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MANUAL 
 
 OF THE 
 
 Practice of Surgery 
 
 BY 
 
 W. FAIRLIE CLARKE, M.D. (oxon.), F.R.C.S. 
 
 LATE ASSISTANT-SURGEON TO CHARING CROSS HOSPITAL 
 
 "Chirurgia non quidem medicamenta atque victus rationem omittit, sed manu tamen 
 plurimum prsstat."— CelsuS, Prafat. Lib. VII. 
 
 THIRD EDITION, REVISED, ENLARGED, 
 
 AND 
 
 Illustrated by One Hundred and Ninety Engravings on Wood 
 
 NEW YORK 
 G. P. PUTNAM'S SONS 
 
 27 & 29 WEST 23D STREET 
 1882 
 

PREFACE. 
 
 In preparing the third edition of my Manual of Surgery 
 I have gone carefully throiigh the text, revising it, and 
 endeavouring to bring it up to the level of the present 
 day. At the same time, the number of illustrations has 
 been considerably increased, the Formulary has been 
 enlarged, and many more references to it have been 
 introduced into the text. 
 
 The general arrangement and the classification of disease 
 which have been adopted will be Been at a glance by 
 reference to the Table of Contents. 
 
 Those branches of Surgery which have undergone such 
 rapid develojDment of late years as to have become almost 
 separate sciences — such, for example, as the Surgery of 
 the Eye and of the Ear — I have considered only so far as 
 a knowledge of them is essential to every practitioner. 
 Each of these branches has called forth a special literature 
 of its own, and to this I must refer those who desire 
 fuller information upon these subjects. 
 
 Ever since I was a student it has been my habit to 
 make drawings of any cases of more than usual interest 
 which came before me, and many of the illustrations 
 which will be found in the following pages have been 
 copied from sketches in my own portfolio. Some of the 
 others have been taken from j^reparations in the Museum 
 of Charing Cross Hosi:)ital, which were kindly placed at 
 my service by the j\Iodical Committee. 
 
viii PREFACE. 
 
 I am well aware liow difficult it is to give anything 
 like an adequate view of the present advanced state of oiir 
 knowledge in the compass of a small volume like this. 
 The activity which is apj)arent in all departments of 
 Surgery cannot fail to gratify those who are interested in 
 the progress of the Healing Art ; but it adds to the 
 difficulty of selecting what is of permanent value, and 
 presenting it in a condensed form. 
 
 I hope, however, that nothing which is of real import- 
 ance has been omitted, and that, as far as it goes, this 
 Manual will be found a safe and trustworthy guide to the 
 practice of Surgery. 
 
 W. F. C. 
 
 November, 1870. 
 
CONTENTS. 
 
 PAET I. 
 
 STJKQICAL DISEASES. 
 
 PAGE 
 
 Local Hypersemia . .' 1 
 
 Active Congestion 1 
 
 Passive Congestion 1 
 
 Inflammation 2 
 
 Effusion 10 
 
 Adliesion 10 
 
 Suppuration 11 
 
 Ulceration 16 
 
 Mortification 17 
 
 Processes of repair . 21 
 
 Malformations 23 
 
 Hypertrophy 23 
 
 Atrophy . . , 23 
 
 Tumours 23 
 
 Benign 24 
 
 Sarcomatous 32 
 
 Carcinomatous 36 
 
 Scrofula and Tuberculosis 44 
 
 PAET II. 
 
 INJURIES. 
 
 Arrest of haemorrhage 48 
 
 Secondary hsemorrhage 54 
 
 Venous „ 55 
 
 Capillary „ £5 
 
X CONTENTS. 
 
 PAGE 
 
 Bruises 56 
 
 Wouuds 57 
 
 Incised 57 
 
 Contused 60 
 
 Lacerated 60 
 
 Punctured 61 
 
 Gunshot wounds 62 
 
 Poisoned wounds 67 
 
 „ „ . by healthy secretions ....... 67 
 
 „ „ by morbid products 68 
 
 „ „ by irritant poisons 72 
 
 Effects of heat 72 
 
 Effects of cold 75 
 
 Suspended animation 76 
 
 PAET III. 
 
 CONSTITUTIONAL EXPECTS OE STTEGICAL DISEASES 
 
 AND INJURIES. 
 
 Collapse — shock 79 
 
 Surgical or Traumatic fever 80 
 
 Hectic fever 83 
 
 Erysipelas 84 
 
 Pyaemia , 89 
 
 Tetanus 91 
 
 Hysteria 93 
 
 PART ly. 
 
 DISEASES AND INJURIES OE VARIOUS PARTS, TISSUES, 
 AND ORGANS. 
 
 Diseases and injuries of the skin 95 
 
 „ muscles, tendons, and bursa; . . 103 
 
 „ bones 110 
 
 „ joints l7l 
 
 ,, arteries 194 
 
 veins 202 
 
CONTENTS. xi 
 
 PAGB 
 
 Diseases and injuries of the lymphatics 204 
 
 5, „ nerves 205 
 
 head 206 
 
 „ ,, spine 213 
 
 face 220 
 
 eye 224 
 
 ear 249 
 
 „ ,. nose 250 
 
 „ „ mouth 254 
 
 „ ,, neck 263 
 
 „ „ chest, inchiding the breast . . 270 
 
 „ „ abdomen, including hernia . . 277 
 
 „ „ rectum and anus 296 
 
 „ „ genito-urinary organs, including 
 
 the venereal diseases . . . 303 
 
 „ „ hands and feet ...... 354 
 
 PART Y. 
 
 OPERATIOKS. 
 
 Operations in general 364 
 
 Incisions 366 
 
 Anesthetics 366 
 
 Dressings 369 
 
 Constitutional treatment after operations 372 
 
 Venesection 373 
 
 The cautery, issues, setons 374 
 
 Laryngotomy and tracheotomy 375 
 
 Ligature of arteries 378 
 
 Excision of joints . . ' 386 
 
 Amputations 391 
 
 Formulae and Receipts 40C 
 
PART I. 
 
 SURGICAL DISEASES. 
 
 XiOCAIi UYBEItmiailL OR COITGESTIOir 
 
 means the accumulation of blood which takes place in a part when 
 the vessels are overcharged and dilated. Such accumulation may 
 be either active and arterial, or passive and venous. 
 
 Active congestion (Determination) is a vital process and de- 
 pends upon an excess of blood in the arteries — this excess being 
 brought about sometimes by external irritation, sometimes by 
 increased functional activity of the organ or part. The arteries 
 are distended, and the bright red blood flows through them with 
 great rapidity. Active congestion is not always a morbid state. 
 'J'he afflux of blood to the breast during pregnancy is a true ex- 
 ample of determination. When, however, it occurs unnaturally, 
 or interferes with healthy nutrition or secretion, it becomes a 
 disease. It may be either acute or chronic. When acute, it 
 may relieve itself by hBemorrhage ; when chronic, it may lead to 
 serous effusions, or to changes in the nutrition or secretion of the 
 part. 
 
 The treatment is that of inflammation in its milder degrees, and 
 will be described hereafter. 
 
 Passive congestion is generally brought about by mechanical 
 causes. Most frequently it depends upon venous obstruction; 
 but it may also arise from general debility, or from a want of 
 tone in the vessels of the part, as well as from other causes. 
 When the circulation is only retarded, the blood flows slowly 
 through the distended vessels; when, however, it is altogether 
 arrested, complete stagnation takes place. If the obstruction be 
 removed, the circulation will soon recover itself, and the part return 
 to its normal state. But if the cause of the disorder remain in 
 operation, one of two things will speedily occur — either the 
 
 B 
 
2 SURGICAL DISEASES. 
 
 vessels will give way, and allow the blood to escscge —Jicemorrhaffe ; 
 or the watery constituents of the blood will make their way 
 through the walls of the vessels, giving rise to serous effusion. 
 
 When a part is passively congested, it is somewhat increased in 
 size, becomes of a dusky red colour, and pits on pressure. The 
 patient complains of a feeling of fulness and weight, with a 
 difficulty in movement, accompanied by more or less pain of a 
 dull aching character. 
 
 Treatment. — The great object is to remove the cause, be it a 
 ligature, tumour, fsecal accumulation or anything else. This may 
 sometimes be done by merely studying the position of the patient, 
 and facilitating the return of blood to the heart. The next point 
 is to relieve the distended vessels. This we effect by fomenta- 
 tions, counter-irritation, scarifications, cupping, or leeching. 
 Thirdly, we should aim at giving strength and tone to the vessels 
 themselves by bandaging, friction, cold-bathing, and the use of 
 stimulating or astringent lotions. 
 
 XXFIdAMMATIOIT 
 
 lies at the root of many surgical diseases. It is, therefore, impor- 
 tant that we should consider it at some length. 
 
 When we speak of inflammation, we mean a state which 
 depends essentially upon an alteration in the circulation of the 
 part, and which reveals itself by outward marks. These local 
 changes are accompanied by certain constitutional symptoms, 
 which, taken together, are expressed by the tevva feverishness or 
 pyrexia. 
 
 The outward marks to which we allude are redness, swelling, 
 heat, and pain. " Notse inflammationis," says Celsus, " sunt 
 quatuor, rubor et tumor cum calore et dolore." To these must be 
 added impairment or loss of function. But it must be borne in 
 mind that not unfrequently one or more of these symptoms is 
 entirely absent or greatly modified, according to the seat of the 
 disorder or the constitution of the patient. 
 
 To understand the nature of inflammation we must look below 
 the surface, and study the changes which occur (1) in the circula- 
 tion through the aflbcted vessels, and (2) in the adjacent tissues. 
 
 If the web of a frog's foot is placed under the microscope and 
 irritated, it is seen that the capillaries become dilated ; and the 
 blood stream, which was at first accelerated, is soon retarded. 
 The red corpuscles crowd together in masses, while the white 
 (leucocytes), which appear to be increased in number, adhere to 
 the wi.liS, or roll slowly along. Presently the circulation becomes 
 
INFLAMMATION. 3 
 
 altogether arrested, and stagnation takes place at various points. 
 When the current of the circuh\tion becomes very slow, the 
 minute arteries are nearly blocked up with red corpuscles and 
 the veins with leucocytes. Gradually these latter adhere to the 
 sides of the vessels, and, by their own ama3boid activity, pass 
 through them into the surrounding tissues. The red corpuscles 
 also escape, though less fi*eely. At the same time there is 
 transudation of the liijuor sauffuhns which furnishes the serous 
 eft'usion. The migrated corpuscles not only increase by division 
 and rapid multiplication, but they also excite the tissues into 
 which they have escaped to increased cell-proliferation. There is 
 greater nutritive activity, and thus is formed the cell-growth 
 which plays such an important part in inflammation. This new 
 cell-growth is unstable, and easily breaks down, and forms 
 pus. The more intense the inflammation, the more rapid will 
 be the cell-proliferation, and the lower the organization of the 
 cell elements. 
 
 During inflammatory conditions of the system the blood, as a 
 whole, appears to be thinner and poorer than in its normal state.. 
 The red corpuscles are diminished in number, and have a remark- 
 able tendency to cohere by their flat surfaces, both in the body 
 and after the blood has been withdrawn from it. The white 
 corpuscles are relatively increased, while at the same time the 
 fibrine may be doubled or trebled in quantity. 
 
 When inflammatory blood is drawn from the body, it coagulates- 
 more slowly than healthy blood ; and, as it does so, the red 
 corpuscles sink to the bottom, leaving the white corpuscles and 
 the tibrine at the top. The pale yellow layer thus formed is 
 called the " bufiy coat," or the blood is said to be " bnfled." 
 When the top presents a depression in the centre and elevated 
 edges, it is said to be " cupped " as well as " buffed." These 
 appearances, however, are not peculiar to the inflammatory state. 
 They are met within the blood of plethoric persons and puerperal 
 women, as well as under various other conditions. 
 
 The local changes that we have described are accompanied by 
 certain constitutional symptoms, known as symptomatic, surgical, 
 or irritative fever — feverishness or pyrexia. There is shivering 
 or a "cold and hot fit." The pulse is quickened; the temperature 
 is raised ; the skin becomes dry, the mouth parched, the tongue 
 coated, the bowels constipated ; the urine is scanty and throws 
 down a copious and high-coloured sediment, and the appetite 
 fails ; while at the same time the patient complains of aching 
 pains in various parts of the body, and of a feeling of general 
 weakness and languor. 
 
 The severity of these symptoms will depend much lipon the 
 
 b2 
 
4 SUEGICAL DISEASES. 
 
 degree and extent of the inflammation, as well as upon the nature 
 of the part affected. They vary, too, according to the constitution 
 of the patient. If he is robust and plethoric, the inflammatory 
 lever will have a sthenic character, with a flushed face, a bounding 
 pulse, and a white furred tongue. If, on the other hand, he is 
 feeble or debilitated, the pyrexia will be of the asthenic kind, 
 with a vveak pulse, a brown tongue, and a tendency to low 
 muttering delirium. 
 
 Hippocrates laid great stress upon the importance of watching 
 the animal heat ; and ever since his time surgeons have made it 
 a matter of observation. But it is only of late years that we 
 have been able, by means of the clinical thermometer, to record 
 the exact variations of the temperature from day to day and from 
 hour to hour. The information which this little instrument gives 
 us is of the utmost value in all inflammatory diseases. 
 For the varieties of Surgical Fever, see p. 80. 
 Spread of ivflammation. — Inflammation may spread in several 
 ways : — (1) by continuity, along the same tissue; (2) by contiguity, 
 from one tissue to an adjacent one ; (3) by metastasis, the disease 
 suddenly leaving one part and appearing in another; or (4) morbid 
 material, capable of exciting inflammation, may ^e carried by 
 the blood from one point to another, as in pyaemia. 
 
 Termination of inflammation. — There are two ways in which 
 inflammation may terminate : — (1) by the death of the patient, 
 from the severity of the attack, from the exhaustion produced by 
 its long continuance, or from the vital importance of the part 
 affected: (2) by resolution. The circulation may recover itself; 
 healthy nutrition may be restored ; any effusion that has occurred 
 may be absorbed ; secretion may be re-established, and the part 
 may return in every respect to its normal state. 
 
 These are the only ways in which inflammation can properly 
 be said to terminate. There are, however, certain secondary 
 processes : — Effusion, adhesion, suppuration, ulceration, and mor- 
 titication — which are often spoken of as terminations, but which 
 are more correctly called the events of inflammation. To each 
 of these conditions we shall allude presently. 
 
 Local effects of inflammation. — These are of the most oppo- 
 site kinds — induration and softening, enlargement and atrophy ; 
 but they may all be regarded as the result of imperfect 
 resolution. 
 
 Induration occurs after long-standing inflammation with effu- 
 sion, as the result of the interstitial deposit of plastic material. 
 Softening follows the more acute forms of inflammation, as the 
 result of impaired nutrition. Again, mflammation sometimes leads 
 10 ail increase of bulk Irom enlargement of the vessels, effusion 
 
INFLAMMATION. 5 
 
 and cell-growth. Sometimes, on the contrary, its effect is to pro- 
 dnce a decrease of size, by interstitial absorption. 
 
 Varieties of inflammation. — Inflammations are classified ac- 
 cording to their duration, or their character. 
 
 Thus we speak of them as acute, subacute or chronic, accord- 
 ing to the time that they last. The acute run a short course ; 
 the subacute a soinewhat longer; while the chronic have a 
 tendency to become indefinite in tlieir duration. Or, if we look 
 to the character of the inflammation, we speak of it as healthy or 
 unhealthy, circumscribed or diff'use, strumous, syphilitic, &c. 
 
 The causes of i)ifl.ammation are (1) predisposing, (2) exciting ; 
 and in each case they may act locally, or through the medium of 
 the constitution. 
 
 Local predisposing causes are such as these : — The habitual 
 over-use of a part — for example, of a joint; a chronic state of 
 congestion ; a previous attack of inflammation. 
 
 The constitutional predisposing causes are those which impair 
 the purity of the blood, whether it be by excessive stimulation, or 
 by a want of proper nourishment. Thus, it is well known that 
 indulgence at table predisposes to gouty inflammations ; while, on 
 the other hand, the poor and persons of a strumous habit, whose 
 vital powers are enfeebled, are especially liable to other forms 
 of inflammatory disease. 
 
 The local exciting causes are obvious. We need only mention 
 injuries, contusions, wounds, scalds, &c. 
 
 The constitutional exciting causes are those states of the blood 
 wherein it would appear that a morbid material accumulates, 
 until it manifests itself in a local inflammation — as, for example, 
 carbuncle, gout, acute rheumatism, &c. 
 
 Treatment of infl-ammation. — In considering this subject we 
 must fall back upon the classification which we have already 
 given, and speak first of the treatment of acute inflammation. 
 When such a disease occurs in young and robust persons it calls 
 for prompt and energetic measures. Sthenic inflammation is 
 much under control, and we are often able to exercise more influ- 
 ence over it than we can over the other varieties. 
 
 The first thing is to remove the cause, if it be possible to do so. 
 Thus, if a joint is inflamed from excessive use, it must be kept 
 at rest ; if an eye is inflamed from the presence of particles of sand, 
 they must be taken away. 
 
 The next point is to diminish the flow of blood to the part, 
 and this may be done either through the medium of the consti- 
 tution, or by local means. The sum of such measures forms 
 what is called the antiphlogistic treatment. 
 
 Constitutional treatment of acute inflammation of the sthenic 
 
6 SUEGICAL DISEASES. 
 
 type. — In tlie first place, everything which can irritate the 
 patient, whether in body or mind, should be removed. He 
 should be kept at rest in a well-regulated temperature, and 
 placed upon a low diet. We must then consider what can be 
 done for him by medical treatment) properly so called. 
 
 The most powerful weapon that we possess for subduing acute 
 inflammation is Mood-letting. But it is a weapon which must 
 not be used without great caution, especially in the case of the 
 young or the old, or in persons whose vital powers are enfeebled 
 from ill-health, dissipation, or any other cause. It is so easy to let 
 hlood, and so difficult to restore it, that it is only when some 
 organ of primary importance is in danger that we are justified in 
 having recourse to this remedy. 
 
 Happily we have other means at our disposal, which are very 
 efifectual in reducing inflammation, and which are not open to the 
 same objections as bleeding. These are purgative, diaphoretic, 
 and diuretic medicines. 
 
 In almost all cases of inflammation it is right to give a free 
 purge at the outset of treatment. The exceptions to this rule 
 are certain cases of abdominal inflammation, when we desire to 
 keep the bowels quiet rather than to excite tbem to action. 
 Perhaps for an adult the best purge that can be given is a 
 mercurial, followed by a saline or aloetic draught — e.g., 5 grains 
 of blue pill at night, followed next morning by ^j of the mist, 
 sennse co., or of the decoct, aloes co., or a seidlitz powder. This 
 has the eSect of clearing the primce vice, promoting the secretions 
 and relieving the circulation. It may be necessary to repeat this 
 remedy from time to time as the case proceeds. 
 
 If we use diaphoretic or diuretic medicines their action must be 
 kept up by doses given every three or four hours. Antimonials often 
 answer admirably by encouraging perspiration and tranquillizing 
 the circulation. At the same time, the skin and the kidneys 
 may be stimulated by salines, such as the acetate of ammonia, 
 or the nitrate of potash. (F. 33, 55, 64, 69.) 
 
 Mercury has a time-honoured reputation for allaying inflamma- 
 tion, especially in serous and fibrous membranes. Of late years, 
 however, its value in this respect has been called in question ; but 
 there can be little doubt that it is a useful remedy in acute inflam- 
 mations of a sthenic type, particularly when combined with 
 opium. Its action seems to be that of an alterative, promoting 
 secretion and moderating the force of the heart. But besides 
 this, it would appear to exert a special influence over the fibrine 
 of the blood by diminishing its quantity. (P. 82.) 
 
 Opium is of great service in allaying pain, soothing the patient, 
 and procuring sleep. In the form of Dover's powder it is in- 
 
INFLAMMATION. 7 
 
 valuable. Its use in combination with mercury has been already 
 mentioned. 
 
 Local treatment of actde inflammation of the sthenic type. — 
 Local blood-letting is a practice much in vogne at the present 
 day, and may almost be said to have superseded venesection. 
 Undoubtedly it gives us many of the good effects of general 
 bleeding, without the disadvantages which belong to that method 
 of depletion. 
 
 It may be carried out in a variety of ways — by incisions, 
 scarifications, cupping, or leeches. • 
 
 Incisions are specially applicable to the skin when it is 
 stretched in such a way that it is in danger of sloughing. A 
 number of small cuts should be made with a lancet in parallel 
 rows, extending only to the depth of the true skin. 
 
 Scarification is chiefly used when the inflammation attacks the 
 mucous membranes — as, for example, the lining of the mouth or 
 the gums. In quinsey it is a good practice to scarify the most 
 prominent part of the tonsil. 
 
 Cupping is an efficient means of removing blood, and relieving 
 the over-burdened circulation. It is, however, more suited to 
 deep-seated than to superficial inflammation. The cupping-glasses 
 should not be placed upon the inflamed spot ; nor should the 
 scarificator be used in parts which are left uncovered by the 
 dress — as, for example, the neck — because the scars are apt to 
 remain for life. The "artificial leech" is a modification of cup- 
 ping, which is well adapted to some deep-seated and localized 
 inflammations — for example, those of the eye. 
 
 Leeches are extremely useful in allaying acute inflammation. 
 They should be placed, not upon, but around, or in the neighbour- 
 hood of, the disease. They should be used in sufficient numbers 
 to produce a marked effect. It is estimated that each leech ab- 
 stracts fully half an ounce of blood. There are some situations 
 in which they ought not to be employed — for example, on the 
 scrotum, or eyelids, for fear there should be difficulty in prevent- 
 ing haemorrhage or ecchymosis; nor near specific sores, lest the 
 bites should become affected with the morbid poison. 
 
 Bleeding may be encouraged by warm poultices or fomentations. 
 On the other hand, it may be arrested by pressure or styptics, 
 such as the tincture of the perchloride of iron, powdered matico, 
 or lunar caustic. 
 
 Warmth, particularly when conjoined with moisture, is a 
 remedy of the utmost service in acute inflammation. It may be 
 applied either in the form of a poultice or a fomentation, and both 
 these methods maybe rendered more efficient by medication. The 
 poultice may be mixed with laudanum or tincture of henbane j or 
 
8 SURGICAL DISEASES. 
 
 in making the fomentations a decoction of poppy heads or chamo- 
 mile flowers may be used instead of plain water. Warmth and 
 moisture are particularly applicable when the inflammation is 
 at its height. They relieve tension, mitigate pain, and promote 
 suppuration. But for the earlier stages, while suppuration may 
 yet be averted, as well as for the later, cold will often be found 
 a more useful remedy. In deciding whether to have recourse to 
 warm or cold applications, it may sometimes be well to consult 
 the patient's feelings, and to see which gives him the most relief. 
 The general -rule, however, is as we have stated — namely, that 
 when the inflammation is at its height, warm and moist applications 
 will be found the most efiicient, while cold will be more useful in 
 the earlier and later stages. When cold is employed in the early 
 stage of an inflammation it is with the view of anticipating the 
 morbid action, and preventing its further progress. Thus, a 
 wound of a joint, threatening the most serious consequences, may 
 sometimes be conducted to a successful result by the use of a 
 splint, and the continuous application of cold. In the later 
 stages of acute inflammation, cold is of great use in giving tone to 
 the vessels, and preventing a congested state of the part, which is 
 apt to remain after the more urgent symptoms h^ve subsided. 
 It may be applied by irrigating the part with cold water, or by 
 covering it with evaporating lotion ; or more eff"ectually by an ice 
 poultice (F. 97), or by a bladder or india-rubber bag filled with 
 pounded ice, or ice and salt, and laid upon the part. 
 
 The treatment of acute inflammation of the asthenic type must 
 not be in the slightest degree antiphlogistic. Depletion would do 
 harm instead of good. Everything which is calculated to lower 
 the patient should be carefully avoided. Locally we must con- 
 fine ourselves to the milder and more soothing measures that have 
 been mentioned, poultices, fomentations, &c. 
 
 It is the general health which is at fault, and to this we must 
 address ourselves. We must examine the state of the pulse, 
 tongue, skin, and secretions. If the pulse is rapid and weak, the 
 tongue brown and covered with sordes, and the skin hot and dry, 
 we must have recourse to a stimulating and supporting plan of 
 treatment. A light but nourishing diet should be given, com- 
 bined with a little wine or brandy. We must take care that the 
 patient has a proper and sufl[icient diet on the one hand, and that 
 he is not over-stimulated on the other. The medical treatment 
 consists in clearing out the bowels by a gentle purgative, and 
 then giving salines with carbonate of ammonia, ether, bark, and 
 similar drugs. The action of the skin may be promoted by 
 diaphoretics, while restlessness and irritability are allayed by 
 opium. 
 
INFLAMMATION. 9 
 
 Treatment of chronic inflammation. — Chronic inflammation — 
 that is to say, an inflammation which tends to last an indefinite 
 time — may depend either upon a continued source of irritation, 
 or upon relaxation of the vessels following an acute attack. Our 
 first business must be to ascertain the cause of the disease. If 
 this should pi'ove to be irritation, we must endeavour to remove 
 or allay it. Should it be a relaxed and dilated state of the vessels 
 of the part, we must try and restore their healthy tone. 
 
 The source of irritation is sometimes local — as, for example, a 
 foreign body or a morbid growth. But much more frequently it 
 has a constitutional origin, and depends upon a strumous habit, or 
 a disordered digestion, or a faulty state of the secretions. 
 
 If the irritation is kept up by the presence of a foreign body, 
 we must consider whether it admits of removal ; or, if not, how 
 far its effects may be mitigated. If, however, the irritation 
 arises from an impaired digestion, great benefit may be derived 
 from a regulated diet, combined with moderate exercise in the 
 open air, and the use of aperient, alterative, or tonic medicines. 
 Small doses of grey powder or Plummer's pill may be given at 
 short intervals, and continued for a length of time, but they must 
 never be allowed to produce salivation. When nsed in this way 
 mercury has a double value. It serves to subdue inflammation, 
 and at the same time it promotes the absorption of the eff"used 
 material. Iodide of potassium, in addition to its antisyphilitic 
 properties, is useful as an alterative and absorbent. 
 
 If the patient is of a strumous habit, we must prescribe cod- 
 liver oil, or the preparations of iron and quinine ; taking care at 
 the same time that the diet is light, nutritious, and given with 
 regularity. 
 
 If the chronic inflammation depends upon a relaxed state of the 
 vessels of the part, we must, in addition to constitutional remedies, 
 resort to local measures. The distended vessels may be relieved 
 from time to time by local bleeding, w'hile we endeavour to im- 
 part strength and elasticity to their coats by stimulating or 
 astringent applications, such as the sulphates of zinc or copper, 
 or the nitrate of silver. 
 
 Friction is very useful in cases of this kind ; particularly if some 
 stimulating liniment is rubbed in at the same time, and the 
 rubbing conducted in such a manner as to promote the venous 
 circulation. 
 
 Counter-irritation, by means of blisters, setons, issues, the 
 actual cautery, or rubefacient embrocations, is one of the most 
 efficient remedies that we possess for removing chronic inflamma- 
 tion. 
 
 Rest and equahle jpresaure by means of a well-adjusted bandage 
 
10 SUEGICAL DISEASES. 
 
 are often of the first inrportance, and without them the other 
 measures I have enumerated are frequently of little avail. 
 
 Culd sponging, or the use of a cold douche bath, is a very simple 
 and at the same time a very efficacious remedy. This may often 
 be employed in conjunction with some of the other means already 
 mentioned, as friction and bandaging. 
 
 EFFUSZOXO'. 
 
 EjBFusion — the escape of some of the constituents of the blood — 
 is, as we have seen, an integral part of the inflammatory process. 
 But effusion occurs also as the result of passive congestion ; and 
 both these conditions are of so much interest to the surgeon that 
 we shall devote a brief section to their consideration. 
 
 The effusions which are met with in surgical practice some- 
 times consist of blood, sometimes of liquor sanguinis, sometimes 
 of serum. 
 
 When blood is effused it is by the rupture of some of the 
 minute vessels. The effusion of liquor sanguinis is, properly 
 speaking, a transudation. The watery portion of the blood, hold- 
 ing the fibrine in solution, escapes, while the corpuscles are left 
 behind. The fluid drawn by a blister is liquor sanguinis. But 
 the most common effusion is the serous. The fluid that is poured 
 out usually contains a small quantity of fibrine, together with a 
 large amount of albumen. When such effusion occurs in the 
 serous cavities, it gives rise to clrojisies ; when it takes place in 
 the cellular tissue, it occasions oedema. When the serum has been 
 absorbed, and the fibrine deposited in the tissues, the condition 
 known as solid oedema is produced. 
 
 ABHESIVZ: ZI^FZiAMIVIATZON'. 
 
 Inflammation is said to be adhesive when it leads to the effusion 
 of fibrine, lymph, or plastic material. The study of this variety 
 of inflammation is of great importance, because it is the medium by 
 which the natural reparative processes are carried out in a large 
 majority of cases. Effused lymph is met with in two states. 
 Sometimes it is healthy, 'plastic, fibrinous ; at other times it is 
 unhealthy, aj)lastic, corpuscular. These are the terms in general 
 use to distinguish the two kinds of lymph. The former is the 
 "coagulable lymph," properly so called. It contains a large {pro- 
 portion of fibrine, and tends to become organized. The latter is 
 composed chiefly of corpuscles, suspended in a thin serous fluid, 
 and it tends to degenerate. Such degeneration often takes the 
 form of an unhealthy suppuration. For the sake of clearness, the 
 
SUPPUEATION. U 
 
 two kinds of lymph may be contrasted with one another in tliis 
 way. But in practice they are found blended and intermingled 
 in an endless variety of proportions. It is hardly too much to 
 say that no two specimens are exactly alike. 
 
 When lymph has been effused, it may undergo absorption, 
 development, or degeneration. 
 
 When lymph is absorbed it probably first breaks down, and 
 is carried away as debris. The part is then restored to its natural 
 state. 
 
 Coagulable lymph is capable of being organized into a variety 
 of forms ; for it is, as we have said, the medium through which 
 Nature effects all her reparative processes. It passes through the 
 form cither of " nucleated blastema," or of a mass of nucleated 
 cells, and becomes fibrous or fibro-cellular. It is then more fully 
 developed, and gradually approaches the characters of the tissue 
 which has to be repaired. It is only the simpler tissues which 
 are perfectly reproduced ; while the place of the more complex 
 ones is supplied by an imperfect substitute. 
 
 The way in which lymph becomes organized is an interesting 
 question. It is now held by most observers that offsets from 
 existing vessels enter it at its margins, and, by forming a series 
 of loops or arches, ultimately pervade the whole mass. 
 
 The degeneration to which lymph is liable is of two kinds. 
 It may wither into a dry and horny substance, or it may become 
 granular and fatty. 
 
 SUPFURATIOIT. 
 
 Suppurative inflammation is that variety which leads to the 
 formation of pus. 
 
 Healthy or laudable pus is a thick, opaque fluid, of a yellowish- 
 white colour, a faint odour, and generally of an alkaline reaction. 
 Under the microscope it is found to consist of a thin fluid, 
 tlie liquor puris, and corpuscles. The greater the number of cor- 
 puscles, the better is the quality of the pus. Sometimes it is 
 mixed with blood, and then it is said to be sanious ; sometimes it 
 is watery and acrid, when it is termed ichorous ; sometimes it is 
 curdy, and contains flakes of coagulated lymph. These are some 
 of the chief varieties of pus that occur in practice ; but, whatever 
 its particular characters, it is never met with except as the result 
 of inflammation. The corpuscles may be regarded as exudation- 
 cells, and the liquor puris as serum, modified by the progress 
 of the inflammatory action. 
 
 In most cases pus may be easily recognised by its appearance, 
 or by its becoming viscid und ropy on the addition of liquor 
 
12 SURGICAL DISEASES. 
 
 potasscB. If, however, any diflBculty should arise, the microscope 
 will generally enable us to distinguish it from tubercle, cancer, 
 softened fibrine, turbid serum, or other substances with which it 
 might be confounded. 
 
 Pus may either be formed on a free surface, as, for example, 
 on a mucous membrane ; or deeply among the tissues. In the 
 latter case it constittites an abscess. 
 
 Suppuration, whether superficial or deep, may be either acute 
 or chronic ; it may run its course in a few days, or it may last for 
 months or even for years. 
 
 Again, it may be either circumscribed or diffused. When 
 suppuration takes place in a healthy individual, the lymph, which 
 is poured out in the early stage of the inflammation, serves as a 
 boundary wall and limits the spread of the suppuration. But 
 when the patient's constitution is broken, no such barrier is 
 formed, and the suppurative inflammation becomes diffuse. 
 
 When pus is about to be formed on a free surface, we observe 
 the ordinary signs of acute inflammation. 
 
 When an acute abscess is about to form there are some ad- 
 ditional points which may be noticed. The pain has a throbbing 
 character. The skin becomes tense, shining, and sometimes oede- 
 matous. In the course of a short time, fluctuation may be 
 detected — that is to say, when a finger is placed on each side 
 of the swelling, and pressure is made from one point to the other, 
 a peculiar sensation is communicated, which indicates the presence 
 of fluid. 
 
 Suppuration, like other events of inflammation, is commonly 
 attended by certain constitutional symptoms. There is feverish- 
 ness, with loss of appetite, and, when matter has begun to form, 
 there are " chills and heats," or perhaps distinct rigors. 
 
 When the discharge of pus is profuse and long-continued, it is 
 apt to give rise to hectic. {See Hectic.) 
 
 In the case of a chronic abscess the signs are somewhat obscure; 
 neither the local nor the constitutional symptoms are well-marked. 
 An indolent, circumscribed swelling appears, which is indistinctly 
 fluctuating, and free from pain or tenderness. If it happens to 
 be enclosed in a tough cyst, the difficulty of diagnosis will be 
 increased. When it approaches the surface it becomes painful, 
 involves the skin, ulcerates, and discharges itself. 
 
 Sometimes the inflammation which precedes suppuration is so 
 slight, or so slow in its progress, that it excites no uneasiness, 
 until a swelling is detected containing pus. Such, at least, would 
 seem to be the pathology of cold abscesses. 
 
 What circumstances conduce to suppuration ? How comes it 
 that in one case inflammation gives rise to adhesion, while in 
 
SUPPURATION. 13 
 
 another it leads to the formation of pus ? This seems to depend 
 upon the quality of the eifused material. In proportion as it is 
 healthy or fibrinous, adhesion is likely to take place ; while, on 
 the other hand, in proportion as it is lanhealthy or corpuscular, it 
 is prone to suppurate. In truth, there is but a step between the 
 exudation-cell and the plus-globule. 
 
 The quality of the effusion depends in a great degree on the 
 state of the patient's health ; when this is good, the character of 
 the eff"Msion will be good also, and vice versa. 
 
 Again, the seat of the disease influences the nature of the 
 effusion : mucous membranes very readily suppurate ; serous 
 membranes but seldom. 
 
 Again, the access of air seems to promote suppuration. 
 Hence the advantage of a subcutaneous incision to which little or 
 no air is admitted. 
 
 The treatment of suppuration is partly local and partly consti- 
 tutional. 
 
 Locally, we must try to take away the cause, if it be a foreign 
 body, a piece of dead bone, or anything else that is capable 
 of removal. Such things are often the causes of chronic abscess. 
 Then we must endeavour to reduce the inflammation, by study- 
 ing the position of the part, and by using cold lotions, water- 
 dressing, fomentations, or poultices, as the case may require. 
 Lastly, we must give a favourable exit to the pus, and do what 
 we can by antiseptic, stimulating, or astringent applications, to 
 bring about a more healthy action, and to limit the amount of 
 discharge. 
 
 An acute abscess should be covered with a poultice made of 
 bread, bran, chamomile flowers or linseed-meal. As soon as 
 fluctuation is detected, a sufficient incision should be made to let 
 out the pus, and the poultice continued. 
 
 A chronic abscess will often require to be laid freely open, 
 stuffed with lint, and allowed to heal from the bottom. 
 
 In the case of a large chronic abscess — connected with disease 
 of the spine, for example — it is best to make a small valvular 
 incision, that is to say, to pass the knife obliquely under the skin 
 for a short distance before it reaches the cavity ; or the air-tight 
 syringe, known as the " aspirator," may be used. By these 
 means the entrance of air is prevented, while the uiatter is 
 drawn off", a little at a time, on repeated occasions, so as to 
 allow the walls of the abscess to contract gradually. 
 
 The Aspirator represented in Pig. 1 is portable and convenient, 
 for it can be fitted to an ordinary bottle. When it is to be used, 
 the right stop- cock is closed, the left opened, and the air in the 
 bottle exhausted by a few strokes of the piston. The lett stop- 
 
14 
 
 SURGICAL DISEASES. 
 
 cock is then closed, the needle introduced into the abscess, and 
 the riglit stop-cock opened. The fluid will then run up the tube, 
 and fall into the bottle. 
 
 Fi-. 1. 
 
 Pneumatic aspirator. 
 
 The older surgeons used to regard suppuratioi» with more 
 favour than we do at the present time. With certain exceptions 
 it is scarcely too much to say that the modern surgeon wishes to 
 prevent altogether the formation of pus, and that the aim of 
 surgery in this respect is to counteract the irritating influence of 
 putrefaction, so as to reduce all wounds, as it were, to the condi- 
 tion of subcutaneous injuries. Many attempts have been made 
 to eflfect this object, and various methods of practice have been 
 suggested ; but the most successful is undoubtedly that which 
 has been introduced by Professor Lister. I have had the advan- 
 tage of witnessing the antiseptic system as it is carried out in his 
 wards, and I cannot doubt its value. I shall, therefore, briefly 
 describe it. 
 
 Mr. Lister has found no substance so convenient for antiseptic 
 dressings as carbolic acid. He employs a watery solution (1 to 
 100), an oily solution (1 to 10 of olive oil), a gauze impregnated 
 witli carbolic acid in paraffin, and a protective plaster of silk 
 coated with copal varnish, containing no carbolic acid, but 
 intended to protect raw surfaces from the immediate contact of 
 what would act as an irritant. With the watery solution milder 
 cases are dressed, and an antiseptic atmosphere is kept up around 
 h wound by means of a spray-producing apparatus during the 
 time that it is being examined. With the oil the hands of the 
 surgeon and his instruments are smeared; and sometimes the 
 ligatures and the dressings are saturated with it. The anti- 
 
SUPPUEATION. 15 
 
 septic gauze, which retains and gives off the carbolic acid for a 
 long time, is placed over the wound to create an antiseptic 
 atmosphere. 
 
 In dressing an ordinary flesh wound the following is the method 
 to be pursued : — Wash around the wound with the watery solu- 
 tion, and apply a piece of protective large enough to overlap the 
 edges of the wound ; this should be previously dipped in the solu- 
 tion. Then a piece of gauze, dipped in the solution, is placed 
 over the protective, so as considerably to overlap it. Above this 
 six or eight folds of loose carbolized gauze are laid, and lightly 
 bandaged with a gauze bandage. Lastly, a turn of elastic bandage 
 is stretched over the edges of the dressing, so as to keep it in 
 close contact \\ith the skin. A carbolic spray should be diffused 
 over the wound and the dressings during the whole process ; and 
 the operator's hands should be kept moist with the solution. 
 
 Let us now suppose that a lumbar abscess is to be opened upon 
 Lister's principle. The skin around the point of pui^ture and 
 the knife are smeared with carbolic oil, and a large piece of lint 
 saturated with the same is held over it. The abscess is freely 
 opened, the veil of lint is dropped over the incision, and the con- 
 tents of the cavity are gently pressed out, the discharge oozing 
 from underneath the carbolized veil. Or the whole operation may 
 be performed in an antiseptic atmosphere created by a cloud of 
 spray from Richardson's apparatus, or from Lister's " spray- 
 producer." Over the incision are then placed a few folds of 
 antiseptic gauze, secured by a bandage. The same precautions 
 must be observed every time the wound is dressed. Putrefac- 
 tion is thus prevented, and the evils that it carries with it are 
 avoided. ANhen the wound is granulating freely, the protective 
 is used to moderate the direct action of the carbolic acid, that 
 the atmosphere of the wound may be thoroughly antiseptic, 
 while the granulations are not unduly irritated. The freedom 
 from all offensive smells, and the fact that the protective 
 (which contains a small quantity of litharge), keeps its normal 
 colour, and is not blackened by the escape of sulphuretted 
 hydrogen, give proof of the absence of putrefaction. Prac- 
 tically this last is a very delicate and useful test, for as soon as 
 decomposition ■ comiuences in the albuminous discharges a black 
 sulphuret of lead is formed on the protective. Even when, in 
 spite of all our efforts, suppuration takes place in a wound, the 
 antiseptic treatment should not be abandoned, for there is a wide 
 difference to the patient whether the pus which is lying in con- 
 tact with a raw surface is or is not in a state of putrefaction. 
 
 The " germ theory," upon which Lister's method rests, must 
 still, I think, be couddered sub judice. That the irritation which 
 
16 SURGICAL DISEASES. 
 
 the air undoubtedly causes in a wound is due to the organic par- 
 ticles vvhicli it contains, and not to its chemical or physical 
 qualities, seems to me a proposition which is "not proven." 
 Still there can be no question of the value of carbolic acid, what- 
 ever may be its modus operandi, and of the credit which is due 
 to Lister for having introduced it into practice. 
 
 When it is used as a simple lotion (F. 12), or when dressings are 
 kept constantly moist with it by droppings from a syphon bottle, 
 its beneficial effect is beyond a doubt ; but it should be borne in 
 mind that this is not Lister's method, and that cases thus treated 
 should not be classed with those in which all the details recom- 
 mended by him have been thoroughly carried out. In the treatment 
 of abscesses Callender has recommended that they should be 
 opened and injected with a solution of carbolic acid (1 part in 20), 
 until they are hyper-distended. By this means the antiseptic 
 wash is brought into contact with every part of the interior surface. 
 
 Carbolic acid is not the only substance which has been used to 
 check suppuration. Mr. Campbell De Morgan introduced a 
 strong solution of chloride of zinc (40 grains to the ^j) to sponge 
 out wounds immediatel}'^ after operation; and a weaker solution 
 (F. 27) may be used in subsequent dressings. Sulphurous acid 
 lotion (F. 14) may be employed with great benefit for the same 
 purpose. 
 
 The constitutional treatment of suppuration consists in sup- 
 porting and improving the patient's health. This may best be 
 done by placing him in the most favourable hygienic conditions, 
 ordering a light and nutritious diet, and such medicines as the 
 mineral acids, steel, cod-liver oil, and quinine. 
 
 VXiCERATZOXr. 
 
 Ulceration is commonly described as the " molecular death" 
 of a part; and this destructive action may either occur where 
 the surface is already broken, or it may itself give rise to a solu- 
 tion of continuity. The essential nature of ulceration is involved 
 in some obscTirity. We may, however, divide the process into 
 two stages — (1) That in which the tissues are broken down and 
 disintegrated; (2) That in which the debris is re*ioved or dis- 
 charged. 
 
 The first stage, that of disintegration, seems to arise either 
 from simple arrest, or from an impairment of nutrition. 
 
 When the supply of blood to a part is cut off, ulceration is apt 
 to follow, from simple arrest of nutrition. There are certain 
 situations— ^the al<B nasi, for example — where the circulation is 
 naturally feeble, which are specially prOne to this form of disease. 
 
MOKTIFICATION. 17 
 
 But an impaired or faulty nutrition is a far more common 
 cause of ulceration. These unfavourable changes in the nutrition 
 of the part are generally brought about by inflammation. Some- 
 times they follow directly upon an acute attack ; sometimes they 
 result from the alterations of texture — the hardening or the soft- 
 ening — which are left behind after the acute symptoms have sub- 
 sided. In these two ways inflammation is a frequent source of 
 ulceration, though, as we have said, ulceration may occur without 
 inflammation. 
 
 Whatever lowers the vital power, either of the part or of the 
 constitution generally, predisposes to ulceration — for example, 
 advancing age, broken health, loss of nerve force, chronic con- 
 gestion, a strumous or syphilitic taint, and many other con- 
 ditions. 
 
 The most common exciting causes of ulceration are acute in- 
 flammation, mechanical injuries, chemical irritants, and con- 
 tinuous pressure. 
 
 The second stage of ulceration is that in which the debris is 
 removed. Such removal may take place either outwardly or in- 
 wardly. The disintegrated tissue is in the great majority of cases 
 thrown off from the ulcerating surface in a purulent discharge, 
 but it may also be absorbed by the lymphatics and veins. This 
 " ulcerative absorption " is, however, comparatively rare. The 
 purulent discharge is sometimes gritty from the presence of minute 
 particles of solid matter. This is specially the case when bone is 
 involved. 
 
 Treatment. — The local treatment consists in studying the 
 position of the part, allaying inflammation by the means that 
 have been already mentioned, and endeavouring to mitigate the 
 ulceration or to improve its character. This may be done by the 
 use of sedative, anodyne, astringent or stimulating applications. 
 In some cases the ulcerating surface may be destroyed by a strong 
 caustic. This mode of treatment is particularly applicable to 
 specific and unhealthy sores. 
 
 The constitutional treatment is of the utmost importance. 
 The patient should be placed in a puj-e.and fresh air. His diet 
 and manner of life should be regulated ; while, at the same time, 
 his general health may be improved by tonic, anti-syphilitic, or 
 anti-scorbutic medicines. 
 
 nXORTIFXCATZOir. 
 
 Mortification signifies the death of a part. The process of 
 dying is by some called gangrene, and the state of complete death 
 sphacelus. By others these terms are used as synonymous. 
 
 c 
 
18 SURGICAL DISEASES. 
 
 When a limited portion of tissue dies, it is said to slough ; but 
 the changes which take place in sloughing and mortification are 
 much the same, the only difference is in extent. Indeed, ulcera- 
 tion, sloughing, and mortification may be taken to be ascending 
 degrees of the same morbid process. 
 
 Gangrene is divided into moist and dry. The former generally 
 depends upon venous obstruction, and is usually accompanied by 
 inflammation. The latter may exist without inflammation. Its 
 most frequent cause is a deficient supply of blood ; and this de- 
 ficiency may arise either from disease or from injury — e.g., from 
 senile changes or from crushing violence. This leads us to 
 another distinction, which it is very important to bear in mind — 
 namely, that a part may perish either from constitutional or from 
 local causes. 
 
 When a part is about to die it becomes of a dusky red or 
 purple colour, and frequently presents a mottled appearance. It 
 becomes doughy, and easily breaks down under pressure. The 
 temperature falls, and there is loss of sensibility. There is dull, 
 heavy pain, occasionally rising into acute paroxysms. The cuticle 
 is raised into bullse, and an evolution of gas takes place. These 
 symptoms are more marked in moist gangrene, attended by a 
 high dpgree of inflammation, than in the dry variety. In the 
 latter the part simply withers — becomes mummified. 
 
 These local symptoms are always accompanied by great 
 exhaustion, and by a tendency to the typhoid forms of inflamma- 
 tory fever. 
 
 The principal causes of gangrene are — (1) external injuries, (2) 
 an arrest in, or a deficiency of, the blood-supply, (3) obstruction 
 to the venous circulation, (4) specific poisons, as in the cases of 
 cancrum oris, malignant pustule, or sloujjhing phagedsena. 
 
 Under the first head fall accidents attended by severe contu- 
 sion and laceration. 
 
 Under the second, ligatures of the main arteries, embolisms 
 and cases of deficient blood-supply' from weakness of the heart, 
 exhaustion, or narrowing of the arterial channels. Fig. 2 repre- 
 sents a case of gangrene in an infant eleven months old who 
 was under my care. The little patient was recovering from 
 an attack of measles wlieu the left foot became black, hard, 
 and dry ; and on the thirty -second day dropped ofi" at the ankle- 
 joint, leaving the ends of the tibia and fibula protruding. A 
 proper stump was then formed, and the child made an excellent 
 recover}'. (Path. Soc. Trans, vol. xx.) 
 
 But how is the spread of this destructive process limited ? If 
 the gangrene depends upon a simple arrest of the circulation — 
 e.g.t on plugging or deligation of the main artery — then the seat 
 
MOETIFICATION. 19 
 
 of such obstruction will determine the point where the disease 
 ceases. A red line of healthy inflammation — the line of demar- 
 cation — will indicate the separation between the living and the 
 dying tissues. 
 
 Fig 2. ^^ 
 
 Gangrene of the foot in an infant. 
 
 If, however, the gangrene arises from inflammation, it may 
 continue to spread until it reaches a point where the vitality 
 of the tissues resists its action. They are in a more healthy state, 
 and the inflammation which they exhibit is of a more healthy kind 
 also. Instead of being killed by the intensity of the inflammation, 
 they are able to throw out lymph, which forms a barrier to its 
 further progress. The gangrenous inflammation is then changed 
 into the adhesive. 
 
 The same happy result occurs when the inflammatory action 
 subsides to a degree which is compatible with the efiusion of lymph. 
 
 When a line of demarcation has been formed, a process of 
 ulceration immediately begins, by which the mortified part is 
 separated and thrown off. 
 
 Treatment. — In the early stage of a traumatic gangrene in a 
 robust adult, attended by much inflammation, we may have 
 recourse to the local abstraction of blood. Nature herself indicates 
 this, for we sometimes see great benefit follow spontaneous hse- 
 morrhage. By taking blood from the part tension may be relieved, 
 the circulation freed, and the spread of the gangrene arrested. 
 
 Incisions — either a number of small, or a few larger ones — 
 may often be made in the affected part with advantage. They 
 not only relieve the over-stretched tissues, but they may also 
 give vent to the materies morbi, as, for example, in extravasation 
 of urine. 
 
 At the same time the other local means for allaying inflam- 
 mation, which have already been mentioned, should not be 
 omitted. 
 
 The separation of sloughs should be promoted by poultices, and 
 the unpleasant smell may be overcome by disinfectant lotions, or 
 by charcoal or yeast mixed with the poultices. 
 
 o2 
 
20 SURGICAL DISEASES. 
 
 The denser tissues, as tendons and bones, may be divided in 
 order to hasten the process of separation ; but it is best to leave 
 the soft parts to themselves. 
 
 After the mortified portion has been removed, the exposed 
 surface should be treated as an ordinary sore with water dressing, 
 or with anodyne, antiseptic, or stimulating lotions, as the case 
 may require. 
 
 In regulating the constitutional treatment we must bear in 
 mind that mortification is often the result of debility, and that 
 the gangrenous inflammation is always accompanied by fever of 
 the asthenic and irritative type. Moreover, the separation of the 
 dead tissues is an exhausting process, and one which makes great 
 demands on the vital powers of the patient. Everything, there- 
 fore, which has a lowering tendency must be strictly avoided. 
 The air of the sick man's room should be kept as fresh as possible, 
 his diet should be light and nourishing, while his strength is 
 upheld by tonic medicines and stimulants. Sedatives and narco- 
 tics will here be found of the greatest service, and should be 
 given freely. 
 
 Senile gangrene is that variety which is met with in persons 
 advanced in life, and which depends essentially upon degeneration 
 of the coats of the vessels. A calcareous deposit takes place in 
 the walls of the arteries, and this aff'ects the circulation in two 
 ways : (1 ) by diminishing the calibre of the vessels, and (2) by 
 impairing the elasticity of their coats. 
 
 Senile garigrene generally attacks the feet. Beginning in the 
 toes it spreads gradually to a greater or less extent over the 
 foot and leg. The local inflammation is usually slight, and con- 
 fined to the margins of the gangrenous part. The tissues at 
 first become mottled, of a bluish or purplish colour, and the 
 cuticle is detached and raised in blisters. Gradually the part 
 becomes brown or black, and at the same time dry and withered. 
 When a line of demarcation has been formed, the dead tissues are 
 separated from the living by a process of ulceration, in the way 
 that has been described. 
 
 Senile gangrene is always attended by great exhaustion, severe 
 pain, and a tendency to low irritative fever. From these causes, 
 combined with the age of the patients, it is a very fatal disease. 
 Occasionally the mortifitd part is thrown off* and recovery takes 
 place, but such a fortunate result is quite exceptional. 
 
 The best treatment consists in enveloping the part in cotton- 
 wool, so as to maintain a high and equable temperature. If need 
 be, a disinfecting lotion may be applied. At the same time 
 everything should be done to support the patient, to husband 
 his strength, and to quiet his nervous system. Alcoholic 
 
PROCESSES OF EEPAIE. 21 
 
 stimulants should be given with caution, because it is hazardous 
 to overstrain the diseased vessels. 
 
 Question of amputation. — A question often arises whether we 
 should resort to amputation in gangrene, and, if so, at what period 
 of the disease. Upon this point the special circumstances of each 
 case must go far to form our opinion. The general rule, how- 
 ever, may be stated thus : — In gangrene resulting from a local 
 cause — as au accident, ligature, or embolism — an amputation may 
 be undertaken as soon as the discoloration of the tissues has 
 indicated the extent of the affected part. But in the state of 
 spontaneous gangrene it is well to wait for a decided line of de- 
 marcation, and then to content ourselves with dividing the hard 
 tissues and shaping the stump, ratlier than to perform a complete 
 amputation. If the gangrene, though beginning in a local cause, 
 shows a tendency to spread indefinitely, it should be treated as a 
 case of spontaneous mortification, and no operation should be 
 undertaken until a well-marked line of demarcation has declared 
 itself. 
 
 PROCESSES OF REPAIR. 
 
 We may here conveniently consider the processes of repair. 
 They are — 
 
 (1) Immediate union. — This only occurs in slight and clean- 
 cut wounds. When the oozing of blood has ceased, and the sur- 
 faces have been brought into accurate apposition, they become 
 directly incorporated with one another. In such a case there is 
 no inflammation and no appreciable uniting medium. 
 
 Even if a small part of the body, such as the point of a finger, 
 is entirely cut off, the surgeon need not despair of union taking 
 place. Though we have no Balsam of Fierabras — of which Don 
 Quixote says he had the receipt in his head — and cannot promise 
 that if a man were cut in two, stuck neatly together, and took 
 two draughts of the Balsam, he would immediately become whole 
 and sound as an apple (ch. x.), yet many cases are on record in 
 which a small portion, after having been completely separated, has 
 been replaced, and has united and grown as if it had only been 
 partially, and not entirely, removed. 
 
 (2) Z'nion hy adhesion — "union by the first intention" — can 
 only take place between surfaces which are in apposition, and in 
 persons whose general health is pretty good. It is attended with 
 some degree of inflammation, enough to produce a layer of plastic 
 material between the opposed surfaces. By this means they are 
 glued together. There is union by adhesion. Gradually the 
 layer of lymph becomes organized and assimilated to the adjacent 
 tissues. 
 
22 SURGICAL DISEASES. 
 
 (3) Healing ly seabhing is a process of repair which takes 
 place on free surfaces. Like the foregoing, it is attended with a 
 very limited amount of inflammation. There is a slight effusion 
 of lymph, which protects the raw surface from the external air, 
 and allows healthy nutrition and repair to b« carried on beneath 
 it. We sometimes endeavour to bring about this mode of heal- 
 ing, and to imitate the action of Nature, by an artificial scab of lint 
 saturated with Friar's balsam or collodion. 
 
 (4) Granulation — " union by the second intention." When 
 the destructive processes, ulceration, suppuration, and gangrene 
 have terminated. Nature immediately begins to repair the damage 
 that has been done. The raw and exposed surface is covered 
 with a layer of plastic material — coagulable lymph ; beneath 
 this, and in its substance, granulations spring up — small elevated 
 papillae, closely studded together, of a bright florid colour, and 
 bathed in healthy pus. They are freely supplied with blood by 
 loops and arches from the subjacent vessels, but their sensibility 
 is generally low. These are the characters of healthy granula- 
 tions. But they vary exceedingly. Sometimes they are irregular 
 and exuberant ; sometimes they are pale and flabby ; at other 
 times they have a dusky and congested appearance; or, again, 
 they may secrete a thin and acrid discharge. 
 
 When two granulating surfaces, as the sides of a wound, 
 are brought into apposition, adhesion may take place between 
 them. 
 
 (5) When the granulations have risen to the level of the 
 surrounding tissues cicatrization commences. The margins of the 
 granulating surface cease to secrete pus, and become smooth and 
 varnished over with a thin bluish-white layer, which is the first 
 indication of the new skin. This process of healing spreads from 
 the edges, or from any islands of skin that may have been left, 
 or tltat may have been grafted by the surgeon. It never seems to 
 begin in the centre of the raw surface. As it goes on, it draws 
 the margins together by concentric contraction. 
 
 After the whole has been skinned over, other important 
 changes are gradually developed. The cicatricial tissue, which 
 was at first thin, blue, and shining, becomes thicker, of a natural 
 colour, and covered by a layer of epithelium ; in fact, it ap- 
 proaches, though it never attains, the character of true skin. 
 Again, after a cicatrix is fully formed it continues to contract. 
 This contraction may go on for months or years, and give rise 
 to some of the most dreadful disfigurements and inconveniences 
 that are met with in surgical practice — as, for example, in the 
 case of a severe burn. 
 
23 
 
 BZil.X.FORIVIilTZOirS. 
 
 The cases of congenital malformation may be divided into two 
 classes : — 
 
 1 . Those in which there is an arrest of development, as spina 
 
 bifida, harelip, cleft palate, imperforate anus, &c. 
 
 2. Those in which there is an excess of development, as super- 
 
 numerary fingers and toes, &c. 
 
 Of the causes of such malformations, our present knowledge 
 enables us to offer no explanation. 
 
 Intra-uterine disease often gives rise to deformities. Thus, 
 the foetus may meet with a fracture or a dislocation, or it may be 
 born with club-feet. One of its limbs may even be caught in a 
 noose of the cord, and spontaneously amputated. 
 
 HYPHRTROPKir 
 
 means an increase in the size of a part from over-development of its 
 normal and healthy structure. It is sometimes congenital, but 
 generally it is the result of increased use, and in many cases it is 
 a provision of Nature to meet the exigences of disease. As ex- 
 amples I may mention the congenital hypertrophy of the tongue 
 that is sometimes seen in infants ; the increase which takes place 
 in the muscular coat of the bladder in long-standing cases of 
 stricture ; or the development which one kidney undergoes when 
 the other is unable to perform its functions. 
 
 ATROPHir, 
 
 on the other hand, means the decrease which takes place in a 
 part from wasting of the proper tissue, or from its deficient 
 deposit. It depends upon a variety of causes, want of use, excessive 
 use, impaired vitality, a diminution of the muscular or nervous 
 supply, &c. I know a lad whose right leg and foot are atrophied, 
 and who has a large patch of white hair on the top of his head — 
 both apparently depending upon a want of proper innervation. 
 
 Atrophy is very often accompanied by degeneration. The 
 proper tissue is not formed at all, or is formed in deficient quantity; 
 while its place is occupied by fibrous, earthy, or fatty material. 
 Of these degenerations the most common is the fatty. Indeed, 
 there is hardly a tissue in the body which is not liable to be 
 affected by it. 
 
 TUmOlTRS. 
 
 By a tumour is meant a living mass, which is either different 
 in character from the healthy tissues or else excessive in its 
 
24 SUEGICAL DISEASES. 
 
 growth. A cancer diifers from every other tissue which is met 
 with in the body, not so much in its histological elements, as in 
 their arrangement. A fatty tumour is merely excessive in its 
 growth ; the material of which it is composed is identical with 
 the ordinary adipose tissue. 
 
 Tumours have long been divided into two great classes — the non- 
 malignant (innocent, benign), and the malignant or cancerous. To 
 these it has been found necessary to add a third class, the semi- 
 malignant or recurrent. This is not perhaps a very scientific 
 classification, but it is one of great practical value. 
 
 The non-malignant or innocent tumours may be regarded as 
 being from first to last local diseases. They may often be traced 
 to purely local causes. When they are solid, their structure 
 resembles some one of the normal tissues of the body — they are 
 homologous. Moreover, they only grow in situations where such 
 tissue is naturally found. They do not invade the adjacent struc- 
 tures. They do not aficct the general health, unless it be 
 accidentally, from their size or position ; and when they are once 
 thoroughly removed, they show no tendency to return. Such 
 are the marks of a typical non-malignant tumour. 
 
 The malignant growths, on the other hand, present a complete 
 contrast in all these pai'ticulars. They seem to depend in some 
 degree upon a constitutional taint or an hereditary predisposition ; 
 though some local imperfection — a cicatrix, a wart, a mole — often 
 serves as their starting point. They are unlike anything that is 
 found among healthy structures — they are heterologous. They 
 penetrate the neighbouring tissues. Thej' impair the general 
 health. They have a tendency to reproduce themselves in various 
 parts of the body, as well as to return after removal. 
 
 But between these two extremes there is an intermediate class, 
 the cancroid, semi-malignant, or recurrent tumours. This class 
 comprises growths which in their earlier stages resemble the 
 benign, but in their later history present many of the characters 
 of malignancy. 
 
 The benign and malignant tumours are not separated by any 
 well-marked line. The two groups shade ofi" into one another. 
 That infinite variety, which we observe in every department of 
 disease, supplies links which unite the two extreme points of the 
 chain. 
 
 EHrCYSTED TUMOURS 
 
 are met with under two forms — (1) Those which consist in the 
 distention and hypertrophy of natural cysts or ducts ; and (2) 
 those which result from the enlargement of a primitive cell or 
 of an areolar interspace. 
 
ENCYSTED TUMOURS. 
 
 25 
 
 1. To the first class belong the atheromatous tumours, which 
 are so frequently met with about the scalp, face, and other parts, 
 as the result of obstruction to the ducts of the sebaceous glands. 
 They are situate in the skin, or subcutaneous cellular tissue. 
 They are rounded and smooth in their outline. Their growth is 
 unattended by inflammation, and they are free from pain. They 
 are often found in great numbers in the same individual. They 
 vary from the size of a pea to that of an orange. A few years 
 ago I related to the Pathological Society (see Trans, vol. xx.) a 
 case in which a tumour of this kind, as large as a walnut, was 
 met with in rather an unusual situation — on the free border of 
 the prepuce. Fig. 3 was made from the contents of this 
 
 Fie:. 3. 
 
 Contents of a sebaceous cyst. 
 
 cyst. As these tumours grow larger they are apt to soften and 
 ulcerate. But more frequently they are removed before suppu- 
 ration has commenced. The cyst may be dissected out unopened, 
 or an incision may be made through it, its contents squeezed out, 
 and then the cyst itself either torn or dissected away. This 
 should be done carefully, so as to leave none of it behind. When 
 there is reason to avoid a cutting operation, the c^'^st may be 
 punctured, its contents squeezed out, and the cavity stirred with 
 the point of a probe ; or a seton may be passed through it. 
 
 The material with which these cysts are rilled has usually a fawn 
 colour, and a pasty or putty -like consistence. Sometimes it has 
 a very offensive smell. It is made up of the sebaceous secretion, 
 epithelial scales, oil globules, granular matter and crystals 
 of cholesterine. 
 
 If the cyst is allowed to soften and ulcerate, it may give rise 
 to a very unhealthy sore. The edges become everted ; there is 
 
26 
 
 SUEGICAL DISEASES. 
 
 a thin and offensive discharge ; coarse granulations spring up, and 
 an intractable ulcer is established, having some of the characters 
 of malignancy. 
 
 When a tumour of this kind ulcerates and breaks, some of the 
 contents escape, dry, and form a hard scab. If this is allowed to 
 remain it gradually becomes more and more prominent, by the 
 escape of fresh portions of the contained secretion, and thus in 
 process of time " a horn " is formed. Such horns may be met 
 
 with on any part of the body, 
 
 Fig. 4. 
 
 Horny tumour on the lower 
 eyelid. 
 
 and sometimes they acquire an 
 extraordinary length and de- 
 velopment. Fig. 4 represents 
 such a tumour, which occurred 
 in an old man who was Mr. 
 Bowman's patient at the 
 Royal Ophthalmic Hospital 
 when I was his clinical assis- 
 tant. 
 
 To the same class of en- 
 cysted tumours belong the di- 
 latations which arise from ob- 
 struction of the duct of the 
 parotid gland, or of the lacti- 
 ferous ducts of the mamma. 
 In all cases of this kind the 
 principle of treatment is simple 
 enough. It consists in re- 
 establishing the natural pas- 
 sage. But in practice this 
 
 is sometimes no easy matter, and requires much patience and 
 ingenuity on the part of the surgeon. The various affections that 
 have been alluded to will be described hereafter, when we speak 
 of the glands with which they are connected. 
 
 Again, to the same class belong the swellings which are formed 
 by the distention of closed cysts. The bursse, when they are 
 dilated, afford the best example of encysted tumoi\rs of this kind. 
 The effusions into the sheaths of tendons and muscles may be re- 
 garded in the same light. In these cases the cyst is originally of 
 no more than natural thickness, but gradually, as the disease per- 
 sists, it becomes tough, and dense, and fibrous. The fluid contained 
 in these cysts is sometimes thick and glairy, sometimes thin and 
 serous. Not unfrequently fibrinous bodies, like melon seeds, are 
 found mixed with the fluid, or attached to the sides of the cavity. 
 
 In treating these cysts, we endeavour to produce absorption 
 of the fluid by stimulating applications. If this fails, we may tap 
 
SOLID TUMOUES. 27 
 
 the cyst simply ; or we may tap it and scrape the internal sur- 
 face, or inject a stimulating fluid ; or we may introduce a seton ; 
 or, lastly, we may dissect the cyst out. A pedunculated tumour 
 of this kind, as large as a walnut, situated over the sternum in a 
 man who was a shoemaker hy trade, I removed without pain by 
 merely slipping a small elastic band over it, and thus constricting 
 its base. 
 
 2. The second class of encysted tumours includes those which 
 may be considered new formations, originating in the enlargement 
 of a primitive cell, or an areolar interspace. These cysts vary 
 much in size. Sometimes they attain a great magnitude. They 
 are filled with fluid secreted from their lining membrane. The 
 character of this fluid varies considerably. Sometimes it is 
 thin and serous ; at other times it is thick and viscid. Some- 
 times it is straw-coloured ; at other times it is dark brown or 
 green. 
 
 These cysts are sometimes simple — that is to say, composed 
 of only a single cavity. At other times they are compound — the 
 primary cyst containing within it other secondary ones, or solid 
 masses of fibro-plastic material, or of cancer. In some rare and 
 curious cases they have been found to enclose teeth, hair, &c. 
 Compound cysts are generally met with about the uterus, broad 
 ligament, or ovary. 
 
 The treatment of simple cysts should be conducted on the plan 
 already laid down. We may first try to promote absorption 
 of their contents. If this fails, we may puncture them, and 
 endeavour by various means to excite inflammation within them. 
 Or, as a last resource, we may, if circumstances permit, remove 
 them with the knife. 
 
 The treatment of compound cysts is a much more difficult 
 matter. We can hardly hope to effect a cure by any means 
 short of excision ; and this is generally such a formidable opera- 
 tion, that it should not be undertaken without great care and 
 forethought. 
 
 Cysts are often met with in the substance of other tumours. 
 In such cases they have probably the same origin as in the two 
 varieties that we have described. They arise either from dilata- 
 tion of existing cavities or canals, or else from the enlargement of 
 primitive cells. 
 
 SOIiIB TUMOURS. 
 
 The simplest form of solid tumours that we meet with are warts. 
 They are formed by excessive growth of the papillae of the skin, 
 with an accumulation of epithelial scales. When they are situated 
 on the exposed parts of the body they are hard and dry ; when 
 
28 SURGICAL DISEASES. 
 
 they grow between folds of skin, where the perspiration is 
 retained, they are soft and moist. 
 
 Simple warts of this kind are often seen on the hands of 
 children and young persons. But it is more common for the 
 surgeon to be consulted about the warts {condylomata acuta) 
 which are often seen on the genital organs as the result of 
 gonorrhoeal or other irritation (see Fig. 153), or about the mucous 
 tubercles (e. lata) which are apt to grow near the verge of the 
 anus, the vulva, and in other situations, as a manifestation of 
 constitutional syphilis. 
 
 The treatment of simple warts consists in burning them down 
 with caustics. Gonorrhoeal warts should be cut off with scissors, 
 and their bases touched with nitrate of silver. Mucous tubercles 
 should be dusted over with calomel, or smeared with a calomel 
 ointment (F. 89), or moistened with black wash. 
 
 The true skin sometimes becomes hypertrophied, and rises into 
 a flat tumour of a reddish-brown colour, and with an irregular 
 outline. Such overgrowths are known by the name of chelis, or 
 cheloid tumours. Sometimes they arise spontaneously, at other 
 times they appear to originate in local irritation. They often 
 commence in a cicatrix, especially the cicatrix resulting from a 
 burn. Their favourite situation is the chest, but they may show 
 themselves anywhere, and when once they have begun to grow 
 they may spread indefinitely. They cause no pain, only uneasiness 
 and disfigurement. 
 
 No remedies appear to have any efiect upon them. The only 
 treatment that holds out a hope is excision; and even after com- 
 plete removal they are extremely apt to return. 
 
 poi.irpus. 
 
 When a mucous membrane becomes inflamed and thickened it 
 may give rise to polypus. These tumours are met with in the 
 nose, the pharynx, the uterus, and in fact in almost all the 
 mucous surfaces. Polypi diff^er widely in their texture, and in 
 the nature of their attachments. The gelatinous polypus con- 
 sists of an expansion of the normal elements of the mucous 
 membrane. Such a growth as this, springing from a narrow 
 pedicle, forms the simplest kind of polypus. But sometimes 
 fibrous tissue enters more or less into the composition of the 
 tumour, or it may rise from a broad base, adherent perhaps to 
 bone. When these conditions are present, the disease assumes 
 a more serious aspect, and is very prone to degenerate into 
 medullary cancer. 
 
 The treatment consists in early removal. This may be done in 
 various ways, according to the nature and situation of the 
 
GLANDULAR TUMOURS. 29 
 
 tumour. Sometimes the polypus-forceps serve our purpose tlie 
 best; sometimes the loop of the ecraseur, or a noose of ligature, 
 is the most convenient appliance; sometimes we must have 
 recourse to the knife, the gouge, and the bone-forceps. 
 
 GIiAITDUIiAR TUMOURS. 
 
 The various superficial glands often become hypertrophied. 
 Such hypertrophy is commonly associated with changes of texture. 
 The lymphatic glands are often affected in this way ; so are the 
 mamma?, the testes, the thyroid body, &c. The gland becomes 
 enlarged, though without pain, and presents a tumour which is 
 circumscribed, smooth or lobulated in its outline, movable, firm, 
 and often elastic to the touch. Sometimes it is callous, at other 
 times tender on pressure. 
 
 Tumours of this kind may often be attributed to chronic 
 inflammation. They frequently cause great inconvenience by 
 interfering with the action of adjacent organs or parts. They 
 almost always betoken a faulty state of the general health, and 
 we must deal with them accordingly. 
 
 Treatment. — If the patient is of a strumous habit, we must 
 give cod-liver oil, or the preparations of iron or of arsenic ; while 
 iodine tincture or ointment, or an ointment composed of equal 
 parts of ung. hyd. and ung. iodi, or the emp. ammoniaci c. hyd., 
 or fly blisters, or other resolvent remedies are applied. The nng. 
 hyd. iodidi rubri is held in high estimation by some surgeons ; 
 but it must be used with caution. Some of the natural mineral 
 waters — e.g., those of Woodhall in Lincolnshire, and Kreutznach 
 in Rhenish Prussia — are often most beneficial in this class of 
 cases. Chronic enlargements of the cervical glands are common 
 in young persons of a strumous constitution. In such cases the 
 surgeon should be on the alert for the slightest indications of 
 Inng disease, for scrofulous glands are often the forerunners of 
 scrofulous pneumonia. 
 
 If the enlargement depends upon a syphilitic taint, a mercurial 
 ointment should be applied to the part; and at the same time 
 the preparations of mercury or the iodide of potassium should be 
 given internally. 
 
 When all otlier remedies have been found ineffectual, the ques- 
 tion of excision may be entertained. I have seen fifteen enlarged 
 glands removed from the right axilla, the largest was as big as a 
 kidney. The patient was a young man, and the disease quite 
 incapacitated him for work. 
 
30 
 
 SUEGICAL DISEASES. 
 
 THE FATT7 TUMOUR (liIPO»Cii) 
 
 is identical in structure with the healthy adipose tissue. It is 
 generally found in those situations where there is naturally a 
 good deal of fat, as the back of the neck, the shoulders, or the 
 buttocks. Sometimes it has a broad base; sometimes it is 
 pedunculated. 
 
 It consists of large polygonal fat-cells crowded together in the 
 meshes of an areolar tissue. Fig. 5, as well as several of the other 
 drawings with which this chapter is illustrated, were taken from 
 preparations which were kindly lent me by Dr. Mitchell Bruce. 
 The lipoma is enclosed in a fibrous capsule, from which it receives 
 its supply of blood. This capsule gives off septa which divide it 
 into lobules. It is generally free from pain, and causes incon- 
 venience only by its size or situation. It is smooth and rounded 
 in shape. It feels soft and doughy ; but sometimes, when the 
 capsule is stretched, it is elastic, and may easily be mistaken for a 
 fluid tumour. It is most likely to occur at middle age ; and it is 
 not often that we find more than one present in the same in- 
 dividual. It grows slowly but steadily, and may reach an 
 enormous size. 
 
 Fiff. 5. 
 
 Lipoma, traversed by a small vein, x 300. 
 
 Some cases are on record in which tumours of this kind have 
 been observed gradually to shift their position — for example, from 
 the groin to the perineum, or from the shoulder to the breast. 
 As such movements are always in a downward direction, it is 
 probable that they are caused by the weight of the tumour, and 
 are due to the force of gravitation. 
 
 Treatment. — Little or no benefit is likely to result from inter- 
 nal remedies, though the iodide of potassium and the liquor 
 
THE NEUROMA. 
 
 31 
 
 potasssE have been recommended. Removal with the knife is the 
 proper treatment. An incision should be made across the tumour, 
 and then the entire mass, capsule and all, should be torn from its 
 connexions, or separated by a few touches of the scalpel. If this 
 is carefullv done, it is highly improbable that there will be any 
 return of the frrowth. 
 
 Figr. 6. 
 
 THE FIBROUS TUIVIOUR (FIBROMA) 
 
 is developed from the connective tissue, and presents the varieties 
 with which all are f;\uiiliar in that structure. Sometimes it is 
 dense and compact, like tendon ; at other times it is looser and 
 more separable. The fibres are sometimes straight, and laid side 
 by side in parallel rows ; at other times they are wavy and inter- 
 laced in every direction. For the specimen from which Fig. 6 was 
 drawn I am indebted to Dr. T. Henry Green. Like the normal 
 fibrous tissue, these tumours are very sparingly supplied with vessels. 
 If we except the so-called fibrous 
 tumours of the uterus (which are 
 really composed in great part of 
 unstriped muscular tissue), their 
 most frequent seat is the neck; but 
 they also grow elsewhere — in the 
 breast, or attached to the perios- 
 teum in various situations. They 
 often occupy the antrum, and 
 give rise to great disfigurement. 
 They are hard and inelastic to 
 the touch. Their outline is 
 smooth and lobular, and they are 
 usually enclosed in a capsule. 
 They grow slowly, and are attended by little or no pain. They 
 may attain a great size. They belong to the middle and later 
 periods of life. It is seldom that we find more than one in the 
 same subject. 
 
 As they advance they may degenerate and become infiltrated 
 with earthy salts; or cysts may be developed in their interior; 
 or they may infiame atid suppurate, ulcerating through the skin, 
 and giving rise to a foul and ofiensive sore. 
 
 THB NHUHOTflA. 
 
 is a tumour connected with a nerve or its sheath. The substance 
 of it is fibrous. In shape it is generally rounded or oval, and it 
 may attain the size of a cocoa-nut. 
 
 It is commonly multiple. It is harmless in its nature, but it 
 
 Fibroma, x 300. 
 
32 SURGICAL DISEASES. 
 
 gives more or less inconvenience by the pressure it exerts upon 
 the neighbouring parts. Sometimes it is callous and free from 
 pain ; in other cases it is very painful and sensitive to the touch. 
 Everything seems to depend upon the exact relation it bears to 
 the nerve with which it is connected. 
 
 Extirpation is the only treatment that is likely to be successful. 
 
 The painful subcutaneous tumour must be distinguished from 
 the foregoing. It is generally single, and it gives rise to exquisite 
 pain, though it does not appear to be connected with any nerve 
 of appreciable size. 
 
 These tumours should be excised at an early period of their 
 growth, for they are not amenable to any milder treatment. As 
 a rule they are not liable to return. 
 
 THE SARCOniATii. 
 
 The group of new formations which were formerly called 
 Jihro-plastic, fibro-cellular, and Jlbro-nucleated, and which consti- 
 tute the semi-malignant or recurrent class of tumours, are now 
 usually spoken of as sarcomata. They are essentially connective 
 tissue growths, the connective tissue undergoing rapid develop- 
 ment, but always retaining its embryonic structure, and never 
 reaching maturity. They are all made up chiefly of cells, together 
 with a small but variable proportion of intercellular substance, 
 ' and it is by the prevailing character of their cells that they are 
 usually classified. Thus they are divided into (1) spindle-celled 
 sarcoma, (2) round-celled sarcoma, and (3) myeloid sarcoma. 
 
 1. The spindle-celled sarcoma — the fibro-plastic tumour of 
 earlier writers — bears a close resemblance to the fibroma. 
 It consists of fusiform cells, ranged closely together in parallel 
 rows, which traverse the growth in various directions. In 
 Fig. 7 they have been fretted out so as to bring some of the 
 individual cells more clearly into view. They often begin in the 
 subcutaneous cellular tissue, or in the cellular tissue of the 
 mamma and lymphatic glands. Not unfrequently they have a 
 deeper origin, and spring from the periosteum, more especially of 
 the facial bones. They grow more quickly than the fibrous 
 tumours, and are attended by more pain. They occur chiefly 
 about middle life, and are usually single. They may attain a 
 very large size. 
 
 2. The round-celled sarcoma is softer and more vascular than 
 the preceding. The cells are small and round, and there is little 
 or no intercellular substance. They grow rapidly, and extend by 
 invading the adjacent connective tissue. This sarcoma bears a 
 general resemblance to the encephaloid variety of cancer, but is 
 
THE SARCOMATA. 
 
 33 
 
 distinguished from it by the want of a fibrous stroma, by the 
 uniformity of its cells, and by the mode of its extension along the 
 lines of areolar tissue. 
 
 Fls. 7. 
 
 Spindle-celled sarcoma, x 30O. 
 
 3. The myeloid sarcoma, like the two preceding varieties, con- 
 sists of embryonic connective tissue, but it is distinguished by the 
 large irreorular mother-cells which it contains. These cells are 
 merely the cells of the medulla (juveXoy, the spinal marrow) in a 
 state of excessive activity. And this fact points to one of the 
 peculiarities of the myeloid tumours — namely, that they always 
 originate from bone, and almost alwaj's from a medullary cavity. 
 Some examples of epulis belong to this class ; so do many of the 
 tumours that we see connected with the ends of long bones. 
 They generally have a capsule derived from the periosteum of 
 the bone from which they spring. They are sometimes so vascular 
 as to pulsate and give rise to an aneurysmal bruit. If they are 
 punctured, they bleed freely. 
 
 As a group the sarcomata approach in some of their characters 
 to the cancers. Thus they extend along the planes of cellular 
 tissue, invading the adjacent parts, and they are apt to recur 
 after removal, as well as to reproduce themselves in internal 
 organs, through the dissemination which takes place in the 
 blood. They are the new formations to which early life is 
 most subject, and they are very fatal. They are therefore 
 malignant diseases, though histologically they are distinguished 
 from cancers. Besides the difference in their microscopical charac- 
 ters, they are contrasted w^ith the cancers by not infecting the 
 lymphatic glands, and not invading other tissues than the areolar. 
 The softer and more vascular the species of sarcoma the more 
 rapid will be its local development, and the more readily will it 
 disseminate itself throughout the body by means of the cir- 
 culation. 
 
 D 
 
34 
 
 SUEGICAL DISEASES. 
 
 Speaking generally, the sarcomata have a smooth rounded 
 surface; sometimes they are hard to the touch, at other times 
 elastic ; sometimes they have a uniform consistence, at other times 
 the same tumour presents both hard portions and soft. They 
 often grow to a large size. If the skin breaks, they may ulcerate; 
 and the patient may be worn out by an exhausting discharge, by 
 pain and by discomfort. Fig. 8 was drawn from a middle-aged 
 
 woman who had 
 
 Fig. 8. 
 
 Eecurrent fibroid tumour. 
 
 a "recurrent fib- 
 roid" tumour be- 
 tween the collar- 
 bone and the 
 breast on the left 
 side. Its history 
 extended over six- 
 teen years, and it 
 was seven times 
 removed by opera- 
 tion. At the time 
 the sketch was 
 made it measured 
 twenty - seven 
 inches in circum- 
 ference, and the 
 mass which was 
 removed by Sir W. 
 Fergusson weighed 
 almost six pounds. 
 Ultimately the 
 patient sank at 
 the age of forty- 
 three. 
 
 No treatment 
 
 short of excision is of any avail ; and even after they have 
 been removed, these tumours are extremely apt to recur again 
 and again. In operating upon them the surgeon should cut 
 wide of their apparent circumference, so as to take away all 
 the areolar tissue that may be in the least degree afi'ected, 
 and the wound should be washed out with strong chloride 
 of zinc lotion (F. 28). 
 
 ENTCHOM-DROMA. 
 
 The cartilaginous tumour (enchondroma) is, in its simplest form, 
 almost identical with foetal cartilage. On section it presents a 
 
BONY TUMOUES. 
 
 35 
 
 hard shining surface, of a bluish-white colour. Under the 
 microscope it is seen to consist of a stroma, which may be hyaline, 
 granular, or slightly fibrillated, and in which there are large 
 round, oval, or caudate cells, containing nuclei (Fig. 9). 
 
 It is developed from con- 
 nective tissue, and is often 
 associated with the perio- 
 steum, especially of the 
 bones of the hand ; but it 
 may also occur in the 
 soft tissue of glands — for 
 example, in the parotid, or 
 in the testicle. Its outline 
 is smooth and nodulated. 
 It feels firm and slightly 
 elastic to the touch. It 
 
 3UU. 
 
 Enchondi'oma, 
 
 often appears in childhood or about the early period of adult 
 life, and it is no uncommon thing to see several tumours growing 
 near one another. At first it progresses slowly, and is unat- 
 tended with pain. But if it is 
 
 Fig. 10. 
 
 
 '■^ 
 
 :ik 
 
 allowed to remain, it involves 
 the skin and ulcerates ; and 
 the result is an intractable sore, 
 which has something of a 
 malignant aspect. 
 
 The only remedy is re- 
 moval. If circumstances per- 
 mit, the tumour should be 
 thoroughly extirpated. If it 
 is attached to bone, the base 
 must be freely removed ; and, if 
 need be, a resection, or perhaps 
 even an amputation, will have 
 to be performed. 
 
 Boxrv TunxouRs. 
 
 A deposit of osseous matter 
 having more or less the charac- 
 ters of true bone, sometimes 
 takes place in the substance 
 of fibrous or sarcomatous 
 tumours. Such a growth is 
 usually spoken of as an osteo-sarcoma. Fig. 10, taken from a 
 preparation in the maseum of Charing Cross Hospital, shows 
 the bony skeleton of such a tumour. 
 
 D 2 
 
 1 fHs 
 
 ir^^ 
 
36 SURGICAL DISEASES. 
 
 Again, an enchondroma sometimes becomes developed into 
 bone. 
 
 But it is more common to meet with osseous tumours spring- 
 ing directly from bone (exostosis). Such growths occur under 
 two conditions — either they are dense in texture, like ivory ; or 
 they are composed of cancellated tissue. They will be more 
 fully considered hereafter when we come to speak of the diseases 
 of bones. 
 
 THE CANCERS— CARCZlUOniATA, 
 
 We come now to that group of malignant diseases which is 
 distinguished by the name Cancer or Carcinoma, and which 
 includes four varieties — Scirrhous, Encephaloid, Epithelioma, 
 and Colloid. 
 
 The cancers are new formations of an epithelial type, and con- 
 sist of cells, compaeted together without any intercellular substance 
 and lying in the spaces of a fibrous stroma. They are heterolo- 
 gous — that is to say, the elements are alien to the situation in 
 which they are found, and they present in a high degree the 
 clinical marks of malignancy — i,e., they invade the surrounding 
 structures, they impair the general health, they are apt to return 
 after removal, and they give rise to secondary deposits in various 
 parts of the body. Paget says they are hereditary to the extent 
 of one case in three. 
 
 The cells that are met with in cancers vary much, for they 
 represent all the varieties of epithelium, both when it is fully de- 
 veloped and while it is in process of formation. But if the tumour 
 is examined at a spot where the cells are fully formed, but have 
 not yet begun to undergo retrogressive changes, it will be found 
 that they are like the epithelium of the part in which the 
 growth originated. Thus, the cells may be large or small, 
 regular or irregular in outline. They may be round, or oval, 
 or pyriform, or caudate — the exact shape depending much upon 
 the degree of pressure to which the elements of the growth have 
 been subjected. Some are simple; others are compound, and 
 contain two or three complete cells within them, with nuclei 
 and nucleoli. When degenerative changes have commenced — 
 and such changes are very common in morbid growths of this 
 kind — the cells are often loaded with oil-globules and granular 
 matter. 
 
 All the cancers, inasmuch as they are apt to affect the organs 
 of digestion and assimilation, are sometimes attended by the 
 leaden hue, the emaciation, and the deep dejection to which the 
 old writers gave the name of the " cancerous cachexia." But 
 in truth there is no cachexia peculiar to cancer. Some persons 
 
THE CANCERS — CARCINOMATA. 
 
 37 
 
 suffering from this complaint present a very healthy appearance ; 
 while, on the other hand, many patients affected with organic 
 diseases of very different kinds exhibit in a marked degree the 
 symptoms to which I have alluded. 
 
 Scirrhous or hard cancer is a disease of adulb life. It occurs 
 in two forms : (1) as a close compact mass ; and (2) infiltrated 
 through the substance of an organ or tissue. In either case it 
 gives rise to a rough, irregular tumour of almost stony hardness. 
 
 It is three times more common in women than in men. It 
 often attacks the uterus, but still more frequently the fsmale 
 breast. A small lump is detected, perhaps as large as a marble. 
 Slowly, but surely, it increases in size ; and as it grows, it draws 
 to itself, by a kind of concentric contraction, the surrounding 
 structures. The skin becomes puckered, and the nipple retracted. 
 There is pain of a shooting, darting character. Still the tumour 
 moves freely between the skin and the subjacent muscle. 
 Presently adhesions are formed. In front the skin becomes in- 
 volved; while behind the disease attacks the pectoral muscles. 
 Enlarged lymphatic glands may be felt in the axilla, which are 
 distinctly connected with the tumour by a line of swollen 
 absorbents. Gradually the skin covering the tumour turns to a 
 purple or bluish colour, breaks, and ulcerates. An unhealthy 
 and offensive discharge commences. The pain becomes more 
 acute and more constant. The patient's general health begins 
 to suffer. She grows sallow, loses flesh, and becomes dispirited. 
 Secondary deposits are formed in other parts of the body, very 
 probably in the lungs or liver ; and she at length sinks, worn out 
 by incessant pain and pro- 
 fuse discharge, or by the 
 damage done to some vital 
 organ (see Fig. 122). 
 
 The secondary cancer is 
 not necessarily of the same 
 variety as the primary 
 disease which gave rise to 
 it. Thus, scirrhus of the 
 breast may lead to en- 
 cephaloid of the liver or 
 lungs. The same general 
 rule holds good of all 
 cancers. 
 
 If a section is made 
 of a scirrhous tumour, it is 
 so dense and tough that it 
 creaks as the knife passes 
 
 «t"^. 
 
 Scirrhous cancer, x 300. 
 
38 SURGICAL DISEASES. 
 
 through it, and the cut surfaces present a white, glistening, 
 satiny appearance, intersected hy bands of fibrous tissue. If a 
 thin section is examined under the microscope, it presents the 
 appearances depicted in Fig. 11 — an abundant fibrous stroma 
 containing cells of an epithelial type. If the cut surface of 
 the tumour is scraped, the fluid thus obtained — the cancer-juice 
 — will be found to contain these cells, and thus far will furnish 
 an indication of the nature of the disease. 
 
 The encephaloid, medullary, or soft cancer is the acutest and 
 most malignant variety of the disease. It differs from the fore- 
 going chiefly in the rapidity of its growth, and the scantiness 
 of its fibrous stroma. It is met with in many situations where 
 scirrhus is unknown : it often attains an enormous size, and 
 sometimes bleeds freely. 
 
 It begins as a soft, smooth, and lobulated tumour, somewhat 
 elastic to the touch, and not unlikely to be mistaken for fluid. 
 It increases apace, making its way towards the sui'face. The 
 skin covering it is marked by dilated veins, and is some- 
 times even oedematous. When it has reached this point, 
 it very soon involves the skin, ulcerates, and bursts forth 
 in the form of large fungoid protrusions, from which 
 there escapes an offensive discharge. Fig. 12 was taken from a 
 
 Fig. 12. 
 
 Encephaloid cancer in the forearm. 
 
 young woman, aged 27. The tumour had been growing for 
 two years ; and, as it resisted all ordinary treatment, amputation 
 was recommended. An encephaloid cancer is very vascular, and 
 if any obstruction to the return of blood occurs, either from 
 constriction at the point of protrusion, or from any other cause, 
 bleeding is very apt to take place. Such appears to be the 
 pathology of that variety which is known as fungus hcBmatodes, 
 and which consists of nothing but the soft, spongy, encepha- 
 loid tissue, surcharged with blood (Fig. 13). In these very 
 vascular tumours pulsation may sometimes be felt, and a bruit 
 
THE CANCEES — CARCINOMATA. 
 
 39 
 
 detected with the stethoscope. This has heen particularly noticed 
 when the disease is connected with bone. 
 
 Encephaloid cancer may occur 
 at any age. It is often met 
 with in young children. It 
 may show itself almost any- 
 where ; but its favourite seats 
 are the orbit (see Fig. 112), the 
 nasal cavities, the mamma, the 
 testicle, the bones, and the vis- 
 cera. 
 
 To the naked eye it has the 
 appearance of brain- substance. It 
 contains an abundance of the can- 
 cer juice, and but little fibrous 
 tissue. Under the microscope its 
 cells are found to be irregular 
 in outline, imperfectly formed, 
 and loosely arranged, and very 
 prone to fatty degeneration. It 
 disseminates itself rapidly, and 
 soon leads to a fatal termination. 
 
 Soft cancer surcharged with 
 blood. 
 
 Fig. 14 represents this brain- 
 like substance growing from the hand after the third finger had 
 been already removed on account of encephaloid disease. 
 
 The third variety 
 of cancer is that -^^S* ■^^* 
 
 which is known as 
 epithelioma or ejoi- 
 thelial cancer. Both 
 histologically and 
 clinically it difiiers 
 somewhat from the 
 varieties already de- 
 scribed; so much so 
 that somewritershave 
 regarded it as not 
 being of a cancerous 
 
 nature. But when it shows itself in a soft and moist tissue — 
 e.ff., the tongue — it presents all the clinical features of the most 
 malignant cancers; and when it occurs on external parts it can 
 only, at the best, be regarded as rather a milder and more 
 chronic form of the disease. 
 
 Histologically it is distinguished by the fact that it almost always 
 originates in a mucous or cutaneous surface; and by its cells 
 having the type of squamous epithelium. As these cells multiply 
 
40 
 
 SUEGICAL DISEASES. 
 
 they arrange themselves in globular masses. The outer cells ot 
 these masses become flattened by the pressure of the surrounding 
 tissues, while those near the centre retain their expanded form. 
 These are the laminated capsules, the concentric globes or nests 
 of cells, which are characteristic of epithelioma (Fig. 15). In 
 the older parts of the disease these globes will be found com- 
 pressed into dense masses where no cellular arrangement is 
 visible, while in the oldest portions they present only the ap- 
 pearance of granular debris in the interspaces of an abundant 
 fibrous tissue. 
 
 Fig. 15. 
 
 Epithelioma ; laminated capsules, x 200. 
 
 Epithelioma appears to originate in an excessive growth of the 
 papillae of the skin or mucous membrane, and of the epithelium 
 covering them. Sometimes, however, it commences among the 
 deeper tissues. As a general rule it advances slowly at first. For 
 years it may remain inactive, making little or no progress. Then 
 it may begin to grow more rapidly, springing up in the form of 
 warts, tubercles, cauliflower excrescences, &c. Cracks and fissures 
 appear on the surface. The pain, which was before occasional 
 and trifling, now becomes constant and acute. The patient's 
 health begins to sufier. The surface of the tumour ulcerates and 
 gives rise to an offensive discharge, while the disease spreads 
 apace, invading the surrounding tissues, and extending to the 
 neighbouring lymphatic glands. In some rare instances it has 
 given rise to secondary deposits in other parts of the body. 
 
 Epithelial cancer is most frequently seen upon the muco- 
 cutaneous surfaces, the lips, the anus, the penis, the labia, &c. 
 But it is not confined to these situations. It may begin almost 
 
THE CANCERS — CAKCINOMATA. 
 
 41 
 
 anywhere, in any part of the skin or mucous membrane, in the 
 lymphatic glands, or even in the bones. 
 
 There is sometimes an hereditary predisposition to epithe- 
 lioma, and, when such is the case, long-continued local irritation 
 seems to determine its seat — as, for example, the smoker's cancer 
 of the lip, and the chimney-sweep's cancer of the scrotum. Acrid 
 discharges, or a want of proper cleanliness, may have something to 
 do with its frequent occurrence about the labia or anus. It has 
 long been observed that those who have congenital phimosis 
 are more liable than others to epithelial cancer of the penis ; no 
 doubt in consequence of the irritation caused by the retained 
 secretion. 
 
 The Eodent ulcer (lupus exedens), which will be described 
 hereafter, is probably an epithelioma. Perhaps it may be viewed 
 as an epithelioma which never goes beyond a certain early stage 
 of development. 
 
 The variety of cancer called villous may be regarded as 
 epithelioma attacking niucous surfaces — for example, the lining 
 membrane of the mouth or bladder. 
 
 Colloid or gum cancer consists of an alveolar bed, formed of 
 fibrous tissues arranged in large circular outlines, and filled up 
 with semi-transparent mucoid substance. It has but few vessels, 
 and grows slowly. The cells of which it is composed are large, 
 spherical, and filled with the same gelatinous material in which 
 they are imbedded. It would seem that they are too large to 
 travel easily through the lymphatics ; and hence this form of 
 cancer does not readily disseminate itself. It is a disease of adult 
 life. It is most frequently seen in the intestines ; though it may 
 
 Fig. 16. 
 
 Melanosis infiltrating muscle, x 300. 
 
 occur elsewhere, and is sometimes found blended with masses ot 
 medullary cancer. It may be regarded as forming the link be- 
 tween the cancers and cystic disease of the ovary. 
 
42 
 
 SUEGICAL DISEASES. 
 
 Melanosis. — Some examples of cancer — more particularly those 
 which spring from the choroid or skin — are distinguished by the 
 presence of pigmentary matter, and some writers have described 
 these as a distinct variety under the name of llacJc cancer. But 
 their growth and development is essentially the same as that of 
 the other cancers, only their cells retain the power of selecting 
 pigments from the blood — a power derived from the tissue in 
 which they originated. The pigment is scattered throughout the 
 mass in the form of minute granules, which gradually coalesce 
 and become small masses (Fig. 16). In other respects the 
 growth closely resembles encephaloid. Of this we have a remark- 
 able proof in the fact that a pigmented cancer, springing from 
 the choroid, may be black within the globe of the eye, and white 
 (ordinary encephaloid) when it has burst through the coats, and 
 affected non-pigmented tissues. The disease may be confined to 
 a single spot, or it may gradually disseminate itself until it has 
 invaded a wide area and implicated many organs. Tig. 17 is 
 
 taken from a case which I had the 
 opportunity of watching from be- 
 ginning to end. The patient 
 was a woman aged 47. The 
 disease commenced in a mole on the 
 third toe of the left foot. Two 
 years and a half from the time 
 when she first began to feel irrita- 
 tion and pain, the thigh was in 
 the condition represented. It was 
 stained almost all over a uniform 
 grey colour, and speckled with an 
 infinite number of black nodules, 
 like small shot. Four months later 
 the patient died, and it was found 
 that all the muscles of the left thigh, 
 as well as the lymphatic system 
 generally, and the liver and lungs, 
 were infiltrated with the disease. 
 Fig. 16 was made from the left 
 sartorius muscle. 
 
 The diagnosis of cancer is not 
 always easy, especially in its earlier 
 stages ; and yet it is a disease which 
 it is of great importance to detect 
 before it has made much progress. 
 Scirrhus may generally be distinguished by paying attention to 
 its situation, its hard, nodular outline, the age and sex of the 
 
 Diffuse melanosis of the thigh. 
 
THE CANCERS — CARCINOMATA. 
 
 43 
 
 patient, the family history, the stabbing character of the pain, 
 the retraction of the surrounding tissues, the implication of 
 lymphatic glands, and the impaired state of the health. 
 
 In the case of encephaloid disease, the diagnosis is more difficult. 
 It is more likely to be confounded with other tumours, and we 
 have fewer points to guide us. Still, the rapidity of growth, the 
 smooth, uniform aspect of the tumour, with dilated veins coursing 
 over it, and, if need be, a microscopical examination ^. 
 of its contents, will go far to establish its nature. 
 
 The causes of cancer are very obscure. As we 
 have said, it is, to a certain extent, an hereditary 
 disease. The tendency to it appears to increase 
 steadily as age advances. In some instances it 
 would seem that the predisposition is called into 
 activity by a blow or a wound or a long-standing 
 irritation. But much more often it cannot be 
 traced to any cause. In the majority of cases it 
 has a constitutional origin, and that of so subtle 
 a nature that we are as yet unable to grasp it. 
 
 Treatment of Cancer. — Constitutional treat- 
 ment, however useful it may be in improving the 
 patient's health, and mitigating his sufferings, has 
 no power to disperse the tumour, or to arrest its 
 growth. 
 
 Our only hope of effecting a cure lies in early 
 and complete removal. Yet it is seldom indeed 
 that a cancer can be said to be cured by extirpa- 
 tion. In most cases all that can be done by this 
 means is to promote the patient's comfort, and 
 to prolong his life. If the disease is very exten- 
 sive, ramifying among important parts, or if the 
 patient's health is much impaired, or if there is 
 reason to think that vital organs are secondarily 
 affected, removal is almost out of the question. 
 
 But supposing an operation to be admissible, 
 what means shall we select in performing it ? 
 Either the knife, the ecraseur, or the galvanic- 
 ecraseur, the ligature, or caustics may be used. 
 Undoubtedl}-^, as a general rule, the best method is 
 excision. If the tumour is of moderate size, it 
 may be easily removed by the knife, under chloro- 
 form; and the clean-cut surfaces may unite by 
 adhesive inflammation, or be left to granulate. 
 
 If, however, the patient should object to any cutting operation, 
 we may propose the use of the ecraseur or of the galvanic-ecraseur. 
 
44 SUEGICAL DISEASES. 
 
 or of the ligature, or of caustics according to the nature and 
 situation of the disease. Fig. 18 represents Hicks' ecraseur for 
 the removal of uterine polypi. It carries a wire cord composed 
 of several strands, and is a useful instrument in dealing with 
 some of the smaller cancers. 
 
 Many ways have been proposed for destroying cancers by 
 caustic, and various agents have been tried. Among these we 
 may mention the strong sulphuric and nitric acids, the paste com- 
 posed of potash and lime (Vienna paste), and the sulphate or 
 chloride of zinc applied either in the form of powder or paste 
 (Pell's paste), or in the shape of " caustic arrows." These con- 
 sist of the caustic made into a paste with flour, baked to hardness, 
 and then cut into small-pointed strips. They may be inserted 
 into or around the tumour, through punctures in the skin. The 
 pain which is given by caustics varies much. Sometimes it is 
 not great ; at other times it is severe and protracted. Perhaps, 
 on an average, it may be expected to last for four or five hours. 
 
 Narcotics are invaluable in alleviating pain and procuring 
 sleep. Opium, conium, or henbane may be given freely (F. 10, 53). 
 
 Tonics may do much to improve the patient's general health 
 and to enable him to resist the disease. The preparations of iron, 
 quinine, or cod-liver oil should be prescribed ; while at the same 
 time care should be taken that the patient has a generous diet, 
 combined with moderate exercise in the open air ; and he should 
 be advised to avoid all such use of the part as tends to keep up 
 local irritation. 
 
 SCROFULA, STRVIVIA, AND TUBERCUIiOSIS. 
 
 Scrofula (or struma) is the name given to a constitutional 
 affection of whose essential nature we are ignorant, but which 
 evidently depends upon a deficient or depraved nutrition, and 
 which declares itself by certain outward marks. It is most prone 
 to appear in early life. Its symptoms are slow and insidious in 
 their progress, but afford unmistakable evidence of debility. 
 
 Though it may occur in almost any one, it is chiefly met with 
 in individuals of two very different aspects : — (1). The sanguine — 
 with clear complexions, delicate features, graceful outlines, fine 
 skins, large lustrous eyes with long silky lashes, and quick, 
 lively intellects — children who are beautiful in person, precocious 
 in mind, and almost unnaturally good and docile. Wordsworth 
 seems to be describing such a child when he says — 
 
 " I see the dark -brown curls, the brow, 
 The smooth transparent skin, 
 Refined as with intent to show 
 The holiness within." 
 
 Jewish Family at St. Goar. 
 
SCROFULA, STRUMA, AND TUBERCULOSIS. 45 
 
 (2). The flilegmatic — with muddy complexions, coarse features, 
 thick lips, dull heavy eyes, large joints, and awkward, stunted, 
 or deformed figures. In persons of this temperament the 
 intellectual faculties are sometimes obtuse, sometimes capable of 
 great and sustained exertion. It has been customary to point to 
 Dr. Samuel Johnson, the lexicographer, as a type of this class. 
 Boswell tells us that even in early life " his immense structure of 
 bones was hideously striking to the eye, and the scars of the 
 scrofula were deeply visible." 
 
 These external characters are accompanied by a weak, irritable, 
 and imperfect digestion, a feeble circulation, a relaxed state of the 
 muscles, and a tendency to derangements of health. 
 
 The scrofulous constitution is often inherited ; but it may also 
 be produced by unfavourable conditions of life, as a want of pro- 
 per nourishment, fresh air, sunlight, clothing, exercise, &c. 
 
 The parts where it most frequently shows itself are the bones, 
 the joints, the lymphatic glands, the skin, and the eyes. In 
 internal organs it gives rise to diseases which fall under the care 
 of the physician, such as phthisis pulmonalis, tabes mesenterica, or 
 tubercular meningitis. -p. ^q 
 
 In the skin, the cornea, ' * ' 
 
 and the mucous membranes it 
 occasions a low and unhealthy 
 inflammation, with ulcera- 
 tion ; while in the lymphatic 
 glands and bones it leads to 
 chronic inflammation, the 
 deposit of tubercle, and sup- 
 puration. 
 
 The accompanying illus- 
 tration (Fig. 19) represents 
 chronic enlargement of the 
 cervical glands in a strumous 
 boy, aged 14, who was under 
 my care at Charing Cross 
 Hospital. As it is the can- 
 cellated structure of bones 
 which is most liable to suffer, 
 the neighbouring joints are 
 in great danger of being 
 secondarily affected. Some- 
 times the scrofulous disease 
 appears to begin in the joint 
 itself, and to spread to the adjacent bones (see p. 178). 
 
 Such being the habit of body in scrofulous persons a very 
 
 Chronic enlargement of the 
 cervical glands. 
 
46 SURGICAL DISEASES. 
 
 slight cause is sufficient to determine some manifestation of the 
 disease. Thus, a sprain may be followed by disease of the joint, 
 a long walk by enlargement of the inguinal glands, or the irrita- 
 tion of dentition — more particularly the eruption of wisdom teeth 
 — by the enlargement of those in the neck. 
 
 Tubercle is the morbid material which is deposited in lym- 
 phatic glands, bones, internal organs, or elsewhere, as a result 
 of strumous disease. Its essential nature and the mode of its 
 production are involved in much obscurity. It would appear, 
 however, to be a degraded form of plastic material, the result of 
 an affection of the lymphatic system, produced by faulty and 
 perverted nutrition. 
 
 Tubercle is met with under two forms — either as minute beads 
 of a gre}% semi-transparent appearance and a firm consistence ; 
 or as a soft, yellow, opaque substance like cheese. The " grey 
 granulations" seem to be nothing more than the early stage of 
 the " crude tubercles.'^ 
 
 Under the microscope tubercle presents a homogeneous mass, in 
 which are seen some imperfect cells. 
 
 Chemically it consists of albumen, phosphate and carbonate of 
 lime, together with a little oil. 
 
 Tubercle is never organized, and never entirely absorbed. In 
 a few fortunate cases it withers into a dry and chalky substance ; 
 but in the great majority of instances it softens, suppurates, and 
 gives rise to abscess. 
 
 The treatment of scrofula is partly constitutional and partly 
 local. It has been said that the disease is one of debility and 
 faulty assimilation. Everything, therefore, must be done which 
 can promote digestion and nutrition, and improve the general 
 health. By careful attention to this rule the active manifestation 
 of the disease may be prevented, even in those who have an here- 
 ditary tendency to it. The patient should live in a pure atmo- 
 sphere — if possible, in an elevated situation, or at the seaside. He 
 should have plenty of sun-light, 
 
 " Since light so necessary is to life, 
 Nay, almost life itself." 
 
 Milton's Samson Agonistes. 
 
 His diet should be plain but nutritious, including a large propor- 
 tion of animal food, and given with regularity. His clothes 
 should be sufficiently warm, and he should be encouraged to take 
 a moderate amount of exercise in the open air. The surgeon 
 must pay attention to the state of the skin and of the secretions. 
 A mild aperient or alterative should be given occasionally ] and, 
 if other circumstances permit, a cold, tepid, or sea-water bath 
 
SCROFULA, STRUMA, AND TUBERCULOSIS. 47 
 
 should be used every morning. At the same time the prepara- 
 tions of iron, or of iodine, or cod-liver oil may be prescribed with 
 great advantage; and the extract of malt or koumiss may be 
 useful. Some natural mineral waters — more particularly those of 
 Woodhall in Lincolnshire, and Kreutznach in Rhenish Prussia — 
 are often of great service in the treatment of scrofulous cases : 
 while in many instances a sea voyage is the best thing that the 
 surgeon can recommend. 
 
 The local treatment must vary according to the particular form 
 and stage of the disease. The inflammation, both before and 
 after suppuration has taken place, must be treated on the same 
 principles which guide us in dealing with inflammation generally. 
 But after all that can be done there are a few obstinate and in- 
 veterate cases which will remain, as they were in Shakspeare's 
 time, " the mere despair of surgery" (Macbeth, iv. 3) — cases in 
 which some of the larger joints are diseased, or in which the whole 
 extent of a limb is riddled with sinuses, and for the cure of which 
 nothing short of a severe operation — an excision or an amputa- 
 tion — will suffice. When, however, the patient's constitution is 
 impaired, and his strength undermined by long-continued suflfer- 
 ing, he is not, of course, in a very favourable condition for under- 
 going any operative treatment. 
 
PART 11. 
 
 INJURIES. 
 
 THE ARREST OF HEMORRHAGE. 
 
 HjEMOERHAGE is of three kinds — arterial, venous, and capillary. 
 
 In arterial hsemorrbage the blood leaps forth in bright, red 
 jets. In venous hsemorrbage it wells out in a dark purple 
 stream. In capillary haemorrhage it oozes from the general 
 surface. We shall speak of each of these three varieties in turn. 
 
 Arterial Haemorrhage. — It will be well to study, first, the 
 natural, and second, the artificial arrest of haemorrhage. 
 
 Natural arrest. — This must be considered under two heads — 
 (1) the temporary, and (2) the permanent arrest of bleeding. 
 
 1. When an artery is cut across its coats both contract and 
 retract. They contract so as to reduce the size of its orifice, and 
 diminish the jet of blood. They retract so as to leave the sheath 
 projecting beyond them. On the rough areolar surface of this 
 sheath, as well as in the extremity of the vessel itself, the blood 
 is arrested, and forms a coagulum. This coagulum occludes the 
 mouth of the artery. In some cases there are other circumstances 
 which come to our aid. As haemorrhage proceeds, the force of 
 the heart decreases, while at the same time the blood itself 
 becomes more and more disposed to coagulate. These are the 
 means by which bleeding is temporarily arrested. 
 
 2. From the cut edges of the artery plastic material is poured 
 out, which blends with the fibrinous clot, and gradually the 
 wl)ole becomes vitalized. By degrees the colouring matter of 
 the coagulum is absorbed, aud the fibrine alone is left. 
 
 Within the artery itself the blood stagnates, and the fibrine is 
 deposited — forming the " internal coagulum." This is of a conical 
 shape with the apex directed upwards. At the same time fibrine 
 is also deposited on the lining membrane of the artery adjacent to 
 the cut end. This is sometimes called the " secondary internal 
 clot." The arterial coats continue to contract upon the " internal 
 coagulum," and become adherent to it, the " secondary internal 
 
THE AEEEST OF HEMORRHAGE. 49 
 
 clot" blending with the " internal coagnlum." The fibrlne of this 
 coagulum becomes firadually organized into fibro-cellular tissue, and 
 after the lapse of time nothing is left but a fibrous cord. These 
 are the means by which the artery becomes permanently occluded. 
 
 When an artery is torn across the arrest of hsemorrhage takes 
 place somewhat differently. The two inner coats yield to the 
 lacerating force before the outer one gives way. The outer one 
 is thus drawn to a point beyond the two inner ones. In thia 
 way a double barrier is formed to the passage of the blood ; first 
 by the outer coat, and secondly by the slieath, as in the former 
 case. A conical clot with its apex downwards forms in the space 
 between the two inner and the outer coats; while, as before, an 
 " internal coagulum" — a conical clot with the apex upwards — 
 forms in the channel of the artery itself. The subsequent changes 
 are the same as in the former case. 
 
 When an artery is wounded, or partially divided, it is important 
 to observe how Nature provides for the arrest of ha3morrhage. 
 The blood which is poured out at the aperture lodges in the 
 sheath and adjacent tissues, coagulates, and presses upon the 
 artery. By this means the calibre of the vessel is reduced, and 
 its position relatively to the wound in the skin is somewhat 
 altered. Thus the hsemorrhage is temporarily arrested. 
 
 Permanent closure takes place by adhesive inflammation in the 
 wound itself. But in many cases the effusion of plastic material 
 is so great as to lead to the entire occlusion of the artery. A 
 longitudinal incision will always heal more favourably than a 
 transverse one. When the wounded artery is of large size union 
 by adhesion can hardly be expected. A traumatic aneurism will 
 usually be the result of such an injury. 
 
 Artificial arrest. — The surgeon has various means at his dis- 
 posal for stopping the flow of blood. He need, therefore, never 
 fear haemorrhage, provided the bleeding point is within his reach, 
 for then it can always be controlled, at any rate for a time. 
 
 The position of the part should be studied ; the seat of injury 
 being raised as high as possible above the level of the heart. 
 
 Cold is very useful in constricting the vessel. It may be 
 enough merely to expose the wound to the air ; or cold water or 
 ice may be applied according to circumstances. 
 
 Pressure may be employed by means of the fingers, a tourni- 
 quet, or a graduated compress, according to the nature of the 
 case and the situation of the vessel. A graduated compress 
 (Fig. 20) is formed of several folds of lint laid one on the top of 
 the other, each fold being a little smaller than the one below it. 
 In this way a pyramidal pad is made, and when it is applied the 
 apex is directed downwards and placed just over the point upoa 
 
 s 
 
50 
 
 INJURIES. 
 
 ! 
 
 iVS->-— .-: 
 
 which the surgeon desires to exert the greatest amount of pres- 
 sure. The pad, or compress, may be of any shape that suits 
 the part ; or of any thickness, according to 
 Fig. 20. i\^Q amount of force which we wish to use ; 
 
 for the greater the thickness the greater will 
 v>>:'->>^ ' be the degree of pressure that it is capable 
 of exerting. 
 
 If such a compress is secured by a nodose 
 bandage it is capable of exerting a great 
 degree of force. 
 
 The nodose bandage (nodus, a knot) is 
 perhaps most frequently applied to the temporal artery, and we 
 shall describe it as it is used in this situation ; but it may be 
 modified to suit various localities, and it may often be employed 
 as a sort of extemporized tourniquet to make deep pressure upon 
 a particular spot. 
 
 It requires a double-headed arm-bandage, and a graduated com- 
 press. The compress is first laid 
 Fig. 21. upon the temple, on the spot upon 
 
 which it is desirable to exert the 
 pressure. The central portion of 
 the bandage is then applied over 
 the compress, and the two rollers 
 are carried horizontally round the 
 head; one to the right hand and 
 the other to the left, to the oppo- 
 site temple, where they cross one 
 another, and are brought round 
 again to the compress. They are 
 now twisted upon one anotlier, 
 forming a knot over the compress, 
 and being turned so that one may 
 be conducted over the head and 
 the other under the chin to the 
 opposite temple. Here they meet 
 and cross one another, and are 
 Nodose bandage. brought round again to the 
 
 compress (Fig. 20), Having 
 arrived at the compress, they are again twisted upon one another, 
 so as to make another knot. The operator is now enabled to 
 carry the roller horizontally round the head as at the first turn. 
 When as many twists as are necessary have been made over the 
 compress, the bandage may be finished off" with two or three 
 circular turns round the head. 
 
 The twists or knots, from which the bandage takes its name, 
 
THE ARREST OF ILEMORRHAGE. r,l 
 
 sliould all fall upouthegraduatedcompres?, and if they are rightly 
 applied they are capable of exerting a great degree of pressure. 
 The bandage may be secured on the opposite temple by passing 
 oue or two pins through the point where the horizontal and 
 vertical folds cross one another. 
 
 Styptics. — Various substances are employed as styptics. Some 
 of these act by coagulating the blood, others by constricting the 
 coats of the vessels. To promote the coagulation of the blood, to 
 give it a tine mesh-work whereupon the fibrine may be deposited, 
 it is a popular practice to apply some cobwebs, or a little fretted 
 blotting-paper to the bleeding surface. The use of the former is 
 alluded to in Shakspeare's " Midsummer Night's Dream," where 
 Bottom says to the fairy named Cobweb, " I shall desire you of more 
 acquaintance, good master Cobweb. If I cut my finger I shall 
 make bold with you." Such applications as these imitate the natural 
 haemostatic process wherein the blood coagulates upon the rough 
 areolar sheath of the divided artery. Of the styptics which act by 
 their astringent power upon the coats of the vessels the most useful 
 are the perchloride of iron, gallic acid, alum, zinc, and matico. 
 
 The actual cautery is a certain, though a severe, means of stop- 
 ping bleeding. It acts by coagulating and hardening the tissues. 
 It is particularly suitable to some situations whei'e it is diflBcult to 
 apply ligatures — the interior of the mouth, for example. The 
 lunar caustic has the same effect, only its action is more superficial. 
 
 Torsion. — The bleeding artery may be seized wdth a forceps, 
 drawn gently forwards, and twisted two or three times. The 
 part that is included in the forceps should not be twisted com- 
 pletely ofi'. It does not slough, so that there need be no fear that 
 it wall act as a putreftictive foreign body. When torsion is em- 
 ployed in this way, the eflect is to rupture the two internal coats of 
 the artery, which become more or less incurved by their own 
 elasticity, while the external coat is folded over the end of the 
 vessel. 
 
 Fig. 22 illustrates this point. It is taken from a microsco- 
 pical section which I obtained when making experiments on the 
 carotid of a rabbit. The artery had been closed by torsion. The 
 ruptured, retracted, and incurved inner coats are well seen, as 
 well as the internal coagulum and the secondary clots. 
 
 Torsion has long been practised upon small arteries, and for 
 such all surgeons are agreed that it is a good method. But in 
 the case of large arteries — e.g., the femoral or the brachial — it 
 seems neither so convenient nor so safe as the ligature. 
 
 Acupressure was recommended to the profession by Sir James 
 Simpson as a means of arresting haemorrhage. It consists in 
 passing a needle across the artery, through the tissues, and 
 
 E 2 
 
5-2 
 
 INJUEIES. 
 
 making pressure upon it by the elasticity of the tissues themselves. 
 As a general practice acupressure lias not met with much favour. 
 It is open to the great objection that it only presses together the 
 
 Fig. 22. 
 
 Artery closed by torsion, x €0. 
 
 sides of the divided artery and does not rupture the two inner 
 coats, upon which so much of the safety of the patient depends. 
 There are, however, some situations in which it is extremely use- 
 ful — e.g., there is no readier way of stopping the bleeding from a 
 superficial artery, such as the radial or ulnar, than by passing a 
 needle across it so as to compress it. 
 
 The safest and most convenient way of stopping the flow of 
 blood from an artery is to put a ligature upon it. When an 
 artery presents itself upon a cut surface it is to be seized with a 
 forceps, drawn gently forward, and a ligature passed round it. 
 The ligature should then be tied with a reef knot, and one of the 
 ends cut off. It is usual to employ hempen ligatures, but from 
 time to time various substances — chiefly animal membranes — 
 have been tried in the hope of finding something which would not 
 act as a foreign body, but would gradually undergo liquefaction 
 and absorption. With tbis object Mr. Lister has recommended 
 carbolized catgut. Fig. 23 represents a thin section of the carotid 
 artery of a rabbit twelve hours after it had been ligatured with 
 carbolized catgut. The clear homogeneous circles are the ligature 
 cut transversely. On the left of the drawing the earliest stages 
 
THE ARREST OF HAEMORRHAGE. 53 
 
 in the formation of the internal coagulum and the secondary clots 
 are well seen. When any material like catgut is used both ends 
 are cut off short, and the surgeon aims at healing the wound as 
 
 Fig. 23. 
 
 Artery closed by catgut ligature, x 60. 
 
 rapidly as possible, leaving the noose and knot to be absorbed. 
 When the ligature is drawn tight the internal and middle coats 
 of the artery give way and turn inwards, while the external one 
 is drawn over the orifice. An internal coagulum immediately 
 begins to form in the channel of the vessel, and plastic lymph is 
 poured out from the divided coats of the artery, both on the distal 
 and proximal sides of the ligature, which helps to agglutinate 
 and close the opening. 
 
 When a vessel has been completely severed by a wound both 
 tlie cut ends should be secured. 
 
 Mr. Spencer Wells has recently drawn attention to the value 
 of forcipressure as a haemostatic — i.e., the simple compression of 
 the bleeding artery by forceps. This may either be done by the 
 little " bulldog" forceps, which have long been in use, or by the 
 larger forceps — something like polypus forceps — which Mr. 
 Wells has devised. This instrument is furnished with serrated 
 teeth, and the handles are secured by a catch. By this means 
 the bleeding vessel is forcibly compressed, and its coats squeezed, 
 or almost crushed, together. This alone is often sufficient to 
 stop the bleeding, especially if the compressing force is con- 
 
5i INJURIES. 
 
 tinned for a few minutes. But, if need be, torsion may be prac- 
 tised in addition, or a ligature may be passed over the end of the 
 forceps. — (£rit. Med. Jour., June 21, 1879.) 
 
 When called to a case of haemorrhage the first thing the surgeon 
 should do is to remove all bandages, dressings, &c., and to see 
 exactly from whence the bleeding proceeds. Sometimes the mere 
 exposure of a wound to the air may do much to arrest the 
 haemorrhage. If blood is flowing fast the surgeon should apply 
 a tourniquet, or direct an assistant to compress the main artery 
 above the seat of injury, while he removes the clots, and sponges 
 out the wound. If there is a jet of arterial blood he should take 
 up the bleeding point with a forceps, and have a ligature thrown 
 around it. If the hsemorrhage consists in a general oozing from 
 the cut surface, the part should be freely exposed to the air, and 
 well washed with a stream of cold water, and then pressure 
 should be applied by means of a pad and bandage. If the blood 
 is welling up from the bottom of a punctured wound, local 
 pressure by means of a graduated compass should be tried, and 
 at the same time a tourniquet should be applied to the main 
 artery above the seat of injury. If these means fail, the wound 
 must be enlarged and both ends of the bleeding vessel secured. 
 If this is found impracticable, the artery must be tied in the 
 upper part of its course. 
 
 Whenever it is possible the surgeon should tie the bleeding 
 vessel at the seat of injury. He is not justified in making afresh 
 wound and cutting down upon the artery in the upper part of 
 its course, unless it is absolutely necessary to do so in order to 
 save the patient's life. 
 
 In cases of emergency a tourniquet may be extemporized by 
 taking a cork, a stone, or any other suitable substance, folding it 
 in lint, and laying it upon the main artery. 
 Fig. 24. Upon this pressure may be made by passing 
 
 a handkerchief or a bandage round the 
 limb, and tying it in a knot. Then, if a 
 piece of stick be introduced into the knot 
 and twisted round, a great degree of force 
 may be exerted upon the pad (Pig. 24). 
 
 If hsemorrhage follows an operation, and 
 continues in spite of all that can be done 
 by position, pressure, cold, &c., the surgeon 
 should not hesitate to re-open the wound, 
 and search for the bleeding point. It is 
 better that the patient should suffer a little 
 pain than that he shoild go on losing blood. 
 
 Secondary Abteeial H^moeehage, that is to say, hsemor- 
 
THE AREEST OF HEMORRHAGE. 55 
 
 rhage whicli comes on after the bleeding has once been controlled, 
 may occur at various periods, since it depends upon different 
 causes. 
 
 1. It may come on in a few hours after an accident or opera- 
 tion. Vessels from which no blood issued at the time the wound 
 was first dressed, on account of the collapse of the patient, may 
 begin to bleed as soon as he gets warm in bed, and recovers 
 from the shock he has sustained. This, as Mr. Spence suggests, 
 should be called " reactionary haemorrhage." 
 
 2. Unhealthy inflammation may take place in the wound 
 within a few days, sloughs may occur, and vessels may be opened up 
 in this way. Or the artery alone may ulcerate or slough. When 
 these accidents happen, styptics or pressure may be tried ; but more 
 often a ligature at, or above, the seat of disease will be required. 
 
 3. When the ligature separates in the course of ten or fifteen 
 days, bleeding may ensue ; the line of ulceration, by which the 
 ligature normally separates, having spread, and opened up the 
 artery. In such a case, it will be needful to enlarge the wound, 
 and tie the vessel again. Sometimes it may be necessary to 
 make a fresh incision and secure the artery in a higher part of 
 its course; and even after this has been done, haemorrhage may 
 again occur in the wound, as soon as the collateral circulation has 
 become established. This is a form of secondary haemorrhage 
 which is less likely to occur now that it is so usual to employ 
 a ligature of animal membrane, and to cut the ends ofi^ short. 
 
