." — Bkitannia. " We have placed this among the gift hooks because it ought to be one, so profusely is it illustrated. The season will not produce a more useful prize book than this." — Ckitic. KITTO — The History of Palestine, for Schools. From the Patriarchal Age to the Present Time ; with Introductory Chapters on the Geo- graphy and Natural History of the Countiy, and on the Customs and Institu- tions of the Hebrews. By John Kitto, D.D., F.S.A., Editor of the '• Pictorial Bible," &c. &c. With Questions for examination, by Alexander Reid, A.M., Eector of Circus Place School. 12mo, 3s. 6d., or with Map of Palestine, 4s. bound. "Beyond all dispute it is the best historical compendium of the Holy Land, from the days of Abrnham to those of the late Pasha of Kgvpt, Mehemet Ali." — Obseeveb. " Not only a complete description of tlie Holy Land, but a condensed History of the Jewish People. * * * On the whole, this ably compiled and elegant manual is well cal- culated to Kssist the young in obtaining a right understanding of Holy Scripture, and to im- pai-t a hfe-like interest to their study of the Sacred volume."— John Buf.l. LAUDER — Highland Rambles, and Long Legends to Shorten the Way. Bj' Sir Thomas Dick Lauder, Bart., Author of " An Account of the Morayshire Floods," " Lochandu," &c. &c. Third Edition, post 8vo, 5s. cloth. " We heartily recommend this volumes to all tourists to the ' Land of the Mountain and the I'lood,' who are setting forth on their dehghtful trip." — Bentley's Miscellant. "Full of legend, full of adventure, fuU of interest." — Athenjeum. LECOUNT — Railways. A Practical Treatise ; explaining their Construction and Management, being the article under that head in the Ency- clopaedia, with additional details. By Lieutenant Lecount, R.N., F.R.A.S., C.E. of the London and Birmingham Railwaj'. Illustrated with Woodcuts and En- gravings. Post 8vo, 4s. 6d. cloth. LEES — Arithmetic, Algebra, and Geometry. An Elementary Work for the Use of Students. By George Lees, A.M., &c. 8vo, 5s. cloth. PUBLISHED BY ADAM AND CHARLES BLACK. 17 LESLIE — Natural and Chemical Philosophy. Being the Contri- butions of Sir John Leslie on the following important subjects of Natural and Chemical Philosophy : 1. Achromatic Glasses. 2. Acoustics, 3. Aeronautics. 4. Barometer. 5. Barometrical Measurements. 6. Climate. 7. Cold and Con- gelation. 8. Dew. 9. Meteorology. Illustrated with Plates and Woodcuts, and prefaced by a Biographical Memoir of the Author. Post 8vo, 9s. cloth. LINDSAY — High School Vocabulary. By Samuel Lindsay, A.M. ISmo, Is. bound. LOTHIAN — Consistorial Law. The Law and Practice peculiar to the Actions of Declarator of Marriage, Nullity, Separation, Divorce, Legiti- macy, &c., transferred from the Commissary Court to the Court of Session ; comprehending the Stj-les of these Actions, Pleas, Modes of Proof, and general detail of Procedure. With Remarks on the Present State of the Consistorial Law, and the Recent Judicature Act. By Maurice Lothian, Solicitor in the Con- sistorial Court of Scotland. Bvo, 7s. 6d. boards. MACAULAY — A Medical Dictionary. Designed for Popular Use ; containing an Account of Diseases and their Treatment, including those most frequent in Wai-m Climates ; with Directions for Administering Medicines; the Regulation of Diet and Regimen ; and the Management of the Diseases of Women and Children. By Alexander Macaulay, M.D., Fellow of the Royal College of Surgeons of Edinburgh, and Physician-Accoucheur to the New Town Dispensary. The Eleventh Edition, enlarged, corrected, and improved. Dedi- cated by permission to the late Dr. Abercrombie. In one thick volume 8vo, double columns, 12s. cloth. "Just such a work as every head of a family ought to have, on his book-shelf." — Brighton Herald. M'CULLOCH — Treatises and Essays on subjects connected with Economical Policy, with Biographical Sketches of Quesnaj', Smith, and Ricardo. By J. R. M'Culloch, Esq., Author ^of Commercial Dictionary, &c. 8vo, 14s. cloth. M'CULLOCH — The Principles of Political Economy, with some Inquiries respecting their Application, and a sketch of the Rise and Progress of the Science. By J. R. M'Culloch, Esq. Fourth Edition, corrected, enlarged, and improved. New Edition, Bvo, los. cloth. MACKINTOSH — Ethical Philosophy, a Dissertation on the Progress of Ethical Philosophy, chiefly during the Seventeenth and Eighteenth Centuries. Bj' the Right Hon. Sir James Mackintosh, LL.D., F.R.S. With a Preface by William Whewell, D.D., Professor of Moral Philosophy in Cambridge University. 8vo, 9s. cloth. "Done with taste, discrimination, and, as far as the subject would admit, that ease and perspicuity which flow from the complete mastery of a congenial subject." — Quakteelt Keview. "That inimitable 'Dissertation on Ethical Philosophy' wliich is prefixed to the New Edition of the Enoj'-clopiedia." — Francis jErritEY. MACLAREN — Geology of Fife, and the Lothians; Including Detailed Descriptions of Arthur's Seat and Pentland Hills. By Charles Mac- laren, Esq., F.R.S.E. Illustrated with 90 Woodcuts, 11 Geological Sections, and 2 Coloured Maps. Fcp. 7s. 6d. cloth. MAESHALL — On the Enlisting, Discharging, and Pensioning of Soldiers, with the Official Documents on these Branches of Military Duty. By Henry Marshall, F.R.S.E., Deputy-Inspector-General of Army Hospitals. Se- cond Edition. 8vo, 7s. 6d. cloth. " A most valuable book, and ought to be in the library of every medical officer in the public ser\ice, whether of the army or navy."— British akd Foreign Medical Review. 18 CATALOGUE OF WOEKB MATTHEW — Emigration Fields: North America, the Cape, Australia, and New Zealand, describing these Countries, and giving a compara- tive view of the advantages they present to British Settlers. By Patrick Matthew, Author of '' Naval Timber and Arboriculture." With two Folio Maps, engraved by Sidney Hall. Post 8vo, 3s. 6d. cloth. "The information contained in tliis work is of such a nature, that every one who has an intention of emigratino;, should, before fixing upon any country as his futiu-e residence, consult the EiiiGaATioN Fields." — Dundee Chkonicle. MATTHEW — Naval Timber and Arboriculture, being a Treatise on that subject, with Critical Notes on Authors who have recently treated the subject of planting. By Patrick Matthew. 8vo, 12s. cloth. MILLER— The Principles of Surgery. By James Miller, F.R.S.E., Professor of Surgery in the University of Edinburgh, &c. &c. New Edition, illustrated by 238 Wood Engravings, 16s. cloth. " An admirable epitome of the surgical science of the day. Being written by a sound practical surgeon, accustomed to the public teachhig of his science, it has that clearness of diction and arrangement which renders it an excellent manual for the student, as well as that amount of scientific and practical information which makes it a safe and valuable guide to the practitioner." — Lancet. MILLER— The Practice of Surgery. By James .Miller, F.R.S.E., Professor of Surgery in the University of Edinburgh, &c. New Edition, illus- trated by 227 Wood Engravings. 8vo, 16s. cloth. "We have no hesitation in stating that the two volumes form, together, a more com- plete text-book of surgery than any one that has been heretofore offered to the student." — NOKTHERN JOUKNAL OF MEDICINE. MILLS — The Sportsman's Library. Comprising Instructions on every matter connected with Hunting, Shooting, Coursing, and Fishing; in- cluding the Condition of Horses, Breeding and Breaking of Dogs, Preservation of Game, Destroying of Vermin, &c. By John Mills, Esq., Author of " The Old English Gentleman," &c. 8vo, 9s. cloth. MOIR AND SPALDING — Poetry, Romance, and Rhetoric. By William Spalding, Professor of Rhetoric in the University of Edinburgh, and George Moir, Esq., Advocate. Post 8vo, 3s. 6d. cloth. MOOR — Elementa LinguEe Grsecse. Studio Jacobi Moore, LL.D. Emendavit auxitque Jacobus Tate, A.M., Cantab., Editio Quinta Correctior, with an Appendix, containing a list of Irregular and Defective Greek Verbs, and a Synopsis of the Indeclinable Parts of Speech. 