 Venous HjEMOEehage. — The surgeon should first of all make 
 sure that there is no constriction of the vein above the seat of 
 injury ; and then he may apply pressure. Much less force is 
 required to control a vein than an artery. Sometimes, when a 
 large vein presents itself upon an exposed surface, it may be 
 closed by a ligature ; but, as a rule, it is neither necessary nor 
 advisable to tie veins. 
 
 Capillary HjEMOEehage may generally be arrested without 
 difficulty by exposing the surface to the air, by allowing a stream 
 of cold water to fall upon it from a little height, by pressure, 
 or by styptics. 
 
 But occasionally we meet with persons who present what is 
 called the Ttcemorrhagie diathesis, and in such even a capillary 
 haemorrhage may be followed by fatal consequences. They are 
 generally young — more often males than females — of a delicate 
 or unhealthy constitution, which shows itself by swellings about 
 the joints. The slightest pressure causes a bruise, a trifling cut 
 bleeds alarmingly, while any operation, however small, is attended 
 by the greatest danger to life. 
 
 Treatment. — When a child exhibits this tendency, everything 
 
56 INJUEIES. 
 
 should be done to secure him against blows, abrasions, and wounds 
 of all kinds. At the same time the general health should be 
 improved by a bracing and invigorating plan of treatment. The 
 cold batli, sea air, moderate exercise, a nutritious diet, combined 
 with cod-liver oil, the preparations of iron, or the mineral 
 acids — these are the best remedies that we can recommend. 
 
 If, after all precautions, bleeding takes place, as it often does, 
 from the nose, gums, or elsewhere, full and frequent doses of tur- 
 pentine, gallic acid (F. 29), or other styptics should be given ; 
 while pressure — with or without the tincture of steel — or ice is 
 tried in the oidinary way. The cautery, whether actual or 
 potential, should be avoided, as being likely, when the slough 
 separates, to increase the mischief. 
 
 BRVXSES. 
 
 A bruise or contusion is an injury caused by a fall, a wrench, 
 or a blow from a blunt instrument, without rupture of the skin. 
 The degree of such injury may vary widely— from the slightest 
 discoloration to complete disorganization. The severest bruises 
 are those which are produced by spent cannon balls.' 
 
 When a bruise is inflicted, the subcutaneous tissues are always 
 more or less lacerated. Blood is poured out. There is ecehy- 
 niosis. The discoloration is at first bluish-black ; then it passes 
 through shades of violet, green, and yellow, until by the end of 
 ten days or a fortnight it has disappeared altogether. Even in 
 slight cases the surface is tender, and there are pain and stiffness 
 in moving the part. 
 
 The injury is generally confined to the subcutaneous areolar 
 tissue and its capillaries. But sometimes an artery of considerable 
 size is torn across, and blood extravasated in large quantity. 
 Occasionally the whole of the soft tissues are involved to a greater 
 or less depth. 
 
 Treatment. — When the injury is of moderate extent, all that 
 we have to do is to guard against inflammatory symptoms, and 
 to promote absorption. With this view the part should be kept 
 at rest, and assiduously bathed with an evaporating or discutient 
 lotion (F. 18, 19, 21). A poultice mixed with black bryony root 
 or the liydrochlorate of ammonia is highly recommended by some 
 { F. 96). It is astonishing how large a quantity of effused blood will 
 sometimes be absorbed (see Fig. 95). When an artery has been torn 
 across and is bleeding, we must endeavour to stop the haemorrhage 
 by position, by cold, by pressure (possibly acupressure), or by the 
 application of a tourniquet. If the bleeding continues in spite of 
 all that can be done by these means, the case must be treated as 
 one of diffuse aneurysm. But it is only under urgent circumstance* 
 
WOUNDS. 57 
 
 that the surgeon is justified in laying open a fresh ecchymosis, and 
 then he should use all the antiseptic precautions. If inflammatory 
 symptoms arise they must be treated in the ordinary way by 
 poultices, fomentations, leeches, and an antiphlogistic regimen. 
 
 For the treatment of those cases in which the whole of the 
 tissues are disorganized, we must refer our readers to the section 
 on Gunshot Wounds. 
 
 It should be borne in mind that ecchymosis may be produced 
 by other causes besides those we have enumerated — e.g., by the 
 application of a cupping-glass, by scurvy, by purpura, and by 
 low fever. 
 
 "WOUNDS 
 are divided into Incised, Contused, Lacerated, Punctured, and 
 Poisoned. 
 
 Incised ivounds are inflicted by a sharp cutting instrument. 
 They present clean-cut surfaces, which are favourable for imme- 
 diate union, or union by primary adhesion. The chief danger 
 that we have to dread from an uncomplicated incised wound is 
 bleeding. The various methods of arresting haemorrhage have 
 already been explained. When the flow of blood has ceased, the 
 surgeon should see that the wound is free from all extraneous 
 matter, and then the edges should be brought together in such a 
 way as shall best promote a speedy and perfect union. Sometimes, 
 when the wound is slight, the surfaces may be brought together 
 at once. In other and more severe cases it is well ta wait till 
 all oozing has stopped, for the eflTused blood is apt to coagulate, 
 and act as a foreign body. 
 
 What means are we to use for securing coaptation ? This is 
 a very important question, for much depends upon bringing the 
 surfaces accurately together, and keeping them in this position. 
 We are often able to effect these objects by very simple means — 
 by studying the position of the patient, by applying a suitable 
 bandage, by using small strips of plaster, or even by cover- 
 ing the line of incision with a film of collodion, or of Richardson's 
 " colloid styptic." 
 
 In the case of deep incised wounds, such as may be inflicted 
 on the thigh, we sometimes require a bandage which shall 
 draw the edges together, and keep them in that position. 
 A uniting bandage, as it is called, may be made by taking 
 a piece of calico of suitable width, and long enough to go fully 
 twice round the part. Near one end of the bandage two or three 
 parallel slits should be cut, and the other end should be torn into 
 an equal number of tails. When the bandage has to be applied 
 it should be folded round the limb, and the tails passed through 
 the corresponding slits, and pinned. As the ends are drawn across 
 
o8 
 
 INJURIES. 
 
 Fie:. 26. 
 
 
 ^ a 
 
 e 
 
 a 
 
 the wouud a certain degree of compression is exercised upon it, 
 and the edges are hrought together. The effect of the bandage 
 may be enhanced by laying pads of lint along the edges of the 
 wound, disposed in such a way as to make a gentle lateral pres- 
 sure upon the deeper parts. 
 
 Smaller wounds may conveniently be brought together with 
 adhesive plaster. This may be done in various ways. Thus, an 
 oblong opening may be cut near one end of a suitable strip of 
 
 diachylon, while another piece is shaped 
 in the manner represented in Fig. 25, 
 by nicking the edges and folding down 
 the plaster so as to form a tongue which 
 may be passed through the correspond- 
 ing opening, and drawn tight across the wound — in fact, it is not 
 
 unlike the uniting bandage that we 
 liave just described. Or the surgeon 
 may take two pieces of plaster shaped 
 something like the letter L, and place 
 one on each side of the wound, in 
 the way represented m Fig. 26, so 
 '^ that when they are drawn together 
 
 a may come to c and h to d. 
 If more than this is necessary, we must have recourse to 
 stitches — sutures. Sutures are made of various m.aterials, and 
 are applied in many different ways, according to circumstances. 
 Some surgeons prefer hempen thread or silk ; others an animal 
 membrane, such as catgut; others, again, a fine wire. The ad- 
 vantages claimed for the latter are that it does not irritate the 
 tissues, and that it does not absorb the secretions. The catgut 
 suture, particularly if it has been rendered antiseptic, is much 
 used at the present day. It is soft and pliable ; it does not 
 harbour putrefactive secretions, and it liquefies after a short time 
 — the knot coming away without any pain or difficulty. For all 
 ordinary cases, however, a hempen or silken suture, well waxed, 
 is probably as good as any. 
 
 The needle, armed with suitable material, should be passed 
 
 through the whole depth of the 
 ^ig- 27. true skin, entering and emerg- 
 
 ing at a short distance from the 
 line of incision. The thread, gut, 
 or wire is then to be drawn 
 through, and knotted or twisted, 
 so as to keep the opposed sur- 
 faces in their proper position. 
 When separate sutures are introduced, each half an inch or an inch 
 
WOUNDS. 
 
 59 
 
 Fig. 28. 
 
 apart, they are called interrupted (Fig. 27). As many such 
 stitches are to be inserted as are necessary to keep the parts in 
 accurate apposition — but no more. Sometimes, when the wound 
 is deep, and we wish to make sure of bringing the lower part of 
 the cut surfaces together, a pad of lint may be laid along each side 
 of the incision, in addition to the sutures, and pressure made 
 downwards and inwards by means of a bandage. 
 
 The tivisted suture is a variety of the interrupted. It is made 
 by passing a hare-lip pin through the wound which we wish to 
 unite, and then twisting a silk thread firmly over it in the form of 
 a figure of 8, embracing one end of the pin in each loop of the 8. 
 This kind of suture may be made to lay hold of the tissues to 
 almost any depth. It is particularly applicable to wounds in the 
 face — as, for example, those made in the operation for hare-lip. 
 
 The quilled suture (Fig. 28) is another variety of the inter- 
 rupted. It has the same advantage as the preceding — namely, 
 that it brings the deep surfaces of wounds into 
 apposition. But it is applicable to some situa- 
 tions — the perineum, for example — where hare- 
 lip pins would be inconvenient. It is made in 
 this way. A needle, mounted in a handle, is 
 armed with a double thread, and passed deeply 
 across the wound, and then withdrawn, leaving 
 a loop at one side and two ends at the other. 
 This proceeding is repeated as often as the 
 length of the incision may require. A quill, or 
 a piece of a gum catheter, is then inserted 
 through the whole line of loops ; the threads 
 are drawn tight; and the ends are firmly tied 
 around a similar piece of gum catheter on the 
 other side of the incision. Lastly, the edges of 
 the wound are united by simple interrupted sutures. 
 
 The continuous or Glover's suture is chiefly used for slight 
 wounds of the intestines. Recently, however, it has been employed 
 to close external wounds, in the hope of bringing about more per- 
 fect contact, and more speedy union. It is made with a delicate 
 needle and fine thread — the needle passing through and through, 
 while the thread goes over and over, the two edges of the wound, 
 like the seam of a glove. 
 
 Sutures are only temporary expedients. With rare exceptions 
 they are removed in the course of from twenty -four hours to a week. 
 If they cause great irritation, they must be taken away at once ; 
 for it must be remembered that they are foreign bodies, and may 
 set up so much inflammation as to prevent union by adhesion 
 from taking place at all. 
 
60 IN.TUEIES. 
 
 Some surgeons object altogether to the use of sutures in wounds 
 of the scalp, on the ground that they increase the tendency to 
 erysipelas. But practically this is not found to be the case, and 
 the only extra caution which need be observed is not to pass the 
 needle so deep as to penetrate the aponeurosis of the occipito- 
 frontalis muscle. 
 
 In dealing with an incised wound we must not forget the con- 
 stitutional treatment. We must study to keep the inflammation 
 within the limits necessary for union by adhesion. To do this it 
 may sometimes be needful to reduce the patient a little by pur- 
 gatives, salines, and a spare diet ; sometimes to give him alcoholic 
 stimulants and animal food. 
 
 If the conditions of the wound are not favourable for union by 
 adhesion, the edges begin to gape, and a discharge of thin pus 
 makes its appearance. Suppuration has commenced. The sooner 
 then that the stitches — or a sufficient number of them to give a 
 free vent — are removed the better, for we must now treat the 
 wound as a granulating one, and be contented with " union by 
 the second intention," But if, after a time, the inflammation 
 should be reduced within the limits that are compatible with the 
 effusion of healthy and plastic lymph, we may again bring the 
 granulating surfaces into apposition, and endeavour to get a 
 secondary union bv adhesion. 
 
 Subcutaneous wounds may be considered as a variety of the 
 incised, A narrow-bladed knife is passed through the skin, and 
 then the tissues are divided subcutaneously, the superficial wound 
 hardly exceeding the breadth of the blade of the knife. Tendons 
 and cicatricial bands are often divided in this way ; and recently 
 Mr. W. Adams, Mr. L. S. Little, and others, liave applied the same 
 method to sections of bone. The advantage of such incisions 
 consists in this, that no air is admitted, suppuration does not take 
 place, and the blood which is effused is absorbed, as in the case of 
 a simple bruise. The incision in the skin may easily be closed by 
 a strip of plaster, or by a pad and bandage. 
 
 COSTTUSEB AND IiACERATSD WOUXDS 
 
 may be conveniently considered together. 
 
 In a contused wound the adjacent tissues are bruised or 
 crushed. In a lacerated wound the edges are torn and ragged. 
 These two conditions — bruising and tearing — often go together 
 in practice. 
 
 In a lacerated wound there is little to fear from haemorrhage. 
 Vessels which are torn across soon cease to bleed. 
 
 However slight the degree of contusion or laceration may be, 
 it is likely that the vitality of some portion of the tissues will be 
 
PUNCTURED WOUNDS. 61 
 
 destroyed. If so, it will be thrown off in the form of a slough ; 
 suppuration is established ; union by primary adhesion is out of 
 the question. The extent of the slough will depend not only 
 upon the amount of bruising, but also upon the nature of the 
 tissue that is injured. The scalp, the face, the hands, and other 
 parts which are very vascular, are not nearly so apt to slough as 
 parts which are less highly supplied with blood. 
 
 Erysipelas, gangrene, and tetanus are the evils that we have 
 chiefly to dread in wounds of this description. 
 
 In the treatment of contused and lacerated wounds our first 
 care should be to cleanse the part, to replace the tissues, and then 
 to perform any operation that may be necessary. In doing this 
 we should remove as little as possible. A very slender tongue of 
 skin often serves to maintain vitality in apparently hopeless cases. 
 
 We should endeavour to promote the separation of sloughs, and 
 to moderate the suppuration, so that there may be as little loss of 
 substance as possible. With this view water-dressing or a poultice 
 should be applied, and subsequently a carbolic acid or other anti- 
 septic lotion (F. 12, 14). Perhaps some of the other means which 
 we have before mentioned in speaking of inflammation may be 
 required. At the same time it will almost always be necessary 
 to support the general health. 
 
 The question of amputation in connexion with this class of 
 injuries is often a difficult one. It would be impossible for me to 
 discuss it fully here. All I can do is to mention the principal 
 points which must influence the surgeon in forming his opinion. 
 
 If part of a limb has been severed, or all bat severed, from the 
 body, an operation should be undertaken with the view of making 
 a useful stump. 
 
 When the whole substance of the limb has been crushed, there 
 can be no doubt that an amputation should be performed. 
 
 When the limb has been much lacerated, the bone comminuted, 
 or I he main arteries torn across, amputation will generally be the 
 wisest course. 
 
 When one of the large joints has been freely opened amputa- 
 tion may be requisite. If, however, the case at ail permits of it, 
 an effort may be made to save the limb, either by performing a 
 resection, or by treating the wound with a strictly antiseptic 
 dressing or with ice-bags, combined with absolute rest. 
 
 FUNCTUREB "WOUXBS 
 
 are such as are made by a narrow sharp-pointed instrument — 
 e.g., an arrow, a dagger, or the point of a knife. They mar 
 penetrate to any depth, and are often accompanied by some 
 degree of laceration. They are dangerous ; because of the injury 
 
62 INJURIES. 
 
 they may do to subjacent organs or parts, and because they may 
 be followed by inflammation in the deeper portions of the wound. 
 
 Formerly it was the custom at once to dilate all punctured 
 wounds, and to convert them into incised wounds. But this is 
 not done now except under special circumstances — e.g., when a 
 large artery has been injured and must be tied, or a piece of the 
 weapon remains behind and cannot otherwise be extracted. In 
 all ordinary cases we endeavour by the pressure of pads and a 
 bandage to bring tbe lower parts of the wound into apposition, so 
 as to get it to unite from the bottom by adhesive inflammation. 
 If this fails, it may be necessary to enlarge the opening, so as to 
 give a free vent to the pus ; while poultices are applied to promote 
 the separation of the tissues whose vitality has been destroyed. 
 Subsequently antiseptic or stimulating lotions may be used. 
 
 The most frequent, if not the most severe, punctured wounds 
 which are met with in civil practice in this country are those 
 which are made by the entrance of a needle. The readiness with 
 which needles introduced under the skin bury themselves in the 
 tissues, or even travel to distant parts, is extraordinary. The 
 surgeon should therefore be on his guard, and not undertake an 
 operation unless he can feel the needle, or is satisfied of its lying 
 in a particular spot. If he has sufficient proof of its presence, he 
 should make a tolerably free incision over it, and remove it with a 
 fine forceps. Swain recommends that a flap should be made by cut- 
 ting from within outwards. If the surgeon cannot assure himself 
 of its position, the best plan is to order a poultice, and to keep the 
 part at rest. By this means the superficial tissues will be softened, 
 the needle will make its way in the direction of least resistance — 
 i.e.y towards the surface — and then it can be easily removed. 
 
 GUNSHOT -WOUSTDS 
 
 include all those which are caused directly or indirectly by the 
 discharge of firearms, by powder, wadding, shot, shell, fragments 
 of stone, splinters of wood, &c. 
 
 Such injuries are always more or less contused or lacerated. 
 The bleeding is generally slight; unless one of the main arteries 
 is divided, or a vascular organ, such as the lung, has been pene- 
 trated, there is not much dang er from haemorrhage. 
 
 Gunshot wounds vary from the slightest contusion to the most 
 frightful laceration. They may produce but little uneasiness, or 
 they may cause instant death. 
 
 When the wound is inflicted by a round ball, discharged from 
 a smooth-bore weapon, the aperture of entry is smaller and more 
 sharply defined than the aperture of exit. Such is the general 
 rule. When, however, the firearm is discharged at a very short 
 
GUNSHOT WOUNDS. 63 
 
 distance the case is reversed, and the aperture of entry is larger 
 and more irregular than the aperture at the exit. 
 
 The wounds made by conical balls fired from rifled weapons 
 vary extremely in their characters — from a simple abrasion to a 
 ragged and lacerated wound. They are, as a rule, much more 
 dangerous than the injuries inflicted by round shot. 
 
 Gunshot injuries are generally accompanied by shock, both 
 physiciU and mental ; the measure of which depends chiefly upon 
 the severity of the wound. It is the greatest when the superfi- 
 cial wound is large, when much blood is lost, or when some 
 internal organ of vital importance is afiected. In these cases it 
 approaches to syncope ; at the same time the mental depression is 
 so great as to fill the most stout-hearted with alarm and despair. 
 
 It used to be held that a mere "wind-contusion" was capable 
 of producing a fatal result. But it seems certain that such is not 
 the case, and that in all the recorded instances there must have 
 been actual contact, though the skin may not have been broken. 
 
 Eound bullets are very easily diverted from their course. A 
 button, a bone, even the thyroid cartilage, has been sufiicient to 
 change their direction. Sometimes they have made a circuit 
 round the trunk, and presented themselves at their aperture of 
 entry. Sometimes they have gone half round the cranium, so 
 that their aperture of exit was exactly opposite their aperture of 
 entry — making it appear as if they had passed through the head. 
 At other times they have followed the most devious courses, 
 guided from point to point by the obstacles that came in their 
 way. The history of military surgery is full of such strange and 
 hair-breadth escapes. 
 
 At a very short distance powder alone will produce a ragged 
 and scorched wound. Wadding will penetrate at a somewhat 
 greater range. At a short distance small shot enter in a com- 
 pound mass, making a wound like a bullet. At a greater distance 
 they separate, and only pepper the surface. When a round bullet 
 enters it makes a clean-cut track ; but it may inflict a severe 
 bruise, and even break a bone without penetrating the skin at all. 
 The following case shows how slight a bruise may give rise to the 
 most serious and even fatal results : — A writer in the " Annals of 
 Military and Naval Surgery " (1864) says : " To show the effect 
 of being hit by a spent ball, or one that has lost its greatest im- 
 petus, I may mention a case that came under my notice when a 
 colonial volunteer was standing talking in a group of his com- 
 rades, and was struck by a ball in the abdomen, over the region 
 of the bladder. The ball fell on the ground at his feet without 
 either injuring his clothes or even marking the skin. He did 
 not feel much pain at the time, and walked to the hospital, a 
 
64 INJUEIES. 
 
 distance of two miles, with the ball in his pocket, without feeling 
 much pain; but he died shortly afterwards from peritonitis and 
 extensive inflammation of the bladder. The entire surface of the 
 abdomen presented the appearance of a severe bruise in a few 
 hours after being struck." 
 
 The old round bullet was much more apt to lodge both in the 
 soft tissues and in the hard than the conical ball of modern 
 warfare. The increased force with which the rifle bullet is pro- 
 jected, as well as the rotatory movement which is imparted to it, 
 cause it to inflict the most severe and dangerous wounds. Nothing 
 is capable of arresting its progress : it splinters bones, and tears 
 its way through the flesh. 
 
 Irregular pieces of iron, such as the fragments of shells, make 
 very ghastly and dtmgerous wounds. 
 
 The smooth round bullet, after it has lodged, may become 
 encysted, and remain in its fibrous envelope for the rest of the 
 patient's life without giving rise to much inconvenience. 
 
 Irregular missiles of all sorts set up so much irritation that 
 they cause their own ejection by suppuration. • 
 
 Portions of dress, accoutrements, &c., are apt to be driven into 
 the wound by the bullet. Sometimes it has been known to carry 
 a pouch of the clothing before it ; so that when the clothing was 
 removed, the bullet was withdrawn along with it. 
 
 In a gunshot wound bones may be simply broken, or the 
 fracture may be compound, or comminuted. Again, a bone may 
 be perforated, or the bullet may be arrested and lodge in it. 
 
 When a bone is simply bruised without being broken, the 
 injury may be more serious than it appears at first sight, giving 
 rise to prolonged inflammation and necrosis. 
 
 It is impossible to estimate the extent of a gunshot wound 
 until the sloughs have separated ; and even then there may be 
 accidents which may ai-ise to complicate the case — hsemorrhage, 
 abscess, gangrene, erysipelas, pyaemia, tetanus, non-union of 
 fracture, or necrosis. These are some of the conditions which 
 may supervene, and which render the prognosis very uncertain. 
 
 Treatment. — Gunshot wounds are to be treated on the same 
 general principles as other contused and lacerated wounds. The 
 surgeon's aim should be to arrest haemorrhage, to remove foreign 
 bodies, to replace the tissues, to hasten the separation of sloughs, 
 and to put the parts in the most ftwourable position for union 
 by granulation. 
 
 The wound should not be enlarged, unless it be to tie a bleed- 
 ing vessel, remove a foreign body, evacuate matter, or for some 
 similar object. If there is reason to think that a foreign body is 
 present in the wound, a careful examination should at once be 
 
GUNSHOT WOUNDS. 65 
 
 made with the finger or with a probe ; and if any extraneous 
 substance is detected, it sliould be extracted with the bullet 
 forceps or other suitable instrument. The patient's position should 
 be carefully studied. At first, cold water should be applied to 
 the wound. Afterwards, poultices will probably be required. 
 When the sloughs have separated disinfectant or stimulating 
 lotions should be used, as the case may demand, and the part 
 should bo supported by a bandage. Constitutionally our first 
 object is to rally the patient from the shock that he has received 
 at the time of the injury. This we do by stimulants and 
 restoratives. There are, however, cases in which they must be 
 given with great caution, and where the state of collapse is even 
 a benefit ; in penetrating wounds of the lung, for example. Our 
 next endeavour is to allay the fever which accompanies the 
 process of suppuration. Lastly, we have to support the strength 
 during repair, to guard against any of the complications which 
 have been mentioned, and to deal with them promptly if they 
 arise. 
 
 G-unsJiot tvounds of the chest. — A bullet may penetrate the 
 chest, and lodge in the cavity of the pleura. It may there become 
 encysted, and give rise to no further symptoms. More commonly 
 it enters the substance of the lung — sometimes lodging there, 
 sometimes passing quite through. 
 
 When the lung has been wounded there is generally great 
 collapse, approaching to syncope ; the face is pale and anxious^ 
 the breathing difficult. Often there is expectoration of frothy 
 blood, and sometimes the edges of the wound are emphysematous. 
 When the bail lodges in the lung the prognosis is very un- 
 favourable. 
 
 Treatment. — The wound should be examined as gently as 
 possible. Any foreign body that can be felt should be removed. 
 When there is no counter-opening the bullet may sometimes be 
 found lying beneath the scapula. The patient should be laid in 
 bed, and the wound lightly covered with water-dressing, but no 
 immediate efibrt should be made to counteract the state of 
 collapse. 
 
 If it seems probable that internal haemorrhage is going on it 
 has been recommended to bleed the patient to syncope, in the hope 
 of promoting the formation of a clot. But this plan of treatment 
 is open to question. If outward hsemorrhage is going on there 
 will be no necessity for venesection. The external application of 
 cold, or the internal administration of styptics (F. 29, 47) will 
 assist in arresting the flow of blood. The patient should 
 be kept perfectly at rest, on a low diet, consisting chiefly of cold 
 milk and iced drinks, and everything should be done which 
 
66 INJURIES. 
 
 can promote the healing of the bullet track. With this view 
 feverish symptoms must be allayed, pain mitigated, and sleep 
 procured (F. 7, 10, 53). But after all that the surgeon can do, it is 
 only too probable that abscess, or empysema, or pneumonia, will 
 bring the case to a fatal issue. 
 
 Gunshot wounds of the abdomen are very fatal in their results. 
 As we have seen, even a slight contusion, which appears at the 
 time insignificant, may give rise to diflfuse peritonitis and death. 
 
 Flesh wounds of this region are still more dangerous. They 
 should be handled with great gentleness for fear of opening the 
 peritoneal cavity, lightly dressed, and treated on general 
 principles. 
 
 In the case oi penetrating wounds, if the viscera escape injury, 
 as they sometimes do, still there is the risk of peritonitis. But 
 it much more frequently happens that the viscera are implicated, 
 and then the danger is greatly increased. A wound of the solid 
 viscera — e.g., the liver, spleen, or kidney — is more hazardous 
 than a wound of one of the hollow viscera. Again, a wound of 
 the stomach or large intestine is more dangerous than a wound 
 of the small intestines. 
 
 The chief symptoms are great collapse — which often terminates 
 fatally — pain, vomiting, and perhaps melffina. These symptoms 
 declare themselves at once. Subsequently there may be 
 peritonitis, or a disturbance of the special function of the wounded 
 viscus. It seldom happens that the intestines protrude through 
 the wound unless it is of large extent. 
 
 Treatment. — The wound should be carefully but gently exa- 
 mined. No immediate effort should be made to arouse the 
 patient from the state of collapse, unless, indeed, it threatens to 
 prove fatal. If the bowel is wounded to a small extent only, it 
 is better not to attempt to sew it up. The protrusion of the 
 mucous membrane will probably close it sufficiently until a cover- 
 ing of lymph has been formed. If the rent is larger it should 
 be closed with a continuous suture of fine silk or carbolized catgut, 
 and the bowel returned ; or it may be stitched to the edges of 
 the wound and treated as a faecal fistula. The exact size and 
 situation of the rent must determine which of these two courses 
 is to be adopted. 
 
 The patient should be kept perfectly at rest, on very low diet, 
 supplemented by nutritious enemata, and opium in full and 
 repeated doses should be given. 
 
 Question of amputation in gunshot injuries of the limbs. — 
 Under this head it is impossible for us to do more than lay down 
 a few general rules. Each case has its own peculiar circum- 
 stances, which must receive special consideration. Moreover, it 
 
rOISONED WOUNDS. 67 
 
 will make great difference whether the injury occurs in civil or 
 military practice. Many a limb has been saved in a regular 
 hospital which must have been sacrificed in campaigning. As a 
 general rule "conservative surgery" is not practicable in war- 
 fare. 
 
 Amputation should be performed under the following circum- 
 stances : — 
 
 1. When part of a limb has been severed from the body, or 
 hangs only by the integuments. 
 
 2. When the whole substance of the limb has been crushed 
 and bruised to disorganization, with or without laceration of 
 the skin. 
 
 3. When a large mass of the soft tissues has been carried away, 
 involving important vessels and nerves. 
 
 4. When one of the larger joints is opened, or the bones which 
 enter into its formation are splintered. 
 
 5. When there is a severe compound fracture. In a case of 
 compound fracture of the lower end of the femur an amputation 
 may be performed. But when the injury is seated at the upper 
 end of the bone the operation is so uniformly fatal that it is 
 perhaps wiser not to undertake it. 
 
 When one of the smaller joints is injured the question of 
 excision should be entertained ; but this class of operations is 
 attended with great difficulties in military practice. 
 
 Every amputation should be performed as far from the trunk 
 as circumstances will permit, for the higher we rise on the limb 
 the greater is the mortality. 
 
 Supposing the surgeon has determined to amputate, another 
 question arises. When should the operation be performed ? 
 Should it be a primary amputation — i.e., an amputation per- 
 formed within forty-eight hours before febrile symptoms have 
 arisen, or should it be a secondary amputation, performed after 
 the traumatic fever has subsided ? Experience has decided this 
 question in favour of the former ; for it appears that primary 
 amputations are not nearly so fatal as secondary. 
 
 POZSOXSD WOTTNBS 
 
 may have any form ; they maybe incised, lacerated, or punctured. 
 Their essential character is that through them a poisonous mate- 
 rial is introduced into the blood, which may affect the whole 
 system, and even produce death. 
 
 The virus may be either a healthy secretion, like the poison of 
 serpents, or a morbid product, like the poison of hydrophobia. 
 
 Wounds poisoned by healthy secretions. — It is seldom, in this 
 country at any rate, that the stings of insects lead to serious 
 
 f2 
 
68 INJTJUIES. 
 
 results. When such a case is brought before a surgeon, the wound 
 ought to be carefully examined with a lens, and if the sting can 
 be found, it should be extracted. The part should then be 
 frequently bathed with an alkaline or evaporating lotion. If it 
 is the tongue or the fauces that are stung, active measures may 
 be required. It may be necessary to scarify the part, or to open 
 the veins beneath the tongue, or even to perform tracheotomy in 
 order to prevent suffocation. But the symptoms must be very 
 urgent indeed to warrant the surgeon in undertaking this opera- 
 tion, because the inflammation excited by such an injury, though 
 it may run high, is generally of short duration. 
 
 The bite of a snake is a formidable thing in the Tropics, but 
 not so in England. The common viper is the only poisonous 
 snake that we have in this country, and his venom has but little 
 effect upon healthy and vigorous persons. It is only in the case 
 of the very old or the very young, or when the bite has been 
 inflicted on a critical part — such as the interior of the mouth — 
 that active local measures need be used. In most instances all 
 that is wanted is a restorative to support the patient under the 
 alarm which he is apt to feel. 
 
 In warmer climates several very formidable snakes are met 
 with — e.g., the rattlesnake in America, the puff-adder in Africa, 
 and the Cobra-di-capello in India. When a bite has been in- 
 flicted by one of these the treatment must be prompt and active. 
 A ligature should be immediately thrown round the limb above 
 the seat of injury, to obstruct the return of blood to the heart. 
 The wound should then be thoroughly cleansed by sucking, or by 
 the application of a cupping-glass ; or its surfaces should be 
 destroyed by nitric acid, nitrate of silver, or the actual cautery. 
 If it is favourably situated, the bite may be excised. At the same 
 time that these local measures are adopted stimulants should be 
 freely given to support the patient and to prevent the collapse 
 which is so apt to follow from alarm and the depressing action 
 of the venom. Professor Halford, of Melbourne, has recommended 
 the injection of ammonia into the veins. The practice has been 
 attended by success in his hands, and is worthy of a further trial 
 {Brit. Med. Jour., Jan. 30th, 1869). 
 
 Wounds poisoned hy morbid products. — Hydrophobia is caused 
 by the bite of the dog, wolf, fox, and some other animals, when in 
 a state of rabies. Such rabies seems to occur under two forms. 
 Sometimes the animal shows unusual activity, sometimes unusual 
 depression. In either case the bite is capable of producing hydro- 
 phobia. But it is worthy of notice that of those who are bitten 
 only a small proportion manifest the disease — about one in twelve 
 or lifteen. The virus requires a period of incubation, and seldom 
 
EQUINIA. 69 
 
 shows its effect for a month or longer. Tlie most dangerous bites 
 are those on the hands, face, and other exposed parts. 
 
 The premonitory symptoms of hydrophobia are these : — the 
 wound becomes irritable, painful, and discoloured. Though it may 
 have healed, it sometimes opens again, and begins to discharge an 
 unhealthy matter. The patient becomes uneasy, restless and 
 feverish ; fits of excitement alternating with periods of depression. 
 
 In the course of three or four days the actual symptoms com- 
 mence, and no doubt remains as to the fearful nature of the 
 malady. There is inability to swallow fluids in consequence of 
 spasm in the pharynx. The muscles of respiration as well as 
 those of deglutition, are thrown into painful and violent con- 
 tractions by the slightest exciting causes, and there is loud and 
 distressing hiccup. The patient is usually horror-struck. Nothing 
 can exceed his alarm and despair. He is quite unable to sleep. 
 His eyes are wild and bloodshot ; his. breathing difficult ; his 
 mouth loaded with viscid saliva, which froths upon his lips, and 
 which he is constantly trying to expectorate. He may die 
 asphyxiated in one of the attacks of dispncea, or he may sink at 
 the end of a few days from exhaustion. 
 
 Of the pathology of hydrophobia we know nothing. The con- 
 ditions which induce rabies in animals, and the changes, local and 
 constitutional, which take place in the patient are alike involved 
 in mystery. The principal morbid appearance that has been met 
 with after death has been congestion of the brain, spinal cord, and 
 their membranes, with serous eftusion. 
 
 Treatment. — When there is the slightest suspicion of danger 
 the bite should be freely excised and bleeding promoted. In 
 situations where the knife cannot be used, the surfaces of the 
 wound should be thoroughly touched with a pencil of lunar caustic, 
 or with a glass rod dipped in the strong nitric acid. 
 
 We have no specific for hydrophobia ; when it is once 
 established all that can be done is to support the patient by 
 careful feeding, and to palliate the symptoms by powerful seda- 
 tives and narcotics. Our best hope of mitigating the severity of 
 the disease lies in the use of opium, Indian hemp, chloroform, 
 ice to the spine, or the subcutaneous injection of morphia. (F. 10.) 
 At the same time everything should be done which can soothe the 
 patient and allay his irritability. All causes of excitement, 
 mental as well as bodily, should be carefully removed. But it is 
 seldom that we succeed in averting the fatal issue. 
 
 EQUZN-ZA. 
 
 The poison of equinia is generated in animals of the horse tribe. 
 It may be transmitted to a man either by inoculation, through a sore. 
 
70 INJURIES. 
 
 or by mere contact with the skin or mucosa without abrasion of 
 surface. It manifests itself under two forms — glanders and 
 farcy. In both there is feverishness with glandular enlarge- 
 ments, and the formation of pustules on the skin, particularly 
 about the face and in the neighbourhood of the joints. 
 
 The most characteristic symptom of glanders is an inflammation 
 of the lining membrane of the nose. An offensive discharge mixed 
 with blood pours from the nostrils. Sometimes this inflammation 
 runs so high as to cause sloughing. At the same time the salivary 
 glands as well as the cervical lymphatic glands become swollen, 
 tender, and prone to suppuration. 
 
 In farcy the subcutaneous glands throughout the body become 
 hard and painful, constituting what are known as " farcy-buds." 
 
 The glandular enlargements in equinia, as well as the pustules, 
 are probably due to the deposition of a material analogous to 
 tubercle. The affection of the Schneiderian membrane is no doubt 
 of the same kind. This is borne out by the fact that, if the 
 patient lives long enough, there is always some consolidation of 
 the lungs with circumscribed patches of pneumonia. 
 
 Each variety of the disease may run an acute or a chronic 
 course. When acute, it is almost certainly fatal. When chronic, 
 there is a hope of recovery. 
 
 The treatment of equinia must consist in supporting the patient 
 by a well regulated diet, favourable hygienic conditions and tonic 
 medicines, while the pustules and sloughs are treated on general 
 principles. For the offensive discharge from the nose the nasal 
 cavities should be frequently syringed with astringent or disin- 
 fectant lotions. 
 
 BzssECTZOM- uvomrDS 
 
 are generally free from danger ; sometimes, however, they give 
 rise to the most serious and even fatal consequences. Everything 
 seems to depend upon the health of the person who is wounded, 
 and the nature of the matter which is inoculated. 
 
 An individual whose health is impaired from over study, 
 dissipation, or any other cause, is much more likely to suffer than 
 one who is robust and in good condition. 
 
 If the matter is inoculated from a body but recently dead, it is 
 much more dangerous than if it is taken from one in an advanced 
 stage of decomposition. For this reason wounds received in the 
 deadhouse are more to be feared than those which are met with 
 in the dissecting-room. 
 
 The matter derived from different dead bodies seems to vary 
 much in its poisonous qualities. Cceteris paribus, that which is 
 drawn from the bodies of those who Lave died of erysipelas, 
 
MALIGNANT PUSTULE. 71 
 
 pyaemia, peritonitis, and puerperal fever appears to be much the 
 most dangerous. 
 
 In a severe case the symptoms are local irritation, heat, swelling, 
 and throbbing pain. Sometimes a pustule forms at the seat of 
 injury. Soon the absorbents inflame. The lymphatic glands 
 lecome enlarged and tender, suppuration takes place, diffuse 
 cjUular inflammation follows, and abscesses form in various 
 parts. 
 
 These symptoms are accompanied by a high degree of fever of 
 tte asthenic type, and tlie patient either sinks at the end of a few 
 days or weeks from exhaustion of the vital powers; or, if he 
 recovers, it is only after a tardy and prolonged convalescence. 
 
 Treatment. — The first thing to be done is to bind a ligature 
 tightly round the part above the seat of injury. The wound should 
 then be washed with a stream of cold water, and afterwards 
 sucked, so as, if possible, to get rid of the matter altogether. If 
 it seems desirable to do more than this, the wound may be 
 touched with strong nitric or pure carbolic acid. If, however, not- 
 withstanding these precautions, it should inflame, poultices must 
 be applied at once. As soon as the lymphatic glands become pain- 
 ful, they should be assiduously fomented ; and if suppuration takes 
 place, incisions should be made without delay. If abscesses form 
 in remote parts, they should be opened immediately. 
 
 The constitutional treatment consists in clearing the intestinal 
 canal by a purgative, allaying the febrile symptoms by salines, 
 and procuring sleep by opium, while the strength is upheld by 
 stimulants and a nutritious diet. 
 
 iviAiiZCN.A.ia'T pvsTiriiZ: 
 
 {Charhori)\% caused by a poison which is generated in horned cattle. 
 Of the " bovine disease" which gives rise to the virus very little is 
 known. The poison, however, may be transmitted to man either 
 by inoculation or by contagion. Whether it can be introduced 
 by inhalation or by eating the diseased meat is uncertain. In 
 my work on the Diseases of the Tongue, I have alluded to 
 some remarkable cases of malignant pustule affecting that 
 organ. 
 
 Symptoms. — A dark pustule forms on the affected part, bursts 
 and discharges an offensive slough. The resulting ulcer spreads 
 rapidly by phagedaenic action. This local inflammation is accom- 
 panied by fever of a putrid and typhoid character. 
 
 The treatment consists in arresting the unhealthy ulceration 
 by caustics, favouring the elimination of the poison from the 
 system, and upholding the patient's strength. 
 
72 
 
 "WOTTN-BS BIT IRRITAITT POXSOITS. 
 
 Tlie irritant poisons, externally applied, give rise to injuries 
 which fall under the care of the surgeon. 
 
 The mineral acids rapidly destroy the tissues with which ther 
 come in contact, and cause extensive wounds. 
 
 The injured part should be well washed — first with warm 
 water, and then with a solution of carbonate of soda ; after tHs 
 has been thoroughly done a poultice or a fomentation should "be 
 applied. 
 
 When the poisonous agent is one of the caustic alkalies the 
 part should be freely bathed with a weak acid solution — e.ff,, 
 vinegar and water — and then poulticed. 
 
 The only metallic substance which we need mention is the 
 nitrate of silver. It is readily decomposed by a solution of com- 
 mon salt. 
 
 BFFECTS OF HSAT. 
 
 Heat, communicated from solid bodies, gives rise to Burns; 
 from fluid or gaseous bodies it occasions Scalds. 
 
 Injuries caused by the application of heat are attended by 
 various dangers. 
 
 (a) They are accompanied by a shock, which sometimes ap- 
 proaches to syncope, and may even prove fatal. 
 {h) The period of depression is followed by proportionate reac- 
 tion, with inflammatory symptoms, 
 (c) During this second stage internal organs are apt to become 
 affected, particularly the lungs and the small intestines. 
 {d) If the patient survive these dangers, he has still to go 
 through the exhausting processes of suppuration and 
 repair. 
 Injuries caused by heat are divided by Dupuytren into six de- 
 grees. His classification — which is one of great practical value 
 — is now generally adopted :— 
 
 1. Where the cuticle is merely scorched. 
 
 2. Where the cuticle is raised in blisters. 
 
 3. Where the cutis vera is more or less destroyed. 
 
 4'. Where the injury extends through the cuticle and true 
 skin, and reaches the sub-cutaneous cellular tissue. 
 
 5. Where the muscles and fascia? are involved. 
 
 6. Where the whole thickness of the limb is implicated. 
 
 In practice we generally find that several of these degrees go 
 together. A case in which the muscles are touched will probably 
 show the milder forms of injury as well. 
 
EFFECTS OF HEAT. 73 
 
 Mr. Curling has drawn attention to an interesting point con- 
 nected with extensive burns. He has observed that they often 
 seem to occasion ulcers in the duodenum ; and he supposes that 
 Brunner's glands, in order to compensate for the functions of the 
 skin, take on an increased and even excessive action. This point 
 well deserves further inquiry, and it should make the surgeon 
 attentive to the slightest indications of gastric or intestinal 
 irritation, as shown by vomiting or purging. 
 
 The prognosis in burns or scalds will depend in a great 
 measure upon the amount of surface that is involved; both 
 because the skin is a complex tissue, highly supplied with nerves, 
 and also because, when its functions are arrested to any consider- 
 able extent, internal organs are very apt to become congested 
 and inflamed. Speaking generally, when a sixth part of the surface 
 of the body is affected, the prognosis is unfavourable. But the 
 age of the patient, the situation of the injury, and the depth to 
 which the destructive action has penetrated, are points which 
 must not be overlooked in forming an opinion on the case and 
 its probable issue. The cuticle is speedily replaced ; but the 
 cutis vera is never reproduced ; and wherever it has been de- 
 stroyed, a cicatrix will be left. 
 
 The old, the young, and those in impaired health are par- 
 ticularly liable to suffer from the shock of a severe burn or 
 scald. 
 
 The situation of the injury is very important. If it is on the 
 head it may give rise to inflammation of the brain or its mem- 
 branes. If it is on the chest, pneumonia or bi-onchitis is likely 
 to ensue. If a child has scalded the back of its mouth by 
 attempting to drink out of the kettle, the injury may cause 
 speedy death by inflammatory closure of the rima glottidis. 
 
 The treatment of burns and scalds is partly constitutional and 
 partly local. 
 
 Constitutional treatment. — The first thing to be done is to 
 rally the patient from the state of shock, and to bring about 
 reaction. With this view the patient should be placed in bed 
 with a hot-water bottle to his feet, and stimulants should be given 
 at once — a glass of warm brandy and water or a cup of hot tea, 
 for example. If the depression is accompanied by much anxiety 
 or alarm, sedatives, such as the tincture of hyoscyamus or the 
 vinum opii, may be combined with the restoratives. Death not 
 unfrequently takes place during this first period of the case. 
 
 When reaction has begun, our aim must be to keep it within 
 moderate limits — to restrain the inflammatory action. To this 
 end perfect quietness and repose should be enforced, and mild 
 purgatives or salines should be given from time to time as occa- 
 
74 INJURIES. 
 
 sion requires. The strength must be upheld by stimulants and 
 by a nutritious diet. Pain must be mitigated and sleep procured 
 by the cautious use of sedatives and narcotics. 
 
 This is the most fatal stage in the course of a severe burn, and 
 the surgeon ought to be on the watch for the earliest signs of 
 complications — meningitis, bronchitis, pneumonia, albuminuria, or 
 intestinal ulcers. 
 
 When the inflammatory symptoms have subsided the patient 
 will still have to pass through a period of suppuration. If the 
 injury has been of considerable extent, his strength will, even 
 under the most favourable circumstances, be severely taxed ; but 
 if hectic should supervene, it will go hard with his life. To 
 uphold the vital powers, by cordials, tonics, and good food, is the 
 great aim of constitutional treatment while suppuration con- 
 tinues. 
 
 Local treatment. — The patient's clothes should be gently and 
 carefully removed, being cut wherever they are adherent to the 
 body. If blisters have formed they should be pricked and the 
 serum let out, but the cuticle should on no account be detached. 
 
 In all injuries from burns or scalds it has been found that the 
 sufferer experiences great relief when the surface is coated with an 
 unirritatinar substance which excludes the air, and maintains an 
 equable temperature. This principle may be carried out in a 
 variety of ways. Some surgeons dust flour, or starch, or gum 
 tragacanth over the affected surface. Others prefer to varnish 
 the part with a mixture of collodion and castor-oil, two measures 
 of the former to one of the latter (F. 73, 74). Others employ a 
 weak turpentine lotion or ointment. " Carron-oil " (equal parts 
 of lime-water and linseed-oil) enjoys a widespread reputation. 
 But whatever application is used, a smooth and thick layer of 
 cotton-wool should be laid over it, and retained by a bandage ; 
 for it is not merely an equable temperature, but a Mgli one as 
 well, that seems to allay the scorching pain. When once the 
 dressing has been applied it should be changed as seldom as pos- 
 sible — indeed, only where the discharges render such change 
 absolutely necessary. In this way the repair goes on most 
 favourably, and the patient is saved from much pain and distress. 
 
 If the burn is of the fourth degree, or more, this treatment 
 should be followed for a few days, and then poultices should be 
 applied. When the sloughs have separated, the wound should be 
 treated on general principles with water-dressing, or stimulating 
 or astringent lotions, as the case may require. An ointment of 
 chalk, or a weak solution of carbolic acid (F. 12) forms an excellent 
 dressing when the suppuration is very profuse. 
 
 When cicatrization commences, the surgeon must bear in mind 
 
EFFECTS OF COLD. 75 
 
 the great tendency there is to contraction, and do all in his power 
 
 — by studying the position of the patient, by bandages, by me- 
 chanical appliances — to prevent it. But notwithstanding all his 
 efforts, more or less contraction is sure to take place. Some- 
 times this gives rise to the most frightful disfigurement and dis- 
 tortion. Can anything be done to prevent or to remedy these 
 evils ? The character of the cicatrix may perhaps be improved 
 by adopting Reverdin's method of making skin-grafts. But if, 
 notwithstanding, an unsightly or inconvenient cicatrix is left, 
 nothing short of an operation has any permanent value. In 
 planning sucb operations the surgeon has great scope for his 
 ingenuity. Sometimes the cicatrix may be divided subcutaneously, 
 and stretched by mechanical means. Sometimes a flap of skin 
 may be partially dissected from the adjacent parts and turned 
 across a corresponding surface which has been laid bare on the 
 cicatrix. Or a portion of skin may be similarly dissected from a 
 distant part, the cicatrix being brought to it, and firmly bound 
 in that position till union has taken place — constituting a true 
 Tagliacotian operation. Sometimes the best we can do is an 
 amputation. 
 
 EFFECTS OF COIiB. 
 
 When severe cold is applied to the body it depresses the action 
 of the heart, and paralyses the nervous force. These eflects are 
 most visible in parts where the circulation is naturally feeble, as 
 the nose, ears, feet, &c. The arterial supply is diminished, while 
 the blood is retarded in its passage through the veins. Hence the 
 part loses its natural colour, and becomes purple or blue. Sensa- 
 tion is almost goue, vitality is reduced to a very low ebb — in fact 
 there is fi'osf -bite. Still, however, the circulation may be restored 
 by judicious measures. 
 
 But if the degree of cold is very intense, or if exposure to it is 
 long continued, vitality is wholly destroyed, mortification takes 
 place, and restoration is impossible. This untoward result is 
 particularly apt to occur in those whose vigour is already impaired 
 by want of sufficient food and clothing. 
 
 It should be noted that one effect of extreme cold is to produce 
 an overpowering sense of drowsiness, but to yield to the inclina- 
 tion, and to lie down to sleep under such circumstances, is almost 
 certain death. 
 
 Treatment. — When a part is frost-bitten, our object should be 
 to bring about vert/ gradual reaction. The patient should be 
 placed in a room without a fire, and the part must be gently but 
 continuously rubbed with snow or other cold applications. Heat 
 should on no account be applied, as it is very apt to produce 
 
76 INJURIES. 
 
 gangrenfi. The temperature must be restored from within, not 
 from without. The object is to make the circulation advance 
 from the deeper parts to the more superficial. Stimulants — a 
 little warm coffee or brandy and water, for example — may be 
 given from time to time in small quantities. 
 
 When reaction has taken place, and the circulation has been 
 restored, it may be evident that some portion of the tissues has 
 mortified. If this is the case, poultices should be used to hasten 
 the separation of the sloughs, and the wound which remains 
 should be treated on general principles. 
 
 Chilblains arise from a mild degree of frost-bite, and, when 
 circulation is restored, an almost intolerable itching and tingling 
 is experienced, and the part is red and swollen. They are fre- 
 quently induced by wearing boots that are too thin for the season, 
 and then sitting before the fire with damp or wet feet. When 
 the inflammation thus set up runs on to ulceration it produces 
 what is called a hrolcen chilblain. 
 
 Chilblains are most often seen in children, but they may occur 
 also in adults who have a languid circulation, or who are in weak 
 health. 
 
 Treatment. — When persons are subject to chilblains they should 
 be careful to change their stockings after exercise, as the damp- 
 ness caused by confined perspiration is very apt to induce them. 
 When inflammation has commenced, the affected part should be 
 painted with tincture of iodine, or with a mixture of camphor 
 and zinc in glycerine, or bathed with a lotion of Goulard 
 water and laudanum ; or rubbed with compound camphor, iodine, 
 or turpentine liniment; or with iodine or calamine ointment. 
 If the chilblain breaks, it must be treated on general principles, 
 first with poultices or water-dressing, and afterwards with stimu- 
 lating applications. In any case it will be necessary to give 
 proper attention to the patient's food and clothing, and also to 
 prescribe tonics, more particularly the preparations of iron. 
 
 SUSPEITDBS AZa-ZMATZOM'. 
 
 The suspension of animation may commence either at the 
 heart or at the lungs. It may be due either to synco'pe or to 
 a/pncza. 
 
 Syncope {fainting) depends upon an irregular and deficient 
 supply of blood to the brain. It may arise from hajmorrhage, 
 debility, emotion, impure air, or other causes. 
 
 The symptoms are giddiness, swimming in the head, insensi- 
 bility, and loss of consciousness. The patient lies still and 
 motionless. Tlie lips are white ; the surface of the body blanched 
 and cold. The breathing is slow and shallow. The pulse feeble 
 
SUSPENDED ANIMATION. 77 
 
 and intermittent. Death may result from the entire stoppage of 
 the heart's action. 
 
 The treatment consists in laying the patient flat on a bed or 
 on the floor, and even depressing his head slightly by placing a 
 pillow underneath his back. His face and chest should be 
 sprinkled with cold water, strong smelling salts should be held to 
 his nose, and warmth and friction applied to the surface of the 
 body. As soon as he begins to rally, a little stimulant — brandy, 
 or sal volatile, with water — should be given. 
 
 Apnoea (or, as it used to be called, asphyxia) occurs when the 
 supply of air to the lungs is cut off. This may arise in 
 various ways — by hanging, drowning, iipmersion in irrespirable 
 gases, &c. 
 
 The blood in the lungs is not aerated; dark-coloured blood 
 circulates through the brain, giving rise to coma or convulsions, 
 and after the lapse of three or four minutes the heart's action 
 ceases altogether. 
 
 Treatment. — The cause should, if possible, be removed. Any liga- 
 ture that may be round the patient's neck, any pressure that may 
 be preventing the expansion of the chest, should be taken away. 
 
 If respiration is still going on, the surface of the body should be 
 rubbed, hot-water bottles applied to the epigastrium and feet, 
 and ammonia held to the nostrils. When sensibility and con- 
 sciousness begin to return, a cordial should be given. 
 
 If breathing has ceased, but the heart still beats, artificial 
 respiration should be commenced without delay (see Artificial 
 Respiration), while at the same time the stimulating measures 
 mentioned in the foregoing paragraph should also be employed. 
 
 If the heart's action has ceased as well as the breathing, gal- 
 vanism should be used in conjunction with artificial respiration. 
 When the case has gone as fur as this, there is but a very small 
 hope of restoring animation. 
 
 In cases of hanging, death may take place by dislocation of the 
 cervical vertebrae, or by congestion of the brain and apoplexy, as 
 well as by apnoea from pressure upon the trachea. 
 
 In cases of drowning the patient should of course be removed 
 from the water, and carried to the nearest shelter. He should be 
 at once placed in a hot bath or wrapped in a warm blanket, with 
 hot-water bottles beside him ; the surface of the body rubbed, 
 and smelling salts applied to his nostrils. At the same time 
 artificial respiration should be practised. As the water does not 
 find entrance into the lungs, it is not necessary to invert the 
 patient before courmencing the artificial respiration as was for- 
 merly done. All that is needed is to remove the mucus from the 
 mouth, and to draw the tongue well forward. 
 
78 
 
 ARTZFZCXAXi RESPIBATZOir 
 
 may be practised in several ways, but the principle is the same in 
 all. Our aim is, first, to expand the thoracic cavity, and then to 
 contract it in imitation of the natural movements of inspiration 
 and expiration. Whatever plan is adopted the steps of the pro- 
 cess should be repeated about fifteen times a minute, steadily and 
 with regularity, and persevered in as long as there remains the 
 slightest hope of restoring animation. 
 
 Dr. Marshall Hall's method consists in laying the patient on 
 his face on the floor, or on a table, and then turning him over on 
 his back. By this means the weight of the body compresses the 
 chest while it expands again by the natural elasticity of the 
 ribs. 
 
 Dr. Sylvester's method is easier of application, and has now 
 been generally adopted by the Royal Humane Society. The pa- 
 tient should be laid on his back, and then both his arms should be 
 raised above his head, held there for a second or two, and brought 
 down again on the sides of the chest with some degree of pressure. 
 After the lapse of two seconds the process should be repeated. 
 Thus the muscles of respiration attached to the humerus serve 
 to dilate the thorax, while it is compressed by the adduction of the 
 arms. This plan is as efficient as any other ; it is simpler, and it 
 has the additional advantage of appearing less rough in practice. 
 
PART III. 
 
 CONSTITUTIONAL EFFECTS 
 
 OP 
 
 SURGICAL DISEASES AND INJURIES. 
 
 SHOCK.— COI.I.il.PSE, 
 
 When a person receives a severe injury his nervous system sus- 
 tains a shock. This shock manifests itself in a variety of ways, 
 but especially by its effect upon the heart. The supply of nerve- 
 force Ls disturbed, or even stopped altogether. The heart may 
 suddenly cease to beat, or its action may gradually fail. 
 
 The symptoms vary widely in degree. To take a typical 
 case : — The patient lies in a helpless, half-conscious state. When 
 addressed, he answers in an incoherent way. He is cold and 
 shivering, the surface of the body being blanched and bedewed 
 with clammy moisture. The pulse is quick, small, and almost 
 imperceptible J the breathing irregular and sighing; the fea- 
 tures pinched ; the expression anxious ; the eyes vacant ; the 
 sphincters relaxed. The temperature, if tested by the ther- 
 mometer, is found to be lowered. Sometimes convulsions ensue, 
 especially in children. Sometimes there is vomiting, which is 
 rather a good sign, and often indicates the approach of reaction. 
 
 These symptoms may be so severe as to produce complete col- 
 lapse, followed by death from syncope in the course of a few 
 minutes or hours. This fatal result is most likely to happen 
 when the injury is very extensive, when the chest or abdomen is 
 penetrated, or when some internal organ of primary importance 
 is involved. 
 
 It is interesting to observe that the shock may be communi- 
 cated to the nervous system through the mind, as well as through 
 the body. Persons have been killed by a fright, or by the 
 receipt of distressing or alarming news j and in every case the 
 
80 CONSTITUTIONAL EFFECTS. 
 
 mental constitution of the patient will influence the degree of 
 prostration. In persons of a lively and excitable temperament 
 the effects of shock are likely to he the most severe. 
 
 Treatment, — When the shock is chiefly mental, a few reassur- 
 ing words, a cordial, and rest in bed, with an extra blanket, and 
 a hot-water bottle to the feet, will suffice to restore the patient. 
 
 In the milder examples of shock from injury the same treat- 
 ment will generally be found enough. 
 
 If the case is more severe, the patient should be laid in bed with 
 his head rather low. Warm flannels, hot-water bottles, and friction 
 should be applied to the surface of the body. Stimulants should 
 be given gradually and with caution. If the collapse continues, 
 and the patient has not lost much blood from the injury, Mr. 
 Savory recommends that the jugular vein should be opened to 
 relieve the over-distended heart, and thus facilitate its contraction. 
 No operation of magnitude, which can be deferred, should be 
 undertaken during this stage. If there is a wound, it should be 
 washed, and treated in the ordinary way. 
 
 In extreme cases we must have recourse to stimulating ene- 
 mata, rubifacients, blisters, sinapisms, or galvanism to restore the 
 natui'al functions. Stimulants — ammonia to the nostrils, or a few 
 drops of brandy placed within the lips — are often of great value. 
 Of course if the patient is in an insensible state, fluids ought not 
 to be given in any quantity, for fear they pass into the larynx. 
 
 As the sufferer recovers from the shock, reaction takes place, 
 and our aim must be to keep it within the limits consistent with 
 health. In mild cases it is easy enough to do this by keeping 
 the patient quiet, restricting his diet, and acting upon the 
 bowels. During the period of reaction any operation which is 
 necessary may be performed, and if aether or chloroform are 
 administered, they may have a stimulating effect, and thus tend 
 to support the patient. But all severe cases will be followed by 
 more or less fever. 
 
 SURGZCAIi OR TRAUMATIC FEVER 
 
 is the name given to the general febrile state which is apt to follow 
 injuries or operations. It is probably due in some measure to 
 shock, but in a still greater degree to the absorption of morbid 
 fluids from the blood. It ought, therefore, to be regarded as a 
 septicamic disease. 
 
 The nature of such fever varies with the degree of injury, the 
 particular part affected, and the constitution and habits of the 
 patient. 
 
 If he is robust and vigorous, the inflammatory symptoms will 
 be of the sthenic kind. There will be a full and quick pulse, a 
 
SURGICAL OR TRAUMATIC FEVER. 81 
 
 hot skin, a high temperature, a flushed face, suffused and blood- 
 shot eyes, and great thirst. 
 
 If delirium (traumatic delirium) comes on, as it often does, 
 especially in those who have been accustomed to take large quan- 
 tities of alcohol, it is furious in its character. The patient is un- 
 governable, talks loudly, and is under the influence of delusions. 
 Sometimes he is inclined to be merry, but more often he is angry. 
 He tosses himself in bed, is always wanting to get up, and does 
 not seem to feel any pain from the injury, however severe it 
 may be. 
 
 The treatment of this form of traumatic fever and delirium 
 must be actively antiphlogistic. Venesection, leeches, and ice to 
 the head, purging, and low diet — these are the only remedies that 
 hold out a hope. Opium is almost useless, and may even do harm. 
 If it is given at all, it should be combined with tartar emetic, as 
 recommended by Dr. Graves. (F. 39.) 
 
 If, on the other hand, the patient is broken in health or of a 
 feeble constitution, the symptoms will be of the asthenic or 
 irritative type — the pulse quick and small, the tongue brown, 
 the skin pale and clammy, the features pinched, and the expression 
 anxious. 
 
 If delirium ensues, it is of the low muttering kind ; or else it 
 is busy, meddling, and suspicious, like delirium tremens. 
 
 Treatment. — The bowels should be relieved, and then opium 
 should be given in full doses, and repeated every three hours, until 
 sleep is induced. It will generally be found advisable to combine 
 the opium with stimulants, and to give it in brandy or in stout, or 
 in whatever the patient has been accustomed to drink. At the 
 same time he should have plenty of plain, nutritious food. 
 
 In all cases of traumatic delirium the patient will have to be 
 restrained so as to prevent his getting out of bed. If possible, 
 this should be done by persuasion, management, skilful nursing, 
 and gentle force. If more than this is required it will be neces- 
 sary to put on a strait-waistcoat. Such a waistcoat is made of 
 strong cotton cloth or of ticking, and extends from the root of the 
 neck to the waist. It has no opening in front, but at the back 
 it is fastened with tapes. The sleeves are long, so as to extend 
 some little distance beyond the hands, and closed at the extremi- 
 ties. A cord is generally tied round them below the hand, and 
 carried down to the foot of the bed, so that the patient is obliged 
 to keep his arms by his sides ; or else they are crossed over his 
 chest, and secured in that position. The waistcoat is usually fur- 
 nished with shoulder-straps, through which a belt may be passed 
 in order to restrain the movements of the patient's body. 
 
 We have described extreme cases as types of the two forms ot 
 
 a 
 
82 
 
 CONSTITUTIONAL EFFECTS. 
 
 traumatic fever, but in practice they are often found more or less 
 blended. 
 
 In all cases of surgical fever the clinical thermometer ought to 
 be regularly employed. Any sudden alteration in the tempera- 
 ture bodes ill for the patient. If it is in the upward direction, 
 it shows an increase in the feverish symptoms ; if in the 
 downward direction, a collapse of the patient's strength. The 
 annexed chart (Fig. 29) affords a good example of the value of 
 
 Fig. 29. 
 
 Thermometric Chart. 
 
 exact thermometric records. It was kindly furnished by Mr. 
 Barwell. The patient was a young man, aged 17, whose thigh 
 was amputated in Charing Cross Hospital on April 3rd, 1879, on 
 account of a myeloid sarcoma of the femur. Both the operation 
 and the subsequent dressings were done with strict antiseptic 
 precautions. A drainage tube was left in the wound. At the 
 first dressing, on April 5th, ( X ) everything was normal ; at the 
 second dressing, on April 7th, ( X )ashealinghadmadegreat progress 
 and as there was but little discharge, the whole of the drainage tube 
 was removed, except about three inches. It will be seen that 
 from this time the temperature gradually rose till the 10th, (*) when 
 the stump was again dressed. On this occasion the drainage tube 
 was missing. A careful search was made, and it was found deep 
 down in the stump close to the bone. Probably it had slipped in 
 at the date of the second dressing. It was at once removed, and 
 the temperature gradually fell to the normal point. 
 
 All injuries which have been attended by much shock or which 
 have been followed by severe traumatic fever, are apt permanently 
 to weaken the nervous system of the patient. Sometimes this 
 
HECTIC FEVER. 83 
 
 change shows itself in his temper and disposition ; sometimes in 
 his bodily health. In such persons disease is lighted up by a 
 slight cause ; and they not unfrequently become chronic invalids, 
 or die suddenly. 
 
 HSCTZC FEVER, 
 
 "When suppuration is very profuse or long-continued, or attended 
 by much destruction of tissue, it gives rise to a febrile state, 
 known as hectic. It is important to observe that this condition 
 does not declare itself as long as the pus is pent up in a cavity — 
 e.g., in a psoas abscess. 
 
 The si/mptoms are in many respects those of asthenic fever, but 
 with some peculiar features. Hectic is marked by periodic remis- 
 sions and exacerbations. The exacerbations, which are often 
 accompanied by rigors, take place towards night, while the remis- 
 sions occur in the morning. After the paroxysm has reached its 
 height, it commonly terminates in profuse sweating, with great 
 exhaustion. The pulse is quick, soft, and easily excited. The 
 tongue is covered with white fur in the centre, while the tip and 
 edges are unnaturally clean and red. The skin is at one time 
 hot and dry, at another soft and moist. The temperature rises. 
 The urine is turbid and offensive. Occasionally there is diarrhcea. 
 The appetite is good ; sometimes it is excessive. The eyes are 
 brilliant; the cheeks flushed. The strength fails, while the 
 emaciation increases. 
 
 The mental phenomena are hardly less characteristic than the 
 bodily. The patient is easily depressed, but more easily excited, 
 his mind is buoyant and hopeful, and, as soon as he is relieved 
 from his present distress, he is sanguine of recovery. 
 
 Treatment. — Hectic is a fever of irritation and debility, and 
 the treatment which it requires is essentially soothing and tonic. 
 The patient should be removed from everything that can excite 
 him, and placed in the most favourable hygienic conditions. 
 With this view he should have plenty of fresh air. If possible, 
 he should be taken to the sea-coast — such a resort being selected 
 as is not too keen and stimulating. His diet should be liberal 
 and generous, and should include a large proportion of animal 
 food. If his strength permits, he should take moderate exercise, 
 short of fatigue. If walking is out of the question, he should 
 go out in a carriage or Bath-chair. In any case he should be as 
 much in the open air as possible. The secretions should be regu- 
 lated, while such medicines are given as cod-liver oil, arsenic, 
 quinine, and the preparations of iron. The mineral acids 
 are particularly useful, both as tonics and to check the pro- 
 fuse sweating. The diarrhcea, which is so apt to arise, 
 
 a2 
 
84 CONSTITUTIONAL EFFECTS. 
 
 must be treated by astringents and sedatives. Hot sponging 
 and rapid drying is sometimes very refreshing to the patient. 
 
 Of course, every local means must be employed, including any 
 operation that may be desirable, and the various antiseptic 
 dressings, which can limit the suppuration, and bring about a 
 healthy condition of the wound, which is the cause of the 
 hectic. 
 
 ERYSXPEIiAS 
 
 is the name given to a constitutional disease of the inflammatory 
 kind, which is caused by a specific poison, and which commonly 
 manifests itself by certain local symptoms. The constitutional 
 disorder is always present; the local phenomena admit of some 
 variation, and may even be altogether absent. 
 
 The fever which attends erysipelas is of the asthenic kind. 
 The disease may safely be regarded as one of debility. There is 
 shivering and nausea ; a quick, weak pulse ; a brown tongue ; a 
 hot, dry skin; and a tendency to low muttering delirium. At 
 the same time it is no uncommon thing to see the brain, the 
 lungs, or the alimentary canal involved in the inflammatory 
 process. There may be encephalitis, or pneumonia, or bronchitis, 
 or diarrhoea, or vomiting. 
 
 When erysipelas shows itself locally, it is by an unhealthy 
 inflammation which has a remarkable tendency to spread. The 
 lymph which is poured out is of the aplastic, corpuscular kind, 
 and forms no barrier to the progress of the disease. This extends 
 chiefly by continuity along the same plane of tissue. Its favourite 
 seats are the free surfaces, such as the skin, the mucous mem- 
 branes, and the inner coats of arteries and veins ; but it also 
 affects the deep layers of cellular tissues. 
 
 Erysipelas is broadly divided into idiopathic and traumatic. 
 
 Of the essential nature of the poison of erysipelas we know 
 nothing. When the disease arises spontaneously, it may be said 
 to depend upon a want of proper attention to the laws of health. 
 Thus there is a predisposition to it when the system is disordered 
 from living too high, or living too low; from intemperance; 
 from insufficient clothing or exercise ; from a want of cleanliness 
 and fresh aii*, or from any other similar cause. The same may 
 be said also of persons who are labouring under any disease 
 which affects the purity of the blood, as albuminuria or diabetes. 
 
 The changes of the weather, and the alternation of the 
 seasons have some effect in favouring the development of the 
 disease. 
 
 Wounds are the most frequent exciting causes of erysipelas. 
 It behoves the surgeon, therefore, to beware how he undertakes 
 
ERYSIPELAS. 85 
 
 an operation when the disease is epidemic. Those wounds are 
 likely to be attended with the most serious consequences in which 
 the deep planes of cellular tissue are exposed. 
 
 The disease may easily be produced, at least in hospitals, by 
 over-crowding, and a want of proper cleanliness and ventilation ; 
 and, when once it has been set up, it is highly infectious. It is, 
 therefore, of the greatest importance that a patient affected with 
 erysipelas should be isolated, and that the utmost care should be 
 taken by personal cleanliness on the part of the attendants, and 
 by the free use of disinfectants to prevent it from spreading. 
 
 The best classification of erysipelas is into (1) cutaneous ; (2) 
 ceUulo-cutaneous ; and (3) cellular. 
 
 1. The cutaneous is the mildest form of the disease. It extends 
 only to the true skin. The surface becomes of a bright rose 
 colour, whicli disappears on pressure, and usually fades away at the 
 edges into the healthy skin. The part is dry, hot, swollen, hard, 
 and sometimes oedematous; and there is pain of a smarting 
 character. 
 
 When erysipelas arises spontaneously without a wound it gene- 
 rally attacks the face ; but it may show itself anywhere. Some- 
 times it suddenly leaves one part and appears in another. 
 (Metastasis.) This erratic form of the disease always indicates 
 great debility, and is accompanied by considerable risk, inasmuch 
 as it is apt to attack the fauces, or other important parts. Hip- 
 pocrates long ago observed that when erysipelas fixes upon a par- 
 ticular part of the body it is more formidable in appearance than 
 in reality, and that the disease is attended by most danger when 
 it leaves an external part and is determined inwardly (Syd. Soc. 
 Translation, i. 401). 
 
 2. CeUulo-cutaneous (or phlegmonous) erysipelas extends 
 through the skin to the subjacent cellular tissue. When once 
 inflammation has been lighted up in a layer of areolar tissue it 
 runs on rapidly to suppuration and sloughing. 
 
 The local phenomena are much the same as in the former case, 
 only they are more intense. The tint of surface is deeper and 
 more fiery, the skin is harder and more brawny, the swelling is 
 much greater, while the cuticle is raised in unsightly blisters. 
 After about a week, these symptoms undergo a change. Some- 
 times that change is a favourable one, and resolution takes place. 
 But much more frequently it is an unfavourable one. The part 
 becomes soft and doughy. The surface loses its uniform colour, 
 and becomes mottled. It is then evident that suppuration has 
 occurred, and that sloughing is imminent. "WTien an extensive 
 surface is affected, or when the patient is feeble or out of condi- 
 tion, the danger is great. When the disease attacks the face and 
 
86 CONSTITUTIONAL EFFECTS. 
 
 head, as it not unfrequently does, the aspect of the case is alarm- 
 ing, and there is considerable risk, lest the membranes of the brain 
 should be affected. At the best, recovery will be tedious, and it 
 is highly probable that some impairment of tissue, or of function, 
 will remain for years. 
 
 3. The cellular variety of erysipelas {cellulitis) is the most 
 severe and the most dangerous. The inflammation attacks the 
 planes of cellular tissue, diffuses itself rapidly along them, and 
 leads to the most destructive suppuration and sloughing. Some- 
 times it is the more superficial layers which are affected, e.g., that 
 which lies immediately beneath the skin; sometimes it is the 
 deeper layers, e.g., those which divide the muscles or envelop the 
 bladder. 
 
 In any case the symptoms come on apace and run high. There 
 is great pain and swelling. The part becomes of a dusky purple 
 colour, hard and tense, and the skin is oedematous. In two or 
 three days these symptoms alter. There are rigors. Suppura- 
 tion has begun. The parts become boggy from infiltration of pus, 
 and mottled from the approach of gangrene. Sloughing takes 
 place rapidly and extensively, leading in most cases to a fatal 
 issue in the course of a week. 
 
 The constitutional symptoms which attend these different forms 
 of erysipelas are the same in kind, though they vary in degree. 
 
 If the inflammation has a sthentic character at the outset, it 
 rapidly degenerates. The typical erysipelatous fever is of the 
 low asthenic kind. The pulse is quick and weak, the skin dry 
 and pmigent, the temperature high, the tongue furred and brown, 
 with a tendency to muttering delirium. Frequently there is 
 diarrhoea. In an uncomplicated case it is death from exhaustion 
 that the surgeon has to guard against. 
 
 The access of suppuration will be marked by rigors ; and when 
 gangrene commences, there will be a sudden depression and 
 prostration of the vital powers, which will probably be indicated 
 by a corresponding decrease of the animal heat. 
 
 In all the more severe cases it is, as we have said, most likely 
 that some of the internal organs will be secondarily affected. 
 There will be encephalitis, or bronchitis, or pneumonia, &c. 
 
 The prognosis in cases of erysipelas depends chiefly upon the 
 variety that we have to deal with, the seat of the disease, and the 
 constitution and habits of the patient. If he is the subject of 
 chronic disease of any internal organ — more particularly of the 
 kidneys — it will add very much to the danger of the case. 
 
 The treatment of cutaneous erysipelas is partly constitutional 
 and partly local. 
 
 In the constitutional treatment the first thing to be done is to 
 
ERYSIPELAS. 87 
 
 clear the primce via by an emetic or a purgative, or both. If 
 the inflammatory symptoms run high, a mildly antiphlogistic 
 plan may be followed, by limiting the patient to a fluid diet, and 
 promoting the action of the skin, kidneys, and bowels. It must 
 not be forgotten, however, that though at the outset the inflam- 
 mation may be sthenic, it will ere long in all probability become 
 asthenic. Soon stimulants and tonics — the preparations of 
 ammonia and iron (F. 34, 35, 47), and a light but generous diet, 
 with a fair allowance of brandy, port wine, or egg-flip (F. 100) 
 — will be required to support the failing strength. In many cases 
 it is necessary to pursue this method from the first. Large 
 and frequent doses of the tinct. ferri perchloridi have sometimes 
 been followed by very marked benefit. 
 
 Local treatment. — In every case the part should have perfect 
 rest ; and, if possible, it should be elevated, while fomentations — 
 plain or medicated — are diligently used ; and if the fomentations 
 are covered with oiled silk or waterproof cloth, they will retain 
 the heat and moisture for a long time. Cold applications should 
 be avoided : they are apt to produce metastasis, which is very 
 undesirable. The surface should be dusted with flour or starch, 
 or painted with a mixture of collodion and oil (F. 73), so as to 
 exclude the air and keep up an equable temperature. These are 
 excellent applications, and very grateful to the feelings of the 
 patient. Some surgeons prefer astringent lotions (F. 15, 16, 23). 
 These may be used warm or tepid. In erratic cases blisters are 
 often beneficial, and tend to fix the disease to one spot. When 
 there is much tension, small punctures should be made in the 
 skin with the point of a lancet — the number varying according 
 to the extent of surface aflected. In this way a little blood 
 and serum escape, and the pressure is relieved. Sometimes an 
 attempt is made to limit the inflammation by a boundary line of 
 lunar caustic : but the success which has attended this practice is 
 hardly sufficient to justify it. 
 
 After the acute symptoms have disappeared, a bandage should 
 be employed in order to restore the healthy condition of the 
 tissues; and the part should be regularly rubbed with soap lini- 
 ment or camphorated oil. By this means the stiff'ness resulting 
 from eff'usion will be removed. 
 
 Treatment of the cellulo-cutaneotcs erysipelas. — The constitu- 
 tional treatment of this variety is much the same as that of the 
 cutaneous erysipelas. But as the disease is more formidable, the 
 patient must be watched more narrowly, and the tonic remedies 
 pushed further, if need be. 
 
 The local treatment does not differ in its earlier stages from 
 that which has been described above. As soon as the skin 
 
88 CONSTITUTIONAL EFFECTS. 
 
 becomes tense, limited incisions should be made in it, and when 
 matter has formed, it must be let out without delay. 
 
 This variety of the disease is apt to be followed by troublesome 
 sequelse, such as solid oedema, contracted cicatrices, sinuses (con- 
 nected perhaps with dead bone), &c. 
 
 The treatment of cellular erysifelas is only an advance upon 
 that which we have described as suitable to the cellulo-cutaneous 
 variety. 
 
 Stimulants will probably have to be given both more freely 
 and at an earlier date. The surgeon should be on the watch for 
 abscesses, and open them as soon as possible. The clinical ther- 
 mometer will give him a hint when suppuration is taking 
 place. 
 
 There are some situations in which erysipelas is particularly 
 apt to occur, and where, from local or other conditions, it deserves 
 special notice. 
 
 Cellulo-cutaneous (phlegmonous) erysipelas of the scalp is 
 often seen in persons who are enfeebled by age, or by any other 
 cause. If the disease extends to the sub-aponeurotic plane of 
 cellular tissues, then, on the one hand, the occipito-frontalis 
 muscle may slough, while, on the other, the inflammation may be 
 communicated to the brain or its membranes. These disastrous 
 consequences seldom occur in idiopathic cases, but they are 
 common after wounds. 
 
 Special treatment. — The head must be shaved. If the surface 
 is doughy, and there is reason to think that suppuration has taken 
 place in the sub-aponeurotic cellular tissues, free incisions must at 
 once be made down to the bone, in a direction radiating from the 
 vertex. 
 
 Erysipelas is not confined to the external parts of the body. 
 It may affect the mucous or serous membranes, or the lining of 
 arteries, veins, or lymphatics. The general character and ten- 
 dency of the disease is essentially the same as when it attacks the 
 skin or cellular tissue. 
 
 Erysipelas of the fauces may arise spontaneously, or as a con- 
 sequence of the disease in some other part. In addition to the 
 ordinary local symptoms — redness, swelling, &c., which manifest 
 themselves upon the soft palate, uvula, and fauces — the voice and 
 breathing are generally more or less affected. The disease is 
 always an alarming one, and calls for active treatment. If the 
 inflammation spreads to the lining membrane of the larynx, the 
 case is almost hopeless. 
 
 Treatment. — Tlie parts should be painted with a strong solu- 
 tion of nitrate of silver — 30 or 40 grains to the ounce of distilled 
 water — the patient should breathe a warm moist atmosphere, he 
 
PYEMIA. 89 
 
 should steam his throat from time to time, and make frequent use 
 of stimulating, astringent, or disinfecting gai-gles. (F. 3, 4.) If 
 it is apparent from the increasing dyspnoea, hoarse cough, and 
 tenderness about the neck, that the inflammation is extending to 
 the larynx, the question of laryngotomy or tracheotomy will have 
 to be considered, and that without delay. 
 
 The difficulty of breathing and swallowing which accompanies 
 this disease renders it a peculiarly exhausting one. The treat- 
 ment must, therefore, be of a supporting and stimulating kind 
 from the first. 
 
 Erysipelas of serous membranes. — Among serous membranes 
 the arachnoid and the peritoneum are those which are most often 
 attacked by erysipelatous inflammation. In either case the 
 disease generally follows an injury, or an operation, or erysipelas 
 of some contiguous part. Under any circumstances it is extremely 
 fatal. The treatment must be conducted on those general prin- 
 ciples which have already been indicated. 
 
 PYJEMZA 
 
 is the name given to a disease which is nearly related to the 
 worst forms of surgical fever and erysipelas, and which manifests 
 itself by well-marked constitutional phenomena of a febrile kind. 
 
 It is always preceded by suppuration, and it leads to the forma- 
 tion of abscesses in difierent parts of the body. Hence it has been 
 supposed to depend upon the admixture of pus with the blood. 
 But this theory is scarcely tenable, for — 1st. How, it may be 
 asked, does the pus effect an entrance into the circulation ? 2nd. 
 It has been proved by experiment that pus may be mixed with 
 the blood without producing pysemia. 3rd. Though sometimes, 
 on microscopic examination, the blood seems to contain pus 
 globules, it is much more probable that they are in reality white 
 blood corpuscles. 
 
 On the whole it appears most probable that the pysemic fever 
 is generated by a poison which is absorbed from the suppurating 
 surface, but which is much more subtle and delicate in its nature 
 than pus. Hence the disease is now often spoken of as ichorcemia 
 or septiccemia — putrid infection of the blood. And thus it is 
 linked to the large class of cases which are included under the 
 term " blood-poisoning," many of which arise without any wound 
 or any suppuration. 
 
 Two other points are worthy of notice which are common to 
 pyaemia and many other cases of blood-poisoning. (1) The white 
 blood corpuscles are increased in number : there is leucocytosis : 
 and if the patient survives the attack it may be months or even 
 years before the proper quality of the blood is restored. (2) There 
 
90 CONSTITUTIONAL EFFECTS. 
 
 is a tendency to phlebitis and the formation of blood clots. In this 
 way sudden and alarming complications may arise at any time. 
 
 When a person is about to be attacked by pyaemia, the wound 
 usually becomes dry and unhealthy. The pus which is secreted 
 is scanty and thin. At the same time there is increased frequency 
 of the pulse and breathing. The temperature rises, and the 
 patient has a rigor, more or less distinct. This is soon followed 
 by a copious perspiration, and coincidently the temperature 
 falls. 
 
 WTien the disease is fully established the complexion is sallow 
 or leaden. The eyes sunken. The features pinched. The tongue 
 dry and brown. The pulse quick and weak. The respiration 
 hurried. The breath has a faint sweetish hay-hke odour. The 
 skin is moist, and, after a well-marked rigor, it is bathed in sweat. 
 There are occasional shiverings, and wandering pains are felt in 
 various parts. With all this there is great prostration, rapid 
 wasting, and a tendency to delirium. The urine often contains 
 albumen. 
 
 The secondary abscesses that are apt to form ai'e usually met 
 with in internal organs, particularly in the lungs and liver, or in 
 the neighbourhood of joints; but they may appear almost anywhere. 
 When they are situated in internal organs the disease generally 
 runs a short and fatal course ; but when they are in the neigh- 
 bourhood of joints, or among the muscles, it may last for weeks or 
 months. In these protracted cases the patient may either sink 
 from exhaustion, or he may recover with more or less impairment 
 of the structure or function of the affected part. 
 
 When the pyaemia has taken its origin from a wound which 
 is discharging/cB^Jc^ pus, the disease is usually particularly virulent. 
 
 Treatment. — As pysemia is promoted by a want of fresh air, by 
 overcrowding, and by unfavourable hygienic conditions, so it may 
 be, in a great measure, prevented by scrupulous cleanliness, 
 attention to drains, free ventilation, and plenty of cubic space. 
 
 In a case where it has declared itself, the first matter which 
 must engage the surgeon's attention is, therefore, to secure 
 thorough ventilation — in fact to immerse the patient in a fresh- 
 air bath. The medical and dietetic treatment should be stimulating 
 and supporting. The food should consist of beef-tea, and milk, 
 with a little wine or brandy. If there are superficial abscesses, 
 they should be opened, and poulticed. 
 
 Ammonia, quinine, bark, and the chlorate of potash, are the 
 remedies that hold out most hope. (F. 34, 42, 59, 65.) 
 
 Indeed the treatment of pyajmia may almost be summed up in 
 the words — free support and free ventilation. 
 
91 
 
 TBTAITUS 
 
 is a disease of the spinal nervous system — the cord and the 
 medulla oblongata — and indicates an undue excitability. It may 
 arise spontaneously {idiopathic), but much more often it follows 
 an injury (traumatic). 
 
 It is characterized by tonic spasm and rigidity of the muscles, 
 with frequent exacerbations. Sometimes the muscles of the neck 
 and jaws are chiefly or solely affected {trismus). Sometimes the 
 muscles of the back are so strongly contracted that the body is 
 bent like a bow, resting on the head and the heels {opisthotonos). 
 
 It is much more common in men than in women, and usually 
 occurs during the early years of adult life. 
 
 The disease may be either chronic or acute. The chronic cases 
 are generally idiophatic, and often recover. The acute cases are 
 usually traumatic, and are very fatal. 
 
 Traumatic tetanus may follow a mere contusion, but much more 
 frequently it is caused by a wound. Wounds of the hands and 
 feet are particularly apt to give rise to it, perhaps because these 
 parts are highly supplied with nerves. Ragged and dirty wounds 
 are more dangerous in this respect than those which are made 
 with a clean sharp instrument. It often follows burns. The 
 alternations of temperature, heat and cold, and the changes in the 
 weather seem to have some share in favouring its production. 
 
 The disease may come on when the wound is in any stage, but 
 most frequently it shows itself during the period of cicatrization. 
 The symptoms are referrible to the true spinal system, and indi- 
 cate extreme irritability. There are no unusual appearances at the 
 seat of injury. Indeed, throughout the whole illness there are no 
 local phenomena worthy of notice. The first symptom is pain and 
 stiffness about the neck. This soon spreads to the muscles of 
 mastication, deglutition, and respiration. Hence the popular name 
 of the malady — lock-jaw. The muscles of the face are thrown 
 into strong contractions, giving rise to a characteristic expression 
 of countenance — the risus sardonicus. The disease next extends 
 to the diaphragm. There is pain at the ensiform cartilage, 
 shouting backwards and causing irregular and embarrassed breath- 
 ing. Gradually the muscles of the abdomen, back, and lower 
 limbs become affected. The whole body is stiff and rigid — perhaps 
 strongly arched, resting upon the occiput and the heels. The arms 
 and the tongue are among the last parts that are implicated. 
 
 With all this the cerebrum is unaffected ; the mind remains 
 clear. The bowels are constipated, and the stools offensive. 
 There is usually but little fever. It is true the pulse is quick 
 
92 TETANUS. 
 
 and the skin hot and perspiring, but this may be explained by the 
 strength of the contractions, and the pain that accompanies 
 thera. Sometimes, however, especially as the disease approaches 
 a fatal termination, very high temperatures have been re- 
 corded. 
 
 Death takes place either from apnoea consequent upon spasm of 
 the larynx, or from exhaustion. The morbid appearances do not 
 throw much light on the nature of the disease. There is gene- 
 rally, but not always, congestion of the cord, with some degree 
 of serous effusion. Dr. Lockhart Clarke has seen softening and 
 disintegration of the grey matter. Mr. Erichsen has observed 
 that some one nerve, leading from the seat of inj ury, will always 
 be found distinctly congested. 
 
 Treatment. — When there is a suspicion of danger the wound 
 should be excised ; or a deep incision should be made round it on 
 its proximal side, so as to divide its nervous connexions. But 
 when once the disease is thoroughly established no local treat- 
 ment seems to be of any avail. 
 
 The constitutional treatment should consist in the administra- 
 tion of a purgative — castor oil or calomel, for example — and this 
 should be followed by enemata from day to day, as occasion 
 requires. To moderate or suspend the muscular contractions the 
 surgeon may try the effect of ice to the spine, or the inhalation 
 of chloroform, or full doses of opium, Indian hemp, Calabar bean, 
 chlorodyne, or chloral. The use of an anaesthetic will at least 
 have the effect of mitigating the patient's sufferings; but no 
 remedy has been found which appears to have any constant or 
 uniform influence over the disease. Profuse sweating has proved 
 successful in Wagstaffe's hands. But what is most important of 
 all is that the patient should have perfect quiet — that every 
 possible source of irritation should be removed. At the same 
 time he must have plenty of beef-tea, milk and other fluid food, 
 with brandy or wine, to support his strength, and to resist the 
 tendency to death by exhaustion. 
 
 Tetanus sometimes requires to be distinguished from poisoning 
 by strychnia. Speaking generally, the symptoms of poisoning 
 come on suddenly, and recur in paroxysms, with intervals of com- 
 plete remission. The onset of tetanus is more gradual, but when 
 once established it is persistent, though subject to exacerba- 
 tions. 
 
 Hysteria sometimes simulates tetanus; but the imitation is 
 seldom so complete as to give rise to much difficulty in the diag- 
 nosis. 
 
93 
 
 HVSTERZa. 
 
 is a disease of the nervous system, characterized by more or less 
 disturbance of volition, sensation and emotion. The mind has 
 lost its firmness, and is a prey to morbid fancies. 
 
 It is a disease which affects women much more often than 
 men. It generally comes under the notice of the physician, but 
 it is necessary that the surgeon should be aware of its manifesta- 
 tions, or it may betray him into serious errors of practice. 
 
 In an " hysterical fit " the patient becomes insensible, and falls 
 down. She lies in an unconscious state, or perhaps talking in- 
 coherently, or tossing her arms about in a restless manner. The 
 pulse and the temperature are not afiected. The breathing is 
 slow and shallow ; but every now and then the patient relieves 
 herself by a long sighing inspiration. Such a fit may last for a 
 few minutes or for hours, and that in spite of all that can be 
 done to restore the patient. 
 
 As we have just said, hysteria sometimes simulates tetanus, at 
 other times it assumes the characters of spinal disease, or of 
 disease of the joints or breast, or of neuralgia, or of other com- 
 plaints. Indeed, there is hardly a malady which may not be 
 modified, if not altogether simulated, by the hysterical tempera- 
 ment. 
 
 The collateral circumstances of the case, and a careful examina- 
 tion of the part when the patient's attention is directed to some- 
 thing else, will generally enable us to form a correct diagnosis, 
 and to disentangle the real from the imaginary symptoms. 
 
 Treatment. — When a patient is seized with an " hysterical fit," 
 cold water should be sprinkled on her face and chest, strong 
 smelling salts applied to her nose, the lips moistened with brandy 
 or sal volatile, the hands and feet rubbed, and hot water bottles 
 applied to the body. 
 
 When the " fit " is over, as well as in that large class 
 of cases which do not manifest any such severe symptoms, we 
 must endeavour to improve the patient's general state by tonics 
 (Fig. 47, 52, 66) and a change of air, as well as to brace the mind 
 by giving it healthy occupation. All trifling amusements and all 
 listless habits should be forbidden, and the patient should be en- 
 couraged to follow some branch of industry or learning, to devote 
 herself to some active work of charity, or to practise diligently 
 some accomplishment or fine art for which she may have a taste, 
 and which, by engrossing her attention, will divert her thoughts 
 from herself. If the occupation is one which necessarily takes 
 
94 CONSTITUTIONAL EFFECTS. 
 
 the patient much into the open air, such as botany, geology, or 
 sketching from nature, it is likely to be all the more beneficial. 
 At the same time late hours should be prohibited, the patient 
 should rise as soon as she awakes in the morning, and take a cold 
 or tepid sponge bath. In short, a well-regulated dietary — using 
 the word in the fullest sense which its derivation suggests, and 
 including not merely the food taken, but the hours of meals, and 
 the exercise and stated employments of the day — is essential to 
 the recovery of the patient. 
 
 Having secured the observance of these, the most necessary 
 conditions, some mild local treatment may be used to satisfy the 
 invalid. But we must carefully abstain from all such active 
 measures as we should employ if the case was one of organic 
 disease. There is no use in trying to argue the patient out of 
 her morbid fancies. They are real to her, and must be treated 
 as such. Any attempt to prove that they are merely the result 
 of a diseased imagination will only aggravate the symptoms and 
 make her cling to her delusion with all the greater tenacity. As 
 Archbishop Whately justly observes — "When a person has a 
 morbid fancy the worst course is to attempt to argjje or reason 
 him out of it ; this only makes him the champion to defend it 
 against all opponents. The only way is to lead the mind to other 
 topics, and to insensibly cause it to be forgotten. That which 
 did not come in at the door of reason will not come out of it." 
 
PART IV. 
 
 DISEASES AND INJURIES OF VAUIOUS 
 PARTS— TISSUES AND ORGANS. 
 
 CUTAZTSOTTS Vl^CERS. 
 
 The skin is liable to be affected by ulcers of various kinds. 
 Their commonest situation is the leg, just above the ankle. The 
 ulceration is the result of a local and circumscribed inflammation. 
 Such inflammation may have either a non-specific or a specific 
 origin, but in either case the ulcers are divided according to their 
 characters into (1), healthy (2), weak (3), indolent (4), irritable 
 (5), inflamed (6), phagedsenic. 
 
 1. The healthy ulcer is nothing more than a sore when it is 
 granulating normally. The granulations are small, regular, close - 
 set, of a deep rose colour, and highly vascular. The pns, which 
 bathes the surface, is laudable. The edges have a bluish or 
 bluish-white tint, and the margins have a tendency to contract. 
 
 The treatment of such an ulcer is of the simplest kind. A 
 studied position, together with water-dressing, or a little simple 
 ointment, is all that is needed. 
 
 When the sore is large, such as is sometimes left after an 
 extensive burn, the healing process may be expedited by skin- 
 grafting, in the manner recommended by M. Reverdin. A 
 minute piece of healthy skin is raised with a forceps, cut off with 
 scissors, laid upon the granulating surface, and secured in that 
 position by a pad of dry lint and a strip of plaster. The 
 transparent isinglass plaster is particularly well suited for the 
 purpose. As many such grafts may be made as the size of the 
 wound requires, but they should on no account be tried unless 
 the ulcer is in a perfectly satisfactory state. The graft need 
 
96 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 Skin-graft. 
 
 not extend through the whole thickness of the skin. It is 
 enough if rather more than the cuticle is taken. Fig. 30 repre- 
 -p. OA sents such a graft on the 
 
 twelfth day. The original 
 piece of skin transplanted 
 was about the size of a 
 canary seed. It not only 
 grew rapidly, but it seemed 
 to stimulate the edges of the 
 wound so that they rapidly 
 approached one another, and 
 the whole was soon healed 
 over. 
 
 . The medical treatment of 
 ulcers must not be over- 
 looked. In some cases opium 
 is of great value ; in others, 
 arsenic ; and where there is a syphilitic taint, mercury or iodide 
 of potassium should be prescribed. 
 
 2. The weaTc ulcer is a degenerated form of the preceding. 
 From some cause — constitutional or local — the granulations be- 
 come pale, irregular, and flabby, and the discharge thin and serous. 
 The treatment consists in using stimulating applications — e.g., 
 ung. zinci, or ung. hyd. nit. or zinc lotion (F. 25), or nitric acid 
 lotion (F, 13) ; while the part is supported by strapping or a 
 bandage, and we try to improve the patient's general health. 
 
 For strapping an ulcer of the leg the surgeon should 
 provide himself with a number of strips of adhesive plaster, 
 about an inch broad and long enough to go once and a half 
 -p. Qi round the part. The patient 
 
 should be directed to place 
 his heel on the edge of a 
 chair, and then the sur- 
 geon should apply the strips 
 of plaster in regular order 
 from below upwards, laying 
 the centre of the strip on 
 the limb opposite the ulcer, 
 and bringing the ends round 
 and crossing them over the 
 dressings in the way repre- 
 Strapping an ulcer. sented in Fig. 31. The 
 
 strapping should extend from a little below the ulcer to a little 
 above it, and each strip of plaster should overlap the preceding 
 one to a slight extent, so that there may be no intervals between 
 
CUTANEOUS ULCERS. 
 
 97 
 
 them. After the strapping has been applied, the leg should be 
 bandaged from the toes upwards, to give it firm and even support, 
 and to prevent it from becoming cedematous. For this purpose 
 flannel, cotton elastic, or India-rubber bandages are the best. 
 
 The indolent ulcer is often seen in old persons. Its most com- 
 mon situation is the leg just above the outer or inner malleolus. 
 
 Fig. 
 
 32 
 
 and sometimes it attains 
 an enormous size (Fig. 
 32). The raw surface is 
 pale, smooth, callous, and 
 not unlike a mucous 
 membrane. The edges 
 are abrupt, thickened, 
 hard, and white. The 
 adjacent tissues are in- 
 durated by solid oedema. 
 
 The treatment consists 
 in destroying the callous 
 surface by a blister or 
 by caustics, and then 
 stimulating the ulcer by 
 such lotions and ointments 
 as have been named above, 
 while we depress the 
 edges by strapping or 
 bandaging, and at the 
 same time give support 
 to the venous circulation. Indolent iilcer of the leg. 
 
 Indeed, the treatment of ulcers by careful strapping — the 
 method recommended by Mr. Baynton nearly eighty years ago — 
 is too much neglected at the present day. When it can be 
 thoroughly carried out it is the most satisfactory way of dealing 
 with a chronic sore. Sometimes, in obstinate cases, which are 
 not dependent upon varicose veins, the operation recommended 
 by Mr. Gay may be undertaken. It consists in making an in- 
 cision through the skin down each side of the ulcer, about half 
 an inch from its margin, so as to divide the thickened tissues, and 
 allow the edges of the sore to approach one another. The incisions 
 must be filled with lint to prevent them from closing too soon. 
 
 4. The irritable nicer is shallow, with thin edges. The surface 
 presents a number of irregular granulations of a dark-red colour 
 and highly vascular. It is accompanied by constant pain, is 
 extremely sensitive, and bleeds on the slightest touch. It pours 
 forth a thin, acrid secretion, mingled with fragments of a greyish 
 slough. Usually the whole surface has been irritated by the 
 
 u 
 
98 DISEASES OF TISSUES AND ORGANS. 
 
 friction of the patient's clothes, or some similar cause. According 
 to Mr. Hilton, a spot may sometimes be found where the extreme 
 sensibility resides; and then careful examination may detect 
 filaments of denuded nerves. In such a case an incision across 
 the course of the nerve will destroy sensation and secure physio- 
 logical rest. 
 
 The treatment consists in removing everything that can fret 
 the sensitive surface, and then touching the part thoroughly all 
 over with nitrate of silver. This may be repeated every two or 
 three days. During the intervals the sore should be dressed 
 with sedative or anodyne applications — e.g., nng. plumbi acetatls, 
 or lead lotion with laudanum. (P. 24.) 
 
 Constitutional treatment is here of the utmost importance. The 
 secretions must be regulated, the health improved by tonics, and 
 nervous irritability allayed by sedatives or narcotics in full doses. 
 
 5. The inflamed ulcer may either arise from an aggravation 
 of the original inflammation, or it may be induced by excessive 
 stimulation. 
 
 The marcjins are red and swollen. The surface is soft and 
 friable, emitting a profuse and unhealthy discharge. There is 
 heat and pain in the part with constitutional febrile symptoms. 
 
 The treatment should be mildly antiphlogistic. Aperients and 
 salines should be given, while the part is elevated, and constantly 
 fomented or poulticed. To do this thoroughly, the patient should 
 lie in bed with his leg raised on a pillow, and protected from the 
 bedclothes by a cradle. Sometimes leeches may be requisite. 
 When the inflammation has been subdued, water-dressing is all 
 that will be needed. 
 
 6. The pJiacfedcBnic ulcer, when it is not syphilitic, is merely an 
 advanced stage of the foregoing. The ulceration spreads rapidly, 
 the tissues breaking down and becoming disintegrated. When 
 sloughs form round the margins of the wound, and the tissues 
 perish en masse, the disease is called sloughing pJiagedcena. 
 
 These varieties of ulceration are commonly accompanied by 
 a good deal of pain and constitutional disturbance. They indi- 
 cate that the patient is in bad health from some cause which 
 de])resses the system and vitiates the blood — the exhalation from 
 drains, for example. They are frequently associated with 
 syphilis, and, when this is the case, they often commence in the 
 disintegration of a subcutaneous gumma. 
 
 The treatment consists in placing the patient in favourable 
 hygienic conditions, restoring his general health, destroying the 
 ulcerating surface by escharotics, — the strong nitric acid, for 
 examjjle — and dressing the sore with antiseptic or stimulating 
 lotions. (l<\ 12, 13, 25.) 
 
VARICOSE ULCERS. 
 
 HOSFITAI. GAM-GRENZ:. 
 
 It sometimes happens that sloughing phagedaena prevails as an 
 epidemic in hospitals. It is then called hospital gangrene. At 
 the present day this disease rarely occurs in civil practice. It is 
 most frequently seen in naval and military hospitals, when the 
 wards are overcrowded and the cases severe, and when it is 
 impossible to pay proper attention to cleanliness and ventilation. 
 These are the conditions under which it originates. 
 
 When once established, it is very prone to spread, the poison 
 being conveyed from one person to another either directly by 
 sponges, dressings, &c., or indirectly through the atmosphere. 
 
 It may supervene upon a wound of any kind, or even upon a 
 mere bruise. 
 
 The edges of the wound become painful, swollen, and livid ; a 
 greyish slough covers the surface ; the discharge becomes thin 
 and scanty. 
 
 If the disease is not checked, the surrounding tissues soon 
 become gangrenous, and this destructive action spreads with fear- 
 ful rapidity. Eones may be exposed ; or vessels may be opened, 
 and copious hoemorrhage may ensue. These local symptoms are 
 accompanied by great constitutional disturbance. 
 
 Treatment. — The patient should, if possible, be placed in con- 
 ditions more favourable to health. The sloughing surface must 
 be destroyed with strong nitric acid or with the actual cautery, 
 and the resulting wound treated on general principles, with a free 
 use of washes containing Condy's fluid or carbolic acid. The 
 strength must be upheld by a generous diet and stimulants, while 
 pain is allayed by opium or similar drugs. It is hardly necessary 
 to add that everything should be done to prevent contagion and 
 to disinfect the atmosphere. 
 
 VARICOSE UXiCERS. 
 
 A great many ulcers on the legs are due to the presence of 
 varicose veins. All such ulcers, whatever other characters they 
 may have, are called varicose ulcers. (See Fig. 42.) 
 
 The special treatment must have reference to the dilated con- 
 dition of the veins — while the limb is in a state of passive con- 
 gestion, from the retardation of the venous current, it is almost 
 impossible to cure the ulcer. In some cases the varicose veins ad- 
 mit of being obliterated. In other cases the surgeon must be con- 
 tent to support them by means of a bandage or an elastic stocking. 
 
 As the surgeon has often to bandage the leg not only for 
 varicose veins, but also for m.any other conditions, we shall take 
 this opportunity of explaining how it should be done. Let us 
 
 H 2 
 
100 
 
 DISEASES OF TISSUES AND OEaANS. 
 
 suppose that the right leg has to he bandaged. The patient 
 should be allowed to sit in an easy position with his 
 
 heel supported upon a 
 Fig. 33. chair and his foot placed 
 
 in the mid-position be- 
 tween flexion and exten- 
 sion. The surgeon then 
 takes the bandage in his 
 right hand, and lays the ex- 
 ternal surface of the roU on 
 the inner ankle. Then 
 with his left hand he 
 draws out a few inches of 
 the end of the bandage, 
 and this free extremity he 
 conducts round the back of 
 the ankle, and lays it across 
 the dorsum of the foot. 
 (Fig. 33.) He then brings 
 the roUer across the instep 
 and over the extremity of the bandage. In this way he 
 secures the end, and obtains a fixed point to start from. He 
 then carries the roller round the outside of the foot, keeping 
 the roll of bandage close to the skin, and makes one or 
 two circular turns round the foot, a little above the roots of the 
 toes. The bandage is next brought up on the inside of the arch, 
 taken over the dorsum, then round the ankle, and brought 
 obliquely across the instep to the outer edge of the foot. It is 
 now carried under the sole as before, then obliquely across the 
 dorsum, and on reaching a point immediately above the ankle the 
 bandage is conducted in simple circular turns round the small of the 
 leg until it reaches the calf, where " reverses" will be required, 
 in order to make it lie evenly. (Fig. 34.) The "reverses" 
 ought not to be placed over the shin, but a little to its outer side. 
 When the bandage has reached the upper part of the calf, it 
 should be finished ofi" with one or two circular turns, and fastened 
 on the outside of the leg. 
 
 There are various ways of commencing this bandage. Some 
 surgeons begin by laying the end of the roller upon the instep j 
 others upon the outer edge of the sole ; but all agree in bringing 
 up the bandage on the inside of the foot so as to support the arch- 
 When it is necessary to cover the heel, the surgeon should use 
 an " arm-bandage," because a " leg-bandage " is rather too broad 
 to adapt itself readily to the part; and a flannel roller will 
 generally be found better suited to the purpose than a calico one. 
 
BOIL. 
 
 101 
 
 The bandage shoiild be applied to the foot in the ordinary way, 
 only more turns will be required, and it will be necessary to apply 
 
 Fig. 34. 
 
 them more closely over 
 the heel. It is always 
 a difficult matter to 
 cover the heel evenly, 
 and the aid of a few 
 stitches may sometimes 
 be needed to enable the 
 surgeon to do it in such 
 a manner that the 
 bandage shall keep its 
 place for any length of 
 time. 
 
 But to return to the 
 subject of varicose 
 ulcers. In every in- 
 stance rest in the hori- 
 zontal position with the 
 
 leg raised upon a pillow, so that it may be a little higher than the 
 hip, should form an important element in the treatment. The 
 patient should be warned against standing much. A brisk walk 
 is not nearly so harmful as " hanging about on the feet." The 
 general treatment of the sore must be conducted on the 
 principles already laid down and accoi'ding to its peculiar 
 characters. 
 
 Mr. Hilton recommends that those who have varicose ulcers 
 should raise the foot of the bedstead, on which they habitually 
 sleep, a few inches from the ground. By this simple device an 
 ulcer which has once been healed may be prevented from breaking 
 out again. 
 
 BOII.. 
 
 A boil ifurunculus) is a limited and circumscribed inflammation 
 of the true skin. It often originates in a sebaceous follicle. It 
 is attended with considerable pain. It usually runs on quickly 
 to suppuration, bursts, and discharges its contents by a single 
 orifice. Sometimes, however, it advances but slowly. There is 
 much inflammation and induration with little or no tendency to 
 suppuration. This is what is popularly called a blind boil. 
 
 Sometimes the boil is single, but more frequently a number 
 appear at once or in succession. 
 
 It depends upon a vitiated state of the blood, from living too 
 high, or living too low ; from a want of proper exercise ; or 
 from a want of cleanliness. Sometimes it is excited by local 
 irritation, as every oarsman knows. Some persons are subject to 
 
102 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 boils every spring, depending apparently upon the feeble state of 
 health into which they fall at that season. 
 
 Boils generally show themselves on the trunk, more particu- 
 larly in those situations where the skin is thickest, as the shoulders 
 and buttocks. 
 
 The treatment consists in clearing out the bowels, and after- 
 wards regulating the secretions. The diet should be light, 
 nutritious, and unirritating. Tonics, such as the mineral acids, 
 quinine, or the preparations of iron or of arsenic, should be 
 prescribed. (F. 47, 52, 65.) A change of air will generally be 
 found very beneficial. 
 
 Locally the boil should be poulticed or treated with water- 
 dressing until suppuration takes place. If it is slow to open, it 
 may be pricked with the point of a lancet, and the poultice con- 
 tinued ; but if it breaks naturally, so much the better. 
 
 Blind boils should be touched with nitrate of silver, strong 
 nitric acid, potassa fusa, or the acid nitrate of mercury, and 
 then poulticed. If a hard indolent swelling remains, it shonld 
 be rubbed with a stimulating ointment, or painted with tincture 
 of iodine. • 
 
 CARBUXTCXiB 
 
 (anthrax) is also a local and circumscribed inflammation of the 
 skin, but more extensive than a boil and more severe in its 
 
 symptoms. 
 
 The affected part becomes 
 of a dull red colour, slightly 
 raised, brawny, and intensely 
 painful and tender. In two 
 or three days, it suppurates, 
 and discharges pus from a num- 
 ber of points. Large portions 
 of the skin, and of the sub- 
 cutaneous cellular tissue, slough, 
 and a foul, irregular sore is left. 
 With this there is more or 
 less constitutional disturbance, 
 generally of an asthenic kind. 
 
 Carbuncle occurs most fre- 
 quently on the back of the 
 neck, the shoulders, and but- 
 tocks (Fig. 35). It is dis- 
 tinguished from a boil by its 
 greater size, by its proneness 
 to spread, by the flat eleva- 
 
RUPTUEE OF MUSCLES OR TENDONS. 103 
 
 tion which shows no tendency to " point," and by the number 
 of openings from which the discharge escapes. 
 
 It is a disease of middle and old age, and depends upon a 
 faulty condition of the blood. It is r\re to see more than one 
 carbuncle present in the same individual. The prognosis will 
 depend upon the size and situation of the carbuncle, upon the 
 age and constitution of the patient, but most of all upon the 
 soundness of the viscera — especially of the kidneys. 
 
 Treatment. — An aperient should be prescribed at the outset, 
 and followed by alteratives and tonics as occasion requires. 
 Opium, or drugs of the same kind, will have to be given in full 
 doses. A nutritious diet with stimulants will be needed from 
 the first. 
 
 The local treatment consists in giving a free vent to the dis- 
 charges and sloughs. This may be done by nnaking a free crucial 
 incision, or several small straight ones, across the affected pirt. 
 This should be done early, so as to save the skin. A poultice 
 should then be applied to hasten the separation of sloughs. Some 
 surgeons prefer to open the carbuncle by the application of 
 potassa c. calce, or nitrate of silver. The potassa fusa answers 
 admirably. Two or three pieces the size of a pea should be laid 
 on the carbuncle, and secured by strips of plaster. The pain 
 they cause is trifling. Sometimes the unhealthy action spreads, 
 and it becomes necessary to make further incisions, or to apply 
 caustics. When the sloughs have all come away, and the raw 
 surface has assumed a healthy character, it must be treated on 
 general principles. The healing process is usually slow and 
 tedious. 
 
 RUPTURE OF mUSCIiES OR TETiTDOWS. 
 
 Muscles or tendons are sometimes ruptured by sudden and 
 violent action. The muscles of the limbs are most liable to this 
 accident. The tendo Achillis is particularly apt to give way. 
 Sometimes, however, the muscles of the trunk are torn across — 
 e.g., in tetanus. 
 
 The symptoms are sharp pain, sometimes accompanied by a 
 snapping noise, loss of power, and a palpable depression in the 
 continuity of the muscle or tendon. 
 
 In the treatment of such cases the great object is to relax the 
 muscle or tendon, and to approximate the torn surfaces. The 
 part should be kept at perfect rest in this position for a month, 
 and then passive motion should be cautiously made. When the 
 tendo Achillis is ruptured, the leg should be flexed at the knee, 
 and retained in that position by a cord connected at one end with 
 the heel of the patient's slipper, and at the other with a bandage 
 
104 DISEASES OF TISSUES AND ORGANS. 
 
 passing round the thigh. For some time after he begins to move 
 about he should wear a high-heeled shoe. 
 
 Repair takes place by the effusion of plastic material within the 
 sheath, and this material gradually becomes organised into a i 
 structure resembling tendon. But it will probably be some ' 
 months before the patient has the free use of the part. 
 
 SFRAixrs. 
 
 A sprain consists in the sudden and forcible stretching of the 
 tendons or ligaments connected with a joint, without dislocation. 
 Sometimes the tissues are more or less lacerated. The accident 
 is accompanied by severe pain, and followed by rapid swelling. It 
 is always troublesome and tedious, and may lead to serious 
 results. Many a case of joint-disease has originated in a neglected 
 sprain. 
 
 The treatment should aim at preventing inflammation, pro- 
 moting absorption, and restoring healthy action. During the 
 first stage the part should be kept at rest in an elevated position, 
 and cold continuously applied. If, notwithstanding, there is in- 
 flammation, fomentations should be used, perhaps even leeches 
 may be required. 
 
 As soon as the acute symptoms have subsided, absorption 
 should be promoted by systematic rubbing, with or without stimu- 
 lating liniments or ointments, or by the pressure of a well-adjusted 
 bandage. If the patient is of a rheumatic or gouty habit of body, 
 the bicarbonate or the nitrate of potash, with colchicum or the 
 iodide of potassium, should be prescribed. (F. 56, 61, 64.) 
 
 Gradually passive motion may be begun in order to restore the 
 part to its proper functions, and the patient may be allowed to 
 make moderate use of the joint. If any stiffness remains, warm 
 salt water douches, or a visit to the thermal springs of Bath, Aix- 
 la-Chapelle, or Bareges, are often attended with benefit. 
 
 Sprained ankle. — Sprains of the ankle are so common, and so 
 important, that their treatment deserves a special mention. 
 
 If the patient is seen soon after the accident, nothing more is 
 required in many cases than to support the part by applying a 
 roller from the toes to a short distance above the ankle, or by 
 strapping and a bandage. 
 
 When the ankle has to be strapped, the surgeon should provide 
 himself with a number of strips of the common diachylon plaster, 
 about an inch wide and long enough to encircle the part. These 
 should be well warmed by holding them before the fire, or by 
 dipping them in hot water. The patient should then be directed 
 to place his foot upon the edge of a chair, and the surgeon 
 should apply the first strip of plaster across the sole of the foot, 
 
WHITLOW. 105 
 
 immediately above the roots of the toes, bringing up the ends on 
 each side, and crossing them on the instep. Thus he applies one 
 strip after another, each strip overlapping Yig. 36. 
 
 the previous one by about a third of its 
 breadth, until the whole of the anterior por- 
 tion of the foot has been covered. The next 
 strip he passes behind the leg, applying it 
 immediately above the heel, and bringing 
 the ends forward, one on each side, and 
 crossing them in front of the ankle. In 
 this way he places as many strips as may 
 be necessary, each strip rising a little 
 higher up the leg than its predecessor. 
 The plaster should be applied firmly, so 
 as to make a slight degree of pressure, 
 and if the strips are properly placed it is Strapping the ankle, 
 only the point of the heel which will be left uncovered. As a 
 rule the narrower the pieces of diachylon, the more closely will 
 they adapt themselves to the shape of the part, and the more 
 even will be the support which they afford. If the plaster does 
 not lie flat, or if its edges press unduly upon the skin, and impede 
 the circulation, it should be nicked in different situations with a 
 pair of scissors. It is a good plan to apply a narrow flannel or 
 calico bandage over the strapping, so as to fix the plaster and 
 give additional support to the limb. 
 
 If, however, the sprain is not seen until effusion and swelling 
 have taken place, then it may be necessary to confine the patient 
 to the sofa, to enjoin rest, and to use warm or cold applications 
 according to the circumstances of the case. Sometimes a poultice 
 or a fomentation will be found to give most relief: but at other 
 times the surgeon will have to try the effect of a spirituous lotion 
 or a bag of pounded ice. After the acute symptoms have been 
 subdued, the pressure and support which are afforded by a well- 
 adjusted bandage will be found of great benefit. A flannel or 
 cotton-elastic roller is best suited to such cases ; or an elastic 
 gaiter may be worn with great comfort. The patient should be 
 encouraged to use his ankle in moderation, in order to prevent the 
 formation of adhesions about the joint. 
 
 "WUITJmO'W. 
 
 {Paronychia) is an acute inflammation at the point of the finger. 
 It may be considered under two degrees. The first and most 
 severe form is that which affects the tendons and bone ; the 
 second involves only the skin, the matrix of the nail, and the 
 subcutaneous cellular tissue. 
 
106 DISEASES OF TISSUES AND OEGAXS. 
 
 1. In the more severe variety of wlntlow the inflammation is 
 deeply seated from its commencement. It begins in the sheath 
 of the tendons, or in the periosteum. The redness and swelUng 
 extend to the hand and forearm. The tension is great. The 
 pain is intense and throbbing. The patient gets no rest by night 
 or by day, and is worn out by the severity of his malady. 
 Matter forms in the course of a few days, but it takes a long 
 time to make its way to the surface, and in the meanwhile the 
 vitality of the bone will probably be impaired, and more or less 
 of it destroyed. 
 
 2. The milder form of the disease generally originates in the 
 pulp of the finger or in the matrix of the nail. The patient, who 
 is probably out of health at the time, receives a prick, or a 
 poisoned punctured wound, near the end of the finger. The part 
 begins to swell, and becomes hot, red, and piinf'ul. These symp- 
 toms increase in severity until matter forms, and discharges 
 itself. Tlie nail will probably be thrown ofl', and its place gradually 
 supplied by a new one. 
 
 In both these varieties of whitlow there is more or less con- 
 stitutional disturbance, according to the severity of the symptoms. 
 The bowels are constipated, the tongue turred, and the pulse quick. 
 At the same time the blood is probably in an impure state, 
 either from over-living or from a want of proper nourishment. 
 
 Treatment. — The hand should be supjiorted by a sling in an 
 elevated position so that the fingers point towards the opposite 
 shoulder. The bowels should be freely opened, and an antiphlo- 
 gistic regimen adopted as long as the acute symptoms last. The 
 part should be constantly poulticed with linseed meal. As soon 
 as suppuration has taken place, a free incision should be made ; if 
 possible, at the side of the finger, so as not to impair its tactile 
 power, or to interfere with its future usefulness. While the 
 inflammation is at its height, sedatives must be freely given to 
 mitigate pain and procure sleep. 
 
 If the bone is necrosed, it may have to be removed, in whole or 
 in part, before the sore will heal. In such a case the soft tissues 
 should always be left, and supported on a small finger-splint. 
 Even if the entire phalanx has come away, the skin and nail will 
 make a very useful point to the finger. 
 
 When the thecal inflai-nmation has been extensive, the tendons 
 are apt to become attached to their sheaths, and the utility of the 
 finger is more or less impaired. Sometimes it is left stiff and 
 straight, sometimes it is contracted. In such cases soaking the 
 hand in warm water, rubbing the finger with soap liniment, and 
 making as much use of it as possible will be likely to do great 
 good. Forcible flexion and extension under chloroform may some- 
 
GANGLION. 107 
 
 times be practised with benefit. As a last resource, when the 
 stiffness cannot be cureil, and is interfering with the patient's 
 livelihood, amputation may be performed. 
 
 If the inflammation spreads to the hand and forearm, as it 
 occasionally does, it must be treated on general principles. 
 
 When the acute symptoms have been subdued, a course of 
 tonics and a change of air will be of great service in restoring 
 the patient's health. 
 
 GANGImION 
 is the name given to an accumulation of fluid upon, or within, the 
 sheath of a tendon. 
 
 Such ganglia are of two kinds, simple and compound. 
 
 Simple ganglia are encysted tumours, formed in the fringes of 
 the synovial sheath. Compound ganglia are diffuse collections of 
 fluid in the sheath of the tendon itself. 
 
 Each variety of the disease appears under an acute and a 
 chronic form. Ganglion is often caused by a blow or a strain, 
 but more frequently it arises spontaneously. The chronic form 
 of compound ganglion is sometimes the result of tenosynovitis. 
 
 The fluid contained in a ganglion is usually straw-coloured and 
 viscid, like synovia. Sometimes, however, it is brown from the 
 admixture of blood. Sometimes it contains fibrinous bodies, like 
 melon seeds, floating in it. 
 
 The tumour presented by a simple ganglion rarely exceeds the 
 size of a small walnut. (Fig. 37.) It is smooth and rounded, 
 
 Simple ganglion of the wrist. 
 
 elastic and translucent. It grows slowly and without pain, but 
 as it increases in size it may give rise to a good deal of incon- 
 venience by interfering witli the action of adjacent parts. It 
 may even cause acute pain and sensitiveness by stretching the 
 nerves that pass over it. This is peculiarly apt to be the case 
 with those about the palm of the hand. 
 
 The simple ganglion generally forms in connection with the 
 extensor tendons of the wrist or ankle: the compound is often 
 associated with the flexor tendons, or with both the extensors and 
 flexors at the same time. Fig. 38 represents a compound ganglion 
 
108 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 of the wrist. The patient, a young woman, was a laundress, and 
 the disease was probably brought on by wringing clothes, and 
 
 Fig. 38. 
 
 Compound ganglion of the wrist. 
 
 using heavy irons. Both wrists were sintiilarly affected, and both 
 the flexor and extensor tendons were involved. 
 
 Treatment. — A simple ganglion may frequently be ruptured 
 by pressure or by a smart blow, and then the contained fluid is 
 absorbed. Or it may be painted with tincture of iodine, or 
 smeared with a mercurial ointment, or with an ointment com- 
 posed of equal parts of ung. hydrarg. and ung, iodi, or blistered. 
 While any of these measures are being adopted, it should be 
 firmly bandaged so as to promote absorption, and fixed upon a 
 splint, so that it may have perfect rest. 
 
 If these means fail, the tumour may be punctured by a sub- 
 cutaneous valvular incision, the contents let out into the sur- 
 rounding tissues, and pressure again applied. Or the tincture of 
 iodine may be injected, or the lining membrane scarified so as to 
 set up adhesive inflammation. Or a couple of silk threads may be 
 passed through it, as a seton ; or it may be laid open, and allowed 
 to heal from the bottom ; or, as a last resource, the cyst may be 
 dissected out. These operative measures are, however, attended by 
 some risk. When any of them are undertaken, the part should 
 be fixed upon a splint, so that it may be kept perfectly at rest. 
 
 The compound ganglion is a more severe affection, and will 
 generally be found very obstinate. It must be treated on the 
 same principles as the simple variety. The effect of rest, pressure, 
 and coimter-irritation must be patiently tried. If these means 
 fail, a seton may be introduced, or tincture of iodine injected, or 
 the cavity laid freely open. But operative measures must not 
 be undertaken without great caution. If diffuse suppuration 
 should occur in the sheath of the tendon, the most serious con- 
 sequences might ensue. 
 
 TEXrOSYHrOVXTIS. 
 
 Sometimes the sheaths of tendons become acutely inflamed 
 [tenosynovitis). Such inflammation is generally caused by sprains, 
 or by the violence which gives rise to dislocations. 
 
INFLAMMATION OF BUES^. 
 
 109 
 
 In addition to other symptoms of inflammation — heat, pain, 
 tenderness, loss of power — there is more or less swelling along 
 the course of the tendon, arising from effusion into the sheath. 
 
 When the surgeon examines the part, a peculiar creaking 
 sensation is communicated to his hand. This creaking of effusion 
 has sometimes to be carefully distinguished from the crepitus of 
 broken hone. 
 
 Treatment. — The local treatment of acute inflammation of 
 tendinous sheaths consists in rest, fomentations, leeches, and 
 blisters. If the disease becomes chronic, it must be dealt with 
 as a compound ganglion. If, as often happens, there is reason to 
 believe that it is associated with a rheumatic habit, appropriate 
 medical treatment must be adopted. (F. 56, 60, 67.) 
 
 ZM-FIiAnxnCATIOM' OF BURS2:. 
 
 Bursse may become acutely inflamed from external violence, 
 irritation, or undue pressure. Any bursa in the body may in this 
 way give rise to a swelling ; but there are some which are more 
 apt to be inflamed than others. 
 
 Inflammation of the bursa 
 on the inner side of the meta- 
 tarsal bone of the great toe 
 gives rise to a bunion. When 
 the bursa between the tubero- 
 sity of the ischium and the 
 gluteal muscles is afiected, it is 
 popularly called " weavers' 
 bottom." Enlargement of the 
 bursa under the deltoid some- 
 times needs to be carefully 
 distinguished from disease of 
 the shoulder-joint. The bursa 
 over the olecranon, commonly 
 calledtheminer'sorthestudent's " Student's bursa," inflamed. 
 bursa, is liable to be inflamed. In the case from which Fig. 39 
 was drawn, there were gouty deposits about the olecranon which 
 kept up constant irritation. The bursa connected with the 
 semi-membranosus may give rise to a swelhng in the popliteal 
 space, which may simulate aneurysm. The bursa between the 
 OS calcis and the tendo Achillis is occasionally enlarged, causing 
 a swelling at the back of the ankle, sometimes on one side of 
 the foot, sometimes on both sides. Fig. 40. But the bursa 
 over the patella is that which is most often afiected in 
 this way, constituting what is known as housemaid's knee 
 (Fig. 41). The bursa enlarges. There is excessive secretion, and 
 
110 
 
 DISEASES OF TISSUES AND ORaANS. 
 
 Fiar. 40. 
 
 Inflamed bursa behind the ankle. 
 
 the secreted fluid is apt to become purulent. The tumour is elastic, 
 very painful and tender to the touch. The sliin is hot, red, and 
 
 sometimes. oedematous. 
 With this there is gene- 
 rally pyrexia — a quick 
 pulse, a white-coated 
 tongue, and constipation. 
 Treatment. — When 
 the inflammation runs 
 high, the patient should 
 have a light, unstimu- 
 lating diet, and the 
 bowels should be kept 
 freely open. The part 
 should have perfect rest, 
 the limb being fixed upon 
 a splint, and raised on a 
 pillow. Fomentations or 
 poultices should he con- 
 stantly applied, and, if need be, leeches. If suppuration takes place, 
 an incision should be made at once, and the case treated as an acute 
 Fig. 41. abscess. The opening should be over the 
 
 centre of the patella, and the direction of 
 the incision should be vertical. Fig. 42 
 was drawn from a patient who had a large 
 suppurating cavity, a bursal abscess, over 
 the patella. When she applied for advice, 
 it had already broken in several places. 
 Though it had a formidable appearance, 
 it was easily and speedily cured. The 
 patient had also a varicose ulcer on the \e^. 
 If the inflammation is chronic — if 
 there is an indolent swelling which gives 
 inconvenience, but which is not attended 
 by acute symptoms — it should be treated 
 by a back-splint and the pressure of a 
 Housemaid's Knee, bandage. At the same time it should be 
 painted with iodine tincture, or liniment; or covered with the emp. 
 ammoniaci c. hydrargyro, or with lint spread with ung. hyd. iodidi 
 rubri; or it may be blistered ; or a seton may be passed through it ; 
 or, if the tumour is so solid that it resists all milder measures, it 
 must be excised. 
 
 EXOSTOSIS 
 signifies an outgrowth from bone. It is met with under two 
 forms. Sometimes it is of ivory hardness, composed entirely of 
 
EXOSTOSIS. 
 
 Ill 
 
 the dense tissue of bone ; sometimes it is soft and spongy, and ba« 
 the structure of tlie cancellated tissue, enclosed in a sliell of hard 
 bone, and overlaid with a thin cartilage. 
 
 The ioort/ exostosis generally springs from the flat bonea, 
 particularly those of the head and face. 
 
 The cancellated exostosis is usually connected witb the long 
 bones. It is most, frequently met with about the lower end of 
 the femur, and the upper end of the tibia. 
 
 Exostosis is a disease of early Fig. 42. 
 
 adult life. Tumours of this 
 description are often multiple. 
 Sometimes they seem to originate 
 in the intiammation caused by 
 external violence ; sometimes 
 they are found at the tendinous 
 insertions of muscles; sometimes 
 they result from the bony trans- 
 formation of a fibrous or cartila- 
 ginous tumour connected with the 
 periosteum; frequently they arise 
 without any assignable cause. 
 
 An exostosis grows without 
 pain, though it soon begins to 
 cause inconvenience by the pres- 
 sure it exerts on theneighbouring 
 parts. It forms a smooth, 
 globular tumour, hard to the 
 touch and immovable. Some- 
 times it is attached by a broad 
 base ; at other times it springs 
 from a narrow pedicle. A bursa 
 is often developed between it and 
 the tissues which lie over it. 
 
 Treatment. — Constitutional 
 remedies are not likely to be of much use ; still the iodide of potas- 
 sium (F. 60) or the corrosive sublimate (F. 50) should be given, iu 
 the hope of promoting absorption, or at least of arresting growth. 
 
 The part should, as far as possible, have perfect rest. If the 
 tumour is situated on one of the limbs, a light splint should be 
 applied, and everything should be done to allay inflammatory 
 action. Not unfrequently exostoses cease to grow, and remaiu 
 stationary for years. 
 
 If, in spite of our efforts, the growth goes on increasing, and 
 gives rise to serious inconvenience, the question of extirpatiou 
 must be considered. If circumstances permit, an incision should 
 
 Bursal abscess and varicose 
 ulcer. 
 
112 DISEASES OF TISSUES AND OEGANS. 
 
 be made down to the tumour, and it should be removed with 
 Hey's saw or with bone-pliers ; or it may be enucleated in the 
 manner described by Sir James Paget (Med. Chir. Trans. ,yo\. liv.). 
 Sucb an operation will probably be followed by a good deal of 
 inflammation, and should therefore be undertaken with caution. 
 As the disease is purely local in its character, it is not likely that 
 it will reappear after it has been once thoroughly removed. 
 
 As we have already said, bone tissues enter more or less 
 into the formation of various other tumours, such as osteo- 
 sarcomatous growths and fibrous and enchondromatous tumours. 
 
 RICKETS 
 
 (racMtis) is a disease of the bones depending upon a constitutional 
 disorder allied to scrofula. 
 
 It would appear that the animal constituents of the bones are 
 normally deposited ; but there is a deficiency of the earthy salts, 
 and at the same time an expansion of the cancellous structure. 
 
 Rickets is an afiection of early life, and generally shows itself 
 about the period when children begin to walk. The natural 
 curves of the bones are increased, the shafts do not lengthen as 
 they should, and the articular ends become enlarged. These 
 characteristics are most apparent in those bones that have to bear 
 the weight of the body — the lower limbs, the pelvis, and the 
 spine. The legs are short, thick, and bent forwards and out- 
 wards. The pelvis becomes compressed and deformed; and, 
 towards the approach of puberty, the spine not unfrequently 
 shows signs of lateral curvature. An expansion of the cranial 
 bones and a prominence of the forehead are also very charac- 
 teristic of rickets. In process of time the shafts of the long bones 
 become strengthened by increased deposit of osseous matter on 
 their concave sides. After puberty the constitution generally 
 undergoes a change, and the disease makes no further progress. 
 
 Treatment. — As the disease is a constitutional one, our treat- 
 ment must be directed mainly towards improving the general 
 health. The child should have plenty of fresh air and sunlight, 
 good and sufficient food, warm clothing, and regular exercise. He 
 should have a tepid, cold, or sea-water bath every morning, and 
 friction should be applied to the surface of the body to promote 
 the action of the skin, and the development of the muscles. The 
 secretions should be carefully regulated, and tonics prescribed — 
 especially cod-liver oil and the preparations of iron. Lime-water 
 with milk sometimes seems to have a beneficial influence, and 
 Parrish's ** Chemical food" is an excellent remedy. 
 
 As long as the disease is progressing, the child must not be 
 allowed to stand or walk much — indeed, the less the better. 
 
MOLLITIES OSSIUM. 113 
 
 While indoors he should lie on a couch, or on a mattress spread 
 u})on the floor, or he encouraged to creep " upon all fours." 
 When in the open air, he should he driven in a carriage, or 
 wheeled ahout in a perambulator, or he should ride a donkey or 
 a pony. But, as far as possible, the recumbent posture should be 
 maintained, and that, if necessary, for a year or two. 
 
 If the spine is aflfected, the patient should lie down once or 
 twice a day for an hour or two upon a hard, flat sofa. A light 
 mechanical appliance should also be worn so as to take the weight 
 ofi'the vertebral column, and to press upon the out-growing part. 
 
 In the same way if the legs are becoming bent, and if it is 
 impossible to take the child entirely ofi" his feet, he should wear 
 steel supports, which will have the advantage of enabling him to 
 take exercise in the open air, while they prevent the deformity 
 from increasing. 
 
 In some very severe cases of rickets, Billroth of Vienna, and 
 Howard Marsh and other surgeons in this country, have per- 
 formed operations with the view of straightening the legs. Some- 
 times the bone has been divided subcutaneously; sometimes it has 
 been laid bare, and a wedge-shaped piece excised. These opera- 
 tions can but seldom be necessary, and they should never be 
 performed till the acute stages of the disease have passed. 
 
 XIXOXiIiITZES OSSZUM 
 
 {malacosteon, osteomalacia) is another disease which seems to 
 depend upon a want of tlie earthy constituents of the bones ; 
 but here it appears that there is degeneration of the animal 
 matter as well. The bones become soft and brittle, and are 
 often distorted into shapes that cause the patient great incon- 
 venience and distress. Death generally takes place either from 
 exhaustion, or from compression of the lungs. 
 
 MoUities ossium occurs more often in women than in men, and 
 it is particularly associated with the child-bearing period. Unlike 
 rickets, it is a disease of adult life ; and, when once it has com- 
 menced, it gets gradually worse. It may be confined to a few 
 bones, or it may aflect the entire skeleton. The urine is com- 
 monly loaded with phosphates, which are absorbed from the bones 
 and excreted by the kidneys. 
 
 After death the bones are found to be light, soft, and greasy. 
 They can be easily broken, or cut w ith a scalpel. The cancellated 
 tissue is often expanded, and the interspaces filled with semifluid 
 fat. 
 
 All that we can do in the treatment of this disease is to endea- 
 vour to improve and support the general health. Xo remedy has 
 yet been found which has any specific influence over the malady. 
 
 I 
 
114 DISEASES OF TISSUES AND ORGANS. 
 
 PERIOSTITIS 
 
 signifies inflainmation of the investing membrane of bone. It is 
 often caused by exposure to cold, or by external violence ; but 
 still more frequently by an impure state of the blood arising from 
 syphilis, scrofula, or rheumatism. 
 
 The subjacent layer of bone partakes in some degree of the 
 inflammation. There is more or less osteitis. And similarly, 
 when the bone is primarily inflamed, there will be more or less 
 periostitis. 
 
 When the disease is acute, the periosteum becomes thickened 
 by the active congestion and the inflammatory effusion. There 
 is intense pain, and exquisite tenderness. The part swells and 
 the skin around becomes red and oedematous. In the course of 
 two or three days suppuration takes place, and then the mem- 
 brane becomes detached from the subjacent bone. 
 
 When the inflammation is chronic, a flat, hard, circumscribed 
 tumour — a node — forms. There is deposit of plastic material in 
 the periosteum and neighbouring parts. There is great pain, 
 which is worse at night. Chronic nodes are generally of syphilitic 
 origin, and when such nodes are situated on the flat bones — the 
 cranium for example — they often suppurate, but when on the 
 long bones, the formation of matter is comparatively rare. 
 
 Acute periostitis is attended by severe constitutional disturb- 
 ance. In the chronic form there are generally syphilitic or 
 rheumatic symptoms. 
 
 The local treatment of acute periostitis consists in an elevated 
 position, leeches, and fomentations. 
 
 When suppuration takes place, an early and free incision should 
 be made, and poultices applied. Under any circumstances necro- 
 sis and exfoliation will most probably ensue, and after a time an 
 operation may have to be undertaken in order to assist Nature to 
 throw off the dead bone. 
 
 The constitutional treatment is that of acute abscess. 
 
 The chronic form of node, if it depends upon syphilis, is gene- 
 rally reduced by iodide of potassium or mercurj'. (F. 50, 60.) 
 Locally, iodine tincture or blisters are of great service. 
 
 OSTEITIS. 
 
 Bone, as well as the soft tissues, is liable to inflammation, and 
 such inflammation may be either acute or chronic. 
 
 Acute inflammation of bone is generally more or less diffuse. 
 Its favourite seats are the shafts of the long bones. When it 
 
OSTEITIS. 115 
 
 extends to the medullary merabrane, it runs rapidly along the 
 whole length of the canal. It occurs most frequently in children 
 of a scrofulous constitution, and in those who are out of condition 
 from want of the necessaries of life. It is often caused by 
 exposure to cold and damp. 
 
 The attack is ushered in by rigors and a high degree of fever. 
 There is severe deep-seated pain in the limb, rapid swelling, and 
 oedema, with an erysipelatous blush on the surface. The inflam- 
 mation runs on quickly to suppuration, and matter points in 
 various situations. Bryant draws attention to the fi\ct, that when 
 the pus proceeds from inflamed bone, it is mixed with a large 
 quantity of oil-globules ; and this is an important diagnostic 
 mark. 
 
 If the patient recovers from the immediate violence of the 
 attack, there is always more or less necrosis of the bone. When 
 the inflammation has spread along the medullary membrane, it is 
 probable that the articular. ends will sufler as well as the shaft. 
 
 The treatment of acute cases consists in opening the bowels 
 freely, and then endeavouring to moderate the febrile symptoms 
 by salines, while Dover's powder and other sedatives are given 
 to allay pain. (F. 7, 10, 53.) The part should be elevated, 
 and constantly fomented. Leeches may sometimes be employed 
 with advantage. As soon as matter forms, it should be let out 
 by direct incision, and poultices applied. 
 
 When the inflammation is chronic, the bones become slowly 
 thickened, and perhaps elongated. The bone-tissue becomes 
 dense and compact, like ivory. Iodide of potassium internally, 
 with local counter-irritation, is the treatment which holds out the 
 best hope of relieving this obstinate disease. (F. 60.) Erichsen 
 recommends in addition that a linear incision should be made 
 down to, and through, the affected bone. 
 
 Occasionally a circumscribed suppuration takes place : an 
 abscess is formed in the bone. Such abscesses are small ; they 
 contain pus mixed with the debris of the osseous tissue. Their 
 most common situation is the cancellous structure at the upper or 
 lower end of the tibia. They may generally be traced to an in- 
 jury. The skin is not altered in appearance, but the part swells 
 somewhat, and becomes thickened. There is aching, deep-seated, 
 intermittent pain, which is always worse at night, and which is 
 aggravated on pressure. The patient can lay his finger on the 
 spot which gives rise to all his distress, and to that spot the 
 symptoms are invariably referred. 
 
 The treatment of such aii abscess consists in exposing the bone 
 by a crucial incision, and then perforating it with a trephine, so 
 as to give vent to the pus, and allow the cavity to heal. 
 
 i2 
 
116 DISEASES OF TISSUES AND OEGANS. 
 
 CARIES 
 
 is commonly described as the molecular death and disintegration 
 of bone. 
 
 It would appear that the nutrition of the bone undergoes a 
 morbid change. The bone-tissue becomes soft and vascular. Pre- 
 sently it breaks down, ulcerates, and is discharged in the form of 
 pus, mingled with minute fragments and spicula of bone. 
 
 Caries is very apt to begin in the deep layers of bone, in the 
 centre of the cancellated tissue — perhaps because the circulation 
 there is feeble. This description of caries is very common in 
 persons who are of a strumous habit of body, and is often found 
 to co-exist with tubercular deposits in the viscera. 
 
 Sometimes, on the other hand, it attacks the surface of flat 
 bones. Here it produces an extensive sore, but never penetrates 
 to any great depth. To this kind of caries the term ulceration 
 of hone is sometimes applied. It is often seen on the surface of 
 the cranium, as a consequence of syphilis (see Fig* 161). 
 
 The early symptoms of caries are much the same as those of 
 abscess. There is pain and tenderness, redness and swelling. 
 Presently an abscess forms, and discharges itself. It is then 
 found that the pus is gritty and offensive. If a probe is passed 
 along the track of the abscess, it comes in contact with the sur- 
 face of the bone, which is stripped of its periosteum, and feels 
 rough and excavated. 
 
 The appearance of a part afiected with caries is very character- 
 istic. The tissues are thickened ; the skin glazed, and of a dusky 
 red; while here and there are the openings of sinuses, which dis- 
 charge a thin unhealthy pus, and are commonly surrounded by 
 coarse granulations. It is evident at a glance that the disease is 
 of a chronic inflammatory character, and is due to some permanent 
 source of irritation. 
 
 Treatment. — The first thing is to ascertain whether the disease 
 depends upon a strumous habit, a syphilitic taint, or any other 
 special cause of debility. If it does, we must endeavour to meet 
 this condition by appropriate remedies. Many cases of caries 
 improve with the improvement in the general health, and ulti- 
 mately undergo a spontaneous cure. Everything therefore should 
 be done which can contribute to this desirable end. The part 
 should, if ]iossible, be kept at rest by a moulded splint of leather 
 or gutta-percha (see Figs. 55 and 57). The patient should have 
 a change of air ; if possible, he should go to the sea-coast. He 
 should have a light but nutritious diet, and take regular exercise 
 in the open air. At the same time alteratives should be pre- 
 
NECEOSIS. 
 
 117 
 
 scribed, together with cod-liver oil, or the preparations of iron 
 or of iodine, as the case may require. (P. 45, 47.) Locally 
 counter-irritation by means of iodine tincture, blisters, or stimu- 
 lating liniments should be used. 
 
 If, notwithstanding these means, the disease still continues in a 
 chronic and intractable form, we must consider whether the case 
 admits of an operation. 
 
 Tlie simplest operation consists in removing the affected sur- 
 face of the bone, in the hope of arresting the unhealthy action. 
 This may be done by enlarging any fistulous tracks which may 
 exist, and taking away the cai'ious portions of bone by means of 
 a gouge or other suitable instrument. The diseased bone is soft 
 and friable, and crumbles easily under pressure, while the healthy 
 bone is firm, and offers a natural amount of resistance. Before 
 an operation of this kind is undertaken, Esmarch's bandage should, 
 if possible, be applied. It restrains the haemorrhage, and enables 
 the surgeon to judge of the condition of the bone. 
 
 If the operation is followed by healthy action, the wound soon 
 heals by granulation. 
 
 In some cases the gouge is inadequate to the occasion, and 
 excision or amputation will have to be performed. 
 
 ig-ECROSIS 
 
 is the term given to the destruction of bone in mass. When por- 
 
 Fig. 43. 
 
 tions of the bone-tissue perish 
 as a whole, without undergoing 
 disintegration, they are said to 
 necrose. 
 
 Necrosis affects chiefly the 
 hard structure of bone, and 
 the shafts of the long bones 
 more often than their articular 
 extremities. In these two 
 points it is contrasted with 
 caries. Fig. 43 was taken from 
 a boy, aged 14, who died of 
 acute necrosis of the humerus 
 and tibia. The dead and dis- 
 placed shaft of the humerus is 
 seen to be surrounded by a 
 quantity of new bone which has 
 been irregularly thrown out. 
 
 As in the case of caries, ^'^^^ necrosis of the humerus, 
 whatever lowers the vital powers, — exhausting disease, syphilis, 
 scrofula, &c. — predisposes to necrosis. 
 
118 DISEASES OF TISSUES AND ORGANS. 
 
 It is generally excited by injury, and hence it is more frequent 
 in certain exposed situations, as the shin, than elsewhere. It is 
 very apt to follow the spontaneous inflammation of bone, or acute 
 periostitis. Those who work among the irritating fumes of 
 phosphorus, as lucifer-match makers, are particularly prone to 
 necrosis of the lower jaw. 
 
 When a shell or scale of bone separates from the surface, it is 
 called an exfoliation ; when a portion of the deeper tissue perishes, 
 it is termed a sequestrum. 
 
 A case of necrosis may be divided into two stages — 1. That of 
 death and separation ; 2. That of renovation and repair. 
 
 1. The symptoms which attend the death of bone are those of 
 acute local inflammation — great pain and tenderness, swelling and 
 oedema, and suppuration. By the severity of the attack, the 
 vitality of the bone-tissue is destroyed ; and then, in its turn, the 
 dead piece of bone acts as a foreign body, and keeps up the 
 inflammatory action, whereby it is separated and thrown off. 
 The separation of a piece of dead bone is effected much in the 
 same way as the separation of a slough in the soft parts. A line 
 of demarcation is formed between the living and the dead tissue. 
 Along this line disintegration and absorption are carried on, until 
 separation is complete. 
 
 2. As soon as the dead bone has been detached from the living, 
 and even before this has taken place, the process of repair begins. 
 Granulations spring up from the healthy surface, pushing before 
 them the exfoliated bone. This is one of the chief means that 
 nature adopts for ridding herself of that which has now become a 
 foreign body. But it often happens, especially when the seques- 
 trum is of large extent and irregular in its outline, that the new 
 bone grows around it and embraces it in such a way as to prevent 
 its separation. Hence it is that the time required for Nature to 
 throw off dead bone varies extremely. Sometimes two or tliree 
 weeks are sufficient ; while, in other cases, the process is not com- 
 pleted at the end of months or years. Solly relates a case of 
 necrosis, after fractuie, in which exfoliation was still going on after 
 the lapse of thirty years {Surg. Experiences, p. 307). 
 
 If the suppuration, which necessarily takes place, is very pro- 
 fuse, hectic may be induced, and the patient may die, worn out 
 by the exhausting discharge. 
 
 From what source is the new bone produced ? Partly from the 
 sound and healthy bone which is left, and more particularly from the 
 epiphysal extremities ; partly from the periosteum and medullary 
 membrane ; partly from the granulations which spring from the 
 surrounding soft tissues. When the periosteum is left, it supplies 
 the principal part of the new bone — this has been demonstrated 
 
NECROSIS. 119 
 
 by Oilier of Lyons and others; but when it is destroyed, 
 repair takes place by granulation from the other adjacent 
 tissues. When the shaft of a long bone perishes, and bridges of 
 new bone are thrown across it, the apertures or interspaces are 
 called cloaccB. 
 
 Treatment. — The first thing to be done is to endeavour to 
 remove the predisposing cause — be it scrofula, syphilis, 
 general debility, or anything else. The principles upon which 
 this is to be done, have been already laid down in speaking of 
 caries. If the necrosis has been caused by the fumes of phos- 
 phorus, the patient should at once be removed from their 
 influence. 
 
 The next point is to support Nature in her efforts to throw off 
 the dead bone. Everything should be done which can improve 
 the general health, limit the suppuration, and husband the 
 patient's strength. It is astonishing how gi-eat an amount of 
 destruction will sometimes be repaired by the efforts of Nature 
 alone. We occasionally see cases where the foot is fixed, puffy, 
 and cedematous, and the tissues of the leg thickened, glazed, and 
 riddled with sinuses, restored to a sound and healthy condition 
 by very little more than perfect rest in the horizontal position; 
 the leg being raised on a pillow, or suspended in a " Salter's 
 swing" (see Pig. SO), and treated with poultices, water -dressing, 
 or stimulating lotions. 
 
 Until a line of demarcation has formed, it is impossible to say 
 how much or how little of the bone has lost its vitality. The 
 surgeon, therefore, should not interfere until nature has com- 
 pleted the work of separation. When, however, the sequestrum 
 is deeply situated, it is no easy matter to say whether it is 
 detached or not. Under these circumstances, a tentative opera* 
 tion may be undertaken after the lapse of a moderate time. 
 
 When the diseased bone can be scooped out, Mr. Pollock 
 recommends that the wound should be packed with cotton wool 
 saturated with sulphuric acid. 
 
 In some cases, a very slight force sufiices to remove large 
 portions of dead bone. Little or no injury is done to the soft parts, 
 while the cure is greatly hastened. In other cases sinuses have 
 to be opened, bridges of new bone have to be divided, and after 
 all, the sequestrum may be very imperfectly removed. 
 
 When the necrosis is situated in the extremities, if it is very 
 extensive, if it involves a large joint, if it is attended with 
 much disorganization of the soft tissues, or if the suppuration 
 and hectic threaten to prove fatal, amputation will have to be 
 considered. In some of these cases the limb may be saved by a 
 resection. 
 
120 DISEASES OF TISSUES AND ORGANS. 
 
 FRACTURES 
 
 are caused either by external violence or by muscular action. 
 
 External violence may be either direct or indirect. When a 
 bone is broken by direct violence, the fracture takes place at the 
 seat of injury. When it is broken by indirect violence, the frac- 
 ture may take place anywhere between the seat of injury and 
 the point of resistance — as when the clavicle is broken by a fall 
 on the shoulder. 
 
 The bone which is most frequently broken by muscular action 
 is the patella. It is torn across by the strength of the quadriceps 
 extensor muscle at the moment when it is stretched across the 
 condyles of the femur. 
 
 Various circumstances predispose to fracture. The situation 
 and shape of the bone, the presence in it of organic disease, the age, 
 sex, and constitution of the patient — these are all points which 
 influence the liability to fracture. Thus, a bone which is pro- 
 minent, and which serves as a point of support, such as the 
 clavicle, is very apt to be broken. The elastic bones of children 
 are less liable to fractures than the firm bones of adults. Men 
 are more exposed to accidents than women. Where there is 
 organic disease, the bones sometimes break from very slight 
 causes. Such fractures are called spontaneous, and are often slow 
 to unite. 
 
 In children and young persons fractures frequently occur at 
 the line of junction between the epiphysis and the shaft of a 
 long bone. 
 
 Fractures are of various kinds. Sometimes they are simple — the 
 bone is merely broken into two pieces. Sometimes they are com- 
 minuted — the bone is broken into several pieces. Sometimes they 
 are impacted — the fragments are driven into one another. Some- 
 times they are compound — the fracture communicates with an 
 open flesh wound. Sometimes they are complicated — the bone 
 is not merely broken, but some large vessel or some internal 
 organ is injured as well. 
 
 Again, fractures are named transverse, longitudinal, oblique, 
 &c., according to the direction of the fissure. 
 
 Again, fractures are usually complete. Sometimes, however, 
 they are incomplete — that is to say, the bone is partly bent, 
 and partly broken. The greensiicic fracture, which is occasionally 
 met with in children, is the best example of an incomplete or 
 partial fracture. Fig. 44 is taken from a preparation in Charing 
 Cross Hospital Museum, and represents a greenstick fracture of 
 
UNION OF FRACTURES. 121 
 
 the ulna in a boy, aged 14. The particulars of the case were 
 related by Mr. Canton in the Lancet of January 8, 1859. 
 
 The special indications -p. ^^ 
 
 of fracture are loss of 
 power, alteration in shape, 
 unnatural mohility, and 
 crepitus, or grating. With 
 these signs there is more 
 
 or less pain and swelling. "^Qreenstick fracture. 
 
 When all these symptoms 
 are present, they prove that a fracture has taken place ; but the 
 surgeon must not expect to find them all equally well marked in 
 every case. 
 
 As the distal part of the bone, to which the muscles are 
 attached, has lost its support, the patient is unable to move it, 
 - 'inless it be indirectly. There is, therefore, more or less loss of 
 poiver. 
 
 The alteration in shape is caused, either directly by the 
 violence of the blow which produced the fracture, or by subse- 
 quent muscular action. In ascertaining the nature and extent of 
 the displacement, accurate measurements should be made, first on 
 one side, and then on the other, taking as landmarks some of the 
 bony prominences — the acromion, the crest of the ilium, the 
 trochanter major, &c. In studying the position of a fractured 
 bone, the surgeon should bear in mind the attachments of the 
 various muscles, and the efiect which would naturally be produced 
 by their contraction. 
 
 Though there is on the patient's part, as we have just seen, loss 
 of power to move the limb, yet, if the surgeon grasps the injured 
 bone, he finds that there is unnatural mobility/. The broken 
 fragments move freely upon one another. 
 
 But the most important and valuable sign of fracture is crepitus 
 — the grating which is produced by rubbing the broken ends of 
 the bones together. This grating may be both felt and heard. 
 When present, it is an unmistakable indication of fracture. But 
 a long bone may be broken, and yet there may be no crepitus, 
 because the fragments are impacted. When the short or flat 
 bones are broken, we are not so well able to avail ourselves of this 
 aid to diagnosis. As we have already said, when speaking of teno- 
 synovitis, this crepitus of broken bone needs to be carefully dis- 
 tinguished from the creaking or crackling of efiusion. 
 
 UN-XOIO' OF FRACTURES. 
 
 When the fragments of a broken bone are kept in apposition, 
 union takes place by the deposition of new bone around and 
 
122 DISEASES OF TISSUES AND ORGANS. 
 
 between them. Such new bone is called callus. That which is 
 formed first, and which is generally very abundant, is termed 
 provisional callus. While that which remains ultimately, after 
 a good deal has undergone absorption, is termed the definitive 
 callus. 
 
 When a simple fracture occurs, the injury itself sets up inflam- 
 mation in the surrounding tissues, and this inflammation is of the 
 adhesive kind. Plastic lymph is poured out, forming a thick and 
 dense sheath — a sort of natural splint — around the broken frag- 
 ments. Between the ends of the bones the same plastic material 
 is efi"used, and the medullary canal is filled up and obliterated by 
 it. Gradually the eff'used lymph becomes developed into bone. 
 When it is first deposited, it has a finely granular appearance 
 under the microscope ; then cells and vascular canals are found in 
 it ; and, ultimately, it assumes all the characters of true bone. 
 Sometimes it passes through the stage of fibrous tissue, cartilage, 
 or fibro-cartilage. Although the bone is firmly united by the 
 end of six weeks or two months, it is not reduced to its normal 
 shape and size until after the lapse of a considerable time. The 
 superfluous callus undergoes gradual absorption, a fibrous perios- 
 teum is formed, a medullary canal is established, and at length 
 the bone returns almost entirely to its natural state. 
 
 The amount of provisional callus seems to depend upon the 
 mobility of the fragments, and the depth of the soft tissues that 
 cover them ; in other words, upon the degree of irritation, and 
 the extent of tissue, which is apt to become inflamed by it. 
 When the broken bones are kept in accurate apposition, and 
 when they are covered by little more than their own periosteum, 
 the provisional callus is small in quantity. In impacted fractures 
 there is but little ; in cases of broken ribs, on the other hand, 
 there is usually a great deal. 
 
 Union in compound fractures takes place somewhat differently. 
 Here the inflammation which is excited by the injury is not of the 
 adhesive, but of the suppurative, kind. Pus is poured out. 
 Granulations spring up around and between the fragments, and 
 in these the osseous matter is deposited. The amount of new 
 bone will be in proportion to the extent of the granulating 
 surface. At the same time, there is apt to be much constitutional 
 disturbance, with a proneness to erysipelas, phlebitis, or pya3mia. 
 
 TREATIVIEIiTT OF FRACTURES. 
 
 Simple fractures, — In treating simple fractures, we have to 
 aim at — (1), reducing the fragments to their proper position ; 
 and (2), keeping them in such position, until nature has effected 
 their union. 
 
TREATMENT OF FEACTUEES. 123 
 
 1. No time should be lost in reducing the fragments. The 
 muscles soon become rigidly contracted, and then the difficulties 
 of the case are greatly increased. 
 
 Sometimes there is so little displacement, that there is no need 
 of reduction. All that is then wanted is to study the position of 
 the limb, and to relax the muscles. But, in other cases, we have 
 to employ both extension and counter-extension. 
 
 Extension is made by drawing upon the distal fragment; 
 counter-extension by drawing upon the proximal fragment. In 
 every case the force should be applied slowly, gradually, and 
 continuously — without jerking or violence. Chloroform is of 
 gi-eat value, by enabling us to overcome muscular rigidity and 
 spasm. 
 
 2. When the fragments have been reduced, our next care is to 
 keep them in position. Here again it is of great importance to 
 maintain the studied position of the limb, so that no displace- 
 ment may occur from muscular contraction. But in most cases 
 something more than this will be requisite. Bandages, splints, 
 or mechanical appliances will have to be used. 
 
 Some fractures — fracture of the clavicle, for example — may be 
 treated by bandages alone. But in the majority of fractures, a 
 splint of some kind will be necessary. 
 
 Originally, no doubt, splints were straight pieces of wood — 
 splits or splinters — and wooden splints are still by far the most 
 commonly used; but from time to time splints of various 
 materials and forms have been introduced, so that now the 
 surgeon can make his choice among a number of appliances, and 
 select that which is best suited to his purpose. 
 
 Wooden splints are clean, light, and cheap, and hence they are 
 particularly suitable for our purposes. Moreover, they can be 
 obtained everywhere. A village carpenter can easily make all 
 the ordinary splints ; and even the surgeon himself, if he is 
 furnished with a half-inch board, a saw, and a knife, ought to be 
 able to supply the patient with an apparatus which will answer 
 the purpose. If the surgeon is an ingenious man, he will seldom 
 have any ditBculty in finding materials to form a temporary ap- 
 pliance; a little reflection will soon suggest something which 
 will accomplish the object that he has in view. For example, a 
 bundle of straw, a folded newspaper, the board of a book, and 
 many other things have been used on an emergency. 
 
 The variety of wooden sphnts is great, because they may be 
 made to serve nearly all the purposes for which such appliances 
 are called into use. Some are straight ; others are bent at a 
 right angle. Some are flat ; others are concave, or cut out so as 
 to fit the part for which they are intended. Some are made of a 
 
124 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 Fig. 45. 
 
 single piece of wood, others are furnished with hinges. Indeed, 
 their variety is almost endless ; and when a student first goes 
 into the splint-room of his hospital, he will be amazed at their 
 number; but a short experience will soon teach him the use of each. 
 One of the most useful kinds of wooden splint is 
 what is known as the common lined splint, and 
 which may be obtained at any surgical instru- 
 ment maker's (Fig. 45). It consists of a thin 
 board fastened upon a piece of leather or canvas, 
 which accurately fits the size of the splint. The 
 wood is then cut lengthwise with a number of 
 parallel incisions, which penetrate nearly, though 
 not quite, to the leather or canvas, so as to leave a 
 series of narrow strips of wood held closely 
 together by the material upon which they are 
 secured. A slight degree of force suffices 
 to separate the pieces of wood entirely from one another, so that 
 a hinge is formed between each pair, and thus the splint is 
 capable of being made concave throughout its whole length. 
 Moreover, these splints have other advantages. They can be 
 used as flat splints by simply turning the wooden side towards 
 the limb ; and the surgeon will find that by keeping a few com- 
 mon lined splints at hand, he is furnished with materials which 
 he can easily cut down with a penknife, so as to form small 
 splints for fingers, &c. 
 
 Another variety of splints which is in constant use is that 
 which is made of metal — either of japanned iron or of tin. These 
 splints have special advantages. They are thin and do not take 
 up much space; they can be made of any shape; they can be fitted 
 with hinges or screws more efficiently than wooden ones, and 
 they can be kept cleaner, as they do not allow the discharges 
 to soak into them. As a rule, these metal splints are made for 
 special cases, and for particular parts. It is to complicated cases 
 — cases requiring special mechanism — that they are the most 
 applicable. Thus, those wliich are commonly used for excisions 
 of the elbow and knee are made of japanned iron, because the 
 peculiar form of apparatus which is needed for these cases can be 
 made more efficiently in that material than in wood. Again, as 
 an example of the simplest form of metal splints, we may mention 
 those which are generally used for cases of club-foot in infants. 
 They consist of a flat piece of tin, of suitable length and breadth, 
 rounded at the corners and perforated with a series of small holes 
 near the edge, to which a pad can be attached. These splints 
 have the advantage of being very cheap, and clean, and light ; at 
 the same time the surgeon can bend them to any angle that 
 
TREATMENT OF FRACTURES. 125 
 
 the circumstances of tbe case may require, so that they may be 
 made to serve all tbe purposes of a more complicated and expen- 
 sive apparatus. 
 
 As a general rule, splints are applied next the skin. They 
 should therefore be well padded with tow or cotton-wool. Those 
 splints which are closely moulded to the form of the part, such 
 as the gutta-percha or leather splints, will not require padding, 
 except under peculiar circumstances. 
 
 The splint is to be fixed by means of bandages firmly and evenly 
 applied, but not so tight as to impede the circulation. 
 
 Bandages or rollers, as they are sometimes called, are of several 
 difierent kinds. Those which are most commonly used are made 
 of unbleached cotton or calico. Others are composed of a woven 
 cotton fabric, and pass under the name of elastic-cotton or stocking 
 bandages. Others are made of flannel — a thin, open flannel, 
 which is known as " Domett" or " Welsh flannel gauze." Some- 
 times a coarse muslin roller is required, as in the application of a 
 plaster of Paris bandage. 
 
 These difierent kinds of bandages have each their special advan- 
 tages, and are preferred in certain situations, or for particular 
 purposes. 
 
 Bandages are classed under three heads, according to their 
 length and breadth; and are spoken of as arm-landages, leg- 
 handages, and rib-iandages. But each of these is suitable for 
 other purposes besides those which its name indicates. 
 
 An arm-bandage should be about two inches wide by eight 
 yards long, a leg-bandage two and a half inches wide by ten 
 yards long, and a rib-bandage five inches wide by twelve yards 
 long. These are the dimensions in which, 
 they are usually cut, and which wiU be Fig. 46. 
 
 found most generally useful in practice ; 
 but, of coarse, they may be made broader 
 or narrower, longer or shorter, according 
 to the purpose for which they are in- 
 tended, and the situation to which they 
 are to be applied. It is always well that 
 they should be cut ofi" as soon as their 
 object has been attained ; there is no ad- 
 vantage in making more turns than are j^^ning a bandage, 
 necessary. 
 
 All bandages should be rolled into a firm, even, and compact 
 mass. This may be done perfectly well with the hand ; but 
 sornetimes a simple machine is used for the purpose. The machine 
 consists of a small wooden box without a lid, traversed from side 
 to side by a rolhng-pin, which is moved by a crank attached to it. 
 
126 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 The whole is not unlike a miniature barrel organ. The end of 
 the bandage is introduced through a slit at the extremity of the 
 box, and fastened to the rolling-pin. The handle is then turned 
 until the whole length of the bandage has been rolled ; the rolling- 
 pin is then withdrawn ; and the bandage, ready for use, remains 
 in the box. This machine has been variously modified ; but the 
 form we have described is perhaps the simplest in use. 
 
 One method of rolling 
 ^^" • bandages with the hand is 
 
 represented in the annexed 
 woodcut (Fig. 46), but it 
 is a plan which is only 
 suitable to narrow ban- 
 dages. Another method, 
 which is applicable to all 
 bandages alike, is shown in 
 Fig. 47. But this requires 
 the assistance of a second 
 person to hold the bandage 
 out and make it tight. 
 When a bandage is rolled from one end only, it is called a 
 single-headed bandage ; but when it is rolled from both ends it is 
 spoken of as a double-headed bandage (Fig. 48). 
 
 Fi^. 48. 
 
 Single- and double-headed bandages. 
 
 For all ordinary purposes, both in private and in hospital 
 practice, there is nothing so generally useful as the common 
 calico or unbleached cotton bandage. It is cheap, it is strong, 
 and it is clean. It is admirably adapted for fixing splints, for 
 retaining dressings, or for keeping parts at rest. It ought to be 
 of a sufficiently good quality to tear with a clean edge, and to be 
 firm and unyielding. 
 
 Sonrietinies, however, we desire a bandage which shall contract 
 a little upon the part to which it is applied, so as to keep up a 
 slight degree of pressure or aff )rd a little support ; and then 
 we have recourse to an elastic-cotton or to a flannel bandage, 
 pjither of these may be very appropriately applied to an cedema- 
 tous limb, to support varicose veins, or to promote absorption of 
 tlie thickening and effusion that are frequently left after fractures 
 or other injuries. A flannel bandage has some special advantages. 
 
TREATMENT OF FEACTUEES. 127 
 
 It is capable of absorbing moisture, it retains warmth, and its 
 surfaces adhere to one another, so that it keeps its place better 
 than any other kind of roller. 
 
 As fiir as possible the bandage ought to be made of one con- 
 tinuous piece, without any joinings ; and the selvages ought always 
 to be torn off. In a word, the surfaces and edges of the bandage 
 should be as smooth and even as they can be made. There 
 should be nothing which can press unequally upon the part, or 
 constrict it, or irritate it in any way. 
 
 In applying a bandage it is necessary to secure the end of the 
 roller, and to get a point upon which we can make traction. 
 Thus we often take a turn round the thigh or arm for no other 
 reason than to fix the commencement of the bandage. 
 
 If possible, the seat of fracture should be left uncovered, so 
 that it may be observed from day to day, and locally treated, 
 without undoing the bandages. If it is desirable, a second bandage 
 may be applied over the seat of fracture, and this may be removed 
 without interfering with the splints. 
 
 Every fracture is attended with more or less inflammation. 
 Sometimes this runs so high as to give rise to abscess. When 
 this happens, the bandages must be undone, the matter evacuated, 
 and the case treated as one of compound fracture. 
 
 If blood has been extravasated, its absorption may be promoted 
 by a spirituous lotion (F. 21). An incision should never be made 
 for the purpose of letting it out. 
 
 All fractures are apt to be followed by slight oedema from 
 inflammatory effusion or extravasation. But if the swelling is so 
 great that the pressure of the splints and bandages interferes 
 seriously with the circulation — if the extremities become cold 
 and blue — then the bandages must be loosened at once, and every 
 care taken to prevent gangrene. 
 
 If erysipelas, traumatic delirium, tetanus, &c., follow fracture, 
 they must be promptly treated; but without interfering with 
 the special apparatus more than is necessary. 
 
 The use of waxed bandages in the treatment of fractures is as 
 old as the time of Hippocrates (Syd. Soc. translation, i. 21), 
 but of late years such applications have come much more into 
 vogue than formerly ; and the use which is now made of bandages 
 stiffened with solutions of starch, dextrine, or other substances, is 
 one of the many improvements which have taken place in modern 
 surgery. Such bandages are particularly suitable to the treat- 
 ment of fractures. They form a light, firm, closely-fitting 
 appliance, well adapted to keep the ends of a broken bone in 
 position. By this means we are sometimes enabled to allow a 
 patient to leave his bed in a few days after he has met with a 
 
128 DISEASES OF TISSUES AND OEGANS. 
 
 fracture of the leg, or even of the thigh, and to go about on 
 crutches during the time that union is taking place. 
 
 The starch bandage is made in the following manner : — The 
 starch is mixed with water until it forms a thick paste ; and if a 
 little spirit is added, it will dry more quickly. A cotton roller is 
 then moistened with the paste ; and in doing this it will be found 
 convenient if an assistant rolls up the bandage as the surgeon 
 unrolls it, and saturates it with the starch-paste. The surgeon 
 should keep the basin of paste at hand while he is applying the 
 bandage, as well as rollers, lint, paste-board, and everything else 
 that he may require ; for when its application is once begun, it 
 ought to be completed without delay and without interruption. 
 
 Having made these preparations, the surgeon first of all lays 
 a piece of broad tape along the whole length of the surface to 
 which the bandage is to be applied. The object of this will be 
 explained immediately. He then takes a narrow flannel roller 
 and binds it upon the part, in the usual manner, in order to pro- 
 tect the skin. If he is dealing with the leg, it may be well to 
 cover the heel, so as to prevent the starch, whan it dries, from 
 injuring the skin ; and, as this is a difficult matter, a few stitches 
 may sometimes be required to keep the roller in its place ; for it 
 is important that it should not slip when the starch bandage is 
 applied over it. The flannel roller should form a thick and 
 complete protection to the part; and any hollows which may 
 exist should be filled up with a little cotton-wool or other soft 
 material. 
 
 The bandage, which has previously been moistened with starch- 
 paste, should now be applied in the same way as an ordinary 
 roller. The whole surface ought to be covered with at least two 
 layers of bandage ; and if, after this has been done, there are any 
 parts which appear weak, they should be strengthened by short 
 strips of bandage, or of lint, in order to give the necessary 
 support. 
 
 iSome surgeons prefer to envelop the part in a layer of cotton- 
 wool, instead of in a flannel roller. 
 
 When the starch bandage is applied for fracture, it is a good 
 plan to lay strips of pasteboard along the sides of the limb over 
 the flannel roller or cotton-wool, so as to fix the joints above and 
 below the seat of injury. 
 
 Sometimes, instead of a roller, short strips of bandage moistened 
 with the starch-paste are folded round the part in regular order. 
 Sometimes the roller is applied dry, and the paste rubbed into 
 it by an assistant, as each fold is laid down. This is a neater and 
 cleaner method than the one which we have described at length, 
 but it does not make such an efficient bandage. 
 
TEEATMENT OF FRACTUEES. 129 
 
 Bandages of this sort may be made of various other substances 
 besides starch. Of these we may mention dextrine, lohite of egg 
 and flour, and poivdered gum, or precipitated chalJc. We have 
 spoken of starch because it is the cheapest of all, and because it is 
 to be found in every household. But whatever substance we 
 select as the basis of our paste, the principle of application is the 
 same in all cases. Our object is to moisten the bandage with a 
 solution which will not interfere with the pliability of the roller, 
 but which, as it dries, will harden, and form a firm covering for 
 the affected part. 
 
 When a starch bandage has been applied, eight or ten hours, 
 or perhaps even a longer time, will have to elapse before it becomes 
 dry and hard. During the time that it is drying, it may be conve- 
 nient to lay paper under the part, in order to protect the bed- 
 sheets ; care being taken that the limb is in proper position. 
 
 When the bandage has become thoroughly dry, it will generally 
 be found to be rather loose. If this is the case it should be slit 
 up throughout its whole length with a strong pair of scissors, or 
 with an instrument sold for the purpose, under the name of 
 " Seutin's pliers." It is with a view to facilitating this operation 
 that we have recommended that a piece of tape should be laid next 
 the skin, as the first step in the application of the bandage. By 
 this simple expedient we are enabled to raise the bandage, and to 
 slit it up with less pain and risk to the patient than if we had to 
 push the point of the scissors between it and the skin. After the 
 bandage has been slit up, it may be reapplied by the addition of 
 a common cotton roller on the outside. In this way a light case 
 is formed which fits the limb accurately, but which can be easily 
 removed, so as to observe the exact condition of the part. 
 
 If there is any sore — for example, the wound of a compound 
 fracture — a sort of small door may be cut in the starch bandage, 
 so as to admit of the wound being dressed without disturbing 
 the general arrangement. 
 
 Paraffo-stearine handages were introduced to the notice of the 
 profession by the late Mr. Startin. They consist of rollers saturated 
 with a waxy composition, which readily melts sufliciently to admit 
 of its application to the part, and then quickly hardens. 
 
 These bandages are said to have the advantage of being con- 
 venient and cleanly, and easy of application ; moreover, they adapt 
 themselves with great exactness to the shape of the part, so that 
 they would seem to be particularly suitable for cases in which the 
 surgeon wishes to give even and continuous support, as in varicose 
 veins and ulcers of the leg. 
 
 A plaster of Paris or gypsum (Gr. yv^os, chalk) splint is made 
 in the following: manner : — 
 
130 DISEASES OF TISSUES AND ORGANS. 
 
 The surgeon takes a coarse muslin roller, and into the meshes 
 of this he dusts the dry, powdered plaster of Paris. A stock of 
 bandages prepared in this way may be kept rolled up and ready 
 for use. "When the surgeon is about to apply one he ought to 
 have at hand a bag of the dry plaster and a basin of water. He 
 then proceeds to cover the limb, which has to be bandaged, with 
 a flannel roller, or to envelope it in a layer of cotton-wool. After 
 this he takes the roller, which has been previously prepared, and 
 soaks it in water, or pours Vv'ater upon the ends of the roll until 
 the whole is moistened. He then applies it as he would an or- 
 dinary bandage. As each fold is laid down it naay be necessary 
 to sprinkle it with water, or to dust it with the dry powdered 
 plaster, in order to strengthen the application. After a sufficient 
 amount of bandage has been applied in this way the outside ought 
 to be smeared with a thick paste made by mixing some of 
 the plaster with water. This external layer ought to be as 
 smooth as possible, not only to give the splint a finished appear- 
 ance, but also that there may be no irregularities which might 
 catch upon the bedclothes, or upon the patient's dress. In a few 
 minutes the plaster of Paris " sets," and forms a firm, hard 
 splint. Care must be taken to keep the limb in its proper position 
 until this has taken place. 
 
 Some surgeons prefer to apply this splint in the form of short 
 strips of bandage, moistened with the plaster of Paris paste, 
 and folded round the part until a sufficient thickness has been 
 attained. 
 
 Plaster of Paris has some disadvantages as compared with starch 
 or dextrine. It is more bulky, heavier, and less easy to cut; so 
 that if the splint is found to fit badly, or if the limb shrinks away 
 from it, it cannot be slit up and readjusted without a good deal 
 of difficulty. On the other hand it has peculiar advantages. It 
 "sets" quickly, it forms a hard and unyielding case, and the 
 patient cannot remove it himself, as he can the starch bandage, 
 and this is sometimes a point of importance, especially in dealing 
 with children or unruly patients. 
 
 The " Bavarian splint" is an improvement upon the plaster 
 of Paris sphnt which has just been described. It is made in the 
 following manner: — Two pieces of flannel are cut, long enough 
 and broad enougli to envelope the whole part to which the splint 
 is to be applied. These are laid one on the top of the other, and 
 stitched down the middle line. The limb is then laid upon them 
 in the direction of the stitching, and the uppermost layers are 
 folded over the part, and secured by long pins. Thus the limb is 
 encased and protected by flannel. The mixture of gypsum, of the 
 consistence of thick cream, is then applied over the part ; the other 
 
TREATMENT OF FEACTUEES. 131 
 
 laj'er of flannel is folded over it, the superfluous plaster is rapidly 
 scraped away, and in a few minutes the whole case will have " set." 
 The pins may then be removed from the inner layer, and the two 
 halves folded back, like wings, the stitching serving as a hinge. 
 If the flannel is turned over the edges, the splint is complete, and 
 may be reapplied by means of webbing and buckles, or a bandage. 
 Gutta-percha splints are made in the following way : — 
 First of all a shape must be taken of the part to which the 
 splint is to be applied. This may be done with paper ; or, better 
 still, with a piece of damp calico. When an accurate pattern has 
 been obtained, the surgeon cuts a piece of gutta-percha of the 
 same shape and dimensions. This he dips in boiling water, taking 
 care that the dish which he uses is of sufficient size to contain the 
 gutta-percha without folding it upon itself. For large splints a 
 flat tin bath serves the purpose admirably, while for smaller ones 
 an old tea-tray or a foot-pan may be conveniently used. The 
 gutta-percha soon softens under the influence of heat ; and when 
 it has become quite plastic the surgeon takes it out of the water, 
 dries it quickly, and then lays it upon the part for which it is in- 
 tended. In order to prevent the heat from being painful to the 
 patient the calico shape may be placed next the skin, and the gutta- 
 percha laid upon it. The gutta-pevcha ought then to be rapidly 
 moulded on the part, and a roller applied over it. By this means 
 it adapts itself closely to the surface. After it has cooled it may 
 be removed ; and it will then be found to have taken the required 
 shape. The edges should now be pared, and the corners rounded 
 off; after which the splint should be lined with wash-leather, the 
 leather being turned over the edges, and continued for a shore 
 distance on the outside. It is a good plan to punch holes of 
 variable sizes in the splint, so as to alloiv a free circulation of 
 air, otherwise it is apt to become inconveniently hot and irksome 
 to the patient, when it has to be worn for any length of time 
 (see Figs. 55 and 57). 
 
 Splints made of sole leather, or of what is sold under the name 
 of " Spark's leather," or of millboard, may be formed in the same 
 way as the gutta-percha ones which we have just described. 
 
 Complicated fractures. — A simple fracture maybe complicated 
 by laceration of the main artery. "When this occurs, a diffuse, 
 semi-elastic tumour rapidly forms. At the same time the pulsa- 
 tion ceases in the arteries on the distal side of the swelling. 
 What is to be done in such a case ? A tourniquet should be 
 at once applied to the main artery in the upper part of its course. 
 If this arrests the bleeding, the pressure may be continued, and 
 the absorption of the extravasated blood promoted. If, however, 
 this fails, and if the case is becoming urgent, a ligature may be 
 
 K 2 
 
132 DISEASES OF TISSUES AND ORGANS. 
 
 put round the main artery above the seat of injury — provided 
 always that the circulation has been restored on the distal side 
 of the swelling. Or the tumour may be laid open, and the ends 
 of the artery tied ; but this practice is of very doubtful expediency. 
 Or, lastly, amputation may be performed. 
 
 Sometimes a fracture is complicated with a wound which does 
 not communicate with the broken ends of the bone. In such a 
 case the treatment must be modified, and the surgeon will have 
 to arrange his appliances in such a way that the wound may be 
 dressed without disturbing the position of the fragments. 
 
 Compound fractures. — The wound which communicates with 
 the fracture may be the result of direct violence at the time of 
 injury, or of a sharp fragment of bone having been subsequently 
 driven through the skin by muscular action, or it may be caused 
 at a still later date by sloughing of the soft tissues. 
 
 Compound fractures must be " set " in much the same way as 
 simple ones, only more solid splints, such as Mclntyre's, or the 
 fracture box, will often be found necessary. Here, however, it is 
 essential that the seat of injury should be left uncovered by 
 bandages. If one of the fragments protrudes, and there is 
 difficulty in reducing it, a piece may be cut off with Hey's saw, 
 or with bone-pliers. 
 
 Everything should be done by an elevated posture, perfect rest, 
 the continuous application of cold, or of an antiseptic dressing, 
 to anticipate and prevent inflammation. 
 
 VVhen the wound is but small, it should be covered with a 
 pledget of lint soaked in collodion, in Friar's balsam, or even in 
 the exuding blood. Beneath this artificial scab the opening may 
 heal, and the bone unite, as in the case of a simple fracture. 
 
 If suppuration is once established, we must be contented with 
 union by granulation. A free vent must be given to the pus, and 
 the wound treated on general principles — either by strictly 
 antiseptic dressing, as recommended by Lister, or by poultices, 
 water-dressing, astringent or stimulating lotions, &c. The amount 
 of suppuration, and the time that the bones take to unite, will 
 depend chiefly upon the extent of the wound, the quantity of 
 tissue destroyed, and the constitution of the patient. 
 
 In all the more severe cases of compound fracture in the ex- 
 tremities the question of amputation will arise. Such amputa- 
 tion may be eitlier primary or secondary. 
 
 Pnmary amputation — amputation within twenty-four hours — 
 may be required when the bone is much splintered and commi- 
 nuted, when the soft tissues are extensively disorganized, when 
 the main vessels are torn, or when a large joint is freely opened. 
 
 These are gome of the circumstances which the surgeon should 
 
UNUNITED FRACTURES AND FALSE JOINTS. 133 
 
 take into account, in determining whether a primary amputation 
 should be performed or not. At the same time the age, constitu- 
 tion, and habits of the patient are points of great importance, 
 and must not be overlooked in forming an opinion. 
 
 Secondary amputation — amputation after active inflammation 
 has subsided — may be required on account of gangrene, extensive 
 necrosis, non-union, &c. 
 
 Sometimes when a broken bone is not treated at all, or has 
 been badly treated, and deformity results, it may be necessary to 
 break it afresh, in order to put it in proper position. 
 
 UXUNZTZD FRACTURES AlffB TAJtSJl JOINTS. 
 
 Bony union may fail to take place from a want of perfect 
 apposition and of rest, from an insufficient supply of blood to the 
 fragments, from excessive suppuration and necrosis, or from 
 defects in the general health and condition of the patient. In 
 the first two cases a fibrous or ligamentous union takes place — 
 a false joint is formed. This fibrous union is generally all that 
 we can obtain in intracapsular fracture of the neck of the 
 femur and in transverse fracture of the pateUa. In the other two 
 cases, it not unfrequently happens that there is no union at all. 
 Either no callus is thrown out, or else it is wholly absorbed 
 without becoming ossified. Non-union is most common in the 
 humerus and in the femur. On the whole, it is a rare mischance, 
 and in many cases no satisfactory reason can be assigned. 
 
 Treatment. — If the non-union depends upon constitutional 
 causes or phthisis or scurvy, we must do what we can to improve 
 the general health of the patient, at the same time that we 
 adopt suitable local measures. 
 
 If it depends upon an insufficient supply of blood, there is 
 but little hope of a remedy. In a suitable case, some of the 
 measures which will be mentioned immediately should be tried. 
 Generally, however, we must be contented with fibrous union, 
 and endeavour by means of a special splint, or other apparatus, 
 to mitigate the inconvenience arising from the broken bone. 
 
 If it depends upon a want of proper apposition and of rest, the 
 first and mildest measure is to put up the fracture firmly in starch 
 bandages, and to keep it so fixed for a considerable time. If 
 this fails, various means of exciting inflammation may be tried. 
 The ends of the bones may be roughly rubbed together ; or a 
 seton may be passed through the false joint; or the ligamentous 
 union may be subcutaneously divided with a knife or with a noose 
 of wire. If these means do not succeed, the surgeon may cut 
 down upon the false joint, saw off the ends of the bones, and 
 treat the case as one of compound fracture. If need be, the in- 
 
134 DISEASES OF TISSUES AND ORGANS. 
 
 flammatory action may be increased by inserting ivory pegs into 
 the ends of the bones. As a last resource, amputation may have 
 to be performed. 
 
 FRACTURES OF THE SKUIil^ 
 
 always arise from external violence. They may be either simple 
 or compound. 
 
 The skull may be fissured at the seat of injury, or by con- 
 trecoup, the force being applied at one part of the skull, and pro- 
 ducing its effects upon a distant and more fragile part. In either 
 of these cases, the fissure may traverse the outer table alone, or 
 the inner table alone, or both together. Or, again, the skull may 
 be punctured by a sharp-pointed instrument, causing a starred 
 fracture. Or, again, it may be broken into fragments and commi- 
 nuted, with or without depression. 
 
 The dangers which attend these injuries are — 1, concussion ; 
 2, compression ; 3, haemorrhage within the cranium ; 4, inflam- 
 mation of the brain or its membranes (see p. 206). 
 
 When union takes place in fracture of the skull it is by defi- 
 nitive callus. There being but a thin covering of soft tissue, and 
 little or no movement of the fragments, the provisional callus 
 which is formed is very small in quantity. 
 
 Simple fissures vary greatly in their extent. They may be very 
 short, or they may traverse the entire circle of the cranium. 
 
 Symptoms. — ^There is always more or less concussion. After a 
 time there may be signs of compression from internal hsemorrhage ; 
 and this may be followed by symptoms of inflammation of the 
 membranes, or of the substance of the brain. 
 
 The aim of treatment is to remove any causes of compression, 
 and to anticipate and prevent inflammation. As soon as the patient 
 begins to rally from the shock of the injury, his head should be 
 shaved, and ice or cold lotions continuously applied (F, 21, 23). 
 His bowels should be freely opened. His diet should be of the 
 most unstimulating kind, and perfect quietness and rest should 
 be enforced. Some surgeons recommend that blood should be 
 freely taken from the arm. But this is rarely necessary, and 
 should not be thought of unless the patient is of a full habit 
 of body. 
 
 Fracture of the base of the skull is an accident of frequent 
 occurrence and most serious import. The danger is lest the brain 
 should be lacerated, or one of the large arteries or venous canals 
 torn across. 
 
 The special signs of this accident are bleeding into the orbit, or 
 from the nose or ears, and the discharge of serous fluid from the 
 ears or nose. When the blood shows itself at the orbit or nose, 
 
FRACTURES OF THE SKULL. 135 
 
 it points to a fracture through the anterior fossa ; when it flows 
 ft-om the ears, it shows that the fracture is situated in the middle 
 fossa, and probably runs through the petrous portion of the tem- 
 poral bone. 
 
 The bleeding may be superficial, and, if so, is unimportant. If, 
 however, it comes from within the cranium, it is a very alarming 
 symptom. 
 
 The serous fluid, which is sometimes discharged from the ears 
 or nose, seems to be derived from the cerebro-spinal fluid. Its 
 escape proves a rupture of the arachnoid. The fluid itself consists 
 chiefly of water with some common salt, a little albumen, and a 
 trace of sugar. 
 
 There is very little to be done in the way of treatment. All 
 that we can do is to try to prevent inflammation on the plan 
 already laid down. , 
 
 Fracture of the sJciiU with depression may occur without pro- 
 ducing any serious consequences. In such cases the outer table 
 alone is depressed; the inner is left uninjured. Generally, how- 
 ever, the inner table is more broken and depressed than the outer 
 one. This is particularly apt to be the case in gunshot and 
 punctured wounds of the skull. Sometimes, in children, the 
 whole thickness of the skull is depressed without any ill 
 effects. 
 
 Depressed fractures may be either simple or compound. When 
 simple, the depression may be masked by extravasation of blood, 
 and thus there may be difficulty in establishing the diagnosis. 
 When compound, the depression may be felt with the finger. 
 
 The special dangers, in cases of depressed or comminuted frac- 
 tures of the cranium, are compression of the brain and inflam- 
 mation of its membranes. The latter is far more likely to prove 
 fatal than the former. The dura mater is easily inflamed, and 
 the inflammation rapidly extends to the brain. 
 
 Treatment. — If there is a simple fracture with depression, un- 
 accompanied by any symptoms of compression, the patient should 
 be carefully watched, but no operation should be undertaken. 
 Under such circumstances, it is better not to convert the simple 
 fracture into a compound one. If, however, symptoms of com- 
 pression come on, a crucial incision should be made without delay 
 over the seat of injury, in order that any fragments of bone that 
 are loose may be removed, and any portions that are depressed 
 may be elevated. 
 
 If the wound is compound, it should be explored with the 
 finger, and the fragments taken away, or the depression elevated, 
 as in the foregoing case. 
 
 The depressed bone may be raised, by introducing an elevator 
 
136 DISEASES OF TISSUES AND OEGANS. 
 
 underneath it, and using the handle as a lever. Or it may be 
 removed with Hey's saw, or with bone-pliers. Or, lastly, a 
 circular piece may be cut out with the trephine. 
 
 It is surprising how much the brain may be injured without a 
 fatal result. I have elsewhere related the case of a boy who 
 received a compound comminuted fracture of the skull, with 
 laceration of the brain and loss of brain substance, and yet re- 
 covered, so that he could return to his work and earn the same 
 wages as other boys of his age (Path. Soc. Trans., xxi.). 
 Subsequently, however, he became imbecile ; and I suspect that 
 some such result happens in all these cases, after the lapse of a 
 longer or shorter time. 
 
 FRACTURES OF THE BOITES OF THE FACE. 
 
 The nasal hones. — These bones are not unfrequently broken 
 by direct violence. The bridge of the nose is depressed, and the 
 whole organ looks flat and broad. Such injuries are accompanied 
 by a great deal of swelling and ecchymosis ; and until this has 
 been subdued, the exact state of the bones cannot be ascertained. 
 
 Treatment. — The depressed bones should be elevated by a 
 director, polypus-forceps, or other suitable instrument, and re- 
 tained in their proper position by a small roll of lint introduced 
 into the nostril, while strips of plaster and small pads are placed 
 outside. 
 
 The lower jaw. — Fracture of this bone only occurs as the 
 result of direct violence. Frequently it is due to gunshot injury. 
 It may be simple, compound, or comminuted. It may take 
 place anywhere, but its most frequent seat is at the base of the 
 bone, near the bicuspid teeth. 
 
 The diagnosis is generally easy. The mental portion is 
 depressed, while the ramus is drawn upwards or inwards. 
 Crepitus is distinct. The point of fracture can be felt. The 
 gums are lacerated. The saliva dribbles from the half-open mouth. 
 
 Treatment. — Teeth which are only loosened should be left, and 
 secured in their places by silver wire. Teeth or fragments of 
 bone that are wholly detached had better be removed. When the 
 fragments have been restored to their proper places and the teeth 
 brought into line, the jaw should be fixed in that position by a 
 pasteboard or gutta-percha splint. Such a splint may be made 
 in the following manner : — A piece of pasteboard or gutta-percha 
 about eight inches long by four broad is taken and split up the 
 middle irom each end to within an inch of the centre. The 
 material should next be dipped in hot water, so as to make it 
 soft and pliable, and the lower limbs folded upon the upper in 
 
FRACTURES OF THE RIBS. 137 
 
 the way indicated in Fig. 49. The splint should then be applied 
 to the chin, and carefully moulded to the jaw. By a little mani- 
 pulation, and by paring the edges, it may 
 be made to adapt itself closely to the Fig. 49. 
 
 part, and to give it equal and uniform 
 support. It then only remains to pad it, 
 and it is ready for use. It should be re- 
 tained in its place by a four-tailed ban- 
 dage for the chin, which is made in much 
 the same way as the four-tailed bandage 
 for the head, only it is narrower. The 
 surgeon takes a piece of calico about three 
 inches broad and a yard, or a yard and a Splint for lower jaw. 
 half, in length. In the middle line of this 
 
 he cuts a slit large enough to receive the point of the chin ; and it 
 adds greatly to the comfort of the patient if the slit is made about 
 an inch from one side of the bandage, so that, when it is applied, 
 and the narrower portion is placed upwards, it may not rise so high 
 as to cover the lower lip or the mouth. The bandage is then torn 
 down from each end to within a couple of inches of the slit for 
 the chin, so as to make four tails. When it is applied, the point 
 of the chin is placed in the slit — the narrower sides being up- 
 wards. The two upper tails are then carried horizontally back- 
 wards, and tied at the nape of the neck, or crossed and brought 
 round in front ; after which the two lower ones are conducted 
 upwards, and fastened on the top of the head. It is a good plan 
 in applying such bandages as this to leave the ends of the two 
 knots sufficiently long to enable the surgeon to tie them together, 
 so as to prevent them from slipping. Or the bandage may be 
 retained in its place by means of a few circular turns made with 
 another roller round the forehead, and secured with pins. This 
 bandage is also useful for retaining poultices or dressings upon 
 the chin. 
 
 When the lower j;iw is broken it is no easy matter, even by 
 the aid of a splint and a bandage, to keep the fragments in line, 
 and it is very probable that some degree of irregularity will be 
 left. 
 
 FKACTURES OF THE RIBS. 
 
 The ribs are liable to be broken by blows or falls, or by a 
 crushing weight passing over the chest or back. It not unfre- 
 quently happens that several ribs are broken at once. 
 
 When the injury results from direct violence, any part of the 
 bone may be broken, but when it is caused by compression, the 
 fractm'e is generally situated at or near the angle. 
 
138 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 The symptoms are sharp local pain, which is aggravated hy 
 drawing a long breath, and great tenderness on pressure. 
 Crepitus may sometimes he felt or heard, and a depression 
 detected in the outline of the bone. No attempt should be made 
 to elevate such a depression. 
 
 The chief dangers are lest the pleura and lung should be 
 wounded, giving rise to pleurisy, pneumonia, or surgical emphy- 
 sema ; or lest the case should be complicated by laceration or 
 rupture of the liver, spleen, or other of the abdominal viscera. 
 
 Treatment. — When the injury is confined to one side, the 
 broken ribs should be supported with broad strips of adhesive 
 plaster passing half round the chest. In this way they are kept 
 at rest, while the respiratory movements of the sound side are not 
 interfered with. But when ribs on both sides are broken, a broad 
 roller should be applied in circular turns round the chest, begin- 
 ning from below and gradually ascending — each fold overlapping 
 about a third of the preceding one. The bandage should be 
 drawn sufficiently tigbt to give a firm and even support to the 
 whole chest. In order to retain it in its place, a separate 
 strip of calico should be passed round the 
 neck, in the form of a brace, with the ends 
 coming down in front as low as the bandage 
 extends. These ends ought then to be 
 pinned — or, better still, stitched — to the 
 circular turns, and the circular turns 
 ought to be stitched to one another, so as 
 to make the whole into a firm bandage, 
 wliich will keep its place for some time 
 (Fig. 50, a). In hospital practice a calico 
 bandage is generally used, and answers 
 the purpose sufficiently well ; but a flannel 
 one is better, for it both gives more sup- 
 port, by exercising a slight degree of 
 compression, and it also retains its place 
 for a longer time without requiring to be 
 re-applied. 
 
 Instead of this roller for the chest some 
 surgeons prefer to use a lacing body- 
 bandage ; others a single broad binder of flannel ; while others 
 again employ a simple belt of adhesive plaster about a foot 
 broad and long enough to go once and a half round the 
 chest. The latter is a particularly suitable application for chil- 
 dren. Whatever appliance is used it should be kept on for a 
 fortnight or three weeks at least. 
 
 [a) Rib- bandage. 
 
139 
 
 FRACTURES OF THB CIiAVICIiX:. 
 
 The clavicle is very often broken, pirtly on account of its ex- 
 posed position, and partly because it forms one of the bearing 
 points of the upper extremity. 
 
 The fracture generally occurs about the middle of the bone, but 
 sometimes it is near the acromial end. 
 
 When the seat of fracture is near the acromial end, the signs 
 are not well marked, but when it is about the middle, there is 
 a displacement which is very characteristic. The outer frag- 
 ment is drawn downwards and inwards. This is owing partly to 
 the weight of the arm, and partly to the action of the pectoralis 
 minor and subclavius muscles. The inner fragment is drawn up- 
 wards by the action of the sterno-mastoid. 
 
 Treatment. — When the clavicle is broken near its acromial 
 end, all that is needed is to support the elbow and fore-arm in a 
 sling, and to put a broad strip of plaster over the seat of injury. 
 Sometimes a few turns of a figure-of-8 bandage, or a " compound 
 axillary bandage," may be added with advantage, in order to keep 
 the shoulder at rest. 
 
 The compound axillary handage is a ready and efficient means 
 of drawing back the shoulders, and may often be of use, especially 
 in cases of emergency. 
 
 It requires two common hand- 
 kerchiefs, folded in the form of 
 cravats, about three inches broad. 
 One of these is passed round 
 one shoulder and firmly knotted, 
 so as to form a loose ring. The 
 other is then thrown round the 
 opposite shoulder and tied in a 
 single knot. One tail is then 
 looped through the ring formed by 
 the first cravat, the necessary 
 amount of tension is exerted, and 
 the two tails are tightly fas- 
 tened together. A glance at the 
 woodcut will show how the ban- 
 dage is adjusted (Fig. 51). 
 
 When the fracture is situated, 
 as it generally is, about the 
 middle of the clavicle, something more than this will be necessary. 
 There are then three points to which special attention ought to 
 be paid: — the shoulder should be drawn back by a figure-of-8 
 
 Fisr. 51. 
 
 Compound axillary bandage. 
 
140 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 bandage ; the point of the shoulder kept out by a pad placed in 
 the axilla ; and the elbow and fore-arm well supported in a sling. 
 It is not always needful to carry out the first of these indi- 
 cations, for it frequently happens that the displacement is so 
 slight that there is no over- riding of the fragments, and then 
 there is no occasion to draw back the shoulders, and we are able 
 to dispense altogether with the figure-of-8 bandage. 
 
 The axillary pad should be somewhat wedge-shaped, the thick 
 end being placed upwards. It ought to be broad enough to keep 
 the shoulder out to its full extent, and long enough, from before 
 backwards, to project a little both before and behind the axilla. 
 It may be made of folds of lint, or of a cushion stuffed with bran, 
 cotton-wool, tow, or horsehair. On an emergency a towel or a 
 stocking may be rolled so as to serve the purpose sufficiently well. 
 ^. , For an adult the pad ought 
 
 °' ' to be from two to two and a 
 
 half inches thick, and five or 
 six inches from before back- 
 wards. In some cases it may 
 be necessary, in order to keep 
 it in its place, to tie it over 
 the shoulder with tapes or a 
 bandage (Fig. 52). 
 
 In rare instances it may 
 suffice, after placing a pad 
 in the axilla, to support 
 the arm in a sling, with- 
 Fracture of the clavicle (1). Q^t the application of any 
 
 bandage ; and in such cases the sling ought to be so adjusted as 
 to make pressure upon the elbow, drawing it inwards across the 
 chest, and at the same time pushing it slightly upwards. In this 
 way the humerus is used as a lever to raise the point of the 
 shoulder, and to keep it out. But in the great majority of cases 
 the arm will not be kept sufficiently still by means of a sling only. 
 To obtain greater security we have recourse to bandages. These 
 are sometimes applied in the manner recommended by Desault, and 
 the arrangement bears his name. The surgeon takes an arm 
 bandage, and makes a turn or two round the chest so as to 
 fix the end. He then passes the roller round the arm of the 
 affected side in such a way as to fasten it to the chest, and draw 
 it well forward, and support the fore-arm. When this has been 
 done he takes a second bandage, and binds it in ovals round the 
 elbow, across the chest, and over the opposite shoulder; and 
 finishes off with three or four circular t\irns round the chest to 
 fix the whole, and keep it in position. 
 
FEACTUEES OF THE SCAPULA. 
 
 141 
 
 The accompanying illustration (Fig. 53) represents a simpler 
 method. Here the numerous oval turns are dispensed with, and 
 their place is supplied by a 
 
 single fold with a hole cut 
 in it to receive the elbow. 
 
 A yet easier method, and 
 one which is particularly 
 suited to hospital practice, is 
 to fasten one end of a ban- 
 dage round the wrist of the 
 aflected side by a clove-hitch, 
 and then to bind the arm to 
 the side, and to support the 
 elbow. Thus one continuous 
 bandage, and a pad, suffices 
 for the whole appliance. 
 
 When the bandage is ad- 
 justed, it ought to be pinned, 
 or stitched, here and there, so 
 as to keep it in place, for it 
 
 Fig. 53. 
 
 Fracture of the clavicle (2). 
 
 is very apt to shift, and it is desirable that it should not be 
 moved oftener than is absolutely necessary. 
 
 In infants and young children a fractured clavicle may be con- 
 veniently put up with two or three strips of plaster, each about 
 a couple of inches broad. If necessary, the shoulders must be 
 drawn back by a figure-of-8 bandage, a pad must be placed in the 
 axilla, and then a strip of plaster passed round the arm, so as to 
 bring it well forward, and lix it upon the chest — the ends of the 
 plaster being made to adhere to the chest and back. A second 
 strip of plaster is then to be passed round the fore-arm to support 
 the elbow, and brought up before and behind, and attached, like 
 the other, to the back and chest. 
 
 By attending to these directions it will generally be easy to 
 bring the fragments of the broken bone into apposition, though it 
 often requires constant attention to keep them in their proper 
 place. It will usually be necessary to continue the use of the 
 appliances for five or six weeks. 
 
 FRACTURES OF THE SCAPUIiA. 
 
 The body of the scapula may be broken in any situation, but as 
 this accident can only occur as theresult of great and direct violence, 
 it is usually associated with severe injuries to the ribs or spine. 
 
 In some very rare instances the neck of the scapula has been 
 broken. This accident is so uncommon that some surgeons 
 have doubted whether it ever occurs at all. There can, however. 
 
]42 DISEASES OF TISSUES AND ORGANS. 
 
 be no question about it. If other evidence were wanting, a case 
 which has been recorded by Speuce in his " Surgery " (Pt. ii. 
 p. 434), and which was verified by post-mortem examination, puts 
 the matter beyond a doubt. 
 
 The acromion and the eoracoid processes are occasionally broken 
 off — the latter very rarely, the former more often. When the 
 acromion is fractured, the arm hangs useless by the side, the out- 
 line of the shoulder is flattened, the head of the humerus is 
 slightly depressed, and an irregularity may be felt in the bone at 
 the seat of injury. 
 
 The treatment consists in supporting the arm in a sling so as 
 to bring the two fragments of the bone into line. The union is 
 sometimes by bone, but more often by ligament. 
 
 FRACTURES OF THE HUIVIERVS 
 
 may be considered under three divisions — those of the upper 
 extremity, those of the shaft, and those of the lower extremity. 
 
 It may be mentioned, once for all, that these fractures, when 
 they occur in the neighbourhood of joints, are often attended with 
 so much inflammation that it is necessary to keep the patient in bed 
 for a week or ten days, and to use fomentations or cold lotions. 
 
 As a general rule, the lighter and cooler the method of fixing 
 splints, the more agreeable will it be to the feelings of the patient. 
 The irritation which arises when the part is covered, and there 
 is no escape for the perspiration, is almost intolerable, and it is of 
 great importance to be able to undo the apparatus easily, and to 
 wash the limb with soap and water. 
 
 FRACTURES OF THE UPPER EXTREMITY OF 
 THE HUZVIERUS. 
 
 This bone is occasionally, though very rarely, broken at the 
 anatomical neck — i.e., just within the line of insertion of the 
 capsule (Fig. 54). Such a fracture is, of course, intra-capsular. 
 It may be either simple or impacted. 
 
 Fig. 54 was drawn from a specimen in which the line of frac- 
 ture ran throughout the greater part of its course along the 
 anatomical neck. 
 
 The signs of this injury are rather obscure. There is pain, 
 swelling, loss of power, the outline of the upper end of the bone is 
 irregular, and, if the fracture is impacted, there is a slight degree 
 of siiortening. If the fracture is simple, there may also be crepitus. 
 
 Separation of the greater tuberosity. — It sometimes happens 
 that the greater tuberosity is broken off, either by direct violence 
 or by muscular action. In such a case the shaft and head of the 
 bone are drawn upwards and inwards, while the greater tuberosity 
 
FRACTURES OF THE HUMERUS. 
 
 143 
 
 Fig. 54. 
 
 is carried upwards and outwards. By this displacement the 
 breadth of the shoulder is increased to a remarkable degrree, and 
 the separation of the frag;ments is very distinct. 
 
 Fracture at the surgical necJc — i.e., at that part of the bone 
 which lies between the tubercles above, and the 
 insertion of the latissimus dorsi and associated 
 muscles below. 
 
 In this accident the upper fragment is turned 
 upwards and outwards by the muscles which are 
 inserted into the greater tuberosity, while the 
 lower fragment is drawn upwards and inwards 
 by the deltoid and the pectoralis major. 
 
 Signs. — The head of the bone is in its right 
 place, but below it there is a depression. The 
 lower fragment points beneath the skin in the 
 direction of the coracoid process. The limb is 
 shortened, and crepitus can easily be obtained. 
 
 In children the fracture not unfrequently hap- 
 pens at the line of junction between the epiphysis 
 and the shaft of the bone. It is, in fact, a sepa- 
 ration of the upper epiphysis. The signs of such 
 an accident are much the same as the foregoing. 
 
 Treatment. — The fractures which occur about the shoulder- 
 joint are extremely difficult to diagnose with accuracy; and 
 although they have been described under four divisions for the sake 
 of clearness, yet in practice it is by no means easy to determine 
 the precise nature of the injury, and the surgeon must be pre- 
 pared to vary his appliances according to the particular symptoms 
 of the case, and the age and temperament of the patient. 
 
 In treating the first two varieties of these fractures, the 
 
 Fracture 
 
 through the 
 
 anatomical 
 
 neck. 
 
 Fig. 55. 
 
 Fig. 56. 
 
 Gutta-percha shoulder-cap. 
 
 Sling for the elbow. 
 
144 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 Fig-. 57. 
 
 principal thing to be attended to is to keep the arm at rest, and 
 to support it in the natural position. With this object, as soon 
 as the acute symptoms have been subdued, it is usual to 
 envelope the shoulder and upper-arm in a leather or gutta- 
 percha cap (Fig. 55), and to place the fore-arm in a sling 
 which shall support the elbow without pressing it upwards 
 (Fig. 56). The shoulder-cap should be large enough to 
 fix the parts thoroughly, and to keep them perfectly still. 
 To do this it should extend from the middle of the clavicle 
 nearly to the lower end of the humerus, and should be moulded 
 upon the shoulder and arm in the way described in speaking of 
 gutta-percha splints in general (p. 131). 
 It is hardly necessaryto say that such a 
 shoulder-cap as this should be lined, and 
 pierced with holes in the ordinary way. 
 Some surgeons prefer to carry the gutta- 
 percha or leather round the elbow, and 
 to make a trough for the fore-arm, con- 
 tinuous with the cap for the shoulder and 
 upper arm (Fig. 57). But this is seldom 
 required, and it always makes the ap- 
 paratus more irksome to the patient. 
 The gutta-percha splint should be secured 
 by a light, cool bandage passing evenly 
 round it throughout its whole length, or 
 by ribbons placed at intervals, or by 
 straps of webbing and buckles. The 
 upper arm should then be bandaged to 
 the chest, and the fore-arm comfortably supported in a sling. 
 Sometimes it may be necessary to put a pad in the axilla, to 
 assist in restoring the proper outline of the shoulder. But this 
 is a point upon which the surgeon must use his own judgment. 
 
 In almost all these cases, where there is apt to be pressure 
 upon the axillary veins, either as the consequence of inflammation 
 about the shoulder-jomt, or because of the splints which it is 
 necessaryto apply, it is well to begin the treatment by bandaging 
 the arm evenly from the hand to the fold of the axilla. 
 
 The last two of the four varieties of fracture which have been 
 enumerated — viz., fracture through the surgical neck, and frac- 
 ture through the epiphysis — generally present more displacement, 
 and require accordingly other appliances. Here the object is not 
 only to keep the parts perfectly at rest, but also to press the lower 
 fragment outwards, for it has a tendency to be drawn upwards and 
 inwards by muscular action. 
 
 Fig. 58 was drawn from a boy, aged fourteen, who had met 
 
 Gutta-percha shoulder 
 cap with arm-piece. 
 
FRACTUEES OF THE HUMERUS. 
 
 145 
 
 with a fractureof the surgical neck of the humerus. He lived in a dis- 
 tant part of the country, far from medical assistance. No scientific 
 treatment had been adopted, and the natural displacement had 
 occurred. When he came to London for advice, the fracture was 
 firmly united, and the wasting of the muscles from disuse allowed the 
 relative position of the bones to 
 be seen with great distinctness. "~-n>^ Fie:. 58 
 
 To fulfil the indications men- 
 tioned above, it is customary to 
 put a splint on the outside of the 
 arm, long enough to reach from 
 the shoulder to the elbow, so as 
 to fix the whole length of the 
 humerus. A second shorter splint 
 is then placed on the inner side 
 of the arm, so as to push the 
 lower fragment outwards, and 
 keep it in its proper position; 
 and in order to carry out this 
 object more efficiently it may 
 be necessary to apply a small pad 
 over the point of fracture. The 
 most suitable splints for these 
 cases are the common lined 
 splints (see Fig. 45). They 
 should be well padded through- 
 out, and the surgeon should see that there is additional padding 
 over the condyles, so as to prevent any undue pressure upon those 
 prominences. Care must also be taken that the upper end of the 
 
 Fractm-e of humerus 
 (untreated). 
 
 inner splint does not gall the fold 
 of the axilla. The splints should 
 be secured by bands of webbing 
 encircling the limb, and fastened 
 on the outer side by buckles. This 
 mode of retaining the splints in 
 their places has the advantage of 
 being cool, and of enabling the 
 surgeon easily to undo the appara- 
 tus, and examine the position of 
 the broken bones. 
 
 After the splints have been ap- 
 plied, the upper arm should be 
 fixed by a few turns of a bandage 
 passing round the chest. The 
 hand and wrist should then be sup- 
 
 Fi°:. 59 
 
 Sling for the fore-ann. 
 L 
 
146 DISEASES OF TISSUES AND GROANS. 
 
 ported in a sling, care being taken in this case not to include the 
 elbow, but to allow it to hang down, so as by its weight to 
 assist in counteracting the displacement upwards (Fig. 59). 
 
 Some surgeons recommend that these fractures should be treated 
 by means of a splint placed on the outer side of the arm, and a 
 pad in the axilla, to press the lower fragment outwards. Others, 
 again, prefer a leather or gutta-percha shoulder-cap, such as 
 we have already described, and a suitable pad under the arm. 
 
 FRACTURE OF THE SHAFT OF THE 
 HUMERUS 
 
 may be either transverse or oblique. When oblique they com- 
 monly run from above downwards and outwards. There is great 
 mobility, and crepitus can easily be produced. The displace- 
 ment which occurs depends upon the precise seat of fracture. 
 If it is above the insertion of the deltoid, the upper fragment 
 is drawn inwards by the pectoralis major and associated muscles, 
 while the lower fragment is drawn upwards and outwards by the 
 deltoid. If the point of fracture is below the insertion of the 
 deltoid, the lower fragment will be drawn inwards, while the 
 upper portion of the bone is tilted outwards. 
 
 Treatment. — Fractures of the shaft of the humerus are gene- 
 rally treated by means of wooden splints. The " common lined 
 splints" are the best ; but if these are not at hand, the ordinary 
 straight ones will answer the purpose well enough. The arm 
 should first be bandaged from the hand upwards, and then a 
 splint should be placed on the outside, extending from the 
 shoulder to the elbow. A second shorter splint should next 
 be fitted upon the inner side of the arm, and, if need be, one or 
 two smaller ones may be placed on the anterior and posterior 
 aspects of the limb to counteract any special displacement that 
 may be present. 
 
 The precise number of splints that are reqiiisite must depend 
 upon the circumstances of each individual case, and the surgeon 
 must use his judgment upon this point. The size and circum- 
 ference of the limb will generally determine how many are needed. 
 When the arm is small, two will be enough to embrace it, but 
 when it is fat or muscular, a third, or even a fourth, will have to 
 be employed. After the splints have been adjusted, the hand and 
 wrist should be comfortably supported in a sling. 
 
 Some surgeons prefer to place a rectangular splint on the inner 
 side of the arm. This is an excellent method of treatment, par- 
 ticularly in the case of children or irritable patients. Sometimes 
 a starch bandage is applied to the upper-arm, especially when 
 satisfectory union has not been obtained in the ordinary period. 
 
147 
 
 FRACTURES OF THS IiOTVER EXTREMITT 
 OF THE HUIMERUS 
 
 may be considered in a group. The lower end of the humerus 
 may be fractured transversely, or obliquely, above the condyles; 
 or either condyle may be broken off; or, in children, the lower 
 epiphysis may be separated from the shaft of the bone. 
 
 In these cases the fracture is often comminuted or compound, 
 and tiot unfrequently it is associated with dislocation. For these 
 reasons, and on account of the rapid inflammation which sets in, 
 it is often difficult to say what is the precise nature of the injury, 
 but it is sufficiently evident that a fracture has taken place, and 
 the treatment of all such cases is much the same. 
 
 Treatment. — If there is much pain, heat, and swelling about 
 the joint, we must have recourse to fomentations, cold lotions, 
 leeches, &c., and the patient must be kept in bed, with the arm 
 simply laid upon a pillow, until the inflammation has subsided. 
 The arm should be bent to rather less than a right angle, so as to 
 place it in the position that would be most useful to the patient 
 in the event of ankylosis. 
 
 A rectangular splint should then be applied on the inner side, 
 and fastened by straps of webbing and buckles, or by a bandage. 
 The best kind of splint for these fractures is a concave one made 
 of iron or perforated zinc, and jointed at the elbow, so that it can 
 be set at any angle that may be necessary. Or two rectangular 
 splints, made of wood, pasteboard, leather, or gutta-percha, may 
 be applied, one on each side of the limb. 
 
 There is an advantage in applying a splint only on one side 
 of the arm, for then the surgeon can easily watch the state of the 
 part, and can use any local measures that may seem necessary to 
 subdue the inflammation about the joint. Whatever splints are 
 employed, great care should be taken that they do not press upon 
 any of the bony prominences. With this view the padding should 
 be increased in thickness above and below the condyles, so as to 
 relieve them from the weight of the splint. After the apparatus 
 has been adjusted, the fore-arm must be supported in a sling. 
 At the end of three or four weeks passive movements should be 
 begun, to prevent ankylosis. 
 
 If the fracture is compound, and the opening into the joint is 
 but slight, an attempt may be made to save it by the continuous 
 application of cold, or by antiseptic treatment ; but if the joint is 
 freely opened, excision — either primary or secondary — will probably 
 have to be performed ; and if the main vessels are torn, and the soft 
 tissues extensively lacerated, amputation will have to be considered, 
 
 L 2 
 
148 DISEASES OF TISSUES AND OEGANS. 
 
 FRACTURES OF THE FORE-ARM. 
 
 The olecranon may be broken either by external violence or by 
 muscular action. Sometimes the soft tissues are much bruised ; or 
 the fracture may be compound. 
 
 Treatment. — In simple fracture of the olecranon the arm 
 should be kept extended by means of a straight splint on the 
 anterior surface. The splint should be long enough to reach from 
 the middle of the upper-arm to the middle of the fore-arm. It 
 may be made of wood, or of tin, or even of millboard. Perhaps 
 nothing is better than a "common lined splint '' (see Fig. 45), 
 or an ordinary straight wooden splint, bevelled off at the ends, 
 so as to prevent it from galling the patient. But whatever kind 
 of splint is used, it ought to be well padded. It need not, however, 
 be burdensome to the patient, for its only object is to check the 
 movements of the arm, and a very slight apparatus will be found 
 sufficient for this purpose. Indeed, it is not necessary that the 
 arm should be perfectly straight. This position is so irksome 
 that a slight degree of flexion must be allowed. To meet this 
 the pad should be graduated so as to be thicker in the centre, 
 opposite the bend of the elbow, than at the ends. Some surgeons 
 place a small pad on the back of the arm, just above the elbow, 
 with a view of drawing down the upper fragment. The splint 
 should be fastened near its upper and lower ends either by strips 
 of adhesive plaster, or by tapes, or by pieces of webbing and 
 buckles, or by a bandage. In the simpler cases of fractured 
 olecranon the splint should be worn for about three weeks, and 
 then the surgeon should begin to make passive movements, and 
 to encourage the patient to use his arm by degrees. 
 
 When the soft tissues and the joint are much implicated, a con- 
 siderable amount of inflammation will take place. The patient 
 must be confined to bed, and the arm treated with fomentations, 
 lotions, or leeches, before a splint can safely be applied. While 
 this is being done, the arm should be laid upon a pillow in the 
 position which is easiest to the patient, and that will generally 
 be a slight degree of flexion. After the inflammation has been 
 subdued, a straight, well-padded splint should be placed on the 
 front of the arm, and the case treated as an uncomplicated one — 
 only where there has been a high degree of inflammation the 
 surgeon will have to use every effort to restore the movements 
 of the joint. In some of the most severe cases, where there is 
 great probability of ankylosis, it is the best plan to lay the arm 
 upon an angular splint, fixed at a little less than a right angle. 
 
FEACTURES OF THE FOEE-AEM. 
 
 149 
 
 But after all our care, and when the immediate union is most 
 satisfactory, we ahnost always find that the uniting medium 
 yields to the movements of the arm, so that, in the course of 
 time, an interval is established between the broken fragments. 
 For this reason the surgeon will do well, for his own sake, to 
 warn the patient at the outset that this is likely to occur. 
 
 In cases of compound fracture, with laceration of the soft parts, 
 excision of the elbow-joint, or even amputation of the arm, may 
 be necessary. 
 
 Fracture of the middle of the fore-arm. — Both bones may be 
 broken, or only one. When both are broken, the displacement 
 and crepitus make the diagnosis easy. When only one bone is 
 broken, it may be more difiicult to determine the exact nature of 
 the injury. The fracture may be either simple or compound. 
 In this locality compound fractures generally do well, though 
 they are apt to impair the power of pronation and supination. 
 
 Fractures of the radius alone are not very uncommon, but it is 
 seldom that the ulna alone is broken. Mr. Bellamy has reported 
 the case of a little girl, aged six, who fell on the ulnar aspect of 
 her wrist, and broke the ulna alone {Brit. Med. Jour., Sept. 
 16, 1876). 
 
 Treatment. — Fractures about the middle of the fore-arm, 
 whether of one or both bones, are treated by placing the arm in 
 the mid-position between pronation and supination, and fixing a 
 straight splint on each side. The splints should be a little 
 broader than the arm, so as to 
 prevent the injured parts from 
 being pushed together by the 
 bandage, and long enough to ex- 
 tend from the elbow to the palm, 
 so that they may support the 
 whole length of the broken bones. 
 Care should be taken to maintain 
 the interosseous space by means 
 of a narrow pad laid along the 
 arm before the splints are applied. 
 Such a pad may be formed of a 
 few folds of lint, or the ordinary 
 padding of the splint may be made 
 a little thicker in the central line. 
 The splints should be fixed by an 
 " arm bandage " carried round 
 them in simple circular turns, or Trougn-shng, 
 
 in "reverses," or in a figure-of-8. Any of these modes of applying 
 the roller may be used, and the one which is found to adapt 
 
 Fiff. 60. 
 
150 
 
 DISEASES OF TISSUES AND OEGAXS. 
 
 itself most evenly to the splints will be tlie best. After the arm 
 has been put up in the way that we have described, it should 
 be carried in a sling which will support the whole length of the 
 fore-arm and hand (see Fig. 56), or else in a trough such as that 
 represented in Fig. 60. 
 
 Fracture of the loioer end of the radius (Colles's) is a common 
 consequence of falls upon the hand. It must be carefully distin- 
 guished from dislocation of the wrist. The latter is a very rare acci- 
 dent, while fracture of the lower end of the radius is frequent. 
 
 It may be either simple, comminuted, or impacted: and the 
 signs vary somewhat with the precise nature of the injury. 
 
 The case from which Fig. 61 was drawn was that of a boy, aged 
 sixteen, and it may be taken as a typical example. There is a dis- 
 tinct prominence on the dorsal aspect, which looks very much as if 
 a dislocation backwards had occurred at the wrist. Corresponding 
 to this on the palmar surface is a well-marked depression, and 
 above this again there is another prominence, smaller and less 
 distinct than that on the dorsal aspect. The hand is thrown a 
 little towards the radial side, and the styloid process of the ulna 
 becomes remarkably prominent. 
 
 Fig. 61. 
 
 Colles's fracture of the radius. 
 
 The prominence on the dorsal aspect is due to the lower frag- 
 ment of the radius, which is thrown backwards on to the lower end 
 of the upper fragment, carrying the carpus along with it. This 
 also explains the palmar depression. Tlie prominence on the palmar 
 aspect is caused by the lower end of the upper fragment. The 
 obliquity of the hand and the projection of the styloid process of 
 the ulna are due to muscular action, and are brought about by the 
 contraction of the supinator longus, the extensors of the wrist, and 
 the pronator quadratus. 
 
 This accident is accompanied by loss of power, particularly in 
 supination, and great pain. In the Lancet of June 28, 1873, I 
 have related the case of a woman who fell down a flight of stairs, 
 and simultaneously fractured the lower ends of both her radii. 
 She made a good recovery. Her arms were afterwards strong. 
 
FRACTUllES OF THE FOEE-ARM. 
 
 151 
 
 and the movements almost perfect, so that she was able to return 
 to her work as a charwoman. 
 
 Treatment. — Extension must be made so as to bring the 
 fragments as far as possible into their proper places, and then 
 the hand should be bent strongly over towards the ulnar side. 
 In this position it is to be fixed by means of a " pistol splint" 
 (Fig. 62) — i.e., a straight splint bent downwards at one end so 
 
 Fig. 62. 
 
 Pistol-splint, 
 as to adapt it to the shape of the fore-arm and hand, when the 
 latter is turned somewhat obliquely. The splint should be long 
 enough to reach from the elbow to the roots of the fingers. It 
 is desirable that it should not extend further, so as to allow the 
 patient to move his fingers. It is generally placed on the 
 anterior aspect of the limb, but, if need be, it may be applied on 
 the posterior, and it should be secured by means of an " arm- 
 bandage." If necessary, a second straight splint may be laid 
 along the opposite side of the arm ; and pads may be used to make 
 pressure upon the prominences, so as to keep the fragments of 
 bone in their proper positions. The arm must be carried in a 
 sling or trough. 
 
 This is the usual way of deahng with an ordinary case of 
 Colles's fracture ; but if a " pistol-splint" is not at hand, the 
 case may be treated perfectly well by two straight splints, such 
 
 Fiff. 63. 
 
 Splint for the hand and arm. 
 
 as are used for fractures of the middle of the fore-arm. This 
 plan has the advantage of being less irksome to the patient than 
 the constrained position which the " pistol- splint" involves. But 
 it is always well to warn the patient that, whatever mode of 
 treatment is adopted, some degree of deformity and stiffness will 
 almost invariably remain after this accident. 
 
152 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 Fractures of the metacarpal hones and phalanges are generally 
 easily detected by the history of the injury, loss of power, pain, 
 and crepitus. 
 
 Treatment. — The best mode of treating a fracture of the meta- 
 carpal bones is by laying the extended hand upon a wooden or 
 gutta-percha splint cut to the shape of the part (Fig. 63). 
 
 The surgeon should bear in mind that the palmar aspect of 
 these bones is concave, and he should have the splint well-padded 
 so that it may adapt itself to their form. It is often recom- 
 mended to treat the central metacarpal bones by binding the 
 hand over a ball of lint or tow. These bones are so well pro- 
 tected by Nature that a very little padding, judiciously placed, 
 keeps them in their proper position. If one metacarpal bone only 
 is broken, it may suffice to lay a narrow strip of wood along it, 
 reaching from the point of the finger to a short distance above 
 the wrist. This may be laid either along the palmar or the 
 dorsal aspect, and may be secured by strips of adhesive plaster. 
 
 When the phalanges are broken they should be treated by lay- 
 ing the finger upon a narrow splint of wood, or millboard, or 
 gutta-percha. If the injury is very severe, and several fingers 
 are involved, it may be needful to lay the whole hand flat upon a 
 wooden splint cut to the shape of the thumb and fingers (see Fig. 
 63). Here, also, the surgeon should bear in mind that the palmar 
 
 aspect of the bones is concave, 
 ^ ig. d4:. j^j^^ arrange the pad accord- 
 
 ingly. If the injury is com- 
 pound, and an operation is 
 necessary, as little as possible 
 should be taken away. The 
 vitality of the tissues is great : 
 they do not readily slough, 
 and every portion which is 
 left may in due time add to 
 the usefulness of the organ. 
 In all these cases the arm 
 should be supported in a sling 
 so disposed as to raise the hand 
 above the level of the elbow. 
 
 After these fractures, as well 
 in various other conditions, 
 i t is desirable to bandage the hand and arm. We shall therefore 
 take this opportunity of explaining how it ought to be done. 
 
 Bandage for the hand and arm. — A narrow roller is carried 
 in a figure-of-8 round the hand and wrist — one loop including 
 the hand and the other the wrist, and the thumb protruding 
 
 Bandage for the hand. 
 
FRACTUEES OF THE FEMUR. 
 
 153 
 
 The bandage may then be con- 
 Fig. G5. 
 
 between the folds (Fig. 64). 
 tinned for some little 
 distance up the arm, in 
 simple circular turns ; 
 but as soon as it reaches 
 the point where the limb 
 begins to enlarge, "re- 
 verses," or figures-of-8, 
 must be made, so as to 
 insure its fitting closely 
 and evenly (Fig. 65). 
 
 Such a bandage as this 
 may be very conveniently 
 fastened by tearing the 
 extremity down the mid- 
 dle to a sufficient extent, 
 and then turning the two 
 ends round the part in 
 opposite directions, and tying them in a knot or in a bow. 
 
 Bandage for the hand and arm. 
 
 FRACTURBS OF THB PZIiVIS 
 
 are often complicated with injury to internal organs, and this 
 makes them very serious. Most frequently it is the front or the 
 back — the rami of the pubes or ischium, or the sacro-iliac articu- 
 lation — which is broken. 
 
 Signs. — Pain, inability to stand or walk, unnatural mobility, 
 and crepitus. The history of the injury by great and direct 
 violence is an important aid to the diagnosis. 
 
 The complications which are most likely to arise are rupture of 
 the bladder, or urethra, with extravasation of urine, laceration of 
 the rectum, or fracture through the acetabulum. 
 
 Treatment. — A catheter should be passed to ascertain the 
 state of the urethra and bladder. A broad bandage, or a padded 
 belt, should be applied round the hips, the knees should be tied 
 together, and the patient kept perfectly quiet. If the urethra 
 has been lacerated, there will be extravasation of urine, and some 
 of the measures mentioned under that heading will have to be 
 adopted (see p. 311). After all, it is probable that a trouble- 
 some stricture will be left. 
 
 FRACTURES OF TKS FE»X17R 
 
 may be considered under three divisions — those of the upper 
 extremity of the bone, those of the shaft, and those of the lower 
 extremity. 
 
 In every case of fracture of the lower limb the patient should 
 
154 DISEASES OF TISSUES AND OEGANS. 
 
 be laid on a flat, hard bed. Xothin^ is better tban a bair 
 mattress, placed upon tbe framework of tbe bed, or upon a straw 
 palliasse. Sometimes flat pieces of wood, about six or seven 
 incbes broad — commonly known as " fracture boards" — are laid 
 side by side across tbe bedstead, so as to form a firm, even surface 
 for the mattress to rest upon. 
 
 In fractures of the lower extremity sand-bags are often of 
 great use to the surgeon. These are cylindrical pillows, four or 
 five inches in diameter, and two or three feet in length, filled 
 with dry sand. The pillow case should be made of strong calico 
 or ticking, and covered first with waterproof cloth, and then with 
 flannel. 
 
 Feactuees op the Uppee Exteemity op the Femtje. — 
 The fractures which occur about the head and neck of the 
 femur are often extremely difficult to diagnose with accuracy. 
 We shall, however, for the sake of convenience, follow the usual 
 classification, and divide them into intra-capsular and extra- 
 capsular. In either case the fracture may be simple or com- 
 pound. 
 
 Intra-capsular fracture of the necTc of the thigh-hone. — This 
 accident is almost peculiar to persons over fifty. It is more com- 
 mon in women than in men, and arises from very slight causes, 
 such as tripping on the carpet, or stumbling over a stone. 
 
 As age advances, the neck of the bone becomes more horizontal 
 in position, so that the weight of the body falls more directly 
 upon it. The bone-tissue itself also undergoes changes. The 
 caucelli become enlarged, and filled with fatty matter ; while the 
 compact tissue is absorbed, until nothing is left but a mere shell. 
 
 Signs. — Pain, loss of power, crepitus, absence of the natural 
 prominence of the trochanter, shortening and eversion of the leg ; 
 but if there is any degree of impaction these signs may be some- 
 what obscured. Pain on pressure over the front of the hip- 
 joint gives a presumption of intra-capsular fracture. It is im- 
 portant to observe, as Mr. Canton has pointed out, that distinct 
 shortening, the result of absorption, may follow a severe blow 
 upon the hip, without fracture. 
 
 Union may take place by bone, but this is an extremely rare 
 occurrence. In the vast majority of cases the union is fibrous. 
 'J'his arises partly from a want of perfect apposition between the 
 fragments, and partly from the very scanty supply of blood which 
 the head receives through the vessels of the ligamentum teres. 
 When bony union takes place, it is probable that the fracture has 
 been impacted, as in Fig, 66, which was drawn from a prepara- 
 tion in the museum of Charing Cross Hospital. 
 
 Treatment. — In these fractures it is seldom necessary to use 
 
FRACTUEES OF THE FEMUK. 
 
 155 
 
 ff. 66. 
 
 Impacted fracture of the neck of the 
 femur. 
 
 any splint. As the subjects of this injury are almost always aged, 
 and as bony union is hardly to be expected, it would be useless, 
 and even dangerous, to 
 confine them to bed for 
 any length of time. The 
 patient should, therefore, 
 be kept in the recumbent 
 position fov ten days or a 
 fortnight, until the in- 
 flammatory symptoms 
 have subsided, and then 
 be allowed to get up and 
 move about on crutches. 
 He will probably be more 
 or less lame for the rest 
 of his life, but with the 
 help of a stick he will be 
 able to walk about with 
 ease. 
 
 Hxtra-capsular fracture of the neck of the thigh-hone is 
 usually the result of great and direct violence. It generally 
 happens before the age of fifty. 
 
 The signs are much the same as in the foregoing injury, only 
 they are more strongly marked. Pain on pressure over the 
 great trochanter gives a presumption of extra-capsular fracture. 
 
 The injury is often associated with fracture through the 
 trochanter, and there is always much bruising and swelling of 
 the hip. In the case of extra-capsular fracture we aim at 
 obtaining body union. 
 
 Treatment. — A broad bandage should be passed round the 
 hips so as to prevent movement between the fragments. The 
 limb should then be extended, and fixed in that position by means 
 of " Liston's long splint ;" or both legs should be flexed, and 
 laid upon a double-inclined plane. These methods will be ex- 
 plained at length in the next Section. 
 
 FEACTrEES OF THE Shaet OP THE Femije are of very com- 
 mon occurrence, and can generally be recognised without 
 difficulty. 
 
 Signs. — There is pain, loss of power, crepitus, shortening, and 
 eversion. The lower fragment is drawn upwards and inwards 
 by the action of the adductors; and, if the fracture is high up, 
 the upper fragment is tilted forwards by the psoas and iliacus, 
 and outwards b^ the external rotators. Indeed, oblique frac- 
 tures at the upper part of the femur are often difficult to treat, 
 and leave a weak limb for a length of time. 
 
156 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 The treatment may be conducted either by means of a long 
 splint or a double-inclined plane. The latter is particularly 
 useful in cases where the upper fragment is tilted forwards ; but 
 the former is more suitable to the majority of cases. The most 
 convenient long splint is Liston's. The surgeon who is about to 
 use it should be provided with a piece of strong tape, or a silk 
 pocket-handkerchief, long enough to pass from tiie upper end of 
 the splint round the perineum to the same point, and to be there 
 tied in a bow. The " perineal band," as this appliance is called, 
 should be well padded at the part where it presses upon the 
 perineum, so as to prevent it from cutting the skin ; and care 
 must be taken, particularly in the case of children, that it is 
 kept scrupulously clean. The splint should be long enough to 
 reach from the fold of the axilla to about four inches below the 
 foot. It should be pierced with two holes near its upper end, 
 and at its lower end it ought to be deeply notched in the manner 
 indicated in the accompanying illustration (Fig. 67). It should 
 
 Fig. 67. 
 
 Fracture of the thigh : Liston's long splint. 
 
 be well padded, and it is advisable to carry the pad over the 
 upper end of the splint, so as to prevent it from galling the skin of 
 the axilla. The pad should be pierced with two holes corresponding 
 to those of the splint, so that the perineal band may slip through 
 it easily, and be loosened or tightened at pleasure. 
 
 In applying the apparatus, the surgeon first of all takes the 
 padded portion of the perineal band and adjusts it to the patient's 
 perineum, bringing up one end in front and the other behind. 
 He then lays the splint along the outer side of the aifected limb, 
 and fastens the foot to the lower end of it. In doing this it is a 
 good plan first to bandage the foot and ankle in the ordinary way, 
 to protect them from the pressure of the splint, and to prevent 
 them from swelling ; or instead of this, the foot may be enveloped 
 in a layer of cotton-wool. The surgeon should then take a " leg 
 bandage," and make a few turns round the foot and ankle in the 
 form of a figure-of8, so as to obtain a firm hold; after which 
 he should carry the roller in a regular way round the ankle, and 
 
FEACTURES OF THE FEMUE. 157 
 
 through the notches in the lower end of the splint, so as to fasten 
 it securely to the foot. He should then get an assistant to make 
 extension from the foot while he draws the perineal band tight, 
 and ties it in a bow on the outer side of the splint. In order to 
 keep the apparatus in position, it is sometimes necessary to apply 
 a bandage over both the leg and the splint, and also to put a few 
 turns of a broad roller round the pelvis and chest. 
 
 When the fracture runs through the great trochanter or the 
 upper part of the shaft of the femur, without involving the neck, 
 the upper fragment of the bone is apt to be tilted forward by 
 muscular action, as we have already explained. If Liston's 
 long splint is used for a case of this kind, it may be necessary 
 to apply a short, well-padded splint on the front of the thigh, 
 to counteract any special displacement that may exist. But it 
 is better to adopt some other method of treatment. Thus, the 
 surgeon may lay the limb on its outer side, flexing the leg upon 
 the thigh and the thigh upon the pelvis, and supporting it upon a 
 broad angular splint of wood or gutta-percha. By this means 
 the muscles are relaxed, and the fragments brought into apposi- 
 tion. Some cases do best on the double-inclined plane. The 
 most convenient contrivance of this sort is that which we have 
 here figured (Fig. 68). By this means a ridge is formed in the 
 
 Fig. 68. 
 
 Double-inclined plane. 
 
 middle of the bed over which the patient's legs are laid. This 
 has the eifect of bringing the broken fragments of the femur 
 into apposition, and nothing more is needed than to maintain the 
 same posture until union has taken place. A double-inclined 
 plane may easily be extemporized by nailing two pieces of wood 
 together at a suitable angle, or even by an arrangement of pillows. 
 In some of these cases the suspensory method of treatment, which 
 used formerly to be employed, and which has lately been revived in 
 a modified form by Dr. Nathan Smith, of Baltimore, may be used 
 with advantage (see Fig. 70). 
 
 If the perineum becomes excoriated, extension may be made 
 from the opposite thigh by placing a collar of adhesive plaster, 
 
158 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 or a padded belt, round it, and carrying tapes from this to the 
 holes at the upper end of the long splint. 
 
 In treating fractures of the femur a great deal may be done by 
 simply attending to the position of the limb without the applica- 
 tion of any splint. Thus, if the patient has a sufficient amount of 
 self-control, he may be laid flat on his back, the hollows under the 
 leg and thigh padded with cotton- wool, so as to bring the broken 
 fragments into their proper line, and then a sand-bag placed on 
 each side of the limb. If, in addition to this, the whole is encircled 
 with two or three pieces of tape, an efficient apparatus will be 
 formed, which is as little irksome to the patient as anything of 
 the kind can be. If sand-bags are not at hand, their place may 
 be supplied by a bundle of clean, dry straw, wrapped in a sheet, 
 or by any other suitable material which will give the necessary 
 amount of support, and accommodate itself to the shape of the limb. 
 
 Sometimes — more particularly in the case of children^f-exten- 
 sion may conveniently be made by fastening a loop of plaster 
 under the foot, and attaching a weight to it — the weight being 
 allowed to hang over the end of the bed. The surgeon should 
 take a long strip of plaster, lay it along one side of the leg, pass it 
 loosely under the sole, and bring it up on the other side of the 
 leg. He should then encircle the leg in two or three places with 
 strips of plaster passing round it transversely ; and over all he may, 
 if he thinks it necessary, apply a bandage in the way represented 
 in Fig. 69. By this arrangement a loop is left underneath the 
 
 Fig. 69. 
 
 Bandage for extension. 
 
 sole which draws upon the whole length of the leg, and the pres- 
 sure does not fall upon any one point, so that the risk of irritat- 
 ing the skin, or producing rodema of the foot, is greatly reduced. 
 The weight need not be so heavy as to distress the patient. 
 All that is needed is that it should make a slight but constant 
 
FRACTURES OF THE FEMUR. 159 
 
 traction upon the limb. It is a good plan to take a bag and pour 
 dry sand into it, such as is used for making sand-bags, adding 
 a little each day, as the patient is able to bear it, until the proper 
 weight has been attained. Or the bag may be tilled with shot, 
 or any other heavy substance ; or the ordinary iron weights, which 
 are furnished with a ring on the upper surface, may conveniently 
 be used. By a simple apparatus of this kind, and by placing 
 sand- bags on either side of the leg, splints may sometimes be dis- 
 pensed with altogether for young subjects. The same method is 
 found of great service in deahng with diseases of the hip and 
 knee. The bones are kept apart, so that the patient is saved 
 from much of the pain that they cause by rubbing against one 
 another, and the limb is maintained in good position in case 
 ankylosis should occur. 
 
 The apparatixs which Dr. Nathan Smith has introduced for 
 treating fractures of the femur, among its other advantages, is 
 particularly suitable to cases in which the back of the limb has been 
 much bruised. It consists of a couple of light iron rods, bent at 
 such an angle as to suit the shape of the thigh and leg when 
 slightly flexed (Fig. 70). The rods are connected together at 
 
 Fig. 70. 
 
 Nathan Smith's anterior splint. 
 
 their lower end, and a space is left between them sufficient to 
 receive the limb. From one end to the other strips of bandage 
 are fastened transversely, side by side, so as to form a trough, 
 fitted to the shape of the leg and thigh. Upon this the limb is 
 laid, and then the rods are attached to cords which are suspended 
 from a point above the bed, and which are regulated by pulleys. 
 The hook to which the cords are fastened ought to be placed, not 
 immediately over the limb, but a little in front of it, so as to 
 make extension, while the weight of the patient's body supplies a 
 counter-extending force. This apparatus has the merit of being 
 remarkably simple, cheap, and clean. Moreover, it enables us to 
 swing the whole of the lower extremity, and to give the thigh 
 some of that relief which we can afford to the knee and the leg 
 by means of " Salter's Swing" (see Fig. 80). 
 
 After the patient has been treated by any of these methods for 
 five or six weeks, a flannel bandage, or a starch bandage, should 
 be applied, and he should be allowed to move about on crutches. 
 
160 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 Fiar. 71. 
 
 Mr. Erichsen and other surgeons treat fractures of the femur by 
 simply confining the } atient to bed for a few days, and then 
 putting up the whole leg and thigh in a starch bandage. This 
 method has the advantage of permitting the patient to go about 
 on crutches while union is taking place. At the same time there 
 is more risk of malposition than when the patient is confined to 
 bed until consolidation has taken place. It must also be borne 
 in mind that the femur is one of those bones in which non-union 
 is apt to occur, and where it is especially desirable that the frag- 
 ments should be kept at rest and in apposition. 
 
 In cases of compound fracture of the femur the course which 
 must be adopted depends entirely upon the extent and severity 
 of the wound. When this is slight, the limb may be put up in 
 the way described already, and the wound sealed, or treated on 
 antiseptic principles. But when the main vessels are torn, or when 
 the injury to the soft parts is very extensive, the question of 
 amputation will have to be considered (see p. 61). 
 
 Fractijees of the Lower Extremity op the Feiiur 
 may be either transverse or oblique. When transverse, they 
 
 generally occur in young subjects, 
 and follow the hne of the epiphysis. 
 When oblique, they are apt to 
 extend into the joint. Fig. 71 
 shows such a fracture. A section 
 has been made through the con- 
 dyle, and it will be seen that 
 inflammation has commenced in 
 the cancellous tissue. 
 
 Treatment. — When the femur 
 is broken near its lower end, 
 great care should be taken to 
 keep the limb at rest so as to 
 prevent, as far as possible, any 
 inflammation of the knee-joint. 
 The simpler cases of this kind 
 may be treated by means of 
 Listen's long splint and a perineal band (see p. 156). But if 
 the injury is more severe, or if the patient is restless, it is better 
 to put the limb upon a " M'Intyre's splint" (see Fig. 74), which 
 gives perfect support to both the thigh and the leg, while it pre- 
 vents any movement at the knee-joint. If the limb is slightly 
 flexed upon the splint, and then laid in a " Salter's Swing," it 
 will give the patient great comfort, and afibrd him the best 
 chance of a good recovery. It must be remembered that in a 
 severe case of this kind ankylosis may take place, and that in 
 
 Fracture into the knee-joint. 
 
FRACTURE OF THE PATELLA. 161 
 
 such an event a slight degree of flexion at the knee is the posi- 
 tion which will leave the patient the most serviceable limb. 
 
 If the fracture is compound, and the joint opened, the case 
 will probably require immediate amputation. 
 
 FRACTURE OF THE PATEXiIiA. 
 
 The patella may be broken either by direct violence or by 
 muscular action. When it is broken by direct violence the 
 fracture may take any direction, or it may be comminuted. 
 When it is the result of muscular accion, it is always transverse. 
 The bone being fixed below by the ligaraentum pitellae, and 
 stretched upon the condyles of the femur at the moment when 
 the leg is bent, the violent contraction of the extensors tears it 
 across. The accident generally occurs in the sudden effort made 
 by a person to save himself from falling backwards, I have 
 known a gentleman slip in frosty, weather and break both his 
 patellae transversely at the same moment. 
 
 Signs. — Inability to stand, or to extend the joint, and crepitus. 
 The line of fracture may be felt ; if it is transverse, the frag- 
 ments are widely separated. 
 
 The kind of union which results varies with the nature of the 
 accident. If the fracture is longitudinal or comminuted, union 
 takes place by bone ; but when the fracture is transverse, the 
 union is almo.st always fibrous. The chief reason for this is that 
 in the former class of cases it is generally easy to keep the frag- 
 ments in apposition ; while in the latter we always find that 
 there is such a wide interval between the pieces of bone that it 
 is very difficult to bring them together, and to retain them in that 
 position. 
 
 The treatment of the longitudinal and comminuted fractures 
 consists simply in extending the leg upon a light wooden back- 
 splint, and then relaxing the extensor muscles of the thigh by 
 propping the patient up in bed with pillows, so as to place him in 
 the semi-recumbent position ; or — which has the same effect — 
 by laying him nearly flat, and raising the limb upon pillows or in 
 a swing, so as to flex the thigh on the pelvis. When one posi- 
 tion becomes irksome, it may be exchanged for the other; or one 
 may be maintained during the day, and the other at night ; care 
 being taken always to preserve the same angle at the hip, so that 
 the extensor muscles of the thigh may be kept constantly relaxed. 
 If there is much swelhng or inflammation about the joint, or if 
 the soft tissues are extensively bruised, it may not be advisable to 
 apply a back-splint at once. In such a case the leg should be 
 simply laid upon a pillow, and treated with cooling lotions or 
 with fomentations until the acute symptoms have subsided ; and 
 
 M 
 
162 DISEASES OF TISSUES AND OEGANS. 
 
 then the limb may be put upon a splint. If there is any fear 
 of ankylosis, the surgeon should bear in mind that the most use- 
 ful position for the patient is that in which the leg is slightly 
 flexed. 
 
 The treatment of transverse fractures is less satisfactory. In a 
 case of this kind the patient should be laid in one of the positions 
 that we have already described, so as to relax the muscles, and 
 allow the broken fragments of bone to approach one another. If 
 there is much inflammation about the knee- joint, it may be im- 
 possible to do more than this for a few days. Fomentations or 
 cooling lotions must be constantly applied. After the swelling 
 has been subdued, it is well to extend the leg upon a back-splint. 
 A concave one made of wood is perhaps the best that can be em- 
 ployed. It ought to be long enough to reach from the middle of 
 the thigh to the middle of the leg, and it should be well padded. 
 It may be fastened either witU broad strips of plaster, or with a 
 few turns of a bandage, at its upper and lower end — the seat of 
 fracture being left uncovered. These simple means often suffice 
 to bring the broken fragments nearly together ; and although a 
 great deal of ingenuity has been expended upon the treatment of 
 these injuries, it is a question whether any better or safer method 
 than this has been devised. 
 
 If, however, the surgeon is anxious to try and bring the frag- 
 ments into closer apposition, there are a variety of means at his 
 disposal. In addition to the back-splint he may place a collar of 
 adhesive plaster round the thigh, attach tapes or elastic bands 
 to each side of it, and carry them down and fasten them to a 
 slipper on the foot, or connect them with weights, and suspend 
 them over the end of the bed. The collar plaster should be 
 about two inches broad, and should overlap the upper fragment 
 of the patella, so that the traction may be exerted upon the broken 
 bone, and not merely upon the skin. Or he may endeavour to 
 draw the upper fragment downwards by a figure-of-8 bandage 
 applied over the back-splint, and the effect of such a bandage will 
 be considerably increased if a pad of lint is laid upon the upper 
 edge of the upper fragment. This pad may be fixed in its 
 place by a strip of adhesive plaster, and then the roller applied 
 over it. Mr. John Wood has devised a splint for these cases, 
 which gives the figure-of-8 bandage a better hold, and increases 
 its power. It consists simply of a straight concave iron splint 
 furnished with two hooks behind the knee. The hooks are 
 placed back to back, and at such a distance from one another as 
 to give the bandage a suitable degree of obliquity. The same 
 principle has been applied yet more simply by cutting notches in 
 the sides of a straight wooden splint, and fixing the loops of the 
 
FRACTURE OF THE PATELLA. 163 
 
 figure-of-8 bandage upon them (see Hamilton on Fractures). 
 When any apparatus of this kind is used, or when any bandage is 
 applied which compresses the limb, care must be taken to cover 
 the leg with a roller from the toes to the knee, in order to pre- 
 vent the swelling which is apt to arise. 
 
 The objection to the methods I have described in the foregoing 
 paragraph is that they have a tendency to tilt the upper frag- 
 ment forward, and to throw it out of its proper place — so 
 difficult is it to act upon a small and very moveable piece of bone. 
 M. Malgaigne has endeavoured to overcome this difficulty by a 
 direct method of treatment. With this view he has devised the 
 hooks which bear his name (Fig. 72). These hooks are fixed into 
 
 Fig. 72. 
 
 Malgaigne's hooks. 
 
 the tendons at the upper and lower edge of the patella, so as to 
 obtain a firm hold of the margins of the bone, and then drawn 
 together by means of a screw, which is worked with a key. The 
 pain of applying the hooks is trifling, and most patients bear 
 them without discomfort ; but it should be remembered that 
 considerable inflammation of the joint has taken place in some 
 cases in which they have been used, and for this reason they are 
 not regarded with much favour by English surgeons. 
 
 Whatever method of treatment is adopted, it must be continued 
 for about six weeks, and then the patient may be allowed to get 
 up and move about upon crutches, wearing an elastic knee-cap, 
 or having a light splint applied to the back of the joint. 
 
 Erichsen speaks highly of the use of the starched bandage, and 
 says that the patient can walk about during the whole of the 
 treatment. " The action of the bandage,^' he adds, " is much 
 increased by drawing down and fixing the upper fragment by two 
 broad strips of plaster firmly applied above it. A back-splint of 
 pasteboard is required to fix the knee, and a good pad of lint 
 with a figure-of-8 bandage should be applied above and below the 
 fracture to keep it in position." Some surgeons have employed 
 plaster of Paris bandages in the same manner. 
 
 In this accident, as well as in many others, it is always 
 
 M 2 
 
164 DISEASES OF TISSUES AND OEGANS. 
 
 desirable to warn the patient that some degree of lameness is 
 almost certain to remain as a result of the injury. 
 
 FRACTURES OF THE IiEG. 
 
 When both bones are broken, the fracture is easily detected by 
 the loss of power, shortening, mobility and crepitus ; when only 
 one has suffered, especially if that one be the fibula, the diagnosis 
 is more difficult. The commonest seat of fracture is at the junc- 
 tion of the middle and lower third of the leg. The fracture may 
 be either transverse or oblique. If oblique, the fissure runs from 
 above downwards and backwards. The lower fragment over- 
 rides the upper, in consequence of the action of the muscles of the 
 calf, and is very apt to protrude through the skin. 
 
 Treatment. — In a case of simple fracture of both bones, if there 
 is but vei'y little swelling or displacement, it sometimes suffices 
 to confine the patient to bed for a few days with his leg laid 
 between sand-bags ; and then the leg may be encased in a starch 
 bandage. This plan has the advantage of allowing the patient to 
 move about on crutches while union is taking place ; but the sur- 
 geon should be careful to examine the limb from time to time, 
 to see that the bones are in their proper position. In the great 
 majority of instances, however, there is so much displacement, or 
 mobility, that the patient must be confined to bed for a longer 
 period, and the leg fixed by some kind of apparatus. The means 
 which have been devised for this purpose are numerous; but here, 
 as elsewhere, the simpler and less complicated the splint the more 
 generally useful will it be found. 
 
 In all ordinary cases of simple fracture of both bones, the best 
 plan of treatment is to apply two side-splints with foot pieces, the 
 splints being well padded, and secured above and below the seat of 
 fracture by broad strips of plaster, or by a few turns of a roller. 
 Some surgeons are of opinion that the outer splint only should 
 have a foot piece, the inner one being cut off at the ankle. 
 But there seems no sufficient reason for this, and it is more 
 convenient to have both splints of the same shape, so that 
 they may be available for either leg. After the side-splints have 
 been applied, the limb may either be simply laid on the bed — 
 placed, if need be, between a couple of sand-bags— or it may be 
 supported in a " Salter's Swing" (see Fig. 80) — or suspended under 
 a common cradle by a few hoops of bandage. Such a cradle 
 may easily be made of light iron rods bent so as to form a series 
 of arches connected by narrow bars of wood (Fig. VS). To 
 keep the patient from hurting his leg during sleep, the cradle 
 should be padded with cotton-wool or covered with a roller. 
 This method of swinging the leg not only gives comfort to the 
 
FRACTURES OF THE LEG. 
 