12mo, 2s. 6d. bound. NEILL — The Fruit, Flower, and Kitchen Garden. By Patrick Neill, LL.D., F.K.S.E., Secretary to the Caledonian Horticultural Society. Fourth Edition. Revised and Improved, illustrated with upwards of 60 Wood- cuts. 12mo, 3s. 6d. cloth. " One of the best modern books on Gardening extant."— Loudon's Gardener's Magazine. NICOL — Manual of Mineralogy ; or, the Natural History of the Mineral Kingdom ; containing a General Introduction to the Science, and de- scriptions of the several Species, including the more recent Discoveries and Che- mical Analysis. By James Nicol, F.R.S.E., F.G.S., Professor of Natural History in Marischal College, Aberdeen. Post 8vo (pp. 596), 12s. cloth. " There is a completeness about this Manual of Mineralogy which must recommend it to every one pursuing this branch of science. Particular attention has been paid to the . crystallographic and chemical characters of each mineral, and the analyses given are more extensive, and selected with more care, than those to be found in any work on mineralogy in the English language." — Athen^um. PUBLISHED BY ADAM AND CHAELES BLACK. 19 NUGENT — Pocket Dictionary of the French and English Lan- guages. In two Parts — 1st, French and English ; 2d, English and French ; containing all Words of General Use, and authorised by the best Writers. As also the several Parts of Speech ; the Genders of the French Nouns, the Naval and Military Terms, a list of Proper Names, &c. &c. New Edition, Pearl, 5s. 6d. bound. OSWALD — An Etymological Dictionary of the English Language, on a Plan entirely new, adapted to the Modern Sj'Stem of Tuition. By the Rev. John Oswald, late Master in George Heriot's Hospital. Fourth Edition. 18mo, 5s. bound. "This very laborious compilation deserves to be introduced into every school where the English Language is taught." —AlHENiEuii. OSWALD — An Etymological Manual of the English Language, for the Use of Schools and Private Families. Eleventh Edition, price Is. cloth. OSWALD — Outlines of English Grammar. Fifth Edition, price 6d. OSWALD— Etymological Primer. Part First. Twelfth Edi- tion, Id. OSWALD — Etymological Primer. Part Second. Fourth Edi- tion, 6d. PHILLIPS— A Treatise on Geology. By John Phillips, F.R.S., F.G.S., Professor of Geology in King's College, London, Author of " Illustra- tions of the Geology of Yorkshire," " A Guide to Geology," &c. &c. Embel- lished with Plates and Woodcuts. Post 8vo, 6s. cloth. "The author has selected and combined all the discoveries which have been made in Geology up to the present time." — Mokning Herald. PILLANS — Eclogse Ciceronianas. A Selection from the Orations, Epistles, and Philosophical Dialogues of Cicero : to which are added selected Letters of Pliny the Younger. Arranged in three distinct divisions ; being in- tended to give the studious youth a specimen of Cicero's compositions in differ- ent aspects of his Character : 1. as an Orator ; 2. as a Man of the World and a Member of Society ; and 3. as a Philosopher. By James Pillans, F.E.S.E., Professor of Humanity in the University' of Edinburgh. 18mo, 3s. 6d. cloth. PILLANS — Outlines of Geography, principally Ancient. With Introductory Explanations of the System of the World, and of the most Ap- proved Methods of Stud^'ing and Teaching Geography ; for the Use of the more Advanced Pupils of the High School of Edinburgh, and of the Students of the Universities. Hy Professor Pillans, of the University of Edinburgh. Illus- trated with Nine Maps. 12mo, 4s. 6d. bound. PILLANS — Principles of Elementary Teaching, chiefly in reference to the Parochial Schools of Scotland ; in Two Letters to T. F. Kennedv, Esq., M.P. By James Pillans, F.R.S.E., late Piector of the High School, and now Professor of Humanitj^ in the University of Edinburgh. Post 8vo, 3s. boards. PILLANS — First Steps in the Physical and Classical Geography of the AncientWorld, with an Illustrative Map. By James Pillans, M.A., F.R.S.E., Professor of Humanity in the College of Edinburgh. 