 165 
 
 patient, but also tends to prevent the injury which might arise 
 from involiTntary starting of the limb. 
 
 Fig. 73. 
 
 Leg placed on a back-splint, and suspended under a cradle. 
 Another excellent plan of treating simple fractures of the leg, 
 is to use a straight iron back-splint, about four or five inches broad, 
 and bent upwards at its lower end so as to form a foot-piece (such 
 as is seen in Fig. 73). The material of which the splint is made 
 should be thin and pliable, so as to allow the surgeon to adapt it 
 in some degree to the shape of the foot and leg. It should be 
 thoroughly padded, especially above and around the heel, so that 
 the weight of the foot may be difi'used over the ankle and leg, 
 and not fall entirely upon the heel ; for the skin in this situation, 
 like the skin over all other bony prominences, is excessively prone 
 to become inflamed, and to ulcerate, under continued pressure. If 
 the simple back- splint is not found sufficient to keep the leg in 
 position, a straight wooden splint may be added on one or both 
 sides to give lateral support. In putting up a fracture of the 
 leg it is well to leave the crest of the tibia as far as possible 
 uncovered, so that the surgeon may run his finger along 
 it from time to time, and ascertain the position of the 
 fragments. 
 
 If the line of fracture through the tibia is oblique, as it fre- 
 quently is, and if there is danger of the lower fragment piercing 
 the skin, it is desirable to relax the muscles so as to prevent them 
 from acting upon the bones, and converting a simple fracture into 
 a compound one. In order to do this the leg may be laid on its 
 outer side upon a broad side-splint, the leg and the thigh being 
 both flexed. But, as this position is apt to become irksome, it is 
 more usual to carry out the same indications by putting up the 
 fracture with side-splints, or with a back-splint, in the way 
 already described, and then swinging the limb in such a manner 
 as to flex both the hip and the knee. 
 
 When one bone alone has been broken, there is generally but 
 little displacement, the sound bone helping to keep the broken 
 one in its proper position. In such a case, the surgeon may have 
 recourse to any of the foregoing methods, being guided in his 
 
166 DISEASES OF TISSUES AND OEaANS. 
 
 choice by the age and temperament of the patient, as well as by 
 the details of the injury. For example, a child, or a patient whose 
 self-control cannot be depended upon, must be confined to bed, 
 and means used to insure the perfect repose of the limb ; but in 
 other instances the fracture may, after a day or two, be put up 
 with a starch bandage. When the fibula alone is broken, it will 
 sometimes suffice to apply strips of plaster and a bandage round 
 the leg in the way described in speaking of sprained ankle (see 
 p. 104), 
 
 Compound fractures of the leg are far from uncommon. When 
 the wound is slight, a pad of lint should be applied, upon which the 
 blood will coagulate, and thus seal the wound ; or the pad may 
 be saturated with collodion or Friar's balsam. The limb may 
 then be put up with side-splints, or with a back-splint. If a 
 point of bone protrudes, and cannot easily be reduced, it should 
 be removed with the saw or bone-pliers. If the wound is of 
 larger size, and the soft tissues are much injured, there will 
 probably be more or less suppuration. It is then well to have 
 recourse to a M'Intyre's splint (Fig. 74) — i.e., a concave iron 
 
 Fisr. 74. 
 
 M'Intyre's splint. 
 
 splint, with a thigh-piece and a foot-piece, and a joint at the 
 knee, regulated by a screw, so that it can be fixed at any angle, 
 and the whole leg kept perfectly at rest. Whether the wound 
 is great or small, or whatever may be the kind of splint 
 selected, care should be taken to leave the seat of injury un- 
 covered, so as to allow the surgeon to examine, and treat it, 
 without disturbing the position of the limb. In putting up such 
 a fracture it is a good practical rule to keep the ball of the great 
 toe in a line with the inner edge of the patella and the ante- 
 rior superior spine of the ilium. To facilitate this, it is well to 
 have at hand one or two small soft pads, which may be used 
 to make pressure upon particular points, in order to bring the 
 broken fragments into their proper line. 
 
 In treating these fractures, the surgeon will find that he must 
 vary his appliances according to the details of each particular 
 case. Among fractures which present much the same appear- 
 ances, and which seem to belong to the same class, one case will 
 do well between side-splints; another will require a back-splint, 
 
FRACTURES ABOUT THE ANKLE JOINT. 167 
 
 with or without lateral support ; while a third will have to be 
 laid upon a M'Intyre's splint before it can be brought into a 
 satisfactory position. 
 
 If the fracture is not merely compound, but the whole thick- 
 ness of the limb is crushed and disorganized, immediate ampu- 
 tation will be necessary. 
 
 Compound fractures of the leg are often associated with 
 troublesome haemorrhage. If the injury is in the middle or 
 upper third of the leg, amputation will almost certainly be 
 inevitable ; if it is in the lower third, it may be possible to secure 
 the bleeding vessels. 
 
 FHACTURES AlELOVT THE ANILJmJI TOIITT. 
 
 When the foot is violently twisted outwards, the fibula is apt 
 to give way about two or three inches from its lower end, and 
 such fractures are frequently attended with more or less injury to 
 the ankle joint. 
 
 The diagnosis is not difl&cult, inasmuch as the seat of fracture 
 can be felt. 
 
 In the simplest cases of this class the fibula alone is broken, 
 whilst the internal lateral ligament of the ankle joint is stretched 
 or lacerated. When this is the whole amount of the injury, there 
 is generally little or no displacement of the foot, and the only 
 symptoms, besides the fracture, are swelling and extravasation of 
 blood about the ankle. Here simple means will suflSce for a cure. 
 The leg should be laid upon a pillow for a few days, and then the 
 fracture can be put up with strapping and a bandage, or with a 
 starch bandage. Indeed, in some cases, if the patient's time 
 is valuable, the leg may be strapped and bandaged at once (see 
 p. 104). 
 
 If the swelling is considerable, it is well to treat the injured 
 part with cold lotions (F. 21, 23), or with fomentations ; and if 
 these are retained by a many-tailed bandage, a little gentle 
 pressure may be exerted at the same time (see Fig. 186). 
 
 But if the case is more severe than this — if, in addition to the 
 fracture of the fibula and the laceration of the internal lateral 
 ligament, the internal malleolus is snapped off as well — then it 
 will be necessary to confine the patient to bed, and to keep his 
 leg at rest by some kind of apparatus. The first step in the 
 treatment should be the same as in the simpler cases — the leg 
 should be laid upon a pillow, and local measures used to subdue 
 the acute symptoms. After this has been effected, the leg 
 should either be simply laid between sand-bags — the sand-bags 
 and the limb being encircled at intervals by loops of bandage, 
 or broad-tape, so as to keep the whole in position — or else it 
 
168 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 may be fixed between a couple of side-splints with foot-pieces, 
 the splints being secured by a few turns of a roller above and 
 below the fracture, or by bands of webbing and buckles. 
 
 Fig. 75. 
 
 When the fibula is broken and the internal 
 lateral ligament ruptured, the foot not unfre- 
 quently suffers a partial dislocation outwards 
 in the manner described by Mr. Percivall Pott. 
 This is clearly shown in Fig. 75, which is 
 reduced from the original illustration in Pott's 
 " Remarks on Fractures and Dislocations," 1768. 
 The same thing may happen when, in 
 addition to the fracture of the fibula, the 
 internal malleolus is splintered ofi". The toes 
 point outwards, and the external border of the 
 foot is turned slightly upwards. As this dis- 
 placement is due in part to the action of the 
 muscles which pass under the outer malleolus, 
 our object must be to relax them. With this 
 view the knee and the ankle should be mode- 
 rately bent, and then the leg may either be laid 
 upon its outer side on a broad side-splint, or fixed 
 between two side-splints with foot-pieces, care 
 being taken to apply the roller in such a way 
 that the outer splint shall press the foot in- 
 wards towards the median line. 
 
 It is in cases of this kind that tbe short, straight splint, known 
 as Dupujtren's, is sometimes used. Tbe accompanying illustra- 
 tion ( Fig. 76) shows the form in which it was originally employed 
 
 Fig-. 76. 
 
 Pott's fracture. 
 
 Dupuytren's splint applied. 
 
 by the eminent surgeon whose name it bears, and the way in 
 which he was in the habit of applying it. It is an ordinary 
 straight wooden splint about three inches broad, and long enough 
 to extend from the knee to a short distance below the sole of the 
 foot. It should be well padded, so as to adapt itself to the inside 
 of the leg, the pad being especially thick and firm where it fits 
 into tbe hollow above the internal malleolus. The splint is ap- 
 plied along the inner side of the leg, and secured at its upper 
 end by a few turns of a roller. The foot is then bent over the 
 
FRACTURES ABOUT THE ANKLE JOINT. 169 
 
 thick portion of the pad, which serves as a fulcrum, so as to press 
 
 outwards the upper end of the lower fragment, and retained in 
 
 this position by broad strips of plaster, or by a bandage. The 
 
 limb, with the splint affixed, may be semiflexed upon its outer 
 
 side on a pillow, or upon its inner side as in the illustration. In 
 
 modern practice, however, a modification of Dupuy tren's apparatus 
 
 is generally preferred. 
 
 It consists of a short Fig. 77. 
 
 straight splint pierced 
 
 with holes near its upper 
 
 end, and furnished with 
 
 deep notches at its lower Modem form of Dupuytren's splint. 
 — in fact, it is like 
 
 Liston's long splint on a smaller scale (Fig. 77). It should be well 
 padded, especially above the internal malleolus, and then applied 
 on the inner side of the leg, secured at its upper end by a few 
 turns of a roller and below by a figure-of-8 bandage passing 
 through the notches, and embracing the instep and heel alter- 
 nately. When the fracture has been put up in this way, the limb 
 may be laid on its back, or suspended in a " Salter's swing" 
 (see Fig. 80). 
 
 In treating these cases of fracture of the fibula with injury 
 about the ankle joint, the splints ought not to be used for more than 
 a month or- five weeks for fear of ankylosis ; and at the end of 
 that time the surgeon should begin to make passive movements, 
 so as to secure the mobility of the joint. 
 
 When both bones of the leg are broken near the ankle joint, 
 the injury is almost always the result of direct violence, and the 
 fracture is frequently compound or comminuted. In such a case 
 the foot may be displaced in various directions, and the toes 
 pointed either inwards or outwards. No very precise rules can 
 be laid down for the treatment of such injuries. Each case must 
 be dealt with according to the peculiarities which it presents. 
 Sometimes the leg may be simply laid upon a pillow, or upon a 
 broad side-splint ; sometimes a short straight splint, placed 
 either upon the inner or outer side of the limb, may be the best 
 means of overcoming the displacement ; sometimes a pair of 
 ordinary side-splints may be the most efficient mode of treatment ; 
 sometimes a common back-splint with a foot-piece, or a M'ln- 
 tyre's splint, will bring the leg into the best position ; and 
 sometimes the surgeon will have to cut down a wooden splint, 
 and shape it so as to meet the special requirements of the case. 
 
170 DISEASES OF TISSUES AND ORGANS. 
 
 FBACTURES OF THE TAKSAIi AITB SS&TA- 
 TABSAIi BOIO-ES. 
 
 These fractures are usually the result of great aud direct 
 violence. They are not unfrequently compound, or complicated 
 by dislocations, and there is always much injury to the soft 
 parts. 
 
 Treatment. — Here, as in the case of the severe fractures about 
 the lower portion of the leg, it is impossible to lay down any 
 precise rules for the guidance of the surgeon. He must study 
 the particulars of the injury, and then select the most suitable of 
 the methods enumerated in the preceding paragraphs. Local 
 applications will have to be used to subdue the inflammation. It 
 often happens that a paste-board or gutta-percha splint moulded to 
 the part will be found more eflScient, and more comfortable than 
 any other apparatus. Such a splint may be so shaped as to give 
 support to the sound parts, while it permits the surgeon to dress 
 the wounds, and allows a free escape for the discharge. 
 
 When the calcaneum is broken, a gutta-percha splint should be 
 moulded upon the heel, and the leg flexed so as to relax the 
 muscles. In the same way, when the tendo Acbillis is ruptured, 
 the leg should be bent at the knee, and retained in that posi- 
 tion by a cord, connected at one end v/ith the heel of the patient's 
 slipper, and at the other with a bandage passing round the thigh. 
 After either of these injuries the patient should wear a high- 
 heeled shoe for some time, when he begins to walk about. 
 
 In the severer injuries about the ankle and foot, more particu- 
 larly if the fracture is complicated with a dislocation, it may be 
 necessary to remove some of the bones. The astragalus has 
 frequently been removed in this manner, and the cases have 
 turned out remarkably well. If the patient is old or sickly, so 
 that he cannot endure the strain of a prolonged or painful illness, 
 amputation maj"^ be the only resource. 
 
 Crutches. — When a patient begins to move about after any 
 severe accident or operation involving the lower extremities, he 
 has generally to support himself upon crutches until he recovers 
 the use of his limb. The crutches should be just long enough to 
 enable him to raise the injured leg off the ground, while he stands 
 firmly upon the other. The cross-bar should be well padded, so 
 as to form a cushion upon which he may bear his weight. If 
 this is not done, the pressure upon the axillary nerves may be 
 such as to lead to a partial paralysis of the arm. In hospital 
 practice it is always well to wrap a piece of leather or cloth under 
 
DISEASES OF JOINTS. 
 
 171 
 
 the lower end of the crutch to prevent it from slipping. This is 
 necessary because patients are rather awkward when they begin 
 to use crutches, and if the floor of the ward is waxed, or if it 
 has been recently washed, they are very apt to fall. 
 
 The best crutches that we can recomnnend in private practice 
 are those in which the shaft and the handle are made out of a 
 single piece of wood. Sometimes a spring is put in the upper 
 part of the shaft, so as to give elasticity to the cross-bar. They 
 should be tipped with little leather shoes to keep them from 
 slipping. 
 
 If the state of the injured limb is such that the patient ought 
 not to use it at all, it is a good plan to support it with a bandage 
 passed under the foot, the ends being brought up evenly in front, 
 and tied behind the neck. In this way a sort of sling is made 
 which assists the patient in keeping his foot oif the ground. 
 
 DISEASES or JOIKTTS. 
 
 Acute Synovitis may arise from external injury, but more often 
 it is caused by cold or wet. It is often associated with a gouty, 
 rheumatic, or syphilitic habit, and it usually attacks those joints 
 which are most exposed — e.g.^ the ankle or knee. 
 
 During the early stage the synovial membrane is red and vas- 
 cular. If the disease continues, it gradually becomes thickened 
 and villous. The quantity of fluid secreted is greatly increased. 
 At first it is clear and serous. Subsequently it becomes turbid 
 and contains flakes of lymph, or is mixed with blood. Ultimately 
 it may become purulent, and when this happens the cartilages are 
 very apt to ulcerate. 
 
 Symptoms. — Heat, pain gradually increasing in intensity, and 
 great tenderness, early and rapid swelling, which is very characteris- 
 tic in its shape, inasmuch as it shows itself between the bony pro- 
 minences, wherever 
 
 the synovial cavity Fig. 78. 
 
 can find room to ex- 
 pand. Thus, in the 
 knee, where it is so 
 often seen, it assumes 
 something of a horse- 
 shoe form round the 
 sides of the patella, 
 between that bone 
 and the condyles of 
 the femur. In the 
 hip it bulges in 
 front; in the shoulder Synovitis of the ankle-joint. 
 
172 DISEASES OF TISSUES AND OEGANS. 
 
 it forms a smooth rounded swelling beneath the deltoid; in the 
 elbow it becomes prominent on each side of the olecranon ; and 
 in the ankle at each side of the extensor tendons (Fig. 78). 
 There is fluctuation. The joint is flexed and powerless, and 
 there is more or less constitutional disturbance. 
 
 Treatment. — The joint should have perfect rest upon a splint. 
 Fomentations or poultices, plain or medicated, should be con- 
 tinuously applied. Sometimes cold lotions give most relief. If 
 the patient is plethoric, and the inflammation runs high, blood 
 should be freely drawn from the joint by leeches. If the hip 
 or the knee is affected, extending the limb by means of a 
 weight gives great relief in some cases, even in the acute stage 
 (see Fig. 69). 
 
 At the outset of treatment a purgative should be prescribed, 
 and this should be followed by salines. If the attack is associated 
 with a gouty, rheumatic, or syphilitic state of constitution, 
 colchicum, the alkalies, and the iodide of potassium should 
 respectively form part of the treatment. (F. 56, 60.) 
 
 If there is reason to suspect, from the occurrence of rigors, 
 that suppuration has taken place, a grooved knife or needle 
 should be introduced into the joint to ascertain the fact, and then 
 an incision — and if need be, a counter -incision — should be made, 
 and poultices applied. 
 
 In traumatic cases the continuous application of an ice-bag, 
 or a strict adhesion to Lister's antiseptic method of treatment, 
 will be the most likely means of securing a favourable result. 
 
 When the acute symptoms have been subdued, friction with 
 unguents or liniments, and a bandage, will help to remove the swell- 
 ing and stiffness, and to restore the part to a natural condition. 
 
 As the knee joint is very often attacked with synovitis, we may 
 take this opportunity of mentioning that a convenient bandage 
 for retaining poultices or dressings upon the knee or in the popli- 
 teal space, as well as in other situations, may be made by taking 
 a piece of calico about a yard and a half long and a foot wide, 
 and tearing it up the middle from each end to within six inches 
 of the centre. It is applied in the following manner : — The 
 surgeon lays the central portion either over or under the knee, 
 as the case may require, and brings the two upper tails round 
 the limb, and crossing them, carries them back to the point from 
 which he started, and ties them there. The two lower tails are 
 then fastened in a similar manner. 
 
CHRONIC SYNOVITIS. 173 
 
 CHRONIC SVSJOVZTZS 
 
 is often the result of the foregoing, though sjoraetimes the inflam- 
 mation has from the first a subacute or chronic character. 
 
 There is less pain and tenderness than in the acute form, but 
 tlie joint is swollen, and the synovial membrane thickened and 
 pulpy. In many instances when pressure is made upon it, a fine 
 crackling can be felt — the result of efi'usion into the meshes of the 
 areolar tissue. When the accumulation of fluid in the joint is 
 great, while the inflammatory symptoms are almost, or quite, 
 absent, the disease is termed hydrops articuli or hydrarthrosis. 
 
 Treatment. — In chronic, as in acute synovitis, there is usually 
 some constitutional taint which must be met by its appropriate 
 remedies. With regard to local treatment it is of the utmost 
 importance to give the pai't perfect rest on a splint, and to make 
 regulated pressure by means of a bandage. In addition to this 
 the surgeon will find it necessary to try various means, one 
 after another. The joint should be rubbed with stimulating 
 ointments or embrocations, or it should be painted with lin. iodi, 
 or blistered, or strapped, with or without the application of 
 " Scott's dressing." This dressing takes its name from " Scott, 
 of Bromley." It is very useful in many of the chronic diseases 
 of joints, and is applied in the following manner : — The joint is 
 first sponged with camphorated spirit, and then evenly covered 
 with strips of lint spread with strong mercurial ointment mixed 
 with camphor (ung, hyd. co.). The strips of lint should be about 
 two inches broad, and they ought to be applied in the same way as 
 a many-tailed bandage (see Fig. 186). The ends ought to overlap 
 one another a little, but care must be taken that this overlapping 
 does not happen to fall upon any bony prominence, such as the 
 patella. After the joint has been covered with the strips of lint 
 it should be encircled in the same way with strips of leather 
 plaster, so as to form a firm, dry case. Over this a bandage 
 may be applied, and by this means a degree of pressure may be 
 employed, if it seems desirable. The dressing may generally be 
 allowed to remain on for a week or ten days before it requires to 
 be renewed. 
 
 Bandage for the Tcnee. — It often happens that the surgeon has 
 to bandage the knee either to give it support after fracture, or to 
 exercise gentle pressure upon it, as in some of the diseases to which 
 the joint is liable. The bandage may be most conveniently 
 applied in the form of a figure-of-8 (Fig. 79). The end of the 
 roller should be laid upon the outer side of the head of the tibia, 
 carried round the back of the leg from without inwards, and some- 
 
174 DISEASES OF TISSUES AND OEGANS. 
 
 what obliquely from below upwards. Then it should be brought 
 round the inside of the leg, and carried across the front of the joint, 
 still tending obliquely from below upwards. Then round the 
 back of the thigh in a transverse direction to its inner side, from 
 whence it is conducted obliquely across the front of the joint 
 from above downwards to the point at which it commenced. These 
 figures may be repeated as often as they are necessary ; each one 
 rising a little higher up the limb than the preceding one, and care 
 
 Eig. 79. 
 
 Bandage for the knee. 
 
 being taken that the corresponding folds are equidistant from one 
 another. The turns ought not to cross one another directly over 
 the patella, but a little to its outer side. It will be observed 
 that the appearance of this bandage, when properly applied, is 
 very much the same as that produced by "reverses." 
 
 I.OOSB CARTZX.AGES IN* JOIM'TS. 
 
 Loose cartilages are most frequently met with in the knee 
 joint. They seem to commence in a thickening of the fringes of 
 the synovial membrane, the result of chronic synovitis, and are 
 often associated with rheumatism. They are usually composed 
 of condensed fibrous tissue. It is seldom that they have a car- 
 tilaginous structure. They can be felt, and moved. Sometimes 
 they come between the articular surfaces causing great pain, and 
 perhaps making the patient fall suddenly to the ground. This 
 pain is probably caused, as Erichsen says, by the sudden and 
 forcible stretching of the ligaments of the joint, for "the sen- 
 sibility of the ligaments of a joint is of that peculiar nature 
 that it is only called into action when an attempt is made to 
 stretch them, and thus forcibly to counteract or destroy their 
 
ARTHEITIS. 175 
 
 natural use. Ligaments may be cut without any suffering, but 
 they cannot be stretched, either by accident or disease, without 
 the most severe pain." 
 
 Treatment, — Sometimes they can be fixed in one corner of the 
 joint by an elastic knee-cap or bandage, until they contract adhe- 
 sions. j\lr. Hilton recommends that the joint should be kept 
 perfectly at rest, and counter-irritation applied over the loose 
 cartilage with a view of procuring its absorption. In this way 
 the symptoms to which they give rise may be palliated. If, 
 however, the sufferings of the patient are great, and if milder 
 measures have failed, the loose cartilage may be pushed into a 
 corner of the synovial cavity, and removed by a subcutaneous 
 incision, being either drawn out, or left in the areolar tissue till 
 it becomes absorbed. Under an antiseptic spray surgeons have 
 dealt more freely with the joint, laying it open and removing the 
 loose cartilages at once. But this operation, simple though it 
 sounds, is not unattended with danger, and should not be under- 
 taken except as a last resource. 
 
 ARTHRITIS. 
 
 By arthritis is meant an inflammatory condition of a joint 
 affecting more or less all the structures that enter into its com- 
 position. 
 
 It may be either acute or chronic. It may begin in the syno- 
 vial membrane, or in the ligaments, or in the cartilage, or in the 
 bones, and spread thence to the adjacent parts. 
 
 It generally occurs in persons who are of an unhealthy con- 
 stitution, or who are out of condition at the time. It is often 
 excited by twists, blows, or wounds. Sometimes it is a conse- 
 quence of pysemia, or puerperal fever. 
 
 Symptoms of acute arthritis. — The whole tissues of the joint 
 are somewhat swollen. The enlargement is general : it does not, 
 as in synovitis, show itself, chiefly in certain situations. The 
 skin is hot, and pervaded by a slight blush. The tenderness is 
 such that the patient cannot bear the part to be touched. The 
 pain is exquisite, and aggravated by the least movement. It is 
 commonly referred to one spot, and is generally worse at night. 
 There are painful startings of the limb, which prevent the patient 
 from sleeping, and add greatly to his sufferings. With these 
 local symptoms there is usually a high degree of constitutional 
 disturbance. 
 
 The disease spreads rapidly, and the various tissues of the joint 
 soon become affected. The cartilages ulcerate, the synovial mem- 
 brane becomes thickened and gelatinous, the ligaments are 
 softened and disorganized, the joint becomes unnaturally move- 
 
176 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 able, and the articular surfaces grate upon one another. Sup- 
 puration commonly takes place, and, if the joint is not opened, the 
 matter makes its way to the surface at various points. 
 
 In the treatment of a case of acute arthritis, the patient should 
 be kept perfectly at rest ; the affected limb should be fixed on a 
 sphnt, or be laid between sand-bags. If it is the knee that 
 is diseased, great relief will be given by extending the limb by 
 means of a weight hung over the end of the bed, or by suspend- 
 ing the leg in a " Salter's swing" (Fig. 80). The joint should 
 
 Fis-. 80. 
 
 Leg suspended in Salter's swing. 
 
 be freely leeched, and constantly fomented; calomel should be 
 given in combination with opium, and the general treatment must 
 be strictly antiphlogistic. If the inflammation subsides without 
 the formation of matter, and falls into a subacute or chronic 
 stage, counter-irritation by blisters or iodine paint, or encasing 
 the part with strips of emp. belladonnae, or emp. ammoniaci c. 
 hydrargyro, or the application of " Scott's dressing," will be 
 found very beneficial. 
 
 If suppuration takes place, a free incision — and perhaps a 
 counter-incision — must be made into the joint, and poultices 
 applied. If it is one of the larger joints that is affected, as the 
 hip or the knee, the patient will be in great danger of sinking 
 from exhaustion or hectic. If he recovers, it will probably be 
 with a stiff joint. The limb should therefore be placed at the 
 outset, and maintained during treatment, in such a position as 
 shall be most useful in case ankylosis should result. 
 
 CHBON-ZC RHEUMATIC ARTHRITIS 
 
 affects small and large joints alike. It is essentially chronic in 
 its character, and is often associated with gout. It is usually 
 preceded by a low and depressed state of the general health, and 
 
CHRONIC RHEUMATIC ARTHRITIS. 
 
 177 
 
 seems to depend almost as much on the state of the nervous 
 system as on the condition of the blood. It steals on 
 gradually from joint to joint, often commencing in joints 
 that have previously been weak or injured. There is dull, 
 aching pain, at first slight and intermittent, afterwards severe 
 and constant, with occasional subacute exacerbations. In the 
 early stages of the disease the movements of the joint are only 
 impeded by the pain, but in the later stages they are limited by 
 the changes that take place in the 
 articular surfaces; the joints "grow out" 
 (as patients say), and then a distinct 
 grating or cracking may be felt, and 
 sometimes heard, on moving the joint. 
 
 Where there is pressure the cartilage 
 becomes gradually worn away, and the 
 subjacent surface of bone grows hard as 
 ivory (eburnated). In other situations, 
 the cartilage becomes irregularly de- 
 veloped, and an ossific deposit takes 
 place in it and in the white fibrous 
 tissues. Together with these deposits 
 the cancellous tissue of the bone some- 
 times becomes distended. The joint 
 becomes more or less fixed, and the 
 muscles waste. Fig. 81 represents a 
 section of the tibia of a man who was 
 long under my observation. The arti- 
 cular extremities of the bone were ex- 
 panded, the cartilages absorbed, the 
 surfaces of the joints like porcelain, the 
 ligaments thickened, and portions of the 
 muscles — especially the tibialis anticus — 
 ossified. In this patient many joints 
 were similarly affected. 
 
 As I have said, the disease often takes 
 its starting point from an injury ; it may 
 be, from a mere bruise. The surgeon 
 should remember this, for the bruise may 
 
 be followed, particularly at the hip-joint, by a train of symptoms 
 which simulate fracture, and unless he has warned his patient, 
 he may be blamed. 
 
 Treatment. — We can do little either to arrest the progress of 
 the disease, or to repair the damage it has done. Tonics are 
 essential : for example, the preparations of iron, or cod-liver oil. 
 Iodide of potassium, the alkalies, and guaiacum should be tried. 
 
 N 
 
 Chronic rheumatic 
 arthritis. 
 
178 DISEASES OF TISSUES AND OEGANS. 
 
 Friction with stimulating liniments, warm clothing, a good but 
 regulated diet, and attention to the general health, are points 
 which must not be overlooked. A visit to the springs of Buxton, 
 Bath, or Aix-la-Chapelle may perhaps be beneficial. The seaside 
 does not generally suit the subjects of this disease. 
 
 XriiCERATIOU OF CARTIIiACE 
 
 may occur as the result of synovitis, or it may depend upon disease 
 of the subjacent bone, or it may originate in the cartilage itself. 
 
 Ulceration beginning in the cartilage itself is a rare disease ; 
 but as a consequence of synovitis, or scrofulous inflammation in 
 the cancellous ends of the bones, it is common. 
 
 The treatment resolves itself into that of synovitis, arthritis, 
 or scrofulous disease of joints. 
 
 SCROFVZiOUS DISEASE OF JOZSTTS 
 
 (white swelling) occurs chiefly before the age of puberty, and in 
 those who are of a strumous habit of body. Its exciting cause 
 is sometimes very slight — e.g., a blow or a sprain. 
 
 The disease usually begins in the synovial membrane. 
 Sometimes, however, it seems to have its origin in the 
 cancellated tissue of the bone. Wherevef it commences, 
 the morbid action soon pervades both the hard and the soft 
 tissues ; the ends of the bones become enlarged, the can- 
 celli dilated and filled with fat or tubercular matter, the synovial 
 membrane vascular and pulpy, the ligaments soft and disorgan- 
 ized, and the subcutaneous tissues swollen and thickened. 
 
 When the disease is fully established, the joint has a very 
 characteristic appearance. It is gradually and uniformly enlarged, 
 the surface is pale, with blue veins traversing it, the skin is 
 doughy or oedematous, and after suppuration has taken place, 
 there are generally the marks of sinuses in various situations. 
 
 The patient lies with his limb semi-flexed. He has not much 
 pain, except when the joint is moved. The muscles of the affected 
 part waste from disuse, and there is gradually a total loss of 
 power. At the same time the general health suffers, there are the 
 constitutional marks of scrofula, and when suppuration takes 
 place, the patient is very apt to fall into a hectic state. If this 
 happens, he will be in imminent peril of sinking from phthisis 
 or some other internal development of the tubercular disease. 
 
 Treatment. — The joint should be kept perfectly at rest by 
 means of a splint, and in such a position as shall make the limb 
 most useful in the event of ankylosis. 
 
 If the symptoms are but slight, the patient should wear an 
 elastic bandage, or a light splint made of gutta-percha or sole 
 leather ; and he should be very careful that the joint sustains no 
 
ANKYLOSIS. 179 
 
 injury. Thus, if the elbow is affected, he should avoid all blows 
 upon it, and if the knee is the part threatened, walking over 
 rough ground, dancing, running, and everything that can jar or 
 twist the joint should be forbidden. 
 
 If the inflammation is acute, leeches may be required. But 
 depletion of any kind should be used with caution, for we are 
 dealing with a disease which is the result of debility. If there 
 is much heat and pain, cooling lotions or fomentations should be 
 constantly applied ; but they should be laid aside as soon as the 
 acute symptoms have subsided. Counter-irritation, or the 
 application of blue ointment and camphor (Scott's dressing), with 
 careful bandaging and well-regulated pressure, will be of use. 
 But what is likely to do most good is constitutional treatment, 
 combined with rest. The patient should have plenty of sunlight 
 and fresh air ; if possible, he should go to the sea-coast. His 
 diet should be generous, but well-selected ; and he should take 
 cod-liver oil or steel, or other tonic medicines. 
 
 If matter forms, it should be let out at once, and a poultice 
 applied. If the suppuration is profuse, it must be dealt with on 
 general principles, the wound being syringed out, and dressed 
 with antiseptic lotions. At the same time everything should be 
 done to ward off hectic by the administration of quinine, the 
 mineral acids, and similar tonics (F. 52, 65). As a last resource 
 excision, or amputation, may have to be performed. 
 
 AM-KYXiOSIS 
 
 means the union which not unfrequently takes place between the 
 articular surfaces of bones. It is always the result of inflamma- 
 tion. Sometimes it is membranous ov fibrous, at other times it is 
 osseous. 
 
 Fibrous or membranous ankylosis occurs in those cases in 
 which the inflammation has been confined to the synovial 
 membrane and cartilage, and in which the bone has not been 
 exposed. The opposed surfaces are held together by fibrous 
 tissue, or by adhesions of plastic lymph. 
 
 Osseous ankylosis takes place, when the deeper tissues have 
 been exposed, and the two bony surfaces are able to coalesce, and 
 grow together. Fig. 82 afibrds a good example of osseous 
 ankylosis at the knee-joint. 
 
 Treatment. — When a joint is in danger of becoming stifi", it 
 should always be placed in the most useful position. The knee, 
 for example, should be extended almost, though not quite, to the 
 full ; the elbow bent to something less than a right angle. 
 
 If the ankylosis is fibrous, and the limb is in good position, 
 passive motion should be made, and the joint bathed with cold 
 
 N 2 
 
180 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 Bony ankylosis at the 
 knee-joint. 
 
 water, or rubbed with stimulating embrocations, in the hope of 
 exciting healthy action, and restoring some degree of movement. 
 In such a case salt-water douches may be 
 very useful. But if the limb is fixed in 
 a bad position, the patient should be 
 anaesthetized, and force applied to the 
 joint, so as to bring it into a more 
 useful form ; and then, if the surgeon 
 thinks fit, passive motion may be made 
 as in the previous case. The synovial 
 membrane having been destroyed by 
 the inflammation, there is little or no 
 risk of doing harm by these forcible 
 measures. 
 
 In dealing with diseases or injuries 
 which involve joints, either directly or 
 indirectly, the surgeon should bear in 
 mind the readiness with which mem- 
 branous adhesions are formed, and en- 
 deavour to prevent them by timely move- 
 ment. These are the cases which furnish 
 the bone-setters with their successes. Dr. 
 Wharton Hood has shown the principle 
 which underlies their rough-and-ready treatment, and has enabled 
 scientific surgery to learn a lesson from quackery — Fas est et ah 
 hoste doceri. Dr. Hood has pointed out that when there is no active 
 disease in a joint, except such as is kept up by the irritation of the 
 membranous bands — when there is a certain amount of movement, 
 checked by pain, and that pain referable to a single spot, we may 
 assume that adhesions are the source of the patient's trouble, and 
 endeavour to break them by quick decisive movements of flexion 
 and extension. Of course, in applying this treatment, great 
 care must be taken in arriving at a diagnosis, and in excluding 
 all possibility of active disease in or around the joint. It is ap- 
 plicable to joints crippled by injury, by inflammation, by strumous, 
 gouty, or rheumatic disease ; but where there is a constitutional 
 tendency to articular affections, as in the case of strumous or 
 gouty persons, it must be used with even greater caution (Hood, 
 " On Bone-setting, so-called"). 
 
 If the ankylosis is osseous, nothing short of an operation can 
 alter it. We must either be content with the limb as it is, or 
 else perform a subcutaneous osteotomy, an excision or an amputa- 
 tion. 
 
 Subcutaneous osteotomy is an operation which has only been 
 practised of late years, and which owes much to Mr. W. Adams. 
 
DISEASE OF THE HIP-JOINT. 181 
 
 The details of the operation must depend upon the situation in 
 which it is to be performed, and the exact relation of the bone 
 to the neighbouring vessels, nerves, &c. Speaking generaDy, a 
 uarrow-bladed knife is passed down to the point where the sec- 
 tion is to be made. This is withdrawn, and a fine saw, or small 
 chisel, is introduced along its track. The bone is then sawn, 
 or cut, through ; the superficial wound closed with plaster ; the 
 limb brought into good position, and fixed on a suitable splint. 
 The chisel is preferable to the saw, because it leaves no debris, 
 and does less injury to the soft tissues. 
 
 DISEASE OF THE HIP-JOZNT 
 
 is very common, very important, and presents some peculiar 
 features. 
 
 It is a truly scrofulous disease, and occurs almost always before 
 the age of puberty. In children, the morbid action usually begins 
 in the bones, but it may originate in the cartilages, synovial 
 membrane, or ligaments. In any case, the course and history 
 of the disease is much the same. 
 
 It is often excited by very slight accidents — e.g., a fall or a 
 twist. Frequently it arises without any assignable cause. 
 
 Symptoms. — The earliest of these are trifling and intermit- 
 tent pain, perhaps referred to the knee ; slight lameness when 
 the patient is tired ; inability to stand upon the affected limb ; 
 some puffiness about the hip, and perhaps also about the knee ; 
 the buttock is flattened from disuse of the glutei muscles ; the 
 knee of the affected side points across the sound one ; the foot 
 is inverted : th6 thigh is adducted, slightly flexed on the pelvis, 
 and cannot be extended without giving pain. If the patient is 
 laid flat on his back, the thigh rises ; and if the thigh is laid 
 flat, the back rises — that is to say, there is some loss of move- 
 ment at the hip-joint. If the trochanter is struck, or if the 
 leg is jerked upwards, there is acute pain in the joint. The 
 limb should be carefully measured and compared with its fellow. 
 At first, it is sometimes slightly lengthened from effusion into 
 the capsule; subsequently, it is apparently considerably lengthened 
 by the obliquity which the patient habitually, and almost invo- 
 luntarily, gives to his pelvis. In order to take the weight of his 
 body off the diseased joint, he "stands at ease;" he bears upon 
 the sound limb, throws out the sound hip, and lowers the 
 pelvis on the affected side. In the later stage there is often 
 shortening from absorption or dislocation. The joint becomes 
 uniformly swollen, the tissues thickened, the skin distended, 
 glazed, and doughy to the touch. If suppuration takes place, an 
 indistinct fluctuation may be felt ; abscesses may point above or 
 
182 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 below Poupart's ligament, or in the neighbourhood of the tro- 
 chanter, or in the gluteal region ; and sinuses may bo left, com- 
 municating with the joint in various directions. After a longer 
 or shorter time dislocation on to the dorsum ilii will probably 
 take place. 
 
 These are the general features of a case of coxalgia, or hip disease. 
 But it is desirable to try and make an accurate diagnosis of the 
 exact part involved in the morbid action. Thus, when the soft 
 tissues are chiefly or solely affected, the disease is called arthritic 
 coxalgia ; when the acetabulum and pelvic bones are involved, 
 „. J.O we s]^eak of acetabular 
 
 coxalgia; and when 
 the femur is affected, 
 it is distinguished as 
 femoral coxalgia. The 
 prognosis, and the 
 fitness of the case for 
 operation, are affected 
 by the exact situation 
 as well as by the 
 extent of the disease. 
 Of course, the various 
 forms of the disease 
 are often associated 
 in the same patient. 
 Fig. 83 represents a 
 case in which the 
 acetabulum has been 
 destroyed, and per- 
 forated in several places ; and in which the head of the femur 
 is also extensively necrosed. 
 
 Treatment. — The joint should have perfect rest on a splint. 
 If the case is in an early stage, the limb should be extended, and 
 fixed by means of a long splint. In young children, it is an 
 excellent plan to lay a sand pillow on each side of the body, 
 and a short one between the legs, and stretch a sheet tightly 
 over them ; or a weight, to be gradually increased, may be affixed 
 round the ankle, and hung over the end of the bed (see Fig. 69). 
 Sayre, of New York, has devised a useful apparatus whereby the 
 limb may be kept straight, and extension made, without the 
 necessity of confining the patient to bed. 
 
 If there is acute inflammation in the early stage, leeches may 
 be required. Counter-irritation by blisters, issues, setons, &c., is 
 extremely useful when the disease threatens to become chronic. 
 If an abscess forms, it should be opened by a direct incision ; in 
 
 Acetabular disease of the hip- joint. 
 
DISLOCATION. 183 
 
 some cases, however, it may be thought preferable to make a 
 valvular opening, or to draw off the pus by means of the aspirator. 
 
 The importance of hygienic conditions and constitutional treat- 
 ment cannot be over-estimated. The patient should have plenty 
 of sunlight and pure air — if possible, at the seaside ; a liberal but 
 regulated diet ; and sufficient clothing. If he is able, he should 
 move about on crutches, or be driven in a carriage. He should 
 take alteratives — occasional doses of grey powder and rhubarb, 
 for example — with cod-liver oil, or the preparations of iodine or 
 of iron. (Fig. 45, 47, 66.) 
 
 In cases where there has been long-standing suppuration, and 
 where there are sinuous tracks leading to bare bone, the head of 
 the femur may be excised with great advantage. At the same 
 time any necrosed bone that is found in or around the acetabulum 
 may be removed. Hancock was the first to show how freely this 
 might be done. 
 
 IXTOUM-BS OF JOINTS 
 
 are known by the escape of synovia. They should never be 
 probed ; but the part should be secured by a splint, and kept 
 perfectly at rest. 
 
 The prognosis depends upon the extent of the injury, the size 
 of the joint, and the constitution of the patient. 
 
 Treatment. — If the wound is small, it should be at once closed, 
 and ice continuously applied to the joint. If it is larger, sup- 
 puration is likely to occur. In such a case the antiseptic treat- 
 ment ought to be thoroughly carried out, and every local and 
 constitutional means should be employed for allaying the inflam- 
 mation. If one of the large joints, particularly the knee, is freely 
 opened, excision or amputation may have to be performed ; though 
 not a few cases are on record which may well encourage the sur- 
 geon, even here, to try what can be done by absolute rest and 
 strict antiseptic dressings. 
 
 BISIiOCATIOIT 
 
 signifies the misplacement of the bones, entering into the com- 
 position of a joint. The distal bone is said to be dislocated from 
 the proximal. 
 
 Dislocation may be partial or complete. The articular surfaces 
 may be entirely displaced, as in dislocation of the hip ; or they 
 may be partially displaced, as we sometimes see in dislocation of 
 the knee. Again, the dislocation may be simple, or it may be 
 compound, communicating with the outer air by means of a 
 wound in the skin. Again, it may be complicated with fi'acture, 
 or with ruptured vessels. 
 
184 DISEASES OF TISSUES AND ORGANS. 
 
 Dislocation is most common during adult life. In the young 
 and old the bones are more apt to break. It also occurs more 
 often in men than in women. 
 
 Like fracture, it may be caused either by direct violence or by 
 muscular action. The lower jaw and the patella are not unfre- 
 quently dislocated in the latter way. 
 
 When a dislocation has once occurred, it is apt to occur again 
 from comparatively trivial causes. The writer knew a lady who 
 dislocated her shoulder, and for many months afterwards the bone 
 would slip out of its place on any slight exertion. 
 
 The signs of dislocation are, distortion of the limb or part, loss 
 of power, immobility, and an irregular and unnatural outline 
 of the joint. In some cases there is lengthening, in others 
 shortening. 
 
 Dislocation is of necessity attended by the rupture of the capsule 
 of the joint or of the ligaments, and laceration of the soft tissues. 
 Though, in all ordinary cases, these injuries are subcutaneous, and 
 hidden from view, yet they must not on that account be overlooked. 
 Treatment. — A dislocation should be reduced as early as possible. 
 The aim of all treatment is to bring the articular surfaces into 
 such a position that the muscles may be able to restore them to 
 their proper places. 
 
 The great difficulty is to overcome the contraction of the 
 muscles. In recent cases this may often be done by mere 
 manipulation J but in other instances gradual extension, 
 either by manual power or by means of pulleys, will generally 
 be required. In order to obtain a firm purchase 
 
 upon the part without unduly 
 ^^S* ■ constricting it, it is customary 
 
 to apply the extending force by 
 means of a "clove-hitch," There 
 are various ways of making this 
 knot; perhaps the simplest is 
 that which is here represented. 
 The surgeon takes the cord or 
 Clove-hitch. j| ^ bandage, and casts a loop upon 
 
 it. This he fixes with his left 
 hand ; then with his right he casts a second loop exactly like the 
 first (Fig. 84 a), and this he passes across so as to bring it above 
 the first loop (Fig. 84 h). 
 
 In more severe cases of dislocation, it will be necessary to relax 
 the muscles by putting the patient under the influence of chloro- 
 form. Indeed in all cases of dislocation anaesthetics are a great 
 assistance to the surgeon, and may save him much labour and the 
 patient much unnecessary pain and alarm. 
 
DISLOCATION OF THE LOWER JAW, 185 
 
 A second difficulty arises from the shape of the articulation 
 itself: thus the margins of the acetabulum present an obstacle, 
 which has to be surmounted before the head of the femur can be 
 restored to its socket. This difficulty must be overcome by 
 bearing in mind the relation of the parts, and applying the 
 manipulation, or the extending force, accordingly. 
 
 If a dislocation is left unreduced, the old socket is gradually 
 filled up or absorbed, and a new one is formed, lined v/ith a 
 layer of fine dense tissue, like ivory or porcelain. Fresh liga- 
 ments supply the place of the old, and in time the patient gets 
 a very useful joint. 
 
 Compound dislocation is a most severe injury, and one which 
 calls for great judgment on the part of the surgeon. If it is one 
 of the larger joints which is aflected, and the patient is old or 
 debilitated, amputation may have to be performed ; but if the 
 patient is young and in good health, an attempt may, perhaps, be 
 made to reduce the dislocation and to save the limb. 
 
 A compound dislocation of one of the smaller joints must be 
 reduced, and then treated on the same principles as a compound 
 fracture. 
 
 Dislocation may he distinguished from fracture by attention 
 to the following points : — 1. The absence of crepitus. 2. The 
 dislocated part is unusually fixed and immovable ; whereas in a 
 fracture there is unnatural mobility. 3. A fractured bone may 
 be easily replaced, but there is great difficulty in keeping it in 
 position ; whereas when a dislocation is once reduced, it remains 
 in place. 4. A broken bone is generally shortened, but a 
 dislocated one is unaltered in length. 
 
 WTien fracture and dislocation co-exist, the rule is to put up 
 the fracture firmly in splints, and then reduce the dislocation. If 
 the dislocation is left till the fracture has united, it wiU probably 
 be found impossible to reduce it. 
 
 DZSIiOCATZOM- OF TBB IiOlVER JAW. 
 
 The lower jaw is occasionally dislocated by direct violence, but 
 more frequently by muscular action — by the sudden and spas- 
 modic action of the external pterygoid, at the moment when the 
 mouth is wide open in yawning, laughing, &c. The condyle is 
 drawn forwards into the zygomatic fossa. This may occur on 
 one side only, or on both. 
 
 Si^ns. — The chin is protruded, the mouth is open, speech and 
 deglutition are very imperfect, saliva flows from the mouth, and 
 the condyle can be felt under the zygomatic arch. When one 
 side only is aflfected, the signs are less distinct. The chin is then 
 pointed to the sound side. 
 
186 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 Treatment. — Our aim is to direct the condyle downwards and 
 backwards. With this view, the surgeon protects his thumbs 
 with a napkin, and then introduces them on the inside of the 
 molar teeth on both sides. By this means he is able to lay firm 
 hold of the angles of the jaw, which he bears downwards and 
 backwards, at the same time that he raises the point of the chin 
 with his fingers, Swain recommends another method: "Place 
 the patient on the floor with his head between yoiar knees. Then 
 put two pieces of cork as far back as possible between the molars 
 on either side. Press the point of the chin steadily and directly 
 upwards" (Emergencies, p. 13). After the dislocation has been 
 reduced, the patient should wear a four-tailed bandage upon the 
 chin for a suflacient time to prevent recurrence. 
 
 BISIiOCATIOir OF TBB CX.AVXCI.E. 
 
 The sternal end of the clavicle may be displaced either 
 forwards, or backwards, or upwards — in front of the sternum, 
 behind it, or above it. 
 
 The treatment consists in making extension by putting a pad 
 
 in the axilla, or by drawing 
 ^^" the shoulders back, as in 
 
 fracture, and then keeping 
 the end of the bone in its 
 place by a suitable arrange- 
 ment of pads and bandages. 
 
 The outer end of the bone 
 is generally dislocated up- 
 wards on to the acromion. 
 Sometimes the bones are 
 merely separated without 
 any over-riding, there being 
 only a small gap into which 
 the point of the finger can 
 be pressed. In these cases, 
 as it is the acromion which 
 is forced away from the 
 clavicle, it seems more in 
 harmony with the general 
 rule to speak of the injury as 
 dislocation of the scapula. Fig. 85 represents such a case, the 
 particulars of which 1 have reported in the Lancet for June 
 28, 1873. 
 
 The treatment must be conducted on the same principles as in 
 the preceding case. 
 
 Although it is easy to reduce a dislocation of the clavicle, it is 
 
 Dislocation of the scapula. 
 
DISLOCATION OF THE SHOULDER. 
 
 187 
 
 extremely diiBcult to keep the bone in its proper place. Indeed, 
 it is probable that some slight amount of deformity will always 
 be left after this accident. 
 
 BISXiOCATIOIO-S OF THE SHOUZiDER 
 
 are more frequent than those of any other joint. This arises 
 from the shallowness of the glenoid cavity, the size and shape 
 of the head of the humerus, the extent of its movements, and 
 the position of the joint, which is not only much exposed to 
 direct violence, but has also to bear the shock of falls on the 
 hand. 
 
 The shoulder is liable to three dislocations : — (1) forivards, 
 beneath the coracoid process or the clavicle (subcoracoid or subclavi- 
 cular) ; (2) dotvmoards, into the axilla (subglenoid) ; (3) back- 
 wards, on to the dorsum of the scapula. 
 
 Sig7is. — Whatever may be the precise nature of the injury, 
 there is pain, loss of power, and immobility ; the shoulder has 
 lost its roundness, and 
 
 looks angular ; the aero- ^^S- ^^^ 
 
 mion projects, and there 
 is a marked depression 
 below it; the bead of 
 the bone may be felt in 
 an unnatural situation. 
 
 But besides these 
 signs which are common 
 to all the varieties, each 
 has its own peculiar 
 marks. 
 
 In the first variety, 
 the head of the humerus 
 may be both seen and 
 felt below the clavicle, 
 the arm is shortened, 
 and the elbow points 
 outwards and backwards 
 (Fig. 86). This dis- 
 location is the most 
 common of all. 
 
 In the second, the 
 head of the humerus 
 may be felt in the 
 axilla, the arm is 
 lengthened, the elbow points outwards, and there is numbness 
 from pressure on the axillary plexus of nerves. 
 
 Dislocation of the shoulder, forwards. 
 
188 DISEASES OF TISSUES AND ORGANS. 
 
 In the third, the head of the humerus may he felt on the 
 dorsum of the scapula, and the elbow points forwards. 
 
 It has been the custom of surgeons to follow Sir Astley 
 Cooper^s classification, and to describe a partial dislocation, 
 wherein the head of the humerus was said to rest on the edge 
 of the glenoid cavity and the coracoid process. But it seems 
 certain that no such dislocation can take place, and that the 
 specimens upon which Sir Astley Cooper founded his opinion 
 were, in truth, cases of rheumatic arthritis in which the glenoid 
 cavity was expanded (see Mr. Ed. Owen's paper in Med. Chir. 
 Trans., 1875). 
 
 Treatment of dislocation forwards. — The patient should he 
 stripped, and laid flat upon a couch. If need be, he should 
 be placed under the influence of chloroform. The surgeon 
 having taken off" his boot, seats himself on the margin of the 
 couch, facing his patient, and having grasped the dislocated limb 
 at the wrist with both his hands, he places his near foot in the 
 arm-pit, so that the hollow of the foot fits into the fold of the 
 axilla. He then draws the arm slowly downwards and inwards, 
 at the same time that he presses steadily with his foot. 
 
 If more force is required, a jack-towel may be fastened round 
 the arm above the elbow by means of the " clove-hitch," so that 
 an assistant may draw upon it ; or the pulleys may be applied. 
 
 The same principle of reduction may be carried out, by seating 
 the patient in a chair, the surgeon standing beside him, and 
 placing his knee in the axilla, while he bends the arm over it ; or 
 the back of the chair, well padded, may be used as the fulcrum, 
 and the head ol' the bone raised into its place by using the 
 humerus as a lever. 
 
 After reduction, a pad should be placed in the axilla, the upper 
 arm bandaged to the side, and the fore-arm carried in a sling for 
 two or three weeks, or for a sufficient length of time to prevent 
 the joint from (as it were) forming a habit of becoming dislocated 
 by slight accidents. 
 
 The other varieties of dislocation at the shoulder-joint may be 
 reduced by extension downwards ; though, in each case, the direc- 
 tion of the extending force will have to be slightly modified to 
 suit the particular position of the bones. The dislocation down- 
 wards (subglenoid) is sometimes reduced by raising the arm and 
 drawing it upwards. The patient is laid flat on his back, the 
 shoulder is fixed by the hand of the operator, or by a jack-towel 
 thrown around it, the arm is raised by the side of the head, 
 and traction is made either by manual or mechanical force until 
 the head of the bone is lifted into its socket. 
 
 After the lapse of three months, it is almost hopeless to attempt 
 
DISLOCATION OF THE WRIST. 189 
 
 the reduction of a dislocated shoulder. If the patient has begun 
 to move his arm, and a false joint has been already in some mea- 
 sure established, the surgeon had better not interfere. The most 
 serious, and even fatal, consequences may follow an injudicious 
 attempt at reduction. 
 
 DZSZ.OCATZOM'S OF THE EXiBOW 
 
 are commonly the result of great violence. They are, therefore, 
 likely to be attended with much inflammation, and are often 
 associated with fracture. 
 
 They may be considered under three heads ; — (1) the disloca- 
 tion of both bones ; (2) those of the ulna alone ; (3) those of the 
 radius alone. 
 
 (1) Both bones maybe 6\sip\aced either hacJctoards or forwards. 
 In the former case, the coronoid process is very likely to be 
 broken ; and, in the latter, the olecranon. In both cases, the 
 diagnosis must be established by a careful comparison of the 
 relative situation of the bony points in the two arms. If there 
 is much swelling, it is often extremely difficult to determine 
 accurately the nature of the injury. 
 
 (2) The ulna may be dislocated lacJcivards. When this 
 happens the point of the olecranon projects unnaturally, and 
 there is a hollow above it. The elbow is fixed at a right angle. 
 That the radius is not implicated may be ascertained by prona- 
 tion and supination. Here, too, the coronoid process is very 
 liable to be broken. 
 
 (3) The only dislocation of the radius which we need 
 mention is the dislocation forivards on to the external condyle, 
 though it is occasionally dislocated backwards, and sometimes 
 outwards. 
 
 Treatment. — If the ulna is dislocated with fracture of either 
 of its processes, it will be easy by extension or by flexion to 
 restore the bones to their proper position, though it may be very 
 difficult to keep them in situ. But if the ulna is dislocated 
 without fracture, reduction will be a more difficult matter. It 
 may, however, be effected by bending the elbow across the 
 surgeon^s knee, which he uses as a fulcrum. In the dislocation 
 of the radius, the arm should be extended, while the head of the 
 bone is pressed down into its place. 
 
 After reduction, the arm should be fixed upon an angular 
 splint, and carried in a sling. 
 
 SISXiOCATZOIT OF THE VTllZST 
 
 is extremely rare. The styloid processes of the radius and ulna, 
 by their undue prominence indicate the nature of the accident. 
 
190 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 It must be carefully distinguished from fracture of the lower 
 end of the radius (Colles's fracture). 
 
 The treatment consists in extending the joint, and then apply- 
 ing a flat splint. 
 
 BISlLOCATZOirS OF THE HAITB. 
 
 The metacarpal bone of the thumb, and the phalanges of the 
 thumb or of the fingers, are sometimes dislocated. These acci- 
 -p- gy dents are, however, 
 
 rare, owing to the 
 strength of the lateral 
 ligaments. The accom- 
 panying Figure, 87, 
 represents a dislocation 
 of the metacarpal bone 
 of the thumb. It was 
 easily reduced under 
 Dislocation of the thumb. chloroform. In severe 
 
 injuries of the hand the phalanges may be carried either backwards 
 or forwards. 1 have seen the phalanges of the two middle fingers 
 dislocated backwards with a large wound in the palm. The heads 
 of the metacarpal bones were cut off, and the dislocation reduced. 
 The treatment consists in making extension by means of a 
 tape, or narrow bandage, fastened to the finger by the " clove- 
 hitch," and then securing the finder upon a splint. In some 
 cases it has been found necessary to divide the lateral ligaments 
 subcutaneously before reduction could be eflfected. 
 
 BZSIiOCATION-S OF THE HIP 
 
 are four in number : — 
 
 (1) Dislocation upwards, on to the dorsum ilii. 
 
 (2) Dislocation downwards, into the obturator foramen. 
 
 (3) Dislocation forwards, on to the pubes. 
 
 (4) Dislocation backwards, into the sciatic notch. 
 
 1. Dislocation upwards, on to the dorsum ilii. — This is the 
 most common of all. The head of the femur rests on the smooth 
 surface immediately above and behind the acetabulum. In this 
 situation it forms a prominence which may be felt, especially on 
 rotating the limb. There is loss of power, and distinct shortening. 
 The thigh is slightly flexed on the pelvis, and the leg on the 
 thigh. The knee points towards its fellow of the opposite side, 
 and the foot is turned inwards. 
 
 2. Dislocation downwards, into the ohturator foramen, is 
 marked by lengthening. The leg is abducted. The toes point 
 forwards, and sometimes a little outwards. The trunk is bent 
 
DISLOCATIONS OF THE HIP. 191 
 
 forwards, by the tension upon the psoas and iliacus muscles. 
 The prominence of the trochanter is lost. The head of the bone 
 may be felt in its new situation. 
 
 3. Dislocation fomoards, on to the pubes. — Here the promi- 
 nence of the trochanter is gone; the limb is shortened and 
 abducted ; the toes point outwards, and the head of the bone can 
 be distinctly felt above Poupart's ligament. 
 
 4. Dislocation backwards, into the sciatic notch, presents 
 much the same signs as the first form of dislocation, only they 
 are not so well marked, because the head of the bone drops into 
 the sciatic notch, instead of resting on the dorsum ilii. The 
 direction of the limb, too, in this dislocation, is more oblique 
 than in the former ; the afiected thigh points across the middle 
 of the opposite one. 
 
 Treatment. — The patient should be anaesthetized, and laid on 
 his back on a mattress, placed on the floor. The pelvis should be 
 fixed by means of a jack-towel, passed under the perineum, and 
 fastened to a staple in the floor. A belt should be attached to 
 the lower part of the femur, and connected with the pulleys. 
 The extending force should then be applied slowly and gradually 
 in the direction of the axis of the limb, until the resistance of 
 the muscles is overcome. At the same time, the leg should be 
 rotated outwards, or manipulated in such a way as shall facilitate 
 the object in view. In some cases it may be necessary to pass 
 another towel between the thighs, so as to abduct the upper part 
 of the femur, and lift the head of the bone over the edge of the 
 acetabulum. 
 
 After reduction, the patient should be confined to bed 
 for a fortnight; a long splint should be applied to his leg in the 
 usual way, and secured by an additional bandage round the 
 hips. 
 
 After six weeks have elapsed it is almost hopeless to attempt 
 the redaction of a dislocated hip. 
 
 But these older methods have been well-nigh superseded, at 
 least for all recent cases, by manipulation. When the patient is 
 fully under the influence of an anaesthetic, the muscles are so re- 
 laxed that the surgeon can deal with the parts in a merely 
 mechanical manner. Bearing in mind the relative anatomy of 
 each dislocation, and using the femur as a lever, he endeavours to 
 impress such movements upon the head as shall roll it into the 
 acetabulum. Speaking generally, so far as the method of reduc- 
 tion by manipulation is concerned, the four dislocations may be 
 divided into two groups — the iliac and the sciatic dislocations, 
 which he behind the joint ; and the obturator and the pubic, which 
 lie in front of it. The patient should be laid upon a hard couch 
 
192 DISEASES OF TISSUES AND OEGANS. 
 
 or upon a mattress spread on the floor. The surgeon then takes 
 a firm hold of the ankle and knee, and proceeds to his manipula- 
 tions. In the case of the iliac and sciatic dislocations, he flexes 
 the leg on the thigh, and the thigh on the abdomen, at the same 
 time bearing it well over towards the opposite sideof the body. Then 
 with a semi-circular sweep he brings it towards himself, carrying 
 it almost to a right angle with the afi'ected hip, and then 
 straightens it out to full extension. In other words, flexion, 
 adduction, abduction, and extension rapidly succeed one another. 
 In the case of the other two dislocations, the obturator and the 
 pubic, the thigh is flexed on the abdomen, but bearing away from 
 the mesial Hue. It is then by a semi-circular sweep carried across 
 the body, and brought down to full extension. It is surprising 
 how easily a recent dislocation slips into place by manipulation. 
 It is only in cases which are not taken in hand till some days or 
 some weeks have elapsed that extension by pulleys can be required. 
 
 SISIiOCATIOXT OF THE PATEIiIiA. 
 
 The patella is sometimes dislocated outwards, on to the outer 
 side of the external condyle. 
 
 This accident is apt to occur from muscular violence in persons 
 who are knock-kneed. 
 
 Signs. — The knee is extended or slightly bent. A depression 
 may be felt in the front of the joint, while the patella can be 
 detected in its new situation. 
 
 The treatment consists in relaxing the extensor muscles by 
 flexing the thigh on the pelvis and raising the leg. Then, by 
 means of a little manipulation, the bone may be restored to its 
 proper place. After reduction, the patient should wear a ban- 
 dage, or an elastic knee-cap, for a few weeks. 
 
 Occasionally the patella is displaced inwards; and in some 
 rare instances it is turned half round, so that its outer edge 
 points forwards, and presents a sharp ridge under the skin. Mr. 
 Bellamy has recorded a case of this kind. A young man, in 
 jumping out of a cart, caught his foot on the rail, and fell. There 
 was great deformity at the knee. The patella was dislocated on 
 its inner edge, with the articular surface turned outwards. By 
 extreme extension under chloroform it was soon reduced, but 
 synovitis followed. Ultimately the patient perfectly recovered 
 (Brit. Med. Jour., Jan. 4, 1873). 
 
 I>ISZ.OCATXOIir OF TKS SEMXIiVia-AS 
 CARTZIiAGES 
 
 sometimes occurs in consequence of a sudden and violent wrench. 
 If the cartilage is compressed between the tibia and the femur, it 
 
DISLOCi^TION OF THE ASTRAGALUS. 193 
 
 gives rise to intense pain, and the patient is unable to stand, or to 
 move his knee. 
 
 The treatment is unsatisfactory, and the case must often be 
 left to Nature. It is difficult to reach, and to act upon, the semi- 
 lunar cartilages. By rotating the tibia on its axis, the surgeon 
 may sometimes succeed in restoring the parts to their proper 
 positions. 
 
 DISIiOCATIOXTS OF THE KM'EE-TOIN'T 
 are the result of great violence, and are more often compound, or 
 complicated, than simple. Nevertheless, the tibia may be dis- 
 placed hacTcioards, or forwards, or to either side. These disloca- 
 tions are generally incomplete, and accompanied by more or less 
 rotation. 
 
 Meduetion is made by flexing the thigh, fixing it in that posi- 
 tion, and then making extension by drawing from the ankle. 
 When this is done, and a little pressure used, the bones may, 
 in most cases, be restored to their proper situations without 
 difficulty. 
 
 Not unfrequently the knee-joint is dislocated by disease. In 
 these cases, the tibia is generally drawn backwards and upwards. 
 
 DZSIiOCATZON- OF THE AITKIiE 
 
 consists in the separation of the astragalus, carrying with it 
 the foot, from the bones of the leg. This injury can hardly 
 occur without fracture of one or both malleoli. 
 
 The foot may be displaced hacJcwards, or forwards, or to either 
 side. The dislocation outwards, with fracture of the external 
 malleolus, is the most common (Pott's Fracture, see p. 168). 
 
 In all cases, reduction must be effected by drawing upon the 
 foot until the bones are brought into their positions, and then 
 fixing them by means of side-splints, or a M'Intyre's splint, as the 
 case may require. 
 
 BISZiOCiLTZOM- OF THE ASTRAGAZiUS 
 
 may take place either forwards, or hacTcwards. Of these dis- 
 placements the former is the most common. The accident 
 generally happens from the patient falling upon his foot, when 
 it is in the extended position. The bone may usually be felt, 
 either on the instep, or in the space between the tibia and the 
 tendo Achilhs. 
 
 Reduction may sometimes be effected by simply drawing upon 
 the foot. Sometimes division of the tendo Achillis may be 
 necessary. 
 
 Not unfrequently it will be found impossible, after all, to 
 bring the bone back to its place. In such a case, it may either 
 
 (X 
 
194 DISEASES OF TISSUES AND ORGANS. 
 
 be excised at once, or left to itself. If left to itself, it is 
 most probable that the skin over it will slough, and then part of 
 the bone may be removed with the saw or pliers, or else allowed 
 to exfoliate. Mr. MacCormac has related two cases of dislocation 
 backwards and inwards, in which no operation was performed, and 
 both of which made good recoveries (Path. Soc. Trans., 1875). 
 
 Mr. Hancock has reported a case in which an excellent result 
 was obtained by removing the bone at once, and treating the 
 wound with a constant stream of carbolic acid lotion from a 
 syphon bottle (Lancet, January 20, 1872). 
 
 But, in truth, the dislocations of the ankle and of the astragalus 
 are much more often compound, or complicated, than simple. If 
 bony points protrude through the skin, and cannot be reduced, 
 they must be sawn off, as in the case of compound fractures. If 
 the soft parts are extensively lacerated, or if the main vessels are 
 torn, or if the age and habits of the patient are unfavourable, the 
 case will probably require amputation. 
 
 Some authors speak of the leg as being dislocated from the foot. 
 This mode of expression is often strictly correct, for it frequently 
 happens in the accidents which lead to dislocation of the ankle 
 or of the astragalus, that the foot is the fixed point, and the leg 
 is wrenched from it by the weight of the body. But it is more 
 convenient to have one general rule applicable to the whola 
 body, and to say that the distal part is dislocated from the 
 proximal. 
 
 ARTERITIS. 
 
 Arteries are liable to become inflamed, and such inflammation 
 may be either limited or diffuse. 
 
 Limited arteritis is probably excited by embolism, ligature, 
 wounds, or other like causes. It is of the adhesive kind, and 
 tends to the occlusion of the vessel. 
 
 Diffuse arteritis is a blood disease, closely allied to erysipelas ; 
 but it is a rare affection — indeed, so rare that some pathologists 
 have denied its existence altogether, and have attributed the 
 symptoms during life to a blood poisoning, and the morbid ap- 
 pearances to post mortem changes. 
 
 Symptoms. — Local pain and tenderness, extending perhaps 
 some distance along the artery, which feels hard and tense. The 
 part which it supplies may become cold and numb, and show 
 signs of gangrene. 
 
 Tlie treatment must be conducted on the general principles 
 which guide us in dealing with inflammation. 
 
195 
 
 DX:GEM'EX^A.TZOM- OF ARTERIES. 
 
 There are two forms of degeneration to which arteries are 
 chiefly liable — the atheromatous and the calcareous. 
 
 "The changes in the arteries known as atheromatous have their 
 seat in the deeper layers of the inner coat. In the earliest 
 stage of the inflammatory process the fibrous and elastic lamellae 
 of the inner coat of the vessel become infiltrated with young cells 
 which are probably partly emigrants and partly derived from the 
 proliferation of the cells of these structures. As these young 
 cells increase in number, they give rise to a swelling beneath the 
 innermost layers of this coat of the artery. This swelling of the 
 intima is very characteristic. It is in the earlier stage of the 
 process of a soft flabby consistence, and the lining membrane, 
 which is continuous over it, can readily be stripped off, leaving 
 the diseased tissue beneath. It thus contrasts strongly with the 
 superficial patches of fatty degeneration which result fi'om the 
 passive metamorphosis of the endothelial and connective-tissue 
 cells of the vessel" (Dr. T. H. Green's Pathology). 
 
 This process gradually extends, until large irregular patches 
 are formed. These patches have a yellow colour and a cheesy 
 cxDnsistence. The middle coat becomes gradually involved in the 
 degeneration. 
 
 Sometimes the young cell-growth softens and breaks down, 
 forming what has been termed an atheromatous abscess or an 
 atheromatous ulcer. In other instances, the more liquid consti- 
 tuents of the degenerated tissues are absorbed, cholestrine forms, 
 and the debris is left in the deeper layers of the inner coat. 
 This may afterwards calcify, and thus calcareous plates are 
 formed. This calcareous degeneration (ossification of arteries) 
 consists in the deposit of earthy matter — carbonate and phos- 
 phate of lime. There may be only a few gritty particles, or the 
 whole circumference of the tube may be rigid from the cal- 
 careous formation. 
 
 The two forms of degeneration are often associated in the 
 same individual, and even in the same artery. 
 
 When the coats of an artery are aftected with atheromatous 
 or calcareous deposits they are apt to give way ; they lose that 
 elasticity which plays an important part in carrying on the cir- 
 culation, and the calibre of the vessel is diminished. 
 
 Thus it happens that the degeneration of arteries leads to many 
 morbid conditions, which are fruitful sources of mortality, espe- 
 cially among elderly people. Hinc subitce mortes atque intestata 
 senectus (Juv. i. 1-44). To this cause we may trace many cases 
 
 o 2 
 
196 DISEASES OF TISSUES AND QEGANS. 
 
 of aneurysm, apoplexy, cerebral softening, senile gangrene, and 
 disease of the heart. A man who has passed middle age should 
 be careful to put no sudden or excessive strain upon his tissues. 
 He should bear in mind that his arteries are not so elastic, his 
 joints not so supple, his bones not so tough, as once they were; and 
 his activity should be moderated in accordance with his years. 
 Taken in this sense there is much truth in the proverb to which 
 Cicero alludes : " Be an old man betimes, if you wish to be an old 
 man long" (De Senectute, x.). 
 
 AN-EURVSIVE, 
 
 An aneurysm is a tumour which is formed by the rupture or 
 distension of the coats of an artery. 
 
 It is a disease of middle life, and more common in men than 
 in women. 
 
 Whatever tends to impair the strength and elasticity of the 
 arterial walls predisposes to aneurysm. The principal exciting 
 causes of the disease are blows, strains, and wounds. 
 
 Mr. Francis H. Welch, Assistant Professor of Pathology at 
 Netley, has carefully studied the records of thirty-four fatal cases 
 of aortic aneurysm at the Royal Victoria Hospital, and finds (1) that 
 they were all associated with a diseased condition of the internal 
 and middle coats — a tissue growth terminating in degeneration ; 
 and (2) that one half of the cases occurred in patients who were 
 undoubtedly syphilitic, and of the rest a large number were the 
 subjects of acute rheumatic affections or of alcoholism (Med. 
 Chir. Trans., 1876). 
 
 There are various kinds of aneurysm. The whole calibre of 
 the artery may undergo gradual dilatation {fusiform a.), or the 
 enlargement may be confined to a part [sacculated a.). Again, 
 one or more of the arterial coats may remain stretched 
 over the tumour (true sacculated a.), or all the coats may 
 have given way (false sacculated a.). Again, when all the 
 coats have been ruptured, the blood may be confined in a sac 
 formed of cellular tissue (circumscribed a.), or it may spread up 
 and down the part (diffuse a.). If the blood makes its way 
 between the arterial tunics themselves, it is called a dissecting 
 aneurysm. 
 
 True aneurysms are generally formed by the rupture of the 
 two internal coats, and the dilatation of the outer. False 
 aneurysms are often the result of punctured wounds. 
 
 It has long been the custom to divide aneurysms into these 
 various classes; but, in truth, the classification is of very little prac- 
 tical value. The inflammatory changes attending the development 
 of atheroma obliterate the nice distinctions between the arterial 
 
ANEURYSM. 
 
 197 
 
 Fis:. 88. 
 
 tunics; moreover, the patient must have died, or an operation 
 must have been undertaken, before any opinion can be formed 
 as to the integrity of the coats of the vessel. 
 
 The interior of the sac is 
 hned by concentric layers of 
 tibrine, of which the oldest 
 are the whitest, and the most 
 condensed. The inner ones 
 are darker in colour, and 
 more loosely compacted. In 
 a fusiform or tubular 
 aneurysm no such deposit of 
 fibrine takes place. 
 
 Si/7)}j)toms. — When an 
 aneurysm presents itself ex- 
 ternally there is usually a cir- 
 cumscribed tumour situated 
 in the line of some artery 
 (Fig. 88). It is tense, but 
 
 Aneurysm of carotid artery. 
 
 Fia;. 89. 
 
 may be partially emptied by pressing on the vessel above it. It 
 pulsates, and expands with each beat of the heart. This expan- 
 sive pulsation is very characteristic. 
 When it is handled it often com- 
 municates a thrill to the fingers. 
 With the stethoscope a distinct 
 bruit can be heard. When the 
 circulation is arrested the pulsa- 
 tion and briiit both cease, and 
 return again as soon as the current 
 is re-established. 
 
 Aneurysm of the lower part of 
 the abdominal aorta, or of the pelvic 
 arteries, though it presents no ex- 
 ternal tumour, may be felt through 
 the parietes (Fig. 89). Aneurysm 
 of the upper part of the abdomi- 
 nal aorta, and of the intra-thoracic 
 arteries, falls chiefly under the 
 care of the physician. 
 
 If left to itself, an aneurysm 
 usually goes on increasing ; and as 
 it increases, its pressure causes 
 absorption of everything that comes in its way, hard and soft 
 tissues alike. At length it reaches a free surface — the skin, or a 
 mucous or serous membrane — ulceration takes place, and an 
 
 Aneurysm of abdominal 
 aorta : sac laid open. 
 
198 DISEASES OF TISSUES AND OEGANS. 
 
 opening is formed, through which the blood flows more or less 
 quickly, and leads to a fatal result. Or, if it is situated in the ex- 
 tremities, the aneurysm may burst, and the blood may become dif- 
 fused through the cellular tissue of the limb ; or the sac may 
 become acutely inflamed, and suppurate; or the disease may 
 destroy life by its secondary effects — for example, by pressure 
 upon some important part, as the trachea or oesophagus. 
 
 In a few fortunate cases, aneurysms have undergone a spon- 
 taneous cure. This may happen from coagulation and consolida- 
 tion of the contents of the sac, or from plugging of the aperture 
 in the arterial wall, or from compression of the artery by the 
 tumour itself. 
 
 Treatment. — As there are many aneurysms which cannot be 
 reached bj' surgical means, it is important to consider the medical 
 treatment of the disease. The first thing to be done is to re- 
 strain the patient's activity ; he should be kept much at rest in 
 the recumbent posture. Then he should be put upon a restricted 
 diet, our object being to avoid everything that would quicken 
 the circulation, while we increase the plasticity of the blood. At 
 the same time, such medicines should be prescribed as will allay 
 irritability and excitement, and quiet the pulsations of the heart. 
 Balfour has strongly recommended the use of iodide of potas- 
 siiim. 
 
 Of the surgical means of treatment, pressure is the simplest 
 and safest. Our object is to arrest, or to diminish, the flow of 
 blood, so as to allow the contents of the aneurysmal cavity to 
 coagulate and solidify. This has been accomplished, in the case 
 of popliteal aneuryism, by merely flexing the knee-joint. But it 
 is not every case that can be treated in this simple way. More 
 Fio-. 90 than this will generally be required. In most 
 
 cases a tourniquet of some kind will have to be 
 applied to the artery above the tumour. Some- 
 times the flngers of an assistant answer better 
 than anything. The pressure need not be 
 constant, nor need it always be applied on the 
 same spot. It may be shifted a little up and 
 down the artery ; and if it is exerted for 
 twelve or fifteen hours out of the twenty-four, 
 that will generally be found quite sufficient. 
 
 Of the mechanical tourniquets, Signoroni's 
 
 and Carte's are the most convenient. 
 
 Signoroni s tour- Signoroni's tourniquet is shaped like a 
 
 '^ ^ * horseshoe (Fig. 90), and consists of two limbs 
 
 which are jointed together at the convexity, and which can be 
 
 separated or approximated by a screw and cog-wheel. At 
 
ANEURYSM. 199 
 
 one extremity of the horseshoe is a small convex pad which is 
 intended to be placed over the artery, and at the other extremity 
 is a large concave pad which forms the point of counter-pressure. 
 This tourniquet has the advantage of only making pressure 
 upon tvjo points, and leaving the rest of the limb free; but, 
 on the other hand, it has the disadvantage of being liable to 
 slip, and shift its position, under the movements of the patient. 
 
 Carte's tourniquet has been variously „. 
 
 modified, but it consists essentially of a „ ' 
 
 broad ring which passes round the thigh, 
 and gives support to an upright screw. This 
 screw carries a pad upon its lower end, and 
 is fitted with an elastic apparatus which 
 moderates the pressure (Fig. 91). The 
 advantages of Carte's tourniquet are that 
 the point of pressure can be regulated with 
 great nicety, and the force has a certain 
 degree of elasticity. 
 
 Carte's and Signoroni's tourniquets are Carte's tourniquet, 
 sometimes used together, or in pairs — the two instruments being 
 placed side by side at a short distance from one another, so that 
 pressure may be made first by one and then by the other. In 
 this way the patient is saved some pain, and the danger of chafing 
 the skin is avoided. When the application of the tourniquet has 
 to be left to imskilled hands it is a good plan to mark out the 
 course of the artery with ink, or with a solution of lunar caustic, 
 so as to be sure that the pressure is always exerted in the proper 
 line. 
 
 Dr. Wm. Murray, of Newcastle, recommends that the flow of 
 blood should be as completely arrested as possible until coagulation 
 seems to have taken place, and that then the patient should have 
 complete repose. Of late years appliances have been introduced 
 under the name of compressors or clamps, for the purpose of 
 arresting the flow of blood through the aorta in the case of ab- 
 dominal aneurysm. Such instruments are for the most part 
 modifications of Signoroni's and Carte's tourniquets on an enlarged 
 scale. One of the best is Lister's. 
 
 If pressure cannot be used, or if it has been tried without 
 success, we must have recourse to the ligature. The artery may 
 be tied either on the proximal or on the distal side of the tumour. 
 As a general rule the proximal side is preferred, at a point well 
 above the aneurysm (Hunter's operation). It is only in excep- 
 tional cases that the surgeon selects the distal side (Brasdor's 
 operation). The ligature may be applied at any point between 
 the aneurysm and the next large branch j but it should not be 
 
200 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 placed too near the tumour on the one hand, nor too near the 
 branch on the other. 
 
 The ligature should be of fine whipcord, or of catgut, or of 
 Lister's " antiseptic ligature." It should be introduced with as 
 little disturbance as possible, and should include nothing but the 
 artery. It is to be drawn tight, so as to rupture the two inner 
 coats of the vessel, for it is upon this that the process of cure, and 
 the safety of the patient, depend. 
 
 After the operation, the limb should be kept warm. If un- 
 happily gangrene supervenes. 
 
 Fig. 92. 
 
 Popliteal aneurysm. 
 
 amputation will have to be per- 
 formed at, or above, the point of 
 ligature. Fig. 92 represents a 
 section of a popliteal aneurysm. 
 In this case the leg was ampu- 
 tated on account of gangrene. 
 
 Other methods of treating 
 aneurysm have been practised, 
 varying with the situation and 
 nature of the tumour. The sac 
 has been laid open, and both 
 ends of the artery ligatured — for 
 example, in dealing with a 
 gluteal aneurysm. Again, the 
 surfaces of the sac have been 
 rubbed together, in the hope of 
 detaching some flakes of fibrine 
 which might obstruct the open- 
 
 in the artery (Fergusson's method of manipulation). Again, 
 foreign bodies have been introduced into the sac in the hope of 
 promoting the deposit of fibrine. Thus, needles have been passed 
 through in various directions. A fine trochar has been inserted, 
 and iron wire passed into the sac. In this manner Mr. C. H. 
 Moore introduced twenty-six yards of fine iron wire into an aortic 
 aneurysm ; and more recently Mr. Bryant has recommended the 
 introduction of horse-hair or fishing-gut. 
 
 Again, galvano-puncture and acupressure are among the most 
 recent suggestions. 
 
 ANEURTSIVX B7 AXTASTOMOSZS (ITAIVUS) 
 
 is a tumour formed by the dilated condition of the arterial or 
 venous capillaries, or of both together. When arterial, it is bright 
 red, tense, and pulsating. When venous, it is soft, and of a blue or 
 purple colour. 
 
 It is generally seen about the face, head, or neck, and its 
 
ANEUEYSM BY ANASTOMOSIS. 
 
 201 
 
 Fiff. 93. 
 
 common seat is the skin, or subcutaneous cellular tissue. It is 
 almost always congenital — " a mother's mark." 
 
 It may vary in size from a mere speck to a large irregular 
 tumour. Sometimes it is cutaneous, and involves only the skin ; 
 sometimes it is mixed, and aifects both the skin and the subcu- 
 taneous cellular tissue. Sometimes it is subcutaneous, and does 
 not reach the skin at all. When it is confined to the subcu- 
 taneous cellular tissue the diagnosis is not always easy. Some- 
 times a naevus is enclosed in a capsule of dense areolar tissue 
 (especially when it belongs to the venous subcutaneous variety). 
 Sometimes it has no defined boundary. Sometimes it remains 
 stationary, at other times it increases rapidly. 
 
 The arterial nasvus, if left to itself, will sometimes undergo a 
 spontaneous cure. 
 
 The treatment varies with the situation, size, and character of 
 the ngevus. Sometimes it may be 
 destroyed by caustics — nitric acid, 
 for example. Sometimes adhesive 
 inflammation may be excited in it 
 by pressure. Sometimes suppura- 
 tive inflammation may be set up 
 by setons ; sometimes the blood may 
 be coagulated by the injection of the 
 tincture of the perchloride of iron. 
 To introduce threads dipped in this 
 tincture is the best way of dealing 
 with a naevus on the eyelids. 
 An orbital naevus, such as that 
 represented in Fig. 93, should be treated with the small cautery 
 dehneated in Fig. 94. The bulb of the instrument is heated by 
 a spirit lamp, and then the point is pushed into the affected 
 part. This is done as often as the surgeon thinks necessary, and, 
 
 Flo-. 94. 
 
 Orbital naevus. 
 
 after the lapse of a few days, the operation is repeated, until the 
 naevus gradually contracts and becomes obliterated. But the 
 most convenient way of dealing with a naevus, and that which 
 is applicable to the great majority of cases, is the ligature. A 
 
202 DISEASES OF TISSUES AND ORGANS. 
 
 strong silk thread is passed beneath and around the disease, and 
 tied in such a manner as to strangulate it. This may be done 
 subcutaneously ; and much ingenuity has been expended in de- 
 vising knots that are suitable to different cases. Sometimes the 
 blood supply may be cut off by acupressure applied to the main 
 feeders, as in a case reported by Mr. Bellamy, in which an 
 extensive nsevus of the face was entirely cured by obliterating 
 the facial, coronary, and angular arteries by acupressure; or, 
 finally, excision may be practised ; but this is a hazardous opera- 
 tion, and offers no special advantage. Of all these methods of 
 treatment, the ligature is that which will generally be found the 
 safest and best. 
 
 PHIiEBZTZS. 
 
 Veins are liable to inflammation, and such inflammation may 
 be either circumscribed or diffuse. 
 
 When a vein is inflamed the coats become thick and soft ; and 
 the blood, as it courses along, coagulates, and the fibrine is de- 
 posited. There is thrombosis. The vessel is plugged, not by 
 the effusion of plastic lymph, but by coagulated blood. There is 
 no adhesive inflammation, as was formerly held. 
 
 If now this blood-clot softens in the centre, a pus-like fluid is 
 formed, but this is not true pus. It is a product of degeneration, 
 not of inflammation. There is no suppurative inflammation, as 
 was formerly held. 
 
 But the inflammation in the coats of the vein may extend to 
 the surrounding areolar tissue, and this inflammation may run 
 on to suppuration. There is then an abscess in the course of the 
 vein, and this may, in a certain sense, be called suppurative 
 phlebitis. But this is a very different thing from the old doctrine, 
 which was that suppurative inflammation occurred inside the vein. 
 
 Inflammation of veins is often the result of an injury in per- 
 sons who are out of health. Sometimes it follows the strain of 
 over-exertion. In many instances it arises spontaneously in con- 
 nection with gout or blood-poisoning ; and frequently we can 
 assign no cause except general weakness. Externally the vein 
 appears red, swollen, and knotty, and is tender and painful. 
 
 When a vein is plugged by a thrombus there is danger lest 
 particles of fibrine should be washed off, carried into the circula- 
 tion, and give rise to embolism. Savory relates the case of a 
 man, aged forty, who had been confined for some weeks to his room 
 and couch with thrombosis of the femoral vein. One evening, 
 after his servant had assisted him into bed, he asked his master 
 if he could do anything more for him before he left him for the 
 night. "No, thank you/' was the answer; and, giving the 
 
VARIX. 203 
 
 affected thigh a slap with his open hand, he added, " I shall be 
 able to help myself now." Before the man could leave the room, 
 he heard the sound as of some one choking, and, looking round, 
 he saw his master fall back, and suddenly die. 
 
 The saphena vein is very apt to be affected by phlebitis in 
 persons who have varicose veins ; and it is a phlebitic plugging 
 of the iliac and femoral veins which gives rise to " white leg" 
 (phlegmasia dolens). 
 
 When the phlebitis is diffuse it is of an erysipelatous kind, and 
 then it is generally associated with septicaemia. 
 
 Treatment. — The patient should rest in the horizontal position. 
 The part should be fomented, or treated (as Savory recommends) 
 with a strong lead lotion (one part of liq. plumbi to eleven parts 
 of water). Drugs will be of use to counteract any rheumatic or 
 gouty tendency, to relieve pain, and to reduce pyrexia. An 
 elastic stocking or a bandage will be required when the acute 
 symptoms have been subdued. 
 
 In the diffuse form of the disease, support and stimulants will 
 probably be required from the first (P. 34, 35, 100, 108). 
 
 VARIX 
 
 signifies a tortuous and dilated condition of the veins. The coats 
 become thickened, and the valves are insufficient for their purpose. 
 The affected part feels heavy, and aches. When the disease is more 
 advanced there is swelling and oedema, with very severe pain. 
 
 This condition is rarely seen in the deep veins, but it is very 
 common in the superficial. The veins of the leg, which have to 
 support a long column of blood, are the ones which are most often 
 affected. Sometimes the large trunks alone are dilated. Some- 
 times it is only the smaller ones which become varicose. Some- 
 times all are affected alike. The limb is apt to become swollen 
 and congested. Then the skin gives way, and the result is a 
 varicose ulcer. Sometimes the veins of the spermatic cord are 
 affected (varicocele), and then the pain is of a dragging cha- 
 racter ; sometimes those of the rectum (haemorrhoids), and this 
 is accompanied with intolerable itching and smarting. Of these 
 two diseases we shall speak at length hereafter. 
 
 Whatever impedes the venous circulation tends to cause varix 
 — be it general debility, or a ligature, or the pressure of a tumour 
 or of the gravid uterus, or a faecal accumulation, or anything else. 
 
 The treatment of varicose veins in the leg is both palliative and 
 curative. The palliative treatment consists in sponging the part 
 every morning with cold water, rubbing the leg from the ankle 
 to the knee — i.e., in the direction of the venous current — sup- 
 porting the veins by means of a bandage or an elastic stocking. 
 
204 DISEASES OF TISSUES AND ORGANS. 
 
 and prescribing an occasional aperient iu order to relieve the 
 portal circulation. 
 
 But, if the veins give much annoyance, or if they are liable to 
 bleed, or if they are associated with an obstinate ulcer, we may 
 have recourse to the curative treatment, which consists in 
 obliterating them altogether. This may be done in several 
 ways. Firm and continuous pressure — a suitable piece of cork 
 retuined by an elastic bandage — will obliterate the vein; or a 
 noose of silver wire may be passed round the vein, and gradually 
 tightened till it cuts its way out ; but perhaps the simplest and 
 best method is to pass a hare-lip pin under the vein, and then 
 twist a thick silk firmly over it in the form of a figure-of-8. 
 By this means the circulation is arrested, a coagulum of blood 
 forms, and the vein is closed by adhesive inflammation. As many 
 ligatures of this kind may be applied as the case requires. Some 
 surgeons divide the vein between the needles, that the circula- 
 tion through it may not afterwards become re-established. But 
 this seems to be an unnecessary proceeding, and one which is 
 not altogether unattended with danger. After this operation 
 the patient should wear a bandage or an elastic stocking, to 
 prevent other veins from becoming varicose. 
 
 INTlMA.Ji/liaA.TIO'N OF THE I.irXVIPSATICS. 
 
 The lymphatics are liable to inflammation. When this is spon- 
 taneous, it is generally of the diff'use, erysipelatous kind. But 
 much more often it arises from the irritation of a scratch or 
 wound in an unhealthy subject. The lymphatics become red, 
 tense, and swollen ; while the lymphatic glands become enlarged 
 and tender. This is accompanied with a good deal of constitu- 
 tional disturbance and prostration. The disease often leads to 
 erysipelas, or to suppuration in the affected glands. 
 
 The treatment should include purgatives and salines, together 
 with a strict diet. The affected limb should be raised, and con- 
 stantly fomented. If matter forms, it should be let out at once. 
 
 Zia-FX.AIVIMATION- OF THE IiYAZPHATZC 
 GIiAITDS (ABESTZTIS). 
 The lymphatic glands not unfrequently become inflamed, 
 without apparent inflammation of the lymphatics themselves. 
 This is due to the absorption of unhealthy matter, or to over- 
 exertion, or to some other source of irritation. In young persons 
 of a strumous habit, it is common to see the glands in the neck 
 enlarged in consequence of carious teeth, or a sore throat, or 
 an eruption on the scalp. But it is the poison of syphilis or 
 gonorrhoea, acting upon the glands in the groin, which supplies 
 the most frequent examples of adenitis. 
 
NEUEALGIA. 205 
 
 The inflammation may be either acute or chronic. When acute 
 the gland becomes rapidly swollen ; there is pain and tenderness, 
 the skin is red and hot, and suppuration soon takes place. 
 When the inflammation is of a more chronic kind, the gland 
 enlarges gradually without much pain. It it hard and callous 
 to the touch, and if suppuration occurs at all, it is long delayed. 
 The chronic enlargements, which are so common in strumous 
 children, probably depend upon the deposition of tuberculous 
 matter in the substance of the gland. 
 
 Treatment. — When a gland is acutely inflamed it must be 
 treated as an acute abscess, by fomentations, an early incision, 
 and poultices. If sinuses remain, they will require to be dressed 
 with stimulating lotions (F. 12, 14, 25, 27), and kept at rest by 
 pads and bandages. 
 
 When the inflammation is chronic it is of great importance to 
 improve the general health, especially where there is a strumous 
 taint. The surgeon should inquire into the climate in which 
 his patient lives and the hygienic conditions by which he is sur- 
 rounded, such as the situation of his house, the drainage, 
 the water-supply, &c. A residence at the seaside or in 
 a dry bracing inland climate, with plenty of fresh air and sun- 
 light, is what is most likely to suit the case. Locally, the 
 disease should be treated w'ith iodine liniment, or with the oint- 
 ment of the iodide of lead, or of the red iodide of mercury. 
 Extirpation is a remedy which should be undertaken with very 
 great caution. It is apt to lead to a manifestation of the disease 
 elsewhere, perhaps in some more vital part, such as the lungs or 
 the mesenteric glands. 
 
 CATO-CEH of the IiVIVXPHATZC GXiAXTDS. 
 
 The lymphatic glands are sometimes afiected with cancer. 
 Primary cancer is rare in this situation, and is generally of the 
 epithelial variety ; but secondary cancer is common, especially of 
 the meduUary kind. 
 
 Ifl-EVRAIiGIA 
 is an acute pain specially aflecting the nerves. It is not con- 
 tinuous, but intermittent. The paroxysms vary greatly in 
 severity, and in duration. The pain usually makes itself felt in 
 the same situation, following the course of some large nerve or 
 its branches. It generally affects the nerves of the head, 
 especially the divisions of the fifth pair. It is also met with in 
 the limbs and trunk, and sometimes it attacks the joints. 
 
 The causes of neuralgia are infinitely various, but they may 
 all be summed up under two heads — (1) local irritation, (2) 
 defective nutrition. 
 
206 DISEASES OF TISSUES AND ORGANS. 
 
 Local irritation includes carious teeth, spiculse of bone, uterine 
 disorder, worms, &c. 
 
 Defective nutrition embraces such causes as anaemia, chlorosis, 
 malaria, &c. 
 
 The diagnosis must be established, first, by a careful examina- 
 tion of the whole course of the nerve, to see whether there is 
 any local cause of irritation ; and, secondly, by an inquiry into 
 the general state of the patient's health. 
 
 Treatment. — If there is local irritation, we must endeavour to 
 remove it. If it is the general health which is at fault, we must 
 try and improve it by appropriate means. A change of air, a 
 more generous diet, and tepid or cold sponging are often of great 
 use. At the same time some of the preparations of iron or of 
 quinine should be prescribed (F. 47, 65, 66). 
 
 CONCVSSIOM' OF THE BRAZST 
 
 signifies the state of nervous depression which is produced by a 
 sudden blow on the head. This blow may produce a shaken 
 brain, a bruised brain, or a lacerated brain ; accordingly the 
 degree of such depression, or shock, varies extremely. Some- 
 times it is slight and transitory ; at other times it is deep and 
 prolonged. Not unfrequently it even proves fatal — either imme- 
 diately, by arresting the action of the heart j or after a time, by 
 leading to its gradual failure and decline. In either case, the fatal 
 termination takes place by synco'pe, death beginning at the heart. 
 
 The signs of a severe concussion are these : — The patient lies 
 motionless and insensible — he is stunned. The surface of the 
 body is pale and cold ; the voluntary muscles and sphincters are 
 relaxed ; the pulse is weak and intermittent ; the respiration is 
 slow and sighing ; as a rule, the pupils are contracted, but some- 
 times they are dilated, and occasionally there is squinting. 
 
 If the eyes are insensible to light, and if the legs cannot be 
 excited to reflex movements, or if there are convulsions (especially 
 in an adult), the prognosis is unfavourable. Vomiting, on the 
 other hand, is a good sign, and often ushers in the reaction. 
 
 Concussion of the brain may, as we have said, pass off" in a few 
 minutes, and leave no trace behind it, or it may lead to the speedy 
 death of the patient, the issue depending upon the amount of 
 injury the brain has sustained. 
 
 But between these two extremes there are other eff'ects which 
 it may produce. The brain may be permanently injured, the 
 intellect may be impaired, or the patient may become irritable 
 and excitable. The special senses may become blunted — there 
 may be amaurosis, or deafness, or loss of smell, or stammering ; 
 or there may be gradual failure of muscular power. Cases which 
 
COMPEESSION OF THE BRAIN. 207 
 
 follow any of these courses are apt to terminate suddenly from 
 white softening, or disintegration of the brain substance. 
 
 The treatment of concussion of the brain aims (1) at restoring 
 the natural functions, and (2) at preventing the reaction from 
 going beyond its proper limits. 
 
 1. The patient should be laid in bed, well wrapped in blankets, 
 with his head rather low, and kept perfectly quiet. A hot-water 
 bottle should be applied to the feet, and the surface of the 
 body gently rubbed. No alcoholic stimulants should be given, 
 except in cases of great depression. 
 
 2. When reaction has began, we must endeavour to keep it 
 from running on to inflammation. With this view the patient 
 should be confined to his bed, and freely purged. He should be 
 restricted to a plain diet, and all sources of excitement or irrita- 
 tion should be carefully removed. If the pulse is quick and the 
 temperature high, cold lotions or an ice-bag should be applied to 
 the head ; and if, in a robust patieut, the symptoms indicate 
 encephalitis, bleeding and antimony should be employed without 
 delay. 
 
 In the treatment of the after-effects, blisters, issues, setons, 
 and even bloodletting may be required. 
 
 COMPRESSXOX OF THE BRAIN 
 
 may arise from various causes — e.g., from depressed bone, from 
 extravasated blood, from the exudation of lymph, from the 
 lodgment of foreign bodies, from the formation of pus, or from 
 morbid growths. 
 
 Signs. — The patient lies in a state of stupor and insensibility ; 
 sometimes he may with difficulty be aroused to answer questions. 
 The skin is natural in colour, warm, and moist. The pupils are 
 almost always dilated, and insensible to light ; sometimes they are 
 unequal. The pulse is slow and full. The face is often flushed. 
 The breathing is regular but stertorous, from paralysis of the velum 
 palati, and the cheeks are distended at each expiration. There 
 is more or less paralysis of the voluntary mnscles; sometimes the 
 sphincter ani is similarly affected, giving rise to involuntary dis- 
 charge of faeces ; and sometimes the bladder, leading to engorge- ' 
 ment, and overflow of urine. There is also a tendency to death 
 by coma, compression of the medulla oblongata, and cessation 
 of respiration ; death beginning at the lungs. 
 
 In speaking of concussion and compression, it is necessary to 
 describe typical examples. But in practice, the signs are often 
 obscured, or the two states are merged into one another, and they 
 may be associated with fractures of the skull. 
 
 Treatment. — The patient's head should be shaved. If frac- 
 
208 DISEASES OF TISSUES AND ORGANS. 
 
 ture exists, it must be dealt with according to the rules given 
 elsewhere (see p. 134). 
 
 If there is no fracture, cold should be continuously applied, and 
 the patient should be freely purged ; one or two drops of croton 
 oil may conveniently be given for this purpose. 
 
 If the symptoms get worse, and death is imminent, the ques- 
 tion of trephining may be considered. But it is often so difficult 
 to ascertain the exact point of compression, that the cases in 
 which we can resort to the trephine, with any hope of success, are 
 extremely rare. 
 
 TRAUMATIC EN-CEPBAIiZTZS 
 
 signifies inflammation of the brain or its membranes, following 
 injury to the head. It presents two types, w^hich may con- 
 veniently be called the acute and the chronic forms of the 
 disease. 
 
 In the acute variety, the symptoms come on early, perhaps in 
 a couple of days, the reaction gradually running into inflamma- 
 tion. There is severe pain in the head, with nausea and vomit- 
 ing, a quick and full pulse, a hot and flushed skin,j:estlessness, 
 iiritability, and intolerance of light ; the mind is wandering and 
 confused, and there is sometimes violent delirium. When sup- 
 puration takes place, there are rigors, followed perhaps by the 
 signs of laceration and compression, such as squinting, stertor, 
 coma, paralysis, twitchings, or convulsions. 
 
 The treatment should be antiphlogistic and sedative. Ice to 
 the scalp, low diet, bleeding, blisters, purging and antimony 
 (F. 38) — these are the means that we must rely upon. As a 
 purge, Bryant recommends calomel in butter, to be followed by a 
 turpentine or castor oil enema. If pus has formed, and its 
 situation can be discovered with any certainty, the trephine may 
 be used. 
 
 In the chronic variety the symptoms do not make their appear- 
 ance until some time, perhaps a few months, after the injury. It 
 is apt to follow comparatively slight accidents, from which the 
 patient thinks that he has completely recovered. There is 
 generally, however, some symptom — loss of memory, impairment 
 of the senses, irritability, persistent headache, or the like — which 
 indicates a permanent alteration in the brain-tissue. Suddenly an 
 attack of inflammation is kindled, which runs much the same 
 course as in the acute variety. In these cases there is probably 
 a chronic inflammation of the bone, w^hich gradually extends till 
 it reaches the dura mater and the brain. 
 
 When these signs of a permanent alteration in the substance 
 of the brain are present, the patient should habitually live on an 
 
CONTUSIONS OF THE SCALP. 
 
 209 
 
 unstimulating diet ; he should take an occasional purge, and 
 avoid all mental or hodily excitement, which might determine an 
 acute inflammation. If^ however, such an attack takes place, the 
 early treatment should be active, for in its later stages the case 
 is almost hopeless. 
 
 CONTUSXOXrS OF THS SCAIiP 
 
 Fig. 95. 
 
 are sometimes followed by extravasation of blood, either beneath 
 the muscular aponeurosis, or 
 beneath the pericranium (cephal- 
 hsematoma). Such collections of 
 blood are not uncommon in 
 new-born children, apparently as 
 the result of compression of the 
 skull during parturition. Fig. 95 
 was drawn from a child who 
 was born in Charing Cross Hos- 
 pital. His mother had been ad- 
 mitted on account of a transverse 
 fracture of the patella, and her 
 leg was on a splint. The infant's 
 head did not touch the splint, 
 but the position was an awkward 
 one for delivery. At the end 
 of eight months the tumour had 
 entirely disappeared. 
 
 When the centre of the tumour softens, while the edges remain 
 hard, it is very apt to be mistaken for a depressed fracture. 
 
 Blood tumour of the scalp : 
 cephal hsematoma. 
 
 Treatment. — In any case, the ex- 
 travasated blood should be left to itself, 
 or treated only with an evaporating 
 lotion (F. 18, 21) ; an incision should 
 never be made to let it out. 
 
 Lotions, or other applications to the 
 scalp, may conveniently be kept in 
 position by a simple bandage, such as 
 that represented in Fig. 96. The 
 roller is first carried horizontally round 
 the head, then pinned at the temple, 
 and passed over the vertex in any 
 direction that the case may require. 
 If necessary, to prevent it from slip- 
 ping, it may be further secured by a 
 turn under the chin. 
 
 Fig. 96. 
 
 Bandage for the head. 
 
210 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 SCAI.F -WOUM-BS 
 
 should be carefully cleansed, the adjacent hair cut away, and then 
 their edges accurately brought together, and fixed by strips of 
 p.^ Q„ plaster, or, if need be, by silk, 
 
 '^' ' catgut, or wire suture. Provided 
 
 that the needle is not carried 
 deeper than the scalp, there is no 
 more danger in using sutures in 
 this situation than in any other, 
 but the aponeurosis of the 
 occipito-frontalis should not be 
 pierced. Haemorrhage may al- 
 ways be controlled by a pad and 
 bandage. It is an axiom in 
 surgery that no part of the scalp 
 ought ever to be removed, no 
 matter how much it may be 
 bruised, or how slender may be its 
 attachments. It is most pro- 
 bable that, if it is replaced, it will 
 retain its vitality. In wounds 
 of the scalp there is always more or less danger of erysipelas, or 
 of encephalitis. The patient should therefore take a purge, and 
 
 restrict himself to rather a low diet 
 for a few days. If there are indi- 
 cations of suppuration having taken 
 place beneath the occipito-frontalis 
 (phlegmonous erysipelas), an incision 
 should be made at once quite down 
 to the bone, and poultices or dressings 
 should be applied, and retained by a 
 four-tailed or a six-tailed bandage. 
 
 Four-tailed handage for the head. 
 — This bandage consists of a strip 
 of calico a yard long and six or eight 
 inches broad, which is slit up the 
 middle from both ends to within 
 three inches of the centre. In this 
 way a bandage is formed which has 
 four tails of equal length and breadth, 
 and a central area of about six inches 
 square. This central portion is applied to the vertex in the re- 
 quired position, the two posterior tails are then brought forward, 
 
 Four-tailed bandage. 
 
 Fig. 98. 
 
 Six-tailed bandage. 
 
WOUNDS OF THE BRAIN. 
 
 211 
 
 and fastened nnder the chin, while the two anterior ones are 
 carried back below the occiput and tied ; or they may be crossed 
 in this situation, brought forward round the neck and secured 
 in front (Fig. 97). 
 
 Sir-failed bandage for the head, — \Yhen a bandage is required 
 which will cover a larger part of the head than the four-tailed, 
 we have recourse to the sbi-tailed. This bandage is formed of a 
 piece of calico a yard long and eight or ten inches broad, split 
 from each end into three tails of equal breadth to within three 
 inches of the centre. The central portion is laid upon the top of 
 the head, the two middle tails are secured underneath the chin, 
 the anterior tails are carried backwards and tied at the nape of 
 the neck, and then the posterior ones are brought forward hori- 
 zontally round the head, and fastened over the brow (Fig. 98). 
 
 "WOTTxarDS of the BRAmr 
 
 arise from various causes — depressed fracture, simple unde- 
 pressed fracture or concussion with lacei'ation, penetrating wounds, 
 whether punctured or incised, &c. 
 
 The symptoms are those of concussion, compression, or inflam- 
 mation. There are no special signs. 
 
 It makes a great difference -pis 99. 
 
 what part of the brain sub- 
 stance is injured. If it is any 
 of the central portions, death 
 takes place rapidly. Children 
 bear wounds of the brain 
 better than adults ; and those 
 who labour with their hands 
 better than those who work 
 with their heads. I have 
 already alluded to a remark- 
 able case which occurred in 
 my practice, and which illus- 
 trates these points (see p. 136). 
 
 Treatment. — The case 
 should be left as much as 
 possible to Nature. If a 
 foreign body is present in the 
 wound it should be gently 
 and cautiously removed. The 
 general treatment should be 
 antiphlogistic. The dressings should be of the simplest kind — 
 e.g., lint dipped in cold water. Slight and equable pressure 
 should be maintained over the wound, to prevent protrusion of 
 
 p 2 
 
 Capitellum bandage (1). 
 
212 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 the substance of the brain (hernia cerebri). For this purpose 
 the capitellum bandage will sometimes be found useful. 
 
 The capitellum, or complete bandage for the head, requires a 
 long double-headed roller, rather narrower than an arm-bandage. 
 In practice it is found a convenient method to stitch two 
 single-headed rollers together, and thus to form a long double- 
 headed one. 
 
 The operator, standing behind his patient, places the centre of 
 the bandage on the forehead, and conducts the rollers horizon- 
 tally round the head, one to the right and the other to the left, 
 as far as the occiput, that in the right hand being passed under- 
 neath the left and lying next the head. Care should be taken 
 to place the bandage low down, both on the brow and on the 
 occiput, so that it may get a good hold, and be prevented from 
 slipping upwards. On reaching the occiput the bandage in the 
 right hand is transferred to the left, and that in the left is trans- 
 ferred to the right. The bandage in the right hand is now 
 pressed firmly against the head, and kept in that position so as to 
 fix the under one ; while that in the left is taken straight over 
 the vertex to the brow in the median line (Fig. 99). The 
 right-hand bandage is now continued horizontally round the head 
 over the right ear, until it arrives at the brow, where it meets 
 the bandage in the left hand, and crosses in front of it. The 
 rollers must now change hands again ; that in the left hand, the 
 horizontal one, is pressed firmly against the head, whilst that in 
 the right is brought over the vertex, from before backwards, as 
 -p. ^QQ far as the occiput, 
 
 ^' * slightly overlapping the 
 
 first fold (Pig. 100), 
 starting from the front 
 a little to the right, 
 and finishing at the 
 occiput, a little to the 
 same side of the median 
 line. By arranging in 
 this way the two folds, 
 which are placed on 
 either side of the central 
 one, we are enabled to 
 make them lie flat, and 
 to adapt them to the 
 shape of the head. The 
 bandage in the left 
 hand is now carried on horizontally round the head, over the 
 left ear, to the occiput, where it passes over that in the right 
 
 Capitellum bandage (2). 
 
SPINA BIFIDA. 213 
 
 hand. The bandages are now made to change hands again ; 
 that in the right hand, the horizontal one, is firmly pressed 
 against the head, whilst that in the left is taken over the vertex 
 from behind forwards, as before. The bandage in the right hand 
 is again carried round the head, over the right ear, as far as the 
 forehead, in front of that in the left hand. The bandages are 
 now again transferred from hand to hand ; and that in the left 
 hand is pressed firmly against the head, while that in the right is 
 conducted directly over the head, from the brow to the occiput, a 
 little to the side of the previous fold. These steps are repeated as 
 often as they are necessary, until the whole head has been covered ; 
 and then the bandages are carried once horizontally round the 
 head, or fastened with pins, or tied in a knot. 
 
 SPINA BIFIDA 
 
 is the name given to a congenital malformation, wherein the 
 spinous processes of the vertebrse are deficient, and the laminae 
 are open. The consequence is that the coverings of the cord 
 yield to the pressure of the cerebro-spinal fluid, and a tumour is 
 formed. 
 
 Spina bifida is generally met with at the lower part of the 
 spine, in the lumber and sacral vertebra3. 
 
 The tumour which is formed is in the mesial line, fluctuating, 
 highly elastic when the patient is erect, but when he lies down it 
 becomes soft and lax. It is usually about the size of an orange. 
 Sometimes the skin is unaffected ; at other times it is congested 
 and blue ; and not unfrequently a nsevus is situated on it. 
 
 If left to itself it may ulcerate and burst, and then it is pro- 
 bable the patient will die of inflammation of the cord and its 
 coverings ; or it may give little or no annoyance, and the patient 
 may grow up to adult life. But, iu the great majority of 
 instances, the patients die at an early age from convulsions, or 
 paralysis, or from some other like cause. 
 
 The treatment is either palliative or curative. The tumour 
 should always be protected by cotton wool and by a leather or 
 felt case, moulded so as to fit it exactly and exercise equable 
 pressure upon it. If, notwithstanding, the disease goes on 
 increasing, the sac may be punctured with a fine trochar, 
 part of the contents let out, and pressure applied as before. 
 This proceeding may be repeated from time to time, as the case 
 requires. Dr. J. Morton, of Glasgow, recommends tapping the 
 tumour, and injecting it with a solution of iodine in glycerine. 
 Cures have occasionally been effected by many different modes of 
 treatment, but, on the whole, the prognosis is unfavourable, and 
 the result of curative measures unsatisfactory. 
 
214 DISEASES OF TISSUES AND OEGANS. 
 
 ZiATERAXi CURVATURE OF THE SPINE 
 
 frequently occurs in young persons, especially in girls about the 
 age of puberty. It sometimes depends upon rickets, b\it more 
 frequently upon weakness and relaxation of the muscles and 
 ligaments of the spine. The primary curve generally takes place 
 in the dorsal region, and, if the disease advances, a second, or 
 compensatory curve, usually manifests itself lower down, in the 
 lumbar region. 
 
 Signs. — One shoulder is higher than the other. The corre- 
 sponding side of the chest or back projects, the scapula " grows 
 out." The pelvis is tilted in the opposite direction. On examina- 
 tion it is found that the spine is curved ; and, if the case is a 
 bad one, the curve will be double, like the letter S. 
 
 Causes. — The predisposing cause is muscular debility. This is 
 generally associated with an ausemic or bilious state of the health, 
 at a time when the patient is growing rapidly. Lateral curvature 
 is more common among the upper classes, who lead a luxurious 
 life, than among those who have to work and who exercise their 
 muscles regularly. 
 
 The immediate cause is the excessive employment of one side 
 of the body — as in standing on one leg, using one arm in needle- 
 work, writing, &c. 
 
 The intervertebral cartillages are unequally compressed, and, 
 if this goes on continuously for a length of time, they do not 
 recover themselves. A permanent alteration takes place in the 
 outhne of the spine, a slight curve is established, and to this the 
 muscles and ligaments soon adapt themselves. 
 
 Treatment. — The first thing is to improve the general health 
 by a careful, but nutritious, diet, by moderate exercise in the 
 open air, and by tonic and alterative medicines. 
 
 The next object is to brace the relaxed muscles and ligaments 
 of the spine. This may be done by cold sponging and friction. 
 The back may be sponged every morning, and rubbed with a 
 stimulating liniment every night — e.g., the lin. ammonise, or the 
 lin. sinapis, or the lin. camph. co. 
 
 The third indication is to relieve the spine of the weight which 
 it has to support. With this view, the patient should not be 
 allowed to stand or sit much. Once or twice during the day she 
 should lie down on a flat sofa for an hour, either in the prone 
 position or the supine. 
 
 If there is much deformity when the case is first seen, or if it 
 continues to make progress, notwithstanding the employment of 
 
ANGULAR CURVATURE OF THE SPINE. 215 
 
 the means we have mentioned, the patient should be treated by 
 means of Sayre's plastei* jacket, or should wear a mechanical 
 contrivance, to take the weight of the body off the spine, and to 
 press the outgrowing part into its proper position. 
 
 A well-devised course of gymnastics may be of great use, not 
 only in improving the condition of the muscles and ligaments, 
 but also in counteracting any deformity which may have already 
 arisen. 
 
 AM-GUZ.AR CURVATURE OF THE SPINE 
 
 is a disease of strumous origin, and, like the other manifesta- 
 tions of scrofula, it is more common in early than in adult 
 life. 
 
 Inflammation takes place in the bodies of the vetebrse — 
 perhaps as a consequence of the deposit of tubercle — the can- 
 cellous tissue softens and breaks down, giving rise internally 
 to abscess, and externally to an angular projection of the spine. 
 The mid- dorsal region is that which is most apt to be affected : 
 sometimes as many as five or -c^- -n 
 
 six vertebrae, with their inter- ^^' 
 
 vertebral discs, are involved in 
 the disease. The measure of 
 the angle will depend in each 
 case upon the number of ver- 
 tebrae which are implicated, and 
 upon the extent to which the 
 morbid action has advanced. 
 In slight cases, the projection is 
 hardly noticeable ; in severe 
 cases, it is sharp and prominent, 
 as in Fig. iOl, which was 
 drawn from a preparation in 
 Charing Cross Hospital 
 Museum. 
 
 Signs. — Weakness of the 
 back, with slight local pain, 
 which is aggravated on pres- 
 sure. Perhaps the spines of 
 the vertebrae are more promi- 
 nent than they should be. 
 These symptoms, coupled with the general indications of scrofula, 
 are all that we have to enable us to form an early diagnosis ; 
 and such a diagnosis is here of great importance. 
 
 When the disease has advanced further, there may be twitchings 
 of the limbs, or partial paralysis j the pain is then more acute. 
 
 Angular curvatm^e of the spine. 
 
216 DISEASES OF TISSUES AND OEGANS. 
 
 particularly when the spine receives a smart blow, or is rudely 
 shaken; and the deformity is greater. 
 
 When cases are submitted to treatment in the early stage, the 
 destructive process may be arrested, the disintegrated tissue may 
 be absorbed, ankylosis may take place between the bodies of the 
 vertebrae, and nothing may remain but a slight projection of the 
 spine. 
 
 In more severe cases, it is probable that an abscess will form 
 (lumbar, psoas, or iliac abscess). If this happens, the patient is 
 very likely to sink from exhaustion and hectic ; or he may die, 
 at a much earlier stage of the disease, by implication of the spinal 
 cord. 
 
 Sometimes the disease affects the cervical vertebrae, and then 
 abscess may form and point either in the pharynx, or at the side 
 of the neck, under the sterno-mastoid muscle. When the atlas 
 and axis are diseased, the symptoms are very urgent, and the 
 aspect of the patient characteristic. He is afraid to bend his 
 neck or turn his head, so he keeps it stiff. When he turns, he 
 turns his whole body. Sometimes he even supports his head 
 with his hands — Nature teaching him that it must be kept at 
 rest. The best hope of a cure lies in keeping the bones perfectly 
 at rest by means of some apparatus. If dislocation takes place, 
 the cord may be compressed, and sudden death may be the 
 result. 
 
 Treatment. — The main points are to take the weight off the 
 spine, and to keep the vertebrae at rest, in a favourable position 
 for repair and union. 
 
 A few years ago. Dr. Sayre, of New York, introduced a great 
 improvement into the treatment of curved spines. His method 
 is applicable both to angular curvature and to the more severe 
 cases of lateral curvature. The surgeon should provide him- 
 self with a bandage of coarse muslin — "crinoline muslin" as it 
 is called. It should be four inches wide and about twelve yards 
 long. Into both sides of it the dry plaster of Paris should be 
 rubbed, and then it should be loosely rolled. When it is re- 
 quired for use, it should be immersed in water for about a 
 minute. The patient should wear an ordinary close-fitting vest. 
 Supports are placed under his armpits, as well as under his chin 
 and occiput, and by these he is carefully suspended under a 
 tripod, and slowly raised until he touches the ground only with 
 his toes. Thus the weight of the body is used as an extending 
 force to uncurve and straighten the spine. There is no danger 
 in this operation, if it is properly performed, even in severe and 
 acute cases. When the patient is suspended, the plaster of Paris 
 bandage is rapidly appHed from the pelvis to the axillae, care 
 
ANGULAE CUEVATUEE OF THE SPINE. 217 
 
 being taken to put a pad of cotton-wool wherever it may be 
 needful. If slips of tin or of whalebone are introduced in a ver- 
 tical direction between the layers of the bandage as it is being 
 applied, they add much to its strength and firmness. In a few 
 minutes the plaster of Paris sets, and forms an unyielding jacket. 
 The patient should then be carefully lowered from the tripod, 
 and laid on his back on a sofa for a short time. As soon as he 
 has become accustomed to his new splint, he may be allowed to 
 walk about ; for, in truth, the jacket is to be regarded as a splint 
 for the now extended spinal column. Various substances have 
 been tried in the hope of finding something more convenient than 
 plaster of Paris; but nothing answers the purpose unless it 
 gives a firm and solid support. The comfort and benefit which 
 patients derive from Sayre's method of treatment are immediate 
 and striking. There are only two classes of cases to which it is 
 inapplicable — namely, those who are confirmed cripples, and 
 those who are sinking under disease. The presence of an 
 abscess need not interfere with the adoption of this treat- 
 ment. 
 
 If the curvature is in the upper dorsal or cervical vertebrae, a 
 "jury-mast" should be attached to the jacket, and by this the 
 head should be supported. 
 
 Great care must be taken that the jacket does not chafe or gall 
 the patient. If it is comfortable, it may be worn for a month 
 or longer; then cut off"; the skin well washed, and a fresh jacket 
 applied in the same way as before. 
 
 Dr. T. J. Walker, of Peterborough, recommends that the 
 plaster bandage should be applied while the patient lies flat on 
 a couch. This method has its advantages; but it may be 
 doubted whether it is so effectual as that by suspension. 
 
 Cooking's poro-plastic jackets, and other similar appliances 
 made of felt, are convenient, and may sometimes be used with 
 advantage; but they lack the solidity of the plaster jackets; 
 and moreover the patient can unfasten them, which is a great 
 drawback. 
 
 In slight cases it may be enough to use a felt jacket, and to 
 desire the patient to maintain the horizontal position during a 
 great part of the day. A mechanical couch, such as Alderman's, 
 will be found very convenient for the purpose. 
 
 It is scarcely necessary to add that everything must be done 
 to improve the general health by fresh air, a careful, but nutri- 
 trious, diet, and tonic and alterative medicines. In cases that 
 are seen early, we must try to bring about a more healthy local 
 action by counter-irritation with iodine, blisters, issues, &c. 
 
218 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 I.UMBAR, FSOAS, ANH ZX.ZAC ABSCESS. 
 
 When the tubercular matter softens, and the cancellous tissue 
 
 breaks down, it often gives rise, as we have said, to abscesses. Such 
 
 ^ -- abscesses attain agreatsize, and 
 
 °' * extend in various directions, 
 
 according to the situation of 
 
 the disease. 
 
 Sometimes they make their 
 way among the muscles of the 
 back, and point in the loins 
 (luTnbar a). Sometimes they 
 travel down the spine, under 
 the pillars of the diaphragm, 
 along the course of the aorta 
 and external iliac artery and 
 point above Poupart's liga- 
 ment {iliac a). An abscess 
 which presents itself in this 
 situation is generally con- 
 nected with disease in the 
 upper dorsal region. When 
 the disease is rather lower 
 down, in the lower dorsal or lumbar vertebrae, the abscess is guided 
 by the sheath of the psoas muscle, and points on the inside of the 
 thigh, below Poupart's ligament (psoas a). Fig. 102 was drawn 
 from a patient who was in Charing Cross Hospital, under the care of 
 Mr. Canton, and who died of a double psoas abscess, connected 
 with disease of the lower dorsal vertebrae. 
 
 Abscesses originating in disease of the spine may present 
 themselves in various other situations — for example, in the pharynx, 
 in the neck, in the front of the abdomen, or in the perineum. 
 In each case, these abscesses will have to be distinguished from 
 other collections of pus, arising independently of spinal disease. 
 
 Treatment. — When the abscess distinctly points, it may be 
 opened by a small valvular incision, part of the contents let out, 
 and the opening closed again. This may be done from time to 
 time, as often as occasion requires. Until the abscess begins to 
 involve the skin, and threatens to ulcerate, it should not be opened : 
 the surgeon should content himself with ordering perfect rest, 
 and improving the general health. If free suppuration and dis- 
 charge once begin, fatal hectic is likely to be the result. On the 
 other hand, every surgeon has seen cases in which large collections 
 of pus have gradually become absorbed, as the patient's health 
 
 Double psoas abscess. 
 
FRACTUEE OF THE SPINE. 219 
 
 improved. Drawing off tbe pus by means of the aspirator may be 
 beneficial in some instances. If it is deemed necessary or desirable 
 to open tbe abscess, tbis sliould be done by Lister's metbod. Pre- 
 paration should be made for tbe thorough application of antiseptic 
 principles, and then the abscess should be freely opened (see p. 15). 
 
 XN-JURIES OF THE SPIM-AIi CORD. 
 
 The spinal cord, like the brain, is liable to be concussed, com- 
 pressed, or ivounded. The vertebrse are sometimes dislocated. 
 Of late years much attention has been devoted to these injuries, 
 both to their immediate and their remote effects, in consequence 
 of the frequent litigation arising out of railway accidents. When 
 the cord is concussed, there may be loss of nerve-power from the 
 mere shock. When there is compression, laceration, or disloca- 
 tion, there may be immediate loss of nervous functions and sub- 
 sequent inflammation. The more severe injuries are often asso- 
 ciated with fracture. 
 
 FRACTURE OF THE SPIITE 
 
 may arise from direct violence, or from the spine being bent until 
 it breaks — as, for example, in the act of falling. 
 
 The symptoms are partly local, such as belong to all fractures, 
 and partly nervous, depending upon the nature and amount of 
 injury which the cord has sustained. 
 
 The local symptoms are pain, loss of power, and an irregularity 
 of the spine. Sometimes tbe spinous processes are unnaturally 
 far apart, with a gap between them ; sometimes one portion of 
 the column is prominent, while another is depressed. 
 
 If the cord is so far compressed, or lacerated, that its functions 
 are arrested, there will be loss of both motion and sensation 
 below the point of injury. If the fracture is situated in the lum- 
 bar region, the lower part of the trunk, the genito-urinary 
 organs, and the lower limbs will be paralysed, while the upper 
 part of the body remains unaffected. In this state the patient 
 may live for a few months ; death taking place from exhaustion, 
 consequent upon sloughing of tbe nates, or disease of the bladder, 
 or an intercurrent inflammation. 
 
 If the injury is in the upper dorsal region, the intercostal muscles 
 will be paralysed as well, and breathing will be carried on entirely 
 by the diaphragm. Under these circumstances, the patient may 
 perhaps live a week, dying ultimately with congestion of the lungs. 
 
 If tbe fracture traverses the lower cervical vertebrae, the upper 
 extremity will share in the paralysis. 
 
 In all these cases the intellect remains clear and unaffected. 
 
220 DISEASES OF TISSUES AND OEGANS. 
 
 If the lesion is a little higher up, above the origin of the 
 phrenic nerve, death takes place instantly from cessation of 
 respiration. 
 
 Treatment. — When the fracture is in the lower dorsal or lumbar 
 region, the patient's life may be prolonged, and much may 
 be done to make it more tolerable. With this view, he should 
 be laid on a water-bed, and kept perfectly clean. Everything 
 should be done to prevent sloughing of the nates. An occasional 
 purgative or enema should be given. As the urine is apt to 
 become offensive and ammoniacal, it should be drawn off, and 
 the bladder washed out twice a day j at the same time, perfect 
 quietness and repose should be enforced. 
 
 When the injury is higher up, little can be done in the way 
 of alleviation. 
 
 In rare cases fracture may occur without serious consequences. 
 The spinous processes alone may be broken off; or the cord may 
 escape uninjured, even though the fissure traverses the laminse, 
 or the bodies of the vertebrse. 
 
 SAIiIVART FZSTUIiA. 
 
 Occasionally the duct of the parotid gland (Steno's duct) 
 is wounded ; or an abscess forms in its track, and bursts 
 externally. In either case, a salivary fistula is likely to be the 
 result. The secretion from the parotid, instead of making its 
 way into the mouth, dribbles over the cheek. 
 
 The treatment consists in establishing an opening into the 
 mouth by means of a few threads of silk, or a wire, or a piece of 
 catgut, passed from without inwards, in the line of the duct, and 
 tied in a loop through the mouth. The next point is to close 
 the skin of the cheek over the fistulous opening. This may be 
 done by touching the edges with nitrate of silver or with the 
 actual cautery so as to make them contract ; or by paring the 
 edges, and bringing them accurately together ; or by dissecting 
 the skin around the wound, and sliding it along so as to cover 
 the opening. But, under any circumstances, salivary fistula is a 
 diflBcult thing to cure. 
 
 HARE-XiZP 
 
 signifies a congenital fissure, or fissures, in the upper lip. It is 
 often associated with malformation of the superior maxillary, or 
 inter-maxillary, bones — especially with cleft palate. When the 
 fissure occurs on one side only, it is said to be single, when on 
 both sides double (Fig. 103). When there is but one fissure, it is 
 generally on the left side. 
 
HAEE-LIP. 
 
 221 
 
 Fig. 103. 
 
 The treatment of an ordinary case of single harelip is simple 
 enough. It consists in dissecting the lip from the adjacent bone, 
 paring the edges of the fissure, bringing them accurately together, 
 and securing them by means of 
 hare-lip pins, over which a thick 
 silk is twisted in the form of a figure- 
 of-8. The wound and the sutures 
 should then be freely painted with 
 collodion, to exclude the air, and pro- 
 mote union by adhesion. The spring 
 compressor, devised by Mr. Hainsby, 
 is a great assistance. It consists 
 of a horse shoe spring, which passes 
 horizontally round the back of 
 the head, on a level . with the 
 upper lip, and which is supported by straps going over the 
 vertex and occiput (Fig. 104). The spring is covered throughout 
 with leather, and at each end it is furnished with small soft 
 
 Double hare-lip. 
 
 Fig. 104. 
 
 Hainsby's spring 
 compressor. 
 
 pads, which bear upon the cheeks, pushing 
 the two sides of the lip together, and thus 
 preventing tension. After the lapse of three 
 or four days the pins may be withdrawn, 
 and the scab allowed to fall off. 
 
 When the fissure is double, both sides may 
 be operated on in a similar way either at 
 the same time, or at an interval of a fort- 
 night. The latter is probably the better 
 plan. 
 
 When the case is complicated with mal- 
 formation of the bones, or protrusion, the surgeon will have to 
 exercise his ingenuity in planning the operation. 
 
 The time at which the operation ought to be performed is an 
 important question. It is now pretty well settled that it should 
 be done at an early age — say at three months — unless special 
 circumstances require delay. " From all my reflections and ex- 
 perience on the question," says Sir William Fergusson, " T am 
 more than ever disposed to recommend a very early operation. 
 Most of my patients have been under three months (some of 
 them only 8 and 10 days) old, and these cases, as well as 
 experience derived from other sources, induce me to recommend 
 the earliest reasonable date in all instances of the kind, unless 
 there be some apparent indication not to interfere. I have 
 frequently observed that the younger the infant the more satis- 
 factory was the union within the first few days." 
 
222 DISEASES OF TISSUES AND ORGANS. 
 
 EPZTHEILIOMA OF THE I.IP 
 
 is a common disease, and one which is much more often seen in 
 men than in women. It commences as a tubercle or a fissure, 
 and may often be traced to some local irritation — for example, to 
 the habitual use of a short clay pipe. The disease may remain 
 for a long time in a state of abeyance; then, suddenly, the 
 
 growth begins to en- 
 ^^' ^' large, becomes painful, 
 
 and ulcerates. A foul 
 and offensive sore, with 
 an indurated base, pre- 
 sents itself. Gradually 
 it spreads, until it in- 
 volves the whole lip. 
 The glands underneath 
 the jaw become en- 
 larged, and the patient 
 at length dies, worn out 
 by the pain and irri- 
 tation. Fig. 105 was 
 drawn from an old 
 woman who was a 
 patient in Charing Cross 
 Hospital. She had 
 been in the habit 
 of smoking for thirty 
 Epithelioma of the lower lip. years. Dr. Elmslie men- 
 
 tions that the Kashmiris 
 are, in a similar manner, subject to epithelial cancers on the thighs 
 and other parts from the practice which they adopt in cold 
 weather of carrying a brazier next the skin, under the flowing 
 garment which forms their only covering. 
 
 The treatment consists in early and free excision. If the 
 disease is limited, a V-shaped incision may be sufficient to include 
 it all. But, if it is more extensive, it will have to be removed 
 by a semicircular cut. In any case, it is but too probable that 
 the disease will reappear in the course of a few months or 
 years. 
 
 X.UPUS 
 
 is the common name which is given to certain obstinate and 
 intractable ulcers which sometimes attack the face. There are 
 two varieties of lupus — 1, 1, non-exedens ; and 2, 1, exedens. 
 
LUPUS. 223 
 
 1. Lupus non-exedens (serpiginous ulceration of the face) is 
 essentially a scrofulous disease. It usually begins on one 
 ala of the nose, as a red, raised tubercle, which ulcerates 
 and spreads. It only affects the surface of the true skin, and 
 never reaches the subcutaneous tissue. It may extend over a 
 great part of the fiice — healing in one direction, while it goes on 
 spreading in another. The ulcerative process goes on merely at the 
 margins. The cicatrix which is left behind is hard and puckered; 
 sometimes it is white and shining ; sometimes red, congested, and 
 irritable. 
 
 Tubercular lupus is a disease which is particularly apt to affect 
 young persons. It often gives rise to great deformity, com- 
 pressing the nose, laying open its cavity, or drawing down the 
 eyelids. 
 
 The treatment consists in soothing the local disease while we 
 endeavour to improve the general health. The patient should be 
 instructed to wear a veil, and avoid exposure to wind and dust. 
 Lint spread with a simple ointment, or a glycerine lotion, 
 should be applied to soften the skin, and exclude the air. If 
 the disease is spreading rapidly, the line of ulceration may be 
 touched with nitric acid, or with the actual cautery. The 
 patient should live on a plain but nutritious diet, and take 
 arsenic, or cod-liver oil, or the preparations of iron, or quinine 
 (F. 47, 65). 
 
 There is a serpiginous ulceration of the face which is of 
 syphilitic origin, and which needs to be distinguished from the 
 above, because it requires specific treatment. 
 
 2. Lupus exedens (rodent ulcer or cancer) almost always attacks 
 the face. " Patients usually describe it as attracting their atten- 
 tion by some trifling change in a small spot of skin which 
 previously had not been quite natural. Some mole, or wart, or 
 minute thickening of the skin, which they had always known to 
 exist, or some pimple which had grovA-n up unnoticed, began to 
 itch or to be tender when touched ; and a slight scab, which showed 
 already a breach of the surface, was found to have formed upon the 
 spot" (C. H. Moore). It gives rise to a raised, red tubercle, which 
 breaks and leaves a foul and offensive ulcer, " It spreads abroad 
 in all directions with a slow but unswerving advance. It grows 
 and ulcerates. It ulcerates, but never heals. The skin suffers 
 most widely from its ravages, but no structure arrests its pro- 
 gress. It removes whole organs, but restores nothing. In its 
 front aU is healthy; behind it is vacancy and frightful disfigure- 
 ment. Whilst eroding integument, cartilage, or bone, the disease 
 is not, or is little painful; but when eyelids disappear, when the eye 
 or the inner ear is invaded, when branches of the fifth nerve are 
 
224 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 exposed, or are ulcerating, pain, and sometimes severe pain, is 
 added to the deformity" (C. H. Moore). 
 
 Rodent cancer is a disease of advanced Kfe. It is never 
 
 spontaneously curable. 
 
 Fig. 106. 
 
 Eodent cancer, from 0. H. Moore, 
 
 but always tends to- 
 v^rards a fatal issue. 
 
 Treatment. — The 
 disease should . be cut 
 out, and the wound 
 treated with chloride of 
 zinc paste, or some 
 other suitable caustic. 
 If the knife cannot be 
 used, the caustic should 
 be applied directly to the 
 eroding surface. By the 
 administration of chloro- 
 form, and the subsequent 
 subcutaneous injection 
 of morphia, the patient 
 may be kept tolerably 
 free from suffering. 
 
 The Diseases of the Eye next claim attention. I shall, how- 
 ever, only speak of the commoner and more superficial affections 
 of the organ, such as are met with in general surgical practice, 
 without alluding to those deeper diseases which are revealed by 
 the ophthalmoscope. 
 
 OPHTHAI.3IIIA TARSI (TINEA CIIiIARIS). 
 
 By this is meant an inflamed state of the margins of 
 the lid. The disease seems to begin in the Meibomian 
 follicles, and to spread thence to the adjacent palpebral con- 
 junctiva, and to the edge of the lid. There is an unnatural, 
 viscid secretion, which causes the eyelids to stick together during 
 sleep, and forms a hard, dry crust around the roots of the 
 lashes. 
 
 The eyelashes become stunted and irregular, giving rise to 
 trichiasis, and the edges of the lids thickened and excoriated. 
 
 There is heat and irritation, with intolerance of light. 
 The disease is generally accompanied by derangement of the 
 digestive organs. Very often it co-exists with a scrofulous 
 habit. 
 
 The term lippitudo is applied to the chronic stage of the 
 disease, when the lasbes have disappeared, and the margins of 
 
ENCYSTED TUMOUES OF THE EYELIDS. 225 
 
 the lids are red, swollen, and everted, from thickening of the 
 palpebral conjunctiva. 
 
 Treatment. — If the inflammation is acute, the eye should be 
 assiduously fomented v?ith water, or with a decoction of poppy- 
 heads (F. 2), and the patient should take some mild aperient or 
 alterative. 
 
 Subsequently, astringent or stimulating applications may be 
 used with advantage — e.g., lotions of alum, or of the sulphate of 
 copper or of zinc (gr. j — ij ad 3J). 
 
 The edges of the lids should be lightly touched at night with 
 the zinc ointment, or with dilute citrine ointment (Ung. Hydrarg. 
 Nitrat. gr. x ad ^' adipis). But before this is done, any crusts 
 that may have formed should be softened with warm water, and 
 removed; otherwise the'ointment does no good. It is an excel- 
 lent plan to touch the sore or thickened parts about the roots 
 of the lashes with a camel's-hair brush, which has been moistened 
 and passed over a stick of lunar caustic. The lids should be well 
 cleaned before the application is made, and carefully wiped with a 
 soft sponge immediately afterwards. This may be repeated once 
 a week. 
 
 HORBEOXiXTM, 
 or sfye, is an inflammation of one of the ciliary follicles. A 
 painful swelling forms on the margin of the lid. It may either 
 suppurate, or remain for some time in an indurated condition, and 
 then gradually subside. It indicates a disordered or enfeebled 
 state of the health. 
 
 Treatment. — Fomentations or poultices should first be applied. 
 When suppuration has taken place, it may be relieved by a 
 puncture, and afterwards treated with a little stimulating oint- 
 ment. The patient should take a purge, and then alteratives 
 and tonics. His diet should be regulated, and if he can have a 
 change of air, it will be of advantage to him. 
 
 In the indurated condition, the cold water douche, combined 
 w4th the dilute citrine ointment, or the nitrate of silver applied 
 with a camers-hair pencil, will be found very useful. 
 
 EXrCTSTBD TUMOURS OF TH£ E'^EXiIDS 
 
 (TjA.RSil.Ii CVSTS). 
 
 Encysted tumours are often met with in the eyelids, 
 especially in the upper. They appear to be produced in 
 a Meibomian gland, which becomes dilated and filled with 
 sebaceous matter. They make their way, either outwards 
 beneath the skin, or inwards, so as to present on the conjunctival 
 surface. They may remain of small size for a length of time, 
 and then slowly disappear. But, more frequently, they become 
 
226 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 inflamed, and increase rapidly, on some slight cause of irritation, 
 such as dust, wind, cold, &c. Fig. 107 represents a tarsal cyst 
 
 of the lower lid, in a situation 
 
 Fig. 107. 
 
 where these little tumours are 
 not very often seen. 
 
 Treatment. — The cyst should 
 be slit up from the conjunctival 
 aspect, and its contents squeezed 
 out, or turned out with a scoop 
 made for the purpose. The 
 point of a probe should be intro- 
 duced from time to time to 
 prevent the opening from 
 healing too quickly. No at- 
 tempt should be made to dissect 
 the cyst out by an incision 
 through the skin. Sometimes 
 the dilute citrine ointment, externally applied, seems to disperse 
 these little tumours. • 
 
 Tarsal cyst of the lower lid. 
 
 MOIiXiVSCUni COn-TAGZOSUIVI (GIiAITDIFOIIAI 
 TUIVXOUR). 
 
 These tumours are found in the skin of the cheeks and 
 nose, but more especially in that of the eyelids. They 
 are very common among children. They are hard, painless, 
 and white, varying in size from that of a pin's head to that 
 of a horse-bean. They are composed of granular-looking matter, 
 probably hypertrophied sebaceous gland-structure. They are 
 seldom met with singly. They usually present a small orifice, 
 through which a white fluid exudes. The disease is undoubtedly 
 contagious, but upon what this depends is a moot point. It is 
 tolerably certain that it is not upon a parasite. Perhaps (as 
 Virchow suggests) the sebum from one patient finds its way into 
 the follicles of another, and there produces a similar irritation 
 and overgrowth. 
 
 The readiest treatment is to divide the tumour across, and press 
 out the contents between the thumb nails. This proceeding 
 seems rude, but it is effectual, and gives very little pain. 
 
 TRICHIASIS 
 
 is a perverted condition of the cilia, in which they have a ten- 
 dency to grow inwards. It is a frequent result of ophthalmia 
 tarti. The whole line of lashes may be affected, or only a part 
 of it. Tlie eye becomes irritated, and its surface is kept in a 
 chronic state of inflammation. 
 
ECTROPION. 227 
 
 Treatment. — The disease may be palliated by pulling out the 
 offending hairs from time to time by means of a suitable pair of 
 forceps. If this fails, the portion of skin containing the follicles 
 of the faulty lashes may be dissected out. Sometimes the whole 
 of both rows requires to be removed in this way. 
 
 EN-TROPZOM- 
 
 signifies an inversion of the lid. It is necessarily attended by 
 trichiasis, and gives rise to great irritation. It may be the 
 result of a cicatrix in the conjunctiva, or of a neglected attack 
 of strumous, or purulent, ophthalmia. Or it may arise from 
 other causes, such as relaxation of the skin of the lid, more 
 especially of the lower. It not unfrequently follows operations 
 upon the eye in elderly people. Cicatrices in the conjunctiva are 
 very apt to result from the use of too powerful applications. 
 
 Treatment. — When the entropion is slight, it may be treated by 
 contractile substances applied to the outside of the lid — collodion, 
 for example. If this is not sufficient to meet the case, some one 
 of the many operations that have been proposed for the cure of 
 the deformity will have to be undertaken. These operations 
 consist, either in removing a narrow strip of skin and muscle 
 parallel to the ciliary margin, so as to produce eversion by con- 
 traction of the cicatrix, or else in taking away the entire row of 
 eyelashes. Burow has lately introduced a different method of 
 dealing with these cases. He makes an incision along the margin 
 of the lid between the row of lashes and the conjunctival surface, 
 so as to separate the skin (with the row of lashes) from the 
 cartilage, for such a depth as may seem necessary and along the 
 whole of the inverted portion. Then, if it is needful, he removes 
 a strip of skin and muscle from the further part of the lid, as in 
 the old operation. 
 
 ECTROPIOM- 
 
 means the eversion of the lid — the opposite condition to the 
 foregoing. The palpebral conjunctiva becomes visible, red and 
 thickened, and the eyeball is exposed. It may be caused by abscess 
 at the margin of the orbit, or by the contraction of a cicatrix 
 on the face, or by inflammation and thickening of the conjunctiva, 
 or by the dropping of the lower lid as a consequence of paralysis. 
 Treatment. — Little or nothing can be done short of an opera- 
 tion, and the precise nature of such an operation will depend 
 upon the peculiar features of the case. Sometimes the redundant 
 and thickened conjunctiva may be removed with scissors; some- 
 times a V-shaped portion of the lid may be excised ; sometimes a 
 flap of skin may have to be transposed, and a plastic operation 
 performed. 
 
 Q2 
 
228 DISEASES OF TISSUES AND ORGANS. 
 
 PTOSIS 
 
 denotes a drooping of the upper lid, which produces hoth de- 
 formity and inconvenience. It depends upon paralysis of some 
 portion of the third nerve. Such paralysis may be congenital, or 
 it may he brought about by mere debility, or it may be caused 
 by disease of the brain, either functional or organic. It is, there- 
 fore, not so much a disease in itself as an indication of disease 
 elsewhere. Sometimes it arises without any assignable cause, 
 and persists in defiance of every remedy. In such cases the 
 patient generally acquires a certain degree of power over the lid 
 by the action of the orbicularis palpebrarum muscle. It some- 
 times follows exposure to cold winds, especially in rheumatic 
 subjects. 
 
 Treatment. — If the ptosis depends upon debility, we must en- 
 deavour to give tone and vigour to the system by a course of 
 strengthening medicines, and by a regulated manner of Hfe. If 
 no cause can be assigned, and the disease does not yield to milder 
 treatment, a strip of the skin at the upper margin of the orbit 
 may be removed, so as to raise the lid by the contraction of the 
 cicatrix. If the ptosis depends upon disease of the brain, it will 
 often be found to be of syphilitic origin. If it follows exposure, 
 the alkalies and colchicum (F. 56,61) may be given with advantage. 
 Galvanism is sometimes beneficial for these cases, but must be 
 used with caution. 
 
 EPIPHORA — STIIiXiICIBIUM IiACHRYMARUM. 
 
 Epiphora signifies an overflow of tears, the result of hyper- 
 secretion. When the overflow arises from obstruction to the 
 onward passage of the tears, it is called stillicidium laohrymarum. 
 The term epiphora is sometimes applied indifierently to both of 
 these conditions. 
 
 Epiphora may depend upon an irritable state of the lachrymal 
 gland, or of the entire surface of the eye. It is a frequent accom- 
 paniment of the scrofulous diseases of that organ. 
 
 Treatment. — The eye should be treated with sedative or 
 astringent coUyria (F. 16, 25). At the same time, the general 
 health should be amended by alteratives and tonics, and by a 
 regulated diet. In all cases the eye should be carefully examined, 
 to see if any particle of sand, eyelash, or other foreign body is 
 present. Sometimes a loose lash becomes lodged in the punctum, 
 where it may easily escape notice. 
 
 Stillicidium lachrymarum may arise from a variety of causes- 
 closure or disi)lacement of the puncta, contraction of the 
 
FISTULA LACHEYMALIS. 229 
 
 canalicnli, inflammation of tbe sac, or thickening of the 
 duct. 
 
 The treatment consists in allaying the acute inflammation, if 
 that is the cause of the impediment, and making a free passage 
 for the tears. If the disease depends upon some other cause, the 
 canaliculi should be slit up to the inner canthus on a grooved 
 director, introduced at the puuctum, in the way recommended by 
 Mr. Bowman. If the duct is obstructed, a nasal probe should 
 be passed into the nose from time to time. 
 
 OBSTRITCTION* OF TBE ITASiLIi DXTCT 
 
 seems to arise from inflammatory thickening of the mucous mem- 
 brane hning it. It is often associated with the scrofulous habit. 
 The only treatment is- to lay open the canalculi, as explained 
 above, and then to pass suitable probes along the duct until the 
 natural passage is restored. 
 
 lUFiiAniniATzosr of the IiAchrtmak sac 
 
 may be either acute or chronic. The chronic variety (mucocele) 
 is often an extension of the disease from the nasal duct. It is 
 marked by tenderness and swelling. A muco-purulent secretion 
 can be squeezed upwards through the puncta. When the inflam- 
 mation is acute, there is pain, redness, and rapid distension, so that 
 the sac threatens to burst. 
 
 Treatment. — The chronic inflammation should be treated by 
 slitting up the canaliculi, and passing a probe into the nose, to as- 
 certain that the passage is clear. The patient should frequently 
 empty the sac by squeezing the contents downwards into the 
 nose. At the same time, the general health should be carefully 
 regulated. 
 
 The acute inflammation requires active antiphlogistic mea- 
 sures — pui'gatives, leeches, fomentations, &c. When suppuration 
 has taken place, the sac should be opened freely by an incision 
 through the skin at the most prominent part, downwards and 
 outwards, and poultices applied. 
 
 FISTVIiA XiACBRTMAXiIS. 
 
 When the sac suppurates and bursts, or when it is punctured 
 through the skin, one of two things will happen — either the 
 inflammation may subside, the tears may take their natural course, 
 and the external opening may heal, or the duct may be left 
 permanently obstructed, and the tears may make their way 
 through the external opening, and flow over the cheek. The 
 latter condition is called ^s-^wZa lachrymalis. 
 
 Treatment. — Our aim is to open up a free passage for the tears 
 
230 DISEASES OF TISSUES AND OEGANS. 
 
 through the lachrymal sac and nasal duct; and then the wound 
 in the skin will close of itself. With this view, the lower punc- 
 turn and canaliculus may be slit up, and probes passed from day 
 to day until the passage is re-established. 
 
 SIAIPI.E con-juircTiviTzs 
 
 may be either acute or chronic. 
 
 In the acute form there is heat, pain, irritation, intolerance of 
 light, with a sensation as if there were sand under the lids. On 
 opening the eye, the conjunctiva is seen to be of a bright scarlet 
 hue. The vessels are tortuous and injected, making their way 
 from the margins of the globe towards the cornea. That they 
 are no deeper than the conjunctiva is evident, for they shift their 
 position as the membrane is moved. The secretion of tears is 
 excessive, especially on opening the eyes. The digestive organs 
 are generally disordered, and there is headache and feverishness. 
 
 The disease may be caused by the irritation of a foreign body, 
 by over-use, by exposure to the glare of the sun, &c. Most 
 frequently, however, it arises from cold and wet-ir-the patient 
 " catches a cold in his eye." 
 
 Treatment. — The cause should, if possible, be removed. The 
 patient should be purged, should wear a shade over both eyes, 
 and should stay indoors for a few days. The eye should be well 
 fomented with plain water, or with a decoction of poppyheads 
 (F. 2), and the edges of the lids should be smeared with fresh 
 unsalted lard. Vaseline, prepared from petroleum, is excellent 
 for this purpose, as well as for most purposes for which lard or 
 simple ointment is used. If there is much pain, and particularly 
 if the patient is plethoric, leeches should be applied to the 
 temples. 
 
 When the acute symptoms are beginning to subside, the eye 
 should be frequently bathed with cold water, or with astringent 
 lotions (F. 15, 16). At the same time a solution of nitrate of 
 silver, or of sulphate of zinc (gr. j — ij ad ^j), should be dropped 
 into the eye twice a day. After the bowels have been freely 
 opened, the patient should have a light but nutritious diet. 
 
 The chronic form may arise from a continued irritation, as of 
 inverted lashes ; or it may be a sequel to the acute disease. In 
 the latter case it is generally associated with disordered and en- 
 feebled health. 
 
 Treatment. — If the inflammation is the result of a previous 
 acute attack, it will require to be treated by stimulant, astringent, 
 or sedative collyria, as a solution of nitrate of silver, or the vinum 
 opii. Occasionally a leech or a blister may be applied to the 
 temple. But the most important point is to improve the general 
 
PUEULEXT CONJUNCTIVITIS. 231 
 
 health by alteratives, tonics, exercise in the open air, and a 
 regulated diet. 
 
 CATARRHAIi OPHTHAIiMIA 
 
 is a variety of the simple inflammation, characterised by more or 
 less swelling of the conjunctiva {chemosis), and by small extrava- 
 sations of blood scattered over the surface. There is much 
 lachrymation, and a thin muco-purulent discharge, which often 
 becomes thick and creamy, and is no doubt contagious. 
 
 The treatment must depend in a great measure upon the indi- 
 vidual case. Sometimes warmth and poppy fomentations give 
 most relief. In other cases, cold water, or astringent applications, 
 as the nitrate of silver (gr. j — ij ad 5J), or alum (gr. ij — vj ad 
 5J), dropped into the eye, are found most beneficial. 
 
 The bowels should be kept open, but the patient must not be 
 lowered. The usual diet should be given, and in some cases wine 
 and bark may be added with advantage. The eye should be kept 
 very clean. The discharge and incrustation should be removed 
 with tepid water, and a little simple ointment or cold cieam 
 applied to the edges of the lids. 
 
 PURUI.SITT COXJTTTN'CTIVITIS 
 
 is an aggravated form of the preceding. The principal diffe- 
 rence is in the severity of the symptoms and in the character of 
 the discharge. 
 
 Symptoms. — There is great irritation, and pain shooting 
 through the head, the eyelids are swollen and oedematous, so that 
 the eye is closed, the conjunctiva is tumid from infiltration of 
 serum and lymph, the vessels are gorged with blood, giving the 
 membrane a bright red tint, and a rough irregular surface. This 
 roughness is most marked on the palpebral portion. When it 
 persists, it constitutes the condition known as granular con- 
 junctiva. The cornea is more apt to be affected in this variety 
 than in the simple catarrhal inflammation. There is profuse 
 secretion of purulent matter. The constitutional symptoms are 
 severe in proportion. 
 
 The disease maybe caused by injury, over-crowding, deficient 
 ventilation, want of cleanliness, exposure to intense glare, or to cold 
 and wet. It is highly contagious. In Egypt it occurs as an 
 epidemic, from the combined effects of sun, wind, and sand. It 
 is said to be propagated there by the flies. 
 
 It may lead to sloughing of the cornea, disorganization of the 
 eyeball, or granular conjunctiva. 
 
 Treatment. — A brisk purgative should be given, and a few 
 leeches applied, if there is much heat and pain. As there is 
 
232 DISEASES OF TISSUES AND ORGANS. 
 
 generally considerable depression, a good diet, with wine^ 
 ammonia, and bark, maybe required from the first (F. 34, 35). 
 But for this no precise rule can be laid down. The surgeon must 
 be guided by the symptoms in each particular case. The patient 
 should be confined to the house for a time, and have his room 
 darkened, but well supplied with fresh air. The eyes should be 
 constantly fomented, and every hour or half-hour they should be 
 syringed out — first with warm water, so as to get rid of the 
 secretion, and then with an astringent lotion, which may be com- 
 posed of alum, sulphate of zinc, tannin, or nitrate of silver. 
 This application may be combined with sedatives, or opium may 
 be given by the mouth. It is a good plan for the surgeon him- 
 self to inject a solution of nitrate of silver (gr. ij — iv ad ^j) once 
 every day, for it frequently happens that through timidity, or 
 unskilfulness, the syringing is not so efifectually done as to wash 
 every part of the conjunctiva. At night the edges of the lids 
 should be touched with simple ointment or cold cream. 
 
 The greatest care should be exercised to keep separate all 
 sponges, towels, handkerchiefs, &c., used by the patient, so as to 
 prevent contagion. 
 
 When the acute symptoms have subsided, a solution of nitrate 
 of silver (gr. j — ij ad ^j) may be dropped into the eye twice a day, 
 and a blister occasionally applied to the temple. Strengthen- 
 ing medicines should be continued for some time after the disease 
 has been arrested. 
 
 OPHTHAIimiA XJEO^ATORTTIVC 
 
 is the name given to purulent conjunctivitis, when it occurs in 
 children a few days after birth. In such cases it most probably 
 arises from the infection of a vaginal discharge in the mother. 
 It may, however, result from a want of proper cleanliness, from 
 excessive exposure to light, or other causes. 
 
 The symptoms are those of acute purulent conjunctivitis. 
 
 The special treatment consists in syringing the eye, every hour 
 or half-hour, with an alum lotion (gr. v ad ^j), so as to wash 
 away the secretion as fast as it forms. Simple ointment or vase- 
 line should be smeared along the lids. The constitutional treat- 
 ment should on no account be neglected. Two or three drops 
 of liq. cinchonse and sal volatile in ^j of water may be given with 
 benefit every three hours. 
 
 If taken in time, and perseveringly treated, the inflammation 
 generally subsides, without leaving any ill effects behind it. 
 
 As any one lotion seems after a time to lose its effect, it is 
 well to vary the applications occasionally, or to combine them 
 (F. 26). In these cases, too, the surgeon may now and then 
 
STRUMOUS OPHTHALMIA. 233 
 
 apply the stronger solution of nitrate of silver with advan- 
 tage (Gr. ij— iv. ad. 3J). 
 
 The extreme ectropion, which sometimes occurs in cases of this 
 kind, generally disappears as the eye becomes stronger. It may, 
 however, be alleviated by an elastic band placed round the head, 
 and passing over small soft pads fitted upon the lids. 
 
 GOirORRHCEAIi OPIITHAI1MZ.A. 
 
 is the most aggravated form of purulent conjunctivitis. It is 
 excited by the application of gonorrhceal matter to the eye. 
 
 The symptoms are essentially the same as those of the acute 
 purulent conjunctivitis. They are, however, very intense, and 
 run a rapid course. Unless the disease is arrested, it leads in a 
 very short time to sloughing of the cornea, and protrusion of the 
 contents of the eyeball. 
 
 The treatment should be prompt and active. It must be con- 
 ducted on the principles already laid down in speaking of acute 
 purulent conjunctivitis. Especial care should be taken lest the 
 discharge from the affected eye be conveyed to the other. The 
 sound eye should therefore be kept closed by a clean pad of 
 cotton-wool. Of course equal precautions must be taken that no 
 one else becomes inoculated with the purulent matter. The eye 
 should be bathed and wiped with clean pieces of linen rag, each 
 piece being burnt immediately after use. 
 
 However successful the treatment may be, it is almost sure to 
 be followed by more or less granulation of the conjunctiva. This 
 should be promptly attended to, lest it should become chronic, 
 when it would be much more difficult to cure. Bluestone may 
 be applied in the solid form ; or finely-powdered acetate of lead 
 may be spread upon the everted lid, and rubbed into the folds and 
 crevices of the conjunctiva, care being taken to wash away the 
 superfluous substance, by means of a stream of tepid water from 
 an elastic bottle, before the lid is returned to its proper position. 
 The application may be repeated once a week. In the intervals, 
 a solution of sulphate of copper or zinc, or of nitrate of silver 
 (gr. ij ad ^'), may be dropped into the eye with a quill, or camel's- 
 hair brush, two or three times a day. 
 
 As the nervous irritability and the mental depression are 
 usually very great, stimulants — e.g., ammonia, brandy, cham- 
 pagne — and a liberal diet should always be ordered. 
 
 STRXnVIOUS OPHTHAIiMIA 
 
 is a disease which is very common among scrofulous children. 
 
 Symptoms. — The conjunctiva is slightly and irregularly vascular, 
 and in the centre of each patch of enlarged vessels is a small 
 
234 DISEASES OF TISSUES AND ORGANS. 
 
 pimple or pustule {pJilyctenula). This is generally seated on, or 
 near, the margin of the cornea. There is usually great intolerance 
 of light. The child buries its head to avoid exposure. The eye- 
 lids are forcibly contracted, and the lashes inverted. In other 
 cases, however, there is little or no photophobia, and but slight 
 pain. Tears are constantly trickling over the cheeks. With 
 this there are the general marks of scrofula. 
 
 Treatment. — The local irritation may be allayed by fomenta- 
 tions, by anodyne drops, especially of the sulphate of atropine 
 (gr. j ad ^j), or by rubbing belladonna ointment round the eye, 
 while conium, henbane, or opium is given internally. If the 
 disease is of long-standing, counter-irritation to the temples, by 
 iodine tincture, or blisters, or a seton, may be very useful. In 
 the chronic stage a solution of nitrate of silver (gr. j — ij ad gj) 
 should be dropped into the eyes at night. 
 
 Care should be taken to smear the lids with simple ointment, 
 so as to prevent them from sticking together during sleep. 
 When there is no photophobia, calomel, dusted into the eye with 
 a brush, often does good. If the first application causes much 
 pain and irritation, it must not be continued ; otherwise it may 
 be repeated daily, and even for a few days after the phlyctenula 
 has disappeared. The same treatment is useful for the ulcers 
 which are sometimes left when the pustule has been situated on 
 the cornea. But the most important part of the treatment is 
 the constitutional. Fresh air, and, if possible, a residence at the 
 sea-side, moderate exercise, a regulated diet, alteratives, cod-liver 
 oil, the preparations of quinine and iron — especially the syrup of 
 the iodide and phosphate (F. 45, 48, 65, 66) — these are the 
 remedies which are most likely to do good. 
 
 GRiLUJUZiAR COirJUN-CTZV.A. 
 
 has been already alluded to as a condition which is apt to remain 
 after an attack of purulent ophthalmia. It depends upon a 
 thickened and hypertrophied state of the mucous membrane of 
 the palpebral conjunctiva. The papillse become prominent and 
 irregular, so as to give the appearance of a granulating surface. 
 
 It is easy to understand that this rough surface rubbing up 
 and down aggravates any inflammation that may exist, and 
 keeps up a chronic state of irritation, so that in course of time 
 it renders the cornea opaque, like ground glass. 
 
 Treatment. — Our aim is to destroy the granulations. With 
 this view they may be touched with nitrate of silver or sulphate 
 of copper, in the solid form or in solution. Some recommend 
 the liquor potassae ; others the acetate of lead ; others, again, 
 prefer counter-irritation on the outside of the lids. In any case 
 
INFLAMMATION OF THE CORNEA. 
 
 235 
 
 the state of the general health ought on no account to be 
 neglected. 
 
 When the whole cornea has become hazy, and has large vessels 
 ramifying throughout it, it is the modern practice to inoculate 
 the eye with purulent matter, so as to set up an acute inflam- 
 mation. This leads to the destruction of the granulations, as 
 well as to the absorption of tlje effused lymph, upon which the 
 " ground glass" appearance of the cornea depends. By this 
 means a valuable degree of sight is often restored to the patient. 
 But inoculation must never be employed, unless the cornea h 
 vascular and hazy in every part. 
 
 PTERYGIUM 
 
 is the name given to a thickening or fleshy growth of the ocular 
 conjunctiva. It generally takes something of a triangular shape 
 with its apex towards the 
 cornea. Of its causes and ^^' 
 
 pathology nothing is known. 
 A large proportion of those 
 who are affected by it have 
 lived for a longer or shorter 
 time in the tropics. At first, 
 it is only unsightly, but by 
 degrees, as it encroaches on 
 the cornea, it interferes with 
 vision. Fig, 108 was drawn 
 from a sailor who had served 
 on the West Indian station. 
 Both his eyes were symmetri- 
 cally affected. 
 
 The most effective treatment 
 is transplantation. The growth 
 is dissected off as far as the 
 base, then turned back, and 
 received into a slit in the 
 conjunctiva, where it is kept in place by two or three stitches. 
 In this position it gradually wastes, and disappears; but when 
 entirely excised it has a great tendency to return. 
 
 UarFIiAMXtZATZOIl' OF THE CORirEii. (KERATITIS, 
 CORIUEITIS). 
 
 The inflammation may begin either in the cornea itself, or it 
 may spread to it from an adjacent tissue. 
 
 It may be caused by an injury, or by debility, or by a specific 
 poison in the blood. It is very common in scrofulous children, 
 
 Pterygium. 
 
236 DISEASES OF TISSUES AND ORGANS. 
 
 and in the subjects of hereditary syphilis. It may be either 
 superficial or deep-seated ; and it may lead to the effusion of 
 lymph, or to suppuration, or to ulceration, or to sloughing. 
 
 Symptoms. — There is pain in the eye and head, a constant 
 flow of tears, intolerance of light, haziness and vascularity of 
 the cornea, with a dilated state of the vessels of the sclerotic, 
 which form a fringe around the margins of the cornea. When 
 the disease has advanced further, there may be ulceration, or 
 suppuration, or pus in the anterior chamber. 
 
 Treatment. — A calomel purge, fomentations, anodyne lotions, 
 sometimes a few leeches, counter-irritation by blisters, or iodine 
 paint applied to the temples — these are the best remedies. 
 Stimulating applications should be avoided. The patient should 
 wear a projecting shade over both eyes, have good food, and 
 plenty of fresh air. He should also take a course of strengthening 
 medicine, with alteratives. If there is evidence of scrofula, cod- 
 liver oil and steel should be given. If there is a syphilitic taint, 
 mercurials or the iodide of potassium will be necessary (F. 49, 50). 
 
 ABSCESS OF THE CORXTEA 
 
 is one of the results of keratitis. The matter forms between the 
 layers, either in patches, or else it sinks down to the bottom, and 
 appears in a crescentic shape (onyx). 
 
 Treatment. — Atropine or belladonna lotions (F. 1) to allay 
 pain, fomentations, counter-irritation to the temples, good food, 
 tonics, and stimulants — these are the means upon which we rely. 
 
 If the pus is not absorbed, the abscess will either burst through 
 the posterior elastic lamina into the anterior chamber, forming 
 hypopyon ; or else it will make its way forwards, and produce an 
 ulcer of the cornea. It is sometimes of advantage to puncture 
 the cornea at the seat of the abscess ; or, if there is great pain, 
 to evacuate the aqueous humour by a broad needle passed through 
 the corneal margin. 
 
 VIiCER OF THE CORITEA 
 
 is often the consequence of keratitis ; but it may arise from other 
 causes, as debility, injury, or a superficial pustule. 
 
 Ulcers of the cornea follow the same general types as ulcers else- 
 where. Sometimes they are acute, spreading rapidly, and with 
 sharply-cut margins ; sometimes they are irritable, attended by 
 great pain, lachrymation, and photophobia ; sometimes they are 
 healthy and healing, the edges rounded off, and the surface 
 covered with a greyish effusion of plastic lymph. 
 
 Treatment, — In the case of the healing ulcer, we have nothing 
 to do but to " let well alone ;" to give the eye perfect rest, and 
 to support the general health. When the ulcer is irritable. 
 
STAPHYLOMA. 237 
 
 fomentations and atropine or belladonna lotions should be used. 
 If the rest is disturbed, sedatives may be given at night. Some- 
 times a rapid improvement is effected by keeping the eye closed 
 with a soft compress and bandage. In other cases, when there is 
 great pain, or a threatening of perforation, the puncture of the 
 cornea with a broad needle, to allow the escape of the aqueous 
 humour, is of much benefit. If the ulcer is in the acute stage, 
 leeches, or counter-irritation, applied to the temples, and ano- 
 dyne lotions, are the best remedies. Lead should never be 
 used, as it is apt to leave a permanent stain on the surface of 
 the ulcer. 
 
 The cicatrix which is left after an ulcer heals is always rather 
 opaque ; except in the case of the most superficial ulcers, which 
 may leave no trace behind them. 
 
 Atropine and belladonna lotions are almost always of value, not 
 only by dilating the pupil, and keeping the iris from approaching 
 the cornea, but also from their soothing and anodyne influence. 
 
 OPACITY OF THE CORirBA. 
 
 The opacity which results from the healing of a cicatrix is 
 called leucoma. But there is another kind of opacity, resulting 
 from the deposit of lymph between 
 the layers of the cornea, or between Fig. 109. 
 
 it and the conjunctiva. When such 
 deposit is only slight, and has a 
 cloudy, diffused chai-acter, it is 
 termed a nebula ; when it is denser, 
 and presents a pearly appearance, it 
 forms albugo. Fig. 109 was taken from 
 a remarkable case of congenital 
 leucoma, which occurred at the 
 Royal London Ophthalmic Hospital 
 at the time I was Mr. Bowman's Leucoma. 
 
 clinical assistant. 
 
 Little or nothing can be done to remove these opacities. In 
 children, they often gradually disappear in the lapse of months or 
 years. After the age of puberty, they rarely undergo much 
 alteration, if they have existed for any length of time ; but in 
 the more recent cases, counter-irritation by blisters or setons, 
 stimulating lotions, and tonic medicines, may be of use. 
 
 The opacity resulting from granular conjunctiva has been 
 already mentioned, and its appropriate treatment explained. 
 
 STAPBVI.03MEA (ATO-TERIOR) 
 
 is the term applied to a protrusion on the anterior surface of the 
 eyeball. It may result from a wound, or from the partial, or 
 
238 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 complete, destruction of a portion of the cornea by ulceration. 
 If there is only a small hole perforated in the cornea, then a 
 part of the iris alone will protrude (s. iridis). But if a large 
 portion of the cornea has either been destroyed or weakened, 
 there will be an extensive protrusion. This becomes covered 
 with a fibrinous deposit, and gradually increases in size, until it 
 
 may contain the lens and 
 Fig. 110. a considerable portion of 
 
 the vitreous body. 
 
 Treatment, — In the for- 
 mer case the lids should 
 be kept closed with a 
 pad and bandage. The 
 protrusion may be punc- 
 tured from time to time, 
 or touched with lunar 
 caustic, or even entirely 
 snipped off. It will then 
 shrink, and nothing re- 
 main but a scar. In the 
 latter case, the best thing 
 Staphyloma. that can happen is that 
 
 the staphyloma should 
 collapse, so as to allow the patient to wear an artificial eye. 
 Sometimes a free incision is made across the protrusion with this 
 view. Sometimes the staphyloma is sliced off. Sometimes the 
 operation of ''abscission" is performed, according to Mr. 
 Critchett's method. Lastly, the entire globe may be extirpated. 
 Fig. 110 represents a staphyloma which was congenital. The 
 mother accounted for it by saying that, when she was pregnant, 
 she had had a longing for grapes. 
 
 CONICAIi CORZrEA. 
 
 Sometimes the cornea, without losing its transparency, 
 gradually assumes a conical shape. This gives the surface a 
 peculiarly bright, suffused appearance. Generally, both eyes 
 become affected in a greater or less degree. As the disease 
 advances, it seriously impairs the sight. The apex of the cone 
 becomes thinned and nebulous, and may at length give way. 
 
 The treatment is unsatisfactory. Sometimes concave glasses 
 are useful. Sometimes the patient can see tolerably well by 
 looking through a small hole, or slit, pierced in a plate of black 
 wood or metal. Sometimes both these remedies can be combined. 
 Iridectomy seems to arrest the progress of the disease, as well as 
 to improve vision, by allowing the rays of light to enter the eye 
 
SCLEEOTITIS. 
 
 239 
 
 "^y - 
 
 through the less conical portion of the cornea. The late Pro- 
 fessor von Graefe shaved off a thin slice from the apex of the 
 cone, and, by touching the point at intervals with nitrate of silver, 
 caused a cicatrix, and thereby lessened the conicity. Mr. Bow- 
 man removes with a trephine and a sharp knife a small layer 
 from the apex, and by repeated punctures of the thinned struc- 
 ture, brings about a gradual contraction and diminution of the 
 cone. This operation sets up much less irritation than Von 
 Graefe' s, and is equally effective. 
 
 ARCirs sz:n-ii.zs 
 
 is the term apphed to the yellow or whitish ring which is often 
 seen round the margins of the cornea in elderly persons. Some- 
 times the ring spreads into 
 broad patches; sometimes there °' 
 
 is an indication of a second and 
 smaller ring. Fig;. Ill was 
 drawn from such a case. Both 
 eyes were similarly affected. 
 The morbid appearance is due, 
 as Mr. Canton has shown, to a 
 deposit of fat. He has fully 
 discussed its nature, varieties, 
 and pathological significance in 
 his treatise on the subject. 
 Its practical importance has 
 been summed up by Sir James Paget, as follows : " The arcus 
 senilis seems to be, on the whole, the best indication which has 
 yet been found of proneness to an extensive or general fatty 
 degeneration of the tissues" (Surgical Pathology, Lecture VI.). 
 
 It admits of no remedy, and does not interfere with any 
 operation which it may be necessary to perform upon the eye. 
 
 SCIiEROTITIS. 
 
 The sclerotic often participates in inflammation of the cornea 
 or of the iris, but it may also be primarily and chiefly affected. 
 Such cases are sometimes spoken of as rheumatic ophthalmia, 
 because the sclerotic is a fibrous tissue, like those which are the 
 chief seats of rheumatism, and because the inflammation of the 
 sclerotic is often caused by cold and wet — the conditions which 
 lead to rheumatism in other parts of the body. 
 
 Sclerotitis is a disease of adult life, and is often confined to one 
 eye. Sight is impaired. There is intense pain of an aching kind, 
 which is worse at night, and which pervades the orbit and brow, 
 as well as the eyeball. The vessels of the sclerotic are seen 
 
 Double arcus senilis. 
 
240 DISEASES OF TISSUES AND ORGANS. 
 
 radiating in straight lines round the margin of the cornea, and 
 presenting a pink or violet hue. There is generally a good deal 
 of fever, and there are often rheumatic pains, or symptoms of 
 gout, in other parts. The iris often participates in the inflam- 
 mation. 
 
 Treatment. — The bowels should be cleared, and then quinine 
 or the iodide of potassium or colchicura should be given (F. 56, 61), 
 with opiates or sedatives at bedtime (F. 7, 41, 53). 
 
 Locally, anodyne ointments or lotions, and the application of 
 dry heat, are the most useful measures. Blisters and leeches 
 often increase the neuralgic pain. Atropine should be dropped 
 into the eye twice a day, both to dilate the pupil and to act as 
 a sedative (F. 6). 
 
 IRITIS 
 
 may be excited by an injury, or by an excessive use of the eye, 
 or it may arise spontaneously. In the latter case it is generally 
 associated with a rheumatic or syphilitic state of the constitution. 
 The injuries which are most likely to lead to iritis are blows 
 upon the eye, and wounds of the iris, especially when a foreign 
 body is lodged in contact with it. A clean-cut wound, such as 
 that which is made in iridectomy, seldom sets up much inflamma- 
 tion. 
 
 Iritis may be either acute or chronic. When it is dependent 
 upon a rheumatic or syphilitic taint, it is particularly apt to be- 
 come chronic. Under any circumstances, when it has once 
 appeared, it is prone to recur. 
 
 General symptoms. — There is a pink or violet zone of vessels 
 around the margin of the cornea, as in sclerotitis. The aqueous 
 humour becomes muddy or yellowish. The iris is clouded and 
 covered with a film, so that its structure cannot be distinctly seen. 
 Its colour is altered, and it appears of a dusky brown, or of a 
 greyish green, owing in some measure to discoloration of the 
 aqueous humour. Its movements are limited by the efiusion on 
 its surface and into its substance ; and the pupil becomes small 
 and irregular. There is impairment of vision, with lachrymation 
 and photophobia. There is great pain in the eyeball, orbit, and 
 brow. With this there may be more or less inflammation of the 
 cornea and conjunctiva. There is always a good deal of consti- 
 tutional disturbance. 
 
 Special symptoms of rheumatic iritis. — The attack has pro- 
 bably been brought on by exposure to cold and wet. There may 
 be a history of rheumatism or gout. The sclerotic is largely im- 
 plicated in the inflammation, and its vessels are congested, so 
 timt the vascular zone is not sharply defined. The neuralgic 
 
lEITIS. 241 
 
 pain in the eye and brow is very severe, and there is great into- 
 lerance of light. 
 
 Special symptoms of syphilitic iritis. — There is a history of 
 syphilis, and often there are some other manifestations of the 
 disease present at the same time. The effused lymph is not 
 spread over the entire surface of the iris, but aggregated here 
 and there in the form of minute nodules or beads. The vascular 
 zone is well defined. There is generally less intolerance of light 
 than in the rheumatic variety. The pain remits during the day, 
 and is worse at night. 
 
 Treatment. — The patient should be confined to a darkened 
 room, or wear a shade. If it seems advisable, the temples may 
 be cupped or leeched. Under any circumstances the bowels 
 should be freely opened, and a moderately low diet enforced. The 
 pupil should be thoroughly dilated with a solution of atropine 
 (gr. j — ij ad ^j). The eftusion of lymph may perhaps be pre- 
 vented, or its absorption promoted, by small doses of mercury, 
 stopping short of salivation — for example, two grains of calomel 
 with a quarter of a grain of opium, or three grains of grey 
 powder, every four hours. Pain should be relieved by belladonna 
 fomentations; by giving opium, coniura, or henbane; and by 
 rubbing anodyne ointments into the brow. 
 
 Special treatment of rheumatic iritis. — The bicarbonate of 
 potass (F. 56), or the iodide of potassium, or guaiacura, or qui- 
 nine (F. 61, 65) should be administered. If there is a gouty habit, 
 colchicum will be found useful. The patient should not be kept 
 on too low a diet. In some cases he will even require brandy 
 or other stimulants from the first. 
 
 Special treatment of syphilitic iritis. — If the patient's con- 
 stitution is sound, a course of mercury by the mouth, or by inunc- 
 tion, may be prescribed, so as slightly to afiect the gums. Under 
 any circumstances the iodide of potassium may be given (F. 50, 60). 
 As soon as the acute symptoms begin to yield, tonics should be 
 ordered, and a more liberal diet allowed. 
 
 If iritis in any of its forms threatens to become chronic, the 
 temples may be leeched from time to time, and counter-irritation 
 kept up by means of iodine paint, blisters, or setons. 
 
 In recurrent iritis, iridectomy will arrest, or at least lessen, 
 the severity of the attacks. It appears to act partly by putting 
 an end to the irritation caused by the adhesions {synecMce), 
 which are almost sure to follow repeated attacks of inflammation, 
 and partly by allowing a freer communication between the anterior 
 and posterior aqueous chambers. 
 
242 DISEASES OF TISSUES AND ORGANS. 
 
 ARTIFICIAIi PUPIIi. 
 
 When the natural pupil is obscured by central opacity of the 
 cornea, or has become closed by inflammatory deposits or adhe- 
 sions, while the rest of the cornea retains its transparency, an 
 artificial pupil may sometimes be formed, so as to allow the rays 
 of light to reach the retina. 
 
 The operation may be performed in several ways. Generally, 
 however, it is done by excising a portion of the iris {iridectomy), 
 or by putting a ligature round it (iriddesis). A small incision is 
 made at the margin of the cornea in such a situation as to allow 
 the iris to prolapse, or to be drawn gently out. This portion of 
 the iris is then either cut off, or included in a ligature of fine 
 silk, according to the judgment of the surgeon. 
 
 In cases of closed pupil after the extraction of cataract, a 
 broad needle may be introduced through the cornea, and the 
 fibres of the iris torn through, or divided, until a sufficient 
 aperture has been made. 
 
 CATARACT 
 
 signifies an opacity of the lens or its capsule. When the lens 
 alone is affected, it is said to be lenticular ; when the capsule 
 alone is affected, it is said to be capsular. Generally, however, 
 both are more or less implicated in the disease. 
 
 It may be a congenital defect, or it may be traumatic, and re- 
 sult from the inflammation which has been excited by an injury, 
 or even from the shock of a blow which leaves no external mark. 
 Most frequently, however, it comes on gradually with old age, 
 and is one of the many manifestations of the degeneration which 
 the body is apt to undergo as life advances. The proper tissue of 
 the lens seems to become opaque and atrophied, while there is a 
 deposit of fatty and earthy matter in the more superficial 
 parts. 
 
 Symptoms. — Vision is impaired, the sight becoming progres- 
 sively worse as the disease advances. The patient can generally 
 see best in twilight, or when his back is turned to the window, 
 because then the iris expands, and allows the marginal rays to 
 reach the retina. The eye presents a dull appearance, and on 
 examining it closely, the lens is seen to be of a pearly-white or of 
 a yellowish colour. 
 
 Cataracts are broadly divided into hard and soft. 
 
 The hard cataract is met with in middle-aged and elderly per- 
 sons. It has a yellowish or brownish tint. The opacity may be 
 greatest at the centre, and then the patient can see best when 
 
CATAEACT. 243 
 
 the pupil is dilated by atropine or otherwise ; but sometimes the 
 circumference of the lens is chiefly afiected. 
 
 The soft cataract is a disease of the young or middle-aged, and 
 is not unfrequently congenital. It has a white milky colour. 
 The lens is enlarged, and vision is much, and uniformly, impaired. 
 In the congenital form, however, the opacity may be confined to 
 the central parts of the lens, and remain for many years without 
 extending to the margins. 
 
 The treatment consists in removing the lens by operation. 
 Medicine has no power to arrest the progress of the disease, or 
 to procure its absorption. 
 
 The lens may be removed in several ways — (1) by extraction, 
 (2) by depressing it below the axis of vision (couching), (3) by 
 breaking it up, and leaving it to be absorbed (solution), (4) by 
 removing the lenticular matter through a small aperture in the 
 cornea (linear extraction). 
 
 1. Extraction is performed by making an incision through half 
 of the circumference of the cornea, opening the capsule, and 
 allowing the lens to escape entire through the pupil. 
 
 A method of extraction, known as Von Graefe's operation, is 
 much practised at the present time. The incision is made with a 
 long narrow knife just within the corneal margin, occupying about 
 one-third of the circumference ; a piece of iris is removed, the cap- 
 sule torn, and the lens pressed out, as in ordinary extraction. By 
 this operation all risk of prolapse of the iris, which is so common 
 after the usual operation, is avoided. The recovery of the eye, 
 too, seems to be more rapid. If the iridectomy is made upwards, 
 the irregularity of the pupil is hidden by the upper lid, and the 
 sharpness of vision does not appear to be diminished. 
 
 If all goes on well, the wound is healed by the end of a week 
 or ten days, but the eye will require protection and rest for a 
 considerable time. The patient should not be allowed to use the 
 glass, which will be necessary for accurate vision, for at least three 
 or four months. 
 
 2. The operation of couching consists, as we have said, in 
 depressing the lens below the line of vision. By the aid of a 
 couple of needles it is lodged in the vitreous humour, behind the 
 ciliary processes, and gradually undergoes absorption. 
 
 Couching is an operation which is very seldom performed at the 
 present day. It is rough in execution, and apt to excite serious 
 inflammation, with perhaps the ultimate loss of vision. 
 
 3. Solution is a method of treatment particularly applicable to 
 the softer varieties of cataract. One or two needles are intro- 
 duced near the margin of the cornea, and the anterior capsule of 
 the lens is torn through, so that the aqueous humour comes in cou- 
 
 E 2 
 
244 DISEASES OF TISSUES AND OEGANS. 
 
 tact with the lenticular substance. Absorption then takes place. 
 The operation may have to be repeated two or three times before 
 the whole of the cataract has been absorbed. On this account, 
 the process is rather a tedious one. 
 
 4. Linear extraction is a modern improvement on the fore- 
 going. After the capsule has been ruptured, either at once or 
 after a few days' interval, the soft lenticular matter is stirred up, 
 a curette is introduced through a suitable puncture in the cornea, 
 and the whole, or the greater part, of the lens is removed. 
 
 Before solution is undertaken, the pupil should be dilated with 
 atropine ; and it should be kept dilated until entire absorption has 
 taken place. It is often beneficial to support the eye by a light 
 pad of cotton-wool and a bandage. Where only a small corneal 
 wound has been made a thin piece of wet linen, laid over the eye, 
 is all that will be required. 
 
 In every case in which the lens has been taken away the patient 
 will have to use a convex glass to correct the refraction. 
 
 GIiilUCOMA 
 
 is a disease which has attracted a great deal of attention of late 
 years. Though it has been very carefully studied, its pathology 
 is not yet satisfactorily explained. It seems to depend upon 
 intra-ocular pressure, which first palsies the retina, and then 
 gradually disorganizes the other structures of the eye. 
 
 The disease is now usually divided into the infiammatory and 
 the non-inflammatory varieties. The inflammatory cases are 
 further subdivided into acute and chronic. 
 
 Acute glaucoma is generally preceded by a premonitory stage, 
 during which the patient is liable to occasional attacks, attended 
 with increased hardness (tension) of the eyeball, congestion of the 
 vessels, dimness of sight, and pain in and around the eye. There 
 is increasing presbyopia, and contraction of the visual field. When 
 the patient looks at a lighted candle, he sees a halo or rainbow 
 around the flame. These attacks become more frequent, till at last 
 the patient is suddenly seized with great pain in the eye and neigh- 
 bouring parts, with feverishness and sickness. The eye is found 
 to be very liard, the lids swollen, the conjunctiva inflamed, the 
 pupil dilated, the anterior chamber shallow, and the cornea hazy. 
 Vision is impaired or destroyed, and there are flashes or stars of 
 light before the eyes. Generally the humours are so cloudy that 
 an ophthalmoscopic examination cannot be made. 
 
 The attack may yield to treatment, or it may subside spon- 
 taneously, and the patient may recover a portion or the whole of 
 his sight. But after a time it recurs, and the vision is either 
 irreparably lost, or the inflammation passes into the chronic form. 
 
GLAUCOMA. 245 
 
 Chronic glaucoma may follow an acute attack, or it may be 
 gradually developed from the premonitory stage. The eye remains 
 hard, the field of vision is contracted, there is dimness of sight, there 
 are motes before the eyes by day and flashes or sparks by night, the 
 pupil is dilated and sluggish, there are frequent attacks of pain, 
 the conjunctiva is congested, and there are large tortuous veins on 
 the sclerotic, the cornea becomes rough, hazy, and callous, and the 
 humours become turbid. If an ophthalmoscopic examination can be 
 made, the retinal veins are seen to be dilated and tortuous, while 
 the arteries are small and pulsating, and the optic nerve is 
 cupped, or hollowed out, from the continued intra-ocular 
 pressure. Spots of haemorrhage are also often visible about the 
 fundus. 
 
 Non-inflammatory or simple glaucoma comes on so gradually 
 that it often passes unnoticed, until the patient suddenly finds that 
 he has lost the sight of one eye. The eye may look quite healthy, the 
 media may be clear, and the movements of the iris may be normal. 
 There is generally, however, increased hardness of the eyeball, and 
 on an ophthalmoscopic examination, the optic nerve is found to be 
 cupped, with dilated retinal veins and pulsating arteries. The 
 sight gradually fails, and the field of vision becomes contracted. 
 
 The disease may thus advance painlessly to blindness ; but it 
 more frequently takes, after a time, the characters of the acute or 
 chronic infiammation, and presents the symptoms which have 
 been already described in speaking of those varieties. 
 
 Glaucoma may also follow various affections or injuries of the 
 eye, as choroiditis or traumatic cataract. 
 
 It is then termed secondary. For details of these varieties, the 
 reader may be referred to Mr. Soelberg Wells's or to Mr. 
 Lawson's works on the Diseases of the Eye. 
 
 Treatment. — Medical treatment is of little avail in any of the 
 various forms of glaucoma. The immediate inflammation and 
 pain may be relieved by mercury, opium, leeches, fomentations, 
 &c., but the eye is not cured. A solution of eserine (gr. i ad ^i), 
 dropped into the affected eye two or three times a day, seems 
 sometimes to lessen the undue tension. Sooner or later the disease 
 will again show itself, perhaps more acutely than before. 
 
 Several operative measures have been adopted for the relief of 
 this affection. 
 
 Paracentesis of the anterior chamber is of value in relieving 
 the immediate symptoms, and, if it is frequently repeated, it may 
 arrest the disease for a time. 
 
 Mr. Hancock recommends the division of the ciliary muscle. 
 
 In 1856, the late Professor von Graefe, of Berlin, introduced 
 the method of treating glaucomatous affections by the removal 
 
246 DISEASES OF TISSUES AND OEGANS. 
 
 of a portion of the iris {iridectomy). This measure has been ex- 
 tensively practised in this country, and is,, indeed, almost the only 
 operation now employed in this disease. Its eflScacy depends much 
 ou the removal of a large piece of iris, and on its being torn 
 away quite up to the ciliary margin. 
 
 AMAUROSIS. 
 
 The term amaurosis used to be employed to denote dimness, or 
 loss of sight, from causes unexplained by the external appearance 
 of the eye, and which was attributed to disease of the retina, optic 
 nerve, or brain. But, since the introduction of the ophthal- 
 moscope, our knowledge of the diseases affecting the deeper 
 structures of the eye has made great progress. Many of the 
 cases which were formerly called amaurosis have been classified 
 under other heads, and the term is now, by common consent, con- 
 fined to blindness depending upon cerebral or cerebro-spiual causes. 
 Thus it includes most of the examples of atrophy of the optic nerve. 
 
 The most frequent cerebral causes of amaurosis are tumours, 
 syphilitic deposits, blood clots, hydrocephalus, meningitis, and em- 
 bolism ; while the most frequent spinal cause is locomotor ataxia. 
 
 The prognosis in all these cases is unfavourable — indeed, it is 
 only when the disease is of syphilitic origin, or when it depends 
 upon general ansemia, or uterine derangement, that medicine can 
 be of much avail. 
 
 FOBEIGM- BODIES ON" THE COirJVM'CTIVA OB 
 
 COBIO-EA. 
 
 Foreign bodies, such as eyelashes, particles of dust, &c., often 
 adhere to the conjunctival surface, and give rise to great uneasi- 
 ness. If they are not removed, they may even produce a consi- 
 derable amount of inflammation. They are generally situated 
 just above the margin of the upper lid. To remove them from 
 this position the lid must be everted. This is done by laying a 
 probe across the upper lid about half an inch from its margin. 
 The central eyelashes are then taken between the finger and 
 thumb of the other hand, and drawn outwards, whilst the probe is 
 gently pressed upon the lid, and the patient is told to look down- 
 wards. By this means the tarsal cartilage will tilt over, and 
 expose the conjunctival surface. The foreign body may then 
 be removed with a camel's-hair brush, a feather, or a " spud." 
 If the particle is embedded in the conjunctiva, it may be lifted 
 out with a broad needle. Or the conjunctiva may be raised with 
 a small pair of forceps, and the piece, in which the foreign body 
 is embedded, snipped off with scissors. The trifling cicatrix thus 
 made soon heals, and leaves no trace behind it. 
 
TUMOURS OF THE EYEBALL. 
 
 247 
 
 Particles imbedded in the cornea are held so tight by the 
 elastic structure that they are often difficult to remove. They 
 consist generally of sharp fragments of metal, sand, or coal. 
 
 In order to extract them, the patient should be directed to fix 
 his eye on some convenient point, and then, the globe being 
 steadied, the particle may be picked out with a " spud," or with 
 the point of a cataract knife. 
 
 If the particle is deeply embedded, or if the patient is unable to 
 control the movements of the eye, it may be necessary to give 
 chloroform before extraction will be possible. 
 
 "WOUUDS OF THE EVEBAIil^. 
 
 If the globe is simply wounded, the best thing that can be 
 done is to close the lids, fix them with a strip of plaster, and give 
 firm support to the eye by means of a pad of cotton-wool and a 
 bandage. Should inflammation arise, it must be treated by the 
 ordinary measures — leeches, fomentations, &c. 
 
 When the eyeball has been wounded, and a foreign body lodged 
 in it, an attempt should be made to remove the extraneous substance 
 at once. If this is not done, it may set up suppurative inflamma- 
 tion, and lead to the destruction of the eye. After the removal 
 of the foreign body, the case must be treated as a simple wound. 
 
 TUMOURS OF THE EYEBAI.I. 
 
 are generally malignant in their nature, 
 apt to be attacked by medullary 
 sarcoma, or rather by that variety 
 of it, the small round-celled sarcoma, 
 known as glioma. The disease appears 
 to spring from the retina or choroid. 
 It growls rapidly, fills the globe, bursts 
 the tunics, and then protrudes between 
 the lids in a fungous mass. Fig. 113 
 was drawn from a little boy, aged V, 
 who was Mr. Bowman's patient. The 
 tumour had been growing about six 
 weeks, and was of the size and shape 
 of a small orange. 
 
 In later life the choroid often 
 becomes the seat of melanotic cancer. 
 The disease advances very slowly. It 
 may, however, be easily detected in its 
 early stage by the ophthalmoscope. 
 
 In children scrofulous deposits in 
 the deep structures of the eye are not 
 
 In early life the eye is 
 Fig. 112. 
 
 Medullary tumour of 
 the eyeball. 
 
248 DISEASES OF TISSUES AND ORGANS. 
 
 uncommon, and produce equally destructive results, as far as the 
 eye is concerned. 
 
 Treatment. — In any case the only remedy is the extirpation of 
 the eyeball. This is done by slitting up the ocular conjunctiva 
 around the globe, and dividing each of the tendons in turn. The 
 eye is then drawn gently forwards, and the optic nerve cut with 
 a pair of curved scissors. The bleeding should be arrested by a 
 stream of cold water ; a fold of wet lint should be laid over 
 the orbit, and perfect rest enjoined for some days. 
 
 SQUIITTIirG, 
 
 or strabismus, may be defined to be a want of parallelism between 
 the visual axes of the eyes. If the lines of sight converge, the 
 squint is said to be convergent ; if they diverge, it is said to be 
 divergent. 
 
 When only one eye is affected, the squint is said to be single. 
 When the obliquity is observable in both eyes, it is termed 
 
 Squinting depends upon a want of equilibrium between the 
 opposing muscles of the eyeball. This want of equilibrium may 
 be congenital, or it may come on at any period of life. The 
 causes which give rise to it are numerous. Sometimes it 
 follows the irritation of teething, or of worms. Sometimes it 
 is a sequela of fever, or of exanthematous disease. Sometimes 
 it arises from weakness of one eye, and consequent want of use. 
 Sometimes it depends upon defective vision, such as myopia, 
 or hypermetropia. Sometimes a nebula on the cornea leads 
 the patient to use his eye obliquely. Sometimes it is asso- 
 ciated with hydrocephalus, convulsions, or compression of the 
 brain. 
 
 The treatment necessarily varies with the cause. When the 
 squint depends upon organic disease of the brain, nothing can be 
 done to remedy it. When it is a symptom of compression, we 
 must endeavour to remove the compressing force. When it is 
 due to irritation, it may be relieved by judicious medical treat- 
 ment. But when it is congenital, or has existed for a long 
 time, when the eyesight is unimpaired, and when there is no 
 disease of the brain or retina, an operation should be recom- 
 mended. The tendon of the preponderating muscle should be 
 divided, close to its insertion into the globe. If the squint is 
 convergent, the internal rectus will have to be cut; if the 
 obliquity is outwards, the external rectus must be divided. 
 
 The patient being anaesthetized, the conjunctiva at the lower 
 margin of the tendon, near its insertion, is raised with a forceps, 
 and snipped with a pair of blunt-pointed scissors ; a blunt hook 
 
POLYPUS OF THE EAE. 249 
 
 is then passed under the tendon, which is next divided subcon- 
 junctivally with the scissors. Sometimes a second opening is 
 made in the conjunctiva at the upper border of the tendon to 
 allow the eiFused blood to escape. 
 
 ACCUlVIUIiATION- OF "WAX Xir THE EAR. 
 
 Not unfrequently the wax, mixed with hairs and epithelium, 
 collects in hard, dark-brown masses in the external meatus. 
 When this happens, it gives rise to crackling and singing noises 
 in the ears, deafness, and perhaps giddiness. 
 
 The treatment consists in dropping a little oil, or glycerine, 
 into the ears every night, and syringing them gently, but 
 efficiently, every morning with warm water, until all the super- 
 fluous wax has been removed. In syringing the ear the helix 
 should be drawn gently upwards and outwards so as to 
 straighten the canal ; and the stream should be directed rather 
 along its upper wall. The accumulation of wax seems often to 
 be associated with other defects of the ear, for Toynbee found 
 that in 60 cases only out of 165 did the removal of cerumen 
 restore normal hearing. 
 
 OTORRHCEA 
 
 is the name given to a purulent, or muco-purulent, discharge 
 from the ear. It may arise either from inflammation of the ex- 
 ternal meatus, from polypus, or from disease of the internal ear. 
 The first variety is often seen in scrofulous children ; the last is a 
 frequent consequence of scarlatina. 
 
 Treatment. — In the first case the meatus should be syringed 
 with warm water, or with astringent lotions, while attention is 
 paid to the general health. The syringing should be done with 
 great care : to a sensitive and delicate organ like the ear a forcible 
 stream of water is not so harmless as some suppose. If the 
 disease is situated in the inner ear, and the tympanum is per- 
 forated, the case is much more serious. There is danger of 
 meningitis, or abscess of the brain, or phlebitis, or other com- 
 plications. During the acute stage, the treatment must be 
 active — leeches behind the ear, fomentations, purgatives, and 
 salines. Afterwards a course of tonics will be very beneficial, and 
 the impairment of hearing, which is sure to follow, may be 
 remedied by an artificial tympanum. 
 
 POX.YPVS OF THE EAR. 
 
 The polypi which are met with in the ear are sometimes of a 
 solid fibrous consistence and bright red colour; at other times 
 they are pale pink and gelatinous. Sometimes they are attached 
 
250 DISEASES OF TISSUES AND ORGANS. 
 
 by a broad base to the side of the meatus ; sometimes by a narrow 
 pedicle ; in some instances they even spring from the membrana 
 tympani. They are accompanied by a muco-pnrulent discharge. 
 The treatment consists in removing them by a polypus-forceps, 
 or scissors, and touching the spot from which they grew with a 
 fine pencil of lunar caustic. 
 
 FOREIGN' BODIES IIT THE EAR. 
 
 Foreign bodies, such as peas, beads, pebbles, insects, &c., are 
 sometimes lodged in the ear, and cause great anxiety and alarm. 
 
 In such a case the first thing to be done is to examine the ear, 
 and make sure that there really is a foreign body present, as well 
 as to ascertain its size and situation. This may be done by 
 throwing light into the ear through an ear speculum, or a cone 
 of white paper. 
 
 The ear should then be syringed with warm water, the stream 
 being directed along the upper wall of the meatus. If this fails, 
 a loop of fine wire may perhaps be passed round the foreign body, 
 or a suitable scoop or forceps may be tried ; but such instruments 
 must be used with great caution. If these means fail, it is better 
 to leave it to make its own way out. Force should on no account 
 be used; it is most dangerous. 
 
 EPISTAXIS, 
 
 or bleeding from the nose, may be the result of an operation or 
 an injury ; or it may depend upon plethora and active congestion, 
 or upon passive congestion with disease of the heart or lungs, or 
 upon a medullary growth within the nose, or upon an impoverished 
 state of the blood, arising from general debility', scurvy, or fever j 
 or it may arise from various other causes. 
 
 If the haemorrhage occurs in a plethoric person of middle age, 
 who is subject to giddiness, or other cerebral symptoms, or if it 
 seems to be associated with inflammation of some adjacent part, 
 we must not be in too great a hurry to arrest it. 
 
 But if the bleeding arises from an operation or an injury, or 
 if it depends upon disease of the heart or lungs or general system, 
 then we must take means for stopping it. The patient's head 
 should be elevated, and his nose well bathed with cold water. By 
 these simple means the bleeding which so often occurs in children 
 may generally be stopped. If more active measures are needed, 
 a bag of ice should be held to his forehead ; he should snuff up 
 powdered matico or gall-nuts or tannic acid ; styptics — solution 
 of alum or of the perch loride of iron — should be injected into the 
 nostril; a continuous stream of iced salt and water should be 
 directed through the nostrils by means of a syphon tube ; or the 
 
LIPOMA. 251 
 
 anterior nares should be plugged with strips of lint, dipped, 
 if need be, in the muriated tincture of iron. If all these measures 
 fail, the posterior orifice must be closed as well. 
 
 Plugging the posterior nares. — This is done by arming a 
 catheter, or an elastic bougie, or the instrument made for the 
 purpose (Bellocq's cauula). Fig. 113, with a fiine twine, and then 
 
 Bellocq's canula. 
 
 passing it along the floor of the nose, and making the point 
 project below the soft palate. A forceps is then introduced into 
 the pharynx, the twine is seized, and one end of it is brought out 
 at the mouth. The instrument is then withdrawn from the 
 nose, leaving the twine as before. We have thus got a ligature 
 passing along the floor of the nose, through the posterior nares, 
 looped round the soft palate, and emerging at the mouth. A 
 small roll of lint, or a piece of sponge of suitable size, is next 
 attached to the lower ligature, twelve or fifteen inches from the 
 end of it. By gently pulling the upper or nasal ligature, the 
 plug of lint or sponge is drawn into the mouth, behind the soft 
 palate, and into the posterior nares. Both the ligatures should 
 then be secured, and the plug allowed to remain for two or three 
 days — in fact, until it becomes loose. 
 
 Sometimes it is necessary to plug the anterior as well as the 
 posterior nares, in which case the string that projects from the 
 nostril may be used to secure the anterior plug. 
 
 While these mechanical means are used, gallic acid or turpen- 
 tine or other styptics should be administered internally (F. 29). 
 
 IiZPOIVIA 
 
 is the name given to tumours which are sometimes seen on the 
 external surface of the nose. The tip becomes bulbous, and 
 gradually enlarges, until one or more round, pendulous masses are 
 formed. They consist of an hypertrophy of the skin, subcuta- 
 neous areolar tissue, and fat. Indeed, they are merely fatty 
 tumours whose character is somewhat modified by their situation. 
 The skin appears coarse, the sebaceous glands become distinct. 
 
252 DISEASES OF TISSUES AND ORGANS. 
 
 the vessels are prominent, and the tumour has a purple or livid 
 colour. Altogether it is very unsightly, and gives rise to great 
 inconvenience. 
 
 Treatment. — During the earlier stages it may be bathed with 
 stimulating or astringent lotions : but when it attains such a size 
 as to interfere with the uses of the nose or mouth, it should be 
 removed with the knife. 
 
 POIiYPUS OF THE NOSE. 
 
 The polypi which are met with in the nose are of two kinds — 
 1, gelatinous; 2, fibrous. 
 
 1. The gelatinous polypi consist of an expansion of the ele- 
 ments of the mucous membrane and submucous tissue. They are 
 generally multiple, pear-shaped, and grow rapidly. They almost 
 always spring from the outer wall of the nasal cavity, and are 
 most frequently connected with the superior turbinated bone. 
 In rare instances they are situated on the septum. 
 
 2. The fibrous polypus springs from the periosteum, and is 
 often connected with the sphenoid bone, or the basilar process 
 of the occipital. It is usually single, attached by a broad base, 
 and grows slowly. Its texture is fibrous, or fibro-cellular. It 
 is very prone to degenerate, and to assume a malignant 
 character. 
 
 Symptoms. — Discharge from the nose; the Schneiderian mem- 
 brane is thickened and congested, especially in damp weather ; 
 breathing is impeded ; smell is impaired ; the voice is altered ; 
 there may be deafness, and sometimes even cerebral symptoms. 
 The tumour may be seen by throwing light into the nostril, or by 
 using the laryngoscope to examine the posterior nares ; or it may 
 have advanced so far as to have produced outward deformity 
 of the nose. 
 
 Treatment. — Tonics and astringent lotions may be tried at 
 first, but they seldom effect a cure. Mr. Bryant speaks highly 
 of the value of tannin as a snuff". If these measures fail, the 
 growth must he removed, either by the small ecraseur, the 
 polypus forceps, or the ligature. 
 
 The patient should be seated in a low chair, with his head 
 thrown back. The ecraseur, with the loop of fine wire projecting 
 from it, is passed along the septum, then half turned, so that the 
 loop may slip over the polypus to its pedicle, and the noose drawn 
 tight. If forceps are used, they are introduced closed, slowly 
 opened, the polypus seized, and twisted from its attachment. 
 This process may be repeated until the nostril is entirely 
 cleared. This method of treatment is best suited to the gela- 
 tinous polypus. 
 
OZ^NA. 253 
 
 The ligature is more applicable to the fibrous growth. A 
 noose of twine is passed through the nose, by means of a double 
 canula or elastic catheter, looped around the tumour, and then 
 tied tight. 
 
 The removal of a fibrous polypus often requires great in- 
 genuity and dexterity. 
 
 CAirCER OF TBE ITASAIi CAVITV. 
 
 Besides the degenerated fibrous polypus, which, as we have 
 said, often assumes a malignant character, the nasal cavities are 
 sometimes the seat of medullary cancer. This disease is not 
 unfrequently met with in children. It may either originate in 
 the nose, or spread to it from the antrum. It grows rapidly, 
 expands the nasal bones, protrudes the eyeball, and gives rise to 
 great deformity. It is attended by a profuse and offensive dis- 
 charge, causes severe and distressing pain, and generally proves 
 rapidly fatal by involving the brain, or by profuse haemorrhage, 
 or by exhaustion. 
 
 Treatment. — The only treatment is extirpation, and even this, 
 at the best, is not likely to do more than prolong life for a sbort 
 time. 
 
 is the name given to a discharge from the nostrils of a peculiarly 
 foetid and offensive nature. It manifests itself in persons of a 
 scrofulous habit, or it may arise from syphilis, either inherited or 
 acquired. The discharge is probably unnatural in character, and 
 rapidly decomposes when it is retained in the nasal cavity. 
 
 In some cases there is simply a thickened and unhealthy state 
 of the mucous membrane; in other cases there is ulceration ; and 
 sometimes even the bones are affected. 
 
 Treatment. — The first thing is to examine the nose by reflected 
 light, and to ascertain, as far as possible, the state of the mucous 
 membrane, and the source of the discharge. It may depend upon 
 the presence of a polypus, or of a foreign body. If the lining 
 membrane is congested, thickened or ulcerated, the nose should 
 be frequently steamed, and syringed with astringent, stimulant, 
 or disinfectant lotions (F. 17, 27, 12), and the ulcerated spots 
 touched with a solution of nitrate of silver or with a pencil of the 
 solid caustic. Nothing is better, as a wash, than a liberal use 
 of warm water, to which a little common salt or Condy's fluid or 
 chloride of lime has been added. The best way of using it is 
 with Dr. Thudichum's nostril douche or with the syphon tube. 
 The patient should hold his head over a bason, and open his 
 mouth wide. This causes the soft palate to close the posterior 
 
254 DISEASES OF TISSUES AND ORGANS. 
 
 nares. Then the tube should be directed up one nostril, and the 
 return current will soon begin to flow down the other. Thus 
 the whole nasal cavity will be effectually washed out. Under any 
 circumstances, it is of the greatest importance to study the 
 general health, particularly if there is a strumous tendency or a 
 syphilitic taint. 
 
 ABSCESS OF THB AITTRVM. 
 
 The lining membrane of the antrum is liable to become in- 
 flamed from injury, or from the irritation of carious teeth, or 
 from other causes. Such inflammation is very prone to run on to" 
 suppuration. 
 
 Symptoms. — There is severe, deep-seated, throbbing pain in 
 the part, and the soft tissues become swollen and tender. There 
 is a good deal of constitutional disturbance. If relief is not 
 afforded, the walls of the cavity become distended, the nose is 
 obstructed, and the face becomes deformed. 
 
 The treatment consists in allaying inflammation by local and 
 constitutional measures, in the hope of anticipating suppuration. 
 When pus has been formed, it sometimes escapes through the 
 nose or inside the upper lip, above the gum. Much more 
 frequently, however, an opening has to be made into the antrum, 
 to give vent to the matter. This may be done either by extracting a 
 tooth, and pushing a trochar through its socket into the inflamed 
 cavity ; or by perforating the external wall of the antrum, in the 
 situation of the canine fossa. For a time it may be necessary for 
 the patient to use a small silver tube or some other contrivance 
 to prevent the wound healing, and to give free vent to the dis- 
 charges. 
 
 TUMOTTRS OF THE UPPER JA'W. 
 
 The upper jaw is liable to be the seat of tumours of various 
 kinds. Of these the commonest are the fibrous, the myeloid, and 
 the medullary. They appear to originate in the gum, the alveoli, 
 or the antrum. As they grow, the bones become expanded. 
 The swelling projects outwards on the face, backwards towards 
 the fauces, inwards towards the nose, and upwards towards the 
 orbit. Swallowing is impeded, smell is impaired, vision is dis- 
 torted, and the face is terribly disfigured. 
 
 At first it is difficult to give any opinion as to the precise nature 
 of the tumour. If, however, it grows slowly, our diagnosis will 
 be more favourable ; and less favourable, if it grows quickly. The 
 rapidity of growth is generally in direct proportion to the malig- 
 nancy. Dentigerous cysts — cysts containing undeveloped teeth 
 — are occasionally met with in this situation. 
 
EPULIS. 255 
 
 Treatment. — The only remedy is extirpation — removal of the 
 upper jaw. Though this is a formidable operation, yet the imme- 
 diate result is almost invariably good. The skin may be reflected, 
 and the tumour exposed in various ways. Perhaps that which 
 leaves the least deformity is the one recommended by Sir Wm. 
 Fergusson. The knife is carried through the middle line of the 
 upper lip, and the nostril is entered. In some cases this gives 
 sufficient space. If, however, more is wanted, the incision may be 
 continued round the ala, and up the side of the nose. If need be, it 
 may be turned at right angles along the lower border of the orbit. 
 
 If the whole of the upper maxilla has to be removed, the first 
 step, after making the incision, is to draw an upper incisor tooth 
 on the affected side, and divide the alveolus and the palate- 
 plate with a fine saw, or with bone-pliers introduced into the 
 nostril. The internal angle should then be similarly notched 
 and cut through, and subsequently the outer angle and 
 the zygomatic process. The bone must then be seized with 
 the " lion forceps" and turned out, the soft tissues being 
 divided with a scalpel, and the wound closed with interrupted 
 sutures. 
 
 TUMOURS OF THB IiOlXTER SA.'W 
 
 are much the same in their characters as those which are met 
 with in the superior maxilla. The most common varieties are the 
 fibrous and the fibro-cystic. The soft cancer is less often seen. 
 Tumours are generally situated between the angle and the sym- 
 physis ; but they may occur anywhere, and they have been known 
 to occupy the whole extent of the jaw. 
 
 Treatment. — Complete removal of the tumour, and of the por- 
 tion of bone connected with it, is the only remedy. An incision 
 should be made along the lower border of the bone, and the soft 
 tissues reflected, so as to expose the growth. The Key's saw 
 should then be applied on each side of the tumour, the jaw 
 grooved, and the division completed by the cutting-pliers ; or the 
 bone may be divided from within outwards by means of the 
 chain-saw. When this has been done, the tumour should be 
 carefully dissected from the soft parts on its inner and under 
 surfaces. In performing this operation the " lion forceps" will 
 be found of great service. 
 
 Maunder has shown that tumours which involve even large 
 portions of the bone may be removed through the mouth, with- 
 out making any incision through the skin at all. 
 
 EPUX.IS 
 
 is the name given to a tumour which springs from the alveolar 
 
256 DISEASES OF TISSUES AND OEGANS. 
 
 processes, and from the periosteum covering them. It is more 
 often seen in connection with the inferior than with the superior 
 maxilla. It forms a smooth, rounded, or lobulated tumour, 
 covered with the mucous membrane of the gum. It is firm, or 
 semi-elastic to the touch. As it grows, it loosens and displaces the 
 teeth. Its intimate structure varies considerably. Sometimes 
 it is a simple fibrous tumour ; sometimes it is a round-celled sar- 
 coma ; sometimes a myeloid. At first it is benign ; but if it is 
 allowed to remain, it is apt to ulcerate, and exhibit something of 
 a malignant aspect and character. 
 
 Treatment. — The tumour should be removed, and the portion 
 of the alveolar process from which it springs should be taken 
 away with the gouge, the cutting-pliers, or a fine saw. Unless 
 this is done, the growth is almost certain to return. 
 
 is the name given to an encysted tumour which is apt to form 
 beneath the tongue. It depends upon distension of one of the 
 mucous follicles, which are numerous in this situation ; occa- 
 sionally it may be due to obstruction of the ducts of the 
 salivary glands. The contained fluid is clear, viscid, and 
 albuminous. • 
 
 Treatment. — The cyst may be simply punctured j or a small 
 portion of the cyst-wall may be cut off; or a seton may be 
 passed through it ; or it may be laid open and filled with lint, 
 according to its size, and the circumstances of the case. 
 
 There is another class of cases to which the name ranula is 
 applied, but which are in truth of a difierent, and more formidable 
 kind. Here the swelling is situated between the tongue and 
 the jaw, and becomes prominent in the upper part of the neck. 
 These tumours contain a thick, gritty, putty-like substance com- 
 posed of crystals of cholesterine, oil-globules, and the debris of 
 epithelial scales. In fact they are of the nature of sebaceous 
 cysts (see Fig. 3). The best way of treating these tumours is 
 to lay them open from the mouth, scoop out the contents, and 
 fill the cavity with lint. If need be, a counter-opening should 
 be made in the neck. To dissect out the cyst is an unneces- 
 sary proceeding, and one which is not altogether free from 
 danger. 
 
 SAIiZVARV CiiZiCUIiirS. 
 
 It sometimes happens that a deposit of earthy salts from the 
 saliva — composed chiefly of phosphate of lime — takes place in 
 one of the salivary glands, or in one of the ducts. Such a con- 
 
TONGUE-TIE. 
 
 257 
 
 Fig. 114. 
 
 Salivary calciilus. 
 
 cretion is known as a salivary calculus (Fig. 114). These 
 concretions vary in size from a pin's head to a hazel nut ; and 
 not unfrequently they form 
 around some foreign body, such 
 as a morsel of woody fibre, a 
 fish-bone, or a bristle. 
 
 Treatment. — If a salivary cal- 
 culus can be felt either by the 
 finger, or by a probe passed along 
 the duct, an incision should be 
 made, and it should be removed 
 with a forceps. If it is so small 
 as to elude the grasp of the instrument, it will be washed out at 
 the opening by the discharge of saliva. 
 
 TOXJGVE-TZE. 
 
 In this affection the frcenum linguce is too short, or comes 
 further forward than it should, and thus restrains the movements 
 of the anterior portion of the organ. The infant cannot put out 
 its tongue or use it in sucking ; and, if the defect is allowed to 
 continue, it seriously interferes with the distinctness of the 
 patient's articulation. 
 
 The treatment is simple and effectual. The infant's mouth 
 being held open, the surgeon takes the frcBnum between his Jeft 
 forefinger and thumb, puts it gently on the stretch, and snips it 
 with a blunt-pointed pair 
 
 of scissors j or the tongue ^^' ^* 
 
 may be pressed upwards, 
 and the bridle made tense, 
 by means of the little 
 instrument which has been 
 devised for the purpose 
 (Fig. 115). The incision 
 need not be deep. In 
 most instances an eighth 
 of an inch will suffice ; and care should be taken to direct the point 
 of the scissors downwards, so as to avoid the ranine arteries. 
 Trifling as this operation is, it has sometimes been followed by 
 severe, and even fatal, hsemorrhage. Many children are thought 
 by their parents to be tongue-tied, when, in truth, there is no 
 such defect. The surgeon should therefore be on his guard, and 
 not undertake the operation without good reason. 
 
 VIiCERATIOir OF THE TOXTGVE. 
 
 The tongue is liable to be aftected with ulcei-ation of various 
 
 Instrument for tongue-tie. 
 
258 
 
 DISEASES OF TISSUES AND ORaANS. 
 
 kinds — simple, sypliilUic, apMhous, and cancerous. Of the last 
 we shall speak in the next section. 
 
 The simple ulcer may arise either from internal or external 
 causes. When it arises from internal causes, it is due to derange- 
 ment of the stoiToach, and is termed dyspeptic ; when it is due to 
 external causes, it will probably be found to have been produced 
 by a jagged tooth or an accumulation of tartar. The edges of a 
 simple ulcer are rounded, the surface is yellow, the base is soft. 
 The tongue is coated, and the breath oiFensive. Dr. T. Morton, of 
 Kilburn, has drawn attention to the interesting fact (which had 
 already been observed on the Continent), that in a large propor- 
 tion of cases of whooping-cough an ulcer is found under the tongue, 
 situated on the frasnum. Its cause and significance are not 
 clearly made out ; but it is generally referred to tension over the 
 teeth in coughing. 
 
 Syphilitic ulceration occurs under three forms : — (1) cracks and 
 fissures along the sides of the tongue ; (2) superficial, flat, oval 
 
 ulcers; (3) deep ulceration, the 
 Fig. 116. result of the softening, and dis- 
 
 charge of a gummy tumour in 
 the substance of the organ. 
 
 Aphthous ulcers are met 
 with in infants, "in old persons, 
 and in the last stages of some 
 wasting complaints — in fact, 
 wherever there is great debility. 
 They constitute what is popu- 
 larly called " the thrush." 
 They are due to the develop- 
 ment of a parasitic fungus — 
 the oidium albicans (Fig. 116), 
 which destroys the epithelium 
 upon which it grows, and then 
 the exposed mucous membrane 
 ulcerates. The disease first 
 appears on the tongue, or on the 
 lining membrane of the mouth, 
 as small white flakes, like 
 of curd, for which 
 it is often mistaken. 
 These flakes should not be 
 picked off, for, if this is done, 
 they are soon reproduced. To 
 deal with them successfully we must remove the morbid condition, 
 which favours their development. 
 
 Oidium albicans, x 300. 
 
EPITHELIOMA OF THE TONGUE. iJ59 
 
 Treatment. — In the case of a dyspeptic ulcer t\ie primce vice 
 should be regulated by alteratives, and the general health esta- 
 blished by tonics. Tlie patient should at the same time confine 
 himself to a liquid and bland diet. If the ulcer is due to local 
 irritation, the source of such irritation ought at once to be 
 removed, and the disease treated as in the foregoing case. 
 
 The surftice of the uk-er should be lightly touched with lunar 
 caustic, and the mouth rinsed with stimulating, astringent, or 
 disinfecting washes. The patient should at the same time be 
 desired to abstain from talking. In fact, everything should be 
 done to keep the tongue at rest. 
 
 If the ulceration is syphilitic, the same local measures should 
 be adopted, and the patient should, in addition, be treated with 
 mercury or iodide of potassium (F. 49, 50, 60). 
 
 In true aphthous ulceration our aim must be to destroy the 
 parasitic fungus by lotions of sulphite of soda (^j to 3J of water) 
 or carbolic acid, while we rectify the secietious of the mouth by 
 alteratives and tonics. In infants, a well-regulated manner of 
 nursing and strict attention to cleanliness are often all that is 
 needed to effect a cure. 
 
 EPITKEXiIO»X.a. OF THE TONOUH 
 
 may either commence as a superficial blister or crack, or as a 
 lump in the substance of the organ. If it begins as a blister or 
 crack, it rapidly runs into ulceration. A foul and offensive sore 
 is formed with a sloughy surface, ragged edges, and a hardened 
 base. There is acute, darting pain. The breath becomes foetid, 
 there is profuse salivation, and the submaxillary, sublingual, 
 and lymphatic glands become enlarged. Gradually the general 
 health sufiers, and the patient at length dies, worn out by irri- 
 tation and exhaustion. When the disease begins as a deep-seated 
 lump, it draws the tissues down to itself, and forms a hard mass. 
 There is little or no ulceration, but the other features of the case 
 are much the same as those of the preceding variety. It was 
 this class of cases which used to be called scirrhus. But it is 
 now known that any other form of cancer except epithelioma is 
 extremely rare in the tongue. 
 
 Treatment. — Early and complete removal is the only remedy 
 which holds out a hope. The disease may be taken away with 
 the knife, the ecraseur, the galvanic-ecraseur, or the ligature. 
 If the knife is used, the hsemorrhage is generally so profuse that 
 it is not advisable to give chloroform. But if any of the other 
 methods are employed, the patient can have the comfort of an 
 anaesthetic. It is but seldom that the ligature is now used in 
 these cases. The presence of a slough in the patient's mouth 
 
 s 2 
 
•260 DISEASES OF TISSUES AND ORGANS. 
 
 for a few days after it has been applied is a great objection to 
 it. If the base and sides of the tongue are freed, or if the 
 lower jaw is divided, any part of the organ may be brought 
 within the loop of the ecraseur ; and if this is very slowly 
 tightened, it gives all the advantages of the ligature without its 
 disadvantages. Sometimes an incision is made in the sub- 
 mental region, and the tongue drawn through it. But it is 
 better, if possible, to avoid any extensive wound in the floor of 
 the mouth. Nunneley and Barwell have devised ingenious 
 operations, wherein the wire of an ecraseur has been passed 
 through a puncture in the floor of the mouth. (^Lancet, 
 April 19, 1879.) 
 
 If an operation, even of a palliative kind, is out of the ques- 
 tion, much may be done by the judicious use of conium, hyos- 
 cyaraus, and morphia, to alleviate the patient's sufferings (F. 7, 
 10, 53). In suitable cases signal relief may be afforded by the 
 operation recommended by C. H. Moore — namely, the division of 
 the lingual nerve, where it lies against the inner surface of the 
 lower jaw, just beyond the last molar tooth. 
 
 Though cancer of the tongue is very rapidly fatal — the 
 average duration of life .being only fourteen months — yet statis- 
 tics show that the balance is considerably in favour of cases that 
 have been submitted to operation. This I have shown in detail 
 in my treatise on the Diseases of the Tongue. 
 
 GAM-GREITOUS STOIVIATITZS— CAirCRUnX ORIS. 
 
 In ill-fed children, living in unfavourable conditions, we not 
 unfrequently see foul greyish ulcers on the gums and on the 
 inside of the cheeks. This is termed gangrenous stomatitis. 
 
 Treatment. — Such ulcers may be readily cured by touching 
 the diseased spots with lunar caustic, and prescribing chlorate 
 of potash in combination with a tonic ; while the child is well 
 fed and placed in favourable hygienic conditions. 
 
 But occasionally we meet with a much more formidable 
 disease of the same kind, especially in children who are recover- 
 ing from the eruptive fevers. In cancrum oris one cheek, 
 generally near the angle of the mouth, becomes swollen, red, 
 and brawny. The whole thickness of the cheek is affected. 
 The internal surface is as painful as the external ; and the little 
 patient can scarcely open his mouth. Gradually the redness 
 passes into lividity. A large slough forms, and, when it sepa- 
 rates, the teeth and the interior of the mouth are exposed to 
 view. 
 
 Treatment. — Everything must be done to support the 
 patient's strength by milk, beef-tea, wine, and stimulant medi- 
 
CLEFT PALATE. 261 
 
 cines. A suitable mouth-wash — containing tincture of myrrh 
 or Condy's fluid, or some other detergent — should be frequently 
 used. The cheek must be covered by a poultice or a fomenta- 
 tion till the slough separates, and then the raw surfaces dressed 
 with a stimulating lotion (F. 13, 22, 25). If the gangrenous in- 
 flammation threatens to spread, the edges must be thoroughly 
 touched with the strong nitric acid. But, under any circum- 
 stances, cancrum oris is a very fatal disease. 
 
 CIiEFT PAXiiVTE 
 
 signifies a congenital fissure in the palate, the result of defective 
 development. The cleft varies greatly, both in extent and width, 
 in different cases. It may be confined to the tip of the uvula, 
 or it may sweep through the whole arch of the soft and hard 
 palate, and be associated with hare-lip. Sometimes it is quite 
 narrow — a mere slit ; sometimes it is nearly an inch in breadth. 
 In a severe case food regurgitates by the nose, causing great 
 difficulty in rearing the infant, and great inconvenience in after 
 life. The patient's speech, too, will be nasal and indistinct. 
 
 Treatment. — If the soft tissues are abundant, and the patient's 
 health good, an operation may be undertaken with the view of 
 remedying the defect. If the soft palate alone is cleft, it may be 
 united without any great difficulty. If the hard palate is only 
 slightly fissured, the surgeon may be able to close the soft tissues 
 over it. But if there is a large gap, the patient must be con- 
 tented to wear an artificial palate. When the soft palate has 
 been united, a plate will more easily be worn in the aperture 
 which remains in the hard palate. 
 
 The operation of velosyyithesis or stapliyloraphy consists in 
 paring the edges of the cleft, bringing the soft tissues together, 
 and keeping them in that position until they have united. In 
 order to allow the parts to come together more easily, and to 
 prevent traction upon the stitches, Sir Wm. Fergusson divided 
 the levator palati and the palato-pharyngeus muscles on both 
 sides at the outset of the operation. Others prefer making an 
 incision through the soft parts on each side of, and parallel to, 
 the line of union. The sutures used should be of fine silk, 
 fishing-gut, horse-hair, or silver wire ; and if they cause no irri- 
 tation, they should be allowed to remain for a week. 
 
 The earlier this operation is undertaken the better chance will 
 the patient have of speaking clearly and distinctly. Formerly it 
 was usual to defer it until the child was of sufficient age to exer- 
 cise some degree of self-control. For this reason it was seldom 
 undertaken before the age of puberty. Lately, however, opera- 
 tions have been performed at a much earlier age, both with 
 
262 DISEASES OF TISSUES AND OEQANS. 
 
 and without the aid of chloroform. In these proceedings, Mr. 
 1'homas Smith's gag will be found of great service. It is a sort 
 of double bit, which is introduced into the patient's mouth and 
 secured by a strap, which passes round the head. The two 
 portions are then separated by a screw, and thus the mouth is 
 opened to the full extent. At the same time the tongue is de- 
 pressed by a tongue-plate, and this gives the operator a full 
 view of the fauces. 
 
 Some surgeons detach the mucosa from the hard palate, in a 
 direction from the alveolar ridge towards the margins of the 
 fissure, so as to relax the tissues and allow them to come 
 together ; and some have stripped off the periosteum in a similar 
 manner in the hope that it might cause the fissure to be closed 
 by new bone. 
 
 ACUTE INFIiAniniATION- OF THE TOlTSIXi 
 
 (Tonsillitis, cynancTie tonsillaris, quinsy) is attended by urgent 
 symptoms, and a high degree of fever. There is rapid swelling, 
 with pain which extends over the side of the face and neck. 
 Usually one tonsil is solely or chiefly affected. If both are in- 
 volved, swallowing becomes difficult, speech is thick and indistinct, 
 and breathing is somewhat impeded. 
 
 The treatment should be active, and a brisk purgative should 
 be given, to be followed by a saline mixture. Locally, the 
 throat should be well steanned ; and leeches, mustard poultices, 
 or fomentations applied externally. In some parts of the 
 country there is a popular notion that a poultice made of quinces 
 is a cure for the disease. Hence they call that fruit the " quinsy- 
 apple." No doubt the belief has arisen from the similarity of 
 the names, though the etymological derivation of the words is 
 quite different ; and the efficacy of the remedy does not consist 
 in the particular fruit, but in the warmth and moisture of the 
 application. Much relief may sometimes be given by scarifying 
 the part so as to facilitate the pointing and escape of pus. 
 Tanner remarks that those cases generally do best which are not 
 opened with the knife. If there is reason to think that matter 
 has formed, and the symptoms are so urgent that the surgeon 
 thinks it necessary to let it out at once, the tonsil should be 
 punctured — the point of the knife being directed towards the 
 middle line of the body. 
 
 CHROXrXC ESriiARGEMEM'T OF THE TOIUSIIi 
 
 is usually tlie result of repeated subacute attacks of tonsillitis, but 
 sometimes it is brought about by a slow and chronic inflammation. 
 The latter is often the case in young persons of a scrofulous habit. 
 
STRICTURE OF THE (ESOPHAGUS. 263 
 
 The tonsils become enlarged and hardened. There is slight 
 difficulty in swallowing, some indistinctness of articulation, and 
 perhaps deafness. The patient, moreover, is constantly liable to 
 acute attacks of sore throat supervening on the chronic state. 
 
 The treatment consists in improving the general health, more 
 particularly if the patient is young and strumous. Locally, the 
 disease should be treated with gargles of alum or sulpliate of 
 zinc, or painted with a solution of nitrate of silver, or a mixture 
 of tincture of steel and glycerine. If these means are fairly tried 
 and found ineffectual, a portion of the tonsil must be removed. 
 
 EXCISIOM* OF THE TOirSIZi. 
 
 Though several ingenious instruments under the name of 
 tonsil-guillotines have been devised, I believe the method so tersely 
 described by Celsus, hamulo excipere et scalpello excidere, has 
 never been superseded, . and that the best way of performing 
 this operation is with a long hooked forceps and a blunt- 
 pointed bistoury. The blade of the knife should be wrapped 
 round with a strip of plaster or lint, so as to leave only about an 
 inch at the end exposed. The tonsil is seized with the forceps, 
 and drawn gently forwards and inwards towards the middle line. 
 Tlie bistoury is then introduced under it, and a slice is taken off, 
 cutting from below upwards. In excising the right tonsil, the 
 surgeon may find it convenient to stand behind his patient. A 
 pair of curved, blunt-pointed scissors, or the wire ecraseur, may 
 sometimes be used with advantage instead of the knife. The 
 bleeding is generally stopped without difficulty by washing out 
 the mouth with cold water. The cicatrization and contraction, 
 which follow the removal of even a small slice of the tonsil, 
 generally produce the desired effect. If need be, the operation 
 may be perfurmed upon both tonsils at the same time. 
 
 STRICTURE OF THE CESOPHAGVS 
 
 may be either spasmodic and temporary, or organic and perma- 
 nent. 
 
 Spasmodic stricture is generally met with in nervous and 
 hysterical young women. 
 
 The treatment should consist in re-assuring the patient and 
 strengthening the constitution by those general remedies which 
 have been described in speaking of hysteria (see p. 93). Any 
 local measures that may be adopted should be of the mildest 
 kind, such as may satisfy the patient, without directing too much 
 attention to the part. 
 
 Organic stricture may be either simple or malignant. 
 
 Simple stricture may be the result of spontaneous infiamma- 
 
264 DISEASES OF TISSUES AND ORGANS. 
 
 tion, or of syphilitic ulceration, or of injury sustained by swallow- 
 ing strong acids, alkalies, boiling fluids, &c. Such strictures 
 have a fibrous texture, and are prone, in the course of time, to 
 assume the characters of epithelioma. 
 
 Malignant stricture is caused by the presence of a cancerous 
 tumour in the substance of the oesophagus, or in its immediate 
 neighbourhood. 
 
 Symptoms. — There is diflSculty in swallowing solid food. This 
 difficulty is permanent, goes on gradually increasing, and is 
 evidently not dependent upon pressure upon the oesophagus from 
 without. There is pain in the neck and shoulders, and retching, 
 with regurgitation of food. 
 
 The most common seat of stricture is at the junction of the 
 pharynx and oesophagus, opposite the cricoid cartilage. Various 
 morbid conditions external to the oesophagus, such as aneurysms 
 and intra-thoracic tumours, may need to be carefully distinguished 
 from stricture. 
 
 The treatment of organic stricture consists in passing oesophagus- 
 bougies, so as to dilate the passage and keep it open. In spite 
 of this, the disease will probably get gradually worse, until at 
 length it will become impossible to pass even the smallest gum 
 catheter. The patient may then be kept alive for a few days or 
 weeks by nutritive enemata, or by the performance of gastrotomy j 
 but death by starvation is inevitable. 
 
 In stricture of the oesophagus, in wounds of the throat, in 
 cancer of the pharynx and tongue, it is often necessary to feed the 
 patient by means of the stomach-pump. 
 
 Use of the stomach-pump. — The patient should be seated in a 
 chair with his head thrown back, and his mouth open. The tube 
 of the stomach-pump should be oiled, and slightly curved at the 
 end- It should then be introduced into the mouth, and directed 
 down the pharynx ; at the same time the patient's head should be 
 gently bent forwards, so as to throw the cervical and dorsal 
 vertebrae into one equal curve. The tube should then be pushed 
 on steadily into the stomach. The chief dangers are lest the 
 point should pass into the larynx, or the coats of the stomach be 
 injured. If the patient is insensible or lunatic, the wooden 
 gag must be placed between his teeth to keep the mouth open. 
 
 If our object in using the pump is to remove noxious matters 
 from the stomach, warm water should be injected each time that 
 suction is made, care being taken to inject always rather more 
 than is withdrawn. It is in cases of alcoholic or narcotic poison- 
 ing that the pump is generally used to empty the stomach. 
 
265 
 
 FOREZGir BODIES ZK THE PHABVZTX 
 
 may destroy life in two ways — either by pressing on the glottis, 
 and thus causing spasm and suffocation ; or by leading to ulcera- 
 tion and perforation of the walls of the pharynx. 
 
 Treatment. — The sutgeon should explore the fauces and 
 pharynx with his finger. If anything can be felt, it should be 
 withdrawn with the nail, or seized with a forceps. If nothing 
 can be felt, the long, curved scissor-forceps should be introduced, 
 in the hope of finding the foreign body in tlie lower part of the 
 pharynx ; or an emetic may be given with the view of dislodging 
 it upwards ; or it may be pushed on into the stomach by cautiously 
 passing a bougie. But if it can be avoided, this last plan ought 
 not to be adopted in the case of hard, angular bodies, such as 
 bones, or the plates of artificial teeth. 
 
 FOREIGir BODIES IN" THE X^ARVSTX, TRACHEA, 
 AND BROirCHI. 
 
 Foreign bodies — such as beads, pins, coins, morsels of food, &c. 
 — are sometimes drawn from the mouth into the larynx by a 
 sudden act of inspiration. They may lodge in the rima glottidis, 
 in the ventricles of the larynx, in the trachea, or in the bronchi, 
 more particularly in the right bronchus. 
 
 When the rima glottidis is obstructed, the patient is seized with 
 a sudden difficulty in breathing, his face becomes livid and 
 swollen, and he speedily falls down insensible and moribund. 
 
 When the foreign body is situated either in the folds of the 
 larynx, or in the trachea, or in the bronchi, the leading symptom 
 is violent, suffocative, spasmodic cough. When in the bronchi, 
 this cough comes on at intervals; when in the larynx, it is almost 
 constant. By the laryngoscope, or by auscultation and percussion, 
 the position of the foreign body may sometimes be ascertained with 
 tolerable accuracy. After it has been lodged for some time, it will 
 probably give rise to secondary symptoms of an inflammatory kind. 
 
 Treatment. — When the rima glottidis is obstructed, the treat- 
 ment must be immediate. The trachea should be opened without 
 delay, and a probe passed upwards to dislodge the foreign body ; 
 and, if need be, artificial respiration must be practised. 
 
 When the foreign body is impacted in the ventricles of the 
 larynx, it may perhaps be removed, by the help of the laryngo- 
 scope and a suitable forceps. If it has made its way into the 
 trachea or bronchi, tracheotomy must be performed, and an 
 attempt made to remove it by inverting the patient, or by intro- 
 ducing a long scissor-forceps. 
 
266 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 Fig. 117. 
 
 But it is highly probable that, after all, we shall be unable to 
 dislodge or remove the foreign body. In such a case, it will either 
 become encysted and give no further trouble, or the patient will 
 speedily die, worn out by the irritation and subsequent inflam- 
 mation which it occasions. 
 
 IVRV-XTECK (TORTICOIi]LZS) 
 
 is a disease which consists in a permanently contracted state of 
 the sterno-mastoid muscle of one side. Sometimes the trapezius 
 is involved as well ; and in rare cases both sides are aifected, 
 though in different degrees. The origin of the disease seems to 
 be a faulty condition of the spinal accessory nerve. This appears 
 to be sometimes congenital; but more often it is induced in 
 early life by the irritation of a common cold and swelled face, or 
 of enlarged cervical glands. The head is drawn downwards and 
 sideways, while the face is turned towards the opposite side. 
 
 Treatment. — A bandage, or a mechanical appliance, should be 
 worn, so as to try and draw the head into its proper position. If 
 this produces no effect, the sternal and clavicular attachments of 
 the sterno-mastoid muscle must be subcutaneously divided, and 
 the treatment by bandages and mechani- 
 cal means continued. The subcutaneous 
 division of the attachment of the sterno- 
 mastoid muscle is a delicate operation 
 on account of the important parts which 
 lie behind it. It must, therefore, be 
 undertaken with caution. 
 
 In some instances a portion of the 
 spinal accessory nerve has been excised 
 with a good result. 
 
 Bandage for wry-necTc. — A broad 
 rib-bandage is first applied to the chest, 
 immediately below the armpits. An 
 ordinary roller is then fixed by a few 
 circular horizontal turns round the 
 head, and secured by pins over the 
 temple on the side towards which the 
 surgeon desires to draw the head. The 
 roller is then carried downwards and 
 backwards, and passed under the axilla 
 of the same side, and fastened in front 
 to the rib-bandage, A cushion or pad should be placed in the arm- 
 pit, so as to prevent the roller from irritating the skin (Fig. 117). 
 Dr. Little recommends that, in young subjects, a strip of 
 adhesive plaster should be pasued round the forehead and another 
 
 Bandage for wry-neck. 
 
WOUNDS OF THE THROAT. 
 
 267 
 
 round the waist ; and that then a ribbon should be attached to 
 the plaster immediately above the ear on the unaffected side, 
 carried diagonally across the chest to the opposite side of the 
 waistbantl, and there fastened. 
 
 Such bandages as these are useful not only in cases of spas- 
 modic contraction of the sterno-mastoid muscle, but also in certain 
 operations, and in burns and wounds about the neck. 
 
 -WOVITDS OF THB THROAT 
 
 are generally inflicted with a murderous or suicidal intent. In 
 the latter case the prognosis is particularly unfavourable, on 
 account of the mental condition of the patient. Any part of the 
 throat may be wounded, and the cut may be either superficial or 
 deep. If the larynx or trachea alone is wounded, recovery will 
 probably take place, but if the large vessels have been divided, 
 death will be speedy and inevitable. 
 
 Treatment. — Our first care is to arrest haemorrhage. The 
 wound should be cleaned, coagula removed, and the bleeding 
 stopped by ligatures, pres- 
 sure, or styptics. Our ^^' * 
 next object is to facili- 
 tate breathing by keeping 
 the trachea in position — 
 supposing it to have 
 been wholly or partially 
 divided. The patient 
 should be laid in bed 
 with his head bent for- 
 wards, so as to bring the 
 edges of the wound into 
 apposition. 
 
 In such injuries we 
 endeavour, as far as pos- 
 sible, to adjust the posi- 
 tion of the patient by 
 means of pillows; but 
 if he is refractory, and 
 milder measures fail, we 
 have recourse to the fol- 
 lowing contrivance : — A 
 bandage is first applied 
 
 round the chest, immediately below the armpits. An ordinary 
 double-headed roller is then passed under the chin, carried up on 
 each side of the head, crossed upon the vertex, brought down equally 
 on both sides, and firrnlv fastened in front to the broad bandage 
 
 Baudaare for wounds of uuck. 
 
268 DISEASES OF TISSUES AND OEGANS. 
 
 which encircles the chest. A few horizontal turns may then be 
 made round the forehead, so as to fix the bandage (Fig. 118). 
 Sometimes, before the roller is applied, a nightcap is placed on the 
 patient's head. This is not a necessary part of the bandage, but 
 it serves to make it more secure. By these means the head can 
 be bent upon the chest, and retained at any angle that may be 
 thought proper. No plasters or sutures should be applied to the 
 incision, except when the trachea is completely divided, and it is 
 necessary to preserve its continuity. The wound should be 
 lightly covered with water-dressing. 
 
 If the patient is unruly, and tries to tear open the wound, he 
 must be restrained by a strait-waistcoat. 
 
 When the lary^nx or trachea have been freely opened, or when 
 the oesophagus has been wounded, it may be necessary to feed the 
 patient by means of the stomach-pump. The tube should be 
 introduced through the mouth two or three times a day. 
 
 Every precaution should be taken to prevent inflammation of 
 the larynx or lungs. The patient's throat should be lightly 
 covered with flannel, and he should breathe a warm, moist atmo- 
 sphere of about 80° Fahr, If there are symptoms of bronchitis or 
 pneumonia, sinapisms or turpentine stupes should be applied to 
 the chost, while stimulants and expectorants are administered. 
 
 In every case of " cut-throat" the surgeon should be careful to 
 note down without delay the exact direction, situation, and extent 
 of the wound, together with all the other particulars, as he 
 may have to give evidence in a court of law. 
 
 BROirCHOCEXiE 
 
 (or goitre) is the name given to an hypertrophy of the thyroid 
 gland. Such hypertrophy is simple in its origin, but it may be- 
 come either cystic or malignant. The disease is endemic in some 
 parts of Great Britain — in Derbyshire, for example. But it is in 
 the Alpine valleys that it is most frequently seen, and that it 
 attains its greatest size. The allusion which Juvenal makes to 
 the tumidum guitur is well-known (xiii. 163). In Switzerland and 
 Italy it is often associated with the degraded mental and physical 
 condition to which the term cretinism is applied. In this 
 country it is only seen in its milder forms. 
 
 Bronchocele has been refe^ed to a great variety of causes. 
 Some have thought that it is due to the peculiar waters of the 
 district ; but it is much more probable that the damp and stagnant 
 air of a valley, the want of sunlight, marriages of consanguinity, 
 and the conditions of hardship and privation under which the 
 sufferers too often live, combine to produce the more aggravated 
 c<i£t;s. 
 
BRONCHOCELE. 269 
 
 It is more common in women than in men, and is particularly 
 apt to show itself about the age of puberty. 
 
 The gland enlarges gradually without pain. At first it occa- 
 sions only a slight deformity ; but as it increases, it gives rise to 
 giddiness, headache, and difficulty of breathing and swallowing. 
 If a part only of the gland is enlarged, it may be mistaken for 
 aneurysm of the carotid. In making the diagnosis, it is of great 
 importance to remember that a bronchocele rises and falls with the 
 trachea in the act of deglutition. 
 
 As it grows, cysts may become developed in the tumour, and 
 even attain a considerable size ; or it may undergo a cancerous 
 degeneration. 
 
 Thero is a remarkable prominence of the eyeballs — known as 
 proptosis or exophthalmos — which is frequently associated with 
 goitre. This condition seems to depend upon hypertrophy of the 
 adipose tissue of the orbit, and to arise from a want of tone and 
 strength in the vascular system, for it is invariably ushered in and 
 accompanied by anaemia. Sometimes the protrusion becomes so 
 great that the lids are unable to cover the globes, and the cornea 
 suffers severely from exposure to wind, dust, &c. I have seen a 
 young woman with a well-marked goitre, who had lost both her 
 eyes by suppurative inflammation produced in this way. 
 
 Treatment. — In the case of a simple bronchocele of moderate 
 size and recent growth, it is generally sufficient to place the 
 patient in a pure aii- — if possible, at the seaside — to regulate the 
 health, to apply the tincture of iodine over the tumour, and to 
 give iodide or bromide of potassium internally, with iron, quinine, 
 or other tonics (F. 57, 60, 65, 66). A mixture in equal parts of 
 the ung. hyd. and the ung. iodi. may, as a change, be substituted 
 for the tinct. iodi. ; or the ung. hyd. biniodidi may be occa- 
 sionally and cautiously applied. Dr. Elmslie, who saw a great 
 deal of this disease in Kashmir, recommends that the biniodideof 
 mercury should be employed at the same time both internally and 
 externally (F. 81). In all cases associated with anaemia iron 
 should certainly form part of the treatment (F. 45, 47, 48). 
 
 If these means fail, and the tumour is growing so as to become 
 dangerous to life, setons may be passed through it in various 
 directions ; or the arteries leading to it may be tied ; or the skin 
 may be reflected, and portions of the gland removed with the 
 knife, the ecraseur, or the ligature. But these operations are 
 attended by much risk, in consequence of the haemorrhage which 
 may ensue ; and the benefit that is likely to arise from them is very 
 uncertain. Belief may sometimes be afforded, or dangerous 
 pressure removed, by division of the sterno-mastoid muscles. If 
 cysts have formed, they may be punctured, or tapped and injected 
 
270 DISEASES OF TISSUES AND OEGANS. 
 
 with a solution of iodine, or setons may be passed through them. 
 But, on the whole, the treatment of bronchocele by operative 
 means is very unsatisfactory. 
 
 PARACESTTESIS THORACIS. 
 
 The surgeon is sometimes required to make an opening into the 
 chest in cases of pleurisy and empyema. The operation is called 
 paracentesis thoracis, or tapping the chest. 
 
 The conditions which demand this operation are all attended 
 by somewhat similar symptoms. The chest is dull on percussion, 
 and distended. The ribs are unusually far apart, and appear to 
 be depressed in consequence of the bulging of their interspaces. 
 The patient has difficulty in breathing, and is unable to lie on the 
 affected side. 
 
 Sometimes the fluid which is drawn off is serous — pleuritic 
 effusion {hydrothorax) ; sometimes it is purulent {empyema). 
 
 As a general rule, the space between the fifth and sixth, or the 
 sixth and seventh ribs, and a little in front of the angles, is the 
 most eligible spot for operation. An incision about an inch long 
 should be made through the skin over the lower rib of the inter- 
 space chosen. The skin should then be drawn up* and a trochar 
 and canula thrust sharply into the chest at the lower part of the 
 interspace. The operation is performed in this way to avoid the 
 vessels which lie at the upper part of the interspace, under cover 
 of the superjacent rib. Various instruments have been de- 
 vised for drawing off the fluid without permitting the entrance 
 of air. As soon as the canula has been withdrawn, the skin 
 returns to its original situation and closes the opening. The 
 superficial ineision should be covered with a piece of plaster. The 
 aspirator promises to be very useful in these cases (see Fig. 1). 
 
 If the fluid is serous, the greatest care should be taken to avoid 
 the entrance of air ; but if it is purulent, a free opening and the 
 introduction of a drainage-tube, is probably the best mode of 
 treatment. 
 
 If the pleural cavity is washed out with warm water, or with 
 a medicated fluid, the surgeon should remember that this pro- 
 ceeding, simple as it sounds, has occasionally induced fatal syn- 
 cope. He should, therefore, give a stimulant before he begins, 
 and should proceed in the gentlest possible manner. 
 
 BYPERTROPHV OF THZ! BREAST 
 
 is occasionally met with in pregnant women. In girls it some- 
 times occurs about the age of puberty. One breast may be 
 alfected, or both. The whole gland slowly enlarges. There is 
 no pain, unless it be of an hysterical or neuralgic kind. The 
 
HYPERTROPHY OF THE BREAST. 
 
 271 
 
 tumour feels firm, and is free from tenderness. It may attain 
 an enormous size and weight, so as to be quite a burden. If it is 
 not associated with pregnancy, there is generally some irregu- 
 larity of the menstrual discharge. 
 
 The treatment consists in improving and regulating the general 
 health by ferruginous tonics and a change of air, in giving saline 
 aperients, in rubbing the breast gently with stimulating oint- 
 ments and liniments, and in supporting it with a bandage. As a 
 last resource in extreme cases excision has been practised. 
 William Hay has related the case of a girl, aged fourteen, in 
 whom both breasts were enormously enlarged. He amputated 
 the left breast, and it weighed eleven pounds and four ounces. 
 
 Bandages for the breast. — In some cases the breast may be 
 suflBciently supported by a large handkerchief, folded in the form 
 of a broad cravat, and passed under the affected organ — the 
 ends being brought round, one across the back and the other 
 across the chest, and tied on the opposite shoulder. 
 
 A more efficient bandage, both for supporting and also com- 
 pressing the breast, may be made by taking a piece of calico, 
 about a foot wide and a yard and a half long, and tearing it 
 down the middle from each end to within six or eight inches of 
 the centre. The central portion is applied over the affected 
 organ, and the two lower tails are carried horizontally round the 
 body, one in front and the other behind, and tied at the opposite 
 side. The two upper tails are then tied round the neck, or they 
 may be conducted, one under 
 the axilla of the affected side 
 and the other over the op- 
 posite shoulder, and fastened 
 behind. 
 
 Again, one or both breasts 
 may be bandaged by means 
 of an ordinary roller. In this 
 case the roller ought to be 
 of full length, and at least as 
 wide as a " leg-bandage." 
 
 When one breast only has 
 to be bandaged, tlie surgeon 
 begins by taking a turn round 
 the body so as to fix the end 
 of the roller. He then con- 
 ducts it obliquely from below 
 upwards across the lower margin of the affected breast, over 
 the opposite shoulder, and so round to the point from which he 
 started. He then makes a circular turn round the body, to fix 
 
 Bandage for one breast. 
 
272 
 
 DISEASES OF TISSUES AND OUaANS. 
 
 the oblique one and prevent it from slipping ] after which he 
 carries the bandage for the second time obliquely across the 
 chest, rising a little higher than before, and covering a little 
 more of the breast than he did with the first fold. He then 
 makes another circular turn round the body to fix the second 
 oblique fold, and then a third oblique one, and so on until a 
 sufficient number of turns have been applied to support or com- 
 press the breast, according to the purpose for which the bandage 
 is employed (Fig. 119). Or the oblique turns may be placed 
 
 immediately over one an- 
 £ ig. 12 U. other, and secured by pins, 
 
 or by stitches; omitting 
 all the circular turns round 
 the body except the first, 
 which is necessary to secure 
 the commencement. 
 
 When both breasts have 
 to be bandaged the surgeon 
 fixes the roller, and makes 
 his first oblique turn, 
 exactly as ii» the foregoing 
 case. But his second 
 oblique turn he makes 
 from above downwards over 
 the other breast, and thus 
 he goes on, carrying the 
 oblique turns first over 
 one breast, and then over the other, until he has afforded the 
 required amount of support to both (Fig. 120). 
 
 ILCTJTJi IIO'FIi.A.MMATIOir OF THE BREAST. 
 
 The breast is liable to be acutely inflamed from blows and other 
 external injuries, but it still more often becomes affected spon- 
 taneously during lactation. The inflammation may take place 
 either in the subcutaneous cellular tissue, or in the substance of 
 the gland, or in the cellular plane which is interposed between 
 it and the pectoral muscles. It often happens that these 
 different parts are all simultaneously or consecutively affected. 
 
 The symptoms of " milk abscess " are well marked. There is 
 a high degree of pyrexia. The breast is swollen, hard, hot, red, 
 painful, and exquisitely tender to the touch. 
 
 Treatment. — ^The constitutional treatment should be mildly 
 antiphlofjistic. Tlie breast should be well supported with a 
 bandage or handkerchit-f. If the patient is robust, and the 
 inHamrnaticm very acute, leeches should be applied. In all cases 
 
 Bandage for both breasts. 
 