12mo, Is. 6d., cloth. POE.TEUS — A Summary of the Principal Evidences for the Truth and Divine Origin of the Christian Revelation. By the late Beilby Por- teus, D.D. New Edition, by Dr. Boyd, of the High School, Edinburgh. 18mo, Is. bound. RAMSAY— The Gentle Shepherd. By Allan Ramsay. New Edition. With a Life and Portrait, and numerous Illustrations after David Allan. 18mo, sewed. Is. 9d. ; cloth, 2s. 6d. ; cloth, gilt, 3s. ; morocco, 5s. 6d. 20 CATALOGUE OF WORKS ROBERTS— The British Wine Maker and Domestic Brewer. A Complete Practical and Easy Treatise on the Art of Making and Managing every Description of British Wines, Liquors, Ales, Beer, and Porter, with the aid of the Saccharometer. Containing also a Supplement on the Rhubarb Plant, showing it to be a basis nearly as valuable as that of the Grape for pro- ducing Champagne, Hock. Madeira, and Constantia. By W. H. Roberts, Author of the Scottish Ale Brewer. Fifth Edition, 12mo, 6s. cloth. ROD AND TFIE G-UN. Being Two Treatises on Angling and Shooting. The former by James Wilson, Esq., F.R.S.E., &c. &c. The latter by the Author of " The Oakleigh Shooting Code." Second Edition, with numerous Engravings on Wood and Steel. Post 8vo, 10s. 6d. cloth. " The treatise on Shooting, by the Author of the ' Oakleigh Shooting Code,' is written upon a veiy comprehensive plan, and beautifully illustrated. Its companion on angling is one of. the most interesting, instructive, and agreeable treatises on 'the gentle art' that exists in our language ; and will probably be noticed at greater length in a future article." — Edinbukgh Review. " Know likewise to thy utter discomfort, nay, to thy utter confusion, that a book has lately appeared yclept ' The E.od and the Gun,' so amusingly written and so complete in all its parts, that there is not the least occasion for you to burthen Mr. Murray's shelves with stale precepts that no one will attend to." — Pkepace to "Days and Nights or Salmon Iishing" by William Sckope, Esq. ROGET— Physiology and Phrenology. By P. M. Roget, M.D., Secretary to the Royal Society, &c. &c., Author of the Fifth Bridgewater Trea- tise. Two volumes post 8vo, 12s. cloth. "A luminous and most candid and impartial account of Phrenology. . . . In the Treatise on Physiology, that science is treated clearly, fully, and in the systematic manner which a masterly instructor might adopt for the benefit of his pupils." — Tait's Magazine. RUSSELL — The History of Modern Europe : with an Account of the Decline and Fall of the Roman Empire, and a View of the Progress of So- ciety from the Rise of the Modern Kingdoms to the Peace of Paris in 1763; in a Series of Letters from a Nobleman to his Son. New Edition, continued to the Accession of Queen Victoria of England. Four Volumes, 8vo, o2s. cloth. RUSSELL — A Treatise on the Steam Engine. Illustrated by 248 Engravings on Wood, and 15 Folding Plates on Steel. Post 8vo, 5s. cloth. " Most complete and circumstantial. ... At the same time it is methodi- cally, clearly, and luminously written. Considering the number of illustrations, it is avery cheap book ; and, as it explains all the modem improvements and appiicatioris, it cannot fail iu being a boon which every mechanist and engineer will receive with much gratitude." — The Suevetob, Engikeee, anb Aechitect. RUSSELL — Steam and Steam Navigation. A Treatise on the Nature, Properties, and Applications of Steam and on Steam Navigation. By John Scott Russell, M.A., F.R.S.E., Vice-President of the Society of Arts of Scotland. ] llustrated with upwards of 80 Engravings on Wood, and 15 Folding Plates on Steel. Post 8vo, 9s. cloth. "A work on Steam and Steam Navigation, in which science and interesting informa- tion are equally combined." — Mechanics' Magazine. SCHMITZ — Elementary Grammar of the Greek Language. By Dr. L. Schmitz, F.E.S.E., Rector of the High School, &c. tSsc. Limited to the Attic Dialect, but is more full than the Grammars commonly used in our Schools. The Irregular Verbs are simplified by a system of classification, and the rules of Syntax contain all that is essential to know the Greek Language thoroughly. 12mo, 3s. 6d. cloth. SCOTT — Memoir of David Scott, R.S.A., containing his Journal in Italy, Notes on Art, and other Papers. Bj' William B. Scott. With seven Engravings, 8vo, 10s. 6d. cloth. PUBLISHED BY ADAM AND CHARLES BLACK. 21 SIR WALTER SCOTT'S WRITINGS AND LIFE. Waverley Novels. EACH NOVEL MAT BE HAD SEPARATELY AT THE FOLLO^'ING PRICES : — Abbot 1/9 Anne of Geierstein 2/0 Antiquary 1/8 Betrothed— Highland Widow 2/0 Black Dwarf — Legend of Slon- trose 1/6 Bride of Larnmermoor 1/4 Count Robert of Paris 1/8 Fair Maid of Perth 1/11 Fortunes of Nigel 1/1] Guy Mannering 1/9 Heart of Mid-Lothian 2/3 Ivanhoe 1/11 Kenilworth 1/11 Monastery 1/9 Old Mortality 1/9 Peveril of the Peak 2/6 Pirate 1/11 Quentin Durward 1/11 Redgauntlet 1/10 Rob Roy 1/11 St. Ronan's Well 1/9 Surgeon's Daughter — Castle Dangerous 2/6 Talisman — Two Drovers — My Aunt Margaret's Mirror — Tapestried Chamber — Death of the Laird's Jock 1/9 Waverley 2/0 Woodstock 2/0 I. Library Edition, uniform with the Standard English Authors. To be com- pleted in Twenty-five Volumes. Demy 8vo, price 9s. cloth. Now publishing Monthly. Each volume contains a complete Novel or Novels, illustrated •with a Frontispiece and Vignette, Painted and Engraved by the most eminent Artists. The Library Edition contains all the latest corrections of the Author. XL Ahbotsford Illustrated Edition. With 120 Engravings on Steel, and nearly 2000 on Wood. 12 vols., super-royal octavo, cloth, lettered, £10, 16s. III. Author's Favourite Edition in 48 vols., foolscap 8vo. With 96 Engi-avings on Steel by the most eminent Artists. Cloth, lettered, £7, 4s. IV. Cabinet Edition. In 25 vols., foolscap 8vo. With Vignettes, Fac-simile, and Engraving from Geeenshield's Statue of the Author. Cloth, lettered, £3, 13s. 6d. V. People's Edition. Five vols, royal 8vo. With Portrait, Fac-simile, and Vignette Titles, after designs by Harvey. Sewed, £2, 5s., cloth, lettered, £2, 10s. Poetical Works. I. — In Twelve Vols, foolscap octavo, cloth, uniform wdth the Author's Favou- rite Edition. With the Author's last Introductions, Notes by the Editor, and 24 Engravings, all from Turner's designs. In sets, cloth, lettered, £1 : 16s. II. — In Six Vols, foolscap octavo, cloth, nniform with the Cabinet Edition of the Novels, 12 Engravings after Turner, and Fac-simile. In sets, cloth, lettered, 24s. III. — In One Vol. royal octavo, cloth, uniform with the Novels, People's Edition, Vignette Title, and Fac-simile. Cloth, lettered, 10s. The Same, large paper, with 26 Engravings from Turner, &c., forming a companion to the Novels, Abbotsford Edition. Cloth, lettered, 18s. ; full morocco, elegant, 32s. IV. — A New Edition in One Vol. foolscap octavo, portable size, including The Lord of the Isles, and a variety of other copyright poetry contained in no other pocket edition. With a Life of Scott, and Illustrations on Wood and Steel. Foolscap 8vo, cloth, gilt edges, 5s. ; or cro-vvn 8yo, with additional Engravings, 6s. 22 CATALOGUE OF WORKS Sir Walter Scott's Writings and Life. Poetical Works — Continued. "V^-— PocKiET Edition fob Tourists. Lay of the Last Minstrel — Marmion — Lady of the Lake — Rokeby — and Lord of the Isles. Illuminated Covers, gilt edges, Is. 3d. each. Cloth, lettered. Is. 6d. ; full bound morocco, 2s. 6d. VI. The Lady of the Lake. — New Illustrated Edition. Including all his latest Copyright Notes, Various Readings, and Additions. Exquisitely Illustrated by BiRKET Foster and John Gilbert, uniform with the Illustrated Editions of Thomson, Goldsmith, and Longfellow's Poems, forming