ACUTE INFLAMMATION OF THE BEEAST. 273 
 
 poultices or fomentations must be constantly used ; and when re- 
 solution has begun to take place, the gland should be gently 
 rubbed with some simple ointment or liniment. 
 
 The secretion of milk is generally stopped ; if, however, it 
 continues, a large belladonna plaster should be laid over the 
 breast j and the child should only be allowed to suck the sound 
 breast. If the inflamed breast becomes painfully distended, the 
 milk must be drawn off" by means of a breast-pump. 
 
 If suppuration occurs, the matter should be let out as soon as 
 fluctuation can be detected. The opening should be made at the 
 most dependent point. If the matter burrows, a counter-open- 
 ing will be required, and in such a case a small drainage-tube may 
 sometimes be introduced with great advantage. If sinuses re- 
 main, they should be dressed with stimulating lotions, and their 
 sides kept at rest, and in apposition, by equable pressure. This 
 may sometimes be effected by bandaging the breast in the 
 manner already described, or by covering the sinuses with pads 
 of lint and strapping the breast with strips of plaster. 
 
 Strapping the breast. — When our object is merely to support 
 the breast, the strapping may be applied in the following man- 
 ner : — The surgeon takes a sufficient number of strips of adhesive 
 plaster, about an inch and a half broad, and long enough to pass 
 over the breast and obtain a firm purchase at both sides. He 
 then proceeds to apply the strips in regular order, laying the first 
 on the patient's side, bringing it up under the breast, and carrj - 
 ing it towards the opposite shoulder. The others he then applies 
 one above the other, until he 
 has placed a sufficient number 
 to effect the object he has in 
 view (Fig. 121). 
 
 When the strapping is used 
 to compress the breast, it is 
 better to lay the alternate strips 
 of plaster crosswise. When the 
 whole organ has been covered 
 in this way, it may be necessary 
 to stretch a few pieces of plaster 
 in various directions, wherever 
 there is a chink through which 
 the skin can protrude, or where 
 the part seems to require 
 additional pressure. 
 
 " Milk abscess " is generally associated with an exhausted and 
 debilitated state of health. As soon, therefore, as suppuration has 
 taken place, all lowering measures should be abandoned, and the 
 
 Fig. 121. 
 
 Strapping the breast. 
 
274 DISEASES OF TISSUES AND OEGANS. 
 
 patient should have a nutritious diet, with a moderate allowance 
 of stimulants. At the same time she should take the mineral 
 acids and bark, or other strengthening medicines (F. 30, 31, 32). 
 
 THE CHRONIC V/lATi/lT/tAJfY OR ADENOID 
 TUMOUR 
 
 is not unfrequently met with, and may easily be mistaken for 
 a malignant growth. It generally occurs in young women under 
 thirty, who are otherwise in good health ; and it may often be 
 traced to some local source of irritation, such as a blow. A portion 
 of the gland, generally at the circumference, enlarges : there is 
 a partial hypertrophy. A tumour is formed which is hard, 
 lobulated, and moveable. It is usually free from pain or tender- 
 ness. Sometimes it feels nodulated, like a bunch of grapes. 
 Along with the enlargement of the gland-structure, the fibrous 
 septa become hypertrophied, and it is very common to find cysts 
 developed in the tumour, either from the areolar interspaces, or 
 from obstruction of the milk-ducts (sero-cystic tumour). The 
 chronic mammary tumour is distinguished by the following 
 characters : — It does not affect the axillary glands. It does not 
 implicate the skin. It does not impair the general health. It 
 may remain stationary for years, and then gradually disappear ; 
 or, after a long period of quiescence, it may suddenly begin to 
 increase rapidly in size. 
 
 Its minute structure consists of the gland tissue greatly hyper- 
 trophied, mixed with fibrous and areolar tissue. 
 
 The treatment consists in regulating tlie general health, and 
 endeavouring to bring about absorption by internal remedies, 
 such as bromide or iodide of potassium (F. 57, 58, 60), or corrosive 
 sublimate (F. 49, 50) ; or by external applications, such as iodine 
 tincture, or by pressure applied by strapping the breast in the 
 manner above described either with common diachylon, or the 
 emp. belladonnse, or the emp. aramoniaci c. hydrargyro. If there 
 is neuralgic pain, anodyne liniments should be used, and sedatives 
 or narcotics given internally. If there are occasional attacks of 
 inflammation, a few leeches will be found beneficial. If the 
 tumour is growing rapidly, and threatening to ulcerate, it should 
 be excised. In doing so, it is not necessary to remove the whole 
 gland, but only that portion of it which is diseased. 
 
 MAIiIGNiiia-T TUMOURS OF THE BREAST. 
 
 Besides the tumours of which we have already spoken, the 
 breast is sometimes the seat of morbid growths of a fatty, fibrous, 
 Sarcomatous, or syphilitic kind. But by far the greater number 
 of tumours in this situation belong to the carcinomatous class. 
 
MALIGNANT TUMOURS OF THE BEEAST. 275 
 
 They are chiefly of the scirrhous and medullary varieties. The 
 disease is always primary, and is generally confined to one breast. 
 Sometimes it occurs as an infiltration, but more often as a cir- 
 cumscribed tumour. 
 
 Scirrhus is remarkably common in the breast between the ages 
 of forty and fifty — that is, at the " change of life." 
 
 It begins as a small, 
 hard tumour near the Fig. 122, 
 
 centre of the gland. At 
 first it is moveable, but 
 soon it becomes adherent 
 to the skin in front and to 
 the pectoral muscle behind 
 (Fig. 122). The nipple 
 is retracted. There is pain 
 of a darting character. The 
 axillary glands become en- 
 larged. The skin ulcerates, 
 and an oflensive, exhausting 
 discharge commences. 
 
 Along with this the 
 general health usually 
 sufiers much. The system 
 is deeply affected by the 
 local disease, constituting 
 what is sometimes called 
 the cancerous cachexia. 
 The growth of a scirrhous 
 tumour of the breast is 
 
 slow, but sure. According to Sir James Paget it tends to destroy 
 life in an average period of about four years. Sometimes the 
 disease runs its whole course in a few months ; sometimes it exists 
 for tw^enty years. As a general rule, the younger the patient the 
 more unfavourable is the prognosis. 
 
 Medullar ij cancer, as a primary aflPection, is less common than 
 scirrhus ; though as a secondary growth, it is often met with 
 after extirpation of a hard cancer .^^^ It occurs at an earlier age 
 than scirrhus, grows rapidly, and^Ron forms a large, smooth, 
 elastic tumour with dilated veins coursing over it. As it in- 
 creases the axillary glands become afiected ; it attaches itself to 
 the subjacent muscles ; the skin becomes purple and ulcerates, 
 and the morbid growth protrudes in fungous masses. It does not 
 infect the system so deeply as scii-rhus, nor does it produce the 
 same degree of prostration. The constitutional effect is not in 
 proportion to the local manifestation of the disease. When 
 
 T 2 
 
 Malignant tumom- of the breast. 
 
276 DISEASES OF TISSUES AND OEGANS. 
 
 malignant disease occurs as a diffused infiltration of the tissues, it 
 belongs to this variety. The prognosis in such cases is very 
 unfavourable. I have known an instance which ran its whole 
 course in seven weeks : the patient was a woman aged forty. 
 
 The male breast is sometimes, though very rarely, the seat of a 
 malignant tumour. It is usually scirrhus. 
 
 The treatment of malignant tumours of the breast is unsatis- 
 factory. Constitutional reiuedies are of no curative value. They 
 are of much use in improving the state of the patient's health, 
 and enabling her to withstand the violence of the disease ; but 
 beyond this they are powerless. Neither can we boast of having 
 any local means of effecting a certain cure. Entire removal, which 
 holds out the best hope, seldom does more than relieve the more 
 urgent symptoms, and prolong life for a few months or years. And 
 there are many cases to which even this remedy is inapplicable. 
 For example, when the skin is brawny over a large extent, when the 
 general health is seriously impaired, when there is reason to think 
 that internal organs are secondarily affected, when the tumour is 
 widely adherent, or very much ulcerated, when both breasts are 
 diseased, or when the glands under or above the clavicle are 
 enlarged — in all these cases an operation is forbidden. On the 
 other hand, when the tumour is of moderate size, moveable, and 
 growing slowly, when the axillary glands are unaffected, and the 
 patient's health is not yet impaired, the results of an operation 
 will probably be good. If a scirrhous cancer shows itself rather 
 late in life, say after the age of fifty-five, and progresses but 
 slowly, it may be a question whether an operation ought to be 
 recommended. To know exactly when to interfere in a case 
 of this kind is a difiicult practical point. Again, should an 
 operation be undertaken if the patient is pregnant ? This is a 
 question of some difficulty. As a general rule, we may say 
 that if she has not yet " quickened," an operation may be per- 
 formed ; but if she has felt the movements of the child, the 
 surgeon had better not interfere. In either case, the prognosis is 
 unfavourable, because of the active nutritive changes that go on 
 in the breast during pregnancy. 
 
 Small tubercles of cancer may be removed either by the knife 
 or by caustic; 80 also may the chronic superficial sores and 
 cracked nipples, which not unfrequently give rise to cancer in the 
 subjacent gland. 
 
 Equable pressure has occasionally been found to be of great 
 service in allaying pain, and sometimes even in arresting 
 growth. 
 
 Under any circumstances, pending an operation, or if an opera- 
 tion is forbidden, the breast should be treated with anodyne 
 
PAEACENTESIS ABDOMINIS. 277 
 
 lotions and ointments ; and, if ulceration has taken place, poultices, 
 either plain or medicated, should be applied. 
 
 If the patient declines a cutting operation, the growth may 
 sometimes be removed by caustics — either spread on the surface, 
 in the form of a paste, or inti'oduced into or beneath the tumour 
 in the shape of " caustic arrows.'^ When caustic is to be applied, 
 the surgeon should take a piece of thick leather plaster, cut in it 
 a hole of the size of the desired slough, lay it in the proper 
 situation, and then fill the aperture with the caustic. The 
 " Vienna paste," of which the basis is potash and lime, is one 
 of the best. A few years ago " Fell's paste," made of chloride 
 of zinc, was much in vogue. 
 
 EXCISION- OF THE BREAST 
 
 is performed by making two curved incisions including an elliptical 
 portion of skin, of which the nipple is the centre. The amount 
 of skin removed must depend upon the extent to which it is in- 
 volved in the disease. All that is affected should be taken away, 
 but no more. The integument should be dissected back, so as to 
 expose the whole anterior aspect of the tumour. The growth 
 should be lifted from its cellular bed, and the dissection carried on 
 under it, beginning from above and proceeding downwards. If 
 there are any enlarged glands in the neighbourhood of the tumour, 
 they should be removed at the same time. The bleeding points 
 should be ligatured, or secured by torsion, and the edges of the 
 incision must be carefully united by sutures. A large flat pad of 
 folded lint should then be placed over the seat of operation, and 
 retained by a bandage. 
 
 In operating upon a cancerous breast, some surgeons take away 
 all that is affected, but no more; others think that, however 
 limited may be the disease, the whole gland should be removed. 
 This is probably the safer course. 
 
 FARACEITTESIS ABBOMIM-IS. 
 
 The belly has sometimes to be tapped for ascites, or for ovarian 
 dropsy. In such cases the abdomen is much distended, and there 
 is distinct fluctuation. The patient's breathing is embarrassed, 
 and the general health suffers. Care must be taken not to mis- 
 take a gravid uterus, with an unusual amount of liquor amnii, for 
 an ovarian cyst or for ascites. 
 
 When the surgeon is called upon to tap the abdomen, he should 
 provide himself with a roller about eighteen inches broad, and 
 long enough to go once and a half round the patient's body. 
 Such a binder may most conveniently be made by folding an 
 ordinary bed-sheet. When the operation is about to be performed 
 
278 DISEASES OF TISSUES AND ORGANS. 
 
 the patient should be brought to the edge of the bed, and directed 
 to lie upon his back or side, as may be most convenient ; and 
 then the roller should be passed under him, so that its central 
 portion may be directly beneath the abdomen. The surgeon then 
 folds the ends of the binder across the front of the patient's 
 body, and gives one to each of his assistants, who stand at the 
 opposite sides of the bed, and are prepared to draw gently, but 
 steadily, upon the bandage, so as to support the abdomen as the fluid 
 escapes. An incision, an inch long, is then made through the in- 
 teguments in the middle line of the body, and three or four inches 
 below the umbilicus. Through this a trochar and canula is 
 pushed into the cavity. If the patient feels faint, the flow of 
 liquid may be stopped for a time, and a cordial administered. 
 After the fluid has been evacuated, the pressure should be kept 
 up, while the opening made by the trochar is closed with adhesive 
 plaster and a pad of lint. Then the ends of the binder should 
 be folded round the patient's body, and firmly pinned in that 
 situation. 
 
 OVARZAIO- DISEASE. 
 
 The ovary is often affected by morbid growths. These are 
 either malignant or fibrous, and are commonly associated with 
 cystic formations {cystic disease of the ovary, ovarian dropsy). 
 These cysts appear generally to originate in the Graafian vesicles 
 of the ovary, but sometimes they are developed in the broad 
 ligament. They may bo single or multiple ; the tumour may 
 be unilocular or multilocular. The contents of the cysts vary 
 extremely. They may be either solid or fluid. The fluid is usually 
 thick, viscid, albuminous, and of a brownish or greenish colour. 
 
 Ovarian tumours sometimes remain stationary for a length of 
 time, but much more commonly they go on increasing until they 
 prove fatal by exhaustion, or by interfering with the action of the 
 viscera. 
 
 Treatment. — Little or notliing can be done by medical means. 
 If the case is otherwise suitable, the tumour may be simply 
 tapped, or tapped and injected with iodine. But it is not often 
 that these means are employed at the present day. If the 
 symptoms are urgent, the question of ovariotomy must be enter- 
 tained. The cases which are the most favourable for this opera- 
 tion are those in which there is but little solid matter, where 
 there is a pedicle of some length, where there are no adhesions, 
 and where the patient's general health has not yet begun to suffer. 
 But, unfortunately, the character of the tumour and its con- 
 nections are points which it is often difficult, or impossible, to 
 ascertain beforehand with accuracy. 
 
PENETRATING WOUNDS OF THE ABDOMEN. 279 
 
 Ovariotomy. — An incision, three or four inches in length, is 
 made through the linea alba, between the umbilicus and the 
 pubes, and carried carefully down to the tumour. The hand 
 should then be introduced through the opening to explore the 
 surface of the tumour, and to ascertain if there are many ad- 
 hesions. If there are none, and the tumour consists of a single 
 cyst, it may be tapped, and withdrawn through the aperture. 
 If there are several cysts, they must be tapped one after another, 
 and the whole withdrawn. If, on the other hand, there are 
 adhesions, or if the growth is solid, the incision will have to be 
 enlarged, the adhesions torn asunder or carefully divided, and the 
 tumour separated from its attachment. The pedicle may either 
 be drawn forward, and fixed in the wound by a clamp, or else 
 ligatured, and left in the abdominal cavity — the ligature being 
 either cut otf short, or allowed to protrude through the incision. 
 When the pedicle is long, the clamp answers well. When it is 
 short, probably " tying and dropping" is the best course. The 
 noose of ligature, whether it be animal or vegetable tissue, be- 
 comes imbedded and absorbed, and gives surprisingly little 
 trouble. The wound in the abdominal parietes should then be 
 brought together throughout its whole depth by quilled sutures, 
 and the skin united by a continuous suture. The abdomen must 
 be supported by a bandage, or by broad strips of plaster. 
 
 The after treatment must be conducted with the utmost care 
 and vigilance. The chief dangers to be apprehended are 
 secondary hajmorrhagc, peritonitis, and general exhaustion. 
 
 The superficial wound is then closed with sutures, and a ban- 
 dage applied round the abdomen. 
 
 PENETRATXXG "WOUNDS OF THE ABDOMEIT 
 
 are always attended with danger, and require to be carefully 
 watched. If any of the viscera are wounded, the shock will 
 probably be great. The patient falls into a state of collapse, 
 w4iich is so far favourable that it facilitates the natural lisemo- 
 static processes. The surgeon should not, therefore, be in a 
 hurry to bring about reaction. If one of the large arteries is 
 divided, or if the liver or spleen is wounded, there will be danger 
 of fatal haemorrhage. If there is extravasation of bile or of 
 urine, peritonitis is inevitable. If the intestines are injured, 
 there will probably be hsematemesis, or melsena. If the kidneys 
 are wounded, there will be blood in the urine — hsematuria. 
 
 Treatment. — The most perfect rest and quietness should be 
 enforced. Opium should be given freely. The diet should be 
 strictly limited, and confined to food which is readily absorbed by 
 the stomach. If inflammation threatens, calomel should be com- 
 
280 DISEASES OF TISSUES AND OEGANS. 
 
 bined with the opium (F. 82). Blood should be drawn by the 
 lancet or by leeches. Fomentations or water-dressing should be 
 applied to the abdomen. Purgatives must not be given. If 
 need be, and the circumstances of the case permit, an enema may 
 be administered from time to time. 
 
 If the bowel protrudes, it should be gently replaced. If it is 
 wounded, and the wound is a mere puncture, nothing need be 
 done ; the mucous lining will bulge and close the aperture. If it 
 is slit up, the incision should be accurately brought together by 
 the glover's suture, using a fine catgut or hempen thread. If it 
 is so extensively wounded that there is no chance of union, 
 it should be stitched to the margin of the superficial woiind, so 
 as to form an artificial anus. In cases of this kind the displace- 
 ment is often not so great as we should have expected. The 
 contents of the abdomen, by the even pressure they exert, do 
 something to prevent extravasation. Moreover the peritoneum 
 pours out lymph freely, and repairs the damage that has been 
 done. But whenever the abdominal walls have been wounded, 
 it is probable that a hernia will afterwards occur at the seat of 
 injury. The patient should be warned of this when he begins to 
 move about, and supplied with a suitable bandage or truss. 
 
 Injuries of this nature are very apt to be followed by peri- 
 tonitis. 
 
 PERITOirZTZS 
 
 may arise spontaneously ; but in surgical practice it often occurs 
 after wounds of the abdomen or operations upon the abdominal 
 organs. 
 
 The sym'ptoms of such an attack are these : — The patient lies 
 on his back, and relaxes his abdominal muscles by drawing up his 
 knees. His breathing is chiefly thoracic. He scarcely ventures 
 to move his diaphragm or abdominal muscles. His features are 
 pinched ; his expression is anxious ; the pulse is small, hard, and 
 quick J the temperature raised ; the tongue is dry, and the 
 mouth is parched. There is frequent vomiting j the belly is 
 exquisitely tender, and the bowels are constipated. 
 
 Treatment. — Perfect rest and quietness must be secured. 
 Opium should be given in full doses, combined, if the surgeon 
 thinks fit, with calomel (F. 53, 82). Effervescing salines should 
 be prescribed (F. 35, 68). Small pieces of ice should be given 
 frequently, to allay sickness and to moisten the mouth. Fomenta- 
 tions should be applied ; and, in some cases, if the patient 
 is young and plethoric, a dozen leeches may be placed on 
 the abdomen ; while enemata are administered occasionally, as 
 the occasion requires. 
 
281 
 
 ZNTTESTIUAIi OBSTRUCTION'S. 
 
 These may be either acute or chronic, and this distinction is 
 of great practical importance. 
 
 The free passage through the bowels may be acutely ob- 
 structed (1) by an internal hernia, a knuckle of the intestine slip- 
 ping through a hole in the mesentery or omentum, or becoming 
 constricted by a fibrinous band ; (2) by intussusception — i.e., by 
 the upper portion of the bowel, at some given point, slipping 
 within the lower portion; (3) by a volvulus, the bowel being 
 twisted on itself ; (4) by inflammation of the intestines. 
 
 Symptoms of acute obstruction. — In many instances the 
 patient is seized with sharp local pain, and is aware that some- 
 thing has gone wrong. With this there is nervous shock and 
 depression. The bowels' may act slightly, the irritation causing 
 them to rid themselves of any accumulation there may be below 
 the point of disease ; but, after that, there is complete constipa- 
 tion. Soon there is vomiting ; and ere long the vomited matters 
 become stercoraceous. The belly is distended, the distension 
 being sometimes markedly more in one part than in another. 
 Sometimes the intestines can be seen working under the skin, 
 and these movements are attended by loud gurgling noises. In 
 some cases of intussusception an elongated tumour may be dis- 
 tinctly felt, and blood and mucus escape by the anus. 
 
 Chronic intestinal obstruction is usually the result of (1) habi- 
 tual constipation, the impaction of faeces becoming so great as 
 to block the passage altogether ; (2) malignant disease of the 
 bowels ; (3) tumours of various kinds pressing upon the bowel 
 from outside. 
 
 Symptoms of chronic obstruction. — Constipation gradually 
 increasing till it becomes complete ; retching ; vomiting, perhaps 
 of stercoraceous matters ; tympanitic distension of the bowels ; 
 exhaustion. 
 
 To make an exact diagnosis of the cause of the obstruction is 
 often a matter of great difficulty. The surgeon should be care- 
 ful to see that there is no external hernia. Especially he should 
 look for the rarer kinds of hernia, such as the obturator. 
 
 The treatment must vary with the cause of the obstruction. 
 If there is reason to think that it depends upon inflammation of 
 the bowels, medical means may suffice for its relief. Calomel 
 and opium should be prescribed, and fomentations applied. If 
 the obstruction depends upon intussusception or volvulus, the 
 surgeon may be fortunate enough to remedy it by inflation — i.e., 
 by slowly distending the bowels with air by means of a suitable 
 
282 DISEASES OF TISSUES AND OEGANS. 
 
 pair of bellows. If these measures fail, or if the obstruction de- 
 pends upon an internal hernia or a constricting band, the 
 patient's only hope lies in an operation. If the obstruction is 
 in the colon, colotomy (Calissen's or Amussat's operation) must 
 be performed. If the obstruction is situated in the small intes- 
 tines, gastrotomy (abdominal section) will be required. 
 
 Colotomy consists in opening the colon either in the right or 
 left loin. The surgeon defines the outer border of the quadratus 
 lumborum muscle, for this line indicates, with tolerable exacti- 
 tude, the situation of the colon. He then makes an incision 
 four or five inches long, beginning near the spine and passing 
 obliquely downwards and forwards, parallel to the crest of the 
 ilium. The tissues must be divided cautiously, the transversalis 
 fascia being slit up on a director : the bowel is here uncovered by 
 peritoneum. Sometimes, when it is distended, it presents itself 
 to view at once; sometimes it needs to be sought for carefully. 
 When it is found, it should be drawn gently forward, two double 
 threads passed through it, and then, when it is securely held, 
 an opening made in it. Sometimes a gush of fsecal matter 
 takes place ; sometimes little or nothing escapes at the time. 
 Before the operation is concluded the edges of the aperture 
 must be stitched to the integument. 
 
 Gastrotomy consists in opening the peritoneal cavity, in order 
 to search for the cause of obstruction. If there is an obvious 
 tumour, as sometimes happens in cases of intussusception, the 
 surgeon should be guided by it in making his incision. But if 
 there is no such indication, he should make his incisions down the 
 linea alba, divide the tissues w^ith caution, slit up the peri- 
 toneum on a director, and then trace the bowel in a systematic 
 manner, either upwards or downwards, till he comes to the ob- 
 struction. The diflSculties of this operation are often increased 
 by the protrusion of the intestines. The surgeon should, there- 
 fore, be careful to have them held back by assistants. When 
 the operation has been concluded, the edges of the wound should 
 be brought together with stitches, and the belly supported by 
 strips of plaster or a bandage. 
 
 Mr, Bellamy has lately reported to the Clinical Society a case 
 in which the obstruction was of a most unusual kind. A por- 
 tion of small intestine had become invaginated in the anterior 
 wall of the rectum, apparently separating its muscular fibres, 
 and pushing the rectal mucous membrane before it. It completely 
 obstructed the lumen of the rectum. All attempts to dislodge it 
 by the rectum were useless, so Mr. Bellamy opened the ab- 
 dominal cavity and withdrew the invaginated gut. {Brit. Med. 
 Jour., March 8, 1879.) 
 
283 
 
 ARTZFXCIAI. AITVS 
 
 signifies an unnatural opening into the intestinal canal for the 
 discharge of faeces. It may be made by the surgeon, or it may 
 be the result of a wound, of an abscess, of ulceration, or of the 
 sloughing of a strangulated hernia. When the communication 
 with the bowel is but slight, and the contents merely ooze out, it 
 is called a " faecal fistula."' 
 
 When the artificial anus is in the upper part of the small 
 intestine, life can only be prolonged for a time. The patient 
 must gradually die of starvation by escape of the chyle. But 
 when the aperture is in the large intestine, it is compatible with 
 a fair share of health, though it must always be a source of great 
 discomfort. 
 
 Treatment. — In all affections of this kind the patient's strength 
 must be supported, the wound kept very clean, and the margins 
 smeared with simple ointment or vaseline to prevent excoria- 
 tion. A fa3cal fistula will probably close of itself, and heal over. 
 If the case is one of artificial anus, and the bowel is pervious, 
 an attempt may be made to unite the edges of the wound. It 
 generally happens, however, that after the artificial anus has existed 
 for a short time, the lower and unused part of the gut becomes 
 contracted. Moreover, the wall of the bowel opposite the aper- 
 ture protrudes, and forms a septum, dividing the part which is 
 traversed by the faeces from the part that is not. This is one 
 great obstacle to re-establishing the natural channel. Dupuytren 
 proposed to get rid of the septum by compressing it between the 
 blades of a forceps until it sloughed away; after which an attempt 
 might be made to close the supei-ficial wound. 
 
 HERiriA 
 
 signifies a protrusion of the contents of one of the natural cavi- 
 ties. Thus we speak of hernia of the brain, of the lung, and of 
 the intestines. But when the term stands alone it is taken to 
 mean the protrusion of a portion of the intestines through the 
 walls of the abdominal cavity (rupture) ; such protrusions being 
 by far the most common hernise that are met with in adult life. 
 Hernise are variously classified. If we look to the seat of the 
 protrusion, we speak of inguinal, femoral, umbilical, dia'phrag- 
 matic, and obturator hernia. If we consider their pathology, 
 we describe them as reducible, irreducible, incarcerated, or 
 strangulated. According to their anatomical relations, they are 
 divided into congenital and infantile; and according to their 
 contents, into enterocele, epijplocele, &c. 
 
284 DISEASES OF TISSUES AND ORaANS. 
 
 Sernia cerebri has been explained in speaking of wounds of 
 the brain, and diaphragmatic and obturator hernise are of such 
 rare occurrence that I need not do more than mention them. 
 
 Predisposing causes of abdominal hernia. — Whatever tends 
 to weaken the abdominal walls — e.g., congenital deficiency of 
 muscular or tendinous structures, penetrating wounds, or abscess 
 in the parietes — predisposes to hernia. 
 
 Exciting causes. — Among the exciting causes of hernia may 
 be mentioned whatever makes pressure upon the weakened part 
 of the parietes, as excessive crying in infants, coughing, strain- 
 ing at stool or in micturition, violent exertion, riding, leaping, &c. 
 
 The coverings of a hernia differ with its precise situation. In 
 almost all cases it has a sac, formed by the parietal layer of peri- 
 toneum, which it carries before it. The cases in which there is 
 no sac are rare. They are the hernige which follow penetrating 
 wounds, and the protrusions of those viscera which are only par- 
 tially covered by peritoneum. With these exceptions, every 
 hernia is invested by a sac of peritoneum. That part of the 
 sac which is at the point of protrusion is called the necJc, while 
 the rest is termed the body. The neck is often the seat of con- 
 striction in cases of strangulated hernia. 
 
 Diagnosis of hernia. — The tumour has come suddenly, per- 
 haps while the patient was making an unusual exertion. It has 
 increased from within outwards. It is not persistent, but retires 
 when the patient lies down, and appears again when he gets up. 
 It is situated at one of the natural apertures in the abdominal 
 walls. It is regular in outline, circumscribed, pyriform, free 
 from pain or tenderness, and does not implicate the skin. If it 
 is composed of omentum, it is doughy to the touch ; but if it 
 contains bowel and fluid, it may be tense, elastic, and gurgling. 
 An impulse can be communicated to it by coughing ; it can be 
 reduced by making the patient lie down, and using a little mani- 
 pulation, technically called the taxis. Such are the characteristics 
 of an ordinary reducible hernia. 
 
 A rupture is said to be reducible when it can be returned 
 without diflflculty. When it is permanently protruded, and can- 
 not be returned, but gives rise to no urgent symptoms, it is 
 termed irreducible. This state of things is apt to arise when 
 the sac becomes adherent to the tissues which cover it on the one 
 hand, and to the viscera it contains on the other : or it may be 
 due to the deposit of fat in a descended omentum. Irreducible 
 herniffi are always attended with inconvenience, and they are 
 apt to cause irregularity of the bowels, with derangement of the 
 digestive organs. Moreover, they are very liable to become 
 strangulated from slight causes. 
 
HERNIA. 285 
 
 When ail irreducible hernia becomes temporarily obstructed 
 by accumulation of faeces or of gas, but without any urgent 
 symptoms, it is said to be incarcerated. When the passage of 
 faeces is interrupted, such interruption being attended by acute 
 inflammatory symptoms, the hernia is said to be strangulated. 
 Incarceration is often a step towards strangulation. If acute 
 symptoms supervene upon an incarcerated hernia, it becomes 
 strangulated. 
 
 With these general remarks I shall proceed to speak in detail 
 of some of the commoner varieties of hernia. 
 
 And first of inguinal hernia, which presents itself under two 
 principal forms, the oblique and the direct. 
 
 Oblique inguinal hernia is the name applied to that variety 
 in which the protrusion orginates at the internal abdominal 
 ring, on the outer side of the deep epigastric vessels, travels 
 obliquely along the whole length of the inguinal canal, and 
 appears at the external abdominal ring. The bowel follows the 
 course of the spermatic cord. This is the most common rupture 
 that is met with in the male. 
 
 When the intestine is lodged in the inguinal canal, and has 
 not yet made its way through the external ring, it is called a 
 bubonocele. After it has passed the external ring, it gradually 
 protrudes into the scrotum or labium. 
 
 Bubonocele may have to be distinguished from undescended 
 testicle. In the latter case the testis is absent from the scrotum, 
 and there is sickening pain upon pressing upon the tumour. 
 
 The coverings of an oblique inguinal hernia are, from without 
 inwards : (1) skin, (2) superficial fascia, (3) inter-columnar fascia, 
 (4) cremasteric fascia, (5) fascia propria (infundibuliform) derived 
 from the fascia transversalis, (6) sac. 
 
 The hernial protrusion lies in front of the spermatic cord, and 
 the neck of the sac is just outside the deep epigastric vessels. 
 
 Congenital hernia. — When, from imperfect foetal development, 
 the prolongation of the peritoneum, which goes to form the tunica 
 vaginalis, is not closed, the intestine makes its way along the 
 pervious canal into the tunica vaginalis, and comes into imme- 
 diate contact with the testis. A congenital hernia has no proper 
 sac ; its sac is the parietal layer of the tunica vaginalis. 
 
 Infantile hernia occurs in cases where the pouch of peritoneum, 
 which goes to form the tunica vaginalis, is separated from the 
 general cavity of the peritoneum, but still remains open to a 
 higher point than usual. When this happens, and the intestines 
 protrude in the ordinary way (as they are very apt to do under 
 such circumstances), we have the condition known as infantile 
 hernia. The rupture insinuates itself behind the elongated 
 
286 DISEASES OF TISSUES AND ORGANS. 
 
 tunica vaginalis. It has, therefore, as it were, a double sac — a 
 proper sac derived from the peritoneum, and a secondary sac 
 formed by the layers of the tunica vaginalis, which are com- 
 pressed in front of the proper sac. In cases of this sort, the 
 tunica vaginalis is very prone to become inflamed, and distended 
 with fluid (hydrocele). 
 
 Direct inguinal hernia originates on the inner side of the deep 
 epigastric vessels, immediately behind the external abdominal 
 ring. It either bursts through, or pushes before it, the con- 
 joined tendon. It then presents itself at the external ring, and 
 makes its way gradually down to the scrotum or labium. Its 
 coverings differ from those of the oblique inguinal hernia in that 
 it lacks the cremasteric fascia ; but sometimes (as we have said) 
 it has a tunic formed by the conjoined tendon. 
 
 Diagnosis of inguinal hernia. — It is often impossible to dis- 
 tinguish between a direct and an oblique inguinal hernia. In 
 recent cases, the diagnosis may be made by attending to the 
 situation and direction of the tumour; or by restoring the 
 intestine, and then insinuating the finger, and examining the 
 anatomical relations of the passage. 
 
 Hernia and hydrocele may be distinguished by attending to 
 the following characteristics. Hernia begins from above, is 
 opaque, does not fluctuate, does not obscure the testicle, receives 
 an impulse on coughing, and can generally be reduced by making 
 the patient assume the horizontal position. Hydrocele begins 
 from below, is translucent, receives no impulse on coughing, 
 fluctuates, obscures the testicle, and does not disappear when the 
 patient lies down. The two conditions, however, not unfre- 
 quently coexist. 
 
 Varicocele may be mistaken for rupture. The best test is to 
 make the patient lie down, when the swelling, of whichever 
 nature, will disappear ; the surgeon then presses his finger on 
 the external ring, and orders the patient to stand up ; if it is a 
 rupture, it will not descend, whereas if it is a varicocele, it will 
 quickly show itself. 
 
 Femoral hernia passes through the crural ring, beneath 
 Poupart's ligament. When the patient stands erect, the neck of 
 the sac has in front of it Poupart's ligament, behind it the pec- 
 tineus muscle and the pubes ; on its inner side Gimbernat's liga- 
 ment ; and on its outer side, the femoral vessels in their sheath. 
 The protrusion takes place into the crural canal, that is to say, 
 into the innermost compartment of the crural sheath. When 
 the bowel reaches the saphenous opening in the fascia lata, it 
 comes forward beneath the skin; then, instead of descending 
 down the thigh, it makes its way upwards, so that the tumour is 
 
HERNIA. 287 
 
 doubled upon itself, the neck of the sac being beneath Poupart's 
 ligament, while its fundus is immediately over it. It is impor- 
 tant to notice this, because in all attempts at reduction the force 
 should be applied in the opposite directions, that is to say, down- 
 wards, inwards, and upwards. 
 
 The coverings of a femoral hernia are, from without inwards; 
 (1) skin, (2) superficial fascia, (3) cribriform fascia, (4) crural 
 sheath, (5) septum crurale, (6) sac. 
 
 This variety of hernia is most common in women on account 
 of their greater breadth between the hips. 
 
 Femoral hernia may be distinguished from inguinal by observ- 
 ing the relative position of Poupart's ligament. 
 
 From a varicose condition of the superficial veins of the thigh 
 it may be diagnosed, by making the patient lie down ; and then, 
 when the swelling has subsided, placing the thumb firmly on the 
 crural ring. In such circumstances, a hernia cannot descend, 
 whereas a varicose tumour soon reappears. 
 
 From psoas abscess it may be distinguished by the history of 
 the case, and the absence of fluctuation. 
 
 From enlarged lymphatic glands there may be more difficulty 
 in making the diagnosis. The history of the case, and the pre- 
 sence, or absence, of a cause for the glandular enlargement, 
 are the points that must guide us. 
 
 The treatment of these various forms of hernia may conve- 
 niently be considered together. When a rupture descends, the 
 surgeon should reduce it with as little delaj- as possible, endea- 
 vouring at the same time to discriminate accurately to what 
 variety it belongs. This is not always easy, but it is desirable, if 
 possible, because the truss-pad is sometimes made to vary in 
 shape according to the nature of the case. 
 
 For all ordinary hernite the common truss, or, as it is some- 
 times called, Hart's truss, is perhaps better than any of the 
 numerous patent instruments which 
 have been invented. It consists of ^ ^S- 12o. 
 
 a pistol-shaped pad which covers _„^<rTZIIvr — .— ^^--"^t"^ 
 the hernial opening, and a steel irj/ "■^^^^^^^^^.^i**' ^s\ 
 
 spring which passes round the '^J >J 
 
 patient's body, and is affixed by 7^5^^^ _^>^^ 
 
 means of a short strap to a stud on i^^ /^F*^ 
 
 the back of the pad. Sometimes an i| /.•/ vi 
 
 under-strap is added which com- ^"^.^x ^ 
 
 mences at the back of the truss. The common truss (Hart's), 
 passes under the perineum, and is 
 
 attached in front to the stud on the pad (Fig. 123). In 
 applying the truss the surgeon should first place his patient in 
 
288 DISEASES OF TISSUES AND ORGANS. 
 
 the recumbent posture, and ascertain that the rupture is entirely 
 reduced. He should then stretch the spring round the wearer's 
 hips, adjust the pad upon the hernial opening, and secure the 
 strap to the stud. When the patient stands up, a little further 
 adjustment may perhaps be wanted, and the surgeon may have 
 to shift the strap from one button-hole to another, before he 
 brings the instrument into a position which controls the rupture, 
 and is at the same time comfortable to the wearer. 
 
 Coles's truss consists of a steel spring, which goes half way 
 round the body, from the seat of rupture to the spine. At each 
 end of the spring there is a pad — a large flat one which bears 
 against the spine, and a convex one which covers the hernial 
 opening. The hernial pad is hard and unyielding, being made of 
 oin covered with flannel or leather ; but a certain amount of 
 elasticity is given to it by a spiral spring which is placed within 
 it. The principal objection to this truss is its convex pad, which 
 has a tendency in some cases to enlarge the hernial opening ; 
 otherwise it is a light and convenient instrument. 
 
 Salmon and Ody's truss has a steel spring, which goes three- 
 quarters of the way round the body — from the groin where the 
 rupture is situated, across the pubes, and round the hips to the 
 spine. The hernial pad, which is slightly convex, is attached to 
 the spring by means of a ball-and-socket joint, and this adapts 
 itself to the movements of the patient's body. 
 
 The peculiarity of Egg's truss consists in its strong steel 
 spring, which is said to be made out of old sword blades. The 
 spring goes completely round the waist, and is bent to a large 
 curve, so as nearly to follow the outline of the patient's body. A 
 very slight degree of pressure from a strong spring, such as this, 
 serves to restrain the rupture, and to keep the instrument in its 
 place. Indeed, Egg's truss may be said to act rather by sup- 
 porting the abdominal walls than by making pressure upon them. 
 Any kind of pad may be fitted to one of these trusses. 
 
 The Mocmain lever truss has two chief characteristics — (1) 
 The pad is stufied with a peculiar material known as " Moc- 
 main" — a vegetable substance, which has a silky texture and a 
 remarkable degree of elasticity ; and (2) the spring-force is 
 applied by means of a lever, which is placed at the back of the 
 pad, so that the steel girdle is altogether dispensed with. A 
 leathern belt encircles the waist, and supports the pad ; while a 
 strap passes under the perineum from behind forwards, and is 
 affixed to the lever. It is upon the tension of this under-strap 
 that the pressure upon tlie hernial opening depends ; and hence 
 arises the chief objection to these trusses, for when the thigh is 
 flexed, as in going upstairs, the under-strap is relaxed, the 
 
HEENIA. 
 
 289 
 
 Fig. 124. 
 
 Matthews' plated truss. 
 
 pressure upon the lever diminished, and then the rupture may 
 make its escape behind the pad. 
 
 Besides these there are various other patent trusses, which 
 may be found useful in particular cases, but those we have men- 
 tioned are the best known. We must not, however, leave this 
 subject without drawing attention to the plated truss made by 
 Matthews Brothers, of Carey Street. This instrument has an 
 elegant appearance, besides the 
 great recommendation of resist- 
 ing the eifects of the perspiration, 
 and requiring no covering of 
 leather or calico. The spring 
 itself is as delicate as is com- 
 patible with the amount of 
 strength which is required to fix 
 the truss in its place without any 
 other fastening (Fig. 124), A 
 truss of this description, fitted with one of Mr. Wood's pads, is 
 perhaps the best appliance of the kind that modern science and 
 skill have devised. 
 
 Mr. Wood has introduced truss-pads for cases of inguinal 
 hernia which are intended to bear upon the margins of the hernial 
 opening, and not to protrude into 
 the aperture itself, as the ordinary 
 convex ones are apt to do. Mr. 
 Wood's pad for an oblique inguinal 
 hernia is shaped like a horseshoe 
 (Fig. 125, a), whereof the expanded 
 portion presses upon the internal 
 opening of the canal; while the 
 outer limb lies along Poupart's 
 ligament, and the inner one along the internal pillar of the 
 ring. By this means firm pressure may be made upon the 
 sides of the hernial opening, while a space is left for the passage 
 of the spermatic cord and vessels. 
 
 For direct inguinal hernia Mr. Wood uses a circular pad, with 
 a hole in the centre (Fig. 125, h) — the circle following the 
 margins of the opening, and making such firm backward pressure, 
 and so stretching the skin, that the rupture cannot escape. 
 
 For femoral hernia Mr. Wood recommends a pad which is oval in 
 outline, and which has a flat surface that is placed against the front 
 opening of the crural canal, while the upper edge is rounded to 
 support Poupart's ligament, and the lower bevelled ofi" to fit the 
 saphenous opening. 
 
 Mr. Wood's pads are generally made in some hard, smooth 
 
 TJ 
 
 Fig. 125. 
 
 Wood's truss-pads. 
 
290 DISEASES OF TISSUES AND ORGANS. 
 
 material, such as boxwood or vulcanite ; sometimes, however, they 
 are fitted with small air or water cushions ; but in any case they 
 are shaped so as to adapt themselves to the anatomical require- 
 ments of each variety of rupture. 
 
 We may here add a few general remarks applicable alike to 
 all trusses. After a truss has been adjusted by the instrument 
 maker, the surgeon should examine it himself, and see that it fits 
 the patient properly, and that it keeps its place under all ordinary 
 movements. Moreover, he should take care that the spring is 
 strong enough to control the rupture. With this view he should 
 direct the patient to stand up, with his legs apart, and to cough 
 several times in rapid succession. If the bowel does not protrude 
 under this test, the surgeon may feel satisfied that the spring 
 will bear all the pressure that is likely to be put upon it. The 
 truss generally requires to be covered throughout with leather or 
 calico, to prevent it from being affected by the perspiration. 
 It should be worn constantly during the day — being put on before 
 the patient rises from bed in the morning, and not laid aside 
 until he lies down at night. If, as in the case of children, the 
 instrument is used, not merely as a precautionary measure, but 
 also with the view of producing a radical cure, it will be all the 
 better if the patient will consent to wear it by night as well as 
 by day. It is sometimes well for a patient, though ruptured only 
 on one side, to wear a double truss ; for there is often a weak- 
 ness of the corresponding region on the opposite side of the body ; 
 and when one groin is compressed, a greater strain is thrown 
 upon the other, so that it is apt to give way. 
 
 If the skin becomes chafed it should be bathed with a little 
 eau-de-Cologne or brandy, or with a spirituous lotion (F. 21), 
 and then carefully dried with a soft towel, and dusted over with 
 violet powder or French chalk. 
 
 If a patient presents himself to the surgeon with a reducible 
 hernia, and a truss cannot at once be provided, the ordinary spica 
 bandage may be applied over a pad by way of a temporary 
 expedient (see Fig. 155) ; but care should be taken to explain 
 to the patient that his life is in jeopardy as long as he is going 
 about without a proper truss. 
 
 In children we may hope to obtain a cure by the habitual use 
 of a truss ; but in adults such a result cannot be expected. 
 Here the truss is a mere palliative, and if we desire to effect a 
 radical cure, it must be by the performance of an operation. 
 Operations for the radical cure of hernia proceed upon two prin- 
 ciples. They either aim at invaginating the skin, superficial 
 fascia and sac, so as to plug theopening through which the hernia 
 passes (Wiitzer's operation) j or else, after invaginating the sac and 
 
HEENIA. 
 
 291 
 
 Fiff. 126. 
 
 fasc'iM, the sides of the aperture are brought together by means of 
 subcutaneous stitches, and held in that position until a sufficient 
 amount of adhesive inflammation has taken place (Wood's). But 
 I am inclined to agree with Mr. Bryant that " where a hernia can 
 be kept up by a truss, and the patient is likely to remain in a 
 civilized counti'y where trusses can be obtained, any operation for 
 the radical cure is an unjustifiable one" (" Surgery," p. 358). 
 
 If the hernia is found to be irreducible, the patient should be 
 instructed to wear a bag-truss with a hollow pad which accurately 
 fits the protrusion, so as to prevent its increase. If the hernia 
 becomes incarcerated, the treatment must consist in rest in the 
 horizontal position, fomentations or iced applications, clysters, and 
 the taxis. 
 
 If the rupture is strangulated, the symptoms are urgent ; and 
 the treatment must be prompt and decided. 
 
 Symptoms of strangulated hernia. — The patient is restless and 
 uneasy ; his features are pinched, and his expression anxious. He 
 complains of twisting pain at the umbilicus ; the bowels are con- 
 stipated ; there is nausea and vomiting. After a time the matter 
 which is thrown up becomes feculent, stercoraceous. The pulse 
 is hard, small, and frequent; 
 gradually becoming weak and flicker- 
 ing. The tumour, which at first is 
 neither painful nor tender, becomes 
 by degrees tense and exquisitely sensi- 
 tive. These symptoms gradually 
 become aggravated, and the patient 
 grows more and more exhausted. I 
 have reported a case in which the 
 patient — a middle-aged woman — 
 positively refused to have any opera- 
 tion performed, and died on the 
 twenty-fourth day (Lancet, May, 
 1870). If the local pain and tender- 
 ness suddenly cease, if the tumour 
 becomes doughy, emphysematous, 
 and purple, if the patient expresses 
 himself as much relieved — these 
 signs, taken together, indicate that 
 gangrene has commenced, and they 
 are generally followed by speedy 
 death. 
 
 But it sometimes happens that, 
 though the hernia and its cover- 
 ings slough, death does not follow. 
 
 Strangulated congenital 
 hernia. 
 
 The mortified parts are 
 u 2 
 
292 DISEASES OF TISb'UES AND OEGANS. 
 
 thrown off, an opening into the bowel is established, there is a 
 free discharge of fseces, the urgent symptoms subside, and the 
 patient gradually rallies from the state of prostration. The com- 
 munication with the bowel remains, and must be subsequently 
 treated as an artificial anus. 
 
 Fig. 126 represents a large congenital hernia which had be- 
 come strangulated. The hour-glass shape is very characteristic 
 of the congenital variety. The constriction marks the point 
 where the prolongation of the peritoneum which goes to form the 
 tunica vaginalis has been imperfectly closed. In this instance 
 the patient was a man aged forty-four. An operation was per- 
 formed for the relief of the strangulated gut, and about thirty 
 inches of bowel were returned, besides apiece of omentum. The 
 portion of bowel which was lodged at the bottom of the sac, 
 below the hour-glass contraction, was intensely congested. The 
 patient died on the third day after the operation. 
 
 Treatment. — In the treatment of strangulated hernia time is 
 of great importance. The patient should at once be placed in 
 the horizontal position, with his knees drawn up, so as to relax 
 the abdominal muscles. The taxis should then be'used — that is 
 to say, the surgeon should endeavour to restore the protruded 
 viscera by manipulation. With this view, he grasps the body 
 of the tumour with one hand, and while steadily compressing it 
 he pushes it towards the aperture, through which it emerged. 
 At the same time, with the other hand, he gently pinches the 
 neck of the tumour, so as to enable it to enter more easily. The 
 surgeon should ascertain whether he is dealing with an inguinal 
 or a femoral rupture, for the direction in which pressure should 
 be made differs somewhat in each case. The taxis should be 
 employed carefully ; much harm is often done by its prolonged 
 and injudicious use. 
 
 If manipulation fails, the patient may be brought thoroughly 
 under the influence of chloroform ; or he may be placed in a 
 warm bath ; or a full dose of opium may be given — and the taxis 
 tried again. Or a bladder of ice may be applied to the tumour 
 for a couple of hours ; or the patient may be inverted — that is to 
 say, the lower part of his body raised on pillows, so as to empty the 
 sac of some of its fluid contents — and then the taxis may be used 
 as before. Purgatives should not be given, but the lower bowel 
 may with advantage be cleared out by a simple enema. Other 
 remedies, such as venesection, antimony, tobacco, &c., used to be 
 in vogue ; but if those which we have enumerated above are 
 fully and fairly tried without producing any effect, the sooner an 
 operation is performed the better. Delay adds much to the danger. 
 
 Operation for strangulated hernia. — A fold of skin over the 
 
HERNIA. 293 
 
 neck of the tumour should be raised, transfixed, and the knife 
 made to cut its way out. The coverings are then divided by a 
 careful dissection, layer by layer, until the sac is reached. This 
 may be known by its glistening, silvery appearance, and by the 
 branching vessels on its surface. 
 
 The question now arises. Should the sac be opened or not ? To 
 this I reply that, as a general rule, the sac ought always to be 
 opened. Unless we open the sac we cannot tell what is the con- 
 dition of the intestine, nor can we be sure that there is not a 
 second constriction within the sac. Such an opening need not be 
 extensive. In many cases it is enough if it will admit the fore- 
 finger, so as to enable us to explore the cavity. 
 
 The point of constriction is generally found to be either the 
 thickened neck of the sac or some tendinous or membranous band 
 outside it. 
 
 Fig. 127 represents a portion of the ileum, of which a knuckle 
 
 Fiff. 127. 
 
 Strangulated hernia, 
 
 had been strangulated in the crural ring. The patient was a 
 middle-aged woman. The constriction was remarkably tight, 
 and had existed for sixty hours before it was released. The 
 patient died on the fourth day after the operation. The knuckle 
 was gangrenous, and there was considerable peritonitis. 
 
 In operating for a strangulated oblique inguinal hernia, the 
 constriction will sometimes be found at the external, but more 
 frequently at the internal, abdominal ring. It should be divided 
 on the finger, or on a director, with the hernia-knife. The in- 
 cision should be made directly upwards — that is to say, parallel 
 to, and not across, the course of the epigastric vessels. 
 
 In the ease of a strangulated femoral hernia, the constriction 
 will be found either at the inner part of the falciform process of 
 the fascia lata, or else at Gimbernat's ligament. In either case 
 the edge of the knife should be directed ujpioards and inwards. 
 A mere nick often suffices to relieve the constriction. 
 
294 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 It should be borne in mind that the obturator artery sometimes 
 arises from the epigastric. When it does so, it hes close to the 
 falciform border of Gimbernat's ligament, and would thus em- 
 brace the neck of a femoral hernia. The operator should 
 therefore proceed with caution. 
 
 If the gut is merely congested, of a ruby or claret colour, but 
 smooth on its surface, and firm in its texture, it should be re- 
 turned without hesitation ; but if it is rough, friable, patchy, of a 
 black, gvey, or greenish colour, it should be drawn gently out, 
 the gangrenous portion cut off, the edges of the wound stitched to 
 the integuments, and the case treated as one of artificial anus. 
 
 If the omentum is mortified, the gangrenous portion should be 
 cut off, and the bleeding vessels secured by torsion, or by a fine 
 ligature. It may then be left protruding through the aperture, 
 in the hope that it may become adherent, and close the opening. 
 After the operation the edges of the wound should be brought 
 together and secured by sutures. A little water-dressing should 
 be applied, covered by a pad and a bandage. The diet should be 
 bland but nutritious. If need be, a simple enema may be given, 
 but purgatives ought to be avoided ; the bowel sho\ild have a few 
 days' rest in order to enable it to recover itself. 
 
 If the symptoms of strangu- 
 -t ig. 128. lation exist, while the precise 
 
 nature of the tumour is doubt- 
 ful, the general rule is to 
 operate. 
 
 Umbilical hernia often occurs 
 in infants. Sometimes it is 
 congenital, but much more 
 frequently it manifests itself a 
 few days after birth ; the crying 
 or straining of the child causing 
 a portion of the intestines to 
 protrude at the umbilical aper- 
 ture. Occasionally this form 
 of rupture is seen in adults, 
 and then it is probable that 
 there has been some ulceration 
 round the navel in infancy, or 
 some other cause of weakness. 
 Fig. 128 represents a large 
 irreducible umbilical hernia in an old woman, aged seventy- 
 one. It had existed about three years. She attributed it to 
 over-exertion in nursing a relative — a tall, heavy man. 
 
 Treatment. — If tho hernia cannot be reduced, a truss, with a 
 
 Irreducible umbilical hernia. 
 
HERNIA. 
 
 295 
 
 hollow pad adapted to the tumour, should he hahitually worn. 
 If it becomes strangulated, an operation must he undertaken 
 of the same nature, and with the same object, as that which we 
 have described in speaking of inguinal hernia ; but adapted, of 
 course, to the anatomy of the part. 
 
 Usually, however, there is no difficulty in returning an umbilical 
 hernia. By a little manipulation the protruded intestine can be 
 restored to its place, and then the patient must wear a truss to 
 prevent it from protruding again. The simplest sort of truss 
 consists of an elastic band passing round the patient's body, and 
 pressing upon a pad, which is placed over the aperture by which 
 the hernia escapes. Very convenient appliances of this descrip- 
 tion may be obtained from the surgical instrument makers. In 
 hospital practice it often suffices to apply a pad over the umbilical 
 opening, and to fix it by means of a strip of adhesive plaster. A 
 suitable pad for these cases may be made by taking a flat cork, or 
 a small piece of wood, and folding it in lint. With these simple 
 materials a truss may be made vvhich answers all practical pur- 
 poses ; and, as the subjects of this complaint are generally infants, 
 the adhesive plaster has the advantage of not being easily dis- 
 placed by the movements of the little patient. 
 
 If these measures are adopted, Nature seldom fails to do 
 the rest. Hence it is that in rural 
 districts many superstitious practices 
 receive the credit of effecting a cure. 
 
 In cases of umbilical hernia the truss 
 should be worn constantly — being re- 
 newed from time to time as circum- 
 stances may require; and care should 
 be taken that it is always properly 
 adjusted, and that it presses with a 
 slight, but even, force upon the aper- 
 ture over which it is placed, so that the bowel cannot 
 escape behind it. Mr. Wood is of opinion that the pressure 
 ought not to be exerted upon 
 the centre of the aperture, 
 but upon its margins ; for if 
 the pressure is central it tends 
 to enlarge the aperture, 
 whereas if it is marginal it 
 has the opposite effect. With 
 this view he has devised a 
 pad for umbilical hernia (Fig. 
 129) made of india-rubber or 
 gutta-percha, and which con- 
 
 Pig. 129. 
 
 Pad for umbilical 
 hernia. 
 
 Fi^. 130. 
 
296 
 
 DISEASES OF TISSUES AND ORaANS. 
 
 sists of a thin, flat base lying in contact with the skin, and an 
 oval ridge which corresponds to the margins of the hernial aper- 
 ture, and upon which the pressure is exerted by means of an 
 elastic belt. The accompanying diagram (Pig. 130), copied from Mr. 
 Wood's treatise on Rupture, is intended to represent a sectional 
 view of the abdominal walls in a case of umbilical hernia ; and to 
 show the direction in which the pressure is exerted by such a 
 contrivance as we bave described. 
 
 IMPERFORATE JLNVS. 
 
 Sometimes there is a congenital deficiency of the anus : there 
 is no free passage between tbe bowels and the anus. This mal- 
 formation is more common in male than in female children. 
 
 In these cases the rectum may terminate in the bladder j or 
 it may take its proper course, but fail to reach the anus by an 
 inch or more; or the rectum may be complete, but the anus 
 closed by a membrane. These are the commonest varieties of the 
 malformation. Fig. 131 represents the first variety. It was 
 
 Fig. 131. 
 
 Fig. 132. 
 
 Imperforate anus (1). 
 
 Imperforate anus (2). 
 
 drawn from a case of Mr. Spencer Watson's. Fig. 132, showing 
 the second variety, occurred in my own practice. 
 
 Treatment. — If the anus is merely skinned over, and the 
 membrane distended by an accumulation of meconium, an incision 
 should be made at once. 
 
 If, however, the aperture is firmly closed, a sharp-pointed 
 trochar and canula of sufficient size, or a curved bistoury, should 
 be introduced very carefully upwards and backwards, to the 
 extent of an inch. The surgeon should then explore the wound 
 with his finger, in the hope of reaching the gut. If he succeeds. 
 
HAEMORRHOIDS. 297 
 
 he should draw it down, and stitch it to the edges of the super- 
 ficial wound. If he fails, the only remedy is to perform Amus- 
 sat's operation, and make an artificial anus in the left lumbar 
 region. 
 
 FISSURB OF THE ASJUS. 
 
 The mucous membrane at the verge of the anus is apt to be- 
 come cracked or fissured. When this happens, there is exquisite 
 pain, the sphincter is spasmodically contracted, and the nates are 
 pressed together, so that it is extremely diflScult to get a clear 
 view of the disease. The pain is so much aggravated by defeca- 
 tion that the patient dreads going to stool. The general health 
 suffers, and the invalid becomes pale, thin, and anxious-looking. 
 
 The fissure is generally associated with a disordered state of 
 the stomach. Sometimes it appears to depend upon syphilis. It 
 is often found lying at the base of an external pile, or tag of 
 hypertrophied skin. 
 
 Treatment. — The bowels should be regulated, so that the 
 motions shall always be soft and semi-fluid. The fissure should 
 be touched with bluestone, or with a pencil of lunar caustic. If 
 this fails, an incision should be made through the fissure, so as to 
 divide the mucous membrane and a few of the fibres of the 
 sphincter. This clean-cut wound soon heals from the bottom, in 
 the ordinary way. 
 
 UIiCER OF THE RECTVXWE 
 
 often results from an aggravated fissure. Sometimes it is 
 situated upon the verge of the anus ; sometimes it is within the 
 sphincter. The surgeon must search for it carefully both with 
 his finger and also with the small speculum that is made for the 
 purpose. 
 
 It gives rise to much the same symptoms as fissure of the anus, 
 and the treatment must be conducted on the same general prin- 
 ciples. When it is situated at the verge of the anus, it should 
 be divided, and the incision carried through the sphincter. 
 When it is internal to the muscle, it may sometimes be cured by 
 the local use of the nitrate of silver, while the bowels are care- 
 fully regulated, and the pain and irritation are allayed by small 
 anodyne injections or suppositories (F. 90). If the case is of long 
 standing, it may be necessary here also to divide the sphincter. 
 
 H2:iVXORRHOIDS 
 
 (piles) is the name given to certain tumours, which are apt 
 to form at, or near, the anus. They consist essentially of a 
 dilated, varicose, and hypertrophied condition of the veins at the 
 lower part of the rectum. 
 
298 DISEASES OF TISSUES AND OEGANS. 
 
 Whatever favours the accumulation of blood in the lower 
 bowel predisposes to piles ; for example, constipation, disease of 
 the liver, pregnancy, &c. The upper classes, from their luxurious 
 habits and the sedentary nature of their employments, are more 
 apt to have hsemovrhoids than the lower. Whatever irritates or 
 inflames the rectum, excites to "a fit of the piles;" for example, 
 diarrhoea, cold and wet, &c. 
 
 Haemorrhoids are divided into those which are external to the 
 sphincter, and those which are internal. 
 
 External piles form small tumours, at the verge of the anus, 
 of a purple or bluish colour, covered partly by thickened mucous 
 membrane, partly by hypertrophied skin. As a rule, they do not 
 bleed. When they are irritated and congested, as they frequently 
 are towards evening, they give rise to intolerable itching and 
 smarting. When they become acutely inflamed, they form hard, 
 tense, purple tumours, which are exquisitely painful. 
 
 Treatment. — If external piles are cut off with scissors, and 
 the sores allowed to heal, a radical cure is effected. They may, 
 however, be palliated and kept in check by carefully regulating 
 the diet and bowels. The evacuations should always be soft and 
 pasty. To this end, a mild laxative — a little of the confection 
 of senna, for example — should be taken every night. At the 
 same time, soothing or astringent ointments — e.g., cacao butter 
 or the ung. gallse co. — should be applied locally. Sponging the 
 part with cold water every morning, and also after the bowels 
 have been moved, is of the utmost benefit. 
 
 When an external pile is acutely inflamed, fomentations should 
 be used. Or a free incision should be made through it, when 
 small coagula of blood will escape. This will give immediate 
 relief, and ultimately effect a cure. 
 
 Internal piles are situated within the sphincter ani. Some- 
 times they form pendulous tumours ; sometimes they are attached 
 by a broad base. They may habitually protrude from the anus, 
 or they may descend only when the bowels are moved. They bleed 
 freely, and often give rise to general angemia. They are apt to 
 become inflamed, and when this happens the symptoms run high. 
 There is great pain and irritation, not only in the rectum, but 
 in the genito-urinary organs as well. 
 
 The general treatment is the same as for external piles. We 
 must regulate the diet, and study the state of the bowels and 
 liver. The bleeding may be checked by astringents, either given 
 internally — e.g., gallic acid or the muriated tincture of iron, 
 — or as injections — e.g., alum, tannin, &c. (F. 15, 17). Here, 
 too, the cold bath is of great service. It should be borne in 
 mind that, in the case of plethoric persons, it is not always safe 
 
PEOLAPSUS RECTI. 299 
 
 to stop the discharge of blood. If inflammation occurs, fomen- 
 tations and saline purgatives will give the greatest relief. 
 
 In order to eflect a radical cure of internal piles, they must 
 be removed by an operation. The patient should sit over a pan 
 of warm water, and then strain, so as to bring the tumours fully 
 into view. They may then be strangulated, either with a single 
 loop of twine, or by passing a double ligature through the base of 
 the pile, and tying each half separately. In some cases the 
 ecraseur may be used ; in others they may be grasped with a 
 suitable clamp, cut off, and the edges of the wound touched with 
 nitric acid, or with the actual cautery. The most convenient 
 
 Fig. 133. 
 
 Mr. H. Smith's clamp for hEemorrhoids. 
 
 clamp for this purpose is that which has been devised by Mr. 
 Henry Smith (Fig. 133). 
 
 PROIiAPSUS RECTI. 
 
 The raucous lining of the rectum sometimes protrudes beyond 
 the anus, forming prolapsus recti (Fig. 134). Whatever irri- 
 tates, relaxes, and stretches the mucous membrane may lead 
 to this complaint — for example, internal piles, thread-worms, 
 stone in the bladder, constipation, with habitual straining at 
 stool. It is often met with in young children, especially in con- 
 nection with such sources of irritation as have just been mentioned. 
 
 A tumour of varying size presents itself at the anus. At first 
 it is bright red, like healthy mucous membrane; but if it comes 
 down often, it gradually becomes thickened and callous, and more 
 like the skin. 
 
 The treatment consists in removing the cause, as in the case of 
 ascarides, stone in the bladder, &c., in regulating the bowels, so 
 that the fseces shall always be soft and semi-fluid, and in giving 
 tone and vigour to the system. If possible, the patient should 
 pass his motions in the recumbent position. AVhen the bowel 
 
300 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 Fio;. 134. 
 
 surgeons speak 
 applying nitric 
 
 descends, it should be carefully and gently replaced. The parts 
 should be frequently sponged with cold water, or with an 
 astringent lotion. Injections of an 
 astringent character should be introduced 
 into the rectum — e.g., a grain or two 
 of sulphate of iron in an ounce of water. 
 
 If an operation becomes necessary, the 
 ligature should be used ; as in the case 
 of internal piles — our object being to 
 remove some of the superfluous folds of 
 mucous membrane, and to contract the 
 anal aperture. Some 
 highly of the effect of 
 acid. 
 
 Sometimes a pessary, or a pad and 
 bandage, may be worn with advantage. 
 
 "^ -Handage for the Perineum. — The 
 simplest appliance of this kind is made 
 by passing a single turn of bandage round 
 the patient's waist, tying it behind, and then carrying the roller 
 under the perineum, and fastening it to the waistband in front. 
 Or the surgeon may prefer a compound bandage made by sewing 
 together two pieces of cotton roller, or 
 other material, at a right angle to one 
 ' another (Fig. 135). First of all, a piece 
 of broad bandage is taken of suffi- 
 cient length to pass round the waist and 
 fasten in front. To the centre of this is 
 stitched at right angles another strip of 
 bandage, long enough to be brought under 
 the perineum and attached in front to the 
 waistband. It is important that this should 
 be stitched across the whole width of the 
 waistband, so as to give it a firm attach- 
 ment, for it is upon this point that the 
 Sometimes the perineal band is left entire j 
 
 Prolapsus recti. 
 
 Fig. 135. 
 
 T-bandage. 
 
 traction is made, 
 sometimes it is torn down the centre, so as to make two tails, 
 and these are brought up, one on each side of the scrotum, and 
 attached to the waistband in front. The exact way in which the 
 bandage is adjusted depends upon the purpose for which it is 
 applied, and the surgeon must use his own judgment in the 
 matter. It is very useful for supporting the perineum in cases 
 of prolapsus of the rectum or of the uterus, for retaining pessa- 
 ries, for fixing dressings about the anus, &c. As a general rule, 
 in applying dressings to the anus, the bandage ought to be 
 
FISTULA IN ANO. 301 
 
 brought from behind forwards, in the way we have de- 
 scribed. 
 
 FisTUZiA irr Alio 
 
 is the name given to sinuses or fistulous tracks, which are apt to 
 form in the neighbourhood of the rectum, between it and the skin 
 around the anus. The fistula may communicate with a free sur- 
 face at both ends, or only at one. When it is open at both ends, 
 it is said to be complete. If it communicates with the bowel 
 alone, it is called a hlind internal fistula ; if with the skin alone, 
 it is termed a blind external fistula. 
 
 The disease seems sometimes to begin in ulceration of the 
 mucous membrane of the bowel. Perhaps, in consequence of the 
 lodgment of foreign bodies, or minute masses of hardened fiDeces, 
 an abscess forms, which burrows and makes its way in various 
 directions by the side of the rectum. At other times, it appears 
 to originate in spontaneous inflammation of the cellular tissue in 
 the ischio-rectal fossa, running on to suppuration, and extending 
 either outwards towards the skin, or inwards towards the gut. 
 
 Fistula in ano is often associated with phthisis, and in such 
 instances it depends, no doubt, upon the tendency there is in that 
 disease to ulceration of the intestines. 
 
 The symptoms of fistula are those of acute local inflammation, 
 running on to suppuration. At first, there is pain, heat, tension, 
 with disorder of the general health ; then there is commonly the 
 discharge of purulent matter, mixed with fseces and flatus. The 
 symptoms vary of course somewhat, according to the precise 
 nature of the case. 
 
 A fistula shows no natural tendency to heal; partly, because 
 irritating matters from the bowels are constantly filtering through 
 it, but chiefly, because its sides are in frequent motion by the 
 action of the levator and sphincter ani muscles. 
 
 In order to ascertain the extent of a fistula, one finger should 
 be introduced into the rectum, while a probe is passed upwards 
 through the fistulous track. If the case is one of blind internal 
 fistula, there will generally be found an abscess, pointing some- 
 where near the anus. This should be opened, and then the case 
 becomes one of complete fistula. 
 
 The only treatment worthy of notice is by operation, and this 
 is so simple and so efiicieut that it is almost universally prac- 
 tised. In a case of complete fistula, the surgeon introduces his 
 left forefinger into the rectum; while, with his right hand, he 
 passes a blunt-pointed, curved bistoury along the fistulous track 
 through the opening in the bowel, and presses it firmly against 
 the point of his finger. He then withdraws his finger and the 
 
302 DISEASES OF TISSUES AND OEQANS. 
 
 knife together, so as to cut through everything between the sinus 
 and the anus. Thus the fistuhi is laid freely open, and the 
 sphincter divided. Another and more convenient plan is to pass 
 a director in at the fistulous opening, and to bring it out at the 
 anus. This may easily be done by a little manipulation. The 
 intervening tissues must then be divided by running a knife 
 along the groove. If there are several sinuses, a director should 
 be introduced into each before the knife is applied to any. The 
 wound should be filled with a strip of oiled lint, so as to insure 
 its healing from the bottom. Blind fistulse should be converted 
 into complete ones, and then treated as above. 
 
 After the operation, opium should be given freely to keep the 
 bowels quiet. On the third morning a dose of castor oil should 
 be administered. This will bring away the first dressings. The 
 wound should then be dressed every day with oiled lint, carefully 
 introduced by means of a probe, so as to prevent superficial healing. 
 
 In cases where fistula is associated with phthisis — especially 
 if the lungs are much affected — it becomes a nice question whether 
 an operation should be performed or not. 
 
 STRICTURE OF THE RECTUM 
 
 may be either spasmodic or permanent. 
 
 Spasmodic stricture of tJie rectum is rare. It depends, either 
 upon dei-angement of the general health, or on the presence of 
 an ulcer or fissure. 
 
 Permanent stricture of the rectum is more commonly met with, 
 and may be either simple, syphilitic, or malignant. 
 
 Simple stricture is usually the result of chronic inflammation 
 of the rectum, with thickening of the lining membrane, and 
 deposit of lymph in the submucous areolar tissue. The stricture 
 is generally situated within reach of the finger, two or three 
 inches from the anus. 
 
 Symptoms. — There is a difficulty in passing the motions. The 
 fajces are sometimes flattened into ribbons; in other cases, they 
 are formed into small, hard, round masses. The bowel above 
 the seat of obstruction becomes distended, and is very apt to 
 ulcerate. Tl)e genito-urinary organs become sympathetically 
 affected, and the general health suffers. 
 
 The treatment consists in passing bougies, until a full-sized 
 instrument can be introduced without difficulty. Even then, the 
 patient should be warned that the disease will assm-edly return 
 unless a bougie is passed occasionally. 
 
 Syphilitic stricture must be treated by the same mechanical 
 means, and by the prescription of anti- syphilitic remedies (F. 49, 
 50, 60). 
 
RETENTION OF UEINE. 303 
 
 Malignant stricture may be considered along with cancer of 
 the rectum. 
 
 CANCER OF THS RECTUXVI 
 
 is generally of the epithelial, but sometimes of the scirrhous or 
 of the medullary kind. It is often associated with piles, or with 
 simple stricture ; for here, as elsewhere, cancer is apt to attack 
 tissues which are not in a natural state. It is usually situated 
 at the lower part of the rectum, so that it can be felt with the 
 tinger. 
 
 Si/mptoms. — In addition to the ordinary symptoms of stricture 
 of the bowel, there is impairment of the general health, pain 
 darting through the back and thighs, and the discharge of offen- 
 sive, bloody, purulent matter. The inability to control the anal 
 orifice and the involuntary discharge of feculent matter add 
 much to the patient's distress. As the disease advances, the 
 symptoms become more severe, and the obstruction of the bowels 
 is complete. Death generally takes place from exhaustion. 
 
 Treatment. — The bowels should be relieved by enemata, or by 
 small doses of castor oil. Wiien the necessity arises, a bougie 
 should be passed, to keep the passage open. Pain should be 
 allayed by opium or other sedatives, given either by the mouth 
 or in the form of a suppository. Marine tow makes an excellent 
 local application. If the disease is limited, the lower part of the 
 rectum, to the extent of three or four inches, may be excised. 
 As a last resource, to relieve the patient's distress and to prolong 
 his life, colotomy may be performed. 
 
 RETENTXOia- OF URISCTS 
 
 signifies an inability to discharge the urine, and must not be con- 
 founded with suppression, wherein no urine is secreted. 
 
 Retention may arise from various causes. They may, how- 
 ever, all be classed under two heads : (1) a want of power in the 
 bladder to expel its contents, or (2) an obstruction to the passage 
 of the urine. 
 
 "When the retention arises from a want of power in the bladder 
 to expel its contents, it is generally due to lesion of the spinal 
 cord attended by paralysis. In such a case there are no urgent 
 symptoms. The urine collects in the bladder, overflows, and 
 dribbles away by the urethra : it soon becomes offensive, am- 
 moniacal, and loaded with ropy mucus. 
 
 The surgical treatment of these cases consists in drawing off" the 
 water two or three times a day, and washing out the bladder by 
 means of a double-current catheter. The medical treatment 
 must be regulated according to the precise nervous symptoms. 
 
304 DISEASES OF TISSUES AND OEGANS. 
 
 Symptoms of retention from obstruction. — Urgent desire to 
 pass water with an inability to do so, straining, pain, with general 
 anxiety and distress. The bladder may be felt rising above the 
 pubes, forming an elastic, fluctuating tumour, which is dull on 
 percussion. If the retention is not relieved, the ureters gradually 
 become dilated, tlie kidneys affected with diffuse pyelitis, and 
 there is suppression of urine, followed by coma and death. But 
 it more frequently happens that the urethra gives way behind 
 the point of obstruction, and the urine escapes into the surround- 
 ing tissues (extravasation ofurine^. 
 
 When retention depends upon obstruction to the passage of 
 the urine, it is generally associated with stricture of the urethra, 
 or enlargement of the prostate. Each of these subjects will be 
 considered separately. 
 
 STRICTURE OF THE URETHRA 
 
 may be either spasmodic and temporary, or organic and per- 
 manent. 
 
 Some surgeons speak of congestive strictures, but congestion 
 may supervene either upon a spasmodic or upon an organic 
 stricture. It is, therefore, more correct to speak of a spasmodic 
 stricture, or of an organic stricture, in a state of congestion, than 
 to speak of a congestive stricture. 
 
 Spasmodic stricture is caused by contraction of the muscles 
 which surround the membranous portion of the urethra, or of 
 the unstriped muscular fibre, which forms part of the walls of 
 the canal. 
 
 The predisposing causes are an organic stricture, gleet, piles, 
 or other sources of irritation about the urethra or rectum ; and, in 
 women, the hysterical temperament. The exciting causes are 
 usually exposure to cold and wet, or excessive and unwonted 
 indulgence in drink. 
 
 Treatment. — In all cases of stricture the medical treatment 
 ought on no account to be overlooked. Rest in bed, warmth, an 
 active aperient, and sedatives will often do much to relieve the 
 patient. 
 
 In the case of a spasmodic stricture, fomentations, a warm 
 bath, a full dose of opium, or an opiate suppository (F. 90) — these 
 means will often enable the patient to empty his bladder. If they 
 fail to remove the spasm, chloroform should be given, and the sur- 
 geon should introduce a large catheter (No. 8 or 9). If the 
 distension is already great, this method should be adopted at 
 once. When the present attack has been overcome, the patient's 
 general health should be regulated ; and he should be warned of 
 those conditions which are apt to excite spasm. 
 
STRICTURE OF THE URETHRA. 
 
 305 
 
 Fig. 136. 
 
 Organic stricture is the result of inflammation in or near the 
 urethral canal. Such inflammation is very often gonorrhoeal, 
 but it may also be excited by external injury, or by the use of 
 too strong an injection. In any of these cases, a stricture may 
 be formed by the eff"usion of lymph into the lining membrane of 
 the urethra, or into the submucous areolar tissue. A stricture 
 may also result from the cicatrization of an ulcer, simple or spe- 
 cific. In this way, chancres near the orifice often give rise to 
 troublesome strictures. 
 
 The character of the stricture may vary : sometimes it is 
 annular, as if a thread had been tied round the urethra ; some- 
 times it is long ; sometimes it is situated on one side only of the 
 canal J sometimes it is rough and cartilaginous; sometimes a fold, 
 like a valve, is thrown across the canal j sometimes a band, like a 
 bridle. 
 
 The most common seat of stricture is at the junction of the 
 membranous with the spongy portion of the urethra, or a little 
 in front of this point. Fig. 136 was 
 drawn from a specimen in the museum 
 of Charing Cross Hospital, and repre- 
 sents a stricture of the urethra asso- 
 ciated with an abscess in the prostate. 
 
 When a stricture has once formed, 
 it tends to become worse; the con- 
 traction goes on increasing ; the 
 urethra behind the point of constriction 
 becomes dilated. The muscular coat 
 of the bladder gets thickened and 
 hypei'trophied, and the lining mem- 
 brane is disordered. The ureters 
 become distended and tortuous; the 
 kidneys congested, and liable to acute 
 inflammation. Thus the stricture 
 gradually extends its pernicious in- 
 fluence in a backward direction, while 
 the constant irritation makes the 
 patient nervous and depressed. At 
 first the constitution may suffer little or 
 nothing ; but, ultimately, it is apt to 
 become seriously, and even fatally, affected. If, however, the 
 patient takes timely advice, these evils may be avoided. 
 
 Symptoms. — The patient gradually finds that he has more 
 frequent calls to make water. The eflrort to do so is attended 
 with pain and diflBculty. The stream is diminished, forked, or 
 scattered. In very bad cases the urine is passed drop by drop, 
 
 Stricture of the 
 urethra. 
 
306 DISEASES OF TISSUES AND OKGANS. 
 
 and with mucb straining. The act of micturition may be fol- 
 lowed by rigors or prostration. There is often a continuous 
 gleety discharge from the urethra, or intercurrent attacks of 
 orchitis, or other indications of local irritation. The patient is 
 liable to occasional fits of retention, which are associated with 
 more or less inflammation at the seat of stricture. 
 
 Treatment. — If there is reason to suspect a stricture, a catheter 
 of large size (No. 8 or 9) should be cautiously passed along the 
 urethra. If a stricture is present, an obstruction will be felt, 
 and it will be necessary to try smaller instruments, until one is 
 found which can be introduced into the bladder without using 
 undue force. 
 
 With regard to catheters, the most manageable, and therefore 
 the most generally useful, are the silver instruments ; and if they 
 are handled, as they always should be, with a light and elastic 
 touch, and with constant regard to theanatomy of the urethra, the 
 risk of injury is very slight. There are, however, some cases — for 
 example, those of spasmodic stricture — in which a gum-elastic 
 
 instrument, either with or 
 ^°' ' without its stylet, is pre- 
 
 ferable. The soft French 
 hulbous lougie (Fig. 137) 
 Bulbous bougie. is sometimes very useful. 
 
 No instrument glides 
 through an irritable passage with less discomfort to the patient. 
 While in other cases, more particularly if the stricture is long, 
 tight, and twisted, the filiform, or the catgut bougie is of great 
 service. 
 
 When a catheter has to be introduced, the patient may either 
 stand with his back against a wall, his legs separated, and his 
 feet slightly advanced ; or he may lie on his back on a couch. 
 If he stands up, the operator should be seated opposite him ; but 
 if he lies down, the surgeon should stand on his left side. We 
 will suppose the patient to be in the recumbent position. The 
 instrument which is to be used should be well warmed and oiled. 
 The surgeon then grasps it lightly, but firmly, between the fingers 
 and thumb of the right hand, while, at the same time, he raises the 
 penis with his left. The point of the catheter is then inserted 
 into the orifice of the urethra, and the instrument is passed slowly 
 but steadily along, until it reaches the bulb — the shaft, mean- 
 while, being kept low down on the left groin, parallel with 
 Poupart'a ligament. The handle should next be swept round, 
 till it is in the middle line of the body, pointing to the navel. It 
 is then bent forwards and downwards. By this movement the 
 point of the catheter is directed upwards and onwards, enters the 
 
STRICTURE OF THE URETHRA. 307 
 
 bladder, and the urine escapes. The discharge of urine through 
 the instrument is the only certain evidence that it has reached the 
 bladder. 
 
 If the patient is in the erect posture, the surgeon holds the 
 catheter vertically, with the convexity turned towards himself, 
 aud the handle directed downwards. The point of the instru- 
 ment is introduced into the urethra, and carried along as far as 
 the bulb. The handle is then swept round through half a circle, 
 until it lies along the mesial line of the abdomen, pointing to the 
 umbilicus. It is then brought downwards and forwards, between 
 the patient's legs. 
 
 In withdrawing the catheter, the surgeon takes hold of the 
 handle between his middle and forefingers, so that he may, if need 
 be, cover the outlet with his thumb. He then reverses the steps 
 by which he introduced the instrument, so as to remove it with 
 as little pain to the patient as possible. 
 
 If difficulty arises in passing an instrument, there are various 
 little manoeuvres which may be practised. The penis may be 
 stretched upon the catheter, so as to obliterate any folds there 
 may be in the mucous membrane ; or the fingers of the left hand 
 may be applied to the perineum, behind the scrotum, so as to help 
 the instrument in its onward and upward course; or the left 
 forefinger, well oiled, may be passed into the rectum, so as to 
 direct the point. The instrument should be carried along the 
 upper wall of the urethra rather than the lower. If the surgeon 
 fails with a metal catheter, he may perhaps be more successful 
 with a gum-elastic. If he fails in the recumbent position, he 
 may meet with less difficulty if he makes his patient stand up, or 
 if he puts him under the influence of an anaesthetic. The 
 catheter should always be handled lightly, the least possible 
 amount of force being used ; our aim being to insinuate the 
 instrument without irritating the urethra, causing pain, or draw- 
 ing blood. This is one of the occasions on which the young 
 surgeon should bear in mind the oft-repeated maxim of Hippo- 
 crates — " Do good if you can, but at least do no harm." The 
 most serious, and even fatal, consequences may follow an injudi- 
 cious or unskilful use of instruments. It requires much practice, 
 as well as great tact and patience, to pass the catheter skilfully ; 
 and cases not unfrequently arise which baffle the most accom- 
 plished surgeons. It is said that Civiale once spent four hours 
 in introducing an instrument into the bladder. 
 
 If the surgeon fails to pass an instrument, and the case is not 
 urgent, he may content himself with regulating the bowels, and 
 ordering fomentations and opiate suppositories, in order to allay 
 inflammation and spasm, and reduce the stricture as much as 
 
 X 2 
 
308 DISEASES OF TISSUES AND OEGANS. 
 
 possible (F. 90). Then, on a subsequent occasion, he may be more 
 successful. Mr. Nunn holds, and I think with good reason, that 
 many of the dense cartilaginous strictures are of syphilitic origin, 
 and are benefited by a course of anti-syphilitic remedies. 
 
 If the surgeon fails to pass an instrument, and the case is 
 urgent, other methods of treatment must be adopted. 
 
 a. The bladder may be tapped from the rectum. To do this, 
 the surgeon introduces his forefinger into the rectum, and feels the 
 prostate. He then carries it a little further, and touches the 
 distended bladder. On his finger he passes the curved trochar 
 and canula made for the purpose, and by a sharp thrust he forces 
 them into the bladder. The trochar is withdrawn, and the canula 
 left in the wound. When the prostate is much enlarged, this 
 operation cannot be employed. 
 
 b. Or the bladder may be punctured above the pubes, either 
 with a trochar and canula, or with the pneumatic aspirator. 
 
 c. Or the urethra may be opened by a deep incision in the 
 perineum. A full-sized catheter is passed down to the stricture. 
 The surgeon then introduces his finger into the rectum, and feels 
 the point of the instrument. He next runs a knife, with its 
 back turned towards the rectum, deeply into the middle line of 
 the perineum, till he opens the urethra behind the stricture, a 
 little beyond the point of the catheter. As he withdraws the 
 knife, he cuts forwards and upwards so as to enlarge the incision. 
 In doing this he may, if he thinks proper, divide the stricture by 
 cutting on to the point of the catheter. The instrument may 
 then be carried forwards into the bladder, and fastened in that 
 position by tapes. In this way the retention is relieved, and the 
 stricture cured at the same time. This method of treatment is 
 particularly applicable to cases in which there has been extrava- 
 sation of urine, or where there are fistulous openings in the 
 perineum. But the operation is often attended with great diffi- 
 culty ; indeed, Erichsen says it is the most troublesome in surgery, 
 and the after-risks are considerable. 
 
 Another method of dealing with the same class of cases is that 
 which is called the "button-hole" operation. It consists in 
 passing a large catheter down to the stricture, then turning it 
 round so that the point projects in the perineum. The surgeon 
 cuts down upon this, and thus opens the urethra just in front of the 
 stricture. The catheter is next withdrawn, and the edges of the 
 urethral wound are seized and drawn forwards. A probe is passed 
 through the stricture, and upon this a tenotomy knife is guided, 
 and the stricture incised. The catheter is again introduced, and 
 carried on to the bladder. 
 
 The simplest and safest operation of this kind is that which has 
 
STEICTUEE OF THE URETHEA. 309 
 
 been recommended by Mr. Cock, and which he calls "tapping 
 the urethra at the apex of the prostate, unassisted by a guide- 
 staff." 
 
 The operator introduces his left forefinger into the rectum, 
 takes the hearings of the prostate, and lodges his finger on the 
 apex of the gland ; then he Incises the perineum with a broad 
 double-edged knife, taking care to make the incision exactly in 
 the middle line of the body, and to carry the point of the knife 
 towards the tip of his own left forefinger. Thus he can 
 hardly fail to open the urethra immediately in front of 
 the prostate. The superficial incision is then enlarged by an 
 upward and downward movement of the knife. The knife is 
 withdrawn, and a probe-pointed director guided into the bladder. 
 Upon this, Syme's perineal catheter is passed into the bladder, and 
 secured. After a day or two the surgeon can explore the 
 urethra, and deal with the stricture, ^"^ery probably he will find 
 that he can pass a small instrument through it. (Cock, in Guy's 
 Hospital Reports, 1866.) 
 
 d. Or, lastly, a full-sized catheter may be forced through into 
 the bladder. But this must be regarded as a very unsafe and very 
 unscientific proceeding, though it has been recommended by some 
 high authorities. 
 
 But, supposing that the stricture is not impermeable, that a 
 small instrument can be passed, though with difiiculty, what 
 ought to be the subsequent treatment ? 
 
 A great variety of instruments have been invented for the pur- 
 pose of rapidly restoring the urethra to its natural calibre. Some 
 of these stretch the stricture, others rupture it forcibly, while 
 others incise it from its inner aspect. It may here sufiice to 
 mention Sir H. Thompson's, Mr. Holt's, and M. Maisonneuve's 
 instruments, as representatives of these several methods. 
 
 But it may be confidently asserted that no plan of treatment is 
 so safe, or so generally applicable, as the gradual dilatation by 
 catheters. One or two instruments may be introduced every 
 alternate day; and if the largest size which is passed is allowed 
 to remain in the stricture for half an hour or so, it promotes ab- 
 sorption of the thickened tissues, and facilitates the introduction 
 of a larger instrument on the next occasion. In this way No. 10 
 may be passed without difficulty in the course of two or three 
 weeks. When this happy result has been obtained, the patient 
 should be warned that his stricture is almost certain to return, 
 unless he has a full-sized catheter passed at least once a month. 
 
 In the case of cartilaginous " resilient" strictures, Mr. Syme 
 recommended dividing the constriction from its outer aspect 
 (^perineal section). A small staff, grooved on its under surface. 
 
310 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 is passed throug-h the stricture. A deep incision is then made in 
 the middle line of the perineum, the hack of the knife being 
 turned towards the rectum. The point of the blade is intro- 
 duced into the groove on the further side of the stricture, which 
 is divided as the knife is withdrawn. A full-sized catheter is 
 then passed into the bladder, and fastened by tapes. 
 
 In many operations upon the pelvic organs it is necessary to 
 fasten a catheter into the bladder. I may therefore take this 
 opportunity of explaining the various ways in which it may be 
 done. 
 
 To retain a Catheter in the Male Bladder. — The surgeon 
 having ascertained that the catheter is in the required position, 
 attaches two pieces of narrow tape to the rings of the instrument, 
 brings them down one on each side of the penis, and secures them 
 by a strip of adhesive plaster passing round the organ. Or the 
 same object may be effected in the following manner : — The 
 surgeon first applies a single turn of bandage round the patient^s 
 waist. Next he takes an ivory ring of suitable size, and to this 
 he attaches four pieces of narrow tape, each about ■«. yard long. 
 He then passes the ring down to the root of the penis, and 
 brings two of the tapes up in front, one along each groin, and 
 fastens them to the waistband. The other two tapes he conducts 
 backwards, under the perineum, across the fold of the buttock, 
 and ties them to the waistband. In this way the ring is secured, 
 and affords a fixed point to which the catheter may be attached. 
 In both instances the knots should be placed at the patient's 
 sides, for in this situation they will cause him no discomfort, and 
 the surgeon will be able to reach them without difficulty. A 
 similar piece of tape, about half a yard 
 long, is then attached by its centre round 
 the neck of the catheter, or fastened to its 
 rings, and the ends are brought down, one 
 on each side, and tied to the ivory ring 
 (Fig. 138). By this means the catheter 
 may be removed by merely untying the 
 tapes which fasten it to the ring. If a 
 silver catheter is used, care should be taken 
 not to force the instrument so far into the 
 bladder as to press against the posterior 
 wall. The surgeon should see that the 
 orifice of the catheter is furnished with a 
 wooden peg, which the patient may 
 remove at pleasure when he wishes to 
 evacuate the urine. This will be found more convenient than an 
 ordinary atylet, and can easily be supplied. 
 
 Fig. 138. 
 
EXTEAVASATION OF URINE. 311 
 
 To retain a Catheter in the Female Bladder. — A X-^^ndage, 
 the vertical portion of which has been split into two tails, is 
 applied to the patient in the usual waj; ; and the tails are brought 
 up, one on each side of the vulva, care being taken to put a little 
 cotton-wool between them and the labia externa, to prevent 
 excoriation. The catheter ought then to be introduced into the 
 bladder, and a piece of narrow tape, about half a yard long, tied 
 by its centre round the neck of the instrument. The ends of the 
 tape are brought down, one on each side, and tied to the tails of 
 the X-bandage at the point where they pass the orifice of the 
 urethra. Or the X^^andage may be dispensed with, a gum- 
 elastic instrument used, and the free end fastened to the patient's 
 thigh by a broad strip of adhesive plaster. 
 
 After a catheter has been tied into the bladder of either a 
 male or a female patient, it may be necessary to make some ar- 
 rangement whereby the bedclothes may be raised, and kept from 
 pressing upon the end of the instrument. This may be done by 
 means of a cradle, such as that represented in Fig. 73 ; or, if such 
 a thing is not at hand, an apparatus may be made, which answers 
 all practical purposes, by taking a bandbox, from which the 
 bottom has first been removed, cutting it up the side, and then 
 stretching it across the patient's hips. 
 
 EXTRAVASATION- OF URIITE 
 
 may proceed either from the bladder or from the urethra. 
 
 The bladder may give way from ulceration, or it may be 
 wounded in surgical operations, or it may be lacerated by direct 
 violence. But such injuries are comparatively rare. 
 
 When the urethra bursts, it is generally as a consequence of 
 retention following stricture, or from external injury. 
 
 Symptoms of extravasation from, retention. — The patient is con- 
 scious that something has given way, perhaps while he was strain- 
 ing. The rupture is invariably in front of the posterior layer of 
 the triangular ligament. The immediate feeling is one of relief. 
 Soon, however, the scrotum and lower part of the belly become 
 infiltrated with urine. The skin is stretched, feels doughy, crepi- 
 tates, and, if relief is not afforded, rapidly runs into sloughs. At 
 the same time, there is great prostration, with inflammatory 
 symptoms of an asthenic kind — a brown tongue and a tendency 
 to muttering delirium. 
 
 If the extravasation arises from injury, the rupture may be 
 situated in the bladder, or in any part of the urethra. If it is 
 behind the posterior layer of the triangular ligament, the outward 
 signs may be less distinct than when it is in front of that point, 
 but the case v/ill be more certainly fatal. 
 
312 DISEASES OF TISSUES AND ORGANS. 
 
 The treatment must be prompt and vigorous. Free incisions 
 should be made through the skin, wherever the tissues are infil- 
 trated, so as to give vent to the extravasated urine. Poultices 
 should be applied to promote the separation of the sloughs, and 
 afterwards water-dressing or stimulating lotions. If possible, a 
 catheter should be passed at once. If this cannot be done, the 
 urethra should be opened from the perineum, by one of tbe 
 operations which have already been described, the stricture being 
 dealt with at the same time, or subsequently, as the surgeon may 
 think fit. The diet should be liberal, including beef-tea, eggs, 
 and wine or brandy (F. 100, 107). The medical treatment 
 should be stimulating and supporting, as there is a great tendency 
 to death by exhaustion (F. 34, 35, 42). 
 
 ITRIIUARir ABSCESS 
 
 is a frequent result of stricture. It may arise from irritation, or 
 it may be caused by the escape of urine into the submucous cel- 
 lular tissue, in consequence of ulceration. In either case, an 
 abscess forms in the immediate neighbourhood of the urethra, 
 sometimes communicating with it from the first. Such abscesses 
 may occur at any part of the urethral canal, but they are most 
 common near the bulb {^perineal abscess). The symptoms are 
 those of acute abscess. 
 
 Treatment. — T\Tien the abscess is situated behind the line of 
 the scrotum, it should be opened by a free and early incision, for 
 fear the matter burrows in a backward direction towards the 
 neck of the bladder. If a stricture exists, it should be dilated as 
 soon as possible. 
 
 TTRXN-AKV FZSTUIiil. 
 
 often forms, more especially in the perineum {fistula in perineo), 
 as a consequence of stricture or urinary abscess. A fistulous 
 track exists between the urethra and the skin, and by this the 
 urine dribbles away whenever the patient makes water. 
 
 Treatment. — The first thing is to dilate the urethra, so as to 
 establish the natural channel for the urine. The next point is to 
 close the fistula. This is often a work of no small difficulty. 
 Sometimes, when the fistula is narrow and recent, the use of a 
 stimulating lotion, or the application of caustic, or of a red-hot 
 wire, may lead to its contraction. More frequently, however, the 
 sinuses will have to be laid open, and an attempt made to heal 
 them from the bottom. If the fistula is in front of the scrotum, 
 the introduction of a small crystal of nitrate of silver sometimes 
 effects a cure, but more often a urethro-plastic operation will be 
 required. 
 
313 
 
 IlO-FXiAIVIAIATION' OF THE PROSTATS. 
 
 The prostate is liable to be acutely inflamed. The most com- 
 mon causes of this afiection are gonorrhoea, blows on the peri- 
 neum, irritation of the genital organs or about the rectum, and 
 exposure to cold and wet. 
 
 The symptoms are pain and heat in the situation of the prostate, 
 tenderness on deep pressure in the perineum, frequent calls to 
 make water, with some difliculty in doing so. Evacuation of the 
 bowels is attended with pain. 
 
 Treatment. — The patient should be confined to bed, and the 
 part well fomented. Leeches may be applied to the perineum 
 with great advantage, and opiate enemata introduced into the 
 rectum (F. 90). If there is retention of urine, a flexible catheter 
 must be passed from time to time, as occasion may require. 
 
 Abscess of the prostate sometimes occurs as a consequence of 
 acute inflammation. When this happens, an early incision should 
 be made through the perineum, to prevent the abscess from 
 bursting either into the rectum or urethra. 
 
 In this, and in all acute diseases about the pelvic organs, the 
 patient should be confined to bed. The horizontal position and 
 the equable warmth do much to promote his recovery. 
 
 ENIiARGEXVIEM-T OF THE PROSTATE 
 
 is by no means uncommon in advanced life. 
 
 The muscular fibre, which forms the larger portion of the 
 gland, becomes simply hypertro- 
 phied. Sometimes it enlarges 
 imifoi-mly ; sometimes one side, one 
 lateral lobe, increases more than 
 the other. Sometimes the enlarge- 
 ment is chiefly in the central and 
 posterior part, between the ejacula- 
 tory ducts, forming what has been 
 called the "middle lobe." Fig. 
 139, taken from a preparation in 
 the museum of Charing Cross 
 Hospital, shows the enlargement of 
 this middle lobe, and the consequent 
 hypertrophy of the bladder. In 
 any case, the course and dimensions 
 of the urethra are altered. The 
 curve which it forms as it enters 
 the bladder is increased and 
 
 Fiff. 139. 
 
 Enlarged prostate and 
 hj-pertrophied bladder. 
 
314 DISEASES OF TISSUES AND ORGANS. 
 
 lengthened. If the enlargement is confined to one lateral lobe, 
 the urethra will be twisted ; if it is in the posterior median 
 portion, then the passage will be flattened, compressed, and closed 
 as it wei'e by a valve. 
 
 Symptoms. — The water is passed slowly and with straining. 
 There are frequent calls to micturate, but it is impossible for the 
 patient to empty his bladder altogether, on account of the 
 mechanical impediment. A residuum of urine is left, which de- 
 composes, and excites disease in the coats of the bladder, giving 
 rise to great pain and distress. Occasionally, there may be acute 
 attacks of inflammation, or complete retention. On examination 
 per rectum the surgeon feels that there is enlargement ; and if 
 he attempts to pass an ordinary catheter, he meets with difficulty 
 and obstruction. 
 
 The treatment is merely palliative. A flexible catheter should 
 be passed from time to time in order to draw off the residual 
 urine. If this meets with obstruction, the surgeon should try 
 a gum-catheter, mounted on a stylet. By withdrawing the 
 stylet, while he pushes on the catheter, he can increase the curve 
 of the instrument, and very probably it will pass into the bladder. 
 If a silver instrument is preferred, it should have a large curve 
 and a long shaft. The soft French " elbowed" catheter is very 
 
 suitable to some cases (Fig. 
 Fig. 140. 140). The patient may per- 
 
 haps be taught to pass an 
 instrument for himself. He 
 should support himself on 
 his hands and knees while 
 the water is escaping. If 
 the coats of the bladder 
 have become aflected, they 
 must be treated in the way 
 Elbowed catheter. that will be explained in 
 
 speaking of the diseases of 
 that organ. When complete retention occurs, it may be 
 necessary to tap the bladder above the pubes, or to puncture 
 through the rectum, or to force a passage through the prostate. 
 But the last-named operation, though sanctioned by high autho- 
 rity, is not regarded with favour by modern surgeons. The bowels 
 should be regulated, and excesses of all kinds should be avoided, so 
 that, as far as possible, inflammatory attacks may be prevented. 
 
 ACUTE IITFIiAIMEniATZOir OF THE BXiADDER 
 
 {actUe cystitis) may arise spontaneously, or from neglected 
 gonorrhoea, or from the unskilful use of instruments. As an 
 
CHRONIC INFLAMMATION OF THE BLADDEE. 315 
 
 idiopathic disease it is rarely seen, and then it is probably of a 
 gouty character. Sir H. Thompson thinks it is sometimes due 
 to infection conveyed by the use of catheters that have not been 
 thoroughly cleaned ; and he recommends that all instruments 
 which are introduced into the bladder should be smeared with 
 carbolised oil. The following is the formula which he suggests : 
 — R) Acidi carbolic! med. gr. xij. ; olei olivse 3J {Brit. Med. 
 Jour., May 10, 1879). 
 
 Symptoms. — There is pain, which extends to the sacrum, the 
 perineum, and along the urethra, with tenderness on deep pressure 
 over the pubes. The water is passed frequently, with pain and 
 difficulty; and when the bladder is emptied, the symptoms are 
 aggravated rather than relieved. At first, the urine contains 
 only mucus, but afterwards it is mixed with pus and blood. 
 There is great constitutional disturbance, with mental depression 
 and irritability, 
 
 Treatment. — The patient must be confined to bed, and re- 
 stricted to a low diet. Leeches should be applied to the lower 
 part of the abdomen. Fomentations and warm hip-baths should 
 be used, a free purge should be given, followed by gentle laxatives. 
 Opium should be administered, both by the mouth and in suppo- 
 sitories (F. 90). Sir H. Thompson recommends injecting the 
 bladder with borax and glycerine in warm water (F. 9j. 
 
 CBRON-IC XNFIiiilMCniATIOia- OF THE BIiABDER 
 
 {chrome cystitis, catarrhus vesiccB) generally depends upon stric- 
 ture, enlarged prostate, stone in the bladder, or disease of the 
 rectum or kidneys. It may, however, arise spontaneously, and 
 then it is probably due to gout or scrofula in the system. 
 
 Symptoms. — There is frequent and painful micturition. The 
 urine contains a large quantity of viscid mucus, mixed with 
 pus and streaked with whitish lines of phosphate of lime. 
 Subsequently, as the disease progresses, the secretion becomes 
 brownish, ammoniacal, and very offensive. The mucous coat 
 may become ulcerated, and then there will be blood in the urine, 
 with great aggravation of pain. The muscular coat becomes 
 hypertrophied or sacculated, and perhaps encrusted with phos- 
 phate of lime. Ultimately the disease may extend to the kidneys, 
 and then death cannot be long delayed. 
 
 Treatment. — The cause should, if possible, be removed — stric- 
 ture dilated, stone taken away. Disease of the kidneys or pros- 
 tate should be palliated. 
 
 The bladder should be daily washed out with warm water, by 
 means of a syringe and a double-current catheter. Or — and this is 
 simpler and better — an India-rubber tube should be attached to a 
 
316 DISEASES OF TISSUES AND OEQANS. 
 
 large gum-catheter, and a funnel inserted into the free end of the 
 tube. The catheter should then be passed, the funnel raised, 
 and the warm water poured down it. When a sufficient quantity 
 has made its way into the bladder, the funnel should be lowered, 
 and the contents of the bladder will escape. This may be re- 
 peated as often as necessary. A little of Condy's fluid mixed 
 with the water makes a good wash for cases in which the urine is 
 very offensive. 
 
 Opium and henbane should be given by the mouth, or morphia 
 or belladonna by the rectum (F. 90), But if the kidneys are much 
 affected, narcotics must be prescribed with caution. The medical 
 treatment should include the preparations of buchu, pareira, uva 
 ursi, and the muriated tincture of iron ; while the vegetable acids 
 or the alkalies are given, according to the state of the urine. 
 But of all medicines the most valuable in these cases are cod-liver 
 oil and the syrup of the iodide of iron. The diet should be 
 generous but unirritating, and should be accompanied by an 
 abundance of simple diluent drinks (F. 102, 103). 
 
 CAITCER OF THE BXiADBEXt. 
 
 The bladder is often secondarily affected in cases of cancer of 
 the rectum, but it may also be the primary seat of disease. 
 When this happens, the growth will be found to be either 
 medullary or epithelial (villous). 
 
 The symptoms are frequent and difficult micturition, and pain 
 in the loins, the lower part of the body and down the thighs, espe- 
 cially when the bladder is empty. The urine is thick, foetid, and 
 mixed with blood. If the sediment is examined with the micro- 
 scope, it may perhaps facilitate the diagnosis. If the bladder is 
 sounded, no stone can be detected, but a soft mass can sometimes 
 be felt projecting from the wall. 
 
 The treatment is merely palliative. All that we can do is 
 to support the strength by a generous diet and tonics j to check 
 the tendency to hsemorrhage by styptics, such as the gallic acid 
 (F. 29) or the muriated tincture of iron; and to allay pain by 
 opium. In consequence of the frequert micturition the patient 
 is apt to become excoriated. Early attention to this point may 
 save him from much suffering. 
 
 URZITARY DEPOSITS. 
 
 The deposits which are met with in the urine are chiefly the 
 following — 
 
 1. Minute crystals of free uric (lithic) acid, or the urates of 
 ammonia and soda. This constitutes the brick-dust or lateritious 
 
UEINAEY DEPOSITS. 
 
 317 
 
 Fiff. 141. 
 
 deposit", so often seen in inflammatory states, and more particu- 
 larly in gouty or rheumatic afiections. 
 
 2. Oxalate of lime. 
 
 3. Phosphates of lime, magnesia, and ammonia. 
 
 When any of these deposits is habitually present, the patient 
 is said to be of the phosphatic, the oxalic, or the lithic acid 
 diathesis. The deposit may take place in the bladder, as well as 
 out of it. First, minute particles of gravel are formed, and these 
 gradually increase, until they result in a stone {calculus). 
 
 These three diatheses correspond to the three commonest 
 varieties of calculi that are met with in the bladder — the lithic 
 acid, the oxalate of lime, and the phosphatic calculus. 
 
 1. The lithic acid stone is usually of moderate size, smooth, 
 flattened, of a light brown or drab colour, and arranged in con- 
 centric laminae (Fig. 141). It is met 
 with chiefly in children, and in adults 
 of a gouty habit. It indicates derange- 
 ment of the digestive organs and mal- 
 assimilation, often from the use of an 
 over-stimulating diet. The tendency to 
 the formation of lithic acid calculus is 
 shown by the habitual deposit of white, 
 pink, or red lithates in the urine, and by 
 occasional " fits of the gravel." These 
 attacks are of a febrile nature, attended 
 with much pain in the loins, sickness, and constitutional dis- 
 turbance. They depend upon irritation of the urinary organs, 
 from the presence of crystals of lithic acid. 
 
 The general treatment must consist in early hours, sufficient 
 exercise, and a strictly regulated diet, which is plain in quality 
 and moderate in quantity. The bowels should be kept freely 
 open by saline aperients; and in this class there is nothing 
 better than the natural waters of Friedrich shall, Pullna, or 
 Hunyadi-Janos. At the same time alkaline medicines should be 
 prescribed (F. 56, 64, 67), or a tumblerful of Vichy or Carlsbad 
 water should be taken once or twice a day. If the patient lays 
 aside the use of beer, wine, and spirits altogether, and drinks 
 instead a sparkling water, such as Seltzer, or Apollinaris, he will 
 probably find himself much the better. 
 
 2. The oxalate of lime, or mulberry calculus, is generally 
 associated with exhaustion of the nervous system. The urine 
 deposits a slight sediment of octohedral or dumb-bell crystals of 
 oxalate of lime. The stone itself is of a dark purple or brown 
 colour, of a moderate size, more or less round, with a rough tuber- 
 culated surface, and very hard. 
 
 Lithic acid calculus. 
 
318 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 The oxalic diathesis sliould be treated by a liglit but nourishing 
 diet, avoiding sweets and fermented liquors. Tonics should be pre- 
 scribed, especially the mineral acids, iron and quinine (P. 30, 31, 
 32, 47, 65), with plenty of fresh air and sunlight. 
 
 3. The phosphatic calculus is met with in persons of broken 
 health, or of exhausted nervous energy. It is apt to form 
 when there is disease of the bladder, and the urine is imperfectly 
 voided. It is sometimes composed of triple phosphate, sometimes 
 of phosphate of lime, sometimes of a mixture of the two. The 
 mixed variety is the commonest; it is called the fusible calculus, 
 because it melts readily on the application of heat. Phosphatic 
 stones sometimes attain great size — the bladder is filled with an 
 irregular chalky mass, which is easily broken down. Sometimes 
 they are only semi-solid, and present an appearance like mortar. 
 
 The phosphatic diathesis should be treated by the mineral acids 
 (F. 30, 31, 32), a generous but unirritating diet, and a regulated 
 manner of life. 
 
 CA3tCUIaVS IZSr THE KIDSTBY. 
 
 Calculi not unfrequently form in the kidney. Sometimes they 
 remain there, but more often they descend to the bladder. 
 
 In their chemical composition renal calculi present the same 
 varieties as vesical calculi. In some instances they are lodged 
 in the uriniferous tubes, in others they lie in the pelvis of the 
 kidney. As they increase in bulk they disorganize the proper 
 renal structure, and give rise to an irregular development of 
 solid matter and cysts. Abscesses form, sometimes inside, some- 
 times around, the kidney. In rare instances these abscesses have 
 
 opened in the loin, and 
 
 Fig. 142. 
 
 dis- 
 
 the stone has been 
 charged. Much more 
 frequently calculi, while 
 they are yet small, pass 
 into the ureter. This 
 is usually accompanied 
 by intense pain, retrac- 
 tion of the testis, vomit- 
 ing and constipation ; 
 and is not relieved till 
 the stone reaches the 
 bladder. If the calculus 
 remains in the kidney, 
 the patient is liable to severe attacks of pain and sickness 
 — nephritic colic — whenever the stone is displaced, as it may 
 be in walking, driving, &c. Fig. 142 represents a renal calculus 
 
 Kenal calculus. 
 
CALCULUS IN THE BLADDER. 
 
 319 
 
 Fig. 143. 
 
 taken, post-mortem, from one of my patients. The drawing is 
 half the natural size. 
 
 Treatment. — Attacks of nephritic colic must be treated by 
 cupping the loins or applying mustard poultices, by hot baths, 
 and full doses of opium ; and the same treatment must be pur- 
 sued when a calculus is descending along the ureter. 
 
 Ever since the days of Hippocrates surgeons have discussed the 
 possibility of removing renal calculi by an incision in the loins ; 
 and a few cases are on record in which a partial or complete 
 operation has been performed. But nephrotomy can hardly yet 
 be said to have taken its place among the established proceedings 
 of surgery. 
 
 CAXiCUZiUS ZUr TBE BZiADBEB. 
 
 A stone may either originate in the bladder or in the kidney, 
 and from thence, as we have 
 said, make its way into the 
 bladder. In the case of the 
 lithic and oxalic acid calculi, 
 the nucleus is almost invari- 
 ably formed in the kidney. 
 
 Sometimes there is but 
 one stone in the bladder, at 
 other times there are many. 
 When several calculi are 
 present at once, they rub 
 against one another, so 
 that their adjacent sides become flattened, and present facets 
 (Fig. 143). 
 
 Calculi generally lie loose in the bladder, but it occasionally 
 happens that they become encysted in one of the sacculi which 
 are apt to be formed when the muscular coat becomes hyper- 
 trophied. 
 
 Calculus is much more frequent in men than in women. Again, 
 more than half of all the cases occur during childhood ; while in 
 some countries and districts the disease is far more prevalent than 
 in others. Along the east coast of England, in Norfolk particu- 
 larly, it is more common than in other parts of this country. 
 
 Symptoms. — There is pain in the bladder and perineum ex- 
 tending to the glans penis, and down the legs to the soles of the 
 feet. It is aggravated by quick movements, as in riding or 
 leaping, especially when the bladder is empty. There are 
 frequent calls to make water. The urine may be mixed with 
 mucus or pus, and it occasionally contains blood. Sometimes the 
 stone rolls forward during micturition, so as to cover the neck of 
 
 Calculi with facets. 
 
320 DISEASES OF TISSUES AND OEaANS. 
 
 the bladder, and then the flow of urine is suddenly stopped. 
 " When such persons (as have stone in the bladder) make water," 
 says Hippocrates, " the stone forced down by the urine falls into 
 the neck of the bladder, and stops the urine, and occasions in- 
 tense pain ; so that calculous children rub their privy parts, and 
 tear at them, as supposing that the obstruction is situated 
 there " (Syd. Soc. Translation, i. 201). Sometimes there is 
 tenesmus and prolapsus recti, more especially in children ; and 
 sometimes there is priapism. 
 
 When the surgeon suspects the presence of a stone, he proceeds 
 to sound the patient. In the case of children, it is generally 
 necessary to give chloroform before this can be done ; and in 
 every case it is well to raise the patient's hips on a pillow, so that 
 the stone may gravitate towards the fundus vesicae. The sound 
 — a steel instrument with a narrow shaft, and a short, curved 
 and slightly bulbous extremity — is introduced into the bladder. 
 The surgeon holds the handle of the instrument lightly but firmly, 
 and by a series of short, quick movements of the wrist he gently 
 taps the wall of the bladder with the end of the sound. The 
 examination should be systematic. The surgeon should advance 
 the sound to the further part of the bladder, which, if the 
 patient is well placed, will also be the most dependent. If he 
 fails to find the stone here, he should slowly withdraw the sound, 
 tapping (let us say) on the right hand side as he does so. Then he 
 should repeat the same steps, tapping on the left hand. Thus, 
 the whole floor of the bladder will be systematically explored. 
 
 If the stone should happen to be lodged behind an enlarged 
 prostate, or above the pubes, or if it should be encysted, there 
 may be difficulty in detecting it. 
 
 When the point of the sound touches the stone, the hand is 
 conscious of contact with a hard body. By tapping on the stone 
 a clear note may be produced, which is distinctly audible, and 
 which is very characteristic. By a skilful use of the sound the 
 position and size of the stone may be estimated. A stone of 
 moderate dimensions may be accurately measured by means of a 
 lithotrite — much in the same way that the shoemaker measures 
 the foot with his rule. 
 
 If a stone is allowed to remain in the bladder, it is apt to cause 
 enlargement of the prostate, and serious disease of the coats. 
 The muscular tissue becomes hypertrophied, and the mucous 
 membrane t'.iickened, congested, and perhaps ulcerated. 
 
 Treatment. — Hitherto all attempts to dissolve calculi by 
 chemical agents, without injuring the coats of the bladder, have 
 been unsuccessful. It is therefore necessary either to cut into 
 the bladder, and remove the stone entire {lithotomy) ; or else to 
 
LITHOTOMY. 321 
 
 crusb the stone in the bladder, and allow the fragments to be 
 discharged with the urine {lithotrity). 
 
 IiITHOTOmV, 
 
 There are various ways of cutting into the bladder. That 
 which will be here described is commonly called the lateral 
 operation (Cheselden's). We shall suppose that the patient is an 
 adult, and that the left side of the perineum is to be cut. 
 
 In order to prepare the patient for the operation, he should be 
 kept quiet for a few days, his health regulated, and irritability 
 of the bladder allayed. The bowels should be opened before 
 the operation by an aperient, or the rectum cleared by an 
 enema. 
 
 The patient should be directed to hold his urine for a few 
 hours before the operation ; or a little tepid water (§iv) should 
 be injected into the bladder. He should be placed on a table, or 
 hard bed, of convenient height. The thighs should be separated 
 widely, and strongly flexed on the pelvis, while the legs are bent 
 on the thighs. The lower extremities are to be held in this posi- 
 tion by assistants, or tied with a lithotomy bandage. Such a 
 bandage used to be applied as a matter of course, but since the 
 introduction of chloroform it has generally been dispensed with. 
 There are, however, many cases in which the surgeon and his 
 assistants would be greatly aided by this appliance. It can easily 
 be adjusted after the patient is under the influence of the anaes- 
 thetic, and then his movements are much more easily controlled 
 than they are without it. It may be applied in the following 
 way : — The patient being placed in the usual position for litho- 
 tomy, the surgeon takes a flannel " leg-bandage," or a piece of 
 worsted webbing about three yards long, makes a " clove-hitch " 
 in the middle of it, and puts it over one of the patient's wrists. 
 He next places the patient's hand on the outside of the corre- 
 sponding foot, and proceeds to apply the two ends of the flannel 
 roller round the hand and foot, in such a way as to bind them 
 securely together. The roller should be kept as flat as possible, 
 and the ends should be tied in a bow on the outer side, so that 
 they may be readily unfastened. The same steps are then repeated 
 on the opposite side, and the bandage is complete. In cases of 
 this kind, Mr. Prichard, of Bristol, uses a very convenient bracelet 
 and anklet, which are buckled round the wrist and ankle respec- 
 tively, and then hooked together when the proper time has arrived 
 for placing the patient in position. 
 
 When the operation is about to be performed, the patient 
 should be so placed that the buttocks may project slightly over 
 the edge of the bed, and the perineum be freely exposed. The 
 
 T 
 
322 DISEASES OF TISSUES AND OEGANS. 
 
 surgeon begins by introducing a sound, to naalce sure of the 
 presence of the stone. This is then withdrawn, and a full-sized 
 curved or rectangular staff, grooved on the left side, is passed, 
 and entrusted to an assistant, who holds it well up against the 
 arch of the pubes, in such a position as the surgeon directs, and 
 at the same time raises the scrotum. The surgeon next takes 
 his seat opposite the patient. With his left hand he stretches 
 the skin, while with his right he cuts the left side of the perineum. 
 The external incision should begin about an inch and a half above 
 the anus, and in the middle line of the body. It should be car- 
 ried obliquely downwards and outwards, to the extent of about 
 three inches, towards a point midway between the tuber ischii 
 and the anus. By this incision the skin, superficial fascia, and 
 subcutaneous fat are divided. A second and deeper incision is 
 next made along the middle portion of the former one, by which 
 the transversalis perinei muscle is divided, and the space lying 
 between the accelerator urinse and the erector penis muscles is 
 opened. The forefinger of the left hand is then introduced into 
 the wound, until the groove in the staff can be felt, thinly 
 covered by the membranous urethra. The point of the knife is 
 then pushed into the groove, and carried along far enough to 
 notch the prostate. Into this slit in the urethra the point of the 
 left forefinger is insinuated. By combining slight force with a 
 rotatory movement it is carried along the side of the staff into 
 the bladder. The staff is then withdrawn, the surgeon still 
 retaining his finger in the bladder. A lithotomy forceps is next 
 passed along the side of the finger into the bladder, and the finger 
 is withdrawn. The stone is then seized, and removed. Some- 
 times a scoop is found a more convenient instrument for with- 
 drawing the stone. When this is used, the calculus is grasped 
 between the scoop and the point of the finger. If it is necessary 
 to employ gentle force in order to extract the stone, it should be 
 applied very gradually, and combined with a rotatory movement, 
 so as to stretch the tissues slowly and evenly. 
 
 If there is free arterial bleeding, it may be necessary to apply 
 one or two ligatures to the sides of the wound. If there is con- 
 tinued oozing, the wound should be plugged with lint WTapped 
 round a tube or an elastic catheter. At first the urine escapes 
 by the wound j but by the end of a week or ten days it begins 
 to pass by the urethra. If all goes well the wound is generally 
 healed in about three weeks. 
 
 Lateral lithotomy in children is a very successful operation. 
 In performing it, the surgeon should bear in mind that the 
 bladder, before the age of puberty, lies high up towards the ab- 
 domen. Moreover, as the urethra is small, the prostate compa- 
 
LITHOTRITY. 323 
 
 ratively undeveloped, and the tissues yielding, care must be taken 
 not to push the bladder before the finger. 
 
 The success of lithotomy in adults depends in a great measure 
 upon the state of the bladder and kidneys. If these organs are 
 free from disease, the result is much more likely to be favourable. 
 Diffuse inflammation of the cellular tissue about the neck of the 
 bladder — often arising from infiltration of urine — is a frequent 
 cause of death. Occasionally patients die after the operation 
 from haemorrhage, or cystitis, or other complications ; but these 
 cases are comparatively rare. 
 
 Of late years the median operation has been revived by Mr. 
 Allarton. It is most suitable to the case of small stones which 
 cannot be crushed, or for foreign bodies in the bladder. It is 
 performed thus : — A staff, with a central groove on its convexity, 
 is introduced into the bladder, and confided to an assistant. The 
 surgeon then passes his left forefinger into the rectum, and feels 
 the prostate. He next pushes the knife, with its back turned 
 towards the rectum, deeply into the middle line of the perineum, 
 about half an inch above the anus, and hits the groove in the 
 staff at the further end of the membranous portion of the urethra. 
 Here he makes a small incision, cutting from behind forwards, 
 and as he withdraws the knife, he enlarges the external wound 
 upwards. He then introduces the point of his finger, or of a 
 dilator, into the incision in the urethra, and stretches the pros- 
 tate, until he can reach the bladder with a small forceps. 
 
 The bilateral and the supra-pubic operations are so seldom 
 performed, that we need not do more than allude to them. 
 
 DtlTHOTRITir 
 
 is the name applied to the more modern operation of crushing. 
 Suitable instruments are introduced into the bladder, the stone 
 is seized, and is broken into small fragments. These are either 
 removed at once, or allowed to make their way out with the 
 urine. 
 
 When it can be practised, lithotrity is a safer, as well as a less 
 formidable, operation than lithotomy ; but there are many cases 
 to which it is inapplicable. For example, in male children the 
 urethra is too small to admit the passage of the necessary instru- 
 ments. Or, again, where there is stricture, or enlarged prostate, 
 or an irritable bladder, or when the stone is very hard, or very 
 large, or where many stones are present, the case is not suitable 
 for lithotrity. Probably, also, when there is well-marked kidney 
 disease the risk of lithotrity is, on the whole, greater than that 
 of lithotomy. 
 
 The lithotrite, or crushing instrument, is shaped somewhat like 
 
 y2 
 
324 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 Fig. 144. 
 
 a sound. It has a handle, and a long straight shaft with a short 
 curved extremity. It consists of two blades, which are accurately 
 fitted together. The outer blade is fixed, and continuous with 
 the handle. The inner blade travels in a longitudinal groove cut 
 in the outer one. The force is variously 
 applied, either by a screw, or by a rack and 
 pinion in connexion with the handle. By 
 withdrawing the inner blade, the ex- 
 tremity of the instrument opens, so as to 
 embrace the stone. The power is then 
 applied, the blade is pushed home to its 
 original position, and the stone crushed. 
 Fig. 144 represents the lithotrite which is 
 commonly used by Sir Henry Thompson, 
 and which is known by his name. 
 
 The patient should be directed to hold 
 his water for a few hours before the ope- 
 ration, or his bladder should be emptied by 
 the surgeon, and six ounces of tepid water 
 injected. The hips should be raised, so 
 that the stone may gravitate towards the 
 fundus of the bladder. The lithotrite is 
 then introduced, and with a light hand 
 and gentle touch the surgeon feels for the 
 stone. When he has found it, he withdraws 
 the inner blade sufficiently to include the 
 calculus within the grasp of the instru- 
 ment, lifts it from the surface of the 
 bladder, and then applies the force. If he 
 thinks fit, he repeats the same process at 
 once upon the larger fragments. But, 
 under any circumstances, the " sitting" 
 should not be protracted. It is better to 
 await the result of the first operation, and 
 perform a second, a third, or a fourth, if 
 necessary, at intervals of a week. Nothing 
 is more dangerous than the prolonged use 
 of instruments in the bladder. 
 
 Some surgeons extract the fragments 
 
 at the time of the operation with a scoop 
 
 constructed on the same principle as a 
 
 lithotrite. By this means they make sure 
 
 of getting rid of some of the larger pieces, which might with 
 
 difficulty pass along the urethra. Others prefer leaving 
 
 them to be washed out by the urine. Mr. Clover's suction 
 
PHIMOSIS. 325 
 
 apparatus is a simple and efficient means of removing the 
 fragments. 
 
 In the after treatment the patient should he kept perfectly 
 quiet in hed. A catheter may perhaps have to he passed occa- 
 sionally to draw off the water. If inflammatory symptoms arise, 
 they must be met by fomentations ; while pain and irritability 
 are allayed by opium. 
 
 Stone in women is comparatively a rare disease. For this 
 several reasons may be assigned. Their diet is less stimulating, 
 the urine is less concentrated, the urethra is more capacious, and 
 allows small stones to pass ; and women are less subject than men 
 to those diseased states of the bladder which often give rise to 
 phosphatic concretions. 
 
 Calculus in tho female presents much the same train of symp- 
 toms as in the male. 
 
 Treatment. — The stone should, if possible, be crushed. If 
 there is some reason for not performing lithotrity, the urethra 
 may be dilated, either with the surgeon's forefinger or with the 
 3-bladed dilator that is made for the purpose. If this is insuffi- 
 cient, dilatation may be combined with a small incision through the 
 anterior part of the urethra. Or the bladder may be opened from 
 the vagina, and the case treated subsequently as a vesico-vaginal 
 fistula. But it is much better to avoid a cutting operation, if 
 possible i for it is likely to be followed by incontinence of urine, 
 which may make the patient miserable for months or years. 
 Even after dilatation, it will probably be some time before she is 
 able to hold her water. 
 