a beautiful and appropriate Gift-Book. The Illustrations of the Scenery are from Sketches drawn on the spot by Mr. Foster expressly for this Work, and comprise all the principal places alluded to in the Poem. Extra cloth, gilt edges, 15s. ; morocco, elegant or antique, 21s. ; morocco elegant, bound by Hayday, 24s. ^ , ^^.. Prose Works. Complete Edition. I. — In Twenty-eight Volumes, uniform with the Author's Favourite Edition of the Novels, with 56 Engravings from Turner; Portraits and Maps. In sets, cloth, lettered, £4 : 4s. II. — In Three Vols, royal 8vo, imiform with the People's Edition. Cloth, let- tered, £1 : 6s. Tales of a Chxindfather. I. — Nimierous Illustrations, 3 vols, cloth 12s., extra, gilt edges 15s. II. — In One Vol. royal 8vo, uniform with the Novels, People's Edition, cloth, lettered, 6s. The Same, large paper, with 11 Engravings after Turner, uniform with the Abbotsford Edition, cloth, lettered, 10s. 6d. III. — (History of France). By Sir Walter Scott. Numerous Illus- trations, cloth 4s., extra, gilt edges, 5s. Life of Napoleon Bonaparte — I. — In Five Vols, foolscap 8vo, with Maps, Portraits, and 9 Engravings after Turner, uniform with the Cabinet Edition, in 50 Vols. In sets, cloth, lettered, 20s. II. — In One Vol. royal 8vo, uniform with the People's Edition. Set No. III. Cloth, lettered, 10s. The Sa3ie, large paper, with 14 Engravings after Turner and others, uniform with the Abbotsford Edition. Cloth, lettered, 18s. History of Scotland — School Edition. In Two Vols, crown 8vo, with Coloured Map. Bound and lettered, 10s. Life of Sir Walter Scott. By J. Gr. Lockhart, Esq. I. — In Ten Vols, foolscap 8vo, uniform with the Author's Favourite Edition of the Novels, with 20 Engravings on Steel, and Fac-simile. In sets, cloth, lettered, £1 : 10s. ; Separate volumes, 3s. II. — In One Vol. royal 8vo, with Portrait and Fac-simile, uniform with the People's Edition, Set No. III. Cloth, lettered, 10s. The Same, with 11 Engravings from Turner and others, uniform with the Abbotsford Edition, Set No. I. Cloth, lettered, 18s. III. — In One Vol. New Edition, 12 Engravings, cloth, 7s. 6d. ; extra, gilt edges, 8s. 6d. Beauties of Sir Walter Scott — A Selection from his Writings. Two Engravings, cloth, gilt edges, 5s. ; extra, gilt sides and edges, 6s. Readings for the Young, from the Works of Sir Walter Scott — Numerous Illus- trations, 3 vols, in one, cloth, gilt edges, 7s. ; separate vols. 2s 6d. PUBLISHED BY ADAM AND CHARLES BLACK. 23 SCRYIMGEOUR— A Class-Book of English Poetry, comprising Extracts from the most distinguished Poets of this Country, from Chaucer to the Present Time, with Biographical Notices, Explanatory Notes, and an Introduc- tory Essay on the Origin and Progress of the English Language. By Daniel Scry-mgeour, of Circus Place School, Edinburgh. 12mo, 4s. 6d. bound ; or in Two Parts, price 2s. 6d. each. — Part I. containing the Poets from Chaucer to Ot- way ; Part II. from Prior to Tennyson. "The best and compactest view of the subject we have seen." — Spectatob. " Did we believe in the attainment of perfection, we should pronounce this the perfec- tion of Poetical Class Books." — ^Educational Times. SCRYMGEOUR— The Poetry and Poets of Britain. From Chaucer to Tennyson, with Biogi-aphical Sketches, and a rapid View of the Cha- racteristic Attributes of each. Preceded by an Introductory Essay on the Ori- gin and Progress of English Poetical Literature. By Daniel Scrj-mgeour. Post 8vo, 6s. cloth ; 6s. 6d. cloth, gilt edges. SHAW — Experimental Observations on the Development and Growth of Salmon-Fry, from the exclusion of the Ova to the age of Two Tears. By John Shaw, Drumlanrig. 