 PHinxoszs 
 
 means an abnormal contraction of the free border of the prepuce. 
 It may be congenital, or it may be caused by the cicatrization of 
 ulcers or chancres. When it is present, the preputial secretion 
 is apt to be retained under the foreskin, where it gives rise to 
 much irritation, and to occasional attacks of inflammation, with 
 discharge (balanitis). Phimosis is often the exciting cause of 
 cancer of the penis. 
 
 Treatment. — Warm water, or warm water and glycerine, should 
 be injected regularly and habitually under the foreskin. This 
 sometimes effects a great improvement. But in most cases an 
 operation will be required. If the foreskin is long and tight, or 
 if it is thickened by cicatrices, it should be drawn forward, held 
 between the blades of a forceps, so as to protect the glans penis, 
 and cut off evenly by one sweep of the knife. If, however, the 
 case is less severe, it will suffice to slit up the prepuce on its 
 dorsal aspect as far as the base of the glans. This should be done 
 
326 DISEASES OF TISSUES AND ORGANS. 
 
 by introducing an oiled director underneath the foreskin, and 
 passing upon it a curved, sharp-pointed bistoury, piercing the 
 skin, and cutting from within outwards. The mucous membrane 
 will probably require a second incision, for the chief seat of the 
 constriction is there. If the side-flaps are very long, a triangular 
 piece may be taken ofi" each. The skin and mucosa should then 
 be united by continuous or interrupted sutures, and water- 
 dressing applied. In young children it is hardly necessary to 
 use any stitches. 
 
 PARAPHIMOSIS. 
 
 When a tight foreskin is drawn over the glans and allowed to 
 remain there, it constitutes the condition known as paraphimosis. 
 The penis is constricted ; the skin becomes cedematous ; and the 
 mucous lining of the prepuce and glans become congested. 
 If this state of things is allowed to continue, ulceration or 
 sloughing takes place. 
 
 Treatment. — The surgeon, having oiled the parts, takes the 
 penis between the fingers of both hands, and draws the o/)nstric- 
 tion slowly but steadily forwards; at the same time, with his 
 thumbs, he compresses the glans, and pushes it backwards. It 
 gives the surgeon a firmer hold on the penis, if he wraps a fold of 
 lint round it before he begins to make traction and pressure. 
 Sometimes the constriction may have to be divided with a knife 
 before reduction can be effected. 
 
 BVPOSPABIAS AN-B EPISPADIAS. 
 
 Sometimes the urethra, from a congenital malformation, ter- 
 minates on the under surface of the penis before it reaches the 
 point of the glans. This is termed hypospadias. - When it pre- 
 sents itself in a somewhat similar way on the dorsal aspect, it is 
 called epispadias. The malformation may be very slight ; or it 
 may extend, in the one case, to the scrotum ; in the other, 
 to the anterior wall of the bladder {extroversion of the 
 bladder). 
 
 Treatment. — When the deformity is only slight, it does not 
 interfere with the natural functions of the urethra, and requires 
 no treatment. When it is extensive, the patient may have to 
 wear a mechanical contrivance to protect the parts; or an 
 attempt may be made to cure the deformity by means of a plastic 
 operation. Mr. John Wood, Mr. Holmes, and others, have 
 shown much ingenuity and skill in dealing with this malforma- 
 tion. 
 
327 
 
 CAirCER OF THE PEITZS 
 
 occurs only in those who are advanced in life. It may often be 
 traced to the irritation caused by congenital phimosis. It gene- 
 rally takes the form of an epithelial growth. 
 
 A small tubercle, or ulcer, forms on the inner surface of the 
 prepuce, spreads, and implicates the glans. Gradually the 
 growth increases in size, until it presents a rough, irregular mass, 
 which discharges an offensive matter. The lymphatics of the 
 penis become swollen, and the glands in the groin are enlarged. 
 If the orifice of the urethra is involved, micturition may be diffi- 
 cult ; or there may be complete retention. 
 
 The diagnosis between cancer of the penis and gonorrhoea! 
 warts or chancrous ulceration may generally be made without 
 difficulty by attending to the following -p. ^^^ 
 
 points : — Cancer has an indurated base, 
 resists treatment, and progresses con- 
 stantly. In the case of gonorrhoeal 
 warts there is a history of infection, 
 and the base is not indurated : when 
 they are removed, the mucosa is soft 
 and natural. In the case of chancrous 
 ulceration there is a history of infec- 
 tion, and the disease yields to proper 
 treatment. 
 
 Treatment. — If the cancer is small, 
 
 it mav suffice to remove it by a free „ , , , 
 
 *•. , ^ .^ .. . 1 J Cancer of the penis, 
 
 dissection ; but if it is large and 
 
 wide-spread, the penis should be amputated above the seat 
 
 of disease. 
 
 Amputation of the penis. — The surgeon takes the penis in 
 
 his left hand, and puts it on the stretch, while he removes the 
 
 disease with one sweep of the amputating knife. The bleeding 
 
 points must be ligatured or twisted. The mucous membrane of 
 
 the urethra should then be nicked, so as to divide it into four 
 
 equal flaps, and stitched to the margins of the skin. If this is 
 
 done, there will be no fear of the troublesome contraction of the 
 
 orifice, which sometimes follows the operation. 
 
 BTSROCEIiE 
 
 is the name given to a collection of serous fluid in the tunica 
 vaginalis. Sometimes the disease is traced to an injury, or a 
 strain, or an attack of orchitis. Sometimes it arises without any 
 assignable cause. 
 
328 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 rig. 146. 
 
 Hydrocele. 
 
 Symptoms. — The swelling takes place gradually. It begins 
 from the bottoni, and slowly extends upwards. The resulting 
 tumour has a pyriform shape, and a smooth, regular outline 
 (Fig 146). It is free from pain or 
 tenderness, but there is a feeling of 
 weight and dragging. Except in certain 
 rare cases, it does not disappear when 
 the patient lies down. It is translucent, 
 elastic, and fluctuating. The testicle 
 generally lies at the back, almost sur- 
 rounded by fluid. It is never found 
 lying free below the swelling, as in the 
 case of rupture. No impulse is com- 
 municated to the tumour by coughing. 
 If there is any doubt about the diag- 
 nosis, the tumour should be examined 
 by transmitted light. It should be care- 
 fully isolated, and held forward. If a 
 lighted candle is placed on the further 
 side, and the surgeon looks under the 
 edge of his hand or through a roll of paper, he can generally 
 make the diagnosis with certainty and distinguish the position 
 of the testicle. 
 
 The fluid consists of serum of a pale yellow or ^raw colour ; 
 sometimes it is mixed with blood ; and sometimes it is turbid 
 with fibrinous flakes. The average quantity present is about ten 
 or twelve ounces. But sometimes it far exceeds this measure. 
 Cline tapped a hydrocele in Gibbon, the historian, and drew off 
 six quarts of fluid. 
 
 The treatment is either palliative or radical. The palliative 
 treatment consists in tapping the swelling simply ; the radical, in 
 tapping it and injecting a stimulating fluid, such as the tincture 
 of iodine or port-wine. By this means it would appear that the 
 healthy functions of the serous membrane are restored. 
 
 In performing the operation of tapping, the surgeon grasps the 
 tumour firmly behind with his left hand, so as to make it tense 
 and prominent in front. He then pushes the trochar and canula 
 in, at right angles to the long axis of the swelling ; and as soon 
 as he feels that the point has entered the cavity, he directs it 
 obliquely upwards. He then withdraws the trochar, and allows 
 the fluid to flow through the canula. If he desires to inject the 
 sac, a syringe is fitted to the canula, the fluid is thrown in, and 
 the canula is removed. The injection, which is generally used, 
 consists of equal parts of tincture of iodine and water — ^j of 
 each. The scrotum should be lightly shaken, so as to bring the 
 
HYDROCELE. 329 
 
 fluid into contact with every part of the tunica vaginalis, and 
 there it should be allowed to remain. When a hydrocele is in- 
 jected, there is generally a good deal of inflammation. This sub- 
 sides in the course of a few days. In most cases a radical cure 
 is effected, and the normal balance between secretion and absorp- 
 tion is restored. 
 
 Congenital Hydrocele. — Infants are liable to the ordinary 
 form of hydrocele ; but they are also subject to a special variety, 
 known as congenital hydrocele. The communication between the 
 peritoneal cavity and the pouch which goes to form the tunica 
 vaginalis remains open, and the fluid occupies the same place as 
 the bowel in a congenital hernia. The two diseases, congenital 
 hydrocele and congenital hernia, are very apt to occur together. 
 
 Treatment. — In infants the ordinary closed hydrocele may be 
 cured by the use of a discutient lotion (F. 18, 21). In the 
 congenital hydrocele the child should wear a truss, so as to obli- 
 terate the opening into the peritoneal cavity. In young subjects 
 mild measures almost always suffice, for nature does much to 
 promote a cure. 
 
 Encysted Hydrocele. — Here the fluid does not form in the 
 tunica vaginalis, but in a cyst connected with the testis or epidi- 
 dymis. Small cysts in this situation are very common. Some- 
 times they increase to an inconvenient size. 
 
 Symptoms. — In many respects they resemble the common 
 hydrocele. But they do not attain the same bulk, and they may 
 generally be felt to be offsets from the testis or epididymis. It 
 is a curious fact that spermatozoa are often found in the fluid 
 they contain. 
 
 Treatment. — The cyst may be simply tapped, or tapped and 
 injected; or a seton may be passed through it; or, if milder 
 measures fail, it may be laid open and allowed to granulate. 
 
 Hydrocele of the Cord. — A tumour containing serous fluid 
 occasionally forms on the cord, in or below the inguinal canal. 
 Sometimes it is fixed ; sometimes it may be pushed back into the 
 abdominal cavity. It receives no impulse from coughing; is 
 smooth, elastic, and fluctuating. In some cases it appears to be 
 formed by an extension of the pouch of peritoneum, which dips 
 into the internal abdominal ring. In other cases it seems to be 
 developed in a cyst connected with the coverings of the cord. 
 
 The treatment consists in following the same general principles 
 as in the foregoing cases, only the situation of the disease gives 
 rise to a little difficulty. Acupuncture should be tried, or a 
 seton passed through the swelling, or it may be laid open, and 
 allowed to granulate. 
 
330 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 BSMATOCEIiS 
 
 is the name given to a collection of blood in the tunica vaginalis. 
 
 It is generally traumatic, the result of a blow or wound, though 
 
 it may arise spontaneously. Fig. 147 was drawn from a child, 
 
 who had fallen and struck his 
 lig. 147. jg£!j. |;gg^jg against a piece of 
 
 furniture. 
 
 Symptoms. — The tunica va- 
 ginalis becomes gradually dis- 
 tended ; the testicle is com- 
 pressed, and, if the disease 
 persists, it is very apt to waste. 
 If the hsematocele has lasted 
 for a considerable time, it may 
 attain a large size, and the 
 fibrine of the blood may be 
 deposited in layers on the sur- 
 face of the tunica vaginalis, so 
 that it resembles the sac of an 
 aneurysm. 
 Treatment. — When the case is recent, rest, pressure, and dis- 
 cutient lotions should be tried (F. 18, 21). If these means 
 fail, the tumour may be tapped, or a wire seton passed through 
 it. If it has existed for some time, it will probably have to be 
 laid open, the clots turned out, and the cavity allowed to granu- 
 late. As a last resource, castration may be performed. 
 
 VARZCOCEIiE 
 
 •is the name given to the swelling which is formed by a varicose 
 state of the veins of the spermatic cord. It is caused by anything 
 which retards the venous circulation — e.g., debility, constipation, 
 &c. The left side is more often affected than the right ; partly 
 because the veins of the left side are longer than those of the 
 right, and partly because they are subject to the pressure of the 
 distended sigmoid flexure of the colon. 
 
 Symptoms. — A swelling is felt, which has been aptly compared 
 to worms in a bag. It is irregularly pyramidal, its base resting 
 on the testis, and its apex pointing to the external abdominal 
 ring. It subsides to a great extent when the patient lies down, 
 but soon returns when he stands up. It is accompanied by a 
 sensation of weight, and dragging pain in the back and loins. 
 These feelings are aggravated when the patient takes active 
 
ACUTE INFLAMMATION OF THE TESTIS. 331 
 
 exercise. After it has existed for some time it is apt to cause 
 atrophy of the testicle (Fig. 148). 
 
 Treatment. — The disease may be palliated by wearing a sus- 
 pensory bandage, and bathing the parts frequently with cold 
 water. At the same time, the 
 general health should be improved 
 by tonic medicines (F. 47, 52, 65). 
 
 The radical cure of varicocele is 
 effected by obliterating the veins, 
 on the same principle that we treat 
 varix of the lower extremity. Our 
 object is to compress the coats 
 of the veins, so as to excite adhesive 
 inflammation. If the compressing 
 force is continued, the coats ulcerate, 
 and are divided at the point of 
 pressure. A great many methods 
 are practised, but the principle is 
 the same in all. Some pass a hare- 
 lip pin underneath the veins, and 
 then twist a thick silk over it, in the 
 
 form of a figure-of-8. Others put a noose of silver wire round the 
 veins by means of a needle, which enters the scrotum and emerges 
 at the same point, and then twist it, so as to compress them. 
 A few turns are given to the wire every day, and thus it soon 
 cuts its way out. Some tie the veins in two places, and divide 
 them subcutaneously between the ligatures. But this seems to 
 be both unnecessary and hazardous, and should never be done. 
 
 Before undertaking any of these operations, the spermatic 
 cord should be carefully held aside by an assistant. It may be 
 easily distinguished by its hard, even feeling, like whipcord. 
 
 ACUTE USTItAVtatlAT'LOSi OF THE TESTIS. 
 
 Orchitis. — The testicle is liable to both acute and chronic 
 inflammation. The acute variety is most often seen as an accom- 
 paniment of gonorrhoea ; but it may also result from blows, or it 
 may arise in the course of small-pox or mumps or gout. 
 
 Symptoms. — There is pain, with a dragging sensation in the 
 cord, heat, swelling, redness, exquisite tenderness, pains in the 
 back, loins, and perineum. Pressure with the point of the finger 
 causes intense sickening pain. There is great constitutional 
 disturbance, with nausea and vomiting. When the attack is 
 connected with gonorrhoea, the inflammation extends along the 
 vas deferens ; and then it would appear to be the epididymis 
 which is chiefly affected {epididymitis). The discharge from the 
 
332 
 
 DISEASES OF TISSUES AND OKGANS. 
 
 Fig. 149. 
 
 urethra generally ceases while the inflammation in the testis is at 
 its height. This seems to be due to counter-irritation, and not 
 to metastasis. 
 
 Treatment. — Perfect rest in bed must be enjoined, and the 
 testis raised on a small pillow. Fomentations — plain or medi- 
 cated — should be assiduously ap- 
 plied. If the tunica vaginalis is 
 much distended, the fluid may be 
 evacuated by means of a small 
 trochar. At the same time, purga- 
 tives and diaphoretics should be 
 given, with opium to allay pain and 
 procure sleep (F. 53, 64, 69). 
 
 When the acute stage has passed, 
 and nothing remains but hardness 
 and swelling, the scrotum should be 
 supported by a suspensory bandage. 
 Strapping the testicle evenly and 
 firmly will also be found of the 
 greatest benefit. 
 
 Bandages for supporting the 
 Scrotum. — The scrotum may be 
 supported in various wajs. A sus- 
 pensory bandage, such as those 
 which are sold at the instrument 
 makers, is perhaps the best. 
 But if it is impossible to get one of these, or if the scrotum is so 
 much enlarged that it cannot be contained in one, a very useful 
 substitute may be made with a broad roller and a handkerchief. 
 The roller is passed round the waist, and fastened in front. The 
 handkerchief should then be folded in a triangular form, and the 
 centre of the base of the triangle applied to the perineum behind 
 the scrotum. The corresponding ends are now drawn up, one on 
 each side of the scrotum, and tied to the waistband in the way 
 represented in Fig. 149. The apex of the triangle is then 
 brought up in front of the scrotum, passed round the waistband, 
 and fastened with a pin or in a knot. 
 
 CKROiriC ZIO-FIiAIVIlVIATZON- OF THE TESTIS 
 
 {chronic orchitis) may follow an acute attack, or it may be caused by 
 disease of the urethra, or it may depend upon a syphilitic taint. 
 
 Symptoms. — The testicle becomes enlarged and hardened. 
 There is but little pain or tenderness. The whole organ is 
 generally affected equally. There is usually more or less effusion 
 into the tunica vaginalis. One or both testicles may be the 
 
 Handkerchief bandage for 
 the scrotum. 
 
CHEONIC INFLAMMATION OF THE TESTIS. 333 
 
 Fig. 150. 
 
 seat of disease. There is deposit of yellow, cbeesy, fibrinous 
 matter in and between tbe tubules. 
 
 Treatment. — If there is disease of the urethra, we must endea- 
 vour to cure it, and then the inflammation of the testicle will 
 subside by itself. If there is a 
 syphilitic taint, blue ointment should 
 be rubbed in locally, while a mild 
 course of mercury, or of the iodide of 
 potassium, is given (F. 49,60). Some- 
 times small doses of grey powder, or of 
 corrosive sublimate, with tonics, may 
 promote the absorption of the effused 
 material (F. 50). Whatever remedies 
 are tried, rest in the horizontal posi- 
 tion, support by means of a suspensory 
 bandage, and even pressure by strap- 
 ping, should always be used. 
 
 Strapping the Testicle. — This is 
 generally done in the following 
 manner : — First of all the enlarged 
 testis is separated from the rest 
 of the scrotum, and a strip of wash- 
 leather plaster, about an inch in 
 breadth, is rolled round the sper- 
 matic cord and vessels, so as to form 
 a collar which isolates the testicle. 
 The surgeon then prepares a number of strips of the ordinary 
 diachylon plaster, about an inch wide, and long enough to go 
 once and a half round the affected part. These should be well 
 warmed or dipped in hot water, and then applied to the testicle 
 in regular order (Fig. 150). The first two or three strips 
 should be laid on vertically, from behind forwards, and tight 
 enough to exert a slight degree of compression. Then a sufficient 
 number of strips should be placed in the same way, from side to 
 side, beginning on the inside, passing round the lowest point of 
 the testis, and terminating on the outside. If any intervals are 
 left between these vertical strips, they should be covered in a 
 similar manner, after which the plaster should be rolled in a 
 circular or spiral way round the testicle, until it has been com- 
 pletely and firmly enveloped. In the course of a few days it 
 will be found that the strapping has become loose, and then it 
 must be removed, and fresh plaster applied. 
 
 Strapping is, at best, rather a rough method of compressing 
 the testicle. To be effectual it must be renewed every few day, 
 and the removal of the plaster is often a very painful process 
 
 Strapping the testicle. 
 
334 DISEASES OF TISSUES AND OEGANS. 
 
 The same object may be effected more conveniently in another 
 way. After the testis has been isolated by a collar of leather 
 plaster, in the manner described, a piece of flannel or stocking- 
 bandage is taken, large enough to envelop the tumour. This is 
 folded round the testicle, and a running lace made in it with a 
 needle and a stout silk thread. By this means a sort of body- 
 bandage is applied, which can be tightened or loosened at 
 pleasure, which is cleanly, and which can be removed without 
 pain or diflBculty. 
 
 Sometimes the inflamed testicle softens at one point ; an abscess 
 forms and bursts, or is opened. When this happens, the tubular 
 structure of the gland is apt to protrude as a fungus (hernia 
 testis). In such a case, pressure should be made by means of a 
 pad, or the fungus should be freely touched with caustic. If these 
 means fail, the case should be treated in the way that Mr. Syme 
 has recommended. The skin around the protrusion should be 
 dissected back, the edges pared, brought together, and united 
 over the fungus, so as to cover it. 
 
 Scrofulous Testicle. — The scrofulous habit sometimes manifests 
 itself in the testicle. A slow and chronic inflammation takes 
 place, with deposit of tubercular matter in and between the semi- 
 niferous tubules. The gland enlarges irregularly, without pain 
 or tenderness, and its outline becomes rough and nodulated. 
 Here and there, it softens and breaks down. Abscesses form, 
 and open externally, perhaps allowing the structure of the testicle 
 to protrude as a fungus. Such abscesses are apt to burrow in all 
 directions, disorganizing the whole gland, and giving rise to an 
 exhausting discharge. 
 
 Treatment. — The local disease must be met by rest, support, 
 even pressure, and absorbent ointments. At the same time the 
 constitutional treatment must on no account be omitted. When 
 abscesses form, they must be opened, and the resulting sinuses 
 treated by astringent or stimulating lotions (F. 14, 22, 25). If 
 the gland is thoroughly disorganized, and the discharge is exhaust- 
 ing the patient, the entire testicle will have to be removed. 
 
 Cystic Sarcocele. — In all these solid tumours of the testis, 
 whether the enlargement be of a simple, a syphilitic, a scrofulous, 
 or a malignant kind, cysts are apt to be developed by the dilata- 
 tion of the seminiferous tubules. Such cysts may vary greatly 
 in size; usually they are about the size of a marble. When 
 many of them are present in the tumour, it is called by the 
 generic name of cystic sarcocele. But the precise nature of the 
 solid substance in which the cysts are embedded is, after all, the 
 important point for diagnosis. 
 
335 
 
 CAXrCSR OF THS TESTZCXiE 
 
 is generally of the medullary variety. 
 
 The early symptoms are obscure, because they are common to 
 many of the tumours which are met with in this situation. The 
 testicle enlarges from the centre ; feels smooth, hard, and heavy. 
 The patient complains of a sensation of weight and dragging. 
 The growth makes steady progress. The skin of the scrotum 
 becomes distended and purple. Soon it becomes adherent, 
 softens, ulcerates, and then the cancer protrudes in a fungous 
 mass. The cord becomes hard and nodulated. Pain, which is 
 sometimes of the characteristic lancinating kind, extends along 
 the course of it towards the loins. When the tumour begins to 
 increase rapidly, there is no longer any doubt about the diag- 
 nosis. The inguinal glands do not become affected till the 
 disease has existed for some time, and the scrotum is impli- 
 cated. The pelvic and lumbar glands are the first to be- 
 come enlarged, and may give rise to pain in the back and 
 loins. 
 
 Treatment. — As soon as the nature of the tumour has been 
 ascertained, the entire testicle ought to be removed. 
 
 Castration is performed thus: — If the skin is free, a single 
 long incision is made from the external abdominal ring to the 
 bottom of the scrotum ; or, if the skin is involved, a double 
 elliptical incision will be required. Partly by tearing, and 
 partly by a few light touches of the knife, the testicle is raised 
 from the cellular bed in which it lies. The upper part of the 
 cord should then be transfixed with a hook, or held by an 
 assistant, while the tumour is cut off". Unless this is done, 
 there is danger of the cut end of the cord being retracted 
 within the inguinal canal. Two or three bleeding points in the 
 cord and scrotum will have to be secured by ligatures or by 
 torsion. The wound should be lightly dressed, and allowed to 
 granulate. 
 
 (EDEMA OF THE SCROTUM. — KVPERTROPHV. 
 
 Acute oedema of the scrotum is one of the earliest symptoms 
 in some cases of cardiac or renal disease. The patient suddenly 
 finds his scrotum enlarged, and the glistening translucent 
 appearance at once suggests to the surgeon that he must 
 look to the heart or to the kidneys for the origin of the 
 disease. 
 
 Solid oedema, hypertrophy of the scrotum (elephantiasis Ara- 
 bum), is of quite a difierent character. It is rarely seen in 
 
836 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 Fig. 151. 
 
 this country, but is endemic in the tropics. Some regard it 
 as a constitutional disease, but probably it requires also some 
 exciting local cause. It consists essentially of an overgrowth 
 of the elements of the skin and subcutaneous cellular tissue, 
 with infiltration of organizable lymph. The part increases in 
 size, the skin becomes coarse and furrowed ; and in the furrows 
 cracks and fissures form, which give rise to offensive ulcerations. 
 The prepuce is affected, as well as the skin of the scrotum, so 
 that the penis is quite buried. The testicles are found in their 
 natural situation, and there is usually more or less hydrocele of 
 the tunica vaginalis. The hypertrophy sometimes goes on to an 
 enormous extent. 
 
 The largest tumour of the kind I have seen was that which 
 was removed by Mr. Wiblin, of Southampton, and which weighed 
 
 after removal nearly thirty pounds. 
 But cases are on record which have 
 weighed five or six times as much 
 as this. Fig. 151 was drawn from 
 a man upon whom Sir W. Fergusson 
 operated, when I was his house- 
 surgeon. The case is alluded to in 
 his "Practical Surgery," and was 
 reported in the Lancet for Septem- 
 ber 28, 1861. The patient was a 
 tall, strong man, a bricklayer by 
 trade, and had never been out 
 of England. He attributed the 
 commencement of the disease to a 
 blow, eight years before. The 
 tumour, after removal, weighed 
 nearly six pounds. The operation 
 was successful, and several years 
 afterwards I saw the man in perfect 
 health. 
 
 The only treatment is by an operation. Sir Joseph Fayrer, in 
 his " Clinical Surgery in India," describes the best mode of per- 
 forming such an operation, and gives an analysis of twenty-eight 
 cases. 
 
 An hypertrophy, which is essentially similar in its character, 
 sometimes affects the lower extremities (Barbadoes leg). 
 
 The accompanying illustration (Fig. 152) was drawn from a 
 case which occurred in the practice of Dr. C. J. Richardson, and 
 is fully reported in the " Proceedings of the Royal Medical and 
 Chirurgical Society" for 1860. It was chiefly remarkable because 
 the patient was a young woman who had never been out of this 
 
 Hypertrophy of the 
 scrotum. 
 
YESICO-VAGINAL FISTULA. 
 
 337 
 
 country. The disease began when she was fourteen ; at the time 
 the drawing was made it had existed fourteen years. 
 
 Fii?. 152. 
 
 Elephantiasis of the leg. 
 
 In the treatment of these cases drugs are of no avail. Ligature 
 of the main artery has sometimes been followed by excellent 
 results. It acts by diminishing the supply of blood, and thus 
 checking the over-growth, which is the essential feature of the 
 disease. 
 
 CAXrCER OF TH& SCROTUAX 
 
 (^Chimney -sweep's Cancer) is of the epithelial variety, and seems 
 to be due to the irritation which is caused by the soot in consti- 
 tutions that are predisposed to malignant disease. 
 
 It begins as a wart or tubercle. In this state it may remain 
 for a long time. Presently it becomes red, and thinned on the 
 surf>ice, bursts, ulcerates, and spreads rapidly in small warty ex- 
 crescences. If it is allowed to remain, it gives rise to a foul and 
 offensive ulcer, infects the inguinal and pelvic glands, and impairs 
 the general health. 
 
 The only effectual treatment is early and complete removal by 
 the knife, the ecraseur, or the galvanic ecraseur. Under any 
 circumstances, the prognosis is far from favourable. 
 
 VESZCO-VAGIZTAXi FISTTTIiA 
 
 means a communication between the vagina and the bladder or 
 urethra. It is generally the result of sloughing, caused by a 
 difficult and tedious labour. 
 
 z 
 
338 DISEASES OF TISSUES AND OEGANS. 
 
 Treatment. — The patient should keep herself scrupulously 
 clean, and when she passes water she should, if possible, lie on 
 her face, or support herself upon her hands and knees. If the 
 communication is very small, it should be touched with a wire 
 heated by a galvanic battery. If this is done once a fortnight, it 
 may effect a cure. If the communication is larger, an operation 
 will be necessary. It should be performed thus : — The patient 
 should be placed in the lithotomy position, or else made to lean 
 on her knees and elbows, supported on pillows. The vagina 
 should be held open by suitable retractors. The surgeon then 
 pares the edges of the fissure, throughout their whole length, 
 and brings the raw surfaces accurately together by means of wire 
 sutures. A catheter should be kept in the bladder, so as to pre- 
 vent the accumulation of urine. The spasmodic action of the 
 bladder and bowels should be allayed by repeated doses of opium. 
 
 RUPTURED PERXXTEUm. 
 
 The perineum is sometimes ruptured during parturition. When 
 this happens, the rent should be united immediately. If this is 
 not done, the operation will have to be delayed until the patient 
 is convalescent, and in the meantime she will suffer much incon- 
 venience and distress. Sometimes the tear stops at the sphincter 
 ani ; sometimes it extends quite through into the rectum. 
 
 Treatment. — A sufficient number of silk, catgut, or wire stitches 
 should be introduced immediately after delivery, and without 
 shifting the patient's position. If, however, this is not done, or 
 if it has been done but without success, an operation will 
 have to be undertaken at a future time. It should be performed 
 thus: — The patient should be placed in the lithotomy posi- 
 tion, or simply laid on her side with the legs drawn up. The 
 edges of the rent are then to be thoroughly pared, and brought 
 into accurate apposition by means of the quilled suture (see 
 Fig. 28). If the operation is done at once, it is not necessary to 
 pare the edges. If the sphincter has been torn, its contractions 
 will be apt to prevent union. It must therefore be divided on 
 each side of the original wound. A catheter should be kept in 
 the bladder, and opium given to prevent the action of the 
 bowels. 
 
 GOirORRHCBA 
 
 is the term applied to a specific inflammation of the urethra or 
 vagina, the result of impure sexual intercourse, and accompanied 
 by a purulent discharge. After exposure to infection, an uncer- 
 tain period elapses before the symptoms show themselves. On 
 an average it may be set down at four or five days. 
 
GONOEEHCEA. 339 
 
 The disease may be divided into three periods — (1) That of 
 accession ; (2) that of acute inflammation ; (3) that of decline. 
 
 Symptoms. — {First stage.) — In the male, the disease comes on 
 with slight heat and irritation at the point of the penis. The 
 glans becomes congested, and of a bright red colour, the lining 
 membrane of the urethra is swollen, and the orifice partly closed. 
 Tliere is a thin, whitish, watery discharge. The urine is passed 
 with difficulty, and the stream is diminished, twisted, and forked. 
 These symptoms are accompanied by a good deal of dull, aching 
 pain in the back, loins, and testicles, and there is more or less 
 pyrexia. 
 
 (Second stage.) — Soon these symptoms become aggravated. 
 The discharge becomes thick, puriform, and perhaps of a greenish 
 or reddish tinge. There are prolonged and painful erections at 
 night. Sometimes, during erection, the penis is curved, as if it 
 were tied down with a string {chordee) — a state of things which 
 is exquisitely painful, and is probably due to deposit of lymph in 
 the corpus spongiosum, which interferes with the uniform expan- 
 sion of the organ. Sometimes the glans is excoriated, and emits 
 a purulent discharge (balanitis). Sometimes the prepuce is 
 cedematous, and perhaps fixed in the condition of phimosis or 
 paraphimosis. Abscesses may form in the substance of the penis, 
 and burst either internally or externally. The lymphatic glands 
 in the groin may become inflamed and suppurate {bubo). Either 
 testicle may become acutely inflamed (orchitis). These are some 
 of the complications which may arise in the course of a severe 
 case of gonorrhoea ; and when the acute symptoms are on the 
 decline, there are often rheumatic pains of an obstinate kind 
 about the joints of the extremities [gonorrJioeal rheumatism). 
 
 (Third stage.) — When the inflammation has run its course, it 
 is very likely that a thin, muco-purulent discharge (gleet) may 
 remain for some time, and prove very intractable. 
 
 Inflammation may, however, be excited in the raucous mem- 
 brane of the urethra by ordinary causes — external violence, the 
 use of instruments, &c. The disease is then called urethritis. 
 It may run much the same course as gonorrhoea and may re- 
 quire much the same treatment j but on moral grounds it is im- 
 portant to make the [distinction. 
 
 Treatment. — If the gonorrhoea is in its first stage, the patient 
 should be advised to take a purge, to restrict his diet to what is 
 plain and unstimulating, to bathe the parts frequently with cold 
 water, and to use a slightly astringent injection every three hours 
 or oftener (F. 16, 23, 27). Strong applications — whether in 
 the form of injections or ointments — are attended with great risk, 
 and ought not to be used. A mild lotion injected at short in- 
 
 z2 
 
340 DISEASES OF TISSUES AND OEGANS. 
 
 tervals, as I have recommended in the treatment of ophthalmia 
 neonatorum, is perfectly safe and very effectual. Cubebs or 
 copaiba or the oil of sandal wood may be given at the same time, 
 and these means may have the effect of cutting short the attack 
 (P. 43, 54). 
 
 Mode of injecting. — The patient should raise the penis between 
 the forefinger and thumb of his left hand, holding it near the 
 point. He should then carefully introduce the nozzle of a glass 
 syringe into the urethra for the space of an inch or so, and fix it 
 in that position by compressing it gently with his left forefinger 
 and thumb. He then slowly pushes down the piston with his 
 right hand. The injection should be allowed to remain in the 
 urethra for a few minutes. As soon as the syringe is taken away, 
 and the left hand removed, the elasticity of the urethra will 
 expel the fluid that has been thrown in. 
 
 During the second stage, the stage of acute inflammation, if 
 the symptoms run high, the treatment should be strictly anti- 
 phlogistic. The patient should keep the house, and avoid exercise. 
 No injections should be used, unless they be of tepid water. The 
 parts should be constantly fomented with flannels, wrung out of 
 hot water. In milder cases it may suffice to envelope the penis 
 in lint dipped in warm water, and covered with a piece of oil- 
 silk. The bowels should be kept open by small and repeated 
 doses of sulphate of magnesia — ^ three times a day, or a seidlitz 
 powder every morning, while the urine is diluted, and its acidity 
 lessened, by alkaline or mucilaginous drinks — soda water, or im- 
 perial drink (E. 103), or barley water, or linseed tea (F. 102) to 
 which a little nitre or carbonate of potass has been added. By 
 this means the scalding pain in micturition will be much reduced. 
 Chordee may be relieved by a full dose of Dover^s powder at 
 bed-time, or by smearing tbe penis with extract of belladonna, or 
 by a mixture of camphor and opium in a pill or suppository. 
 
 If there is retention of urine, from the swollen state of the 
 mucous lining of the urethra, fomentations or warm hip-baths 
 should be assiduously used, and opium suppositories introduced 
 into the rectum (F. 90). It may even be necessary to leech the 
 perineum. If these measures fail, then, and not till then, a full- 
 sized catheter should be passed into the bladder. 
 
 If the lymphatic glands in the groin become inflamed (bubo), 
 they should be treated by rest, fomentations, and leeches. If 
 matter forms, an incision should be made in a direction parallel 
 with Poupart's ligament. 
 
 When the acute symptoms have subsided, and the discharge 
 has become thin and muco-purulent, we return to the use of mild 
 astringent injections and cold sponging. If the patient's stomach 
 
GONOREHCEA. 341 
 
 will bear it, he should again take cubebs or copaiba or oil of 
 sandal wood. The bowels should be regulated, and the diet 
 must still be restricted ; all alcoholic and stimulating drinks should 
 be forbidden. The same treatment and manner of life should be 
 rigidly pursued for a fortnight after the discharge has ceased. 
 
 If a tliin watery discharge — a gleet — persists, it must be 
 treated by varying the injections — trying the acetate of lead, the 
 sulphate or chloride of zinc, the nitrate of silver, alum, &c., either 
 in turn or by combining them (F, 23, 25, 26, 27). At the same 
 time, it is of great importance to improve the general health by 
 tonics and a change of air. Sometimes much benefit results from 
 passing a full-sized catheter every three or four days. 
 
 If gonorrhoeal rhe^imatism follows the attack, it should be 
 treated by fomentations, alkalies, hot-air baths, diaphoretics in 
 large and repeated doses, and by applying blisters, or leeches, in 
 the neighbourhood of the affected part. When the acute symp- 
 toms have subsided, the iodide of potassium may be given with 
 advantage. A visit to the thermal springs of Bath, Buxton, or 
 Aix-la-Chapelle is often of great benefit. 
 
 Warts {condylomata acuta) often follow gonorrhoea, particu- 
 larly if the patient has allowed the discharge to lodge beneath 
 the foreskin, or if there has been much 
 inflammation of the glans or prepuce. ^' 
 
 They are generally situated along the 
 corona glandis, or on the frsenum (Fig. 
 153). When they are very numerous, 
 and of large size, they may be mistaken 
 for cancer of the penis. But the 
 history of the case, the softness of the 
 base, and the fact that when they are 
 removed a healthy mucosa is left, will 
 generally establish the diagnosis. 
 
 The treatment consists in snipping 
 them off with scissors, and then touch- Gonorrhoeal warts, 
 ing the bleeding points with lunar 
 
 caustic. When they are few, small, and scattered, much benefit 
 may be derived from the use of a calomel ointment (F. 89), or 
 from a lotion of corrosive sublimate. 
 
 Gonorrhoea in the female. — Gonorrhoea in women is altogether 
 a less formidable malady than it is in men. This arises from the 
 fact that the parts concerned are comparatively large and simple. 
 We have not to deal with a long, narrow, and complicated canal 
 like the male urethra. 
 
 The symptoms of gonorrhoea in women are much the same as 
 those which have been already described ; only the disease is less 
 
342 DISEASES OF TISSUES AND OEGANS. 
 
 acute, and is more apt to degenerate into a chronic gleet. The 
 principal complications which may arise are bubo, and ulceration 
 of the neck of the womb. 
 
 When a woman is affected with gonorrhoea, the discharge may 
 proceed either from the external parts — the labia, nymphse, and 
 meatus urinarius — or from the vagina, or from the cervix uteri. 
 In the latter case, it will probably be associated with superficial 
 ulceration. 
 
 Gonorrhoea must be carefully distinguished from other dis- 
 charges to which women are subject : (1) from leucorrhcea {fluor 
 alhus), a thick, white discharge, derived from the cervix uteri ; 
 and (2) from vulvitis, an inflammation of the external parts of 
 generation, depending on ordinary causes, as want of cleanliness, 
 intestinal irritation, &c. This is not uncommon among the chil- 
 dren of the poor, and is of great importance in a medico-legal 
 point of view. Parents are apt to think that their children have 
 been abused, when, in truth, all they want is a warm bath or a 
 vermifuge. 
 
 Treatment. — Gonorrhoea in the female must be treated on the 
 same general principles that guide us in dealing with the disease 
 in the male. During the acute stage, rest in bed, fomentations, 
 warm hip-baths, low diet, purgatives, and salines, are the 
 remedies most to be relied on. Subsequently, the vagina should 
 be syringed with astringent lotions, composed of the acetate of 
 l^d, the nitrate of silver, the sulphate of zinc, or alum (F. 23, 
 25, 26, 16, 8). Women should never use a glass syringe ; one 
 that is made of metal, bone, or elastic-gum, is much safer. 
 
 If the discharge is very intractable, it may be necessary to 
 examine the cervix uteri by means of a speculum ; and, if need 
 be, to touch it with the lunar caustic, or to apply some other 
 medication, such as the tincture of iron with glycerine. 
 
 SYPKIUS 
 
 is the name applied to the more severe form of the venereal 
 disease, which is usually attended with a breach of surface. An 
 important division is made according to the nature of the sore 
 which is present. Thus, they are divided into : — 
 
 1. The simple, soft, non-infecting sore, or local contagious 
 ulcer. 
 
 2. The indurated, infecting, Hunterian chancre. 
 
 We shall consider each of these separately. But in doing so, 
 it will be impossible for us to do more than mention the leading 
 features of each case. The investigation of syphilis is full of in- 
 terest. It is a subject which has made, and is still making, great 
 progress. Many theories have been propounded, many guesses at 
 
SYPHILIS. 343 
 
 the truth have been made, but into these we cannot here enter. 
 We must confine ourselves to a statement of the most recent 
 views on the subject. 
 
 1. The simple, non'infecting sore, or soft chancre, or local 
 contagious ulcer, begins as a small, irritable pimple. The period 
 of incubation of the virus is short. Indeed, it is not improbable 
 that it begins to work from the moment of its application. At 
 any rate, the pimple generally shows itself within forty-eight 
 hours. It rapidly runs on to suppuration, forming a pustule. 
 This bursts, and gives rise to a superficial ulceration. The sore 
 is usually situated in the sulcus between the prepuce and the 
 glans, particularly at the sides of the frsenum. The base of the 
 ulcer is soft j it can be easily compressed between the fingers ; 
 and the discharge from the surface contains pus globules, mixed 
 with the debris of the tissues. The lymphatic glands in the groin 
 soon become inflamed, and generally suppurate. But in most 
 cases the mischief stops here. The system does not become 
 infected, and secondary symptoms do not follow. 
 
 Sometimes, however, the sore spreads deeply and rapidly, with 
 phagedsenic action. Sometimes it creeps over the surface in the 
 form of a serpiginous ulceration. Sometimes a large portion of the 
 tissues, and even the whole body of the penis, sloughs (sloughing 
 phagedsena). 
 
 The soft sore is frequently multiple ; several may be present at 
 the same time. It is auto-inoculable — that is to say, if the 
 matter of the sore is inoculated on another part of the individual 
 who is afiected it will produce a sore like the original one. 
 And if the matter is inoculated on a second person it will 
 have the same efiect. As often as these experiments are repeated, 
 sores may be produced. The disease is strictly local, and at the 
 same time highly contagious- 
 
 2. The infecting sore, the indurated, Hunterian, or true syphi- 
 litic chancre, difi'ers in many respects from the foregoing. It 
 begins as a pimple or crack. Around this, induration takes 
 place, the pimple bursts, and an open sore, with a hardened 
 base, is the result. Ulceration and suppuration are no essential 
 parts of the disease, though they are usually present from some 
 local cause of irritation. 
 
 The virus has a lengthened period of incubation (15 to 25 days) 
 before the sore is developed ; and then a second and shorter 
 period (10 or 12 days) elapses before the induration is complete, 
 and the glands become enlarged and hardened. The sore is gene- 
 rally single. The secretion is said to contain no proper pus- 
 globules. The afiection of the glands is usually multiple, and 
 thej ^i^a'ii no tendency to suppurate. The disease gradually per- 
 
344 DISEASES OF TISSUES AND OEGANS. 
 
 vades tbe whole srstem, and may often be recognised by a similar 
 indolent enlargement of the glands in the axilla, under the occiput 
 and elsewhere. Secondary and tertiary symptoms foUow; to these 
 we shall return presently. The sore is not auto-inoculable — at least, 
 after systemic infection has taken place. The system is so far 
 under the influence of the virus that the inoculation produces no 
 effect. As a rule, the patient is incapable of sufleriug from 
 the same form of the disease a second time ; though, as Mr. Gas- 
 coy en has shown, this rule is open to exceptions (" Med. Chir. 
 Trans.," 1S75). The virus from one individual cannot be inocu- 
 lated on another, who is still suffering from the effects of an in- 
 fecting sore. The disease, though at first local, soon becomes 
 systemic, and then the patient is proof against inoculation. 
 
 Such are the two varieties of specific sores which are recognised 
 by modem surgeons. But, in practice, it is very common to meet 
 with mijced cases, where we can only suppose that there has been 
 a double inoculation at the same time ; or that an inoculation of 
 one kind has been speedily followed by an inoculation of the other 
 kind. These case? are so perplexing, that some distinguished 
 surgeons doubt altogether the doctrine of a " duahty of poisons ;" 
 and hold that all sores — whether hard or soft — depend upon 
 one and the same virus, which produces different effebts, according 
 to the constitution of the patient, the situation of the sore, and 
 other accidental circumstances. 
 
 Treatment of soft, non-infecting sores. — If a case presents itself 
 where there is a suspicious-looking pimple, which has appeared 
 within a day or two after an impure connection, it should be 
 touched with strong nitric acid, and hghtly dressed. When the 
 esd^r separates, a healthy granulating sore will probably be left. 
 If the sore is in a more advanced stage, or if it is irritated and 
 infiamed, this treatment is inapplicable. If more than a very 
 short time has elapsed from the date of the appearance of the 
 sore, it is highly improbable that we shall succeed in preventing 
 systemic infection in the case of an indurated chancre. 
 
 Supposing the sore is well formed when it is first seen, our 
 treatment must depend upon the characters which it presents. 
 
 If it is a soft sore, irritation of every kind should be avoided, 
 while some simple stimulating lotion or ointment should be 
 applied (F. 22, 25). If the inguinal glands become inflamed, they 
 must be treated by rest, fomeiitations, and leeches. If suppuration 
 takes place, an iucision must be made ; or, if the patient shrinks 
 from the knife, a piece of potassa fusa may be pressed firmly down 
 on the summit of tbe bubo. This will produce a limited eschar, 
 and give vent to the pus. 
 
 If ulceration spreads rapidly and deeply (phagedseua), the sur- 
 
SYPHILIS. 345 
 
 face mnst be destroyed with nitric acid, and afterwards dressed 
 with stimulating lotions (F. 13, 27). At the same time the general 
 health must be supported by tonics and a nutritious diet. 
 
 If sloughing occurs (sloughing phagedsena), poultices must be 
 applied until the dead tissues separate, and then the raw surfaces 
 should be dressed with stimulating lotions. A lotion of the tar- 
 trate of iron forms an excellent application in these cases. 
 Powdered iodoform has been highly recommended. If there is 
 much constitutional disturbance, it must be met by aperients, 
 salines, and opiates. 
 
 Treatment of hard chancres. — If, on the other hand, the sore 
 is a hard one, and presents an indurated base at the time it is first 
 seen, the treatment must be different. In a case of this kind 
 some surgeons think it best to heal the local sore 5 and, when 
 secondai'y symptoms follow, to deal with them as they arise. 
 Others endeavour to eliminate the poison from the system at 
 once, so as to prevent the occurrence of secondaries. 
 
 And here we are met by an import^mt question — Should mer- 
 cury be used or not ? Has it any specific influence over the 
 syphilitic poison ? 
 
 These are questions upon which the most opposite opinions 
 have been entertained. That mercury has some specific influence 
 over the poison of syphilis seems clear from the rapid and com- 
 plete cure which it effects in cases of infantile syphilis. On the 
 other hand, there can be no doubt that by far the greater num- 
 ber of chancres will heal without mercury ; that it is a medicine 
 which is capable of doing great mischief; that it must be given 
 with caution, and that it should never be pushed to extremes. 
 Mr. Hutchinson, whose opinion upon this subject deserves great 
 weight, regards mercury as quite an antidote to tbe poison of 
 syphilis. His rule is : — " Begin early, continue long, do not 
 salivate." 
 
 Mercury may always be employed locally, provided the sore is 
 not in an inflamed or irritable state, in the form of blue oint- 
 ment, or of the black or yellow wash. 
 
 If the patient is broken in health from dissipation, if he is en- 
 feebled by privation or disease, if he is of a strumous or cachectic 
 habit of body, mercury should either be withheld altogether, or 
 given with great caution, lest its depressing effect should aggra- 
 vate the malady. 
 
 If there is no objection to its use, it may be administered either 
 by t\\Q mouth, or by inunction, or hy fumigation. 
 
 If we desire to bring the patient rapidly under the influence of 
 mercury, the best preparations are the blue pill, or calomel in 
 combination with opium (F. 82). If our aim is to produce a 
 
S46 DISEASES OF TISSUES AND ORGANS. 
 
 slight but continued effect, it will be better to give Plummer's 
 pill, or grey powder, or the corrosive sublimate (P. 50). These 
 are the preparations which are most suitable for internal use. 
 
 Sometimes mercury given by the mouth irritates the stomach, 
 and purges the patient. When this is the case, it may be em- 
 ployed as an inunction. A drachm of blue ointment may be 
 rubbed into the armpits, or into the inside of the thighs, twice a 
 day ; or the same quantity may be spread on a roll of lint, and 
 worn round the leg, or round the waist. This is the best way of 
 administering mercury to infants. 
 
 Mercury may be used as a fumigation, by causing the patient 
 to undress, and sit upon a cane-bottomed chair, beneath which 
 ten grains of calomel are volatilized over a spirit-lamp, or upon 
 a hot brick. A blanket should be thrown over both the patient 
 and the chair, and as soon as all the mercury has disappeared, he 
 should wrap himself in the blanket and step into bed. 
 
 When mercury produces its characteristic effects upon the con- 
 stitution, the gums become red and spongy, the tongue swells, 
 the sublingual glands become enlarged, and there is a profuse 
 flow of saliva from the mouth. At the same time the breath 
 exhales a heavy, sweetish, and very characteristic odour. When 
 mercury is pushed to an extreme, and salivation is kept up for a 
 length of time, ulceration of the mouth and necrosis of the 
 bones are apt to follow ; but cases in which these untoward 
 results have been brought about are very rarely seen at the 
 present day. 
 
 If we desire to bring the system under the influence of mer- 
 cury, we should content ourselves with keeping up a slight 
 action on the gums. It is seldom or never necessary to go farther 
 than this. 
 
 The iodide is a very useful preparation of mercury. It seems 
 to combine the specific effect of both the iodine and the mercury 
 (F. 49). 
 
 While a patient is taking mercury he should live well; he 
 should have plenty of plain nutritious food, and wear a sufficiency 
 of warm clothing. 
 
 BUSO 
 
 is the term applied to enlargement or inflammation of the lym- 
 phatic glands which lie above Poupart's ligament, consequent 
 upon venereal disease. We have already seen that it is a frequent 
 complication of gonorrhea, but it is also met with in both the 
 varieties of syphilis. 
 
 A bubo that is due to gonorrhoea, or to the irritation of a soft 
 venereal sore, is acutely inflamed, and very prone to run on to 
 
BUBO. 347 
 
 suppuration. The irritation may manifest itself in one groin or 
 in both. One lymphatic gland alone may be affected, or several ; 
 and when suppuration takes place, the pus may burrow underneath 
 the skin from one to the other. 
 
 The multiple and indolent enlargement of the same glands, 
 which is so characteristic of an infecting sore, has been described 
 already. 
 
 Treatment. — The treatment of the indolent buboes which result 
 from a Hunterian chancre is constitutional rather than local. 
 But when the glands are acutely inflamed the surgeon should 
 endeavour to prevent them from suppurating. With this view the 
 patient should be directed to abstain from walking and to give 
 himself as much rest as possible ; at the same time evaporating or 
 discutient lotions (F. 18, 21) should be constantly applied. If sup- 
 puration takes place, the abscess should be opened by an oblique 
 incision, parallel to Poupart's ligament, and poultices or water- 
 dressings applied. If burrowing takes place, the sinuses ought to 
 be laid open, and healed from the bottom. When cicatrization has 
 occurred, and nothing remains but an indurated state of the tissues, 
 even pressure by means of a pad and bandage is of great service. 
 
 In keeping dressings upon the groin, as well as in exerting 
 pressure and in various other cases, the spica or figure-of-8 
 bandage for the groin is of 
 great use. We shall therefore ^^* 
 
 take this opportunity of ex- 
 plaining it. 
 
 Figure-of-^ handage for the 
 groin. — This bandage is fre- 
 quently spoken of as the spica, 
 from some fancied resemblance 
 which it is supposed to bear to p^^^^^^ ^^ 3 .^^ bandages, 
 the arrangement of the grains 
 
 in an ear of corn. But as the word spica conveys no distinct 
 meaning, we have thought better to call it, what it really is, 
 a figure-of-8 bandage for the groin. 
 
 The bandage may be applied either to one groin or to both. 
 When it is applied only to one side it is called a single figure-of.8 
 for the groin (single spica. Fig. 154, a) ; when to both sides, a 
 double figure-of-8 for the groin (double spica. Fig. 154, h). 
 
 To apply the single figure-of-8 to the groin the surgeon lays 
 the end of the roller on the inside of the thigh of the affected 
 side, and conducts the roller once round in a circular form so as 
 to fix the end of the bandage. He then brings the roller up the 
 inside of the thigh and along the fold of the groin, taking care to 
 adjust any pads, dressings, &c., that it is intended to retain. 
 
348 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 Single spica bandage. 
 
 Then he carries it on, round the back of the pelvis to the opposite 
 side, and obliquely across the abdomen, over the pubes, to the 
 outside of the thigh on the affected side, and then continuing it 
 
 under the thigh he completes 
 the first figure-of-8 — one loop 
 of the 8 embracing the pelvis, 
 while the other surrounds the 
 thigh (Fig. 155). The same 
 steps may then be repeated as 
 often as they are necessary. 
 
 In applying the double 
 figure-of-8 to the groins the 
 surgeon begins precisely as in 
 the foregoing case, but after 
 be has completed one figure- 
 of-8 and has carried the 
 bandage for the second time 
 round the back of the pelvis, 
 he brings it down along the opposite groin to the inner side 
 of the corresponding thigh. He then conducts it round the back 
 of the thigh to its outer side, and then obliquely upwards across 
 the pubes and abdomen to the other side of the pelvis, in this 
 way completing the second figure-of-8« These steps may be 
 repeated as often as they are necessary, the upper loop of the 8 in 
 each case surrounding the pelvis, while <^be lower one embraces 
 
 the right and left thighs 
 alternately (Fig. 156). 
 It is important to ob- 
 serve that the turns 
 round the body should 
 fall just below the brim 
 of the pelvis. 
 
 In commencing this 
 bandage the surgeou 
 may, if he pleases, begin 
 by taking a turn round 
 the pelvis, instead of 
 round the thigh, in 
 order to get a fixed point 
 from which to start. 
 A simpler method of retaining dressings in this situation is by 
 means of the triangular bandage for the groin. It consists of a 
 waistband to which is stitched a triangular piece of calico, and 
 to the lower end of the triangle is fastened a strip of narrow 
 roller. Wlien it is applied, the waistband is secured, the trian- 
 
 Double spica bandage. 
 
SECONDARY SYPHILIS. 
 
 349 
 
 gular piece of calico is adjusted over the affected part, and the 
 lower corner, with its strip of bandage attached, is carried under 
 the perineum, and fastened to the waistband at the patient's side 
 (see Fig. 50, b). 
 
 SECONDARV SVPHIXiIS. 
 
 When the poison of syphihs has infected the constitution, it 
 produces certain secondary symptoms. These symptoms show 
 themselves at a variable period, from two weeks to six months or 
 more, after the primary disease. First of all, the skin, and the 
 mucous membranes become affected (secondary symptoms), after- 
 wards the bones and internal organs {tertiary symptoms). 
 
 Constitntional syphilis sometimes leads directly to a fatal 
 result by affecting the brain, the liver, or some other vital organ. 
 In any case it is extremely diflBcult to eradicate, and it often 
 modifies the patient's constitution for the remainder of his life. 
 It is worthy of special notice that the normal secretions of persons 
 having secondary syphilis — e.g., the semen, the saliva, or the milk 
 — as well as the discharges 
 
 from secondary sores, can Fig. 157. 
 
 communicate the disease. 
 But when the later stages 
 have been reached, the poison 
 seems more localised, and is 
 less prone to be eliminated 
 from the blood. 
 
 The syphilitic eruptions 
 on the sl'iii (syphilides) may 
 take almost any form, cor- 
 responding pretty nearly 
 to the ordinary cutaneous 
 diseases. But they are all 
 characterised by their dull, 
 copper colour; by the fact 
 that they do not itch; by 
 their circular shape and 
 grouping ; and by the 
 brownish stains or dis- 
 colourations which the 
 severer forms leave behind 
 
 them. Fig. 157 represents a remarkable case of syphilitic rupia 
 in a young man who was in Charing Cross Hospital under the 
 care of Dr. Silver. 
 
 It would be impossible for us to find space for even a short 
 description of each of the syphilitic affections of the skin, but we 
 
 7;/ ^ Ai; 
 
 Syphilitic rupia on the face. 
 
350 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 may take this opportunity of mentioning that they have heen 
 regarded by Mr. Hutchinson and others as analogous to the 
 rashes of the exanthematous diseases. Indeed, syphilis may 
 well be regarded as an exanthem whose march is very slow, and 
 whose stages are very long. 
 
 Mucous tubercles {condylomata lata) are a peculiar development 
 of the skin, which is apt to occur near the orifices of the mucous 
 canals, especially where the parts are bathed in perspiration, and 
 where irritation is kept up by the movement of two contiguous 
 surfaces : hence they are commonest around the anus and vulva. 
 They form small, soft, flattened tumours, and secrete a thin, 
 offensive discharge, which is probably contagious. I have also 
 seen them on the under surface of the tongue. 
 
 Treatment. — They should be kept very clean, and rubbed 
 with calomel ointment (F. 89), or dusted over with the dry 
 
 calomel, or bathed with a 
 Fig. 158. „^^^ mercurial wash. 
 
 Syphilitic ulcerations. — 
 Secondary syphilis is par- 
 ticularly prone to manifest 
 itself in the mucous mem- 
 brane of the pharynx. The 
 patient complains of sore 
 throat. The affection may 
 consist of a mere conges- 
 tion and excoriation of the 
 mucous membrane of the 
 fauces or tonsils, or it may 
 present a foul, excavated 
 ulcer, with ragged edges, 
 and covered with a greyish 
 yellow slough. 
 
 We often see syphilitic 
 ulcers on the legs. They 
 begin in small gummy 
 tumours in the subcuta- 
 neous areolar tissue, soften, 
 break, and form a deep 
 ulcei', which is characterised 
 by its circular form, its clean-cut edges, its irregular base, and un- 
 healthy discharge (Fig. 158). Such ulcers are often multiple, 
 and one of their favourite situations is the neighbourhood of the 
 knee ; so much so that it may be laid down as a general rule that 
 sores on the leg about, or above, the knee-joint have usually a 
 syphilitic origin. 
 
 SyphiUtic sores on the leg. 
 
SECONDARY SYPHILIS. 
 
 351 
 
 Fig. 159. 
 
 Superficial ulceration between the fingers, such as that which 
 is represented in Fig. 159, or between the toes (Fig. 160), is very 
 characteristic of secondary syphilis. 
 
 The inside of the mouth, the 
 lips, the tongue, and even the 
 larynx, are liable to be affected by 
 syphilitic ulceration. Cracks and 
 fissures form at the angles of the 
 mouth, and along the sides of the 
 tongue. Whitish or yellowish 
 spots appear on the gums and 
 lining membrane of the cheeks. 
 The mucous covering of the larynx 
 is apt to become thickened and 
 ulcerated, leading to impairment of 
 the voice, and even to suffocation. 
 
 Treatment. — In all these ulcera- 
 tive affections, the treatment 
 must be much the same. Cracks and fissures should be thoroughly 
 touched with a pencil of lunar caustic ; or, if the ulcerating sur- 
 face is more extensive, it may be brushed over w^ith a strong 
 solution of nitrate of silver (forty grains to the ounce of distilled 
 water). If the throat is in a sloughing and unhealthy state, 
 the patient should use a chlorinated gargle, and the nitrate of 
 silver may be more freely applied. Fumigating the fauces with 
 calomel, directed to the diseased spot by means of a funnel, is 
 The ulceration between the fingers and 
 a mercurial ointment or wash, and 
 
 Supeificial ulceration of the 
 fingers (syphilitic). 
 
 Fi^. 160. 
 
 often of great benefit, 
 toes is best treated by 
 full doses of " Dono- 
 van's solution." At 
 the same time, the 
 constitutional treat- 
 ment must not be 
 overlooked. The pa- 
 tient should live well, 
 and, if possible, he 
 should have a dry, 
 mild, bracing air. 
 During the winter and 
 spring most parts of 
 England are too cold, 
 damp, and relaxing. Thus a sea voyage, or a residence at St. 
 Leonards, Bournemouth, Malaga, Mentone, or some similar place 
 may often be recommended with great advantage. If the patient 
 is in pretty good general health, and has not already been treated 
 
 Superficial ulceration of the toes 
 (syphilitic). 
 
352 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 Fig. 161. 
 
 with mercury, a mild course may be prescribed. If, however, his 
 health is broken, or he has been already salivated, then the 
 iodide of potassium should be given, in combination with iron 
 and tonics (F. 60, 62). 
 
 In syphilitic ulceration of the larynx, the constitutional treat- 
 ment is of the greater importance, because topical applications 
 are attended with difficulty, If the disease spreads, and suffoca- 
 tion is imminent, it will be necessary to perform tracheotomy. 
 
 Syphilitic affections of the hones are among the later, or 
 tertiary, symptoms of the disease. The bones which are most 
 
 frequently affected in constitutional 
 syphilis are the tibia, the bones of 
 the skull, the clavicle, and the ulna. 
 A slow inflammation takes place in 
 the bone, or in the periosteum cover- 
 ing it. The affected spot is ex- 
 quisitely tender ; there is great pain, 
 which is aggravated at night. Ey 
 degrees, an oval swelling, a node, 
 forms, which has at first a doughy 
 feeling, but which afterwards be- 
 comes distinctly fluctuating. This 
 gradually involves the skin, and 
 bursts, exposing the ulcerated bone 
 beneath. Fig. 161 was drawn from 
 a young woman, who was in 
 Charing Cross Hospital under the 
 care of Mr. Canton. The circular 
 shape of the sore and the exposed bone are well seen. 
 
 If the disease is situated on the skull, it may give rise to 
 irritation ef the membranes, and death by meningitis. Or it may 
 furnish an opening through which the brain may protrude, or 
 there may be internal nodes as well as external j and then the 
 cerebral functions may be very seriously impaired. 
 
 Treatment. — The great remedy for syphilitic affections of the 
 bones is iodide of potassium. It should be given in combination 
 with tonics — the tartrate, or the ammonia-citrate of iron, for 
 example (F. 60, 62) ; and the patient should have plenty of plain, 
 nutritious food, for unless he has a certain amount of vis vitce he 
 cannot resist the violence of the disease. Some patients are very 
 sensitive to the influence of iodide of potassium. I have seen a 
 young man quite prostrated with severe headache and coryza 
 after taking two 5-grain doses, and I have seen large patches of 
 an erythematous eruption on a middle-aged man who had only 
 taken three 5-grain doses. The local pain must be relieved by 
 
 Syphilitic sore on forehead. 
 
INFANTILE SYPHILIS. 353 
 
 blisters, or leeches ; and opiates may be given at bed-time. If 
 suppuration has taken place, a small valvular incision should be 
 made, and the matter evacuated. 
 
 XM-FAITTIIiE STPHZXiZS. 
 
 If either of the parents are syphilitic, the infant may inherit 
 the disease. If the father is syphilitic, he may transmit the 
 disease directly to the foetus at the time of conception, and the 
 mother may be infected through her offspring ; or he may com- 
 municate it to the mother, and she may infect the child ; or if 
 the mother alone is syphilitic, the foetus may become affected 
 during intra-uterine life, through the maternal blood. 
 
 When the foetus is infected in any of these ways, it is apt to 
 die about the fourth month, and the mother miscarries. Re- 
 peated miscarriages at once suggest a syphilitic taint. 
 
 But the case may not be so bad as this. The child may be 
 born alive, but thin and shrivelled, with a prematurely old ex- 
 pression, a hoarse voice, a snuffling breathing, a discharge from 
 the nose, and an eruption about the*anus and genitals. 
 
 Or, again, the child may be born apparently healthy, and the 
 syphilitic symptoms may show themselves a month or six weeks 
 afterwards. 
 
 Treatment. — The infant should be brought up by hand, that 
 it may neither imbibe further poison from its mother, nor infect 
 a hired nurse. Having secured this point, the surgeon should 
 prescribe mercury, either in the form of small doses of grey 
 powder, or as an inunction in the way recommended by Brodie. 
 A drachm of blue ointment should be spread upon a roll of lint 
 or flannel, and tied round the child's thigh or waist. The appli- 
 cation should be renewed every morning until the symptoms have 
 disappeai'ed. 
 
 Though the commonest manifestations of infantile syphilis are 
 of a superficial kind — snuffles, cutaneous eruptions, mucous 
 tubercles, and the like — it sometimes happens that the liver, the 
 brain, and other internal organs are affected by tumours which 
 are due to the same cause. In these cases the child gradually 
 wastes away, or else it is attacked by convulsions, and dies after a 
 short illness. 
 
 When the surgeon is required to treat a case of infantile 
 syphilis, he ought not to overlook the condition of the parents, for 
 by persuading them to submit to timely treatment their future 
 offspring may be more healthy. He should therefore put them 
 upon a mild course of mercury, or prescribe iodide of potassium, 
 or such other remedies as he may think fit, according to the 
 state of their health, and the special symptoms that they present. 
 
 A A 
 
354 DISEASES OF TISSUES AND OEGANS. 
 
 It is of tbe utmost importance, as Sir James Paget has pointed 
 out, that students should learn, by wide observation and extensive 
 practice, to recognise all the characters of syphilitic diseases so 
 thoroughly as not to require the help of any statements from the 
 patients themselves. For many patients are unvpilling, and those 
 that would be willing are often unable, to tell the truth in these 
 cases. Women in the middle and higher ranks of society, when 
 they have syphilis, are generally ignorant of the fact, and must be 
 allowed to remain without even such a suspicion as would be sug- 
 gested by their being asked about it. In such a case a question 
 thoughtlessly put might disturb the peace of a family ; and no 
 benefit which the surgeon might hope to obtain from the informa- 
 tion thus elicited could counterbalance the social mischief that it 
 might occasion. 
 
 The surgeon is often asked how soon it is safe for a person who 
 has had constitutional syphilis to contract marriage. Upon this 
 point his answer should be given with caution, because it is doubt- 
 ful if the syphilitic taint can ever be eradicated. If the patient 
 falls into bad health or destitute circumstances, it may make its 
 appearance after the lapse of many years during which it has lain 
 dormant, and the patient has been apparently in exaellent health. 
 And, of course, if the disease is liable thus to revive, the patient's 
 wife and offspring may become infected. It is, therefore, impos- 
 sible to lay down positive rules, but, speaking generally, the patient 
 should be advised to wait till the expiration of a year from the time 
 when all secondary manifestations disappeared, and in the mean- 
 while to take a course of warm sulphur baths. If he can go to a 
 warm climate, or take warm baths at some of the natural mineral 
 springs — Harrogate, Bath, Spa, or Bareges, for example — that is 
 the best measure to recommend. Formerly it was the custom 
 to prescribe sudoritics, but the course I have indicated is safer, 
 and will probably be also more agreeable to the patient. 
 
 ONVCHZA. 
 
 Onychia is a disease of the matrix of the nail, attended by in- 
 flammation and ulceration of the adjacent parts. It occurs under 
 two forms, (1) the simple, and (2) the malignant or specific. 
 
 1. Simple onychia begins as a circumscribed inflammation in the 
 root of the nail. It is often excited by slight injuries — a prick, 
 or a pinch, for example — in persons who are out of health. 
 
 The affected spot is red, hot, swollen, and painful. Pus soon 
 forms and makes its way to the surface. The nail becomes loose, 
 shrivelled, and black ; gradually it is thrown off and a new one 
 grows in its place. The new one is often rough, and somewhat 
 irregular in shape. 
 
ONYCHIA. 
 
 355 
 
 Fie:. 162. 
 
 Treatment.— The hand should be well supported in a sling, so 
 as to be raised almost to the opposite shoulder. The inflamma- 
 tion must be met by poultices. If the pus is confined, it should 
 be let out by a puncture. Care must be taken to protect the 
 young nail ; and of course everything should be done to regulate 
 and improve the patient's general health. 
 
 2. Malignant onychia commences in the same way as the simple 
 variety, but it runs on to ulceration, and this ulceration is usually 
 of a most intractable kind. The 
 inflamed spot has a dark, livid 
 colour, and breaks down into an 
 ofi'ensive sore. There is a dis- 
 charge of sanious pus. After 
 a while large flabby granulations 
 spring up, and the end of the 
 finger, or toe, becomes much 
 enlarged and clubbed. The nail 
 turns black, shrivels, and breaks 
 oS in pieces ; and any attempt 
 which Nature makes to form a 
 new one is very imperfect (Fig. 
 162). This variety of the disease 
 is often associated with a ca- 
 chectic, strumous, or syphilitic 
 state of the system. 
 
 Treatment. — Locally, the first 
 thing to be done is to remove 
 
 the nail, which acts as a foreign body, and keeps up irritation. 
 The ulcer must then be freely touched with lunar caustic, and 
 dressed with stimulating applications. Powdered iodoform is 
 sometimes very beneficial. If there is a syphilitic history, a 
 mercurial ointment or the black wash will be found useful. 
 
 Mr. MacCormac has drawn attention to the use of the pow- 
 dered nitrate of lead, which has been employed with success by 
 some Continental surgeons as a local application. I have used it 
 in several cases, and have been pleased by the result. It cer- 
 tainly deserves a further trial, for the disease is one which is very 
 intractable under the ordinary treatment. 
 
 Constitutionally, we must endeavour to improve the patient's 
 health by tonics, particularly cod-liver oil and the preparations 
 of iron and quinine (F. 41, 55, 56), by change of air, and a well- 
 regulated manner of life. If the case has a syphilitic origin, 
 Donovan's solution, the iodide of potassium, or the preparations 
 of mercury, in combination with tonics, will be most beneficial 
 (F. 50, 52, 43, 44). 
 
 A a2 
 
 Malignant onychia. 
 
356 
 
 DISEASES OF TISSUES AND ORGANS. 
 
 VIiCEBATIOIO' OF THE GREAT TOE. 
 
 There is a painful affection of the great toe in which the nail 
 is popularly said to " grow into the flesh." It is g^enerally the 
 consequence of wearing tight boots. The truth is, not that the 
 nail grows into the flesh, but that it is pressed against the skin, 
 thus keeping up a chronic irritation and inflammation. The 
 tissues at the side of the nail become swollen and very tender, 
 then ulceration takes place, and a sore is established, which dis- 
 charges a thin, sanious pus. Large granulations spring up, 
 which are exquisitely painful, and which overlap the nail, making 
 it appear as if it grew into the flesh. 
 
 Treatment. — Tight boots, especially those which are narrow 
 across the toes, must be laid aside altogether, and for a time the 
 patient must wear only a loose slipper. The inflammation may 
 be partially subdued by poultices or cold lotions, but to effect a 
 radical cure more will be necessary. The simplest method of pro- 
 ceeding is to scrape down the nail until it is thin and phable, touch 
 the ulcerated surface with a fine pencil of lunar caustic, and then 
 introduce cotton- wool between them, or a fold of lint soaked in glyce- 
 rine, or in liquor potassse, or in a solution of sulphate of copper. 
 Another method is to take a strip of very thin sheet-tin or of 
 gutta-percha, fold it in the middle, 
 and introduce this fold between the 
 nail and the skin, and then to 
 double one side back over the toes, 
 and the other over the granulations. 
 If these or other similar methods 
 are carefully carried out from day 
 to day, much may be done to relieve 
 the patient, and in some of the 
 slighter cases a cure may be eff'ected. 
 But if the disease is severe, and 
 of long standing, a portion of the 
 nail may have to be removed. This 
 is a trivial, but a very painful opera- 
 tion ; and the patient should either 
 be anaesthetised, or the toe benumbed 
 with ether spray. The sharp point 
 of a strong pair of scissors should 
 then be passed underneath the nail 
 as far as the matrix, and the nail 
 divided longitudinally. The slip thus separated must then be 
 seized with a forceps, and drawn out by the root. 
 
 Fig. 163. 
 
 Ulceration of 
 great toe. 
 
CLUB-FOOT. 
 
 357 
 
 A simpler and less painful operation is to cut off the whole of 
 the granulations, togetlier with a portion of the adjacent skin, by 
 a single stroke of a scalpel. The case from which Fig. 163 was 
 taken was treated in this way. The patient experienced imme- 
 diate relief, and the wound healed favourably in a few days. 
 When this last method is adopted, there is but little chance of 
 the disease recurring, for the contraction of the cicatrix tends to 
 draw the skin away from the nail. 
 
 COXTRACTIOX OF THE FZUG-ERS. 
 
 The fingers not unfrequently become contracted, and drawn 
 down towards the palm. The little finger is generally the first 
 to be affected in this way, the 
 disease gradually extending 
 to the others. The process 
 of contraction is a very slow 
 one, but the fingers become 
 so fixed that no ordinary 
 force can extend them. 
 
 The deformity seems to 
 depend upon a chronic in- 
 flammation of the palmar 
 fascia. Sometimes this ap- 
 pears to be excited by the 
 constant and forcible use 
 of the palm, as in handlhig 
 
 Fiff. 164. 
 
 Fingers contracted by gout. 
 
 certain tools. At other times it has a constitutional origin, and 
 is connected with a rheumatic or gouty tendency. Fig. 164 
 represents a striking example of a hand distorted by gout. 
 
 The treatment consists in endeavouring to overcome the con- 
 traction by gradual extension by means of a splint and elastic 
 bandages. If this is impracticable, or if the patient will not 
 submit to such tedious treatment, the surgeon must divide the 
 constrictions by means of subcutaneous incisions, and then ex- 
 tend the fingers upon a splint. If there is well-marked gout 
 in the system, even such a simple operation as this must be 
 undertaken with caution. 
 
 CZilTB-FOOT (TAIiIPES) 
 
 is the name applied to a deformity which arises from contraction 
 and rigidity of the muscles of the leg. 
 
 It occurs under four forms. Sometimes the heel is drawn up, 
 and the patient treads upon the ball of the foot and the toes 
 (talipes eqiiinus). This is the simplest, and also the most re- 
 mediable, form of the disease (Fig. 165). Sometimes the foot 
 
358 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 Talipes equinus. 
 
 is pointed upwards, and the weight of the hody supported on the 
 heel {t. calcaneus). This is a very rare affection. Sometimes 
 the foot is twisted inwards, and the patient walks on the outer 
 
 edge {t. varus) (Fig. 166). Some- 
 times the foot is turned outwards, 
 and the patient walks on the inner 
 edges {t. valgus). 
 
 It frequently happens that these 
 varieties are mixed. The equinus is 
 often associated with the varus 
 {t. equino-varus) ; or the calcaneus 
 with the valgus (t. calcaneo -valgus). 
 Club-foot is generally congenital, 
 but it may also come on in after- 
 life. When this happens, it is due 
 either to — (1) Spasmodic irritation 
 and contraction of the muscles ; or 
 (2) paralysis of the antagonistic 
 muscles ; or (3) the effects of local 
 disease or injury. 
 The fault is generally in the muscles. The tendons, liga- 
 ments, and bones are only secondarily affected. 
 
 The treatment of course varies with the nature of the case. 
 The first thing is to ascertain whether the affection is congenital 
 or not ; and if not, upon what cause it depends. If it is due to 
 the irritation of worms, then a purge may aid in removing it. 
 
 If it arises from debility, then a 
 course of tonics, particularly iron, 
 with the regular use of galvanism, 
 may be of service. If it is associated 
 with a rheumatic tendency, the 
 alkalies are likely to do good 
 (F. 56, 60). In any of these cases, 
 systematic rubbing, and the applica- 
 tion of a light wooden or gutta- 
 percha splint will be found of great 
 use, and should never be omitted. 
 
 If the deformity is so great that 
 these milder measures are inade- 
 quate, the contracted tendons must 
 be divided subcutaneously. A 
 between the skin and the tendon 
 that is to be operated on. The knife is introduced side- 
 ways, and then the edge is turned down, and carried through the 
 tendon. The knife is next withdrawn, and the incision closed 
 
 Fig. 166. 
 
 Talipes varus, 
 tenotomy knife is passed 
 
CLUB-FOOT. 
 
 359 
 
 with a piece of plaster. This operation may he repeated at the 
 same time upon as many tendons as may require division. The 
 cut ends become united by a tendinous structure, which not only 
 adds directly to the length of the original tendon, but also admits 
 of a good deal of extension while it is fresh. 
 
 In t. equinus the tendo Achillis must be divided. The section 
 should be made about an inch above its insertion into the os 
 calcis. In this case it is safest to pass the knife underneath the 
 tendon, and cut from within outwards, for fear of wounding the 
 posterior tibial artery. 
 
 In t. calcaneus the tibialis anticus, the long extensors of the 
 toes, and the peroneus tertius, may all require to be divided 
 before the foot can be brought down to its proper level. 
 
 In t. varus the foot is turned inwards in consequence of the 
 contraction of the tibialis anticus and posticus. These are the 
 tendons, therefore, which must be cut. 
 
 In t. valgus the foot is turned outward by the action of the 
 peroneus longus and brevis. These, therefore, must be divided, 
 and the most convenient place to get at them is where they lie 
 behind the outer malleolus. 
 
 When the deformity is complicated, the surgeon must use his 
 own judgment in deciding what tendons require division. 
 
 Under any circumstances, the patient will have to wear a 
 splint, or a mechanical contrivance adapted to the case, for some 
 time after the operation, in order to make gradual extension, and 
 to reduce the foot to its proper position. 
 
 Mr. Barweil has recommended the use of elastic bands to sup- 
 plement the paralysed muscles, and he has devised various in- 
 genious methods of ap- 
 plying them to the pa- ^_, pi^. 167. 
 tient's leg. He has 
 been led to this prac- 
 tice by observing a pe- 
 culiarly clumsy and im- 
 perfect use of the foot 
 after division of certain 
 tendons — a condition he 
 has accounted for by 
 the false and unsatisfac- 
 tory union found in such 
 cases as have been sub- 
 mitted to post-mortem 
 
 examination. This observation refers especially to the tendons 
 which lie immediately behind the malleoli. These, he believes, 
 need never be divided. Moreover, he holds that the tendon of 
 
360 
 
 DISEASES OF TISSUES AND OEGANS. 
 
 the tibialis anticus, as well as the tendo Achillis, require this 
 operation much less often than is usually supposed. By manipu- 
 lation, by elastic bands, and by appropriate splints, he finds that 
 many cases may be efiectually cured without the division of 
 tendons. This treatment cannot be commenced too early. 
 Indeed, it is only reasonable to suppose that these milder 
 measures will have more efiect upon the young and tender tissues 
 of an infant than they can be expected to produce after the parts 
 have become fixed in their abnormal position. The accompanying 
 illustration (Fig. 167) represents a form of splint which Mr. 
 Barwell finds very convenient for cases of talipes equinus after 
 division of the tendo Achillis. 
 
 FIiAT OR SPXiAT FOOT. 
 
 Talipes valgus is often associated with the condition which is 
 known as flat or s^lay foot. The ligaments which support the 
 arch of the foot give way. The inner side of the sole touches 
 
 the ground, and the 
 
 Fig. 168. 
 
 foot has a tendency 
 to turii outwards. 
 There is constant 
 aching pain in the 
 ankle, particularly 
 across the front of 
 the joint, and the 
 patient walks awk- 
 wardly. This com- 
 plaint is very com- 
 mon in a slight de- 
 gree among young 
 persons of both sexes whose occupations oblige them to stand or 
 walk a great deal. Fig. 168 was taken from a middle-aged man, 
 whose occupation was that of a waiter, and whose case may be 
 considered as a typical example of the disease. 
 
 Treatment. — The patient should sponge the feet and ankles 
 every morning with cold water, and wear a bandage brought up 
 on the inside of the foot to support the arch. He should also 
 have a convex pad adapted to the inside of his shoe so as to efiect 
 the same object. Such a pad may be made of cork, or of a 
 cushion stuffed with horse-hair ; or a few layers of leather or 
 folds of lint, carefully graduated, may serve the purpose sufli- 
 ciently well. The pad should be worn constantly during the 
 day, so that the arch of the foot may never be allowed to drop. 
 
 In private practice the " registered surgical sole," made by 
 Spratt, of Brook-street, is the best appliance that can be recom- 
 
GENU-VALGUM, OR KNOCK-KNEE. 361 
 
 mended. It consists of an arched steel spring adapted to the 
 size of the patient's foot. This is neatly covered with leather, so as 
 to fit into the inside of his shoe or hoot. The " surgical sole" 
 can be worn with any boots or shoes ; but a lacing boot with a 
 broad sole is the best adapted for its use. 
 
 GENU-VAZiGUXVI, OR XN-OCK-KITEE, 
 
 is an affection of early life. It almost always comes on between 
 the age when children begin to walk and the time of puberty. 
 It usually shows itself in one knee more than the other, but both 
 are generally affected in some degree. 
 
 The legs yield under the weight of the body. The angle 
 which naturally exists between the femur and the tibia is in- 
 creased. The internal lateral ligament is stretched. The 
 patella is thrown outwards. The external lateral ligament and 
 the tendon of the biceps become contracted and tense. There is 
 considerable weakness and constant aching pain. 
 
 Treatment. — The legs should be supported, and the knees drawn 
 towards their proper position. If this is done perseveringly, 
 while attention is paid to the patient's general health, a great 
 improvement may be effected. To carry out these indications, 
 the surgeon should provide himself with a pair of straight 
 wooden splints about three inches wide, and long enough to 
 extend from the patient's waist to the outer ankle. They should 
 be perforated with holes near their upper end, so as to fasten them 
 to a waistband. They should be well padded, and then applied 
 in the following manner : — The patient should be undressed from 
 the waist, and laid flat upon a sofa. His legs should then be 
 bandaged with a common calico roller from the toes to a short 
 distance above the knees. Over this he should be allowed to put 
 on his stockings and boots. The surgeon should then lay the 
 splints along the outer side of each leg, taking care that they bear 
 well against the external malleolus and the trochanter. In this 
 position they should be fixed below by strips of plaster or bands 
 of webbing and buckles, and the upper ends of both splints should 
 be fastened to a broad belt passing round the waist, so as to 
 prevent them from slipping forwards. Some surgeons recom- 
 mend that they should be secured by a band passing from one to 
 the other behind the waist, so that they may interfere less with 
 the patient's movements. When the splints have been fixed the 
 knee should be drawn outwards by a strap of webbing secured by 
 a buckle or by a padded belt, which should be broad enough to 
 cover the whole knee from the head of the tibia to the condyles 
 of the femur. This must be kept sufficiently tight to make 
 uniform traction upon the joint. In some instances it may be 
 
362 DISEASES OF TISSUES AND OEGANS. 
 
 desirable to apply a second bandage up the whole length of the 
 leg, so as to draw it towards the splint. The apparatus should 
 be taken off at night after the patient is in bed, and readjusted 
 in the morning before he gets up. Unless the splints are applied 
 with care and attention, and worn continuously for several 
 months, they will be of little or no avail. 
 
 When the patient is a young child, he may with advantage be 
 kept in bed during a great part of the day, with his legs fixed 
 between sandbags or extended by weights (see Fig. 69). 
 
 CORN'S. 
 
 Corns consist of thickened and hypertrophied cuticle, beneath 
 which the papillae are enlarged and tender. When they are 
 situated on an exposed part of the surface they are dry and hard, 
 but when they occur between the toes, where the perspiration is 
 retained, they are soft and moist. They are usually caused by 
 the pressure of tight boots, and their most frequent seat is over 
 the prominences of bone — e.g., on the outer side of the little toe. 
 When they are struck, or trodden upon, they become exquisitely 
 painful ; in fact, their extreme sensitiveness haa passed into a 
 proverb. When they become acutely inflamed, the suffering 
 they cause is equally great and more persistent. 
 
 Treatment. — The first thing to be done is to remove the cause. 
 The patient should wear boots that are properly shaped, and 
 amply broad across the toes. A piece of thick plaster, or amadou, 
 with a hole punched in it large enongh to receive the whole corn, 
 may be laid over it to relieve it from pressure. With the view of 
 curing the corn, the hardened cuticle should be shaved off, or filed 
 down daily, and the part afterwards kept soft by the application 
 of a little cold cream, glycerine, or soap ; or it may be covered 
 with a small piece of galbanum plaster or of " Papier Fayard." 
 Care must be taken in cutting them not to make them bleed — 
 an accident which is very apt to happen in consequence of the 
 overgrowth of the papillae. If this should occur, and any diffi- 
 culty is found in arresting the haemorrhage, the application of a 
 little blotting-paper or charred paper will suffice to stop it ; or 
 pressure may be made by a bandage. If the corn is inflamed, it 
 should be soaked in hot water and poulticed. A poultice made 
 with vinegar often gives great relief. If there is reason to think 
 that suppuration has taken place, a puncture should be made 
 with the point of a scalpel. 
 
 Soft corns are best treated by the free application of lunar 
 caustic or glacial acetic acid. In elderly people these agents 
 must be used with caution, for fear of inducing gangrenous 
 inflammation. 
 
363 
 
 BTTUZOM'S ILNH DZSTORTEB TOES. 
 
 Bunion is the name given to a swelling formed by a chronic 
 inflammatory enlargement of the bursa which is situated on the 
 inner side of the head of the first metatarsal bone. It is at 
 times exquisitely painful, and, if it becomes acutely inflamed and 
 suppurates, a thin, unhealthy discharge is apt to continue for a 
 length of time. It is generally caused by the pressure of boots 
 that are too short as well as too narrow across the toes; and in 
 most instances the great toe is distorted, and pressed against the 
 other toes. 
 
 The pathology and treatment of the disease are much the same 
 as those of inflamed bursse generally (see p. 109). 
 
 Treatment. — The patient must be careful to wear boots that 
 are made of soft and pliable material, and which are thoroughly 
 easy. If the great toe is 
 but little distorted, it 
 may be drawn into its 
 place by means of a steel 
 spring ; or by pads of lint 
 or cotton-wool between 
 the toes, kept in place 
 by strips of adhesive 
 plaster. But if the dis- 
 tortion is great, as in the 
 case represented in Fig. 
 169, such efi'orts will be 
 futile. If the bunion is 
 in an indolent and chronic 
 state, iodine tinctiire, or 
 a mercurial ointment, or 
 a blister will be found 
 
 suitable applications. If it becomes acutely inflamed, it must be 
 poulticed or leeched. If matter forms, it should be let out, and 
 care taken to make the sac heal from the bottom. In any case 
 the patient should give himself as much rest as he can until the 
 bunion is cured, or at least brought into a quiescent state; for 
 it is sure to be aggravated by exercise. 
 
 Distorted toes. 
 
PART V. 
 
 OPERATIONS. 
 
 Ak operation is a serious matter, and ought never to be recom- 
 mended without due consideration. The most trivial operations 
 have occasionally been followed by death, and the possibility of 
 such a contingency ought always to be present to the surgeon's 
 mind. He should, therefore, try to convey to the patient, or his 
 friends, a fair idea of the risk to be incurred, whether it be great 
 or small. In order to form a correct estimate of the danger 
 there are many circumstances which must be taken into account — 
 e.g., the nature and extent of the disease, the age and sex of the 
 patient, his natural constitution and temperament, the present 
 state of his health, his business and habits of life, the conditions 
 in which he will be placed when he is confined to bed, and the 
 nursing he will be able to obtain. All these are points of great 
 importance, for it makes a wide difierence whether he is young 
 or old, of a sound constitution or affected with organic disease, of 
 a calm and placid temperament or irritable and excitable, whether 
 he is in tolerable general health or worn down by protracted 
 suffering. The surgeon must be on his guard, and not mistake 
 high spirits and courage for real strength and rallying power. 
 Again, it makes a great difference whether the patient's time is 
 at his own disposal, or whether he is anxious about the means of 
 earning his livelihood. Whether the operation is to be performed 
 in town or in the country, and whether or not skilful nursing can 
 be obtained, are points which should also be taken into considera- 
 tion. There are many cases in which one of the most important 
 duties of the surgeon is to arrange for the nursing — more parti- 
 cularly during the night. Happily this is not now a very diffi- 
 cult matter, as, in addition to the numerous private institutions, 
 there are so many training schools for nurses in connection with 
 the hospitals. 
 
OPERATIONS. 365 
 
 Wlien an operation is necessary, the patient should, if possible, 
 be prepared for it. He should be kept quiet for a few days, the 
 secretions regulated, and, if need be, the strength supported by 
 the administration of good food and tonics. It is of the utmost 
 importance that every function of the body should be in its 
 normal state, and that the mind should be calm and hopeful. 
 Of course, there are many operations which must be performed 
 without delay, and where there is no time for preparing the 
 patient — for example, the operation for strangulated hernia, or 
 an amputation after injury. 
 
 Again, there are many cases where other considerations must 
 be taken into account. The patient's time may be limited — e.g., 
 he may be under orders for foreign service — and then we must 
 be contented to do the best that can be done under the circum- 
 stances. 
 
 In some operations upon the limbs it is well, before using the 
 knife, to put on " Esmarch's bandage." This is merely an elastic 
 roller which is applied from the extremity upwards. At the 
 highest point to which it is carried an elastic cord is tied round 
 the limb, and then the bandage is removed. It will be found 
 that the blood has been to a great extent driven out of the part, 
 and that there is little or no haemorrhage as the incisions are being 
 made. When the operation is finished, the elastic cord is 
 gradually relaxed, and then the bleeding vessels can be secured. 
 
 The surgeon should himself see that everything is ready for 
 the operation — that the table, or couch, is firm, of a convenient 
 height, and well situated for light — that there is a sufficient 
 supply of sponges and water — that every instrument which can 
 possibly be required is at hand, and within easy reach — that the 
 necessary splints, dressings, and bandages are in readiness. Ke 
 should have a sufficient number of assistants, but no more ; and 
 each should understand beforehand what are his special duties. 
 In the case of a capital operation, three or four will be necessary. 
 If chloroform is to be used, its administration must be entrusted 
 to a competent person, and he should make it his sole business, so 
 that the operator may have no anxiety on that score. The sur- 
 geon should take his stand in the most convenient position, and 
 from that place he should not move till the operation is com- 
 pleted. There should be silence during its performance ; and a 
 word, a look, a gesture, is all that should be necessary on the 
 part of the surgeon to guide the movements of his assistants. 
 Everything should be done quietly and deliberately, without 
 hurry and without loss of time. 
 
366 OPEEATIONS. 
 
 ZM-cisioirs. 
 
 The scalpel may be held like a carving knife, or like a pen, or 
 like a fiddlestick, or in other ways which the requirements of the 
 case and the dexterity of the surgeon will suggest. 
 
 Before commencing an incision, the skin should be gently 
 stretched with the left hand. The point of the scalpel should be 
 introduced at right angles to the surface, and carried quite 
 through the skin ; the handle should then be depressed, and the 
 blade drawn along as far as necessary ; the handle again raised, 
 and the knife withdrawn at right angles to the surface, as before. 
 Sometimes, the superficial incision is made by transfixion. A fold 
 of skin is raised between the forefinger and thumb of the left 
 hand, pierced, and then the blade is made to cut from within 
 outwards. In any case, a sufficient incision in the skin should be 
 made at the outset. It should not be needful, except under 
 special circumstances, to enlarge it afterwards. 
 
 AXa-JESTHETICS. 
 
 The history of ansesthetics is a subject full of interest, but it is 
 one on which I cannot here enter. Suffice it to say that the in- 
 troduction of ether in 1846 is due to Mr. Morton, a dentist of 
 Boston, U.S.A. ; while it was Sir James Simpson who drew the 
 attention of the profession in 1847 to chloroform — an anaesthetic 
 which is more convenient than ether, and which is now very 
 largely used in this country. 
 
 Administration of chloroform. — The patient should, if possible, 
 abstain from food for three or four hou7s before the chloroform is 
 to be given, or take only a little beef-tea or wine. When the 
 stomach is full, sickness is very apt to o(!cur. He should be 
 placed in the recumbent position, lying on his back, and arranged 
 as if for sleep. The administrator should keep his hand on the 
 pulse, watch the breathing and the colour of the lips, and from 
 time to time examine the state of the pupils. 
 
 When a slight and transient insensibility is all that is wanted, 
 chloroform may be given on a handkerchief, or on a fold of lint ; 
 and this will generally be found the best plan in dealing with 
 infants. But when deep and prolonged narcotism is necessary in 
 the adult, an inhaler had better be used. 
 
 At first, a small quantity of chloroform — say, ^j for an adult — 
 should be sprinkled on the lint, and it should be held in front of 
 tlie patient's nose and mouth, at a distance of a couple of inches. 
 After a few respirations, it should be brought a little nearer, and 
 thus the dose should be gradually increased ; but the saturated 
 
ANESTHETICS. 367 
 
 lint should never be placed so near the face as to prevent the free 
 admixture of atmospheric air with the vapour of the chloroform. 
 If an inhaler is used, the valve should be kept open at first, and 
 closed by degrees. It is of great importance that the dose should 
 be small at first, and gradually increased, so that the air-passages 
 may become accustomed to the vapour. Moreover, there is 
 reason to think that the first inhalation of a large dose of chloro- 
 form has sometimes caused instant death by spasm of the glottis, 
 or paralysis of the heart. 
 
 If a fold of lint or an ordinary inhaler is used, the amount of 
 chloroform vapour which the patient breathes must be very un- 
 certain — sometimes it will be more and sometimes less ; and very 
 probably it will be greatest at first, when it is desirable that 
 it should be least. To obviate these disadvantages, Mr. Clover 
 has invented an apparatus whereby the per-centage of chloroform 
 to atmospheric air can be regulated exactly. A measured quan- 
 tity of chloroform and a measured quantity of atmospheric air are 
 introduced into a large air-tight bag, which is fitted with a 
 flexible tube and a mouthpiece. Thus the dilution of the chloro- 
 form vapour can be ascertained with great nicety, and under no 
 circumstances can the patient breathe a larger proportion of the 
 anaesthetic than that which has been predetermined by the 
 surgeon. The apparatus is, unfortunately, rather cumbrous; 
 but, notwithstanding this drawback, it is by far the best means 
 of administering chloroform that has yet been devised ; and 
 nothing can be more satisfactory than the success which has 
 attended its use in Mr. Clover's hands. 
 
 The first efiect of chloroform is to produce a slight excitement. 
 The pulse is quickened ; the spirits are raised ; and the mind is 
 active, but not quite under control. The patient struggles, talks 
 loudly and incoherently, or perhaps sings ; still there is perfect 
 sensibility to pain. Gradually, these symptoms give way, and 
 he falls into a deep sleep. The breathing is slightly stertorous. 
 Voluntary motion and sensation are suspended, but the sphincters 
 are not relaxed. Soon, reflex movements can no longer be 
 excited; if the eyeball is touched, or the nostril tickled, no 
 attempt is made to resent the irritation. This is the state of 
 complete insensibility in which the patient should be placed when 
 the operation is commenced. If the chloroform is pushed farther 
 than this, the breathing becomes slow, and very stertorous, the 
 face congested, the pupils dilated, and there is a tendency to 
 death by coma. 
 
 Thus it will be seen that chloroform acts upon the brain from 
 its circumference to its centre. First, the intellectual faculties 
 are disturbed j then, the central ganglia of motion and sensation. 
 
368 OPERATIONS. 
 
 with which the spinal cord is in communication, hecome aflPected ; 
 and, when the influence of the drug extends to the medulla 
 oblongata, respiration is apt to cease. When chloroform destroys 
 life in this way, it acts like a poisonous dose of opium, or of 
 alcohol. In such cases, the heart continues to beat for a few 
 minutes after the action of the lungs has stopped. 
 
 If the patient retches, and is inclined to vomit, his head should 
 be turned on one side, so as to facilitate the escape of matters 
 from his mouth. 
 
 If he struggles violently, the chloroform should be removed 
 for a moment ; and, as soon as he is composed, the administration 
 should be continued. 
 
 As long as the pulse is good, and the breathing regular, there 
 is no cause for alarm. When the chloroform has been pushed to 
 excess, there is, as we have just said, danger of death by coma ; 
 but this is not the only way in which it extinguishes life. Some- 
 times it seems to act by paralysing the heart. This is particularly 
 apt to occur when the cavities are dilated, and the muscular tissue 
 is thin and in a state of fatty degeneration. When it proves 
 fatal in this way, death may occur at the first inspiration, or at 
 any time during the administration. 
 
 If the patient is old or debilitated — if the impulse of the heart 
 is feeble, the sounds indistinct, the pulse weak ; or if there is a 
 well-marked arcus senilis ; or if the circulation through the lungs 
 is impeded — the utmost care should be used in administering 
 chloroform. It should also be remembered that in some cases the 
 patient receives an additional shock from the nature of the opera- 
 tion, as, for example, when the spermatic cord is divided. 
 
 There are some operations which it is better to perform with- 
 out chloroform. Speaking generally, they may be summed up 
 under two heads : (1) operations about the back of the mouth — 
 excision of the tonsils, for example — where there is danger of the 
 blood finding its way into the glottis, and producing suffocation ; 
 and (2) operations in which we require the assistance of the 
 patient — for example, in the ligature of internal piles. 
 
 As a general rule, chloroform should not be given when a 
 minute's fortitude on the part of the patient will enable him to 
 endure all that has to be done. The occasion does not justify 
 the risk. 
 
 If death seems imminent, whether it be by syncope or by coma, 
 restorative measures should be adopted without delay. The 
 windows should be opened, the patient's tongue drawn forward, 
 the face and chest dashed with cold water, ammonia held to the 
 nostrils, the chest rhythmically compressed, artificial respira- 
 tion performed, and galvanism applied over the heart. 
 
DKESSINGS. 369 
 
 JSther has always been a favourite ana3sthetic in America, and 
 from time to time it has been extensively used in this country. 
 At present, English surgeons are employing it largely. Some- 
 times it is administered throughout the whole operation ; some- 
 times the patient is brought fully under its influence, and then 
 the effect is kept up with chloroform. There can be no doubt 
 that it is, on the whole, safer than chloroform ; but its 
 administration takes a longer time, is apt to be attended by more 
 excitement, and followed by more unpleasant after-symptoms. 
 By a judicious combination of the two substances we may hope to 
 secure the best influences of each, and to avoid their disad- 
 vantages. 
 
 The bichloride of methylene is another substance which has 
 lately been used by some surgeons as an anaesthetic. The 
 advantages which it is said to possess over chloroform are that it 
 produces insensibihty more rapidly, that there is less muscular 
 rigidity, that recovery takes place more quickly, and that it is less 
 liable to be followed by disagreeable consequences. 
 
 The nitrous oxide, or laughing gas, has been introduced into 
 practice by the American surgeons, and has now taken its place 
 as a recognised anaesthetic. As the insensibility it produces can- 
 not safely be prolonged beyond a few minutes, it is not suitable 
 for general surgery ; but for short operations, such as the majority 
 of those in dentistry, it is a very valuable agent. 
 
 Local Ancesthesia. — Local and superficial insensibility may be 
 produced by using a mixture of pounded ice and salt — two-thirds 
 of ice and one-third of salt. The mixture should be made 
 rapidly, placed in a muslin bag, and laid upon the part. In five 
 or ten minutes the skin becomes white, hard, and insensible to 
 pain. After the operation, it should be allowed to recover itself 
 slowly. Heat should on no account be applied. 
 
 But this means of producing local insensibility has been well- 
 nigh superseded by Dr. Richardson's method, which consists in 
 throwing a spray of highly-rectified ether upon the part. By the 
 rapid evaporation which the ether undergoes, the skin is frozen, 
 and rendered insensible to pain. Richardson's apparatus is 
 simple, and can be obtained at any surgical-instrument maker's. 
 
 Local anaesthesia, however, is only applicable to slight opera- 
 tions — opening abscesses, removing small tumours, and the like. 
 
 DRESSISJGS. 
 
 A vast improvement has taken place of late years in the mode 
 of dressing wounds. The present practice is characterised by 
 great simplicity, and by a studious regard to cleanliness. It is 
 also the aim of the surgeon to lay aside all needless appliances, 
 
 B B 
 
370 OPERATIONS. 
 
 to remove all sources of discomfort, and to diminish, as far as he 
 can, pain and suffering. A great deal may be done to carry out 
 these objects by forethought, by minute attention to details, and 
 by a gentle hand. If a patient can be kept perfectly at rest, 
 both in body and mind, he is placed in the most favourable cir- 
 cumstances for recovery, 
 
 I have already said that the aim of modern surgery is to reduce 
 suppuration to a minimum, and, whenever it is possible, to get rid 
 of it altogether. With this view, various applications have been 
 used, and various methods of dressing have been tried. Of these 
 applications the most eflScient is carbolic acid, and the most 
 effectual way of applying it is that which is carried out by Mr. 
 Lister, and which I have elsewhere described (see p. 14). But 
 whether carbolic acid (F. 12), or sulphurous acid (F. 24), or chlo- 
 ride of zinc (F. 14), or any other substance, is used, it is of the 
 first importance that it should be brought thoroughly and con- 
 tinuously into contact with the wound. The plan which Mr. 
 Lister adopts secures this object perfectly. The only fault 
 that can be found with it is that it is too complicated — that 
 it requires too much time and attention from the surgeon. If it 
 could be made more simple, I believe it would be one of the most 
 far-reaching improvements in modern surgery. At Charing 
 Cross Hospital, Mr. Hancock has had some excellent results, 
 after important operations, by merely washing out the wound 
 thoroughly with a carbolized lotion, covering it with lint, and 
 allowing a weak carbolic lotion to drop constantly upon it from a 
 syphon bottle. 
 
 Some surgeons prefer to get rid of all moist applications, and 
 to use only dry dressings. Thus, a wound may be carefully washed 
 out, accurately stitched together, and then the edges sealed with 
 collodion. Friar's balsam, or " colloid styptic." This method is 
 best suited to wounds of moderate size in parts that are highly 
 vascular, such as the face or scalp. In larger wounds, after care- 
 ful closure, a pad of " tenax." (i.e., finely carded oakum) or of dry 
 lint may be laid over the whole surface, and firmly secured by a 
 bandage. This method is very suitable to the wound left after the 
 removal of a tumour — e.cf., of the breast. When such dressings 
 as these are employed, it is no uncommon thing to find that the 
 whole, or a great part, of a wound unites by adhesive inflamma- 
 tion. But these methods of dressing are only applicable to cases 
 in which we may reasonably expect that there will be no slough- 
 ing — that no considerable part of the tissues will have to be thrown 
 off before repair can begin, but that all within the incision will 
 retain its vitality and become united together. 
 
 If the case is not suitable for dry dressings, and if the sur- 
 
DRESSINGS. 371 
 
 geon does not think proper to adopt any antiseptic method, then 
 it is customary to cover the wound with a few folds of wet lint 
 covered with oiled silk (water-dressing); and to secure them by 
 means of a bandage. Sometimes narrow strips of lint, spread 
 with vaseline or simple cerate, are laid along the incisions, to 
 prevent the folds of lint from becoming adherent. These dress- 
 ings are not disturbed for a couple of days, except under special 
 circumstances. Subsequently, the wound is treated, if need be, 
 with a suitable lotion, or a poultice. 
 
 When suppuration takes place, if it is moderate in amount 
 and healthy in character, all that need be done is to receive the 
 discharge on lint, which should be frequently changed. 
 
 If the neighbourhood of the wound becomes red, swollen, and 
 painful, if there are the signs of inflammation, then we must 
 apply a poultice or a bladder of ice ; whichever is found to give 
 the patient most relief will be best for the wound. 
 
 Cold seems to act by constricting the vessels, so as to diminish 
 the quantity of blood in the part, and by absorbing the heat that 
 is generated ; while, at the same time, it relieves pain by deaden- 
 ing the sensibility of the nerves. Continuous cold can only be 
 thoroughly maintained by a bladder of ice, by an ice poultice 
 (F. 97), or by irrigation — that is to say, by causing iced water, or 
 evaporating lotion, to drop constantly on the aflected part, or on 
 a fold of lint laid over it. 
 
 Heat combined with moisture relaxes the tissues, dilates the 
 vessels, favours exudation, and allows the circulation to be carried 
 on more easily. This is one of the special uses of a poultice — it 
 allays inflammation by relieving the tension of the circulation. 
 Fomentations — that is to say, flannels wrung out of hot water 
 (plain or medicated), and enveloped in oiled silk — and water - 
 dressing, act in the same way, but less efficiently. 
 
 There are, however, other conditions in which heat and mois- 
 ture are extremely useful. When a part is lacerated or contused, 
 when it is clear that sloughs must come away before repair 
 can begin, then a poultice is applied with advantage. It would 
 seem that the natural processes go on with greater rapidity in 
 the warm and moist atmosphere, which is kept up by this means. 
 The disintegration of the dead tissues takes place more quickly, 
 the sloughs separate in a shorter time ; and, when once a clean 
 surface has been produced, the granulations spring up with a 
 more luxuriant growth. 
 
 If poultices are continued too long, the granulations are apt 
 to become large, pale, and flabby — constituting what is popu- 
 larly called " proud flesh" — and the surrounding tissues become 
 sodden. In such a case the poultices should be discontinued, and 
 
 B B 2 
 
372 OPERATIONS. 
 
 the wound dressed with a stimulating lotion. Sometimes great 
 benefit may arise from exposing it for a few hours to the air. 
 If the granulations are exuberant, they should be freely touched 
 with lunar caustic. 
 
 If the suppuration is excessive, the wound should be bathed or 
 syringed with an astringent lotion, or dressed with lint dipped 
 in it (F. 12, 14, 27). 
 
 If the discharge is very offensive, lint saturated with a disin- 
 fecting lotion should be applied to the wound, and a poultice laid 
 over it; or the poultice may be mixed with charcoal or yeast. 
 
 In those distressing cases in which the patient's urine is con- 
 stantly dribbling away, it is a good plan to lay a pillow of char- 
 coal between the thighs and under the perineum. 
 
 COXarSTITUTIOXTAZi TREikTni&rrT AFTER 
 OPERiLTIOia'S. 
 
 After a trifling operation it is not necessary to make any 
 change in the patient's way of living, provided that proper atten- 
 tion is paid to the state of the bowels. 
 
 After a second-rate operation the patient should be confined to 
 bed or to the sofa for a few days, the diet should be somewhat 
 restricted, and a laxative prescribed every evening. 
 
 After a capital operation, where there is sure to be more or less 
 fever, the patient should take a saline (F. 33, 35, 69), his bowels 
 should be freely opened every day, and his diet should consist of 
 beef-tea, broth, milk, eggs, light puddings, &c. In some cases 
 an alcoholic stimulant will be required. This is particularly the 
 case when the patient is old, or enfeebled by previous disease, or 
 when he has been prostrated by the shock of the operation, or by 
 hsemorrhage. As a general rule, brandy or port wine are the 
 best ; but it is often the wisest plan to give the patient what- 
 ever he has been accustomed to drink, or whatever he fancies at 
 the time. Egg-flip is of great use in extreme exhaustion (F. 100); 
 and, at the same time, ammonia and spirits of chloroform may 
 be freely given (F. 35). But alcohol should not be given unless 
 there is good reason. 
 
 Some surgeons make a practice of ordering a grain of opium 
 or a sedative draught to be taken every six hours after a capital 
 operation, with the view of allaying nervous irritability ; and the 
 practice is one which may often be followed with advantage, 
 especially in persons of an excitable temperament. Under any 
 circumstances, it is a good plan to give a full dose of opium or 
 morphia the night after a severe operation, to allay pain and 
 procure sleep. 
 
373 
 
 Fig-. 170. 
 
 VEUESECTZOHr. 
 
 Fifty years ago venesection used to be much more often prac- 
 tised than it is at the present time. Persons now living can 
 remember when those in good health 
 thought it necessary to be bled every spring, 
 or every spring and autumn. Bleeding 
 entered largely into the regimen to which 
 pregnant women were subjected; and 
 there is reason to fear that many, like 
 the Princess Charlotte, succumbed to its 
 lowering influence (see the " Memoirs of 
 Baron Stockmar," i. 65). In the treat- 
 ment of disease the lancet was freely used, 
 and the amount of blood that was some- 
 times drawn is almost incredible. Insanity, 
 in all its forms, was supposed to depend 
 upon inflammation of the brain, and was 
 to be cured by blood-letting ; while many 
 morbid states which we now know to be 
 far removed from sthenic inflammation, 
 were treated in the same manner. 
 
 But all this — so far, at least, as British 
 medicine and surgery are concerned — is 
 now happily changed. It is now held that "the blood is the 
 life," and it is our study to maintain its quantity, to preserve 
 
 Bandage before vene- 
 section. 
 
 Fiff. 171. 
 
 its purity, and to regulate its dis- 
 tribution. There should, there- 
 fore, be very clear evidence to act 
 upon, and some very special benefit 
 to obtain, before general blood- 
 letting is resorted to. 
 
 Venesection is generally per- 
 formed at the bend of the elbow. 
 A broad roller is tied round the 
 arm a little above the elboAv, tight 
 enough to compress the superficial 
 veins, without arresting the deep 
 circulation (Fig. 170). The sur- 
 geon then selects the vein to 
 be opened — the median cephalic 
 or the median basilic, the former, 
 if possible — places his thumb on 
 pushes his lancet obliquely through it, so as to lay it open 
 
 Bandage after venesection, 
 the lower part of it, and 
 
374 OPERATIONS. 
 
 without dividing it. When the required quantity of hlood has 
 been drawn, he puts a small compress of lint on the bleeding 
 point, fixes it with a strip of plaster and a figure-of-8 bandage 
 (Fig. I7l), and then undoes the roller. 
 
 If the jugular vein has to be opened, the incision should be 
 carried obliquely downwards and inwards, so as to cross the fibres 
 of the platysma. 
 
 THE CAUTERV, ISSUES, SETOITS. 
 
 Counter-irritation is sometimes made by means of the actual 
 cautery, or by issues, or by setons. 
 
 If the actual cautery is used, the iron, heated to a dull red 
 heat, is drawn lightly over the skin, sometimes in parallel lines 
 and cross-bars, like an heraldic portcullis. The gas cautery, 
 which was devised by the late Mr. Bruce, and Dr. Paquelin's 
 thermo-cautere are convenient means of heating the metal points 
 and keeping them at the required temperature. 
 
 The moxa is a peculiar method of applying cauterization. A 
 small cone is formed of muslin soaked in solution of nitre. It 
 is then placed on the skin, and the apex is ignited. It is allowed 
 to burn slowly down, and the result is an eschar, corresponding 
 in size to the base of the cone. The surrounding skin should be 
 protected by a fold of wet lint, with a hole cut in it. 
 
 Counter-irritation by means of the actual cautery, or the 
 moxa, is particularly applicable to deep-seated and chronic disease 
 of the joints and bones. 
 
 Issues may be made either with caustic or by an incision. 
 
 If caustic is preferred, the best is a thick paste composed of 
 potassa fusa and bread-crumbs or soft soap. A piece of thick 
 leather plaster, with a hole cut in it the size of the desired issue, 
 should be laid on the part, the paste applied to the skin, which is 
 visible at the aperture, and retained by a strip of plaster. For 
 four or five hours the patient experiences a burning pain. 
 An eschar is formed, which must be poulticed till it separates, 
 and then the raw surface should be dressed with savine ointment. 
 
 If the issue is to be made by incision, a fold of skin is raised 
 between the finger and thumb of the left hand, transfixed, and the 
 knife made to cut its way from within outwards. To increase 
 the effect, a string of issue-beads or dry peas is sometimes laid 
 along the incision, and secured by strips of plaster. 
 
 An issue should never be made directly over a projecting pro- 
 cess of bone. In all cases the wound ought to be confined to the 
 skin ; if it extends farther, it may lead to a troublesome sore. 
 When the raw surface ceases to discharge healthily, the sooner it 
 is healed the better. 
 
LARYNGOTOMY AND TRACHEOTOMY. 375 
 
 A seion is made by lifting up a fold of skin between the finger 
 and thumb, and piercing it with a narrow-bladed knife. The 
 author's grooved knife, represented in Fig. 172, is very suitable for 
 the purpose. An eyed probe, armed with two or three threads of 
 
 Fior. 172. 
 
 silk, is then passed through the wound, or along the groove of the 
 knife, and the ends tied together. Or, in minor cases, a large 
 needle, doubly threaded with stout silk, may be passed through a 
 fold of skin, and the ends tied as before. The loop thus formed 
 should be moved a little every day to keep up irritation. 
 
 XiAR'S'ia-GOTOIVI'S- AND TRACBEOTOM7. 
 
 It is often necessary to make an opening into the windpipe 
 when the larynx is obstructed, or when there is a foreign body in 
 the bronchi. 
 
 The obstruction of the larynx may arise either from acute or 
 chronic disease, or from the impaction of a foreign body. 
 
 The acute diseases most likely to require operative treatment 
 are oedema glottidis, erysipelas of the larynx, diphtheria, and, in 
 the adult, acute laryngitis. 
 
 The chronic diseases are chronic inflammation of the larynx 
 with thickening or ulceration ; morbid growths, either in the 
 larynx itself, or pressing upon it from without. 
 
 When a foreign body, such as a morsel of food, has become im- 
 pacted in the larynx, it is necessary to open the windpipe at once, 
 to prevent suffocation ; and when a foreign body has been 
 drawn into the bronchi, an artificial opening may be needful to 
 facilitate its expulsion. 
 
 When an operation has become necessary, the question arises, 
 where shall t^ie windpipe be opened ? The surgeon has a choice 
 of situations. He may perform laryngotomy, laryngo-tracheotomy, 
 or tracheotomy . 
 
 Laryngotomy consists in cutting vertically through the skin 
 and fascia, exposing the crico-thyroid membrane, and then dividing 
 it by a transverse incision. The crico-thyroid membrane may 
 easily be recognised by the depression which it forms about an 
 inch below the pomum AdamL This operation is only applicable 
 to adults. 
 
 In laryv go-tracheotomy the deep incision is carried downwards 
 
376 
 
 OPERATIONS. 
 
 from the crico-thyroid membrane, through the cricoid cartilage 
 and one or two of the upper rhigs of the trachea. 
 
 Tracheotomy is a more difficult and dangerous operation than 
 either of the preceding. It may be performed either above or 
 below the isthmus of the thyroid gland. The patient's head 
 should be thrown back, so as to stretch the neck. An incision, 
 about an inch and a half long, should then be made through the 
 skin and superficial fascia. The dissection should be carried on, 
 partly with the point of the knife and partly with the handle, 
 between the sterno-hyoid and sterno-thyroid muscles of each 
 side, until the rings of the trachea are exposed. As far as pos- 
 sible the larger veins should be avoided ; if any are divided, they 
 should be tied at once. The capillary haemorrhage should be 
 restrained by gentle pressure, or by cold water, before the wind- 
 pipe is opened. When the bleeding has ceased, the surgeon 
 steadies the trachea with a hook or with his finger, and then 
 pushes the point of his scalpel through it, and cuts from helow 
 vpivards, dividing three or four of the rings. The knife should 
 be lightly held in the wound, so as to form a guide upon which 
 the tube can be slipped into the trachea. If this is not done — if 
 the surgeon once withdraws his knife — he may find it very diffi- 
 cult to introduce the tube. The grooved knife represented in 
 Fig. 172 is well suited to form a guide into the winflpipe. 
 
 The isthmus of the thyroid gland should be pushed upwards or 
 downwards, according to the seat of the operation. 
 
 Tracheotomy below the isthmus is a more formidable operation 
 than when the opening is made above that point. In this situa- 
 tion the trachea lies deeper, it is more covered, and it comes 
 into close relation with some very important parts. Superficially, 
 it is covered by the inferior thyroid plexus of veins. The inno- 
 minate artery lies just behind the upper border of the sternum, 
 and may even rise higher ; and there may be a " thyroidea ima" 
 coursing up the front of the trachea itself. 
 
 Fig, 173. 
 
 Outer and inner tracheotomy tubes (Fuller's). 
 
 The tubes that are generally used are those which are double 
 — the inner one (Fig. 173, h) fitting accurately into, and project- 
 
LARYNGOTOMY AND TRACHEOTOMY. 
 
 377 
 
 Fig:. 174, 
 
 ing a little beyond, the outer one (Fig. 173, a). If one of these 
 is used, the inner tube can be withdrawn from time to time, and 
 cleaned. When the outer tube is split up the middle, and 
 reduced to two lateral pieces, which can be pressed together at 
 the point so as to form a wedge, it very much facilitates its intro- 
 duction. These are known as Fuller's bivalve tubes. 
 
 But it is obvious that a stiff, hard tube, such as this, must 
 sometimes press unduly against the posterior wall of the trachea. 
 To remove this objection, various suggestions have been made. 
 Mr. Bryant, and also Mr. 
 Durham, have introduced tubes 
 which are jointed in different 
 ways, so that, while the neck- 
 plate remains fixed, the curve 
 of the tube can adapt itself to 
 the trachea. Mr. Morrant 
 Baker has met the difficulty in 
 another way, and has devised a 
 tube which is made of India- 
 rubber spread upon fine canvas 
 (Fig. 174). 
 
 The tube should be secured 
 by tapes passed round the neck, 
 and tied behind. The edges 
 of the wound should be pro- 
 tected against the pressure and irritation of the tube by a little 
 cotton-wool, or a piece of lint spread with simple cerate. 
 
 The great danger after the operation, more especially in chil- 
 dren, is extension of inflammation to the lungs — bronchitis or 
 pneumonia. To prevent this must be our chief aim. The throat 
 should be lightly covered with flannel. The patient should 
 breathe a warm, moist atmosphere. The curtains of his bed 
 should be drawn, and a kettle, or cans of hot water, giving off 
 steam, should be placed near him, so as to create a sort of vapour- 
 bath. At the same time, his strength will probably require to 
 be upheld by a liberal allowance of strong beef-tea and soup. In 
 many cases stimulants will also be needed. 
 
 If the operation has been performed for a temporary cause, the 
 tube should be removed as soon as possible, and the wound 
 allowed to heal. But in cases of permanent obstruction, it will 
 be necessary for the patient to wear a tube during the remainder 
 of his life. 
 
 Laryngotomy and laryngo-tracheotomy, are, as I have said, 
 safer and easier operations than tracheotomy. They can, more- 
 over, be performed in a shorter time; and they are generally 
 
 Morrant Baker's tracheotomy 
 tube. 
 
378 OPERATIONS. 
 
 sufficient to meet the requirements of all ordinary cases, for in- 
 flammatory action commonly stops at the vocal cords. 
 
 Tracheotomy is especially applicable to those cases in which a 
 foreign body is lodged in the bronchi, and where we must make a 
 large opening to facilitate its expulsion ; and also to cases of croup 
 and diphtheria, in which we want to get as far away from the 
 larynx as possible, in the hope of reaching a point to which the 
 inflammation does not extend. 
 
 It is one of the vexed questions of surgery, whether the wind- 
 pipe ought, or ought not, to be opened in cases of croup and 
 diphtheria. The operation is so far from being successful that 
 few surgeons would venture to recommend it, except as a last 
 resource. And even as a last resource, it ought not to be prac- 
 tised in all cases indiscriminately. If the face has a peach- 
 coloured hue, and the pulse is quick, weak, and failing, then an 
 operation ought not to be undertaken. But if the colour is good, 
 if the blood is still well aerated, and the pulse full, strong, and 
 regular, while at the same time it is clear that the disease is 
 making progress, and will ere long destroy life, then tracheotomy 
 may be proposed with some slight hope of success. Even if it 
 does not save life, the surgeon may have the satisfaction of 
 knowing that death by asphyxia has been averted, and that the 
 patient's end has been rendered less painful and distressing. 
 
 XilGATURE OF .aRTERXES. 
 
 Ligature of the lingual artery has been practised both for per- 
 sistent bleeding from an ulcerated cancer of the tongue, and also 
 in the hope of starving tumours in that situation. I believe the 
 cases are very rare in which it is impossible to arrest hsemorrhage 
 from the tongue at the bleeding point ; and, although cutting off 
 the supply of blood from a morbid growth may have some tem- 
 porary effect on its nutrition, yet it is of no permanent benefit. 
 It must also be borne in mind that it has generally been in cases 
 of malignant disease of the tongue that ligature of the lingual 
 artery has been recommended, and in such cases the normal 
 anatomy of the parts is liable to be disturbed by the enlargement 
 which takes place in the submental region and at the upper part 
 of the neck. For these reasons, therefore, the operation is one 
 which, as a general rule, cannot be recommended. 
 
 If, however, the surgeon deems it necessary to tie the artery, it 
 may be reached most conveniently near its origin, where it lies 
 just above the greater cornu of the hyoid bone, and before it 
 passes beneath the hyo-glossus muscle. An incision should be 
 made, almost from the point of the chin, downwards and back- 
 wards, to a little below the greater horn of the hyoid bone. This 
 
LIGATURE OF AETERIES. 379 
 
 incision should then be turned and carried upwards, almost at a 
 right angle, to near the angle of the jaw. The flap, when dis- 
 sected back, will correspond nearly with the digastric triangle. 
 The posterior border of the subuaaxillary gland will have to be 
 held aside. This will bring into view the central tendon of the 
 digastric, and the posterior edge of the mylo-hyoid muscle ; and 
 the hypo-glossal nerve with a vein will be seen lying horizontally 
 upon the hyo-glossus muscle. If, then, the surgeon feels for the 
 posterior margin of this muscle, he will find the lingual artery 
 lying just above the greater cornu of the hyoid bone. Perhaps 
 he may have to divide a portion of the muscle before he will be 
 able to place the ligature. 
 
 Ligature of the common carotid artery may be required for 
 a wound, or for an aneurysm, either of the vessel itself or of one of 
 its branches. If the trunk itself is wounded, a ligature must be 
 put upon both ends of the vessel, at the seat of injury. 
 
 If the surgeon can select his own situation, he generally places 
 the ligature either immediately above, or immediately below, the 
 crossing of the omo-hyoid muscle. 
 
 The anterior border of the sterno-mastoid muscle, or a line 
 drawn from the sterno-clavicular joint to the depression behind 
 the angle of the jaw, serves as a guide to the course of the artery. 
 Here it lies upon the anterior spinal muscles, having the sym- 
 pathetic nerve behind it, and the descendens noni in front. On 
 its outer side is the internal jugular vein, and between the vein 
 and the artery, and behind them both, is placed the pneumogastric 
 nerve. The vein, artery, and nerve are all included in a common 
 sheath, though each has its own compartment. Occasionally, the 
 descendens noni is found in the same sheath, lying in front of the 
 artery. 
 
 An incision is made about three inches long, commencing 
 opposite the upper border of the thyroid cartilage, and carried 
 
 Fig. 175. 
 
 along the anterior edge of the sterno-mastoid muscle. After 
 cutting through the skin, platysma, and superficial fascia, the 
 sheath of the vessels comes into view. This must be carefully 
 
380 OPERATIONS. 
 
 exposed with the finger-nail or the handle of the scalpel, and 
 freed from the branches of the descendens noni. The sheath 
 should then be lifted with a forceps at the point where the liga- 
 ture is to be applied, and a nick made in it — the flat of the blade 
 being turned towards the artery. The opening in the sheath 
 should then be enlarged on a director. If the vein overlaps the 
 artery, as it sometimes does, it must be held back with a re- 
 tractor. The pneumogastric nerve will probably be drawn aside 
 along with it. An aneurysm needle (Fig. 175), armed with a 
 stout ligature, should then be passed cautiously and closely round 
 the artery from without inwards. Sometimes it is safer and 
 more convenient to pass the needle unarmed, and then to thread 
 it, and withdraw it. In this, and in every operation of the same 
 kind, the parts should be disturbed as little as possible. Before 
 the ligature is tied, it is well to see that it embraces nothing but 
 the artery, and that pressure upon the included vessel arrests the 
 haemorrhage, or controls the pulsation in the aneurysm, as the 
 case may be. The ligature should be drawn tight, so as to divide 
 the two inner coats of the artery, and then tied in a reef-knot. 
 One end should be cut off, and the other left hanging out of the 
 wound. When bleeding has quite ceased, the edges of the wound 
 should be brought together, and secured by strips of plaster. 
 The patient must be kept perfectly quiet, until the ligature comes 
 away. This will probably happen in the course of ten or twelve 
 days. Or the surgeon may prefer to use a carbolized catgut liga- 
 ture, and to cut both ends off short, and to endeavour to heal the 
 wound as rapidly as possible by adhesive inflammation. 
 
 The. pulsation in an aneurysm, which has ceased as soon as the 
 ligature was applied, sometimes returns when the collateral cir- 
 culation becomes established, and then again gradually disappears 
 as consolidation takes place in the sac. 
 
 Aneurysm of the innominate artery has been treated by the 
 ligature of the subclavian and carotid arteries, either simul- 
 taneously, or with an interval of time. In 1865 Mr. C. Heath 
 simultaneously tied the subclavian in the third part of its course 
 and the common carotid for an aneurysm in this situation. The 
 patient was much relieved, and lived for two years. Though 
 such a measure of success is very gratifying, yet, looking at the 
 whole range of such operations, it must, I think, be allowed that, 
 as far as our experience has yet gone, the treatment of this for- 
 midable disease belongs to the physician rather than to the sur- 
 geon. More can be done by medicine and diet, to prolong 
 the patient's life, and to make it tolerable, than by operative 
 surgery. 
 
 Quite recently (May 1879) Mr. Barwell has communicated to 
 
LIGATUEE OF ARTERIES. 381 
 
 the Royal Medical and Chirurgical Society a case in which 
 he ligatured the ri^ht carotid and subclavian arteries for the 
 relief of an aortic aneurysm. This is the first case in which 
 such a proceeding has been undertaken, and the results are 
 encouraging. 
 
 Ligature of the subclavian artery has been performed in all 
 the three parts of its course, though the results which have 
 attended the operations upon the first and second portions have 
 scarcely been such as to warrant their repetition. 
 
 Ligature of the subclavian artery in the first part of its course 
 upon the left side is almost an impracticable operation, on account 
 of the depth at which the vessel lies, and the important parts 
 by. which it is surrounded. On the right side the operation is 
 practicable, but it has never been performed with success. Look- 
 ing at the diflSculty of its execution, Sir Wm. Fergusson says— 
 " Were I asked to state which I thought the most difficult opera- 
 tion in surgery, I should at once name the one last described" 
 {i.e., ligature of the subclavian artery on the tracheal side of the 
 scaleni muscles). While Mr. Erichsen, having regard to the 
 principle upon which it is based, and the results attained by it, 
 says — " While this operation is bad in principle, it is most un- 
 fortunate in practice.^' It is not necessary, therefore, that I 
 should describe the mode of its performance, for it is a proceed- 
 ing which cannot be recommended. The distinguished surgeon 
 whom I have just quoted, says that, in his opinion, it ought cer- 
 tainly " to be banished from surgical practice." 
 
 Mr. A. F. McGill, of Leeds, has cut down upon the left sub- 
 clavian artery in the first part of its course, and applied tem- 
 porary pressure by means of a torsion forceps, in a manner which 
 deserves special attention (" Med.-Chir. Trans.," 1878). 
 
 Ligature of the subclavian artery in the second part of its 
 course, where it lies between the scaleni muscles, has been prac- 
 tised, and with success, by no less distinguished a surgeon than 
 Dupuytren. Still it is not looked upon with favour at the pre- 
 sent day ; and when we consider that the scalenus anticus has to 
 be divided, upon which lies the phrenic nerve, and at the inner 
 margin of which is the internal jugular vein, and that many 
 other most important parts are situated in the immediate neigh- 
 bourhood, we shall not be surprised that Dupuytren's example 
 has been but seldom followed. 
 
 Ligature of the subclavian artery in the third part of its course 
 is the only operation upon this vessel which can be recommended. 
 In performing this operation the shoulders should be lowered as 
 much as possible. The skin should then be evenly drawn down, 
 and an incision made upon the clavicle, from the anterior border 
 
382 OPERATIONS. 
 
 of the trapezius to the posterior edge of the sterno-mastoid 
 muscle. The platysma myoides and the fascia of the neck should 
 then be divided on a director. The external jugular vein will be 
 seen near the inner part of the wound, and must be held aside, 
 together with any other veins that may traverse the space. In a 
 similar way the omo-hyoid muscle must be drawn aside. The 
 various parts should then be most carefully separated by means 
 of a silver probe, until the outer margin of the scalenus anticus 
 is felt. This will serve to guide the surgeon's finger to the 
 first rib, and the artery will be felt passing over that bone. In 
 order to avoid the vein, the aneurysm needle should be passed 
 from before backwards, and the surgeon must be careful not to 
 mistake any of the branches of the brachial plexus for the artery, 
 or to include them in the ligature. 
 
 In a case of subclavian aneurysm. Professor Spence combined 
 amputation at the shoulder with the distal ligature of the vessel, 
 and obtained a very encouraging measure of success. 
 
 Ligature of the axillary artery. — The axillary artery may be 
 tied either in the upper or in the lower part of its course. Its 
 central portion lies so deep, is surrounded by so many important 
 nervous trunks, and gives off so many branches, that its deliga- 
 tion is impracticable. 
 
 The artery has been ligatured in the upper part of its course; 
 but as, before it can be exposed, the dissection must be carried 
 through a thick muscle and the costo-coracoid membrane divided, 
 and as the cephalic and the axillary veins are in intimate rela- 
 tion with it, the operation should not be undertaken without very 
 special reasons. It will generally be preferable to tie the sub- 
 clavian in the third part of its course. 
 
 The axillary artery may be secured in the lower part of its 
 course by raising the arm from the side, and making an incision 
 in the axilla, corresponding to the head of the humerus, and in the 
 line of the great vessels. By cautious dissection the median nerve 
 and the axillary vein are brought into view. These must be held 
 aside while the artery is separated with a silver probe, and a liga- 
 ture is placed round it in the usual manner. 
 
 When considering the aneurysms which occur about the root of 
 the neck and the axilla, we can hardly help coming to the conclu- 
 sion that there are but few of them which can be successfully 
 treated by the ligature of arteries ; and that if surgery is ever 
 to be able to cure them with any certainty, it must be by some 
 other means. Possibly to some of them it may be found prac- 
 ticable to apply pressure in the way that has lately been so happily 
 done in the case of abdominal aneurysms (see p. 199) ; and, indeed, 
 Mr. McGill's operation upon the left subclavian, to which I have 
 
LIGATURE OF AETERIES. 383 
 
 referred, was based upon this principle. Possibly galvano-punc- 
 ture may suflSce to cure others; while the well-known case in 
 which Mr. C. Moore introduced a coil of iron wire into a thoracic 
 aneurysm may suggest the means of dealing with others (" Med.- 
 Chir. Trans.," vol. xlvii.). 
 
 Ligature of the hrachial artery. — The brachial artery is gene- 
 rally tied at the middle of the upper arm. In this situation it 
 lies under the inner edge of the biceps, covered only by the in- 
 tegument and fascia. It is accompanied by its two venae comites, 
 and at this point it is crossed, from without inwards, by the median 
 nerve. It will here be found in close relation to the basilic 
 vein, the ulnar nerve, and the inferior profunda artery. 
 
 An incision, about three inches long, is made along the inner 
 border of the biceps, great care being taken to keep close to the 
 edge of the muscle, which is a sure guide to the artery. After 
 the skin has been divided, the fascia must be cautiously slit up 
 on a director. The artery with its vense comites, and crossed by 
 the median nerve, will then be exposed to view. The nerve must 
 be gently drawn aside with a blunt hook, and the veins carefully 
 separated from the artery; after which the ligature is passed 
 round the vessel, and tied in the ordinary way. 
 
 It may sometimes be necessary, especially in traumatic cases, 
 to tie the artery at the bend of the elbow. Tlie incision must 
 be made carefully on account of the large veins in this situation, 
 and then it must be carried through the strong fascia that 
 spreads out from the tendon of the biceps. The artery, accom- 
 panied by its venae comites, will be found about half an inch to 
 the inner side of the tendon, the median nerve lying on its ulnar 
 aspect. 
 
 Ligature of the radial artery. — It is often necessary to tie the 
 radial artery at the wrist, where it lies beneath the integument 
 and deep fascia, between the tendons of the supinator longus and 
 the flexor carpi radialis. It is accompanied by its vense comites, 
 but in this situation it bears no immediate relation to its corre- 
 sponding nerve. 
 
 The pulsation in the artery will form the best guide to its 
 exact situation. If, however, an anatomical rule is wanted, we 
 may say that in an adult it lies half an inch to the outer side 
 of the flexor carpi radialis. An incision, about two inches long, 
 should be made through the skin and superficial fascia. The 
 deep fascia must then be cautiously divided, or slit up on a 
 director. The artery must be separated from its vense comites 
 with the point of the scalpel, or with the finger-nail, and the 
 ligature passed round the vessel. 
 
 Ligature of the ulnar artery. — It is generally in wounds of" 
 
384 OPERATIONS. 
 
 the paltn that the ulnar artery requires to be tied, and then a 
 ligature may conveniently be placed round it just above the 
 wrist. In this situation it lies between the innermost tendon 
 of the flexor sublimis digitorum and the tendon of the flexor 
 carpi ulnaris. On its inner side it has the ulnar nerve. 
 
 An incision, two inches in length, should be made over the 
 artery, a little to the outer side of the flexor carpi ulnaris. When 
 the superficial and deep fascia have been divided, the vessel and 
 its vense comites will be exposed. In this case it is important 
 that the needle should be passed from the ulnar to the radial 
 side, so as not to disturb or injure the nerve. 
 
 As I have already said, bleeding from the radial, the ulnar, 
 and other superficial arteries may often be quickly and easily con- 
 trolled by acupressure, the needle being passed through the 
 tissues on one side of the vessel, then across the artery, and then 
 again through the tissues on the other side (see p. 52j. 
 
 Ligature of the external iliac artery. — The course of the ex- 
 ternal iliac artery may be described by a line drawn from the 
 left side of the umbilicus to a point midway between the anterior 
 superior spine of the ilium and the symphysis pubis. It lies 
 along the inner edge of the psoas muscle, in a sheath derived 
 from the iliac fascia. Its accompanying vein will be found 
 behind it, and a little to its inner side. It is overlaid in front 
 by the peritoneum. Near its termination it comes into relation 
 with the spermatic vessels and the vas deferens. On the front 
 and inner side of the artery are a number of lymphatic glands 
 with their vessels. The ligature must not be placed too near the 
 internal iliac at the upper end, or the epigastric and circumflex 
 vessels at the lower end. 
 
 The incision should be about three inches long. It should 
 begin about half an inch above and to the outer side of the ex- 
 ternal abdominal ring, and be carried upwards and outwards, 
 parallel to Poupart's ligament. When the aponeurosis of the 
 external oblique muscle has been fairly exposed, it must be 
 divided to the same extent, or slit up on a director. The in- 
 ternal oblique and transversalis must be cut through in the same 
 way, but with even greater caution. The edges of the wound 
 should then be retracted, and the fascia transversalis scratched 
 through with the nail, and broken down with the finger. The 
 peritoneum should next be very lightly and gently raised, and 
 pushed upwards, until the vessel can be reached. An opening 
 should then be made in the sheath, the artery carefully sepa- 
 rated from the vein, and the aneurysm needle passed from within 
 outwards. The wound should be brought together with sutures, 
 and pressure made upon it by means of a pad and bandage. The 
 
LIGATURE OF ARTEEIES. 385 
 
 patient should be propped up in bed, so as to relax the abdouiinal 
 muscles. 
 
 Before the operation is undertaken the rectum should be 
 emptied, and the pubes shaved. 
 
 Ligature of the superficial femoral artery. — The superficial 
 femoral artery is generally tied in Scarpa's triangle, just above 
 the point where it is crossed by the sartorius muscle. It is here 
 covered only by the integument and fascia lata, and has the 
 superficial femoral vein almost immediately behind it. 
 
 The thigh should be slightly flexed and abducted, before the 
 operation is commenced. The course of the artery may be ascer- 
 tained by its pulsation, or by a line drawn from the middle of 
 Poupart's ligament to the inner condyle of the femur. The in- 
 cision should begin about three inches below Poupart's ligament, 
 and be carried down the limb in the line of the artery for the 
 space of four inches. The fascia lata should be divided to an 
 equal extent, and the sartorius drawn a little outwards. The 
 sheath of the vessel sbould then be raised with a forceps and 
 opened, the flat of the blade being turned towards the artery. 
 The aneurysm needle should be passed from within outwards, 
 great care being taken to avoid injuring the vein. 
 
 The point at which the ligature is applied should be about five 
 inches below Poupart's ligament. When bleeding has ceased, 
 the edges of the wound should be brought together with sutures 
 and strips of plaster. The limb should be lightly covered with 
 flannel, or enveloped in cotton-wool, so as to maintain an equable 
 temperature, and diminish the chances of gangrene. 
 
 Ligature of the popliteal artery is rarely undertaken, except 
 for wounds. In such a case, the opening should be enlarged, and 
 the bleeding vessel secured, both above and below the seat of 
 injury. In the upper part of the popliteal space, the tendon of 
 the semi-membranosus may be taken as a guide to the artery, 
 and the incision carried along its outer border. In this situa- 
 tion the internal popliteal nerve, and the popliteal vein, are both 
 superficial to the artery, and a little to its outer or fibular side. 
 
 Ligature of the tibial arteries in the fleshy part of the leg is 
 both a difficult and a dangerous operation, and one which ought 
 not to be undertaken except for a wound of the vessel. In such 
 a case, the wound should be enlarged, and a ligature placed both 
 above and below the seat of injury. 
 
 The posterior tibial artery may easily be tied behind the inner 
 malleolus. Here the vessel is covered only by the integument 
 and by the deep fascia, which ia this situation is unusually thick 
 and dense, forming the internal annular ligament. A semilunar 
 incision, about two inches in length, with its concavity turned 
 
 C C 
 
386 OPEEATIONS. 
 
 towards the ankle, should be made, midway between the heel 
 and the inner malleolus. The deep fascia should then be cau- 
 tiously divided on a director, the artery separated from its venae 
 comites, and the aneurysm needle passed from the heel towards 
 the malleolus, so as to avoid the nerve, which lies between the 
 artery and the tendo Achillis. 
 
 Ligature of the anterior tibial artery. — The anterior tibial 
 artery may be tied in the lower third of the leg, where it lies 
 between the tendons of the tibialis anticus and the extensor 
 proprius pollicis. In this situation it is covered only by the 
 integument and deep fascia. If the pulsation of the artery 
 cannot be felt, the incision should be made half an inch outside 
 the crest of the tibia, and in rather an oblique direction from 
 within outwards. The tendons should be separated, and then the 
 artery will be seen, accompanied by its venae comites, and having 
 the nerve in front of it. 
 
 Ligature of the anterior tibial artery in the upper two-thirds 
 of its course is a more difficult operation. Here the vessel lies upon 
 the interosseous membrane, on the outer side of the tibialis 
 anticus muscle. The surgeon should make an incision down- 
 wards and outwards from the crest of the tibia, and lay open the 
 first inter-muscular septum that he reaches. Here he will find 
 the anterior tibial nerve, and, beneath it, the artery. 
 
 The arteria dorsalis pedis may be secured on the instep, 
 where it lies between the tendon of the extensor proprius pollicis 
 and the innermost tendon of the extensor brevis digitorum. It is 
 here covered only by the integument and deep fascia. It is rarely, 
 however, that it requires to be tied, for bleeding from it can 
 generally be controlled by acupressure, or by a pad and bandage. 
 
 EXCXSIOZr OF JOIITTS. 
 
 When a joint connected with the extremities has become hope- 
 lessly diseased, or has been severely injured, it is the practice of 
 modern surgeons to consider whether the disease cannot be taken 
 away without removing the entire limb. Excision — or, as it is 
 sometimes termed, resection — has been performed upon almost 
 every joint of the upper and lower extremities, and the results of 
 many of these operations are so satisfactory that they have taken 
 an established place in practice. 
 
 JExcision of the shoulder -joint. — In this, as in every operation 
 of the kind undertaken for long-standing disease of the bone or 
 for injury from direct violence, it is well to arrange the incisions 
 so as to fall in with the existing sinuses or lacerations. The line 
 of incision may take the shape of a T, or an L, or a U, or any 
 other figure suited to the peculiarities of the case. The incision 
 
EXCISION OF JOINTS. 387 
 
 must be carried through the deltoid muscle, and the flaps dis- 
 sected bacls, so as to expose the joint. In a case of chronic 
 diseasej the capsule and tendons will probably be more or Itss 
 destroyed ; a few touches of the knife will suffice to divide them, 
 and there will be no difficulty in turning out the head of the 
 humerus. The diseased portion must be cut off with the saw, 
 care being taken to remove as little as possible of the healthy 
 bone. If the glenoid cavity is at all affected, the diseased bone 
 should be scooped out with the gouge. When this has to be done, 
 it indicates that the morbid action is extensive, and accord- 
 ingly in these cases the prognosis is less favourable. 
 
 The flaps should be brought together by a few stitches, and 
 the arm well supported in a sling, and laid on a pillow. 
 
 JExcision of tlie elbow may be performed either by a single 
 longitudinal incision, or by one in the shape of an H or a T ; 
 probably the first is the best. In arranging his incisions, as well 
 as in carrying out the operation, the surgeon must bear in mind 
 the position of the ulnar nerve, which passes round the internal 
 condyle of the humerus. When the flaps have been dissected 
 back, the arm should be forcibly bent. The lateral ligaments 
 may then be easily divided, and the joint exposed. The 
 articular ends of the bones should next be removed with the 
 saw, or with bone-pliers. If any points of disease present them- 
 selves on the sawn surfaces, they must be scooped out with the 
 gouge. If the dissection is carried on close to the bone, the 
 ulnar nerve ought not to be seen. The capillary haemorrhage is 
 sometimes very troublesome after this excision. In a case on 
 which I operated there was great difficulty in arresting the flow 
 of blood. The patient, a strumous boy, was much reduced by it ; 
 but he ultimately made a good recovery. When all bleeding has 
 ceased, the edges of the wound should be drawn together with 
 sutures, and the arm extended on a splint, or simply laid on a 
 pillow. Mr. Maunder lays great stress upon the importance of 
 preserving those fibres of the triceps which are inserted into the 
 fascia of the forearm, especially that which covers the anconeus. 
 Upon this, he says, it depends whether the patient retains the 
 power of extension or not. 
 
 In both of these operations upon the upper extremity what we 
 desire is ligamentous union, and not bony ankylosis. Therefore, 
 after three weeks or a month, when granulation and cicatrization 
 are complete, the surgeon should begin to make a little passive 
 motion, and the patient should be encouraged to use his arm. 
 
 Excision of the tvrist is an operation which cannot be said to 
 have taken the same established place in surgery as many other 
 proceedings of the same kind. The complex nature of the joint, 
 
 c c 2 
 
388 OPEEATIONS. 
 
 and the number of tendons which pass over it, mate the operation a 
 difficult one ; and when the diseased bone has been removed, it is 
 only too probable that the hand and arm which are left will be of 
 little or no use to the patient. If the operation is undertaken at 
 all, the carpus may be reached by a semicircular flap on the 
 dorsal aspect, and the extensor tendons held aside so as to ex- 
 pose the joint. Or the surgeon may prefer to make two lateral 
 incisions, and to remove the joint in the way recommended by 
 Mr. Lister. In the subsequent treatment of the case his splint 
 should be used, so as to support the hand, and to maintain the 
 opposition between the thumb and the fingers {Lancet, March 
 25, 1865). 
 
 Excision of the Mp-joint. — In some cases of chronic disease or 
 gunshot injury the head of the femur may be excised with ad- 
 vantage (see p. 183). 
 
 A longitudinal incision should be made over the great trochan- 
 ter. If need be, it may be converted into a T. Maunder recom- 
 mends a semilunar incision round the great trochanter. The 
 dissection should then be carried on until the flaps can be drawn 
 back, and the articulation exposed. When the ligaments have 
 been divided, the surgeon should cut close to the bone, remem- 
 bering that the sciatic nerve lies just behind the joint, and the 
 anterior crural nerve and the femoral artery in front of it. The 
 leg should then be strongly adducted or rotated, and pushed up- 
 wards, so as to force the head of the femur out of the wound. 
 The diseased portion may then be removed with the saw. The 
 chain-saw, which enables the surgeon to cut from within out- 
 wards, is very applicable to this operation. If any part of the 
 acetabulum is carious, it should be taken away with the gouge, 
 p. ^„„ The leg should be maintained 
 
 ^' ' in the extended position by 
 
 means of a long splint. Op- 
 posite the seat of operation 
 the splint should be inter- 
 rupted, the continuity being 
 kept up only by an iron bar 
 in the way represented in 
 Fig. 176, so as to allow the 
 wound to be dressed, without 
 disturbing the position of the 
 
 "~^ 
 
 ^ 
 
 Interrupted long splint. li'^^- When the cicatrix has 
 
 healed, and the tissues have 
 become consolidated, the patient may be permitted to walk about 
 with crutches. 
 
 Excision of the Tcnee is an operation which has been revived of 
 
EXCISION OF JOINTS. 
 
 389 
 
 late years ; and it bids fair to become the established rule of prac- 
 tice in certain cases of disease or injury of the knee-joint. 
 
 A simple transverse incision should be made across the joint im- 
 mediately below the patella. If this does not give space enough, 
 it may be converted into an H incision. The flaps of skin are 
 then raised and turned back. The ligament of the patella is 
 divided, and the bone dissected away. If the surgeon wishes to 
 retain the patella, it may be raised with the upper flap. The 
 leg should then be strongly bent, the lateral and crucial ligaments 
 divided, the ends of the bones cleared for the saw, and the interior 
 of the joint exposed. The saw should then be applied to the 
 femur, and a portion of the articular extremity removed. A 
 thin slice is next to be taken from the upper end of the tibia. 
 In using the saw, the surgeon must exercise caution, remembering 
 that the popliteal vessels lie immediately behind the bone. The 
 limb should then be extended, in order to see whether the bones 
 come well together. Perhaps the saw may have to be used again. 
 If the position is good, and the bleeding has ceased, the skin should 
 be united by sutures, and the leg extended on a splint. That 
 which is generally used in these cases is a j\r*Intyre's splint, laid 
 straight, and cut down at the sides, opposite the seat of operation, 
 so as to allow the wound to be dressed with ease. 
 
 The time during which the patient will have to be kept in bed 
 after this operation varies extremely. But the surgeon will 
 generally have reason to be satisfied if his patient is able to get 
 up at the end of two months, and walk about on crutches, with 
 
 Fig. 178. 
 
 the leg supported by a plaster of Paris, gutta-percha, or light 
 wooden splint. What we desire in these cases is bony or 
 
390 OPERATIONS. 
 
 fibrous ankylosis, and therefore no attempt should be made to 
 flex the limb. It is quite possible, however, that in course of 
 time the patient may get a little movement at the knee. But, 
 whether this is the case or not, he will probably have a useful 
 and serviceable limb. Of course it will be a little shorter than 
 its fellow, and it will be necessary for the patient always to wear 
 a high-heeled boot. 
 
 The accompanying illustrations are taken from photographs of 
 a case upon which Mr. Bowman operated in King's College 
 Hospital, when I was his dresser. Fig. 177 shows the distorted 
 condition of the left leg at the time the excision was performed. 
 Fig. 178 represents the state of the limb nine months afterwards. 
 
 There has been much discussion of late years with regard to 
 the relative value of excision and amputation for diseases and 
 injuries of the knee-joint. Those to whom we are most indebted 
 for bringing excision to the notice of the profession have not 
 unnaturally been inclined to regard it with rather too favourable 
 an eye; while others have been unjustly prejudiced against it. 
 Perhaps the time has hardly yet come for striking a balance 
 between these two operations, and assigning to each its proper 
 place in surgery. As no one has been at more pains to 
 collect statistics on this subject than Mr. Bryant, or has analysed 
 them more carefully, I shall quote one or two sentences from the 
 general conclusions at which he has arrived. In these he 
 touches upon some very important points — namely, the cases to 
 which excision is applicable, and those to which it is not, and 
 also the relative mortality after the two operations. 
 
 " It would thus appear that it is in young adult life that ex- 
 cisions, although always more fatal than amputation, are the 
 most justifiable ; that in childhood they are far too dangerous ; in 
 patients past middle age all admit their inapplicability. And yet 
 it must be admitted that excision of the knee-joint is a good 
 operation ; that, when successful, a good, useful limb is given — a 
 far better limb than can be given after amputation. Nevertheless, 
 the truth must be recognised that the operation is, as hitherto 
 practised, a far more fatal operation than amputation ; and yet 
 it may with confidence be asserted that the cases in which ampu- 
 tation has been performed are, as a rule, far more severe than 
 those in which excision has been practised" (" Surgery," p. 862), 
 
 Excision of the anhle-joint. — When the articular surfaces of 
 the astragalus and the malleoli are diseased, while the calcaneum 
 and the other bones of the tarsus are sound, the surgeon may 
 undertake excision of the ankle-joint with good hope of curing 
 his patient. This operation was first performed by Mr. Hancock. 
 
 The leg should be laid on its inner side, and an L-shaped incision 
 
AMPUTATIONS. 
 
 391 
 
 Fig. 179. 
 
 Foot after excision of the 
 ankle. 
 
 made over the outside of the joint. By this means the external 
 
 malleolus may he reached, and nipped off. The leg is then turned 
 
 over, and a similar incision made 
 
 over the inside of the ankle. The 
 
 tendons must be carefully held 
 
 aside, together with the artery 
 
 and nerve. The internal lateral 
 
 ligaments must be freed, and 
 
 then the internal malleolus may 
 
 be cut off. If now the foot is 
 
 forcibly turned outwards, the 
 
 lower end of the tibia and the 
 
 upper surface of the astragalus 
 
 will present themselves at the 
 
 inner wound ; and the surgeon 
 
 can deal with them as he thinks 
 
 best by means of a fine saw or 
 
 cutting-pliers. 
 
 Fig. 179 was drawn from a girl, aged nine, upon whom Mr. 
 Barwell had performed excision of the ankle three months 
 previously. 
 
 I have already mentioned that when the astragalus is 
 dislocated it may be removed, and still the patient may retain a 
 very useful foot (see p. 193). If the astragalus, which plays such 
 an important part in the mechanism of the foot, can be taken away 
 without serious injury to the patient, it is not surprising that other 
 bones of the tarsus can in like manner be dispensed with. There 
 is hardly one of the numerous bones of the foot Avhich has not 
 been separately excised. This is one of the advantages which we 
 owe to what Sir Wm. Fergusson has happily termed " conservative 
 surgery." When disease is limited to one or two bones, surgeons 
 are very unwilling to remove the whole, or the greater part, of the 
 foot. They content themselves with excising the affected bones, 
 or even with merely gouging out the dead tissue, and rely upon 
 Nature to repair the gap thus made. In this way, the calcaneum, 
 the scaphoid, or the cuboid may be separately dealt with ; and 
 it is remarkable what a useful foot is often left after the removal 
 of even an important bone. 
 
 AXVIPUTiLTIOIirS. 
 
 Amputations may be performed in two ways, either by the 
 circular method, or by flaps. In the former case the knife is 
 carried evenly round the limb. This is repeated three or four 
 times, until the whole of the tissues are divided — an assistant, 
 meanwhile, drawing the tissues equally and steadily upwards; 
 
392 OPERATIONS. 
 
 so that, wlien the parts are relaxed, the sawn end of the bone 
 will be seen at the apex of a hollow cone formed by the muscles 
 and skin. 
 
 The flap operation is performed by making a couple of flaps 
 from the opposite sides of the limb. Sometimes they are of equal 
 length ; sometimes one is longer than the other ; sometimes they 
 are made by cutting from wdthout inwards; sometimes by trans- 
 fixing the limb, and cutting from within outwards. Sometimes 
 the flaps consist merely of the skin, at other times they include 
 the whole thickness of the soft tissues. 
 
 Speaking generally, the advantages of the circular operation 
 are these : — That it is easily performed, and requires but little 
 skill or practice ; that the vessels are cut transversely, whereas in 
 the flap operation they are divided obliquely; and that the 
 resulting stump is generally satisfactory. 
 
 The advantages of the flap operation are — That the surgeon 
 can take the flap from any point that he likes, and so make the 
 most of the sound parts ; that the sides of the wound come 
 together more accurately, and unite more readily ; and that the 
 operation itself can be performed in a shorter time. 
 
 The late Mr. Teale, of Leeds, introduced a modification of the 
 flap operation, which has special advantages : — 
 
 He directs that a rectangular flap, equal in length and breadth 
 to one-half the circumference of the limb at the seat of operation, 
 should be taken from the extensor side ; and that a short rectan- 
 gular flap, equal only to a quarter of the length of the other, 
 should be taken from the flexor side. The advantages of this 
 method are said to be that the principal vessels and nerves are 
 not included in the flap which forms the bearing-point of the 
 stump ; that the flap covers the ends of the bones in such a way 
 as to close them at an early date; that the cicatrix is drawn well 
 up above the extremity of the stump, and yet tension is prevented 
 by the great length of the flap. 
 
 A mixed form of operation has come into use of late years, and 
 consists in taking the flaps from the skin alone, and then dividing 
 the muscles by circular incisions. 
 
 Every amputation should be performed as far from the trunk 
 as the circumstances of the case will allow. The mortality in- 
 creases in direct proportion as we ascend the limbs. 
 
 Before any of these operations are commenced, Esmarch's ban- 
 dage should be applied, and the limb raised, so that the blood 
 may be driven out of the tissues (see p. 365). If this cannot 
 be done, the main artery should be compressed during the opera- 
 tion, either by the fingers of an assistant or by a tourniquet. 
 
 Amputation of the finger. — When the last phalanx is necrosed. 
 
AMPUTATIONS. 393 
 
 it may often, as we have elsewhere explained, he removed hy 
 lateral incisions. In this way the pulp and the nail are left, and 
 will form a very useful point to the finger (see p. 106). 
 
 When it is necessary to amputate either of the last two 
 phalanges, the finger should he strongly bent, and a transverse in- 
 cision made on the extensor side, a little below the highest point 
 of the flexure ; the lateral ligaments should be divided, the joint 
 opened, and the flap taken from the palmar surface. Or the 
 palmar flap may he made hy transfixion, and the joint opened 
 afterwards, either from its palmar or dorsal aspect. 
 
 Amputation at the metacarpo-phalangeal joint may be best 
 performed by the oval method. The point of the knife is placed 
 on the hack of the metacarpal bone, about half an inch above its 
 head, and drawn obliquely downwards to the middle of the inter- 
 digital web. It is then carried across the fold, which separates 
 the finger from the palm, and brought up through the web on 
 the other side, to the spot where it commenced. The lateral 
 ligaments must next be divided, and the disarticulation completed. 
 The head of the metacarpal bone should then be removed with 
 bone pliers, and the edges of the wound brought together. The 
 hand should be laid on a splint, the wound covered with a suitable 
 dressing, and the finger-ends drawn together, and fixed by means 
 of a strip of plaster. In labouring people, to whom the breadth of 
 the palm is more important than elegance of shape, it may some- 
 times be well to leave the head of the metacarpal bone. In this 
 case, however, the incision must be carried a little further for- 
 ward on the flexor side of the finger, so as to form a sufficient 
 flap. 
 
 The thumb may he amputated either by an oval incision, be- 
 ginning at the carpo-metacarpal joint, passing round the web, 
 and returning to the same point again ; or an incision may be 
 made along the dorsal aspect, from the carpo-metacarpal articu- 
 lation to the middle of the web ; the ball of the thumb may then 
 be transfixed, and a flap made by cutting from within outwards. 
 In any case, it is better, if possible, not to open the carpo-meta- 
 carpal joint, but to cut the bone through near its base. When 
 the metacarpal bone of the thumb is necrosed, it may be exposed 
 by direct incision, the disease taken away, and the phalanges 
 left. In dealing with the thumb, it is of great importance to 
 leave as much as possible, to serve as an opponent to the fingers. 
 
 Amputation at the tcrist should be performed thus : — An assis- 
 tant should grasp the arm and draw the tissues well up. A semi- 
 lunar incision, with the convexity downwards, is then made across 
 the back of the wrist. The flap is raised, the tendons and 
 ligaments arc divided, and the joint is opened from its dorsal 
 
394 
 
 OPERATIONS. 
 
 aspect. The knife is then carried through, and a second flap is 
 taken from the pahu. The styloid processes may require to be 
 cut off, or the articular surfaces of the bones removed, before the 
 flaps are brought together. 
 
 Amputation of the forearm may be performed either by a 
 circular, or by a flap operation. 
 
 In the circular operation the tissues of the limb throughout 
 its whole circumference are to be drawn evenly upwards by an 
 assistant. The surgeon then makes a circular incision round the 
 limb down to the fascia. The skin is next drawn as much farther 
 up as possible. A second circular incision is made through the 
 muscles, immediately below the line of the skin. The bones are 
 then cleared, and the saw applied to both at once. 
 
 Or a flap operation may be performed. In this proceeding the 
 hand should be held midway between pronation and supination, 
 and then two equal flaps should be made by transfixion, one from 
 the extensor, and the other from the flexor side. Or Mr. Teale''s 
 method may be adopted, and a long rectangular flap may be 
 taken from the extensor side, and brought over to meet a short 
 one on the flexor side. 
 
 In dressing the stump which is left after such an amputation 
 as this, either in the upper or lower extremity, the- surgeon may 
 take strips of lint of sufficient length, and fold them over the end 
 of the stump in a longitudinal direction, and at an angle with 
 one another, until the whole surface is covered (Fig. 180) ; or he 
 may cut out a piece of lint in the shape of a Maltese cross, and 
 
 Fig. 180. 
 
 Fig. 181. 
 
 Dressings for a stump. 
 
 lay its ceTitral portion upon the end of the stump, while he folds 
 down the corners (Fig. 181). In either case the dressings 
 should be secured by a few circular turns of a roller round the 
 limb in the manner represented in Fig. 184. 
 
 Amputation of the upper arm is usually best performed by a 
 couple of lateral flaps made by transfixion. But if the limb is 
 very muscular, a better result may, perhaps, be obtained by a 
 
AMPUTATIONS. 
 
 395 
 
 combination of the flap and the circular methods. Two skin-flaps 
 may be made by dissecting from without inwards, and then the 
 muscles may be divided by a circular 
 sweep of the knife. 
 
 Fig. 182 represents the stump, three 
 years after operation, in a middle-aged 
 woman, whose arm I amputated on 
 account of injuries received by a railway 
 accident. 
 
 Amputation at the shoulder- joint may 
 be performed either by transfixion, or by 
 cutting from without inwards. 
 
 If the method by transfixion is pre- 
 ferred, the arm should be raised from the 
 side, and then the knife should be passed 
 from a point a little in front of tlie 
 acromion to the posterior margin of the 
 axilla, and carried downwards, so as to 
 include nearly the whole of the deltoid 
 muscle in the flap. The capsule of the 
 joint is next to be opened, the tendons 
 and ligaments divided, the knife carried 
 over the head of the bone and down the 
 neck, and then made to cut its way out, 
 leaving an inner flap about three inches 
 
 in length. Before the inner flap is cut, an assistant should 
 grasp the whole thickness of the soft tissues which will compose 
 it, so as to control the artery, and prevent haemorrhage, when it 
 is divided. 
 
 If the other method is adopted, an outer flap, of the same size 
 and shape as in the preceding case, should be made by cutting 
 from without inwards. The dissection must then be carried on 
 underneath this flap, until it can be turned back so as to expose 
 the joint. The other steps of the operation are the same as those 
 which have been already described. 
 
 The oval method, commonly called Larrey's operation, is well 
 suited to some cases. It is thus described by Eriehsen : — " Larrey 
 commenced his operation by a vertical incision down to the 
 bone, about two inches in length, commencing immediately below 
 the acromion process. From the end of this he made a curved 
 incision on each side, reaching to the corresponding fold of the 
 axilla. The two flaps thus formed were dissected up, and the 
 head of the bone disarticulated. The knife was then passed in- 
 ternally to the head of the bone, and carried downwards, while 
 an assistant followed it with his hands to compress the axillary 
 
 Stump after amputation 
 through the humerus. 
 
396 OPERATIONS. 
 
 artery. The operation was completed by dividing the tissues in 
 the axilla between the ends of the two curved incisions previously 
 made to its borders." 
 
 Amputation at the hip-joint is performed by transfixion, a long 
 flap being taken from the front of the thigh, and a short posterior 
 one from the gluteal region. The knife should be passed obliquely 
 through the thigh immediately in front of the joint, entering a 
 little below the anterior superior spine of the ilium, and emerging 
 just above the tuber ischii, or vice versa. As the knife cuts its 
 way outwards, the fingers of an assistant should be introduced 
 immediately behind it, so as to grasp the whole breadth of the 
 flap, and compress the femoral artery. Tlie capsule is then to be 
 opened, the ligaments divided, the knife carried round the head 
 of the bone, and the posterior flap fashioned. In order to facili- 
 tate the operation, it ought to be the sole duty of an assistant to 
 move the limb in such a way as to stretch the capsule and liga- 
 ments, make the head prominent, and raise it out of the socket. 
 Before undertaking an amputation at the hip-joint, the surgeon 
 should restrain the circulation through the leg by applying 
 Lister's compressor over the abdominal aorta. 
 
 Amputation of the thigh may be performed either through the 
 trochanters, or in the middle of the thigh, or above the knee. 
 
 The first step is to apply a tourniquet to the femoral artery in 
 Scarpa's triangle. The tourniquet which is generally used for 
 this purpose (Petit's) consists of a pad which 
 Fig. 183. is placed over the artery, a strap of webbing 
 
 which passes round the limb, and a screw 
 which acts upon the strap and tightens it 
 (Fig. 183). By turning the screw the two 
 plates over which the strap passes are sepa- 
 rated, the strap is put upon the stretch, and 
 pressure is made upon the pad. The pad 
 should be placed as nearly as possible opposite 
 the screw, and the buckle should be adjusted 
 in such a manner as not to interfere with the 
 working of the instrument. Instead of the 
 pad which is usually sold with the tourni- 
 quet, it will often be found more convenient 
 Petit's tourniquet, to lay a firm roll of bandage, about an inch 
 in diameter, along the course of the artery, 
 and then to pass the strap over it. In this way the instru- 
 ment may be shifted without interfering with the position of the 
 roll of bandage which serves as a pad. The screw should not be 
 turned until the moment when the incisions are about to be 
 made; for, if it is, the parts will become congested, and there will 
 
AMPUTATIONS. 
 
 397 
 
 be an unnecessary loss of blood. For the same reason, as soon as 
 the principal vessels have been tied, the tourniquet should be 
 relaxed, so that no impediment may be offered to the return of 
 the venous blood. 
 
 When the amputation is high up in the thigh it is impossible 
 to use Petit's tourniquet; and then the surgeon must either apply 
 a compressor over the abdominal aorta, or he must direct an 
 assistant to make digital pressure upon the common femoral 
 artery as it passes over the brim of the pelvis. 
 
 In the upper part of the thigh, the operation by means of 
 antero-posterior flaps, made by transfixion, is the most suitable ; 
 or the anterior flap may be made by transfixion, and the posterior 
 one by a transverse semicircular sweep of the knife. In the 
 middle and lower parts, the surgeon has his choice of several 
 methods. He may perform a circular operation; or a flap 
 operation with antero-posterior flaps made by transfixion, or 
 with lateral flaps made in the same way ; or he may prefer the 
 rectangular flaps (Teale's operation) ; or he may make skin flaps, 
 by cutting from without inwards, and divide the muscles circularly. 
 In making lateral flaps, the inner flaps, which contain the large 
 vessels, should always be made last. 
 
 Dressings may be applied to the stump in the manner that I 
 have explained in speaking of amputation of the forearm. lu 
 bandaging a stump in the thigh, the surgeon begins by taking one 
 or two circular turns 
 
 round the part, with the 
 view of fixing the end 
 of the roller — holding it 
 (let us suppose) in his 
 right hand. Then he 
 secures the last fold with 
 the thumb of his left 
 hand, while with the 
 other he carries the 
 bandage at right angles 
 over the end of the 
 stump to a point directly 
 opposite to that from 
 which he started. Here 
 he secures the bandage 
 with the fingers of his 
 
 Fig. 184. 
 
 Bandage for a stump. 
 
 left hand, while he takes a circular turn round the limb to 
 fix the fold which passes over the stump. Or he may take two 
 or three folds consecutively, and then fix them all by a single 
 turn round the limb. These steps he repeats as often as they 
 
398 OPERATIONS. 
 
 are necessary, until the whole of the stump is covered (Fig. 
 184). 
 
 Amputation at the Icnee-joint is an operation which has occa- 
 sionally been performed ever since the fifteenth century ; but it is 
 only of late that it has taken an established place in surgery, in 
 consequence of the recommendation of Velpeau, Syme, and more 
 particularly of Mr. Gr. D. Pollock. His Paper upon the subject, 
 in the 53rd volume of the " Medico-Chirurgical Transactions," 
 gives a full account of the operation, and of the way in which it 
 should be performed under different circumstances. Speaking 
 generally, a large and broad flap should be taken from the front of 
 the leg, and a shorter one from the back. These flaps should consist 
 of nothing but the integument. The patella and the condyles of 
 the femur need not be touched, unless they are ulcerated ; in 
 which case the patella should be dissected out, and a sufficient 
 slice taken off the condyles of the femur to remove the whole of 
 the disease. Mr. Pollock speaks favourably of the operation, both 
 as regards the stump which is left, and as to the mortality when 
 compared with amputation through the thigh. 
 
 Amputation of the leg may be performed either immediately 
 below the knee, in the middle of the leg, or in the lower 
 third. 
 
 A semicircular flap is taken ftum the front of the leg, by 
 cutting from without inwards ; the limb is then transfixed — 
 care being taken not to pass the knife between the bones — and 
 a long thick flap is made from the posterior aspect. Or, the 
 surgeon may adopt Mr. Teale's plan, and mark out a couple of 
 rectangular flaps, the longer one being taken from the extensor, 
 and the shorter from the flexor side. Or, he may prefer to use 
 the circular method. 
 
 In dressing a stump in the leg the many-tailed bandage is 
 often useful, and we may take this opportunity of describing it, 
 though it is suitable to other situations as well. It is made in 
 the following maimer : — The surgeon cuts a number of strips of 
 "leg-bandage," sufficiently long to go 
 once and a half round the part. These 
 he lays in regular order, from above 
 downwards, one overlapping the other to 
 about a third of its width. It will be 
 seen immediately that it is necessary to 
 follow this plan in order that the bandage 
 may lie flat, when it is applied (according 
 to the general rule), from below upwards. 
 Many-tailed bandage. A sufficient number of strips ought to 
 be taken to cover the whole extent of 
 surface to which the bandnge has to be applied, and the length of 
 
AMPUTATIONS. 
 
 399 
 
 Fig. 186. 
 
 the pieces must vary according to the size of the part which they 
 have to surround. Sometimes the strips are stitched to a longi- 
 tudinal band, which serves to keep them in their places 
 (Fig. 185). When the bandage has been prepared the limb is 
 laid upon it, or the strips, arranged 
 upon a piece of pasteboard, arc 
 shpped under the limb; and then 
 each separate piece is made to en- 
 circle the part, the ends being 
 brought up one on each side and 
 crossed in front. The lowest piece 
 should be folded first, and then the 
 pieces should be taken in regular 
 order from below upwards. This is 
 a very convenient bandage where the 
 surgeon thinks it a matter of import- 
 ance to keep the aiFected part as 
 quiet as possible. It serves to retain 
 dressings, and at the same time it 
 gives a shght amount of support. Mode of applying the many- 
 Moreover, as it is capable of being tailed bandage. 
 
 unfolded piece by piece, the stump 
 
 may be readily exposed without interfering to any extent with the 
 comfort of the patient. The annexed illustration represents a 
 stump in the lower third of the leg, partially 
 
 covered by a many -tailed bandage (Fig. 
 
 186). 
 
 Amputation at the ankle-joint {Syme's 
 
 operation) is performed by making an 
 
 incision from one malleolus to the other, 
 
 across the under-surface of the foot, imme- 
 diately in front of the heel. The points 
 
 of this incision are then united by a second, 
 
 passing across the instep. Or the super- 
 ficial incision may be made at one sweep, 
 
 the knife being carried across the instep and 
 
 round the front of the heel, to the point 
 
 where it began. The joint should then be 
 
 opened from the front, the tendons and liga- 
 ments divided, and the dissection carried 
 
 round the os calcis — great care being taken 
 
 to keep close to the bone, particularly on 
 
 the inner side, where it is in contact with 
 
 the posterior tibial vessels. The malleoli 
 
 should then be cut off, and the flaps 
 
 brought together. The advantages of this operation are, that 
 
 Fig. 187. 
 
 Stump after Piro- 
 goff's operation. 
 
400 
 
 OPERATIONS. 
 
 the foot is removed, while the limb is but little shortened, and 
 that an excellent covering is made for the end of the stump from 
 the thick and tough skin of the heel. 
 
 M. Pirogoff has introduced a modification of this operation, 
 which consists in leaving the posterior half of the os calcis, and 
 turning it up, so as to bring the sawn surface into apposition 
 with the ends of the tibia and fibula. In performing the opera- 
 tion an incision should first be made from one malleolus to the 
 other, passing under the sole. This incision should not be ver- 
 tical, but tending slightly forwards in an oblique direction. The 
 flap thus indicated should be carefully dissected back for a short 
 distance. The ankle-joint is next opened by an incision across 
 the instep, and the astralagus is disarticulated. The saw is then 
 applied to the upper surface of the os calcis, immediately 
 behind the articulation with the astragalus, and the bone is cut 
 through from above downwards, and in an oblique direction from 
 behind forwards. The malleoli, together 
 with the articulating surfaces of tlie 
 tibia and fibula, are sawn off, and the 
 operation is completed by bringing the two 
 osseous surfaces into contact, and uniting 
 the line of incision by interrupted sutures. 
 In order to facilitate union between the 
 bones, it is well to divide the tendo 
 Achillis subcutaneously. By Pirogoff's 
 operation the length of the limb is pre- 
 served, while the resulting stump has a 
 covering of the naturally thick skin which 
 protects the heel. Fig. 187, which was 
 taken from a case of Mr. Canton's, 
 shows what a satisfactory stump may be 
 obtained by this operation. It should 
 not be undertaken where there is exten- 
 sive disease of the tarsus, even though 
 the OS calcis may be sound; for in such 
 instances the disease is very apt to mani- 
 fest itself in the stump. But in cases of 
 injury it is an excellent operation. 
 
 In cases in which the anterior bones 
 of the tarsus are diseased or injured, 
 while the astragalus and os calcis remain 
 healthy, Mr. Hancock has devised, and 
 practised with success, an operation 
 whereby the calcaneum is sasvn through 
 obliquely, the front of the foot taken 
 
 Diagram of the bones 
 of the foot. 
 
AMPUTATIONS. 
 
 401 
 
 away, the head of the astragalus and its inferior articulating sur- 
 faces removed, and the sawn surface of the heel-bone brought 
 into apposition with the under surface of the astragalus. By 
 this operation the ankle-joint is left intact; tlie stump is formed 
 by the tuberosity of the os calcis, which is retained in the 
 integument, and covered by the thick skin which is natural to it 
 (" Surgery of the Human Foot," p. 209). 
 
 Amputation througJi the tarsus {Chofarfs operation) consists 
 in disarticulation between the os calcis and astragalus on the one 
 hand, and the scaphoid and cuboid on the other (Fig. 188, a). 
 The sole-flap should first be marked out by an incision from the 
 tubercle of the scaphoid, along the side of the foot, to the ball 
 of the great toe ; the knife should next be carried across the 
 sole, a little behind the roots of the toes ; and then turned 
 along the outer side of the foot, to a point a little behind 
 the prominent base of the fifth metatarsal bone. An incision is 
 next to be made across the instep, so as to unite the ends of the 
 former incision. The articulations are then opened, and the 
 dissection carried ou close to the under surface of the bones, so 
 as to leave the whole of the soft tissues of the sole in the 
 plantar flap. 
 
 This is a good operation, and the result is generally satis- 
 factory ; and when a methodized operation through the tarsus is 
 required, the surgeon can adopt no better. 
 But, as I have already said, there is at the 
 present day a strong tendency among sur- 
 geons to remove only the diseased or mu- 
 tilated parts, and to retain all that can 
 with any propriety be left. This practice 
 is founded partly upon the confident expec- 
 tation that nature will bind together and 
 utilize all that remains, but still more 
 upon the ascertained fact that the morta- 
 lity increases in direct proportion to the 
 amount that is taken away. Acting upon 
 this principle in the case of a man, aged 
 sixty-one, who was injured in a railway 
 accident, I disarticulated the three cunei- 
 form bones from the scaphoid, and sawed 
 ofl" the projecting extremity of the cuboid. 
 The patient made an excellent recovery, 
 and the appearance of the stump, some two 
 years after the operation, is represented 
 in Fig. 189. The particulars of the case are related in the 
 Lancet of Nov. 20, 1869. 
 
 B D 
 
 Stump after amputa- 
 tion through the 
 tarsus. 
 
402 
 
 OPERATIONS. 
 
 Amputation at the line of the metatarsal hones [Hef/'s 
 operation) consists in making a large plantar flap and a small 
 dorsal one, and then disarticulating the metatarsal from the 
 tarsal bones (Fig. 188, b). In doing this, the surgeon should 
 bear in mind, that the base of the second metatarsal bone is 
 deeply sunk between the internal and external cuneiform bones. 
 As disarticulation is difiicult, and offers no special advantages, 
 the bones are sometimes sawn through just in front of the joints. 
 This I have seen done by Sir Wm. Fergusson, with excellent 
 results, in the case of a sailor who had lost his toes from frost- 
 bite consequent upou long immersion in the sea. 
 
 Fig. 190, which is copied from the original illustration in Hey's 
 
 Surgical Observations, gives a 
 
 Fig. 190. 
 
 i 
 
 
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 ^ .f^' 
 
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 \ J^^' 
 
 "^^ 
 
 
 m 
 
 
 
 
 
 ' IW»^' 
 
 
 '^^Sr-' 
 
 1 Im^-- 
 
 
 
 'IIP'--" 
 
 
 
 VIp 
 
 
 S 
 
 1 )% 
 
 
 
 V ' ' -■''iV'-^'- 
 
 
 
 \r^ 
 
 1 
 
 
 
 
 ' ~ 
 
 
 .1^ 
 
 SM 
 
 Hay's operation. 
 
 good idea of the stump which 
 is left after this operation. 
 
 The metatarsal bone of the 
 great toe, which is often affected 
 by strumous disease, may be re- 
 moved by an incision carried 
 along its dorsal surface, from 
 its base to its head, and then 
 turned down, at right angles, 
 to the ball of the toe. The 
 surgeon should be careful not 
 to interfere with the sole ; and, 
 if possible, the base of the bone 
 should be left, because it gives 
 insertion to the peroneus longus. 
 
 The toes, or any of their 
 phalanges, may be amputated 
 ^much in the same way as the 
 corresponding parts of the hand. 
 
 The toes should be removed 
 
 by the oval method, the surgeon commencing his incision on 
 the dorsal surface, well above the web, and carrying it obliquely 
 forward, so that on the plantar surface it may not interfere with 
 the tread of the foot. 
 
FORMULiE AND RECEIPTS. 
 
 The Doses are apportioned for Adults, and the mixtures and 
 pills are to he taken three times a day, except ivhere otherwise 
 stated. 
 
 1. Fotus Bclladonnee. 
 
 BL Extract! belladonnae gr. 60 
 
 To be dissolved in one pint of boiling water, and used as a 
 fomentation. 
 
 2. Fottis Papaveris. 
 
 R Capsul. papaveris contus 5j 
 
 Aquae destillatse Oj 
 
 Mix, and boil for a quarter of an hour ; then strain through 
 muslin. 
 
 3. Gargarisma Aluminis. 
 
 R Aluminis exsiccati gr. 80 
 
 Tinct. myrrbae . . . . . . . . oj 
 
 Aquae ad §viij 
 
 Misce. 
 
 4. Garg. Alum, et Capsici. 
 
 B- Aluminis exsiccati gr. 60 
 
 Tinct. capsici 5s8 
 
 Syrupi mori §j 
 
 Aqua3 rosse ad § viij 
 
 Misce. 
 
 5. Guttee Argenti Nitratis. 
 
 B- Argenti niti-atis . . . . . . gr. 1 — 2 
 
 Aqnre destillatse • . . . 5j 
 
 Misce. 
 
 To be dropped into the eye with a glass rod or a camel's-hair 
 brush. 
 
 D D 2 
 
404 FORMULA AND EECEIPTS. 
 
 6. Gnttae Atropiae Sulphatis. 
 
 B Atropiffi sulphatis gr. 1 — 4 
 
 Aqufe destillatje 5j 
 
 Misce. 
 
 7. Haustus Hyoscyami, 
 
 R Tinct. hyoscyami ni 25 — 60 
 
 [vel Tinct. lupuli . . . . m 30—60] 
 
 Liq. ammonise acet 3.1 
 
 Syr. Tolutani 5ij 
 
 Mist. caraphor?e ad §iss 
 
 Misce. 
 
 A soothing or sleeping draught, without opium. To be taken at 
 bedtime, or night and morning. 
 
 8, Injectio Bismnthi. 
 
 R Bismuthi subnit ^i\ 
 
 Glycerin! . §j 
 
 Aqufoi ad 5xJ 
 
 Misce. 
 
 Useful in gonorrhoea, urethritis, and vaginitis. 
 
 9. Injectio Boracis at Glycerini. 
 
 R Glycerini 5i.i 
 
 Boracis §j 
 
 Aquse §i} 
 
 Misce. 
 
 Put 3j or 3ij into §iv. of warm water, and inject into the bladder 
 in cases of cystitis, (Sir H. Thompson.) 
 
 10. Injectio Morphige. 
 
 R Morphise acetatis gr. 80 
 
 Aquse destillatte , . . 5j 
 
 liub the acetate gradually with the water, and a-ld a few drops 
 of acetic acid, if necessary for perfect solution. Six drops con- 
 tain one grain of acetate of morphia. For subcutaneous injection. 
 (^Middlesex.) 
 
FORMULAE AND RECEIPTS. 406 
 
 11. Linctus Morphise. 
 
 R' Liq. morpliiaj ni 4 
 
 Aquai laurocerasi tn, 2 
 
 Syr. Tnlutani in 30 
 
 Glycerini ad 3j 
 
 Misce. 
 
 Dose — a teaspoonful occasionally. 
 
 12. Lotio Acidi Carbolici. 
 
 R Acidi carbolici crjstalli , . . . gr. 1 
 
 Aqn?e destillatas iH 40 
 
 Misce. {St. George's, Charing Cross.) 
 
 13. Lotio Acidi Nitrici. 
 
 R Acidi nitrici fort ....... m 4 
 
 Tinct. opii m, 6 
 
 Aquae destillatse gj 
 
 Misce. (Ki7ig's College.) 
 
 14. Lotio Acidi Sulphurosi. 
 
 R Acidi sulpliurosi 3.]* 
 
 Aquae destillatae ad §j 
 
 Misce. {Middlesex.) 
 
 15. Lotio Acidi Tannici. 
 
 R Acidi tannici gr. 4 
 
 Sp. vini rectificati IH, 30 
 
 Aquae rosfe 5ij 
 
 Aquae destlllatae ad §j 
 
 Misce. 
 
 16. Lotio Aluminis Mitior. 
 
 R Aluminis exsiccati ...... gr. 3 
 
 Aquse destillatae §j 
 
 Misce. 
 
 17. Lotio Aluminis Fortior. 
 
 R Aluminis exsiccati gi'. 6 
 
 Aquae destillatae 5j 
 
 Misce. 
 
406 FORMULA AND EECEIPTS. 
 
 18. Lotio Ammon. Hydrochlor. 
 
 R Ainmoni?e hydrochloratis . . . . gr. 24 
 
 Acidi acetici diluti th, 48 
 
 Sp. -^ani rectificati tT], 30 
 
 Mist, camplioras ad §j 
 
 Misce. 
 
 19. Lotio Arnicse. 
 
 R. Tinct. arnicse tn, 20 
 
 Liq. ammon. acet itj, 30 
 
 Sp. rosmarini ni 15 
 
 Aquse destillataB ad 5.1 
 
 Misce. 
 
 20. Lotio Boracis et Glycerini. 
 
 R Boracis gr- 6 
 
 Glycerini 5,1* 
 
 Aquae sambuci . . 3ll 
 
 Aquse destillatse ad §j 
 
 Misce. 
 
 21. Lotio Evaporans. 
 
 (1) R Sp. ^etheris nitrosi Til 10 
 
 Acidi acetici aromatici ITI 2 
 
 Aquae destillatse 5j 
 
 Misce. 
 
 (2) R Ammonise hydrochloratis . . . . gr. 12 
 
 Sp. vini rectificati ni 36 
 
 Aquae ad 5j 
 
 Misce. {Charing Cross.) 
 
 (3) R Liq. amraonife acet tti 108 
 
 Sp. vini rectificati in 108 
 
 Aquae ad §j 
 
 Misce. {St. Thomas's.) 
 
 22. Lotio Myrrhse. 
 
 R Tinct. myiThse m 72 
 
 Aquae ad 5J 
 
 Misce. {King's College.) 
 
FORMULA AND EECEIPTS. 407 
 
 23. lotio Plumbi. 
 
 R Plumbi acetatis gr, 2 
 
 Acidi acetici dil tn, 2 
 
 Aquae destillatse 5J 
 
 Misce. 
 
 24. Lotio Plumbi c. Opio. 
 
 R Tinct. opii 5.1 
 
 Sp. rosniarini 5.1 
 
 Liq. plumbi subacetatis dil. , . .ad §j 
 
 Useful for erysipelas, irritable ulcers, chilblains, &c. 
 
 25. Lotio Zinci Sulphatis (L. rubra). 
 
 R Zinci sulphatis gr. I 
 
 Sp. rosmarini tti 15 
 
 Tinct. lavandulae co tn, 15 
 
 Aquae destillatse o.j 
 
 Misce. {Middlesex.) 
 
 26. Lotio Zinci et Aluminis. 
 
 I^ Zinci sulphatis gr. 2 
 
 Aluminis exsiccati gr. 2 
 
 Aquae 5j 
 
 Useful in some acute forms of ophthalmia. 
 
 27. Lotio Zinci Chloridi (Mitior). 
 
 R Zinci chloridi gr. 1 — 5 
 
 Aqiife 5j 
 
 Misce. 
 
 28. Lotio Zinci Chloridi (Fortior). 
 
 B- Zinci chloridi gr. 20 — 40 
 
 Aquae 5j 
 
 Misce. (Mk. Campbell de Morgan.) 
 
 29. Mistura Acidi G-allici. 
 
 R Acidi gallici ....... gr. 10 — 20 
 
 Acidi sulph. dil tn 15 — 20 
 
 Tine, cinnamomi 5iss 
 
 Aquse distillatse ad §iss 
 
 Misce. 
 
408 f'ORMUL^ AND RECEIPTS. 
 
 30. Mistura Acidi Nitrici Dil. 
 
 (1) R Acidi nitrici dil HI 15 
 
 Tiuct. lupuli rn, 45 
 
 Inf. cascarillae 5j 
 
 Misce. (University College.) 
 
 (2) R Acidi nitrici dil nt 10 
 
 Tinct. card, co 3j 
 
 Infusi gentianse co §iss 
 
 Misce. {St. TJiomas^s.) 
 
 31. Mist. Acidi Nitro-Hydroclilor. Dil. 
 
 (1) R Acidi nitro-hydrochlor. dil. . . . iti 15 
 
 Infusi chiratse 5.1* 
 
 Misce. (King's College.) 
 
 (2) R Acidi nitro-hydroclilor. dil. ... iri 5 
 
 Tinct. chiratse tri 20 
 
 Sjr. aurantii 3j 
 
 Infusi aurantii ad 5j 
 
 Misce. 
 
 (3) Bt Acidi nitro-hydrochlor. dil. . . Tii 5—10 
 
 Sp. chloroforrai m 10 — 15 
 
 Ext. cinchona flavse liq. . . ni 10 — 15 
 
 Aqu£e ad 5 
 
 Misce. 
 
 32. Mistura Acidi Salph. Dil. 
 
 R Acidi Sulphurici dil tn, 10 
 
 Decocti cinchonse 5j 
 
 Misce. {St. Thomas's.) 
 
 33. Mistura Salina. 
 
 R Sp, setheris nitrosi 5y 
 
 Liq. ammon. acet oiij 
 
 Aquae campborse ad 5iss 
 
 Misce. 
 
 34. Mist. AmmoniGe Garb. 
 
 (I) R Ammonijecarb gr, 
 
 Infusi cinchonse 5,1* 
 
 Misce. {King's College.) 
 
FORMULA AND EECEIPTS. 409 
 
 (2) R Ammonige carb. . ... . . gr. 3 — 5 
 
 Tinct. card. CO 5.j 
 
 Sp. chloroformi Til 30 
 
 Tinct. cliiratiB rn, 5 
 
 Syr. aurantii 5iss 
 
 Aquae ad giss 
 
 Misce. 
 
 35. Mist. Ammonise Effervescens. 
 
 (1) R Ammonisecarb gr. 10 
 
 Sp. ammon. aromat tn. 10 
 
 S}T. zingiberis 5,j 
 
 Aquffi ad 5j 
 
 To be taken in effervescence with 
 
 Acidi tartarici gr- 8 
 
 Aquae §ss 
 
 (2) B. Ammonite carb gr. 6 
 
 Sp. chloroformi til 20 
 
 Tinct. calumbse m 10 — 20 
 
 Syr. zingiberis tn, 30 
 
 Aquae ad §j 
 
 To be taken in effervescence with a table-spoonful of fresh lemon 
 juice. 
 
 36. Mist. AmmoniEe Hydrochloratis. 
 
 R Animoniae hydrochlor gr. 5 
 
 Acidi hydrochlor. dil ni 8 
 
 Syr. rhoeados ni 30 
 
 Aquae destillatse ad 5j 
 
 Misce. 
 
 37. Mist. Ammoniee c. Scilla. 
 
 (1) R Ammoniae carb gr. 3 — 5 
 
 Sp. chloroformi lU 20 — 30 
 
 Tinct. scillae tn, 10 — 15 
 
 Infusi senegas ad 5j 
 
 Misce. 
 
 (2) R Sp. ammoniie aromat lU 20 
 
 Sp. chloroformi TH, 20 
 
 Oxymel. scillae ill 10 
 
 Aquae ad 5j 
 
 Misce. 
 
410 FOEMUL^ AND RECEIPTS. 
 
 38. Mist. Antimonii Tartarati, 
 
 (1) R Antimonii tartarati gi*. ^ 
 
 Liq. ammonise acet 3i.j 
 
 Aquae camphorae a-d §j 
 
 Misce. (St. Mary's.) 
 
 (2) R. Vini antimonialis iri 20 
 
 Liq. ammoniae acet 3iss 
 
 Tinct. hyoscyami . . . . . . . Tri 15 
 
 Aquae destillatse . ad 5j 
 
 Misce. 
 
 89. Mist. Antimonii Tart. c. Opio. 
 
 R Antimonii tartarati gr. 4 
 
 Tinct. opii iri 40 
 
 Aquae o^'^j 
 
 Misce. 
 
 One table- spoonful to be taken every hour. (Dr. Graves.) 
 
 40. Mist. Cathartica. 
 
 R. Tinct. zingiber! 8 fort ni 5 
 
 Magnesiae sulph gc. 120 
 
 Syr. sennae 3.] 
 
 Mannae gr. 30 
 
 Infusi sennae ad giss 
 
 Misce. 
 
 A draught to be taken in the morning. 
 
 41. Mist. Chloral. Hydrat. 
 
 R Chloral, hydrat gr. 10—20 
 
 Tinct. aurantii 5j 
 
 Aquae ad 5iss 
 
 Misce. 
 
 A draught to be taken at bedtime. 
 
 42. Mist. Cinchonae Co. 
 
 R Tinct, cinchonae co 3.1 — 3i,i 
 
 Sp. chloroformi ni 20 — 30 
 
 Aquae . ad 5j 
 
 Misce. 
 
FOEMUL.^ AND EECEIPTS. 411 
 
 43. Mist. Gopaibae. 
 
 R Copaibfe "1 .20 
 
 Mucilaginis acacise 3ijss 
 
 Aquse cinnamomi ad oj 
 
 Misce. 
 
 44. Mist. Cubebae. 
 
 R Pulv. cubebae Sss 
 
 Mucilag. acaciae 5ij 
 
 Tinct. hyoscjami 3ss 
 
 Sp. xth. r.it Sss 
 
 Syr. simplicis 3ss 
 
 Aqu?e cinnam ad 5j 
 
 Misce. 
 
 45. Mist. Ferri lodidi. 
 
 R Syr. ferri iodidi 5.1 
 
 Syr. rboeados ttl 15 
 
 Aquae ad 5j 
 
 Misce. 
 
 46. Mist. Ferri et Mag. Sulph. 
 
 R Ferri sulpbatis gr. 2 
 
 Magnesiae suipliatis gr. 20 
 
 Acidisulpk dil ni 10 
 
 Aquae pimentae oj 
 
 Misce. 
 
 47. Mist. Ferri Perchloridi. 
 
 R Tinct. ferri perchloridi ni 1 
 
 Sp. chloroformi tti 20 
 
 Inf. quassiae ad oj 
 
 Misce. 
 
 48. Mist. Ferri c. Zingibere. 
 
 R Tinct. ferri perchlor ni 10 
 
 Tinct. zingiberis tn, 30 
 
 Syr. simplicis 5j 
 
 Aquae ad 5j 
 
 Misce. 
 
412 FOEMUL^ AND RECEIPTS. 
 
 49. Mist. Hydrarg-yri lodidi. 
 
 R Liq. liydrarg. percliloridi 5j 
 
 Potassii iodidi gr. 5 
 
 Infusi quassias ad 5j 
 
 Misce, 
 
 50. Mist. Hydrarg. Percliloridi. 
 
 (1) R Liq. hydrarg. perclilor 3j 
 
 Tinct. gentianse co ni 20 — 30 
 
 Syr. aurantii ni 30 
 
 Aquas destillatse ad 5j 
 
 Misce. 
 
 (2) R. Hydrarg. percliloridi gr. ^^ 
 
 Sp. vini rectificati lU 10 
 
 Aqu£e 5j 
 
 Misce. {^London.) 
 
 51. Mist. Lobelise .Sltherese. 
 
 R Sp. Ammon. co m 30 — 60 
 
 Tinct. lobeliee £etli in 20—30 
 
 Aquse ad 5j 
 
 Misce. 
 
 52. Mist. Nucis Vomicse. 
 
 R Tinct. nucis vom. tn 10— 20 
 
 Acid, nitro-hydrochlor. dil. . . lU 10 — 20 
 
 Tinct. aurantii ni 20 — 30 
 
 Syr. aurantii 5j 
 
 Aquae ad 5j 
 
 Misce. 
 
 53. Mist. Morphiae Acetatis. 
 
 R Liq. Morphiae acet nt 10 — 30 
 
 Liq. ammon. acet 5ij 
 
 Mist, camph ad §j 
 
 Misce. 
 
FOEMULiE AND EECEIPTS. 413 
 
 54. Mist. Olei Santal. Flav. 
 
 R Olei santal, flav tn 30 
 
 Mucilag. acacise 3j 
 
 Syr. symplicis 5j 
 
 Tinct. aurantr ni 30 
 
 Aquae aJ 5j 
 
 Misce. 
 
 55. Mist. Fotassse Acetatis. 
 
 (1) R Sp. setheris nitrosi ni 30 
 
 Potassae acetatis gr. 20 
 
 Decocti scoparii 5j 
 
 Misce. {Charing Cross.) 
 
 (2) R Potassse acetatis gr. 10 
 
 Tinci. scillse . ni 15 
 
 Sp. eetlieris nitrosi ni 20 
 
 'Jinct. hyoscyami rn, 10 
 
 Aquae ad 5j 
 
 Misce. 
 
 A useful diuretic mixture. 
 
 56. Mist. Fotassae Bicarbouatis. 
 
 (1) R Pot assae bicarb gr. 10 — 20 
 
 Syr. zingiberis 5j 
 
 Aquae ad 5j 
 
 Misce. 
 
 Ten or fifteen drops of tbe vinum colchici, and tbe same quan- 
 tity of the tincture of hyoscyamus, may be added to each dose if 
 the patient is of a gouty habit. 
 
 (2) R Potassae bicarb gr. 30 
 
 Syr. simplicis in 30 
 
 Aquae giss 
 
 To be taken in effervescence with a dessert-spoonful of fresh 
 lemon juice. 
 
 57. Mist. Potassii Bromidi. 
 
 R Potassii bromidi g'' lo 
 
 Infusi quassiae 5j 
 
 Misce. {Charing Cross.) 
 
414 FORMULA AND EECEIPTS. 
 
 58. Mist. Fotassii Bromidi Co. 
 
 R Potassii bromidi gr. 10 
 
 Sp. cliloroformi ni 18 
 
 Infusi quassias 5j 
 
 Misce. (University College.) 
 
 59. Mist. Fotassse Chloratis. 
 
 R. Potasses cUoratis gr. 6 
 
 Sjr. tolutani 5j 
 
 Aquee destillatae . . . . . . . ad §j 
 
 Misce. 
 
 60. Mist. Potassii lodidi. 
 
 (1) R Potassii iodidi gr. 3 — 5 
 
 Tinct. aurantii tn, 20 
 
 Sp. chloroformi Tti 10 
 
 Infusi gentianas co ad §j 
 
 Misce. 
 
 (2) B, Potassii iodidi gr. 5 
 
 Ext. sars06 liq 5j 
 
 Misce. 
 
 To be taken in two table-spoonfuls of wate 
 
 (3) R Potassii iodidi gr. 5 — 10 
 
 Sp. ammonise aromat TH, 30 
 
 Tinct. aurantii ni 40 
 
 Syr. aurantii 5j 
 
 Aquae ad gj 
 
 Misce. 
 
 (4) B. Potassii iodidi gr. 5 — 10 
 
 Tinct. card, co IH. 20 
 
 Sp. chloroformi tn, 10 
 
 Syr. zingiberis 5j 
 
 Aquae ad 5j 
 
 Misce. 
 
 61. Mist. Potassii lodidi c. Colchico. 
 
 B- Potassii iodidi gr. 2 — 5 
 
 Potasste bicarb gr. 10 
 
 Tinct. colchici iti 10 — 20 
 
 Aquae destillatse ad 5j 
 
 Misce. 
 
FORMULAE AND RECEIPTS. 415 
 
 62. Mist. Potassii c. Ferro. 
 
 (1) Bt Potassii iodidi g^- 24 
 
 Ferri et iimmoniae citratis . . . . gr. 5 
 
 Aquae pimentse 5j 
 
 Misce. {London.) 
 
 (2) R Potassii iodidi gi'. 10 
 
 Ferri tartarati gr, 20 
 
 Aquse 5j 
 
 Misce. {King's College.) 
 
 (3) R Potassii iodidi gr- 5 
 
 Sp. ammon. aromat tri 20 
 
 Ferri tartarati gr. 10 
 
 Aqufe destillatse §j 
 
 Misce. 
 
 (4) R. Potassii iodidi gr. 3 — 5 
 
 Ferri et ammonise cit gr. 5 — 10 
 
 Sp. cbloroformi iri 20 — 30 
 
 Aquae ad 5j 
 
 Misce. 
 
 63. Mist. Fotassse Liqaoris. 
 
 (1) R Liq. Potassae ra 10 — 20 
 
 Liq. opii sed rn, 5 — 10 
 
 Mist, amygdalae 5j 
 
 Misce. 
 
 (2) R Liq. potassae ttl 10—20 
 
 Tinct. hyoscyami iH, 10 — 15 
 
 Aquae camphorse 5j 
 
 Misce. 
 
 64. Mist. Potassae Nitratis. 
 
 R Potassae nitratis gr. 15 
 
 Sp. aetlieris nitrosi tri 15 
 
 Syr. limonis tn, 40 
 
 Aquae mentliae §j 
 
 Misce. " {Guy's.) 
 
 65. Mist. Quiuiee. 
 
 (1) R Tinct. quiniae 5j 
 
 Syr. simplicis ni, 30 
 
 Aquaj ad 5j 
 
416 FOEMUL^ AND EECEIPTS. 
 
 (2) R Tinct. quiniae ta 20 
 
 Acidi sulph. dil vey 6 
 
 Syr, simplicis ni 30 
 
 Aquae destillatge ad 5j 
 
 (3) R Quinise sulphatis gr. 1 — 2 
 
 Acidi hydrobromici .... HI 10 — 20 
 
 Syr. aurantii floris 5j 
 
 Aquae ad 3j 
 
 Misce. 
 
 66. Mist. Quinise c. Ferro. 
 
 (1) R. QuinijB sulphatis gr. 1 
 
 Ferri sulphatis gr. 1 
 
 Acidi sulph. dil rf[ B 
 
 Syr. simplicis 3.1 
 
 Aquae ad 5j 
 
 Misce. 
 
 (2) Bt Quinise sulphatis gr. 1 
 
 Tinct. ferri perchlor TTl 10 
 
 Acidi nitrici dil Tti 5 
 
 Aquae ad §j 
 
 Misce. 
 
 67. Mist. Sodae Bicarbonatis. 
 
 R Sodae bicarb gr. 10—20 
 
 Acidi hydrocyanici dil . ... tti 3 — 5 
 
 Mist, camphorae 5j 
 
 Misce. 
 
 68. Mist. Sodee Bicarb. Effervesceus. 
 
 (1) R. Sodae bicarb gr. 10 
 
 Potassae bicarb gr. 5 
 
 Ammonise carb gr- 6 
 
 Tinct. calumbse tti 20 
 
 Syr. aui'antii tti 30 
 
 Aquae §iss 
 
 To be taken in effervescence with a dessert-spoonful of fresh 
 lemon juice. 
 
FORMULA AND RECEIPTS. 417 
 
 (2) R 8ocl£e bicarb gr. 20 
 
 Syr. limonis ^ ^9. 
 
 Aquae ad oij 
 
 To be taken in effervescence with eighteen grains of citric acid. 
 Fifteen or twenty drops of sp. cliloroformi may be added to each 
 dose if a stimulant is needed. 
 
 69. Mist. Sodae SulpMtis. 
 
 R Sodse sulphitis »''• 1?. 
 
 Liq. amnion, acet §i,j 
 
 Mist, camph ad oj 
 
 Mi see. 
 
 70. Mist. Strychnise c. Ferro. 
 
 (!) R Liq. stiTchnias IH 5 
 
 Acidi nitro-hydrochlor. dil. . . nil 
 
 Liq. ferri perchlor lU 10 
 
 Aqufe 5.i 
 
 Misce. (Charing Cross.) 
 
 (2) R Liq. strychnise m 5 
 
 Acidi nitro-hydrochlor. dil Til 5 
 
 Liq. ferri perchlor tti 10 
 
 Syr. simplicis 5jss 
 
 Mucilaginis 3j 
 
 Aquae ad §j 
 
 Misce. 
 
 71. Mist. Valerianse. 
 
 R Tinct. Valerianae ni 48 
 
 Infusi Valerianae •5.1 
 
 Misce. (University College.) 
 
 72. Mist. Valerianae Co. 
 
 R Tinct, valerianse amnion in 33 
 
 Tinct. camph. co ni 10 
 
 Sp. ammon. aromat ill 20 
 
 Aquae camphorae 5j 
 
 Misce. {University College.) 
 
 E E 
 
418 FOEMUL^ AND EECEIPTS. 
 
 73. Pigmentum Collodii, 
 
 R. Collodii 5ss 
 
 01. ricini §j 
 
 Misce. 
 
 An excellent application for burns or scalds, or in erysipelas. 
 
 74. Pigmentum Cretae Preparatae. 
 
 R Cretse preparatae 5v 
 
 01. lini (vel olivse) §j 
 
 Acidi acetici dil trt 10 
 
 Misce. 
 
 To be painted on tbe part with a camel's-hair bnish. For burns 
 or scalds, or in erysipelas. 
 
 75. Pigmentum lodi. 
 
 R lodi gr. 10 
 
 Sp. setberis nit , . . , 5ij 
 
 Sp. vini rect gss 
 
 Collodii 3ij 
 
 Misce. • 
 
 A useful application for cbilblains. 
 
 76. Pil, Aloes c. Myrrha, 
 
 R Aloes . . . 
 Myrrbse . 
 Saponis duri 
 01. carui 
 Aquse 
 
 gr. 2 
 gr. 1 
 
 gr. 1 
 
 til i 
 
 q. s. 
 
 Misce. {Guy's.) 
 
 Tbis pill, under tbe name of Eufus' or Widow Welch's Pill, is a 
 very useful and popular remedy in cases of chlorosis and irregular 
 menstruation. 
 
 77. Pil. Assafoetidae. 
 
 R Ext. aloes soc gr. 1 
 
 Saponis duri gr. 1 
 
 Assafoetidse gr. 3 
 
 Misce. {Middlesex.) 
 
FORMULAE AND RECEIPTS. 419 
 
 78. Pil. Colchici Co. 
 
 R Ext. colchici acet gr. 2 
 
 Pulv. Doveri gr. 3 
 
 Misce. {Middlesex.) 
 
 79. Pil. Ferri Sulph, et Aloes. 
 
 R Ferri sulph. exsicc gr. 2 
 
 Ext. aloes Barbad gr. 1 
 
 Saponis duri q. s. 
 
 Misce. 
 
 80. Pil. Hydrarg. lodidi. 
 
 R Hydrarg. iodidi vir. gr. 4 
 
 Pulv. opii gr. i 
 
 Micse panis q. s. 
 
 Misce. ( University College.) 
 
 81. Pil. Hydrarg. lodidi Rubri. 
 
 R Hydrarg. iodidi rubri gr. -^^ 
 
 Pulv. glycerrbizse gr- 2 
 
 Saponis duri gr. 1 
 
 Misce. 
 
 82. Pil. Hydrarg. Subchlor. c. Opio. 
 
 R Calomelanos gr. 1 
 
 Pulv. opii gr. 4 
 
 Conf. rosse caninae q. s. 
 
 Misce. {King's College.) 
 
 83. Pil. Nucis Vomicae. 
 
 R Ext. nucis vomicae gr- 4 
 
 Ext. gentiange gr. 4 
 
 Misce. {London.) 
 
 84. Pil. Podophylli. 
 
 R Podophylli resinse • gr. | — 4 
 
 Ext. hyoscyami ... . . . gr. 3 
 
 Misce. 
 
 To be taken at bedtime. 
 
 E K 2 
 
420 FORMULA AND EECEIPTS. 
 
 85. Fil. Fotassii lodidi. 
 
 B- Potassii iodidi gr. 1 
 
 Ext. gentianse gr. 2 
 
 Misce. 
 
 These pills sliould be silvered. 
 
 86. Pil. QuinisB Co. 
 
 R Quinise sulph gr. 1 
 
 Ext. conii gr- 3 
 
 Misce. (Middlesex.) 
 
 87. Pil. Quiniae c. Ferro. 
 
 R Quinise sulph gr. 2 
 
 Eerri sulph. . , gr. 2 
 
 Ext. gentianse gr. 1 
 
 Misce. (St. Thomases.) 
 
 88. Fil. Zinci Valer. Co. 
 
 B- Zinci valer gr. 4 
 
 Quiniae sulph gr. g 
 
 Pil. rhei co gr. 1 
 
 Ext. gentianse gr. 2 
 
 Misce. _ (iyondon.) 
 
 89. TJng. Calomelanos. 
 
 5t Hydrarg. subchlor gr. 20 
 
 Adipis §j 
 
 Misce. 
 
 90. Suppositories. 
 
 (1) B Pulv. opii gr. 1—2 
 
 Saponis duri q. s. 
 
 Misce. 
 
 (2) B Ext. opii gr. 1—3 
 
 Ext. bellad gr. 4 
 
 Olei theobromai q. s, 
 
 Misce. 
 
 (3) B Ext. bellad gr. 2 
 
 Plunibi acet gr- 2 
 
 Acidi tannici gr. 4 
 
 Olei theobromse q. s. 
 
 (jErichsen.) 
 
FOEMUL^ AND EECEIPTS. 421 
 
 91. Ointment for Bed-sores, 
 
 Take one pound of mutton suet from the kidney. Boil it in 
 three or four pints of water ; strain it ; and, when cold, it will float 
 on the top of the water. Eub it between the hands till it looks 
 like cold cream ; then spread it with the palm of the hand very 
 smoothly upon linen, not too fine. Be careful to boil the suet in a 
 perfectly clean saucepan, and that there is no salt or grit along 
 with it. 
 
 92. Bread Poultice. 
 
 " Scald out a basin, then immediately put in some boiling water, 
 and throw into it coarsely crumbled bread. Cover the basin with 
 a plate. When the bread has soaked up as much water as it will 
 imbibe, drain off the remainder, and there will be left a light pulp. 
 Spread it a third of an inch thick on folded linen, and apply it when 
 at the temperature of a warm bath." (Abeenethy.) 
 
 93. Linseed Meal Poultice. 
 
 " Get some linseed powder, not the common stuff full of grit and 
 sand. Scald out a basin. Pour in some perfectly boiling water, 
 throw in the powder, stir it round with a stick till well incorporated. 
 Add a little more water and a little more meal, stir again, and 
 when it is two-thirds the consistency you wish it to be, beat it up 
 with the blade of a knife till all the lumps are removed. If pro- 
 perly made it is so well worked together that you might throw it up 
 to the ceiling and it would come down again without falling into 
 pieces. It is in fact like a pancake. Then take it out and lay it on a 
 piece of soft linen, spread it the fourth of an inch thick, and as wide 
 as will cover the whole inflamed part. Put a piece of hog's lard in 
 the centre of it, and when it begins to melt draw the edge of a knife 
 lightly over and grease the surface of the poultice." (Abernethy.) 
 
 94. Mustard Poultice. 
 
 Mix the mustard with cold water and knead it to the consistence 
 of putty. Spread it the eighth of an inch thick upon brown paper, 
 or linen, warm it before the fire, and apply it to the part affected — 
 putting a thin piece of muslin between it and the skin. 
 
 95. Bran or Hop Poultice. 
 
 Fill a bag one-third full with bran, or hop-flowers, moistened but 
 not thoroughly wetted, with boiling water. Shake the bag and 
 hold it before the fire till it is thoroughly hot, and then apply it to 
 the affected part. 
 
422 FORMULA AND KECEIPTS. 
 
 96. Bryony Poultice for Bruises. 
 
 A poullice made of black bryony root (deprived of its bark and 
 finely-scraped) and bread crumbs, or flour, should be inclosed in a 
 muslin bag, and applied over the injured part. It will generally 
 cause the ecchymosis to disappear within twenty-four hours. 
 (Tyrrell on "Diseases of the Eye," i. 200.) 
 
 97. Ice Poultice. 
 
 Take of linseed meal a sufficient quantity to form a layer from 
 three-quarters to an inch thick, and spread it on a cloth of proper 
 size. Upon this, at intervals of an inch or more, place lumps of 
 ice the size of a big marble, then sprinkle them over with the meal, 
 cover with another cloth, folding in the edges to prevent the escape 
 of fluid, and apply the thick side to the surface of the wound. 
 (Maisonneuve ) 
 
 98. To Dress a Blister. 
 
 When sufficiently raised carefully draw off the blister ; and where 
 you see the skin overhanging, snip it in three or four places with 
 sharp-pointed scissors, having first taken care to place a clean soft 
 rag below the blister to catch the water that runs from it. Be very 
 careful not to snip anything but the raised skin, or you will have a 
 sore afterwards. When the water has ceased to flow, apply a 
 bread-and- water poultice. When the poultice comes off, spread 
 some lard or cold cream on a clean piece of linen rag, and lay it 
 over the part. 
 
 99. White Wine Whey. 
 
 Boil half a pint of new milk with a dessert-spoonful of sifted 
 sugar. Pour in a wine-glassful of sherry or Madeira. To be taken 
 quite hot. 
 
 100. Egg-Flip. 
 
 Beat the yolks of two new-laid eggs with a dessert-spoonful of 
 sifted sugar, and stir into a quarter of a pint of boiling white wine 
 or brandy-and-water. To be taken hot. 
 
 101. Treacle Posset. 
 
 Boil half a pint of new milk, and while boiling stir in two table- 
 Bpoonfuls of treacle. To be taken hot. 
 
FORMULA AND RECEIPTS. 423 
 
 102. Linseed Tea. 
 
 Put one ounce of linseed and half an ounce of Spanish liquorice 
 into a jug; pour over them a pint and a half of hoiling water, 
 cover close, and let it stand till quite cold. Strain off, To be 
 made hot as wanted or taken cold. 
 
 103. Imperial Drink 
 
 Put half an ounce of cream of tartar, the juice of one lemon, and 
 two table-spoonfuls of sifted sugar into a jug, and pour over them 
 one quart of boiling water. Cover till cold. 
 
 104. Tamarind Drink. 
 
 Take a quarter of a pint of tamarinds. Pour over them one quart 
 ol boiling water. Sweeten to taste. Cover, and let it stand for an 
 hour. 
 
 105. Meat Paste. 
 
 Take a small piece of raw meat perfectly free from fat (beef, 
 nmtton, or chicken), shred it as fine as possible, and rub it through 
 a sieve so as to form a smooth paste. Mix apiece the size of a pea 
 with a little cream and sugar. To be given frequently. In 
 cases of extreme exhaustion from diarrhoea or other causes it is very 
 useful, specially for children. It may be given as a sandwich 
 between thin pieces of bread, if preferred. 
 
 106. Pounded Meat. 
 
 Take some chicken partly, but not thoroughly boiled, clear it 
 perfectly from skin, shred it as fine as possible, beat it to a paste 
 in a mortar with a little of the liquor it was boiled in. Simmer it 
 gently for a few minutes with as much of the liquor as will bring it 
 to the thickness of gruel. 
 
 107. Essence of Beef. 
 
 Cut into small slices a pound of beef from the rump or sirloin, 
 free from fat, put it in a stone jar with a cover, without any 
 water. Fasten the cover down well with a double bladder. Stand 
 the jar in a saucepan of hot water and simmer for six hours. When 
 you take it out you will find about a tea-cupful of the strongest 
 beef juice. Give at first a tea-spoonful at a time. It is palatable 
 either hot or cold, and so light that it will remain on the stomach 
 when even toast-and-water is rejected. If preferred as a jelly, a 
 little isinglass may be put in the jar at first with the meat. Salt 
 must be added afterwards. 
 
424 FORMULA AND EECEIPTS. 
 
 108. Beef Tea. 
 
 1. The beef must be very fresb. Take four pounds of tbe uppei' 
 side of the round, cut it into small pieces, leave out every bit o " 
 fat, put it into a jar with a salt-spoonful of salt and three pints of 
 cold water. Tie it closely down, place it in a saucepan of water 
 and let it boil gently for five hours. The precaution of passing i, 
 piece of stale crumb of bread over the surface, before serving, shouh. 
 be carefully observed, lest any fat should remain. 
 
 2, Take one pound of raw beef, free from fat and bone. Minc( 
 the meat very fine. Pour over it, into a stone or china vessel 
 eight ounces of distilled water to which has been added five drops 
 oi" strong hydrochloric acid. Let it stand for two hours ; ther^ 
 strain thi'ough muslin, adding two ounces moi'e water to help itj 
 through. Season with one tea-spoonful of salt. 
 
 It is best to give it cold ; but if wanted warm, it must be put 
 in a cup and placed in a basin of hot water. It must not be 
 cooked. 
 
 109. Veal Tea. 
 
 1. Cut up into small pieces three pounds of lean veal, put it 
 into an enamelled saucepan with three pints of cold water and a 
 salt-spoouful of salt. When it boils skim very carefully. Simmer 
 for three hours. Strain into a basin, and, when cold, remove 
 every particle of fat. When required pour half a pint, while boil- 
 ing, on to a tea-spoonful of arrowroot which has been mixed with 
 a desert-spoonful of the cold veal tea. 
 
 2. Creme cforge. — Wash half an ounce of pearl barley in cold 
 water. Strain, and let it stand in one pint of fresh water for an 
 hour. Put half a pound of veal cutlet, free from skin and fat, 
 into a pan with the barley and water and a quarter of a salt-spoon- 
 ful of salt. Simmer very gently for two hours. Strain ; set aside 
 the liquor ; pound the meat very smooth in a mortar ; rub it 
 through a liair-sieve, using all the liquor to help it through. Add 
 half a gill of cream, and a little salt. Warm, and serve. 
 
 110. Chicken Broth. 
 
 Cut up a fowl, and break the leg-bones. Put it into a stewpan 
 with a quart of cold water, a tea-spoonful of salt, and the same 
 quantity of loaf sugar. Boil gently, skimming constantly, for 
 four hours. Then strain into a basin. When cold, take off the 
 fat. When required for use, warm a cupful. 
 
 111. Chicken Jelly. 
 
 Take a whole chicken, cut it up, put it into ajar, pour over it 
 a tea-cupful of cold water, tie it down very closely with a bladder , 
 
FOEMUL^ AND RECEIPTS. 425 
 
 place the jar in a saucepan of water, and boil quickly for nine 
 hours. Strain the liquid through a sieve. When it is cold, 
 remove the fat. A most nourishing and agreeable jelly remains. 
 
 112. Port Wine Jelly. 
 
 Take two ounces of isinglass, two ounces of gum arabic, two 
 pints of port wine, and put them into a jar with a lid. Put the 
 jar, well covered, into a stewpan of boiling water, and place it on 
 a hot plate, or over a slow fire, till it is quite dissolved. Then pour 
 into small moulds and let it cool. 
 
 113. Port Wine Lozenges. 
 
 Take two ounces of isinglass, one ounce of gum arabic, two 
 ounces of sugar candy, and one pint of port wine. Set these in 
 a jar of cold water, and let it simmer by the fire, stimng it with 
 a clean wooden spoon till quite dissolved. When it cools, it will 
 harden into a jelly, and may be cut out in squares. 
 
 114. Isinglass and Eggs. 
 
 Boil the third of an ounce of the best isinglass and a dessert- 
 spoonful of sifted loaf sugar in the thii-d of a pint of water. 
 When quite dissolved, add three drops of orange flcwer water, and 
 the yolks of two new-laid eggs well beaten. Boil up for one 
 minute, strain through muslin into small mould, and serve when 
 cold. 
 
 115. Flour Gruel. 
 
 Tie up one pound of flour tightly in a cloth, place it in a sauce- 
 pan of cold water, and boil it for four or five hours. When taken 
 out it will be a hard ball. Pare away the outer rind. When 
 needed for use scrape off a sufficient quantity and mix with 
 boiling milk to the thickness of gruel. 
 
 An excellent food in diarrhoea. 
 
 116. Soupe a Vin. 
 
 Take two or three shoes of bread from which the crust has 
 been cut. Toast them, and lay them in a soup plate, dusting 
 each piece over with sifted white sugar. Then pour over all about 
 a tumblerful of hot wine and water. Port wine or claret is the 
 most suitable for the purpose. 
 
INDEX. 
 
 \ BDOMEN, peBetrating wounds of the 
 -'-^ ,, tapping the 
 
 Abscess, acute . 
 chronic 
 cold . 
 iliac . 
 lumbar 
 psoas . 
 Acromion, fracture of the 
 Acupressure 
 Adenitis . 
 Adenoid tumour 
 Adhesive inflammation 
 Albugo . 
 Amaurosis 
 Amputations 
 Amussat's operation 
 Anaesthesia (local) 
 Ansesthetics 
 
 Angular curvature of the spine 
 Ankylosis 
 Aneurysm 
 
 , , varieties of 
 ,, treatment of 
 ,, by anastomosis (nsevu 
 Animation, suspended 
 Ankle, amputation at the 
 dislocation at the 
 excision of the 
 fractures about the 
 sprained 
 strapping the 
 Anthrax (carbuncle) . 
 Antiseptic dressings . 
 Antrum, abscess of the 
 Anus, artificial 
 
 ,, fissure of the . 
 „ imperforate 
 
 66, 279 
 
 . 277 
 
 . 12 
 
 . 12 
 
 . 12 
 
 . 218 
 
 . 218 
 
 . 218 
 
 . 142 
 
 . 51 
 
 . 204 
 
 . 274 
 
 . 10 
 
 . 237 
 
 . 246 
 
 . 391 
 
 . 282 
 
 . 369 
 
 . 366 
 
 . 215 
 
 . 179 
 
 . 196 
 
 . 196 
 
 . 198 
 
 . 200 
 
 . 76 
 
 . 399 
 
 . 193 
 
 . 390 
 
 . 167 
 
 . 104 
 
 . 105 
 
 . 102 
 
 . 14 
 
 . 254 
 
 . 283 
 
 . 297 
 
 . 296 
 
428 
 
 INDEX. 
 
 
 
 PAGE 
 
 Aphthous ulcers ....... 
 
 . 258 
 
 Apnoea ......... 
 
 . 77 
 
 Arcus senilis 
 
 . 239 
 
 Arm, amputation of the fore- ..... 
 
 . 394 
 
 jj _ „ „ upper 
 
 . 394 
 
 ,, slings for the ....... 
 
 143, 145 
 
 „ trough for the ....... 
 
 . 149 
 
 Arteria dorsalis pedis, ligature of the .... 
 
 . 386 
 
 Arteries, degeneration of . 
 
 . 195 
 
 ,, ligature of . . .... 
 
 . 378 
 
 Arteritis ......... 
 
 . 194 
 
 Arthritis ........ 
 
 . 175 
 
 „ chronic rheumatic ..... 
 
 . 176 
 
 Artificial anus ........ 
 
 . 283 
 
 „ pupil _ 
 
 . 242 
 
 „ respiration ....... 
 
 . 78 
 
 Asphyxia ........ 
 
 . 77 
 
 Aspirator, the pneumatic ...... 
 
 . 14 
 
 Astragalus, dislocation of the ..... 
 
 . 193 
 
 Atrophy ..... ... 
 
 . 23 
 
 Axillary artery, ligature of the ..... 
 
 . 382 
 
 ,, bandage ....... 
 
 . 139 
 
 "D ALANITIS . 
 
 ^^ Bandage, capitellum 
 
 325, 339 
 
 . 211 
 
 
 , compound axillary .... 
 
 . 139 
 
 
 , Esmarch's .... . . 
 
 . 365 
 
 
 , for a stump ..... 
 
 . 397 
 
 
 for bleeding 
 
 . 373 
 
 
 , for both breasts ..... 
 
 . 272 
 
 
 , for one breast ..... 
 
 . 271 
 
 
 , for supporting the scrotum . 
 
 . 332 
 
 
 , for the chin ..... 
 
 . 137 
 
 
 , for the hand and arm .... 
 
 152, 153 
 
 
 for the head .... 209, 
 
 210, 211 
 
 
 , for the knee ..... 
 
 . 174 
 
 
 , for the leg 
 
 100, 101 
 
 
 , for transverse wounds of the neck . 
 
 . 267 
 
 
 , for wiy-neck ..... 
 
 . 266 
 
 
 , four-tailed .... . . 
 
 137, 210 
 
 
 , many-tailed . . . ■ . 
 
 . 398 
 
 
 , nodose ...... 
 
 . 50 
 
 
 , prepared with starch, plaster of Paris, &c. 
 
 . 129 
 
 
 , six-tailed ...... 
 
 . 211 
 
 
 , spica ....... 
 
 . 347 
 
 Barbadoes leg ....... . 
 
 . 336 
 
 Bellocq's canula ....... 
 
 . 251 
 
 Bladder, 
 
 acute inflammation of the .... 
 
 . 314 
 
INDEX. 
 
 429 
 
 Bladder, cancer of the 
 
 ,, chronic inflammation of the . 
 ,, stone in the 
 , , to tie a catheter in the male 
 „ „ female 
 
 Bleeding, bandages for 
 Boil (furunculus) 
 Bone, diseases of 
 Bony tumours . 
 Brachial artery, ligature of the 
 Brain, compression of the . 
 
 ,, concussion of the . 
 
 ,, traumatic inflammation of the 
 
 ,, wounds of the 
 Breast, acute inflammation of th 
 
 ,, bandaging the 
 
 ,, excision of the 
 
 , , hypertrophy of the 
 
 , , malignant tumours of the 
 
 ,, strapping the 
 Bronchi, foreign bodies in the 
 Bronchocele (goitre) 
 Bruises . 
 Bubo 
 
 Bubonocele 
 Bunions . 
 Bums 
 
 Bursse, inflammation of the 
 Bursal abscess . 
 
 pALCULUS, renal 
 ^ ,, salivary 
 
 , , vesical 
 
 Callissen's operation . 
 Cancer .... 
 
 ,, colloid . 
 
 ,, encephaloid or medullary 
 
 , , epithelial 
 
 ,, melanotic 
 
 , , of the nasal cavity 
 
 , , of the rectum 
 
 , , rodent . 
 
 , , scirrhous 
 
 ,, treatment of 
 
 ,, villous . 
 Cancrum oris 
 Capitellum bandage 
 Carbuncle (anthrax) 
 
 PAGE 
 
 316 
 315 
 319 
 310 
 311 
 373 
 101 
 110 
 35 
 383 
 207 
 206 
 208 
 211 
 272 
 
 271, 272 
 277 
 
 270, 274 
 275 
 273 
 265 
 268 
 56 
 346 
 285 
 363 
 72 
 109 
 111 
 
 318 
 
 256 
 
 319 
 
 282 
 
 36 
 
 41 
 
 38 
 
 40 
 
 42 
 
 253 
 
 303 
 
 223 
 
 37 
 
 43 
 
 41 
 
 260 
 
 211, 212 
 
 . 102 
 
430 
 
 INDEX. 
 
 Carcinoma 
 
 Caries .... 
 
 ., of the cervical vertebrae 
 Carotid artery, ligature of the common 
 Carte's tourniquet 
 Cartilages, loose 
 
 ,, ulceration of 
 Castration 
 
 Cataract .... 
 Catheter (in male) to tie in a 
 
 ,, (in female) ,, 
 Catheterism 
 Cauterization . 
 Caustics in cancer 
 Cellulitis .... 
 CepbalhEematoma (blood tumour of scalp) 
 Charbon (malignant pustule) 
 Chelis (cheloid tumour) 
 Chest, tapping the . 
 Chilblains 
 
 Chimney-sweep's cancer of the scrotum 
 Chin, four-tailed bandage for the 
 Chloroform, administration of 
 Cholesterine 
 Chopart's operation . 
 Chordee .... 
 Chronic mammary tumour 
 
 ,, rheumatic arthritis 
 
 ,, synovitis 
 Cicatrization 
 Clavicle, dislocation of the 
 
 , , fracture of the 
 Cleft palate 
 Clove-hitch 
 Club-foot 
 Cold, effects of 
 Collapse (shock) 
 CoUes's fracture of the radius 
 Colloid cancer . 
 Colotomy 
 
 Common lined splints 
 Compression of the brain . 
 Compressors for the aorta 
 Concussion of the brain 
 Condylomata (warts: mucous tubercles) 
 Congestion 
 
 Conjunctiva, foreign bodies in the 
 ,, granular 
 
INDEX. 
 
 
 
 431 
 
 PAGE 
 
 Conjunctivitis, purulent ....... 231 
 
 ,, simple .... 
 
 
 . 230 
 
 Contraction of the fingers .... 
 
 
 . 357 
 
 Contusions of the scalp .... 
 
 
 . 209 
 
 Cornea, abscess of the .... 
 
 
 . 236 
 
 , , conical ...... 
 
 
 . 238 
 
 ,, foreign bodies in the 
 
 
 . 246 
 
 ,, inflammation of the 
 
 
 . 235 
 
 opacity of the .... 
 
 
 . 237 
 
 „ ulcer of the ..... 
 
 
 . 236 
 
 Corns ....... 
 
 
 . 362 
 
 Cretinism ...... 
 
 
 . 268 
 
 Crutches ....... 
 
 
 . 170 
 
 Cupping 
 
 
 7 
 
 Curvatures of the spine .... 
 
 
 . 214, 215 
 
 Cutaneous ulcers ..... 
 
 
 95 
 
 Cut-throat 
 
 
 . 267 
 
 Cystitis ....... 
 
 
 314, 315 
 
 T^EGENERATION of arteries 
 
 -^ Delirium, traumatic .... 
 
 
 . 195 
 
 
 
 . 81 
 
 Determination of blood .... 
 
 
 
 1 
 
 Dextrine bandage ..... 
 
 
 
 . 129 
 
 Diathesis in calculous disease 
 
 
 
 . 317 
 
 Diseases of joints ..... 
 
 
 
 171 
 
 Dissection T?ounds ..... 
 
 
 
 70 
 
 Dislocations ...... 
 
 
 
 . 183 
 
 ,, signs of . 
 
 
 
 184 
 
 ,, treatment of . 
 
 
 
 184 
 
 ,, varieties of .... . 
 
 
 
 183 
 
 Dislocation of the lower jaw 
 
 
 
 185 
 
 ,, ,, clavicle .... 
 
 
 
 186 
 
 ,, „ scapula .... 
 
 
 
 186 
 
 ,, ,, shoulder 
 
 
 
 187 
 
 ,, ,, elbow ..... 
 
 
 
 189 
 
 ,, ,, wrist ..... 
 
 
 
 189 
 
 „ „ hand .... 
 
 
 
 190 
 
 „ hip . 
 
 
 
 190 
 
 ,. „ patella .... 
 
 
 
 192 
 
 ,. ., semilunar cartilages 
 
 
 
 192 
 
 „ ,, knee-joint .... 
 
 
 
 193 
 
 ,, ankle ..... 
 
 
 
 193 
 
 ,, ,, astragalus .... 
 
 
 
 193 
 
 Distorted toes ....... 
 
 
 
 363 
 
 Double inclined plane ..... 
 
 
 
 157 
 
 Dressings ....... 
 
 
 
 369 
 
 ,, for a stump ..... 
 
 
 
 394 
 
 Drowning ....... 
 
 
 
 77 
 
432 
 
 INDEX. 
 
 Duct, obstruction of the nasal . 
 Dupuytren's splint . 
 
 Tj^ AR, accumulation of wax in the 
 -^ „ foreign bodies in the 
 
 ,, polypus of the 
 Ecraseur, use of the 
 Ectropion 
 
 Effects of heat and cold 
 Effusion, inflammatory 
 Elbow, dislocations of the 
 
 ,, excision of the 
 Elephantiasis of the leg 
 Embolism, effects of 
 Encephalitis, traumatic 
 Encephaloid cancer 
 Enchondroma 
 
 Encysted tumours of the eyelids 
 Entropion 
 Epididymitis . 
 Epiphora 
 Epispadias 
 Epistaxis 
 Epithelioma 
 
 ,, of the lip 
 „ of the tongue 
 Epulis 
 Equinia . 
 Erysipelas 
 
 ,, of the fauces 
 
 ,, of the scalp 
 
 ,, of serous membranes 
 
 „ phlegmonous 
 Ether as an anaesthetic 
 Excision of joiats 
 Exostosis 
 
 Extravasation of urine 
 Eye, diseases of the 
 Eyeball, tumours of the 
 ,, wounds of the 
 Eyelids, encysted tumours of the 
 
 FALSE joints 
 Farcy .... 
 Fatty tumours 
 Female, stone in the 
 Femoral artery, ligature of the superficial 
 Femur, fractures of the . 
 
INDEX. 
 
 433 
 
 
 PAGE 
 
 Femur, fractures of the neck of the .... 
 
 154 
 
 Fever, surgical or traumatic ...... 
 
 80 
 
 Fibrous tumours ....... 
 
 31 
 
 Fibula, fractures of the ...... 
 
 165 
 
 Fingers, amputation of the ..... 
 
 392 
 
 ,, contraction of the ..... 
 
 357 
 
 ,, fractures of the bones of the .... 
 
 152 
 
 Fissure of the anus ... .... 
 
 297 
 
 Fistula in ano ....... 
 
 301 
 
 „ in perineo . . . . . 
 
 312 
 
 ,, lactirymalis ....... 
 
 229 
 
 „ salivary ....... 
 
 220 
 
 ,, vesicovaginal ....... 
 
 337 
 
 Flat-foot 
 
 360 
 
 Forcipressure. arrest of haemorrhage by . . . 
 
 53 
 
 Fore-arm, amputations of the ..... 
 
 394 
 
 ,, fractures of the ..... 
 
 148 
 
 Foreign bodies in the ear ..... 
 
 250 
 
 ,, ,, in the eye ..... 
 
 246 
 
 ,, ,, ia the larynx, trachea, and bronchi 
 
 265 
 
 ,, ,, in the pharynx . . . . . 
 
 265 
 
 Fractures, greenstick ...... 
 
 120 
 
 ,, complicated ...... 
 
 131 
 
 ,, compound ...... 
 
 132 
 
 ,, indications of . . . . . . . 
 
 121 
 
 ,, ununited ....... 
 
 133 
 
 ,, treatment of ...... . 
 
 122 
 
 ,, union of ...... 
 
 121 
 
 ,, varieties of ...... . 
 
 120 
 
 Fractures of the skull ...... 
 
 134 
 
 „ ,, bones of the face .... 
 
 136 
 
 I'il^'s 
 
 137 
 
 „ ,, clavicle ...... 
 
 139 
 
 „ ,, scapula ...... 
 
 . 141 
 
 „ „ humerus ...... 
 
 . 142 
 
 „ „ fore-arm ...... 
 
 . 148 
 
 „ ,, metacarpal bones and phalanges 
 
 152 
 
 pelvis 
 
 . 153 
 
 „ „ femur 
 
 . 153 
 
 „ patella . . ... 
 
 . 161 
 
 „ » leg • 
 
 . 164 
 
 ,, about the ankle-joint 
 
 167 
 
 ,, of the tarsal and metatarsal bones 
 
 170 
 
 Frostbite 
 
 75 
 
 Fungus hsematodes 
 
 38 
 
 Furunculus (boil) ........ 
 
 101 
 
 F F 
 
434 
 
 INDEX. 
 
 p ANGLION, simple 
 
 compound 
 
 Gangrene, hospital 
 
 „ inflammatory 
 
 ,, senile 
 
 Gangrenous stomatitis 
 Gastrotomy 
 Genu-valgum 
 Glanders 
 
 Glands, inflammation of the lymphatic 
 Glandular tumours . 
 Glaucoma 
 Gleet 
 
 Goitre (bronchocele) . 
 Gonorrhoea 
 Gonorrhoeal ophthalmia 
 
 „ rheumatism 
 
 , , warts 
 
 Graduated compress 
 Granular conjunctiva 
 Granulation 
 Gunshot wounds 
 Gutta-pei'cha splints . 
 
 TT^MORRHAGE, arrest of 
 -*-^ ,, capillary 
 
 ,, secondary arterial 
 
 , , venous 
 
 Hsemorrhaoic diathesis 
 Haemorrhoids . 
 Hseraatocele 
 Hand, dislocations of the 
 
 ,, fractures of the 
 Hanging, death by 
 Hare-lip 
 
 Head, bandages for the 
 Healing by scabbing 
 Heat, effects of 
 Hectic fever 
 Hernia 
 
 „ congenital 
 
 ,, femoral 
 
 „ inc-ircerated 
 
 ,, infantile 
 
 ,, inguinal 
 
 ,, irreducible . 
 
 ,, strangulated 
 testis , 
 
 PAGE 
 
 107 
 
 107 
 
 99 
 
 18 
 
 20 
 
 260 
 
 282 
 
 361 
 
 70 
 
 204 
 
 29 
 
 244 
 
 341 
 
 268 
 
 338 
 
 233 
 
 341 
 
 341 
 
 60 
 
 234 
 
 22 
 
 62 
 
 131, 143 
 
 48 
 55 
 54 
 55 
 55 
 297 
 330 
 190 
 152 
 77 
 220 
 209-211 
 22 
 72 
 83 
 283 
 285 
 286 
 285 
 285 
 285 
 284 
 291 
 334 
 
INDEX. 
 
 43; 
 
 Ilernia, umbilical 
 
 Iley's operation 
 
 Hip, amputation at the 
 ,, diseases of the . 
 ,, dislocations of the 
 ,, excision of the 
 
 Hordeolum (stye) 
 
 Hospital gangrene 
 
 Housemaid's knee . 
 
 Humerus, amputations through the 
 
 ,, fractures of the upper end of the 
 
 ,, ,, ,, shaft of the 
 
 ,, ,, ,, lower end of the 
 
 Hydrocele 
 
 , , congenital 
 ,, encysted . 
 ,, of the cord 
 
 Hydrophobia . 
 
 Hydrops articuli (hydrarthrosis) 
 
 Hyperasmia (local) 
 
 Hypertrophy . 
 
 ,, of the breast . 
 
 ,, of the scrotum 
 
 Hypopyon 
 
 Hypospadias . 
 
 Hysteria .... 
 
 TCHORiEMIA 
 
 -*- Iliac artery, ligature of the external 
 
 Imperforate anus 
 
 Incisions .... 
 
 Inflammation 
 
 ,, acute 
 
 ,, adhesive 
 
 , , chronic . 
 
 ,, causes of 
 
 ,, events of 
 
 „ local effects of 
 
 ,, spread of 
 
 ,, suppurative . 
 
 ,, terminations of 
 
 ,, treatment of . 
 
 „ varieties of . 
 
 Interrupted splints . 
 Intestinal obstruction 
 Intussusception 
 Iritis .... 
 .. rheumatic 
 
 F F 2 
 
43G 
 
 INDEX. 
 
 Iritis, sypMlitic 
 Issues , application of 
 
 TAW, dislocation of the lower 
 ^ „ fracture ,, ,, 
 
 ,, tumours ,, ,, 
 
 ,, „ of tLe upper 
 
 ,, excision of the upper 
 Joints, diseases of 
 ,, excision of 
 „ loose cartilages in . 
 „ scrofulous disease of 
 wounds of 
 
 KERATITIS 
 Kiduey, calculus in the 
 Knee-joint, amputation at the 
 ,, dislocation of the 
 
 ,, excision of the 
 
 Knock-knee 
 
 T ACHEYMAL fistula . 
 -^ „ sac, inflammation of the 
 
 ,, duct, obstruction of the 
 
 Laryngotomy .... 
 Laryngo-tracbeotomy 
 Larynx, foreign bodies in the . 
 Lateral curvature of the spiue . 
 Leg, amputation of the 
 
 ,, bandage fnr the 
 
 ,, fractures of the 
 Leucoma .... 
 
 Leucocytosis .... 
 
 Ligature of arteries 
 
 Lingual artery, ligature of the . 
 
 Lip, epithelioma of the 
 
 Lipoma ..... 
 
 Lippitudo .... 
 
 Lister's antiseptic method of dressing 
 Liston's long splint . 
 Lithotomy .... 
 
 Litholrity .... 
 
 Local anaesthesia 
 
 Local hyperaemia 
 
 Loose cartilages in joints . 
 
 Lumbar abscess 
 
 Lupus ...... 
 
 Lymphatic glands, inflammation of the 
 
 ids 
 
INDEX. 
 
 437 
 
 Lympliatic glands, cancer of the . 
 Lymphatics, hitiammation of the . 
 
 IVrALFORMATIONS, congenital 
 
 -^^■'- Malgaigne's hooks . 
 
 Malignant pustule 
 
 Many-tailed bandage . 
 
 Mclutyre's splint 
 
 Melanosis (melanotic cancer) 
 
 Metacarpal bones, fractures of the 
 
 Metacarpo-phalangeal joint, amputation at the 
 
 Metatarsal bones, fractures of the 
 
 MoUities ossium (osteomalacia) 
 
 MoUuscum contagiosum 
 
 Morphia, subcutaneous injection of (F. 10) 
 
 Mortificadou 
 
 „ treatment of 
 
 ,, varieties of 
 
 Moxa, the . 
 Mucocele . 
 Mucous tubercles 
 Muscles, rupture of . 
 
 "^^VUS (aneurysm by anastomosis) 
 -'-^ Nasal bones, fracture of the 
 Nasal cavity, cancer of the . 
 Nasal duct, obstruction of the 
 Nathan Smith's antei'ior splint . 
 
 Nebula 
 
 Neck, wry (torticollis) 
 Necrosis ..... 
 Neuralgia ..... 
 Neuroma ..... 
 Nitrous oxide as an ansesthetic 
 Nodes, syphilitic 
 Nodose bandage . . 
 
 Nose, polypus of the . 
 
 kBSTRUCTION of the nasal duct 
 ,, ,, bowels 
 
 (Esophagus, stricture of the 
 Oidium albicans 
 Olecranon, fracture of the 
 Onychia, simple 
 
 ,, malignant . 
 Onyx 
 Operations in general 
 
 constitutional treatment after 
 
 PAGE 
 
 205 
 
 204 
 
 23 
 
 lt)3 
 
 71 
 
 398 
 
 1G6 
 
 41,42 
 
 152 
 
 393 
 
 I7O 
 
 113 
 
 226 
 
 404 
 
 17 
 
 19 
 
 18 
 
 374. 
 
 229 
 
 350 
 
 103 
 
 200 
 136 
 253 
 229 
 159 
 237 
 26fi 
 117 
 205 
 
 31 
 369 
 352 
 
 50 
 252 
 
 229 
 281 
 263 
 258 
 148 
 354 
 355 
 236 
 364 
 372 
 
438 
 
 INDEX. 
 
 Ophthalmia tarsi (tinea ciliaris) 
 
 ,, catarrhal 
 
 „ gODorrhceal 
 
 „ neonatorum . 
 
 „ strumous 
 
 Opisthotonos . 
 Orbital nsevus . 
 Orchitis, acute 
 
 „ chronic 
 Osteitis (inflammation of bone) 
 Osteo-sarcoma . 
 Otorrhoea 
 Ovarian disease 
 Ovariotomy 
 Ozaena .... 
 
 PARACENTESIS abdominis 
 -*- ,, thoracis 
 
 Paraphimosis . 
 Paronychia (whitlow) 
 Patella, dislocation of the . 
 
 ,, fracture of the 
 Pelvis, fractures of the 
 Penis, amputation of the 
 
 ,, cancer of the . 
 Perineum, ruptured . 
 Perinea] section 
 Periostitis 
 Peritonitis 
 Petit's tourniquet 
 Phalanges, fracture of the 
 Pharynx, foreign bodies in the 
 Phimosis 
 Phlebitis 
 
 PirogoflF's operation . 
 Plaster-of-Paris splints 
 Poisons, wounds by irritant 
 Polypus .... 
 
 ,, of the ear 
 
 ,, of the nose . 
 Popliteal artery, ligature of the 
 Pott's fracture . 
 Prolapsus recti 
 Propto-sis (exophthalmos) . 
 Prostate, abscess of the 
 
 ,, enlargement of the 
 
 ,, inflammation of the 
 Psoas abscess . 
 
INDEX. 
 
 439 
 
 Pterygium 
 Ptosis 
 
 Pupil, artificial 
 P.va3iiiia . 
 Pyrexia . 
 
 Q 
 
 UlNSY (cyuanche tonsillaris) 
 
 "pADICrS, Colles's fracture of tlie 
 
 -L^ ,, fracture of the 
 
 Radial artery, ligature of the 
 
 Ranula 
 
 Rectum, cancer of the 
 
 ,, prolapse of the 
 
 , , stricture of the 
 
 ,, ulcer of the 
 Repair, processes of . 
 Respiration, artificial 
 Retention of urine . 
 Ribs, fracture of the . 
 Rickets (rachitis) 
 Rodent ulcer or cancer 
 Rupia, syphilitic 
 Rupture of muscles or tendons 
 Ruptured perineum . 
 
 O ALIVARY calculus 
 ^ ,, fistula . 
 
 Sarcocele, cystic 
 Sarcoma, myeloid 
 
 ,, round- celled 
 
 ,, spindle-celled 
 Sayre's plaster jackets 
 Scalds 
 Scalp, contusions of the 
 
 „ wounds of the . 
 Scapula, dislocation of the 
 
 ,, fracture of the 
 Scarification 
 Sclerotitis . 
 " Scotc's dressing" 
 Scrofula 
 Scrofulous diseases of joints 
 Scrotum, bandages for supporting the 
 
 ,, cancer of the 
 
 ,, oedema of the 
 
 „ hypertrophy of the 
 
 PAGE 
 
 235 
 228 
 
 242 
 
 89 
 
 2 
 
 262 
 
 150 
 149 
 383 
 256 
 303 
 299 
 302 
 297 
 21 
 78 
 303 
 137 
 112 
 41, 223 
 349 
 103 
 338 
 
 256 
 
 220 
 
 334 
 
 33 
 
 32 
 
 32 
 
 216 
 
 72 
 
 209 
 
 210 
 
 186 
 
 141 
 
 7 
 
 239 
 
 173 
 
 44 
 
 178 
 
 332 
 
 337 
 
 335 
 
 335 
 
uo 
 
 INDEX. 
 
 Sebaceous tumours . . . . 
 Semilunar cartilages, dislocation of the 
 Septicseiaia (pyasmia) . 
 Senile gangrene 
 Setons, ajjplication of 
 Shock (collapse) 
 Shoulder, amputation at the 
 ,, dislocation of the 
 ,, excifion of the 
 Signoroni's tourniquet 
 Skin-grafting . 
 
 ,, ulcers of the 
 Skull, fractures of the 
 Sloughing phagedtena 
 Spica bandages 
 Spina bifida 
 
 Spinal cord, injuries of the 
 Spine, angular curvature of the 
 
 ,, lateral ,, ,, 
 
 ,, fracture of the 
 Splay foot 
 Splints . 
 
 , , Bavarian 
 
 ,, gutta-percha 
 Sprains . 
 Sprained ankle 
 Squinting (strabismus) 
 Staphyloma 
 
 Staphyloraphy (velosynthesis) 
 Starch- bandage 
 Stillicidium lachrymarum 
 Stomach-pump, use uf the 
 Stone in the bladder 
 Strabismus (squinting) 
 Strait- waistcoat 
 Strangulated hernia 
 Strapping an ulcer 
 ,, the ankle . 
 „ the testicle 
 Stricture of the ossophagu 
 ,, ,, rectum 
 
 ,, ,, urethra 
 
 Struma (scrofula) 
 Stye (hurdeoluui) 
 Styptics 
 
 Subclavian artery, ligature of th 
 Su[)puratiou 
 Suraicdl ftver . 
 
INDEX. 
 
 441 
 
 Suspended animation 
 Sutiu'es, varieties of . 
 Syncope .... 
 
 Syme's amputation at the ankle 
 Synovitis, acute 
 
 ,, chronic 
 
 Syphilis .... 
 
 ,, infantile 
 
 ,, secondary 
 
 rpALlPES (clul3-foot) . 
 -*- Tapping the ahdomen 
 ,, the chest . 
 Tarsal bones, iractures of the . 
 Tarsal cysts .... 
 Tarsus, amputation through the 
 T-bandage .... 
 Teale's amputation . . . 
 Temperature chart . 
 Ten do Achillis, rupture of the 
 "j-eno- synovitis 
 Testicle, acute inflammation of the 
 
 „ chronic inflammation of the 
 
 ,, cancer of the 
 
 „ excision of the (castration) 
 
 ,, scrofulous disease of the 
 
 ,, strapping the 
 Tetanus 
 
 Thigh, amputation through the 
 Throat, wounds of the 
 Thrombus 
 Thumb, amputation of the 
 
 ,, dislocation of the 
 Tibia, fractures of the 
 Tibial artery, ligature of the anterior 
 ,, _ ,, _ „ ,, posterior 
 
 Tinea ciliaris (ophtlialmia tarsi) 
 Toe, ulceration of the great 
 Toes, amputation of the 
 Tongue, epithelioma of the 
 
 „ -tie ._ 
 
 ,, ulceration of the . 
 Tonsil, acute inflammation of the 
 ,, chronic enlargement of the 
 ,, excision of the 
 Torsion, arrest of hgemorrhage by 
 Torticollis (wry -neck) 
 Trachea, foreign bodies in the 
 
442 
 
 INDEX. 
 
 Tracheotomy . 
 Traumatic encephalitis 
 Traumatic fever 
 Trichiasis 
 Trismus . 
 Trusses for hernia 
 Tuberculosis 
 Tumours . 
 
 ,, adenoid 
 
 ,, atheromatous 
 
 ,, benign 
 
 ,, bony . 
 
 ,, carcinomatous 
 
 ,, cartilaginous 
 
 ,, chronic mammary 
 
 , , encysted 
 
 ,, fibrous 
 
 ,, fatty . 
 
 ,, glandular 
 
 ,, horny 
 
 ,, malignant 
 
 ,, painful subcutaneous 
 
 , , sarcomatous 
 
 ,, solid . 
 
 ULCERATION . 
 ,, of bone 
 
 ,, of cartilage 
 
 , , of the great toe 
 
 Ulcer, how to strap an 
 Ulcers, healthy 
 
 ,, indolent 
 
 ,, inflamed 
 
 , , irritable 
 
 . , of the cornea 
 
 ,, of the rectum 
 
 ,, phagedaenic . 
 
 ,, rodent . 
 
 , , varicose 
 
 ,, weak . 
 Ulna, fracture of the 
 Ulnar artery, ligature of th( 
 Umbilical hei'nia 
 Union, immediate 
 
 ,, by the first intention 
 
 ., by the second intention 
 Uijper-arm, amputation through the 
 Urethra, stricture of the . 
 
INDEX. 
 
 443 
 
 l^rethritis 
 [Trethrotomy . 
 Urinary abscess 
 
 ,, deposits 
 
 ,, fistula 
 Urine, extravasation of 
 ,, retention of . 
 
 TT^ARICOCELE 
 ' Varicose ulcers . 
 ,, veins . 
 Varix .... 
 Veins, inflammation of (phlebitis) 
 Venesection 
 Vesico-va2;inal fistula 
 
 WAISTCOAT, strait 
 '' Warts, simjjle . 
 ,, venereal 
 "Whitlow (paronychia) 
 White swelling (scrofulous disease 
 Wounds 
 
 „ by irritant poisons 
 
 ,, contused 
 
 , , dissection 
 
 ,, gunshot . 
 
 ,, incised . 
 
 ,, lacerated 
 
 ,, of joints 
 
 , , of the brain . 
 
 ,, poisoned 
 
 ,, punctured 
 Wrist, amputation at the 
 
 ,, dislocation at the 
 
 ,, excision of the . 
 Wry-neck (torticollis) 
 
 of joints) 
 
 PAGE 
 
 339 
 308 
 31-2 
 316 
 312 
 311 
 303 
 
 330 
 
 99 
 203 
 203 
 202 
 373 
 337 
 
 81 
 
 27 
 
 341 
 
 105 
 
 178 
 
 57 
 
 72 
 
 60 
 
 70 
 
 62 
 
 57 
 
 60 
 
 183 
 
 211 
 
 67 
 
 61 
 
 393 
 
 189 
 
 387 
 
 266 
 
 THE END. 
 
 TKINIKU BY BALLANTYNii AND HANSON 
 LONDON AND EDINBURGH 
 

 
 
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