2s. 6d. 4to, sewed. SHOOTER'S HAND-BOOK, being the Treatise on Shooting contained in " The Rod and the Gun." By the Author of " The Oakleigh Shoot- ■ ing Code." With Plates and Woodcuts. Post 8vo, 6s. cloth. SHORTREDE— Logarithmic Tables to Seven Places of Decimals, containing Logarithmic Sines and Tangents to every Second of the Circle, with Arguments in Space and Time. By Ptobert Shortrede, F.R.A.S., &c., Captain H.E.I.C.S., late Fh'st Assistant in the Great Trigonometrical Survey of Lidia. In a thick volume, royal Svo, 30s. cloth. SHORTREDE — Logarithmic Tables, containing Logarithms to Numbers from 1 to 120,000 ; Numbers to Logarithms from .0 to 1.00000 to Seven Places of Decimals ; Tables with Centesimal and Decimal Arguments for finding Logarithms and AntUogarithms as far as Sixteen and Twenty-five Places ; Tables to Five Places, for finding the Logarithms of the Sums and Differences of Antilogarithms ; also Tables for Barometric and Thermometric Heights ; together with several other Tables of frequent use. Koyal Svo, 12s. cloth. SMITH— The Wealth of Nations. An Liquiry into the Nature and Causes of the Wealth of Nations. By Adam Smith, LL.D. ; with the Life of the Author, an Introductory Discourse, Notes, and Supplemental Disserta- tions, by J. R. M'Culloch, Esq. Fourth Edition, corrected throughout, and greatly enlarged. With two Portraits. Svo, 16s. cloth. STEVENSON — An Account of the Skerryvore Lighthouse, with Notes on the Illumination of Lighthouses. By Alan Stevenson, LL.B., F.R.S.E., M.I.C.E., Engineer to the Northern Lighthouse Board. With 117 Woodcuts and 33 Engravings on Steel. 4to, £3, 3s. cloth. STEVENSON — Marine Surveying and Hydrometry; being a Treatise on their Application to the Practice of Civil Engineering. By David Stevenson, Civil Engiaeer, Author of " A Sketch of the Civil Engineering of America," &c. Illustrated by 13 Plates, a Coloured Chart, and numerous En- gravings on Wood. Roj'al Svo, 15s. cloth. " A work of more extensive practical utility, more certain to bring honour to its author, and confer lasting benefit on his profession, has seldom come under our notice." — Me- CHAMics' Magazine. 24 CATALOGUE OP WOEK.S STO WE— Uncle Tom's Cabin. By IMrs. Stowe. An Elegantly Printed and highly Illustrated Edition. With 130 Illustrations, by Matthew Urlwin Sears, a Frontispiece by John Gilbert, and Ornamental Title-Page by Phiz. Cloth, gUt edges, price 10s. 6d. ; morocco, 18s. " Accept my thanks for the copy of your Illustrated Edition of Uncle Tom's Cahin. From the examination I have been able to give it, I am disposed to regard it as the best in point of execution, particularly in respect to the wood-cuts, which I have yet seen." — Ex- tract FEOM A Letter raoii Mes. Stowe to the Publishers, Glasgow, April 14, 1853. " Of all the varied forms in which the celebrated story of ' Uncle Tom' has been pre- sented to the public, tliis is by far the most graceful and attractive ; and when we con- sider how extensively the art of the typographer and the pencil of the artist have been employed in London and elsewhere to embellish the numerous issues of the work, it is matter alike of pride and satisfaction that our Edinburgh friends and countrymen, Messrs. Black, have produced an edition without a rival. Brought out in the very first style as regards paper and print, it has a beautiful frontispiece by John Gilbert, an ornamental title-page by Phiz, and no fewer than 130 fine engravings on wood by Matthew Urlwin Sears. These represent, with great taste and fidelity, every important incident in the narrative of Uncle Tom, whether humorous, revolting, or pathetic. A more winsome 'drawing-room book we have rai'ely seen. The binding and external illustrations and decorations are worthy of a work so beautiful within." — Glasgow Herald, April 1853. " Of the many editions of this celebrated woi'k, this is certainly the best that has come under our notice. It is beautifully printed and embellished with numerous engravings by Gilbert, Phiz, and Sears." — Atlas, April 1853. New Edition. By Dr. Frampton. THOMAS— Practice of Physic. 2 vols. 8vo, 28s. cloth. THOMSON — Treatises on Brewing and Distillation. 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